For Providers Who Treat Patients Outside the Gender Binary, New Health Care Standards Light the Way

RAD Remedy, a nonprofit organization that focuses on connecting trans, gender non-conforming, intersex and queer (TGIQ) people to health care, recently published guidelines for health care professionals on delivering culturally competent care to people who do not fall within the binary definition of gender and sex.

The guidelines were developed as a result of an identified need: Not all LGBT organizations include the full spectrum of people whose gender identity and expression are not easily categorized within the traditional female/male rubric, RAD Remedy says. Separate guidelines for those who care for TGIQ folk are therefore needed, it concludes.

People may forego medical care if they fear harassment or do not feel that the provider will understand their needs. The 2015 Transgender Survey and RAD's own research show that TGIQ people with a negative experience in one health care setting will shun medical care in general, including emergency services. The RAD Remedy guidelines offer practical steps that health care practitioners can take to make TGIQ patients feel safe and respected.

The document is divided into five sections: patient/practice interactions, paperwork, office/practice regulatory actions, human resources and marketing/community engagement.

Recommendations for interactions include the creation of community advisory boards that include not only people from LGBT organizations, but also include people from groups that focus on TGIQ folk. The guidelines urge the use of gender-affirming language in all documents and open-ended survey questions to elicit full feedback. Forms (and associated computer systems) should ask for preferred name, pronoun, etc. -- and these should always be used unless the legal name is needed for insurance billing purposes. Providers also need to be sensitive to other issues faced by this community, including poverty and survival sex work, the guidelines say.

When treating minors, the provider's primary responsibility should be the child, and non-reversible procedures (such as genital alterations) should be delayed until the minor can make such decisions themselves, the guidelines recommend. Adult patients should also be offered help to ensure that their emergency contact can make medical decisions for them, even if that person is not a legal relative. Medical practices should ensure that interpreters or other health professionals to whom the patient may be referred provide culturally competent care and use appropriate language.

RAD Remedy's document also offers practical advice on office administration. Highlighting patients' preferred terminology on forms and in computer systems helps to ensure that all staff will address them correctly. Including open-ended options when collecting demographic information, as well as an "opt-out" choice that does not disclose gender or sexual orientation, lets the provider collect data outside the standard binary system and allows patients to guard their privacy. This is critical, since disclosure of TGIQ status may have far-reaching consequences in a person's life, including loss of income or housing, the guidelines note.

In in-patient settings, access to items that aid a person's gender presentation should be permitted unless there are specific medical reasons against doing so -- but if that is the case, clearly explain these reasons, the RAD Remedy guidelines urge. In addition to providing gender-neutral bathrooms for patients, make sure such facilities are also available for staff, RAD Remedy counsels. Medical practices serving TGIQ people should try to hire staff from that community, as well.

RAD Remedy's guidance also offers advice on staff development, including: During the hiring process, ask about TGIQ experience. When bringing new employees on board, include competency training for working with TGIQ folk. Define a grievance process and a TGIQ-identified liaison to whom staff who experience or witness discrimination can turn. Train billing/insurance personnel to work with gender-specific insurance issues. In addition to initial training, conduct periodic refreshers on cultural competency and have senior management and members of governing bodies attend these trainings.

To truly serve this community, providers need to engage with LGBTQIA groups by sponsoring events and partnering with appropriate organizations, the guidelines state. Because of the narrow focus of some LGBT organizations, providers might need to look beyond that horizon for partners that include TGIQ folk. Any promotions for the practice should feature diverse images, including TGIQ persons and gender-appropriate language.

The RAD Remedy guidelines also offer a 10-point summary of the recommendations. Among others, these include: ask about gender and preferred terms, but don't ask more questions than necessary; ask permission to touch or to bring other staff in; respect patients' choices about their transition and allow them to bring advocates to their appointments; and affirm TGIQ lives in waiting room pictures and your marketing. Providers who ask questions instead of making assumptions, respect privacy and let patients guide their own care are on the way to appropriate medical care for this community, RAD Remedy counsels.