Consider this fictionalized situation: Jack, a transgender man, is sitting in the waiting room of a breast imaging center. The staff at the front desk call out, “Jessica” (the name given to Jack at birth). When Jack responds and walks up to the staff person, the gender of the name called and the expressed gender of the person who walked up are obviously very different. Jack, the other patients in the waiting room, and the staff person now are all potentially uncomfortable. And for Jack, the center is no longer a safe space.
The situation above and others like it might seem like the result of a harmless mistake, but failing to consider the needs of lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients can be critical to their healthcare experiences. LGBTQ patients are all different and have unique needs that should be considered. This article will be using the term “transgender” as an umbrella term — which does not describe one specific group but a wide range of people with varied concepts of gender identity, such as bigender (having more than one gender), nonbinary (experiencing gender outside the traditional gender binary of male or female), as well as individuals who are at different stages of transitioning from one gender to another.
Access to Care
Recent polls indicate that 4.5 percent of the U.S. adult population identifies as LGBTQ, with 8.1 percent of millennials identifying as LGBTQ in 2017.1 The transgender population comprises approximately 0.6 percent of this group, and this number is expected to grow as society becomes more accepting of gender identities that do not align with one’s biological sex.2 However, LGBTQ patients are often marginalized and face significant health disparities. For example, according to the 2015 U.S. Transgender Survey Report, released by the National Center for Transgender Equality, 33 percent of the 27,715 respondents reported at least one negative experience related to being transgender when receiving healthcare, such as being verbally harassed or refused treatment because of their gender identity.
Further, nearly a quarter of the respondents reported not seeking healthcare when they needed it due to being mistreated as a transgender person.3 Lesbian, gay, and bisexual men and women face similar issues. A nationally representative survey conducted by the Center for American Progress in 2017 found that 8 percent of lesbian, gay, and bisexual respondents reported a healthcare provider had refused to see them because of their sexual orientation or gender identity in the past year.4 “It’s a horrifying idea that people are not seeking healthcare and treatment such as mammography because they’re not going to be treated well or because they will be made to feel uncomfortable,” says Yasmin Carter, PhD, assistant professor of translational anatomy in the department of radiology at the University of Massachusetts Medical School in Worcester.
According to Carter, “Not only are there access to care issues, but there’s a trickle-down effect where physicians then don’t include transgender and other LGBTQ patient data in larger analyses and studies. Breast cancer research often doesn’t include the discussion of gender, meaning these individuals are invisible in the research.”
“The only thing we know for sure is we don’t have enough information,” says Valerie J. Fein-Zachary, MD, breast imager at Beth Israel Deaconess Medical Center and assistant professor of radiology at Harvard Medical School. “For example, we don’t know the incidence of breast cancer in lesbians — we may assume it’s the same as heterosexual women, but we have observed that many lesbians have more risk factors, due to nulliparity or greater rates of obesity, alcohol use or smoking, but we don’t know. We also don’t know if hormone use by transgender women or testosterone use by transgender men are risk factors. Not knowing these things means I can’t give good counsel as a physician, and that’s a concern.”
Carter agrees. “This is a massive problem because this inadequate research results in, at best, variable guidelines for transgender and queer patients, and almost nothing in the way of population statistics,” she says.
It’s a horrifying idea that people are not seeking healthcare and treatment such as mammography because they’re not going to be treated well or because they will be made to feel uncomfortable.
So how can radiologists help solve this problem? According to both Fein-Zachary and Carter, radiologists can make their practices more inclusive and welcoming to ensure that all patients feel comfortable and safe seeking care. One of the easiest ways to do this is to include rainbow flags or stickers around the practice or on staff badges, say Fein-Zachary and Carter. “Their presence says, ‘This is a safe space, and I am a safe person,’” says Carter. Adds Fein-Zachary, “Small details like this are easily missed if you’re not looking for them, but for these individuals, it makes a world of difference.”
Another way to make a practice more inclusive is to consider the unnecessary gendering of the departments. Some practices such as breast imaging facilities tend to be highly feminized, featuring pink hues everywhere, from the décor to gown color. “Mammography is still a gendered concept; we mostly think of it as a women’s issue. Consider: do you have gender neutral bathrooms? What color are the gowns? What sizes are your gowns? When you provide materials for patients, be sure you’re providing something that can cover and be comfortable for a range of individuals,” advises Carter.
Some practices, such as Fein-Zachary’s, have separate waiting rooms for men and women. “We treat our transgender women the same as we treat our cisgender women [women who identify with the gender assigned at birth],” says Fein-Zachary. “They go to the women’s waiting room and the women’s changing room. Transgender men are asked to wait in the same areas and changing rooms as cisgender men.”
Considering the language you and your staff use is also critical. Often, the legal name of a transgender patient entered into the medical record is not the preferred name, and the gender of the legal name does not match the expressed gender of the patient. If a staff member uses the legal name instead of the preferred name, not only is the patient extremely uncomfortable, but that staff member has essentially made the patient come out all over again.
To combat this situation, make sure staff use the preferred pronouns and names of the patients. To accomplish this, make sure the intake forms and medical records include spaces for this information. Physicians also have to be sure that this information is being shared among staff, so that all staff along the chain will use preferred language. “Make sure that information is being entered in the medical record,” says Fein-Zachary, whose practice has the preferred name in parentheses next to the legal name.
Another language consideration are terms used for the body. “Some individuals prefer you use ‘chest’ instead of ‘breast,’” explains Carter. Adds Fein-Zachary, “There is a white overlay to the term ‘lesbian,’ so some women of color patients prefer we use the term ‘gay’ to identify them. You have to be conscious people have different preferences — you can’t automatically assume someone’s identity.”
And if you’re unsure of what term to use? Ask. However, be sure to restrict your question to the individual’s case and remember that your patient’s role is not to educate you about all things LGBT. “Before you ask, make sure your question is medically relevant. Curiosity is completely normal and human, but it is not helpful or appropriate for the patient,” says Carter.
Finally, make sure your entire staff is trained in these inclusivity practices, says Carter. “We have to do it along the whole chain, from the provider to the technologist to the valet. Even the billing office should be considered. If the patient is misgendered, when working with insurance, that patient could wind up paying for everything instead of having coverage,” she says.
Where to Start
According to Fein-Zachary, if radiologists are looking to get started making their practices more inclusive or offering training for their staff, they should check out institutions that are considered facilities of excellence in LGBTQ care (see sidebar).
The most important thing is to remember that changing a practice takes time, says Fein-Zachary. “No facility changes overnight, and we are constantly learning. It’s an ongoing process,” she says. Carter agrees. “Inclusivity is not about creating unnecessary or burdensome priorities for your practice,” she says. “It’s about understanding that each of our patients has unique needs. By understanding this, we can build the patient-provider relationship in exciting and unique ways.”