When it comes to health care, transphobia persists

Gwen Benaway’s third collection of poetry, Holy Wild, will be published in October.

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It’s 9 a.m. on a Friday morning. I’ve spent the night vomiting and in extreme pain. I have Crohn’s disease, but I don’t know if it is causing my symptoms. Debilitated from dehydration and a low-grade fever, I’m lying on an ambulance stretcher in the ER department of a major downtown hospital. I’m barely able to communicate or think coherently. The paramedics are talking with the intake nurse on my behalf. I’m a 30-year-old transgender woman, but being trans is the last thing on my mind.

Until I hear the intake nurse refer to me as “he” and “him.” She is debating my gender with the paramedics, despite the health card in her hand, which clearly states my legal name, and the medical information on her screen, which identifies my legal gender as female. She refuses to believe that my health card is valid. I’m still vomiting, but she interrupts me to interrogate me.

“How do you have this card?” She stands over me and glares. “Which way are you going? Male to female or female to male?”

I’m not coherent enough to answer her, so she returns to her computer. She types away and then makes a triumphant “ha!” She’s searched the medical information in the hospital database to find my former name. I haven’t been called by my former name in more than two years, but she starts using it immediately with the paramedics and other nurses. Satisfied that she’s located my “real” name and gender, she begins to fill out the medical information required to triage me.

The paramedics explain my symptoms and vitals. As soon as they tell her that I had gender-confirmation surgery 3 months ago, she starts laughing.

“Did you take a peek at it?” she teases one of the male paramedics. “Might be your only chance to see something like that.” She glances over at me and rolls her eyes. “I’m sure it doesn’t look anything like the real thing.”

The paramedic laughs it off, but I can tell he’s uncomfortable. The intake nurse doesn’t stop her mockery, teasing him: “You’re into freaky stuff, aren’t you?”

I’m horrified to think that another woman is encouraging two male paramedics to look at my vagina for entertainment while I’m incredibly vulnerable, but it’s happening right in front of me. If I was more coherent or in less pain, I’d say something, but I know I need to see a doctor and I don’t want to jeopardize my medical care.

My experience is not unique. The Trans Pulse study, conducted in 2010, investigated the health and well-being of trans people in Ontario. The study revealed that we face significant barriers in accessing health care, from discrimination to lack of basic medical knowledge of trans health. The survey found that 21 per cent of trans patients avoid accessing emergency medical services because of a fear of transphobia and 52 per cent of survey respondents indicated they had negative experiences in emergency rooms related to transphobia.

I suppose I should have predicted that transphobia would follow me into every aspect of my life, but I naively assumed that having the correct name and gender on my health card would protect me. I always debate disclosing that I’m trans to medical staff, but my daily hormone treatments are an important part of my medical history. I don’t want to lie about who I am in order to access health care. It’s clear to me that being a trans woman in a hospital is dangerous, a violent collusion of prejudice, ignorance and vulnerability.

Despite improvements in trans rights and visibility, many people, including medical staff, still know little about our lives and have internalized many transphobic messages about our bodies. Increased training and awareness may help change that reality, but right now, I’m in need of urgent care and unable to advocate for myself. Fortunately, I’m tougher than I look. I try to let the transphobia wash over me and conserve for my energy for more important fights, but it scares me and I feel even more vulnerable than I already am.

My mind races with questions that I don’t have answers for. What if something is seriously wrong with me and no one will listen to me because I’m a trans woman? Is there someone I should call to be with me? I’ve texted my partner and let him know that I’m in the hospital, but should I ask him to cancel his meetings to make sure that I’m treated? If I complain, will my life be in danger?

I shouldn’t have to listen to a medical professional encourage her male colleagues to molest me sexually in order to access medical care, but the sharp pain inside my stomach tells me that I don’t have a choice.

***

After I’m processed, I’m wheeled away into a room for examination. Everyone – from the nurses to the doctors – uses the wrong pronouns to refer to me. A male nurse helps me change into a gown. My breasts and vagina are briefly exposed to an entire hallway. The doctor who eventually sees me refers to my vagina as a “surgical site,” refusing to examine it even though it’s possible that my symptoms are related to my recent surgery.

I’m sent for diagnostic imaging. The report back determines that there may be a significant Crohn’s complication occurring, but also highlights my vagina as an “unknown.”

The doctor returns and asks me about my vagina.

“What is this?” He shows me the imaging and circles the area around my vagina.

“My vagina?” I answer him back, incredulous that we’re having this conversation. He nods at me and then traces another small line on the image.

“And this?” His tone implies that he’s staring at an alien autopsy report.

“I think it’s from the surgical drainage tube, but I don’t know.” I’m clearly not a surgeon nor am I equipped to answer any of his questions.

“Okay. Well, that’s something.” He walks out of the room and doesn’t return for several hours. They put me on a strong pain medication and anti-nausea medication. When I stop vomiting, they discharge me with instructions to follow up with my family doctor. Fewer than 5 hours later, I start vomiting again.

I try a different emergency room at a downtown hospital known for treating Toronto’s LGBTQ community and its more marginalized communities. I’m not misgendered this time, but I am treated with a disdain that shocks me. I’m grilled by the physicians, who ask if I’m a sex worker or addicted to drugs. They ask me repeatedly, even though I answer “no” every time. I’m not sure what the medical purpose of these questions are, but they seem to matter a great deal to the medical team.

The primary emergency room physician, a hyper masculine man with a US Marine Corps lanyard, comes into the room I’m waiting in. “Are you addicted to street drugs? Doing sex work?” he asks. I answer no to both questions for what feels like the hundredth time. I’m infuriated by the implication that he wouldn’t treat someone who was a sex worker or had an addiction.

He becomes more aggressive with me. “Well, you say that you’ve been vomiting, but we haven’t seen any evidence of that.” There is a vomit-filled basin sitting on a table beside him. I’m about to point it out to him when another cramp passes through my body and I vomit again. I watch his face harden as I puke, as if my continued symptoms are a personal insult to him.

He switches tactics. “I can discharge you with a prescription for Dilaudid.” It’s a powerful opioid painkiller, but I know that it will not stop my symptoms. If there is something seriously wrong with me, an opioid will just mask the complications until it’s too late to intervene.

“I don’t want drugs. I want to be helped.” My response doesn’t make him happy. He walks out and sends in a nurse who continues to try and push a Dilaudid prescription on me. I get the impression that this is a familiar tactic for emergency room patients that they don’t want to treat, using opioids as a bribe to get people out of the hospital and back onto the streets.

I don’t want an opioid prescription. I want to be properly assessed and treated because I’m growing increasingly weak and ill. They refuse to do any diagnostic tests or treat my pain. Eventually, after spending the night continuously vomiting, I’m discharged again.

***

Research continues to show that trans people face enormous barriers in health care. For example, the 2011 US National Transgender Discrimination Survey found that 19 per cent of trans respondents had been refused medical care and 50 per cent of trans respondents were required to educate medical staff on transgender-specific health needs.

Another trans woman I spoke to said she had the same experience of misgendering and poor treatment at the first hospital I visited. The nurses continually called her by male pronouns despite also having her legal name and gender on her health card. I’m not surprised by her experiences.

As the annual Canadian Community Health Survey continues to demonstrate, many people face discrimination and inequality in health care, especially visibly Indigenous and black people, and people from other racialized communities. Trans people are part of many communities and often face multiple kinds of discrimination accessing health care, including transphobia, racism and gender-based discrimination. In 2015, an American study found that trans people of colour experienced higher levels of anti-trans discrimination in three key areas of medical care: hospitals, emergency rooms and ambulance care.

The intersections in our lives as trans people can’t be ignored. We’re not just trans, but fully realized human beings with a wide range of lived experiences. Addressing transphobia is an important part of improving health-care equity, but we also need to address other forms of oppression in order to realize that goal.

***

My symptoms continue unabated. I see my family doctor, a brilliant and empathetic physician who treats me with dignity and care. She immediately recommends that I go to another emergency department.

We brainstorm about which of the city’s ER departments is less likely to be transphobic. She’s heard good things about a third emergency room at a large, progressive hospital known for its specialization in patient care. Desperate to address my symptoms, I agree to go, but am terrified of more bad treatment. Fortunately, this emergency department doesn’t misgender me and runs diagnostic tests. I have a serious Crohn’s complication which may require surgical intervention. I am admitted to hospital and spend 4 days being treated and observed before being discharged.

Throughout my medical experience, I realize how unaware most front-line medical staff are of transgender-specific medicine. I have to explain what gender-confirmation surgery is to almost everyone I encounter. No one understands the hormone treatment I am on. While common stereotypes of trans people insist that we’re overly obsessed with policing other people’s pronouns, I am far more concerned about the basic lack of medical knowledge regarding trans people.

While I understand that there are many complex challenges in our health-care system, this is an easy problem to fix. Front-line medical staff, especially those working in emergency medicine, should have basic training related to caring for transgender patients. One of my nurses confides in me that they haven’t been trained on anything related to trans people. By and large, it’s the nurses who are the best at supporting me during my time in hospital. It’s not that they have any additional training that the physicians don’t have, but they are more willing to listen to me and respect my gender identity. Implementing basic, transgender-specific training would help address many of those concerns and is an easily accessible solution to a profound problem.

In my experience, trans patients are required to be advocates and educators while also being patients. Pushing back on transphobia or educating medical staff about trans medicine while you are in pain, vulnerable and in need of urgent treatment is too great of a burden for most trans patients to bear. I spent two weeks bouncing from emergency department to emergency department to emergency department trying to find trans-competent medical care. The emotional cost of my experience was as significant as the physical one. Despite being encouraged to file complaints against the hospitals that mistreated me, I didn’t, because the thought of reliving any of those experiences was too much for me.

It may be tempting to write-off my experiences as me simply being upset about the language that was used to describe me. My name and my pronouns are not just words to me, but a reflection of the life that I live and the relationships that fill it. The name and sex I was assigned at birth are not a part of who I am and haven’t been for a long time. I live in the world as a woman and everyone in my life – from my coworkers to my partners to my friends – understand me as one. Refusing to use my name and my pronouns is refusing to respect my humanity and the ways that I am loved by my community.

In June, 2014, an editorial by two emergency physicians was published in the Annals of Emergency Medicine. They argue for many of the same points I do here and make a list of recommendations for emergency doctors to improve the care they provide to trans patients. What frustrates me is that despite sustained advocacy by trans patients for decades and the development of resources and studies to support our concerns, trans people are still having dangerous and discriminatory experiences such as mine. Ignorance is not an excuse.

More critically, it doesn’t cost anything to respect my gender. There are no increased wait times or impacts on care for other patients. Using my pronouns and name doesn’t make anyone’s day harder or complicate their work. It’s a small, but profound act that recognizes my right to safe and respectful care as a member of society. Aside from increasing medical awareness of transgender health and working to ensure that front-line staff have basic training relating to transgender patients, my experience could have been avoided by a simple philosophy.

Treat patients with respect. Listen to them and act with empathy. Acknowledge the differences in their experiences and ask thoughtful questions when you don’t understand something. Above all else, remember that you, as a medical provider, are entrusted with a profound responsibility to do no harm to those under your care.

Not respecting a transgender patient’s gender is doing harm and we, as human beings regardless of our individual characteristics, deserve better.