Experiences of Transgender and Gender Nonbinary Patients in the Emergency Department and Recommendations for Healthcare Policy, Education, and Practice

Abstract

Background.

Transgender and non-binary (trans/NB) individuals face many barriers to accessing healthcare in the U.S. due to systemic and clinician discrimination. Such experiences can lead to avoidance or delays in seeking care. These issues are relevant for emergency department (ED) clinicians and staff since trans/NB patients may use the ED in times of crisis.

Objectives.

The purpose of this study was to qualitatively explore experiences of trans/NB individuals accessing healthcare in the ED and provide recommendations for improvements.

Methods.

This study involved semi-structured qualitative interviews with nine trans/NB individuals living in Arkansas about their experiences when visiting local emergency departments.

Results.

Interviews revealed four main themes: (1) system and structural issues, (2) interactions with clinicians/staff influence care received, (3) perceptions of clinician knowledge and education about trans/NB health, and (4) impact on future health and healthcare access. Participants recommended education for current and future ED clinicians and staff to improve knowledge of best practices for trans/NB healthcare. Recommendations were also made to improve ED policy for inclusive and affirming intake processes, intake forms, and electronic health record (EHR) documentation, including documentation and use of patients’ chosen name and pronouns.

Conclusion.

The negative experiences and discrimination reported by trans/NB patients in ED visits underscores the importance of improving ED clinician knowledge of gender affirming care practices, ED intake policies and practices, and EHR documentation in EDs.

Introduction

Approximately 1.4 million transgender and gender non-binary (trans/NB) individuals live in the United States (U.S.).¹ Roughly one-third of 27,715 trans/NB Americans responding to a national trans/NB survey who had sought healthcare in the past year reported having experienced at least one negative interaction with a clinician after disclosing their trans/NB status.² Almost a quarter of respondents reported avoiding or delaying needed healthcare out of fear of mistreatment related to being trans/NB. Many reported that they do not disclose their trans identity when seeking care out of fear of discrimination.²

There are roughly 139 million emergency department (ED) visits in the U.S. each year.³ The ED can be a particularly distressing healthcare setting for trans/NB individuals, and previous experiences of healthcare discrimination and anticipation of discrimination or negative treatment by clinicians lacking knowledge of trans/NB health can lead trans/NB patients to avoid the ED.^4,5 One study found that nearly half of trans/NB individuals surveyed avoided care in the ED when they needed it due to anticipated discrimination, long wait times, and previous negative experiences.⁶ For trans/NB individuals who do seek ED care, the treatment they receive there is important to their health outcomes, especially when they have experienced service denial or discrimination in another healthcare setting.⁷

Unfortunately, U.S. clinicians lack training on the unique health and healthcare concerns of transgender patients.⁸ A survey of nearly 400 American emergency physicians found that the majority had received no formal training related to healthcare for trans/NB people, despite the fact that the majority of emergency physicians reported caring for both transgender and gender non-conforming patients.⁹

This study grew out of a trans/NB community-academic partnership developed in Arkansas to identify the trans/NB community’s health and healthcare priorities and to address trans/NB health and healthcare disparities.¹⁰ Education of clinicians about trans/NB patients and issues was one of their three greatest concerns,¹¹ which led our partnership to carry out a number of policy and education initiatives to improve affirming practices among future and current providers, including a jointly implemented interprofessional education training for students in the health professions.¹² Previous studies have explored the emergency department experiences of trans/NB individuals in Northern areas of the U.S.,⁶ but few have explored the unique experiences of those living in the South. The current study was conducted in response to trans/NB concerns about their healthcare experiences in emergency departments in Arkansas; the purpose was to formally capture these unique regional experiences of trans/NB individuals and identify their recommendations for education, policy, and practice.

