By Jeanie Davis

Transgender people are becoming more open, and case managers are likely to work with patients who openly identify as transgender, explains Michael B. Garrett, MS, CCM, CVE, NCP, BCPA, principal with global consulting firm Mercer. “All healthcare providers should understand the terminology and how to communicate with a transgender person to establish trust,” he says.

Transgender individuals are legally protected in obtaining healthcare, including transition-related care. Healthcare providers are required to treat these individuals with respect, including using their chosen gender identity. That protection exists because gender dysphoria, a behavioral health diagnosis that may be used with transgender individuals, is covered by the Mental Health Parity Act. In addition, a healthcare professional likely uses a code of ethics requiring non-discrimination based on gender identity.

That means doctors, hospitals, and insurance companies cannot discriminate against transgender patients. Some programs, like Medicare, have been slow in offering coverage, but that has changed. The Veterans Health Administration and some insurance carriers may cover some transition-related care expenses, and patients are advised to understand their coverage.

On the hospital floor, case managers must make it their mission to understand the communication nuances regarding transgender patients. “Some settings, especially academic settings, are more tuned to this,” says Garrett.

Transgender people may receive healthcare services during their transition process (such as surgical procedures), yet some individuals may not undergo any surgeries or other procedures. Transgender individuals also may be admitted to hospitals for many reasons, including diabetes, cardiovascular disease, or other health issues not necessarily related to their transgender status or a transition process, Garrett explains.

“Not every transgender person will have surgery or hormones; they may just choose to dress and express as their identifying gender,” he says. “Others may choose top and bottom surgery, more typical of transgender women. For transgender men, breast reduction is typical but not bottom surgery because it’s not as effective.”

The transgender person undergoes a process of self-awareness and confirmation of gender identity before hormones and/or surgical procedures are considered, he says. This may involve counseling or psychotherapy to assist in that process.

Healthcare professionals should be aware of this process and how to communicate respectfully. “Being transgender is very different from being gay or lesbian,” says Garrett. “When you are transgender, there is a discrepancy between the gender assigned at birth and the gender the person identifies with and how they express themselves, rather than who they are attracted to.”

Do Not Make Assumptions

Also, hospital staff should not jump to conclusions about anyone who chooses to dress in a style that does not conform, he adds. “Just because a woman dresses like a man, or a man dresses like a woman, doesn’t always mean they are transgender,” Garrett explains. “The person may choose to dress as a woman but their voice is low, and there is facial hair, yet they may not identify as transgender, as incongruous as that may seem. Don’t assume anything.”

Some hospitals have offer development programs to acquaint staff with best practices in transgender communication. “Nurses, aides, pharmacists, every healthcare provider should be careful to use the correct pronoun, which indicates their gender identify,” Garrett explains. “Gender should not be assumed. Case managers and others should ask about the identified gender identity and the preferred pronoun use. This could be male, female, gender non-binary, or some other gender identity.”

Garrett provides a checklist for case managers in treating transgender patients:

• Confirm gender dysphoria (distress regarding gender identity and gender role);

• Provide information regarding options for gender identity and expression;

• Assess and discuss treatment options for coexisting mental health concerns;

• Assess eligibility, prepare, and refer for hormone therapy, if applicable;

• Assess eligibility, prepare, and refer for surgery, if applicable;

• Educate and advocate on behalf of patients within the community;

• Assist patients with social determinants of health in preparing a discharge plan.

In discharge planning, Garrett advises screening the transgender patient for depression and anxiety, as these patients are at higher risk. Consider their living environment and financial status as well. “If the transgender patient is young, they may have been rejected by family so they don’t live in a stable household,” he says.

In addition, the transgender patient should be screened for social determinants of health, such as finances (e.g., affording medication), access to transportation, and availability of food. There also may be challenges in accessing healthcare services that specialize in treating transgender patients. “All this needs to be checked out and addressed on the front end to avoid readmission,” Garrett advises. Alcohol and tobacco use also is high among transgender people, he adds.

Nearly three-quarters of transgender patients have experienced some discrimination in healthcare, says Garrett. “The patient may be refused necessary care, or the providers refuse to touch the patient or they use excessive precautions,” he explains. “There may have been verbal or physical abuse from providers. They may be blamed for their health status.”

An estimated 20% of transgender women (male to female) are HIV-positive, he adds.

Transgender people likely have faced negative reactions elsewhere, including employment. “They’re not allowed to dress in their identifying gender, not allowed to use their pronoun of choice,” he says. “In some settings, there’s a complete lack of knowledge about the needs of transgender people. It’s especially difficult if they’re going through transition, as they will change name, gender, bathroom use. Hospitals tend to have gender-neutral bathrooms, so that’s not as much of an issue.”

There is a high risk of incarceration among transgender people because they often have trouble getting regular employment due to discrimination, Garrett adds. There can be altercations triggered by their gender identification. Domestic violence may occur with family members or a partner. In too many cases, Garrett says, transgender people are the victims of homicide. There also is a high rate of suicide attempts (41%).

For case managers and healthcare providers, becoming attuned to trans issues is a process, Garrett explains. “Always ask when you’re not sure,” he says. “It’s better to be empathetic rather than assume. It starts with basics in terminology; that’s the crux of it. You can establish trust with transgender-friendly language.”