June 14, 2022 5:00 AM

Putting gender inclusion into practice

7 ways providers can make health care more gender-affirming and reduce bias.

Four gender-diverse people sitting in chairs at doctor’s office in vibrant color against a background of grey, each wearing the colors of a gender identity pride flag. From left to right, the gender identity flags represented are; transgender, nonbinary, genderqueer and gender fluid.
Justine Ross, Michigan Medicine

Gender-affirming care is health care that respects and supports a patient’s gender identity, which may differ from the sex they were assigned at birth. While all major medical associations in the U.S. currently recognize this type of care as essential and lifesaving, many practicing clinicians, medical students and other health professionals lack any required training on how to practice it or why it is so crucial.

For people who are cisgender--meaning their gender identity aligns with the sex they were assigned at birth--the thought of having to prove their gender identity to a health care provider, or anyone, may seem ludicrous.

Yet, for people who identify as trans, nonbinary, genderqueer or gender-diverse, going to the doctor, or simply existing in the world, can create levels of anxiety and depression that cisgender people don’t have to contend with, like being misgendered, or not believed about their gender identity.

SEE ALSO: How Doctors Can Provide Better Care for Transgender Patients

What’s more, depending on where a trans, nonbinary or gender-diverse person lives, finding gender-affirming health care can be easy, with many informed and supportive providers, to near impossible, with care that is uninformed, unwelcoming or outright hostile.

And while the medical community continues to make strides to meet the needs of gender-diverse patients, many providers incorrectly believe that only those who specialize in gender medicine need to provide culturally competent gender-affirming care.

This is not the case. Clinicians can affirm a patient’s gender regardless of the type of care they provide.

Reducing implicit bias and disparities in health care

In 2019, some states began requiring medical professionals to take part in implicit bias training to gain or maintain their license to practice. In July of 2020, Michigan became the fourth state to require such training, based on a recommendation from the governor’s Coronavirus Task Force on Racial Disparities. Data showed that communities of color, particularly the Black community, were disproportionately impacted by the COVID-19 pandemic, an acute event that threw long-existing, severe health inequities into even more stark relief.

Implicit bias is defined as, “...an attitude or internalized stereotype that affects an individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic.”

Implicit bias can cause significant harm to patients, because it can inform everything from whether a provider believes a patient who says they are in pain, to underpinning historic racial bias in medical technology —determining the quality of care, or whether that patient receives proper care at all.

Implicit bias also impacts gender-affirming care. Research shows that when a person’s gender identity is not affirmed, it leads to higher rates of anxiety, depression and suicidality in trans, nonbinary, genderqueer and gender-diverse youth, adolescents and adults.

Here, several U-M experts discuss easy, actionable steps health care providers can take to make their practice a more gender-affirming space.

7 ways health providers can provide gender-affirming care

1. Use a person’s chosen or affirmed name and pronouns

How you address someone matters. It signifies respect, and for health care providers, it can be a deciding factor for whether a trans, nonbinary or gender-diverse patient feels safe coming to that provider’s office for care.

Daniel Shumer, M.D., clinical director of the Child and Adolescent Gender Clinic at C.S. Mott Children’s Hospital in the Department of Pediatric Endocrinology, notes that in national surveys of transgender people, many respond that they are afraid of going to the doctor out of fear that they’ll be misgendered or deadnamed (when someone refers to a trans, nonbinary, genderqueer or gender-diverse person with the name they had used prior to their affirmed or chosen name that was not aligned with their gender identity).

Said Shumer, “Just the simple act of addressing a person how they want to be addressed makes a huge difference in patients wanting to come back to your office.”

Language also matters, and it evolves over time. Lu Evergreen, a clinical social worker in the Comprehensive Gender Services Program at Michigan Medicine, who identifies as genderqueer, pointed to a crucial example.

“It’s best practice to not say ‘preferred’ pronouns, because it’s just someone’s pronouns, it’s how they see themselves. It can be very traumatic for people to be constantly misgendered.”

However, they point out that the opposite can also be true. When a person is properly gendered, it can be an immense source of joy, and relief.

SEE ALSO: Videos teach inclusion and caring for transgender patients

2. Center the visit around the whole patient, not just their gender identity

“There’s a misconception that only the people who are providing the hormones need to be trained in how to be gender-affirming, and the truth is that everyone needs to be able to do that,” said Alison Clinton, a social worker in the Child and Adolescent Gender Services clinic at C.S. Mott Children’s Hospital. If you were treating a trans person for a broken arm, you need to be able to be gender-affirming. If you are an OB-GYN, you need to be able to give a man a pap smear and be professional about it.”

Clinton also notes that it’s important for providers to remember that while gender-affirming care is critical, not every trans, nonbinary or gender-diverse patient is coming to the doctor’s office with a concern related to their gender identity. It’s essential that patients know “...that you are seeing them as a whole person, not just as their gender identity,” said Clinton.

Clinton notes that it’s important for providers to educate themselves on how hormone replacement therapy might interact with other types of medical treatments in order to provide the best care possible.

Additionally, it’s important to know that gender-affirming care is much more than hormone replacement therapy, and that every patient is unique. Not all people who seek gender-affirming care choose to undergo hormone therapy, and their journey is just as valid as someone who does.

