Rehearsing transgender healthcare

Medical students learn trans care in the classroom and the exam room.

Bianca Leigh is playing a character named Tia Lopez.

“Tia Lopez is a 36-year-old woman of trans experience. She works as a bartender. She’s in a two-year relationship with her boyfriend, and she has come for her annual physical,” Leigh explains.

Leigh is a standardized patient — an actor, pretending to be sick or coming in for a fake checkup, so medical students can practice being doctors in a low-risk environment. She is one of several “patients” that students at New York University School of Medicine will practice with today.

Leigh is a transgender woman in her fifties. She’s wearing light wash jeans and a flowy white blouse, with sunglasses tucked into her hair.

She drapes her cardigan over the back of her chair and settles in to wait for her next student. She’s sitting in front of a one-way mirror, in a mock exam room.

On the other side of the door, med student Sandra Goldlust is also waiting to begin the exam. It’s her first year of medical school, and Leigh will be the first patient she has ever worked with, standardized or otherwise.

A booming voice crackles over the PA system: “You may now read the instructions posted on the door.” A few moments later, it thunders again, “You may now enter the room.”

Goldlust knocks on the door, and Leigh sings out, “Come in!”

Goldlust introduces herself and asks Leigh her preferred name. In character, Leigh says, “Tia!”

Then Goldlust asks which pronouns Leigh prefers.

Leigh is not afraid to push back. “Do you ask everybody that?” she says.

“Um, I ask most, a lot of my patients that, yes,” Goldlust says. “But I do see you’re a trans woman, so I just wanted to clarify, just so that I know and I can respect that.”

“Isn’t it obvious? I’m 100 percent female! Yes, she, her,” Leigh says.

Part of the point of having a standardized patient is to practice scenarios like this one, situations that might be a little uncomfortable or off script.

Goldlust and her peers have been taught the basics of trans-specific care in the classroom — best practices like how to talk about hormones and asking for preferred pronouns at the beginning of a visit.

But the classroom can only get you so far. For example, Leigh explains that some people — particularly older trans people who are on the gender binary — don’t take kindly to being asked which pronouns they use.

“I mean, there are transgender people that are like, ‘I am a woman, and that’s that. And I don’t want to talk about it.’” But, she says, there are also people who are more open to talking about pronouns, or who are nonbinary.

Leigh emphasizes that, from pronouns to pregnancy, not all transgender people feel the same way. She advises med students to be good listeners, and to know how to apologize if they stumble.

That’s the gist of what she tells Goldlust, after the exam has ended and it’s time for feedback.

“My main concern is less about forgetting one or two things on this and [more] how you come in the room and how you interact with a patient. And I thought you did fabulous. Even if you feel nervous, you present calm. Competent, mature, great eye contact, great listening skills,” Leigh says to Goldlust, who thanks her and smiles.

Teaching with standardized patients who are transgender just recently became an official part of the program Goldlust is enrolled in at NYU.

Associate Professor Richard Greene implemented the change after studying how some of his residents examined a trans standardized patient. Most were perfectly polite, but some of them skirted around her gender identity. Less than two thirds of students even brought it up.

Greene says that not mentioning gender identity at the beginning of an appointment leaves transgender patients vulnerable.

“So it’s certainly possible that she was sitting there in that room feeling like, ‘What if they figure it out?’ or ‘What if they say something different?’ or ‘What if something happens?’ And by addressing her gender identity directly, in a non-judgmental and affirming way, you allow her to be who she is and to really talk about what her concerns are.” Once they’ve established the basics, doctors can focus on why their patient came in that day — which might not have anything to do with gender identity at all. “Transgender people fall and break their arm or they have diabetes or they need to stop smoking or any of those things that we would treat any other patient for,” Greene says.

The doctor’s office can be a difficult place for transgender people. A 2015 survey by the National Center for Transgender Equality found that, in the past year, a third had a negative experience with a healthcare provider related to being trans. They reported being asked unnecessary or invasive questions, being verbally harassed, and being refused treatment. Previously, Lambda Legal reported that 70 percent of transgender people had experienced discrimination while seeking healthcare.

Trans and nonbinary people have also reported difficulties at the doctor — including being misgendered and encountering ignorant healthcare providers — on Twitter using the hashtag #transhealthfail.

Me: my shoulder hurts
GP: how did you get them to write male on your file?
Me: I am male
GP: not really @CissexismDaily #TransHealthFail

— Kid-St.Jimmy (@Kid7295) March 29, 2017

Studies show that when trans people feel uncomfortable or mistreated at the doctor’s office, they’re less likely to go and less likely to get the care that they need — which is why Richard Greene and NYU School of Medicine offer a curriculum that includes transgender-specific healthcare and practice with transgender standardized patients.

“[Med students] having this opportunity to talk to a trans patient means that, the next time they walk into a room with a trans patient, they can feel much more comfortable,” says Greene.

It’s his hope that, if future doctors are more comfortable, future patients will be as well.