Diversity in EMS: Better Communication With Transgender and Nonbinary Patients

Diversity in EMS is a new bimonthly column in which rotating authors will confront difficult questions of bias and discrimination in the emergency medical services and how agencies can lead change in their communities.

Hey, baby, what’s goin’ on?” is one of the typical icebreaker lines you might hear on scene when approaching a patient in New Orleans. Working in EMS in New Orleans gives us a bit of an advantage when addressing people because terms of endearment are often better received than honorifics like Mr. and Mrs. or sir and ma’am, which make assumptions about the patient’s gender. 

Helping transgender patients feel safe and comfortable can be as simple as acknowledging their name and using their correct pronouns. It all begins with simple questions: “What is your name?” and “What are your pronouns?” These are great ways to let your patient know you are there to care for them and that you see them. 

The diversity and equity advocates at New Orleans EMS have put together some tips and information we find beneficial when it comes to interactions with our transgender and nonbinary patients. Even though it is not always possible to correctly identify someone’s gender by sight, it is important we use patients’ preferred names and pronouns that match their gender identity. When in doubt, ask. 

Ask, Don't Assume

People who identify as transgender or nonbinary may have anatomy that does not correspond with their gender identity or sex assigned at birth. It is important that providers ask patients about their gender identity and sex assigned at birth to determine what kind of care is needed. A transfeminine person (someone assigned male at birth but who identifies with a feminine identity) may not be offered access to prostate cancer screening. In the EMS setting we might fail to consider a ruptured ectopic pregnancy, ovarian torsion, or pelvic inflammatory disease if we don’t consider that a masculine-appearing patient before us may have ovaries and a uterus. Similarly, patients taking estrogen for gender affirmation pharmacotherapy are at heightened risk for stroke and pulmonary embolism, which may be lower on our differentials in patients we perceive to have fewer risk factors for these conditions. 

Many studies have identified that transgender patients are frequently misgendered in acute healthcare settings, and we fail our patients when they don’t feel safe to reveal a piece of their medical history that could impact their care. It is imperative as providers that we understand and properly address our patients to provide the best possible medical care. 

To better serve our patients, New Orleans EMS changed our electronic medical record fields to include places to record preferred name, gender identity, sex assigned at birth, and pronouns. 

Assuming gender identity based on outward physical appearance can be a major pitfall. Transgender and nonbinary patients with limited financial resources or housing and food insecurity may not have access to gender-affirming medical and surgical treatments or other resources. This can translate into an outward appearance that does not match how they see themselves. It is important to ask about their name and pronouns because many transgender patients may not feel comfortable speaking up once they have been misgendered during the patient encounter.

In a recent patient encounter with an unhoused transgender woman, one of our EMS crews was not able to determine the patient’s gender identity based on her physical appearance. It wasn’t until the team asked for the patient’s name and pronouns that the patient opened up and started talking to them. This improved the communication between the patient and the providers, and the patient repeatedly thanked the EMS crew for its consideration. It is important to pass this information on to the receiving hospital so the patient is not repeatedly misgendered. 

The Value of Trust

Transgender and nonbinary people are more likely to get the care they need when they feel they are with a provider they can trust. One study of transgender people found 33% had postponed preventive care and 28% had delayed necessary medical care when sick or injured. Providing care to transgender and nonbinary patients includes creating a safe and comfortable environment for patients to disclose their gender identity. 

Misgendering contributes to gender dysphoria, a major cause of suicide in the transgender community. If you are having trouble identifying the patient’s pronouns, it is OK to ask. Take note of how their friends and family refer to them. Utilize the same pronouns the patient’s loved ones use for them. Mistakes also happen. If you misgender someone, acknowledge the mistake, apologize, and move on using the correct name and pronouns. Continuing to focus on the mistake can distract from patient care and negatively affect developing a rapport with the patient.

To provide excellent care to our transgender and nonbinary patients, we need to make every effort to create a comfortable environment. Part of that is building a rapport and asking the right questions. Showing the patient you see them is a small yet critical step in improving their care.  

Sidebar: Key Terms to Know

• Pronouns are used in place of a proper noun such as someone’s name. He/him and she/her are commonly used, but there are others people may choose. Gender-neutral pronouns include but are not limited to they/them, xe/xem, and ze/zem. 
• Sex is a label—male, female, or intersex—assigned by a doctor based on the anatomic presentation of external genitalia at birth. It does not necessarily match someone’s gender or gender identity.
• Gender is complex. It encapsulates social and legal status as well as expectations from society about behaviors, characteristics, and thoughts. 
• Gender identity is the internal perception of one’s gender and how they label themselves. 
• Cisgender applies to someone whose gender matches their assigned sex at birth. 
• Transgender applies to a person whose gender is different from their assigned sex at birth. 
• Transmasculine describes a person who was assigned female sex at birth but who identifies 
• with masculinity. 
• Transfeminine describes a person who was assigned male sex at birth but who identifies 
• with femininity. 
• Two-spirit describes a person who embodies both masculine and feminine spirits. This is a culture-specific term used in Native American cultures. 
• Nonbinary is a spectrum of gender identities that are not exclusively masculine or feminine and are outside the gender binary of male and female. 
• Genderqueer people, similar to nonbinary, may feel they move between genders or have a fluctuating gender identity. 
• Genderfluid applies to a person who does not identify as having a set gender.
• Misgendering is to use the wrong pronouns or other gender-specific words when referring to or speaking to someone, especially a transgender person. 

Resources

National LGBTQIA+ Health Education Center. LGBTQIA+ Glossary of Terms for Health Care Teams, www.lgbtqiahealtheducation.org/publication/lgbtqia-glossary-of-terms-for-health-care-teams/. 

National LGBTQIA+ Health Education Center. Providing Affirmative Care for Patients With Non-Binary Gender Identities, www.lgbtqiahealtheducation.org/wp-content/uploads/2017/02/Providing-Affirmative-Care-for-People-with-Non-Binary-Gender-Identities.pdf. 

Meg Marino, MD, FAAP, is deputy medical director for New Orleans EMS, director of pediatric prehospital education for Ochsner Health, and a pediatric emergency medicine physician. Marino has a strong interest in provider wellness and leads the Diversity and Equity Council at New Orleans EMS to improve access to care for marginalized communities and promote diversity in EMS. 

Liliana Varela, NREMT, has been an EMT for eight years. She is a diversity and equity advocate for New Orleans EMS, where she is proud to serve her hometown. 

Kasha Bornstein, MD, MPH, EMT-P, is an intern at the Louisiana State University combined internal medicine/emergency medicine program. Prior to medical school Bornstein worked as a street crew paramedic with New Orleans EMS and a prehospital emergency medicine educator, focusing on integration of social determinants of health in acute care settings.