A routine visit with a transgender patient

“Hey, Rick. They warned you about me, I hope?”

My routine med student opening line elicits a slight smile from my balding forty-two-year-old patient and the patient’s wife. As we shake hands, I continue the script.

“I’m Nat — the medical student. What brings you in today?”

“Well, I’d like to transfer my care to this clinic. We’ve brought my medical records.”

Together, they heave stacks of papers onto the desk. Rick’s hands slide back into the pockets of well-worn work jeans.

“Can you tell me a bit about yourself?” Classic open-ended question.

“Well, I’ve been seeing specialists for years about my headaches. That explains most of the paperwork. High blood pressure and high cholesterol. Plus my family has a bunch of cancers.”

“And what pronouns do you prefer?” Here’s where the script deviates from the medical school boilerplate.

“He/him for now, I guess. I wrote ‘male-to-female’ on the intake form, but I’m not really thinking about that part of my life much until I get this pain under control.”

“We do use she/her at home, though,” says Rick’s wife, obvious affection in her voice. She is a blond woman in her mid-thirties; her warm expression and personality make the room feel less clinical. “But no rush. Whenever he’s ready. I just want Rick to feel supported. We’ve struggled to get him good health care for years, and now that we’re married, we’re looking for a better care environment. And that’s why we came to this clinic — we’ve heard that you are extremely supportive in your care of transgender folks.”

“I’m almost ready to start hormones, I think,” Rick says. “But I want to wait on surgery for a while. It’s just a lot at once, when all you can think about is how much your head hurts.”

The rest of Rick’s appointment is, for the most part, a straightforward family medicine interaction. And yet I know that it’s one that wouldn’t have been possible without a basic understanding of and comfort with this vital part of Rick’s life and experience as a patient.

***

My interest in transgender health care started with one of the first lectures I heard in medical school, in which a panel of transgender patients and advocates answered questions and told stories of transgender health care done right and done wrong. The stories that stuck with me were of care gone wrong: providers insisting on specific pronouns or names despite patients’ requests that they do otherwise, patients being angrily refused care, kicked out of practices or made to feel profoundly unwelcome in the waiting room.

Before my monthlong rotation at this Midwestern family medicine clinic, I’d had only had a handful of experiences with transgender patients. But this clinic belongs to one of the region’s largest transgender healthcare providers, and my exposure to the population has exploded. Suddenly, I’m meeting people from all across the transgender spectrum, including other healthcare workers, happily married couples, elderly patients, and teenagers who come to their appointments alone or accompanied by supportive parents.

A great example of the complexity of these patients’ lives would be Rhonda, a sixty-year-old male-to-female patient who asked if she could bring her elderly mother, Darlene, to her appointment. “I need to show her that this transgender thing is real, and that I’m not just making it all up.”

I was lucky enough to be present at this visit, in which Rhonda’s primary care doctor (one of my preceptors) sat with Rhonda, her mother, and her daughter to discuss the medical and social realities of transitioning.

During the session, Darlene made comments that, though candid, were also clearly hurtful. Each time, my preceptor would diffuse the potentially inflammatory moment with a calm, tactful response. Her answers conveyed some very helpful information — and, even more importantly, her overwhelming support for her patient.

“Well, he’s been talking about this cross-dressing thing for years,” Darlene started, “but I can’t believe that you all are buying it.”

“Actually, ma’am, I have several patients in Rhonda’s situation,” my preceptor replied. “It’s not the same as cross-dressing, which is simply wearing the clothing of the opposite gender. Transgender folks often describe their experience as an ongoing awareness that the gender they identify with does not match their physical body.”

“So then you just give him surgery?”

“Rather than jumping straight to surgery, we start with comprehensive therapy to help patients process their experience. Then, if they’re interested, we can begin management to help their physical body match the way they feel, using medications and eventually surgery in some cases. But often one of the most important steps is the validation they get when their friends and family call them by their preferred names and gender pronouns.”

As my preceptor steadfastly modeled the conversational ground rules (keeping a respectful tone, using Rhonda’s preferred name and pronouns), Darlene slowly seemed to realize that this was a true medical appointment for a legitimate health concern. Her tone changed from one of scorn to one of interest, and I felt the tension in the room ease.

For myself, I deeply appreciated my preceptor’s tact and skill — because, for me, finding the right words had been the toughest part of this rotation.

At the beginning, getting through even the most straightforward appointment felt like doing a delicate dance: I struggled to strike a balance between saying too little, which might make the patients feel like I was treating them differently from my “usual” patients, and saying the wrong thing, which might alienate them or make them feel uncomfortable. Misplacing a pronoun or anatomical term (surprisingly easy when you’re using gender-specific note templates to discuss periods, Pap smears and prostates) seemed inevitable. I constantly evaluated every phrase, every pronoun, knowing that each one could either build up or damage our relationship.

Despite my hesitant uncertainty, my patients were graciously understanding of my verbal missteps — particularly if I caught them, apologized and moved on right away. Over time, as I watched my preceptors do the same, the sense of constant risk began to recede, and I relaxed.

Thanks to my patients’ willingness to open up and discuss their transition experience with me, our interactions have become less about finding the perfect words and more about providing the right care. As my anxiety has dissipated, it has felt easier to ask the right questions, to make the right jokes, to create the feeling of an everyday clinic appointment for my patients while also appreciating the uniqueness of their situation.

***

While they’re getting ready to leave, Rick’s wife says, “I was so happy when I saw your gender-neutral bathrooms and that male/female/other option on your intake sheet. We’ve been filling out so many binary forms since we got married last month — it’s all male or female — so it’s nice to feel accepted the minute you walk in the door. As if you see patients like us all the time.”

Her words are encouraging; that’s exactly how we want them to feel. As we say goodbye, I reflect that, often, a routine visit can be the best care of all.

Nat Fondell is a medical student. This piece was originally published in Pulse — voices from the heart of medicine

Image credit: Shutterstock.com

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