Dr Kamilla Kamaruddin, a GP in transgender healthcare at Tavistock Gender Identity Clinic and the East of England Gender Service, on what nurses need to know about transgender healthcare
Like all healthcare professionals, nurses will care for people from diverse backgrounds and have a responsibility to create a safe and welcoming environment for all patients.
Transgender people often face barriers and discrimination when trying to access healthcare. For example, in a report by LGBTQ+ charity Stonewall1, published in 2018, 41% of trans people accessing general healthcare services said staff lacked understanding of specific trans health needs, while 7% said they had been refused healthcare because they are LGBTQ+. Meanwhile, another report from Stonewall in 2018 found 46% of trans people had thought about taking their own life in the previous year.²
To help nurses better understand and care for transgender patients, and answer any questions they might have, Dr Kamilla Kamaruddin delivered a well-received keynote session on barriers to healthcare for trans people at the Nursing in Practice live event in London on 28 April. To make sure Dr Kamaruddin’s advice is shared with all our readers, below are her answers from the lively Q&A at the end of her talk, alongside a few bonus questions.
Q What advice do you have for healthcare professionals who have questions about how to address a trans or non-binary patient, but feel awkward asking them?
A Just ask, rather than assume. Don’t assume by physical appearance. Trans people often gets lots of questions and we don’t mind telling you what our pronouns are or what our gender identity is. We know that sometimes genuine mistakes happen. If it happens to you, apologise and be willing to learn from it. Mistakes are different from misgendering a trans person with malice. We understand and can tell the difference.
Q What kinds of questions or comments are inappropriate to say to trans people, and which healthcare professionals should stay away from?
A It is inappropriate to comment on a trans person’s appearance. Do not be shocked or question if a trans man with a masculine appearance and voice comes into the practice and requests a cervical screening. Alternatively, a trans man may have a high-pitched voice, or a trans woman a deep one.
Q Do trans men and non-binary people with a cervix still require cervical screening?
A Yes. When they come to see you for testosterone injections, hormone therapy and other treatments, please invite them to cervical screening. The required forms can be generated via Open Exeter – the NHS digital portal³ – and ‘people with a cervix’ should be used as a reason for cervical screening. This is because they now might be registered as male, and we do not wish to reveal their gender to a third party. They also require breast screening if they have adequate breast tissue (such as for trans women who have undergone hormone treatment) and are over the age of 50. However, if a patient is registered as male with a GP, they may not be invited automatically to breast and cervical screening.
The take-home message is: if a person has adequate breast tissue, irrespective of gender, they need breast screening; and if they have a cervix, irrespective of gender, they need cervical screening.
Q How can GP surgeries and other healthcare providers create a welcoming environment for trans people?
A Ensure all staff receive trans-awareness training, which can help increase knowledge and skills about working with trans people and challenge perceptions and assumptions. Humility from a healthcare professional to learn about improving healthcare for trans people can be an enormous support.
Some topics it would be useful to educate staff about include:
- Trans and non-binary inclusive language and the use of pronouns – as sometimes fear of using the wrong language is a barrier to healthcare for trans people.
- Language and actions that can be seen as acts of discrimination against trans and non-binary people (such as misgendering).
- The procedure to change someone’s registered name with the NHS and what to do when a trans patient has a new NHS number.
- Etiquette during telephone and remote consultations.
Gender-neutral toilets can also help trans people feel comfortable. Practices could also consider putting a small rainbow flag or a poster about trans health in the waiting room.
Q What should you do if you are concerned about the way a colleague is treating a trans patient?
A Initially, I would probably have a quiet conversation with the person, point out that what they have said or done is not acceptable and discuss what they can do better. You should also consider if the issue needs to be escalated further to your line manager, or whether the person needs trans-awareness training.
Q What are the biggest barriers to accessing healthcare for trans people?
A Some of the biggest barriers include:
- Long waiting lists to be seen at a gender identity clinic.
- Lack of knowledge, understanding and competency among healthcare professionals to meet specific trans health needs, and a lack of trans awareness.
- Lack of awareness among trans people of the specific trans health services available.
- Trans people avoiding medical care for fear of being mistreated or because of a previous negative experience with a healthcare professional.
Q Why is there a high incidence of mental health issues and suicide among trans people?
A There are many reasons – for example, long waiting lists, stigma and difficulties with social transitioning. Suffering minority stress – a term to describe the high levels of stress faced by members of stigmatised minority groups – from the public, family and press can lead to a high incidence of mental health issues.
Being trans is not a mental illness nor is it classed as such. Trans people might be at greater risk of mental health issues, but it is not the cause of these issues.
Q What is the best way healthcare professionals can ensure they are trained and up to date with trans healthcare issues?
A There are many resources available online, such as the Royal College of General Practitioners’ LGBT e-learning4, which is free for all healthcare professionals. You can also request a protected learning event about trans health and language from local commissioners.
Cisgender or cis Someone whose gender identity is the same as the sex they were assigned at birth.
Gender dysphoria When a person experiences discomfort or distress because there is a mismatch between their sex assigned at birth and their gender identity. This is also the clinical diagnosis for someone who doesn’t feel comfortable with the sex they were assigned at birth.
Gender identity A person’s innate sense of their own gender, whether male, female or something else (see Non-binary, below), which may or may not correspond to the sex assigned at birth.
Non-binary Umbrella term for people whose gender identity doesn’t sit comfortably with ‘man’ or ‘woman’. Non-binary identities are varied and can include people who identify with some aspects of binary identities, while others reject them entirely.
Pronoun Words to refer to people’s gender in conversation – for example, ‘he’ or ‘she’. Some people may prefer others to refer to them in gender neutral language and use pronouns such as they/their and ze/zir.
Transgender or trans An umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth.
Transgender man A term used to describe someone who is assigned female at birth but identifies and lives as a man. This may be shortened to trans man, or FTM, an abbreviation for female-to-male.
Transgender woman A term used to describe someone who is assigned male at birth but identifies and lives as a woman. This may be shortened to trans woman, or MTF, an abbreviation for male-to-female.
Transitioning The steps a trans person may take to live in the gender with which they identify. Each person’s transition will involve different things; some have medical intervention, such as hormone therapy and surgeries, but not all trans people want or are able to have this.
Source: Stonewall: List of LGBTQ+ terms.
- Stonewall. LGBT in Britain – Trans Report. 2018.
- Stonewall. LGBT in Britain – Health. 2018.
- NHS Digital. Open Exeter.
- RCGP. LGBT Health Hub.
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