Materials and Methods

Data for this study were collected within the context of a graduate-level, public health service-learning course on racial and ethnic health disparities in the spring of 2018. Reports of negative emergency department experiences among members of the trans/NB community created a motivation for this project. Trans/NB individuals partnered with course instructors to design study instruments and facilitate training of students in the class to increase their understanding of trans/NB issues and the intersectionality of race and gender identity, as well as to develop students’ self-awareness and cultural humility when conducting interviews. Course instructors provided students with additional training on conducting standardized in-depth interviews, and students practiced using the instrument with trans/NB community trainers.

A letter of determination about the project was submitted to the Institutional Review Board (IRB), which determined the project to be exempt from review. A second letter was submitted to update the IRB prior to conducting analysis of the data for this paper, and this study was again determined to be exempt from review.

Trans/NB community partners assisted with recruitment of participants by word of mouth and through a private Facebook group run by a statewide trans/NB advocacy organization. In addition, a local medical doctor serving trans/NB patients from across the state made her patients aware of the project and referred them to the course instructor for recruitment. One of the course instructors discussed the study with the first 12 trans/NB individuals who responded and provided them with an information sheet about: the purpose and topics of the study; the voluntary, confidential conditions of the project; and, the $20 compensation that would be provided to participants. Through this process eleven trans/NB individuals who reported having had a healthcare experience in an emergency department agreed to participate in in-depth interviews. Two interviews were not sufficiently documented for inclusion in this analysis. Data from the other nine of the eleven participants are therefore included in this analysis. Interviews focused on the most memorable experience for those who had more than one visit.

Prior to each interview, the student interviewers reviewed the information sheet with each participant and answered any questions. They also obtained permission to audio-record the interview for accuracy of notetaking. Participants were informed that by completing the interview they were indicating their agreement to be interviewed. The interviewers wrote reflexive notes throughout the interview. Following each interview, the interviewer summarized their participant’s responses for each question. Exemplar quotes were documented in the interviewers’ written summaries.

Analysis involved a combination of deductive coding and thematic analysis. First, one researcher coded each interview using a deductive approach, applying codes based on the interview items to capture the main topics discussed. This coding was confirmed by a second reviewer. Then, in a process of open coding, two researchers together performed content analysis using an inductive approach to coding to identify emergent themes. Any disagreements in coding were resolved by a third reviewer. Once all data were analyzed using both deductive and inductive coding, themes were identified. The research team then met and discussed and resolved any discrepancies in coding. Once they reached a consensus, they worked together to articulate the themes they had identified through their analysis. The value of these qualitative interviews is that they provide us with a more in-depth understanding of trans/NB Arkansans’ experiences, and therefore the intent is not to quantify the percentage of all trans patients with these experiences. As a result, we are avoiding implying that these are percentages of the population and instead reporting qualitative results using qualitative terms, including “few” (2-3 participants), “some” (4-5 participants), and “most” or “many” (6-9 participants).

Results

A total of nine trans/NB individuals participated in semi-structured qualitative interviews. Most identified as transgender (78%; n=7). Just over half (56%; n=5) of participants were assigned female at birth. Participants were White (56%; n=5), Black or African American (22%; n=2), American Indian or Alaska Native (11%; n=1), and multiracial (11%; n=1). Most were non-Hispanic (89%; n=8), under the age of 50 (89%; n=8), had insurance (89%; n=8), and had some college education (78%; n=7). One-third (33%; n=3) of our participants reported making less than $10,000 per year. Eight participants reported on experiences occurring within four different hospitals in Central Arkansas, with only one occurring in a hospital in a rural community in north Arkansas.

Interviews revealed four main themes: (1) systems and structural issues, (2) interactions with clinicians/staff influence care received, (3) perceptions of clinician knowledge about trans/NB health, and (4) impact on future health and healthcare access (see Table 1).

Table 1:

Themes and Subthemes

Theme #1: Systems and Structural Issues

Legal & EHR Documentation

Intake Forms

Confidentiality

Theme #2: Interactions with Clinicians/Staff Influence Care Received

Inappropriate questions and comments by clinicians

Misgendering

Other Harmful Behavior

Delays in care, refusal of care, or poor care

Theme #3: Perceptions of Clinician Knowledge and Education

Level of clinician knowledge about trans people

Need to educate clinicians about trans health and healthcare

Theme #4: Impact on Future Health and Healthcare Access

Experience’s effect on next visit

Willingness to seek care at that ED again

Theme 1: Systems & Structural Issues.

