- Scenario:
- A 27-year-old transgender man presents to the clinic for a routine gynecological exam. He has not had a pelvic exam in over five years due to feelings of severe discomfort and body dysmorphia related to his reproductive organs. He expresses extreme anxiety about the visit because he fears being misgendered or treated insensitively by the healthcare staff or patients, which has happened to him in the past.
- This scenario requires cultural awareness and humility because it involves gender-affirming care, sensitive handling of body dysmorphia during a gynecological visit, and trauma-informed care.
- Cultural Factors to Consider:
- Transgender identity:
- The patient’s gender identity and pronouns must be respected throughout the entire interaction. Furthermore, he may have added psychological distress secondary to his identity during the encounter.
- Body dysmorphia/Discomfort with reproductive anatomy:
- The patient may experience body dysmorphia that results in discomfort with examinations that require exposure of his body. Dysmorphia surrounding reproductive organs can make gynecological exams especially emotionally and mentally taxing for transgender patients.
- Past medical trauma:
- The patient avoided gynecological care in the past due to prior negative experiences, such as being misgendered or mistreated by healthcare providers. He may have a mistrust in clinicians that requires more intentional efforts to build rapport.
- Transgender identity:
- Unique Beliefs or Considerations:
- Avoiding gendered language in gynecological care:
- Gender-neutral language should be used at all times to respect the patient’s gender identity and reduce distress. Gynecological care is not only for women.
- Anxiety around vulnerable exams:
- The patient experiences discomfort with his anatomy, which has led to avoidance of healthcare services that focus on these areas. Special sensitivity is needed to minimize emotional distress during the exam.
- The patient may be particularly anxious about being undressed or exposed during the exam, especially the parts of his body that trigger dysphoria.
- Impact of HRT:
- If the patient is on testosterone, it may have caused changes to his reproductive organs that should be discussed.
- Fear of misgendering:
- The patient’s past healthcare experiences might make him hypervigilant to any signs of being misgendered, increasing his anxiety during the visit. It may be best to limit the number of personnel that the patient has to interact with, in order to minimize his anxieties.
- Avoiding gendered language in gynecological care:
- Areas of Potential Conflict
- Body dysphoria and exposure:
- The patient may feel overwhelmed or upset by the exam, particularly during the physical exposure of his genitalia. This can cause tension between the need for medical care and the patient’s emotional comfort.
- Misgendering:
- If the provider or staff use incorrect pronouns or language, this could lead to significant distress or trigger dysphoria, making the patient feel invalidated. He could even choose to leave the clinic without receiving care.
- Gendered medical spaces:
- The patient may feel uncomfortable in a health clinic environment that is often perceived as exclusively for women, potentially leading to feelings of isolation or unease.
- Body dysphoria and exposure:
- Expected Skills to Be Demonstrated:
- LGBTQ+ allyship
- The student should acknowledge, but also normalize, the patient’s identity. It would be best for the student to share their own pronouns, and confirm the patient’s.
- Cultural humility:
- The student should be sensitive to the patient’s anxieties and acknowledge the emotional challenges associated with gynecological care as a transgender man. However, the student shouldn’t say things about how they “understand” the patient’s anxieties, especially if the student is cisgender. The patient’s anxieties are unique to him and couldn’t be understood by the student.
- Gender-affirming language:
- Use gender-neutral or patient-preferred terms for body parts. Ask the patient what terms he is most comfortable with to describe his body.
- Empathy and reassurance:
- The clinician should regularly check in with the patient during the visit, ensuring his comfort and emotional well-being throughout the exam.
- Trauma-informed care:
- Approach the exam with patience and an understanding of how body dysmorphia can cause heightened emotional responses. Offer options like having the patient keep his clothes on until absolutely necessary and maximizing coverage during the exam.
- Clear communication:
- Explain each step of the exam before proceeding, and provide options like a smaller speculum or alternative examination positions to minimize discomfort.
- LGBTQ+ allyship
- Patient Education/Counseling/Follow-Up:
- Education:
- Discuss the importance of regular gynecological care and routine cervical cancer screening, even for transgender men.
- Provide education on any health concerns specific to someone on testosterone, such as atrophy, amenorrhea, or changes in vaginal tissue.
- Counseling:
- Offer a referral to a mental health professional experienced in transgender care and body dysmorphia.
- Offer a referral to medical facilities or other community resources that specialize in providing care to LGBTQ+ patient populations.
- Follow-up:
- For routine care, the patient should ideally follow-up annually, but at most every three years for cervical cancer screening. He can follow-up as needed for any episodic complaints.
- Ensure the patient knows he can request another provider if it helps him feel more comfortable and offer a follow-up visit where he can express any concerns about the care he received.
- Emphasize that his emotional comfort is a priority and that future visits can be adjusted to his needs.
- Education: