Volume 36 Number 1 | February 2022

Patient Safety Corner

Courtney Shrader, MSHS, MLS(ASCP)CM, CPHQ, ASCLS Patient Safety Committee (she/her)

Katrina Moreau, MAT, MLS(ASCP)CM, ASCLS Patient Safety Committee (she/her)

Courtney Shrader   Katrina Moreau
Patient Perspective

“He [physician] had looked at my results for my labs, which were for my testosterone levels, and only mentioned high cholesterol and high blood sugar. I was not told about my testosterone levels and what to do about them—if they were high or low. When I had confronted him about this issue, he had said my levels were high. After discussing those results with my current doctor, she had said my level was low in fact, and that the chart was being measured for female levels, but due to my transition, I needed to be at the male level.”

– Quote from a Transgender Patient

The transgender population in the United States has been increasing, according to one survey of students in 9-12th grade; 2.7 percent identified as gender non-conforming1. Another study by Nolan illustrated that 18–24-year-olds currently comprise the largest age group2, and the Williams Institute 2020 data shows the LGBT population in the United States is 4.5 percent3. Laboratory professionals have a duty to patients and society to break down barriers to services and ensure patients are receiving high quality care4.

Breaking Down Barriers

Barriers, such as prohibitive public and private insurance coverage for gender transitioning services, lack of identity fields in medical software, limited availability of healthcare professionals experienced in working with sexual and gender minorities (SGM), and historical and current transgender stigmas, all contribute to furthering the health inequities experienced by this population5. For example, many electronic health records and laboratory information systems do not yet allow for recording of assigned sex at birth, gender identity, and preferred pronouns6.

“One immediate way to make a positive impact on patient care is to become an ally and express humility and sensitivity when addressing patients using pronouns.”

One immediate way to make a positive impact on patient care is to become an ally and express humility and sensitivity when addressing patients using pronouns. It is problematic for phlebotomy services if EMRs do not include gender information5. Within the laboratory, more work needs to be done to set appropriate reference ranges for tests, such as hemoglobin, hematocrit, hormones, and creatinine for the trans population. Clinical research is essential in understanding how cross-hormone therapies impact these values and how the best practice of using local populations can be mitigated when there is a small sample size6,7. Lastly, within the field of transfusion medicine, questions on sexual and gender identity may impact the ability for trans persons to donate blood and receive appropriate transfusions. For example, trans men who have retained their reproductive organs may be incorrectly transfused with Rh-positive blood8.

Provide an Affirmative Experience

“Fifty percent of transgender people reported they felt the need to teach their doctors about transgender care”9. Lack of knowledge and information around transgender health has led to discrimination toward transgender patients10. Every healthcare professional plays a vital role in creating an affirming and inclusive experience for the transgender patient11. It is important that healthcare organizations provide training and create policies around creating an inclusive and safe environment for transgender patients12.

Here are ways to provide an affirmative experience for transgender patients.

  1. Organizational leadership is actively engaged in creating an inclusive environment and writes policies to protect LGBTQIA+ patients12.
  2. Physical environment is welcoming to LGBTQIA+ people12.
  3. Patient forms reflect LGBTQIA+ people and their relationships and the information is entered into the electronic health record, so all providers and staff have access to the information9,12.
  4. Avoid using gender terms when talking to new patients until gender is known9.
  5. Ask patients how they would like to be addressed9.
  6. Assure that all staff and providers receive education and training on affirmative communication and care12.
  7. “All patients should receive routine and inclusive sexual health history”12.
  8. Recruit and retain LGBTQIA+ healthcare professionals12.

It is important that healthcare professionals are educated on transgender terminology. Here is a list of terminology with their corresponding definitions.

Term
Definition

Cisgender

Gender congruent (same sex assigned as birth)6

Gender

A social construct used to classify a person as a man, woman, or some other identity. May differ from the sex one is assigned at birth6.

Gender Expression

Expression of one’s experienced gender by means of clothing, mannerism, behavior, hairstyle, etc6.

Gender Identity

Self-identification and experience as a gendered being. May or may not be the same as sex assigned at birth6.

Gender Non-Conforming

Behavioral variation in gender expression from the expected cultural and societal norms for that gender6.

Sex (Anatomical/Biological)

Assignment as male, female, or intersex based on external anatomy at birth, chromosomes, organs, and/or hormones6.