Participants discussed systems and structural issues of EDs they visited and described how these issues impacted their visit. The main systems issues included legal and electronic health record (EHR) documentation, intake forms, and confidentiality.

Patients’ Legal & EHR Documentation.

Some participants said that their legal documentation did correctly reflect their name (56%; n=5) and gender marker (44%; n=4) and said that their name (67%; n=6) and gender marker (56%; n=5) were correctly reflected in the ED’s EHR system. Some said that the gender marker on their legal documentation and EHR documentation were intentionally not aligned for insurance reasons. One participant described the reason for this mismatch: “According to the hospital I am listed as female, but legally I am male. I am trying to keep this because of insurance. Medicaid will not pay for female services for a male; therefore, my band says female. It is a constant reminder that I am not yet the person I want to be.”

Intake Forms.

Several participants reported that the ED they visited did not have a place on their intake forms for patients to list their pronouns and chosen name. One trans woman said that when she told the staff that her gender was wrong in the hospital records, the staff person wrote, “TRANS WOMAN,” in big letters in her chart. She said, “In an effort to make sure everyone was respected and treated with respect, everyone that has access to my health record had this displayed. This was done with the right intent but actually made everyone afraid of me and made some people very uncomfortable with me. In trying to reach the perfect standard, you can overdo it.”

Confidentiality.

While few participants discussed issues with confidentiality in their ED visit, some reported that their deadname (the legal name they were given at birth that they try to avoid) was called out in the waiting room. One participant said, “They always call my female name out loud… It makes people go ‘oh that’s another trans person’.” The participant felt that this was a violation of their privacy, as the practice of calling out patients’ legal names in the waiting room can potentially violate the confidentiality of patients whose gender expression is not congruent with the potentially stereotypically gendered name they were given at birth.

Theme 2: Interactions with Clinicians/Staff Influence Care Received.

Participants also described their interactions with clinicians and staff in the ED and the impact these interactions had on the quality of their healthcare, overall experience, and sense of being affirmed and respected. Some participants said that they chose to disclose their trans identity to clinicians and staff, while others did not. Some participants had positive experiences despite disclosing their trans identity or did not notice an effect on or change in their care after disclosing; for example, some said that their doctors maintained their professionalism, treated them with respect, and provided care without issue. However, participants often experienced that some ED staff were affirming, while others were not. Some participants said that some staff members intervened on their behalf to correct other staff who were not affirming. For example, one participant described that she overheard the nursing supervisor correcting other nurses when they were using the wrong pronouns in reference to her. However, participants most often described clinicians’ reacting negatively to their disclosure, including: inappropriate comments or questions; misgendering and other harmful behavior; and, delays in, refusal of, or poor quality care. One participant said, “Before I disclosed my trans identity, the nurse was nice and welcoming…but after I disclosed, I could tell that she did not want to do anything with me. I could tell that their opinion of me shifted.”

Inappropriate questions and comments by clinicians.

Inappropriate questions and comments from ED clinicians and staff included, “Have you had ‘the surgery’?”, “What genitals do you have?”, “How long have you been trans?”, “Have you seen ‘Transparent’ on TV?”, and “What do you think about Caitlyn Jenner?” These questions were described as “dehumanizing.” One participant said that a nurse asked, “‘Do you even believe in God?’ with a judgmental tone.” This participant perceived that this inappropriate and disrespectful behavior by the nurse was due to prejudice and attributed this prejudice to religious beliefs. Participants categorized questions as inappropriate when they perceived that the questions were not related to their current medical issue or situation, when the clinician was “just curious,” or when the information could be found in their medical chart. One trans man was asked, “Are you pregnant?” He went on to say, “I understand the need, but it’s triggering because it reminds me that I still have it in my body. Even after I have a hysterectomy, this will still be a question.” Other examples of inappropriate comments made to patients include, “Oh, I wouldn’t have known,” when the patient’s trans identity was disclosed.

Misgendering.

Most participants described being misgendered by ED clinicians and staff, including being called the wrong name or referred to with the wrong pronouns or honorifics (e.g., “Miss” or “Mr.”). Some said the issue was with clinicians and staff assuming their pronouns because of their voice or another characteristic, even though their gender was included in their chart. One participant said, “They kept calling me ‘sir’ after hearing my voice, even though my name and everything reflects that I am a woman. But it didn’t go on for very long. I corrected them, and I didn’t have any more issues really.” Some participants said that they were misgendered once and it did not happen again after the clinician or staff member was corrected; however, others described being misgendered throughout their ED visit. One participant said, “It was just a constant battle.” Another said, “It was really just the fact that they kept calling me ‘sir’ after seeing my name and gender marker all saying that I am a woman. It felt disrespectful, and it made me uncomfortable, but I didn’t feel unsafe or afraid really.”

Other Harmful Behavior.

Other harmful behaviors included gossiping, gawking, and abandoning the patient. One participant generously said, “I feel to some extent they tried their best to be respectful, even though their actions spoke otherwise.” Another participant said that once the clinician knew the patient was trans, “They treated me like they disliked me. I can’t explain how it is, just that they disliked me.” Some participants reported knowing that clinicians were gossiping about them. One said, “I know the nurses are talking about me, I know it's not me being paranoid, I can sense it.” Some participants also described clinicians gawking at them from outside their patient room. One said, “During the time that she [the nurse] was gone, a lot of staff--I would say about five or so--came to peep on me. They were looking at me up and down, standing at a distance. Of course, they wanted to see who and what I must be. I decided to yell at them, ‘Don’t keep this up, I might start charging admission.’ They made me feel like an animal in a zoo.” Another said, “Nurses were looking at me as if something was wrong with me--their look made me feel uncomfortable.” One participant said, “They were repulsed by me,” and, “they really didn’t want to treat me.”

Delay in care, refusal of care, and poor care.

Participants also described experiences indicating that when their symptoms are ignored and they receive poor care, when they are denied care, or their care is delayed, their lives and well-being are put at risk. One trans man said, “He [the physician] didn’t even want to touch me! He was like, ‘Well, I’m going to give her something for pain.’ I got admitted without an examination. … I lost all my pelvic floor muscle. They said I’d never walk, but I’m walkin’!”

Theme 3: Perceptions of Clinician Knowledge and Education.

Participants reflected on their perceptions of ED clinicians’ knowledge of and training about trans/NB health.

Level of clinician knowledge about trans people.

Although many participants said that the ED clinicians had the knowledge necessary to provide needed emergency care, they perceived that their ED clinicians knew little about trans/NB people or their health and the proper treatment for trans/NB patients. For example, one participant reported numerous examples of insensitive actions and questions by his clinician, including being asked to disrobe and remove his chest binder without a stated reason, which worsened his dysphoria. In addition, he was asked about his genitalia and “the surgery,” which led him to assume the clinician knew little about trans men. However, another participant said that the nurse explained to them why they were being asked to take off their clothing, which helped them understand and made them more comfortable complying with the request.

However, some participants were understanding of the lack of clinician knowledge about trans/NB health. One said, “I understand that many clinicians have never interacted with a trans person. We are a minority, and there is not much exposure for clinicians.” Some participants said that clinicians in urban EDs were more understanding of their unique healthcare needs than clinicians in rural EDs. One said, “‘When I met with [urban ED doctor] was the real first experience I felt that someone knew, [understood] what I was going through.” When asked if the ED clinicians know about trans health issues, this participant replied, “Down here in [urban city] they do, but not in [rural, small town].” Another participant said that the lack of knowledge among ED clinicians is due to their refusal to learn about trans/NB health, and they thought some clinicians consider trans/NB health to be “fake news.”

