An expert in LGBTQ+ medicine coached delegates at ACR Convergence on how and when to ask questions about gender-affirming hormones and surgeries.
Asking patients deeply personal questions has always been a part of taking medical history.
Although the wider social conversation around sexuality and gender identity has grown in recent years, there’s still a sense of awkwardness around asking patients their pronouns and whether they identify with the gender assigned at their birth.
“If I show up to your office, most of you may not have any idea that I was assigned female at birth,” Yale school of nursing LGBTQ learning director Nathan Levitt said at the American College of Rheumatology Convergence in Philadelphia last week.
“You may not ever offer me a pregnancy test if I’m going into surgery, and that’s something applicable to me.
“You may not know how to interpret my labs that come out as male-defined labs if you don’t know the anatomy that I have.”
Mr Levitt, a nurse practitioner, warned rheumatologists that even if they were personally an accepting, sensitive and informed clinician, many trans patients have already experienced discrimination in medical settings.
This can put them off presenting for routine primary care testing – especially for gendered tests like prostate or cervical cancer screening – and they may live with more chronic health issues.
In turn, transgender patients may be wary of invasive questions about their medical history.
“When I came in for a cough [one time], I was asked if I had a penis or vagina,” Mr Levitt said.
“I have yet to understand the connection between the cough and the genitalia … that was really just curiosity.”
A better approach, he said, is to directly relate a question back to its medical context.
It’s valid, for instance, to ask about a patient’s transgender status in order to ascertain whether they can get pregnant before starting them on biologics or methotrexate.
“Make sure the patient understands that you’re not just curious, you have a real clinical reason for the questions you ask,” Mr Levitt said.
He also had advice for providers who might feel awkward about asking patients, especially cisgender-presenting patients, about their gender identity.
“It’s not at all the same, but there’s been a lot of work for us as clinicians to ask about intimate partner violence,” he said.
“Asking about domestic violence is one of those things that feels challenging, but we’ve all learned how to do it because we recognise it’s important.”
For patients who do react negatively to the question, it may help to reiterate that it’s asked of every person.
Patients who are transgender and have undergone masculinising or feminising hormone therapy will also likely have anomalous results on tests with different male or female baselines.
At present, the recommended reference range for interpreting test results is the patient’s affirmed gender, unless the test is organ-size dependent, like PSA or high-sensitivity cardiac troponin tests.
There is also preliminary research into the prevalence of certain rheumatic diseases in transgender populations.
“Studies evaluating fibromyalgia symptoms in trans patients … found that it did send seem to be more prevalent among trans men and not trans women,” Mr Levitt said.
Mr Levitt also relayed the story of a trans man whose doctors had noticed elevated markers in his blood test when he went in for top surgery (mastectomy).
This triggered a series of investigations that led to him being diagnosed with mixed connective tissue disease, a rare autoimmune disorder.
ACR Convergence was held in-person and virtually from 10-14 November.