Sexual Orientation

Defines an individual’s physical and emotional attraction to persons of a particular gender6.

Transgender

Gender incongruent (different from sex assigned at birth)6.

Transman (female to male)

A person assigned female at birth who identifies as male6.

Transwoman (male to female)

A person assigned male at birth who identifies as female6.

Non-Binary

Umbrella term describing someone who does not ascribe to one of the binary genders (man/women). May identify as both genders, neither gender, or a combination of male and female genders. Specific terms may include genderqueer, agender, bigender, genderfluid, etc6.

Call to Action

Advocate for professional development and continued research to support the clinical laboratory and provide affirmative experience for the safety and health of all patients. As a healthcare professional says, “Working in transgender healthcare has proven to be one of the most challenging yet rewarding fields of my career. I witness firsthand the constant fight it is to access healthcare in America. What I can say though, is there has been progress and a shift to prioritize healthcare and education. Knowing this, I want to spread a message of hope. I’m inspired by our progress, and I have no doubt that we are moving forward. Now more than ever I’m dedicated to making lasting foundational changes that will normalize transgender health.”

References
  1. Rider, G. N., McMorris, B. J., Gower, A. L., Coleman, E., & Eisenberg, M. E. (2018). Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics, 141(3), e20171683.
  2. Nolan, I., Kuhner, C., & Dy, G. (2019). Demographic and temporal trends in transgender identities and gender confirming surgery. Translational Andrology and Urology, 8(3), 184-190.
  3. UCLA School of Law Williams Institute. (2020) https://williamsinstitute.law.ucla.edu/quick-facts/us-state-data/
  4. American Society of Clinical Laboratory Science. (2021). Code of Ethics. Retrieved from ASCLS: https://ascls.org/code-of-ethics/
  5. Goldstein, Z., Corneil, T., & Greene, D. (2017). When Gender Identity Doesn’t Equal Sex Recorded at Birth: The Role of the Laboratory in Providing Effective Healthcare to the Transgender Community. Clinical Chemistry (Baltimore, Md.), 63(8), 1342-1352.
  6. Gupta, S., Imborek, K., & Krasowski, M. (2016). Challenges in Transgender Healthcare: The Pathology Perspective. Laboratory Medicine, 47(3), 180-188.
  7. Humble, R., & Krasowski, M. (2018). 20 Reevaluating Reference Intervals in Laboratory Testing for Transgender Patients. American Journal of Clinical Pathology, 149(Suppl_1), S174.
  8. Mays, J. A., Greene, D. N., Metcalf, R. A., & Pagano, M. B. (2018). Transfusion support for transgender men of childbearing age. Transfusion, 58(3), 823–825.
  9. Centers for Disease Control and Prevention. (2020, April 1). Patient-Centered Care for Transgender People: Recommended Practices for Health Care Settings. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hiv/clinicians/transforming-health/health-care-providers/affirmative-care.html#understanding
  10. Roberts, T. K., & Fantz, C. R. (2014). Barriers to quality health care for the transgender population. Clinical Biochemistry, 983–987.
  11. LGBTQIA+ Health Education Center. (2016, November 15). Providing Affirmative Care for Patients with Non-binary Gender Identities. Retrieved from LGBTQIA+ Health Education Center: A Program of the Fenway Institute: https://www.lgbtqiahealtheducation.org/publication/providing-affirmative-care-patients-non-binary-gender-identities/
  12. LGBTQIA+ Health Education Center. (2021, April). 10 Strategies for Creating an Inclusive Health Care Environment for LGBTQIA+ People. Retrieved from LGBTQIA+ Health Education Center: A Program of the Fenway Institute: https://www.lgbtqiahealtheducation.org/wp-content/uploads/2021/05/Ten-Strategies-for-Creating-Inclusive-Health-Care-Environments-for-LGBTQIA-People-Brief.pdf

Courtney Shrader is a Clinical Laboratory Quality Assurance Specialist for Exact Sciences Laboratories in Madison, Wisconsin. She is a member of the ASCLS Patient Safety Committee and has a passion for making health care more efficient and safer for patients and healthcare professionals.

Kate Moreau is a Clinical Assistant Professor at the University of Vermont (UVM) and is the Program Director for Medical Laboratory Sciences. She also serves as the Laboratory Manager and CLIA Director at the Community Health Centers of Burlington (FQHC). Her areas of interest are workforce development, community partnerships, point-of-care testing, and population health.