Need to educate clinicians about trans health and healthcare.

Some participants had to teach their ED clinicians about trans/NB health, including hormone therapy. For example, one trans woman’s cardiac symptoms, which were typical of cisgender women, were being overlooked by her physician, who assumed she would only have symptoms experienced by cisgender men. She said, “Those prejudices of gender and assumptions…can cost us our lives.” Other participants said that they “didn’t have to [educate their doctors about trans healthcare] because it did not play into the effect of what [they were] there for.” Some indicated that they did not try to educate their clinicians on trans/NB health and did not disclose that they were a trans/NB person.

Theme 4: Impact of Experience on Future Health and Healthcare Access.

Participants also explained how the previous experiences they had in an ED visit affected their health, as well as their use of healthcare services moving forward.

Experience’s effect on next visit.

Bad experiences while accessing care in an ED affected their next healthcare visit. Some said they avoid or delay needed care in anticipation of future negative experiences. One said that it “made me feel uncomfortable to visit the emergency room in fear of being disrespected, misunderstood, or even mistreated.” One said that he refused to go to the emergency room because he didn’t want to get misgendered or be called the wrong name by ED staff. One participant said, “They still saw in my chart from past visits, some gender specific things, and then all of these questions came about, and I was just there for back pain. It was like as soon as they found out, then pronouns started getting messed up.” That participant went on to say, “There were a couple other times that I probably should have gone to urgent care or the ER, and I just ended up treating myself with over-the-counter medications.”

Willingness to seek care at that ED again.

When asked if they would be willing to go back to the ED they had visited, about half of participants said no. One participant said, “I dreaded it,” “I try to avoid it,” and “I have a bad feeling about it.” However, others said they would recommend the urban EDs they had visited, though these recommendations were primarily for the “medical aspect of it,” not necessarily because they had been treated well there. One said, “I would go back because it is the closest to my house and I feel like I can handle those situations. But some people can’t, and it’s really important for nurses and everyone to know how to talk to those patients and make them feel comfortable.”

Recommendations from Participants for Policy, Practice, and Education.

At the end of their interviews, participants were asked, “What recommendations do you have for emergency department clinicians and staff and hospital administrators?” Table 2 provides a summary of their responses, which focused on hospital policy, healthcare practice, and clinician education.

Table 2:

Participant Recommendations for Policy, Practice, and Education

Policy

Update forms to include the patient’s legal name, chosen name, pronouns, sex assigned at birth (e.g., male, female, intersex), and gender (e.g., cisgender man, cisgender woman, transgender man, transgender woman, nonbinary, genderqueer, prefer not to say) Include trans/NB people in the development of policies and practice guidelines for ED clinicians and staff

Practice

Be respectful and affirming of patients’ gender identities, including using their chosen name and pronouns Use inclusive language, such as gender-neutral pronouns and terminology, and medically accurate terminology for reproductive organs, avoiding referring to them as “male parts” or “female parts” Do not ask unnecessary questions about anatomy, considering that this can be triggering for patients Leave personal religious beliefs out of healthcare practice and interpersonal interactions with patients

Education

Provide training on gender-affirming care for current and future clinicians and staff Engage LGBTQ people and experts from local trans-led organizations in the development and/or delivery of training Incorporate information about trans/NB health into medical and nursing school curricula, including clinical experiences with trans/NB patients during this professional training

Discussion

Qualitative interviews with transgender and gender nonbinary (trans/NB) individuals about their experiences visiting emergency departments (EDs) in Arkansas revealed four main themes: (1) systems and structural issues, (2) interactions with clinicians/staff influence care received, (3) perceptions of clinician knowledge about trans/NB health and the need to educate clinicians about trans/NB health and healthcare, and (4) impact on future health and healthcare access. Our findings are complementary to the findings of Samuels et al. (2018),⁶ who also examined experiences of trans/NB individuals in the ED, though in a northeastern U.S. state. This is important as our study took place in Arkansas, a southern state with more cultural barriers to acceptance. For example 70% of the general population identify as “highly religious” and Arkansas ranks fifth in the nation for religiosity, with 46% of Arkansans identifying as evangelical Christian,^13-15 who studies have shown have less inclusive beliefs about transgender civil rights and lower comfort in associating with trans individuals.¹⁶ It is possible experiences reported would have been more negative had our sample included more visits in rural hospitals.

One step healthcare systems can take to address structural issues identified in our study is to participate in the Human Rights Campaign’s Healthcare Equality Index (HEI). The HEI provides a national benchmarking tool that evaluates healthcare facilities’ policies and practices related to LGBTQ equity and inclusion. Even though four Arkansas hospitals have participated, only two have consistently received leadership status, compared to 30 HEI leader-status hospitals in New Jersey, where Samuels et al. (2018) conducted their study. Although New Jersey’s population is three times as large as Arkansas’s, they have 15 times as many HEI leader-status hospitals. Several of the authors of this paper have participated in our institution’s efforts to gain HEI leader status, and we have seen how this process improves leadership engagement in LGBTQ equity and inclusion efforts, incentivizes efforts to increase participation in training, and raises the priority for policy changes.

Documentation is one domain assessed in the HEI. In the current study, systems and structural issues were often related to documentation, or how the patient’s gender identity, name, and pronouns were documented (or not documented) in the electronic health record or on paper forms. For our participants, lack of clear documentation of name, pronouns, gender identity, and sex assigned at birth caused confusion and conflict with medical staff, potentially leading ED clinicians and staff to use the wrong pronouns or honorifics. This practice is perceived as disrespectful and potentially dangerous for trans/NB patients, particularly when their privacy is not being maintained. Hospitals and clinics have moved towards the collection of sexual orientation and gender identity data (known as “SOGI” data) in addition to collecting sex assigned at birth. However, many institutions still request patient gender and sex in a binary fashion and fail to provide an option for patients to report non-binary gender identities.¹⁷ The Fenway Institute’s LGBT Health Education Center has developed best practice guides, such as the “Do Ask, Do Tell” toolkit¹⁸ and Best Practices for Front-line Health Care Staff,¹⁹ which advise on collecting SOGI data and other best practices, such as using only patients’ last names without honorifics (i.e., Mr., Mrs., Miss) when calling them from the waiting room.

Consistent with similar studies,^6,20,21 our research found many interpersonal experiences between participants and ED clinicians and staff were characterized as discrimination, including being misgendered and treated with disrespect. Some patients in our study did not disclose their trans/NB identity in the ED, which may have been due to a fear of discrimination. This finding aligns with previous studies we have conducted in Arkansas where trans/NB individuals reported being scolded for not voluntarily disclosing their trans identity, having clinicians abandon them during their visit, and being denied care.¹⁰ These kinds of harmful behaviors can negatively impact the health and well-being of patients and may contribute to depression and suicidal ideation.²² Although non-disclosure of trans/NB identity may prevent trans/NB patients from experiencing discrimination, it may limit clinicians’ full understanding of their health needs, which can affect the quality of care received.²³

Many of our participants reported perceiving that the clinicians they saw in the ED knew little about trans/NB people and their health and healthcare needs. Few emergency medicine clinicians have received formal training on LGBTQ health topics--particularly trans/NB health.⁹ Such knowledge gaps can increase tension between trans/NB patients and their providers,²¹ or may result in patients having to teach their clinicians about trans health.²² Our study confirmed that trans/NB patients avoid care, delay care, or attempt to self-treat when they have had a negative experience in an ED or perceive that their ED clinicians were not knowledgeable about trans/NB health needs and anticipate poor or discriminatory care in future visits.²³ Delays in needed care lead to worse health outcomes.^24,25 If patients are avoiding or delaying needed care, they may be forced to use the ED if in a crisis. Receipt of affirming care in the ED can improve patients’ willingness to seek other needed care in the future and mitigate negative coping associated with mistreatment. This highlights the critical role of ED clinicians in providing affirming care to trans/NB patients and the need for education among ED clinicians and staff. Brief education interventions can change attitudes and knowledge among healthcare students and clinicians, at least in the short term.^12,26-31

In addition to participating in our HEI process, the authors have been involved in multiple efforts to improve LGBTQ inclusion efforts, including engagement in our Division for Diversity, Equity, and Inclusion’s LGBTQ Subcommittee, which continues to work on policy, education, and services to improve care for this population. In an effort to address issues raised by our participants and in response to requests for education among practicing clinicians in our healthcare system, we are adapting our interprofessional education module¹² to be implemented virtually with students and with clinicians in practice across our healthcare system. Other efforts will include education and training on “Trans 101” concepts, gender-affirming care, and SOGI data collection for ED clinicians and staff, as well as clinicians, staff, and trainees across other departments in our healthcare system.

Limitations.

This study provides valuable information about the experiences of trans/NB individuals accessing emergency care in Arkansas; however, the study has several limitations. Due to the small sample size, these findings are not generalizable. However, in-depth qualitative interviews provide rich information on the experiences of this unique population, and our findings are consistent with other similar studies. There were several limitations of the research design, including the recruitment strategy and data collection methods. First, all participants were recruited by the last author through a local clinician and in partnership with a nonprofit trans/NB advocacy organization; therefore, the participants may not be representative of the Arkansas trans/NB community overall, and there may have been bias in the sampling method. Second, students conducted the qualitative interviews as part of a graduate course on health disparities. Although the students participated in a brief training on standardized interviewing and mock interviews with trans/NB individuals and followed an interview guide during data collection, the students likely had limited qualitative research training outside of the course. Third, students were asked to summarize the participants’ responses and present exemplary quotations; therefore, data quality should be considered a limitation because interviews were not transcribed verbatim.

Conclusions

This study captured the unique experiences of trans/NB individuals accessing emergency care primarily in the most urbanized area of the state. The negative experiences and healthcare discrimination reported by trans/NB patients suggest that efforts should be made to improve ED clinician knowledge of gender-affirming care practices, like using correct name and pronouns. Additionally, EDs should improve intake policies and practices to ensure patient privacy, such as calling chosen name rather than legal name in waiting rooms. EHR systems should be updated to document chosen name, gender identity, pronouns, and sex assigned at birth in EDs.

Article Summary.

1). Why is this topic important?

Transgender and gender nonbinary (trans/NB) individuals face many barriers to accessing healthcare in the U.S. due to systemic and clinician discrimination. These issues lead to avoidance of or delays in seeking care and are relevant for emergency department (ED) clinicians and staff since trans patients may have to use the ED in times of crisis.

2). What does this study attempt to show?

This study uses data from qualitative interviews to describe the experiences of trans/NB individuals accessing healthcare in the ED and identifies areas for improvement.

3). What are the key findings?

• Trans/NB participants described systems and structural issues in the ED they visited, including issues with maintaining patient confidentiality, problematic intake processes, and electronic health record documentation.

• Participants described how negative interactions with ED clinicians/staff, like misgendering, delays in care, and other harmful clinician behaviors, influence care received and have an impact on their future health and healthcare access.

• Participants perceived ED clinicians as lacking knowledge about trans/NB health and made recommendations for education.

4). How is patient care impacted?

• To improve trans/NB patient care, ED clinicians should be respectful and affirming of patients’ gender identities, use inclusive language and chosen name and pronouns, avoid asking unnecessary personal questions, and leave conflicting personal beliefs out of their healthcare practice and interpersonal interactions with patients.

• Improving electronic health record documentation of gender identity and chosen names and pronouns may help to prevent misgendering and miscommunication between ED clinicians and patients.

• Educating current and future ED clinicians on gender affirming care best practices may improve clinician behavior and, in turn, improve patient experiences and health outcomes.