The transgender inpatient

Transgender and gender-nonbinary people face significant barriers to gender-affirming and high-quality health care.


Illustration by David Rosenman
Illustration by David Rosenman

There are over a million self-identified transgender people in the United States, with the highest proportion living in Washington, D.C., according to a 2016 report from the Williams Institute, a think tank at the University of California, Los Angeles. The report found that over 200,000 people in the U.S. transgender population are 65 years of age or older, and thus at increased risk of hospitalization. Transgender patients face unique challenges in the hospital from registration through discharge. There are distinct medical issues related to hormone replacement therapy and reconstructed anatomy. Transgender patients may also have had previous adverse health care experiences that may affect communication with clinicians as well as the patient experience.

For example, consider this hypothetical patient. Toff Middleton is a 67-year-old transgender person who presents to the ED with severe flank pain. Toff is genetically male but identifies as female. She considered surgery when she was younger but lacked funds and feels that at this point in her life it's too late to undergo such an extensive procedure. Toff had been ill for several days but had not sought care, despite having Medicare and secondary health coverage. Toff's roommate called 911 after returning from a business trip and finding her on the floor, unresponsive.

Toff was moderately encephalopathic on arrival in the ED. Toff's roommate did not accompany her, and there were no available medical records. Toff was found to have nephrolithiasis and early sepsis due to a urinary tract infection. After receiving IV fluids, antibiotics, and pain medication, she was slightly more lucid. She told the ED physician that she felt extremely apprehensive about being admitted, and she appeared more anxious about the hospital environment than about her own medical condition. She reported that she had not seen a doctor in over 10 years, since she went to a local clinic due to a suspicious lesion on her face and was asked to consent to an unnecessary genital exam after disclosing that she was transgender. She explained to the ED physician how embarrassed and enraged she'd felt.

Toff is admitted and is placed in a semiprivate room. Toff's bedside nurse enters the far side of the room to assess her new patient, whom she calls “Mr. Middleton.” The nurse introduces herself and asks for Toff's name and birthday. Toff closes her eyes and feigns unresponsiveness. However, the nurse is appropriately persistent, and Toff spells her last name and gives her birthdate. The nurse checks vitals and oxygen saturation, which are all normal, and is paged out of the room before she can get a more extensive history.

Toff awakens and looks around the room. Her bed is surrounded by a soft pink and blue privacy curtain. On the other side of the curtain she hears a nurse say, “Mr. Smith, are you feeling good enough to take a brief walk with me?” All Toff can focus on is on the word “Mr.” She immediately wonders if she has been placed in a room with a man. She presses the call button and quietly explains the situation to the nurse.

“I'm sorry, no private rooms are available, but maybe we can help you move to the women's side. Have you had your surgery yet?” the nurse inquires, in an attempt to be helpful.

“Good morning, Mr. Middleton,” exclaim the doctors and nurses as they enter the room. No one bothers to ask Toff about her gender identity, pronouns, or preferred name and title. As the day progresses, she feels constantly invalidated as her clinicians misgender her and use masculine pronouns even after being corrected. She is limited to using only the bathroom assigned to her and her hospital roommate. Later that day, her roommate's family members arrive for visiting hours, and she can hear their snickering as she walks across the room to the bathroom. Toff also hears laughter in the hallway. Though the nurses are in fact laughing at a silly dog video, Toff feels as though they are laughing at her. She gets progressively angrier at the situation.

During the multidisciplinary hospital huddle, the social worker explains to the team that Toff Middleton mentioned that she's transgender and is unhappy to still be in a room with a male patient, especially sharing a bathroom. She goes on to explain that gender-affirming room assignment and bathroom access are necessary steps toward creating an inclusive hospital environment. The charge nurse smirks and voices disbelief, stating that the patient never mentioned anything in the ED and doesn't look transgender. She wonders if they are talking about the right patient.

Meanwhile, Toff's physical symptoms have resolved, but the hurt, shame, and frustration triggered by her hospital experience remain. She gathers her belongings and prepares to leave without consulting the care team. The nurse and attending physician come into her room and have a long discussion. They hear her concerns but also emphasize the seriousness of her medical condition. They arrange for a private room, and the hospitalist promises to contact the consulted urologist and explain Toff's concerns in advance of the visit.

Transgender and gender-nonbinary people face significant barriers to gender-affirming and high-quality health care. These problems reinforce the medical mistrust that keeps transgender and gender-nonbinary people from seeking medical care. Education of clinicians can go a long way toward improving communication and the provision of care.