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Addressing Transgender Health Inequity

01/25/2022

By Christina Cordero, PhD, MPH, Project Director, Technical

With more discussion of transgender issues in popular culture and mainstream media, the time has come to address issues transgender people face in health care settings.

Case Example #6 – Part 1: Call Me By My Name: A Case of Transgender Health Inequity is the latest in a Joint Commission series offering examples of real-life issues in health care. In this instance, a transgender individual who was assigned male at birth and whose legal sex is female presented at an emergency department for abdominal pain. Her experience illustrates some of the most common problems encountered by transgender individuals.

Facility Design Considerations
This patient’s issues began at the triage reception desk. The lack of privacy via the exposed area and public triage process generated feelings of embarrassment and fear of being outed, stigmatized and mistreated.

Organizations that are proactive about self-assessing their barriers to the access, provision of care and treatment of transgender patients have re-designed their physical spaces. These forward-thinking organizations have incorporated LGBTQ+ affirming signs and stickers to make the waiting room more welcoming and inclusive. They’ve also established:

  • more private areas at the triage desks
  • workflows for how and when to capture structured collection of sexual orientation and gender identity data
  • tools to facilitate a patient’s self-reporting of sensitive information

Awkward Staff Encounters
Embarrassment deepened during the physician encounter. As the doctor initiated the exam, the fictional patient disclosed her status as a transgender woman to avoid confusion as to the configuration of her reproductive organs. The physician replied with surprise, saying “You look like a woman” before asking if there were future plans for surgery. These questions and comments were not medically relevant to the patient’s chief complaint. Inappropriate and intrusive comments like these can result in transgender patients avoiding or delaying care.

The physician later invited additional health care providers to the visit for training purposes around transgender patients. The doctor was likely well-intended, but the presence of unnecessary personnel disempowered the patient and increased her unease. A better way to educate staff on LBQTQ+ health care issues would have been for the organization to institute mandatory cultural competence training annually for staff and providers on:

  • health disparities
  • terminology
  • implicit bias awareness
  • cultural competency skills 
  • perspective taking

Electronic Health Record Issues
When the electronic health record (EHR) incorrectly references a patient’s data, the patient is put in the position to correct health care providers during every single interaction. This occurred in the case study when the physician altered the medical record to reflect the patient’s sex assigned at birth rather than the sex listed on her insurance and legal documents. The patient was misgendered as “Mr.” during follow-up encounters and was forced to discuss her transgender status in each interaction until the record was corrected. 

Inconsistencies in how to include structured collection of sexual orientation and gender identity (SOGI) data within electronic health systems has led to transgender patient experiences rife with uncoordinated documentation and reiterative questioning. Accurately documenting both current gender identity and assigned sex at birth is critical to the support of clinical processes and understanding of a patient’s unique health needs.

There are some technological solutions to more accurately capture gender identity and sex assigned at birth in the EHR. In the case study, an IT workgroup identified a means to support a two-step process for capturing sex assigned at birth as well as current gender identity within the EHR. It also enabled printing of wristband labels with the name the patient uses and current gender identity. The IT workgroup standardized the interface display with inclusion of one’s legal name and name and pronouns used by the patient within the EHR. It also ensured this can be viewed throughout the EHR system, helping to minimize misgendering a patient and repeated questioning.

Let’s continue to leverage tools to encourage and support transgender patients in receiving safe and quality health care!


Christina Cordero, PhD, MPH, is a Project Director in the Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation, at The Joint Commission. She leads the development of new standards addressing health care equity and has supported past initiatives on patient-centered communication and The Joint Commission’s monograph “
Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals.”