Clinton says one of the most important things providers can do is to listen to their patients.

“Listening to people, trusting them when they tell you what their current concern is, trusting them when they tell you their medical history, trusting them when they tell you they’re trans. Everybody has an assigned sex and a gender identity, and it’s important to understand those things even for cis people.”

3. Be open to learning new things

Listening starts with asking a patient how they identify, but there are more resources available to learn about gender-affirming care than ever before, whether through continuing medical education (CME) courses, or local and online resources.

“You don’t need to be an endocrinologist to take care of transgender people, in fact, a lot of primary care doctors around the country are doing this work as well. The most important thing is wanting to.” said Shumer. “Just because working with trans folks wasn’t part of your training, doesn’t mean that it’s hard to learn.”

SEE ALSO: Bias May Affect Providers’ Knowledge of Transgender Health

The key, says Shumer, is the willingness to learn.

“Wanting to take the time to learn about gender medicine and take the time to listen to your patients and learn how to work with transgender people in a way where they feel heard and understood and also accepted in your office.”

"You don’t need to be an endocrinologist to take care of transgender people, in fact, a lot of primary care doctors around the country are doing this work as well. The most important thing is wanting to."
Daniel Shumer, M.D.
Clinical Director of the Child and Adolescent Gender Clinic

He encouraged providers to be open to the idea of “...expanding [your] medical knowledge so that not only are you a place that people with differences in gender identity aren’t afraid to go to, but that you’re a place that they want to go to.”

4. Normalize sharing pronouns and gender-diversity in your practice

In addition to using a patient’s pronouns and chosen or affirmed name, health care providers can do a few simple things to signal to gender-diverse patients and their loved ones that all gender identities are seen and valued in their practice.

Elizabeth Sandberg, M.D., a pediatric endocrinologist at C.S. Mott Children’s Hospital suggests a few easy ways to start:

  • Include gender options other than only female and male on paperwork, such as an “X” marker for nonbinary patients

  • Display gender pronouns on paperwork, including updating patient intake forms and medical charts

  • Have staff members wear their own gender pronouns

  • Ask patients their pronouns as a routine part of any visit

  • Use inclusive imagery on pamphlets and educational materials

  • Hang posters or other visual communications on the wall that let everyone know that your practice sees and values all gender identities

5. Check in with patients about gender identity as a routine part of patient visits

Sandberg is working to normalize discussing gender identity as she would any health screening question during a patient visit.

“Screening for this as a pediatrician - again, normalizing - we ask [adolescents] about sexual activity in adolescence in a private and protected way, should we also be asking about gender identity to normalize that there are going to be people whose gender identity may not match [the sex they were assigned at birth]. We want them to know that we are there and available if they have questions about that, because there’s not necessarily a clear sign that a kiddo is necessarily thinking about their gender until they tell you.”

She is also working to model this normalization of gender-affirming care in medical education. In addition to creating a curriculum for pediatric residents focused on incorporating gender-affirming care into every area of practice, Sandberg is working on developing a version of these guidelines that will be available for any provider to use as training.

Sandberg stresses the importance of having a full community of gender-affirming care providers for patients, “Our primary care doctors we really rely on heavily to identify and help get people the care that they need, and this really could be life-saving care.”

6. Get familiar with local and online resources

The good news is, for providers who want to make their practices more gender-inclusive and affirming spaces, the resources available to accomplish this only continue to grow.

In addition to several online resources listed below, many major medical centers have gender services programs. Shumer suggests local practices reach out to see if they provide staff trainings, and wants providers to know that there is more research being done in this field that can be a part of their continuing medical education. In Michigan, as availability allows, local providers can contact the Pediatric Gender Services Clinic at C.S. Mott Children’s Hospital, or the Comprehensive Gender Services Program focused on adult care, for guidance.

Shumer also stresses the importance of cultivating relationships with local gender services programs so that providers can send patients to specialists when those needs arise.

“The goal is not to convince everyone to make gender medicine the primary focus of their career, but the goal is to make everyone competent enough that [they’re] treating patients with respect, and also that [they’re] aware of what the medical options are out there for them and can make appropriate referrals as needed.”

7. Beware of misinformation

While patient care for trans, nonbinary and gender-diverse people is improving in some parts of the country, severe health inequities remain, and in some states, gender-affirming care is actively being criminalized. The current landscape of gender-affirming care in America, with many patients having experienced mistreatment, or disrespect, coupled with historical inadequacies in meeting the needs of these patient populations, has led many people to distrust the medical community.

For health care providers, it is crucial that they be able to distinguish fact from fiction, as misinformation and disinformation can have devastating effects for patients.

Clinton says one thing providers who don’t specialize in gender-affirming care can do to nurture trust with their patients is to be upfront if they don’t have an answer to a question.

“Having the humility to say I’m not sure, let me look this up, instead of giving people misinformation,” said Clinton.

Now more than ever, say experts, clinical practice needs more trans, nonbinary and gender-diverse representation as well as more dedicated people willing to specialize in gender-affirming care.

Gender-affirming care treatment guideline resources for providers: