CREATING EQUAL ACCESS TO QUALITY HEALTH CARE FOR TRANSGENDER PATIENTS: TRANSGENDER-AFFIRMING HOSPITAL POLICIES
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CREATING EQUAL ACCESS TO QUALITY HEALTH CARE FOR TRANSGENDER PATIENTS: TRANSGENDER-AFFIRMING HOSPITAL POLICIES
TRANSGENDER–AFFIRMING HOSPITAL POLICIES 2
IN T RO D U C T I O N gency medical problems, a common situation in
communities with suboptimal access to care.2 Adopt-
Over the last decade, hospitals throughout the United ing transgender-inclusive health care practices
States have recognized that some groups of people face can reduce the costs associated with complications that
significant barriers to health care because of historic arise when transgender patients are denied or delay
bias and discrimination against them. Many efforts medical treatment due to discrimination.3
have been launched to identify these groups, learn more In a 2011 survey of over 6,000 transgender
about the challenges they face in health care, and wel- Americans, 19% of the respondents reported being
come them into the nation’s hospitals. To reach out to refused health care due to their transgender or gender-
these long overlooked groups, hospitals have examined nonconforming status. In addition, 28% had postponed
their policies and practices to ensure that discrimination necessary health care when sick or injured, and 33%
is clearly prohibited, recommendations for equitable and had delayed or had not sought preventive care because
inclusive care are being followed, and staff are trained to of experiences of health care discrimination based on
provide knowledgeable, sensitive care. their transgender status.4
Transgender1 people have become widely recog-
nized as one such group that faces significant barriers
to equal, consistent, and high-quality health care. From
instances of humiliation and degradation to outright
refusals to provide care, many institutions – consciously
or not – have made it very difficult for transgender
people to receive respectful, knowledgeable treatment.
The end result often has been disengagement from the
health care system that results in poor health outcomes
for transgender people: rather than enduring abuse and
poor treatment, transgender people often simply do
2 See Access to Healthcare, Transgender Legal Defense & Education Fund,
without health care. As a result of this disengagement, http://transgenderlegal.org/work_show.php?id=2. The barriers transgender people
treatable medical conditions too often become emer- face when seeking access to quality health care are both personal and structural.
Personal barriers stem from the beliefs, attitudes, and behaviors of providers and
patients within the health care system, while structural barriers operate regardless
of individual attitudes. These institutional barriers include limitative insurance
1 “Transgender” is an umbrella term used to describe people whose gender identity, practices, insufficient provider knowledge, and inadequate provider training on the
one’s inner sense of being male or female, differs from their assigned or presumed needs of transgender patients. For a more detailed discussion of the health care
sex at birth. Transgender patients generally are admitted to hospitals for the same disparities faced by transgender patients in the United States, see The Inst. of Med.,
types of care as other patients, although transgender patients may also enter hospi- The Health of Lesbian, Gay, Bisexual and Transgender People: Building a
tals for transition-related health care services. To “transition” means to undergo a Foundation for Better Understanding, 25-88 (2011), http://www.iom.edu/
process by which a person changes their physical sex characteristics and/or gender Reports/2011/The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People.aspx.
expression to match their inner sense of being male or female. This process may
include a name change, a change in preferred pronouns, and a change in social 3 See State of California, Department of Insurance, Economic Impact Assessment Gen-
gender expression through things such as hair, clothing, and restroom use. It may or der Non-discrimination in Health Insurance, REG-2011-00023 (Apr. 13, 2012), http://
may not include hormones and surgery. For more information, see Transgender Rights transgenderlawcenter.org/wp-content/uploads/2013/04/Economic-Impact-Assess-
Toolkit: Transition-Related Health Care, Lambda Legal, (Aug. 29, 2013) http://www. ment-Gender-Nondiscrimination-In-Health-Insurance.pdf.
lambdalegal.org/publications/trt_transition-related-health-care. It should be noted
that the gender marker on transgender patients’ legal identification documents may 4 Jaime M. Grant, Ph.D., et al., Injustice at Every Turn: A Report of the Na-
or may not match their gender identity because some states do not allow individu- tional Transgender Discrimination Survey, 76 (2011), http://transequality.org/
als to change their gender marker on birth certificates or driver’s licenses and other PDFs/NTDS_Report.pdf.
states make the process very burdensome and expensive. See infra at note 21.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 3
A large national LGBT health survey conducted in • Laughter, pointing, joking, taunting, mockery, slurs,
2010 also detailed transgender patients’ experiences and a wide variety of negative comments;
of discrimination in health care.5 Seventy percent of • Violations of confidentiality, regardless of HIPAA7;
transgender respondents reported having one or more • Use of improper name and/or pronoun for patient;
of the following experiences: • Exceptionally long waits for care;
• Inappropriate questions and/or exams, including
• Health care providers refusing to touch them or using needless viewing of genitals;
excessive precautions; • Prohibitions of bathroom use, or challenges to it;
• Health care providers using harsh or abusive language; • Inappropriate room assignments;
• Health care providers being physically rough • Failure to follow standards of care.8
or abusive;
• Health care providers blaming them for their It is negative experiences like these that lead
health status. transgender people to avoid seeking health care. Yet
hospitals can readily prevent these problems, and create
In addition, nearly 27% of transgender survey respon- a welcoming environment for transgender patients, by
dents reported being outright denied health care implementing key policies, practices, and staff training.
because of their transgender status.6 In the pages that follow, we provide a set of
Even when transgender people do receive medi- model hospital policies aimed at eliminating bias and in-
cal treatment, their interactions with hospital staff – sensitivity, and ensuring appropriate, welcoming interac-
including physicians, nurses, allied health professionals, tions with transgender patients. These policies address
admitting and registration personnel, and security of- the issues of confidentiality, non-discrimination, room
ficers – often result in negative experiences. Examples assignments, bathroom access, and admitting/registra-
of inappropriate staff behavior cited by transgender tion procedures – issues that, when mishandled, become
patients include:
7 “The Health Insurance Portability and Accountability Act (HIPAA) of 1996, Pub.
L. No. 104-191 (1996) (amending 42 U.S.C. § 1301 et seq.).” HIPAA is the federal
law that establishes, among other things, privacy and security requirements with
respect to the use and disclosure of an individual’s medical information.
5 Lambda Legal, When Health Care Isn’t Caring: Survey on Discrimination 8 For example, in 1995, emergency medical services workers were called to the
Against LGBT People and People Living with HIV, 5-6 (2010), http://data.lamb- scene of a car accident in which Tyra Hunter, a transgender woman, was seriously
dalegal.org/publications/downloads/whcic-report_when-health-care-isnt-caring.pdf. injured. As Tyra lay unconscious, the emergency medical services workers discov-
This study also found that transgender and gender-nonconforming respondents ered that she had male genitalia and stopped providing emergency treatment to her
reported the highest rates of discrimination and barriers to care, having experienced while they began laughing and making derogatory comments about her. Tyra died
such discrimination up to two to three times more frequently than lesbian, gay, or as a result of their negligence. Tyra’s mother then brought a wrongful death lawsuit
bisexual respondents. against the D.C. General Hospital and D.C. Fire Department. After a five-week trial,
the jury awarded Mrs. Hunter approximately $2.9 million in damages, finding that
6 Id. at 5. Although the great majority of care sought by transgender hospital D.C. General Hospital’s medical malpractice caused Tyra’s death and the emergency
patients is of the same type as sought by other patients, it should be noted that medical personnel had violated the D.C. Human Rights Law. See Sue Anne Pressley,
insurance coverage for transition-related medical procedures is gradually expanding. Realizing, Fulfilling ‘Who They Are’: D.C. Slayings Help Galvanize Transgender Community’s
See “Policy Guidance: Insurance Guidelines,” infra at 15. In addition, widely ac- Push for Acceptance, Washington Post (Nov. 29, 2003); Press Release, Gay & Lesbian
cepted Standards of Care have been developed for transitions. See The World Activists Alliance of Washington D.C., District Settles Hunter Lawsuit for $1.75
Professional Association for Transgender Health, Standards of Care for the Million (Aug. 10, 2000), http://www.glaa.org/archive/2000/tyrasettlement0810.
Health of Transsexual, Transgender, and Gender Nonconforming People shtml. See also Grant, supra n.4, at 74 (finding that 28% of survey participants
(7th ed.), http://www.wpath.org/documents/Standards%20of%20Care%20V7%20 reported being subjected to verbal harassment in medical settings and 2% were
-%202011%20WPATH.pdf. victims of violence in doctors’ offices).TRANSGENDER–AFFIRMING HOSPITAL POLICIES 4
barriers to health care for transgender patients. Below POLICY:
each model policy we have included a short explanation [Hospital] does not discriminate against any person on the basis
of the rationale behind the policy. of gender identity or gender expression. 9
We urge hospital administrators and legal
departments to adopt these policies to ensure that their Further, we recommend that hospitals communicate
hospitals are offering health care that is non-discrimina- this non-discrimination policy to their employees and
tory and transgender-affirming. The policies are styled patients in the following ways:
in a general format that can be tailored to the needs of
individual hospitals. We encourage hospital administra- • Post it on the hospital website and in patient waiting
tors and legal departments to contact us should they areas and employee work areas;
require additional guidance in adapting policy language • Include it in materials routinely given to patients at
to fit their facility’s unique circumstances. admitting/registration or at other times;
These model policies are not intended to pro- • Include it in materials routinely available for take-
vide legal advice, and state and local laws may require away in patient waiting areas;
that hospitals take additional steps to protect the rights • Include it in materials routinely given to employees
of transgender and gender-nonconforming patients. at orientation.
For this reason, hospital administrators are strongly
encouraged to review these policies in consultation E X PL A N AT I ON
with their legal counsel.
Non-discrimination policies that prohibit discrimina-
M ODE L T R A NSG E NDE R- A FF IR MING tion based on gender identity and gender expression are
H OSPI TA L P O LICIE S a first and necessary step toward ensuring that trans-
gender patients have equal access to respectful, knowl-
1. G
ender Identity & Gender Expression edgeable treatment and care. Such non-discrimination
Non-Discrimination Policy policies are now required of accredited hospitals under
Joint Commission standard RI.01.01.01, EP 29. This
2. Patients’ Bill of Rights Joint Commission standard provides that an accred-
3. Admitting/Registration Records ited hospital “respects, protects, and promotes patient
4. Protocols for Interaction with Transgender Patients rights” and “prohibits discrimination based on . . . gen-
der identity or expression.”10 The Joint Commission’s
5. Room Assignments LGBT Field Guide advises hospitals to post, disseminate,
6. Access to Restrooms and publicize this non-discrimination policy on the
7. Policy Guidance: Compliance with Privacy Laws
8. Policy Guidance: Insurance Guidelines
P OLIC Y 1: G E NDE R IDE N T I T Y & G E NDE R E X- 9 Gender identity is one’s internal, personal sense of being a man or a woman. Gen-
PR E SSI O N N O N - DISCR IMIN AT I O N P O LI C Y der expression is the external manifestation of one’s gender identity, usually expressed
through “masculine,” “feminine,” or gender-variant behavior, clothing, haircut, voice,
or body characteristics.
We recommend that hospitals include the following
language in their patient non-discrimination policy:
10 See The Joint Commission, Requirement, Rationale, Reference Report (Feb.
9, 2011), http://www.jointcommission.org/assets/1/18/r3%20report%20issue%20
1%2020111.pdf.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 5
hospital’s website, in written material, and in packets of program that receives federal funds,14 and the U.S.
information distributed to patients and employees.11 Department of Health & Human Services, Office
It should also be noted that a growing number of Civil Rights, has explicitly stated that this prohibition
of state and local governments now require places of extends to claims of discrimination based on gender
“public accommodation” to implement policies forbid- identity.15 The Affordable Care Act references the
ding discrimination based on gender identity.12 For protections of other federal civil rights laws that ban
example, insofar as hospitals are considered public sex discrimination, and, in recent years, courts and
accommodations under the Administrative Code of administrative tribunals have increasingly held that
the City of New York Section 8-107(4), it is an unlaw- these laws should also be read to prohibit discrimina-
ful, discriminatory practice for a New York City hospital tion against transgender people and people who fail to
to directly or indirectly refuse, withhold from, or deny conform to sex stereotypes.16 Because the Affordable
a person any of the accommodations, advantages, Care Act’s prohibition of sex discrimination is to be
facilities, services, or privileges of the hospital based interpreted in the context of these other federal civil
upon the person’s actual or perceived gender, including rights laws, it is likely that the Act will be read by federal
the individual’s actual or perceived sex, gender identity, courts to prohibit discrimination against transgender
self-image, appearance, behavior, or expression, whether and gender-nonconforming individuals.
or not that gender identity, self-image, appearance,
behavior, or expression is different from that tradition- P OLIC Y 2: PAT IE N T S’ BILL OF R IG H T S
ally associated with the legal sex assigned to the
person at birth.13
We recommend that hospitals include the following or
In addition, § 1557 of the Patient Protection and similar language in their Patients’ Bill of Rights:
Affordable Care Act of 2010 (“Affordable Care Act”)
prohibits sex discrimination in any hospital or health The following rights apply to all patients:
11 See The Joint Commission, Advancing Effective Communication, Cultural 14 Affordable Care Act, 42 U.S.C. § 18116(a) (2010) (“[A]n individual shall not,
Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, on the ground prohibited under title VI of the Civil Rights Act of 1964 (42 U.S.C.
Bisexual, and Transgender (LGBT) Community: A Field Guide (Nov. 8, 2011), 2000d et seq.) . . . be excluded from participation in, be denied the benefits of,
http://www.jointcommission.org/lgbt/. or be subjected to discrimination under, any health program or activity, any part of
which is receiving Federal financial assistance, including credits, subsidies,
12 As of June 2013, seventeen states and the District of Columbia have banned or contracts of insurance . . . .”).
discrimination based on gender identity or expression. In addition, at least 143 cities
and counties have also adopted laws prohibiting discrimination based on gender 15 See Letter from Department of Health & Human Services to National Center
identity or expression. For more information on state and local laws prohibiting dis- for Lesbian Rights (July 12, 2012), http://hrc.org/files/assets/resources/HHSRe-
crimination based on gender identity or gender expression, see U.S. Jurisdictions with sponse8612.pdf.
Laws Prohibiting Discrimination on the Basis of Gender Identity or Expression, Transgender
Law & Pol’y Inst. (last updated Feb. 1, 2012), http://www.transgenderlaw.org/ 16 For example, in the recent case of Macy v. Holder, EEOC DOC 0120120821,
ndlaws/index.htm#jurisdictions; Nat’l Gay & Lesbian Task Force, Nondis- 2012 WL 1435995, at *7 (E.E.O.C. Apr. 20, 2012), the Equal Employment Oppor-
crimination Laws Map (last updated Jan. 20, 2012), http://thetaskforce.org/re- tunity Commission (“EEOC”) found that transgender people are protected by Title
ports_and_research/nondiscrimination_laws; States and Regions Map, Lambda Legal, VII’s prohibition of sex discrimination, as have a growing number of federal courts.
http://www.lambdalegal.org/states-regions. The EEOC explained that discrimination against someone because the person is
“identifying as a transgender person,” “has expressed his or her gender in a non-
13 See New York City Commission on Human Rights, Guidelines Regarding stereotypical fashion,” or “has transitioned or is in the process of transitioning from
Gender Identity Discrimination: A Form of Gender Discrimination Prohibited one gender to another” is a form of sex-based discrimination. Such discrimination
by The New York City Human Rights Law, 4 (2006), http://www.nyc.gov/html/ violates the law that an employer may not take gender into account when making
cchr/pdf/GenderDis_English.pdf. employment decisions. Id.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 6
The patient has the right to competent, considerate, and respectful Some state laws expressly recognize a patient’s
care in a safe setting that fosters the patient’s comfort and dignity right to refuse to allow medical students or other health
and is free from all forms of abuse and harassment, including care staff members to be present or otherwise involved
abuse or harassment based on gender identity or gender expression. in the patient’s case discussion, consultation, examina-
The patient has the right to privacy and confidentiality tion, or treatment.18 However, even in states that do
during medical treatment or other rendering of care within the not have such laws, it is important that transgender
[Hospital]. and gender-nonconforming patients be able to refuse
Medical students, residents, and other persons not directly to be examined or observed by health care personnel
involved in the care or treatment of a transgender or gender- who are not directly involved in the patient’s care.
nonconforming patient should not be present during the patient’s Of course, it is important for trainees to have inter-
case discussion, consultation, examination, or treatment except for action with all patient groups, including transgender
legitimate training purposes. Before observing or participating in people, so the goal is not to have these patients
a transgender or gender-nonconforming patient’s case discussion, exercise their right to restrict observation by trainees;
consultation, examination, or treatment for training purposes, rather, the goal is to make the environment
trainees should be counseled on the [Hospital’s] Gender Identity comfortable so that the patient does not feel the
and Gender Expression Non-Discrimination Policy and the need to exercise that right.
Protocols for Interaction with Transgender Patients. In all cases, That said, it is inappropriate for health care
discussion, consultation, examination, and treatment must be providers to invite hospital staff not involved in the
conducted discreetly. patient’s care to observe the patient’s body for any
Transgender and gender-nonconforming patients have reason other than legitimate training purposes.
the right to refuse to be examined, observed, or treated by medical Under no circumstances should persons not directly
students, residents, or any other facility staff when the primary involved in the patient’s care be permitted to observe
purpose is educational or informational rather than therapeutic, or participate in examination of the patient when
without jeopardizing the patient’s access to medical care, including the patient has refused.
psychiatric and psychological care.
E X PL A N AT I O N
and intimate nature of transsexualism, for persons who wish to preserve privacy in
Just as hospitals are obligated to respect patients the matter, is really beyond debate.”)
regardless of race, ethnicity, age, religion, creed, sex,
18 See, e.g., Mass. Gen. Laws ch. 111, § 70E (2012) (“Every patient . . . shall be
disability, and sexual orientation, so too must they provided . . . the right . . . to refuse to be examined, observed, or treated by students
respect a patient’s gender identity and gender expres- or any other facility staff . . . [and] to refuse any . . . examination when the primary
sion. Likewise, all patients, including transgender purpose is educational . . . rather than therapeutic”); N.Y. Comp. Codes R. & Regs.
and gender-nonconforming patients, deserve to have tit. 10, § 405.7 (2012) (“The hospital shall afford to each patient the right to . . .
[know] the identity of any hospital personnel including students that the hospital
privacy when discussing or consulting with their health
has authorized to participate in the patient’s treatment and the right to refuse treat-
care providers on matters related to their health and ment, examination and/or observation by any personnel”); 22 Cal. Code Regs. tit.
when being examined or receiving treatment. Privacy 22, § 70707(a)(7) (2012) (“The patient has the right to be advised as to the reason
can be especially important to transgender patients for the presence of any individual [during case discussion, consultation, examination
who may not want their transgender status disclosed and treatment].”); 77 Ill. Admin. Code tit. 77, § 270.2000(o) (2012) (“Those persons
not directly involved in the patient’s care must have the patient’s permission to be
for personal or safety reasons.17
present.”); La. Admin. Code tit. 48, § 701(A)(4) (2012) (“Those not directly involved
17 Note also that courts have held that transgender people have a particularly com- in [the patient’s] care must have the permission of the patient to be present.”);
pelling privacy interest in preserving the confidentiality of their transgender status. Okla. Admin. Code § 752:15-13-3(a)(5) (2012) (“Those not directly involved in the
See Powell v. Schriver, 175 F.3d 107, 111 (2d Cir. 1999) (“The excrutiatingly [sic] private patient’s care must have the permission of the patient to be present.”).TRANSGENDER–AFFIRMING HOSPITAL POLICIES 7
P OLIC Y 3: A D M I T T ING /R EG IS T R AT I O N he or she should politely and discreetly ask the patient to verify
R ECO R DS whether the patient is a transgender male or transgender female.
Technology and best practices regarding patient admit- The [Hospital] staff person should not attempt to guess
ting/registration records are rapidly evolving, but our whether a patient is transgender or ask the patient whether he
current recommendations are that hospitals adopt or she is transgender. The patient’s transgender status should
the following procedures when recording gender and only be recorded on the drop-down menu if the patient volun-
name designations in the admitting/registration process: teers the information and agrees that it should be recorded.
POLICY: Recording Gender on Paper Admitting/
Recording Gender in Electronic Admitting/ Registration Forms:
Registration Records:
Paper forms completed by the patient upon admitting/
In the existing “Gender” field in admitting/registration records, registration should include the following questions concerning
the [Hospital] staff person will record the patient’s gender as the the patient’s gender:
gender designation (Male or Female) that appears on the patient’s
medical insurance record, legal identification, or other source cus- 1. W hat is the gender designation on your medical
tomarily used in admitting/registration. insurance records?
In addition, the admitting/registration record will include an op- p Male
tional “Other,” “Notes,” “Special Needs,” or similar drop-down
menu that will include the following two options: p Female
p Transgender Male/Trans man/Female-to-Male (FTM) 2. (Optional) Are you transgender?
p Transgender Female/Trans woman/Male-to-Female (MTF) p Yes, I am a Transgender Male/Trans man/FTM
If the patient affirmatively states that he or she is transgender, p Yes, I am a Transgender Female/Trans woman/MTF
the [Hospital] staff person will inform the patient that the
hospital, The Joint Commission, and (if applicable) state law p No
prohibit discrimination based on gender identity and gender
expression, and ask the patient if he or she would like their Recording Name/Pronouns in Electronic
transgender status to be indicated in the patient’s admitting / Admitting/Registration Records:
registration record. If the patient indicates that the information
should be included, the [Hospital] staff person will select either In addition to the “Legal Name” field, admitting/registra-
“Transgender Male/Trans man/Female-to-Male (FTM)” or tion forms will include an optional field for a patient’s “Pre-
“Transgender Female/Trans woman/Male-to-Female (MTF)” ferred Name.” All patients should be asked if they have
from the drop-down menu to indicate the patient’s transgender a “preferred name” or “nickname” that they would like to
status. The first option should be selected when the patient has include in their admitting/registration record.
transitioned from female to male; the second option should be
selected when the patient has transitioned from male to female.
If the [Hospital] staff person is unsure of which option to select,TRANSGENDER–AFFIRMING HOSPITAL POLICIES 8
If a patient volunteers that he or she is transgender, the and quality of care for transgender patients.19 For
[Hospital] staff person will inform the patient that the hospital, example, if a hospital staff person calls a transgender
The Joint Commission, and (if applicable) state law prohibit dis- woman patient by a male name in a crowded waiting
crimination based on gender identity and gender expression, and room, this could not only be a violation of privacy poli-
ask whether the patient would like to have his or her preferred cies, but could also be embarrassing to the transgender
name and pronouns recorded in the admitting/registration record. woman, revealing her transgender status to the crowd
If the patient indicates that this information should be recorded, and potentially exposing her to verbal or physical abuse
the [Hospital] staff person should ask if the patient prefers male from other patients in the waiting room.20
or female pronouns. The [Hospital] staff person will record that Hospital admitting/registration procedures
information by including “M” or “F” in parentheticals in the should enable transgender patients to designate their
optional field that captures the patient’s Preferred Name. gender identity and preferred name even when this
gender identity and name differ from those that appear
The system should be configured to notify providers and staff if the on the patients’ medical insurance or legal identity docu-
patient’s preferred name and/or pronouns differ from the patient’s ments. It is not always possible for transgender people
current legally documented name. The system should include a read- to change their name and gender designation on legal
ily visible notification or alert flag that appears on the viewer’s screen identity documents, such as birth certificates or driver’s
and indicates the patient’s preferred name and pronouns. licenses, because some states prohibit such changes and
others make the process very burdensome and expen-
Recording Name/Pronouns on Paper Admitting/ sive.21 While it is possible for transgender patients to
Registration Forms: change the gender marker on their medical insurance
records, some transgender patients do not change this
Paper forms completed by the patient upon admitting/registra- marker, even though it does not match their current
tion should include the following questions concerning the patient’s gender identity, because their insurance company could
name and pronouns: refuse to cover certain “gender-specific” procedures
(such as hysterectomies) that are typically covered only
1. What is your legal name? for people of one sex. The barriers to obtaining legal
name/gender changes and insurance coverage for
2. (Optional) What is your preferred name or nickname? gender-specific procedures should not prevent transgen-
der patients from using their preferred name and gender
3. (Optional) What are your preferred pronouns identity in a hospital context.
(for example, he/him, she/her)? 19 Deutsch, Madeline B., et al., Electronic Medical Records and the Transgender Patient:
Recommendations from the World Professional Association for Transgender Health EMR Work-
E X PL A N AT I O N ing Group, J. Am. Med. Inform. Assoc., 0:1-4 (Apr. 30, 2013).
20 Id.
An important first step toward respecting transgender
patients’ dignity and creating a transgender-inclusive 21 The process for changing one’s legal name and sex varies by state. For example,
environment is to address transgender patients by their some states will permit changes of name and sex on legal identity documents only
preferred name and pronouns, and to affirm their gen- by court order. Others require proof that the individual seeking the change has
der identity. Failure to identify a transgender patient by undergone sex reassignment surgery. Requiring sex reassignment surgery in order
to amend one’s birth certificate can make it impossible for a transgender person
the patient’s preferred name and pronoun in a medical
to change the sex designation on their birth certificate if they cannot afford or do
setting has been shown to negatively affect satisfaction not want to undergo sex reassignment surgery. For more information, see Sources of
Authority to Amend Sex Designation on Birth Certificates, Lambda Legal (Jan. 3, 2012),
http://lambdalegal.org/publications/sources-of-authority-to-amend.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 9
Hospitals should ensure that the patient’s gender “notes,” or similar field) to record the patient’s preferred
as captured in the “Gender” field in admitting/registra- name and pronouns. We advise that hospital staff ask
tion records matches the gender marker that appears on all patients whether they have a preferred name, as
the patient’s medical insurance so the patient will not be many non-transgender patients are also likely to use a
denied coverage for medical treatment based on a “gen- nickname, but we advise that staff not ask for a patient’s
der mismatch.” However, the admitting/registration preferred pronouns unless the patient affirmatively
record should be designed to also capture a transgender volunteers that he or she is transgender. If a patient
patient’s current gender identity regardless of what is volunteers that he or she is transgender, the staff
on the patient’s legal identity documents or insurance should ask if the patient has preferred pronouns and
records. This information can be most easily recorded would like those pronouns to be indicated in the
by including in the admitting/registration record an admitting/registration record.22
optional drop-down menu from which the hospital
staff person can select “Transgender Male/Trans man/ P OLIC Y 4: PROTOCOL S FOR IN T E R AC T I ON
Female-to-Male (FTM)” or “Transgender Female/Trans WI T H T R A NSG E NDE R PAT IE N T S
woman/Male-to-Female (MTF).” Admitting/registra-
tion records that already contain separate optional fields
or drop-down menus for recording demographic data, PURPOSE:
such as the patient’s ethnicity or primary language, can To ensure that hospital staff members interact with transgender
readily be modified to include the options “Transgender patients with professionalism, courtesy, and respect.
Male/Trans man/FTM” and “Transgender Female/
Trans woman/MTF.” POLICY:
We advise that hospital staff not ask the pa- When a transgender patient presents for health care, they will
tient whether he or she identifies as transgender when be addressed and referred to on the basis of their self-identified
completing the admitting/registration record because gender, using their preferred pronoun and name, regardless of
transgender patients may be uncomfortable answering the patient’s appearance, surgical history, legal name, or sex
that question for a variety of reasons. For example, assigned at birth. If the patient’s family members suggest that
transgender patients may be reluctant to disclose trans- the patient is of a gender different from that with which the
gender status when unsure whether the information will patient self-identifies, the patient’s view should be honored.
be treated confidentially or who will have access to the
information in the future, because disclosure of trans- Hospital staff members will not use language or tone that a
gender status, even to the patient’s medical insurance reasonable person would consider to demean, question, or invali-
company, could result in discrimination. The better date a patient’s actual or perceived gender identity or expression.
practice is to allow the patient to affirmatively volunteer
that he or she is transgender. When a patient states Hospital staff members will not ask questions or make state-
that he or she is transgender, the hospital staff should ments about a transgender person’s genitalia, breasts, other
inform the patient that the hospital, The Joint Commis- physical characteristics, or surgical status except for professional
sion, and (if applicable) state law prohibit discrimination reasons that can be clearly articulated. Information about a
based on gender identity and gender expression before patient’s transgender status or any transition-related services that
asking the patient whether he or she would like the the patient is seeking and/or has obtained is sensitive medical
hospital to record the patient’s transgender status on information, and hospital staff members will treat it as such.
the admitting/registration form. 22 For more information on how to implement the recording of a patient’s gender
Similarly, we recommend that the hospital identity, preferred name, and pronouns on electronic health records, see Deutsch,
create an optional field (or use an existing “nickname,” supra note 19.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 10
PROCEDURE: “Have you had the surgery?”) or makes inappropriate
A transgender patient’s preferred pronoun should be assertions about the patient’s genitalia (e.g., “as long
determined as follows: as you have a penis, I am going to call you by a male
name”). Fortunately, only minimal effort is required to
1. If the patient’s gender presentation clearly indicates to a rea- refrain from using this kind of harassing and disrespect-
sonable person the gender with which the patient wishes to be ful language.
identified, the hospital staff member should refer to the patient Transgender patients may be reluctant to
using pronouns appropriate to that gender. share information regarding transgender status or
transition-related services because they fear discrimi-
2. If the hospital staff member determines the patient’s preferred nation or inappropriate treatment, even when this
pronoun on the basis of the patient’s gender presentation, but information may be integral to the patient’s care. To
is then corrected by the patient, the staff member should then facilitate rapport between health care providers and
use the pronouns associated with the gender identity verbally transgender patients, when a provider asks a patient
expressed by the patient. about transgender status or transition-related ser-
vices, the provider should explain proactively to the
3. If the patient’s gender presentation does not clearly indicate patient why the information sought is relevant to
the patient’s gender identity, the hospital staff member should the patient’s care and that such information will be
discreetly and politely ask the patient for the patient’s preferred treated confidentially in accordance with and to the
pronoun and name. extent required by law. Before the patient discloses
information in response to the provider’s inquiry, the
A patient should not be asked about transgender status, patient should be fully informed of any mandatory or
sex assigned at birth, or transition-related procedures unless permissive disclosures of the information in accor-
such information is directly relevant to the patient’s care. dance with the hospital’s standard notice of
If it is necessary to the patient’s care for a health care provider privacy practices. The inappropriate disclosure of
to inquire about such information, the provider should explain transgender status or transition-related medical his-
to the patient: 1) why the requested information is relevant tory may result in discrimination against the trans-
to the patient’s care, 2) that the information will be kept gender patient, so the transgender patient is entitled
confidential but some disclosures of the information may be to make an informed decision about what informa-
permitted or required, and 3) that the patient should consult tion to share with the provider.
the hospital’s HIPAA policy for details concerning permitted Note also that information about a patient’s
disclosures of patient information. transgender status or transition-related services
may constitute protected health information under
E X PL A N AT I O N HIPAA. As a result, inappropriate disclosure of this
information may be a violation of the Privacy Rule
Referring to transgender people by the wrong pro- and, other than in the context of providing treatment
noun or name, or asking inappropriate questions services (and limited other situations), is subject to
about genitalia or surgical status in an effort to the “minimum necessary” standard described in the
determine their “true” gender, is a form of harass- “Policy Guidance: Compliance with Privacy Laws”
ment. Such behavior violates a transgender patient’s section below.
rights to privacy and dignity. Verbal harassment can
rise to the level of sexual harassment when a staff
member asks inappropriate questions about the pa-
tient’s genital status (e.g., “What’s between your legs?”TRANSGENDER–AFFIRMING HOSPITAL POLICIES 11
P OLIC Y 5: RO O M A SSI G NME N T S 3. If a transgender patient does not indicate a rooming preference,
and a private room is available, the private room should be of-
We recommend that hospitals adopt the following fered to the transgender patient. The offer should be explained
policy regarding room assignments for transgender to the patient as optional and for the purpose of ensuring the
patients: patient’s privacy, safety, and comfort.
PURPOSE: 4. If a private room is not available and the transgender patient
To establish guidelines for the safe, ethical, and appropriate as- does not wish to share a room with a roommate, the transgen-
signment of rooms for transgender patients. der patient should be assigned to an empty double room with
the second bed blocked.
For the purposes of this policy, “transgender” is defined to include
any person whose gender identity, that is, their inner sense of being 5. If there is no private room or empty double room available,
male or female, differs from their assigned or presumed sex at the patient should be assigned to a room with a patient of the
birth. gender with which the transgender patient identifies.
POLICY: 6. If there is no private or empty double room available and a
Where room assignments are gender-based, transgender patients transgender patient does not wish to share a room, other
will be assigned to rooms based on their self-identified gender, patients may be moved to make a private room available if
regardless of whether this self-identified gender accords with their doing so would not compromise the health or safety of the
physical appearance, surgical history, genitalia, legal sex, sex as- patient(s) being moved.
signed at birth, or name and sex as it appears in hospital records.
7. If there is no private or empty double room available, the
That a transgender patient’s physical appearance or genitalia differ transgender patient refuses to share a room, and no other
from other patients who share the same self-identified gender is not patient can safely be moved to make a private room available,
a bar to assigning the patient to a room in accordance with his or the transgender patient should be allowed to remain in the
her gender identity. Sufficient privacy can be ensured by, for ex- Emergency Department or Admitting Office without harass-
ample, the use of curtains or accommodation in a single side-room ment until a private room becomes available.
adjacent to a gender-appropriate ward.
The [Hospital Admitting Office] shall determine a patient’s self-
PROCEDURE: identified gender prior to assigning the patient a room by reviewing
Where patients are assigned to rooms based on gender, the [Hos- the patient’s admitting/registration record. If the patient’s family
pital Admitting Office] shall assign a transgender patient to a members suggest that the patient is of a gender different from that
room in accordance with the patient’s self-identified gender, unless with which the patient self-identifies, the patient’s view should be
the patient requests otherwise. Transgender patients shall be as- honored. If upon admission it is impossible for the patient to
signed to in-patient rooms in the following order of priority: inform the staff of his or her self-identified gender because he or
she is unconscious or incapacitated, then, in the first instance, in-
1. If a transgender patient requests to be assigned to a room with ferences should be drawn from the patient’s presentation and mode
a roommate of the patient’s same gender identity, and such a of dress. No investigation of the genitals of the person should be
room is available, the request should be honored. undertaken unless specifically necessary to carry out treatment.
2. If a transgender patient requests a private room and there is
one available, it should be made available to the patient.TRANSGENDER–AFFIRMING HOSPITAL POLICIES 12
No patient will be denied admission if a gender-appropriate be no different from a situation involving a patient
bed is not available. Furthermore, complaints from another room reassignment due to roommate complaints for
patient related to a roommate’s gender identity or expression do any other reason, except that it recognizes the privacy
not constitute grounds for an exception to this room assignment and dignity of a person’s self-identified gender and
policy, as would be the case for other patients protected by non- provides for the handling of complaints by staff trained
discrimination policy, standards, and/or law. Should hospital in diverse cultural competencies and committed to
staff receive such complaints, they should remedy the situation by optimal patient care.
using curtains or other room dividers to increase the privacy of
both patients. A patient making ongoing complaints should be P OLIC Y 6: ACCE SS TO R E S T ROOMS
moved to another room as long as relocating the patient would be
medically appropriate and safe.
PURPOSE:
Should a transgender patient complain that the patient’s room- To ensure that transgender patients have safe and equal access to
mate is subjecting him or her to harassment based on the patient’s restrooms in accordance with their gender identity.
gender identity or expression, [a member of the hospital staff
trained in handling patient complaints and in issues of transgen- POLICY:
der cultural competency] should remedy the situation by relocating All patients of the hospital may use the restroom that matches
the patient’s roommate to prevent continued harassment, as long their gender identity, regardless of whether they are making a gen-
as relocating the roommate would be medically appropriate and der transition or appear to be gender-nonconforming. Transgender
safe. If the roommate cannot be relocated, the transgender patient and gender-nonconforming patients shall not be asked to show
should be moved. The transgender patient’s health is not to be identity documents in order to gain access to the restroom that is
compromised by an unsafe room assignment. consistent with their gender identity.
Where there are questions or concerns related to room assign- Harassment of transgender and gender-nonconforming patients for
ments, [a member of the hospital staff trained in handling pa- using hospital restrooms in accordance with their gender identity
tient complaints and in issues of transgender cultural competency] will not be tolerated. Transgender and gender-nonconforming
is to be consulted and an ethics consultation may be requested. patients who are harassed in this manner may contact [member of
the hospital staff trained in handling harassment complaints and
E X PL A N AT I O N in issues of transgender cultural competency].
The failure to grant room assignments to transgender For the purpose of this policy, “transgender” is defined to include
patients in accordance with their gender identity is a any person whose gender identity, that is, their inner sense of
form of discrimination that jeopardizes transgender being male or female, differs from their assigned or presumed
patients’ dignity and privacy and, in turn, discourages sex at birth.
them from seeking medical services. Gender-affirming
room assignments are a crucial step toward breaking For the purpose of this policy, “gender-nonconforming” is defined
down barriers that have hindered transgender people’s to include any person who does not meet society’s expectations of
access to health care. gender roles.
The policy provides for the handling of
complaints by a member of the hospital staff who is
experienced in patient relations and, ideally, has received
transgender cultural competency training. This wouldTRANSGENDER–AFFIRMING HOSPITAL POLICIES 13
E X PL A N AT I O N P OLIC Y G U IDA NCE: COMPLI A NCE WI T H
PR I VAC Y L AWS
This policy ensures that transgender and gender-
nonconforming patients will be able to use restrooms HIPAA and other privacy-related statutes and their
throughout the hospital that correspond to their gender implementing regulations currently provide a frame-
identity.23 The medical community now recognizes that work for hospitals and providers to handle confidential
it is essential to the health and well-being of transgen- patient information.26 However, hospitals, physicians,
der people for them to be able to live in accordance employees, and contractors may not be aware that a pa-
with their internal gender identity in all aspects of life, tient’s transgender status or history of transition-related
and that restroom usage is a necessary part of that procedures may constitute protected health information
experience. In addition, courts of law have increas- under HIPAA’s implementing regulation (the “Privacy
ingly found that discrimination against transgender and Rule”). Therefore, we recommend that hospitals review
gender-nonconforming people is sex discrimination, privacy-related materials to ensure that the needs of
making it unacceptable to prevent transgender and gen- transgender patients are adequately met. In particular,
der-nonconforming people from using the bathroom we recommend that hospitals address the needs of
that matches their gender identity.24 In some localities, transgender patients in the following ways:
discrimination related to restroom usage is expressly
prohibited by law.25 A. Privacy Policies and Procedures. A hospital or other cov-
One way hospitals can create a safer and more ered entity must develop written privacy policies and
welcoming environment for transgender and gender- procedures to ensure compliance with the Privacy
nonconforming patients is to offer private unisex Rule.27 These policies and procedures should be
bathrooms. An easy way to create a private unisex bath- reviewed to ensure that transgender patients’ rights
room is to change the sign to “unisex” on the door to privacy are specifically addressed. In particular,
of a single-stall bathroom that was previously labeled a discussion of when a patient’s transgender status
“men” or “women.” and transition-related services would be considered
While this policy is intended to cover patients protected health information should be included in
only, we encourage hospitals to embrace a truly non- the Hospital’s HIPAA Privacy Procedure Manual.
discriminatory bathroom access policy which This will ensure that all physicians, employees, and
allows not only patients but also hospital employees contractors know that a patient’s transgender status
and visitors to access restrooms in accordance with and transition-related services may constitute pro-
their gender identity. tected health information under the Privacy Rule
and also know the particular situations when such
23 Jody L. Herman, The Williams Institute, UCLA School of Law, Gendered
Restrooms and Minority Stress: The Public Regulation of Gender and its Impact on Transgender 26 Under the Privacy Rule, “protected health information” is all “individually
People’s Lives (2013) (discussing minority stress related to gender nonconformity and identifiable health information” held or transmitted by a covered entity or its busi-
the negative affect on health outcomes for transgender and gender-nonconforming ness associate, in any form or medium. This includes all information, including
people who experience prejudice and stigma in accessing restrooms). demographic data, that relates to (i) the individual’s past, present, or future physical
or mental health or condition; (ii) the provision of health care to the individual;
24 For more information, see Transgender Rights Toolkit: Equal Access to Public Rest- or (iii) the past, present, or future payment for the provision of health care to the
rooms, Lambda Legal (Feb. 1, 2011), http://lambdalegal.org/publications/trt_equal- individual; and that identifies the individual or for which there is a reasonable basis
access-to-public-restrooms. to believe it can be used to identify the individual. 45 C.F.R. § 160.103.
25 For more information, see Transgender Law & Pol’y Inst., supra note 12. 27 45 C.F.R. § 164.530(i).TRANSGENDER–AFFIRMING HOSPITAL POLICIES 14
information would be considered protected health C. P
rivacy Training Programs. The Privacy Rule requires
information, for example, when it is coupled with that hospitals and other covered entities provide
identifying information, such as a name, photograph, training to physicians, employees, and contractors
or other medical history which could be used to to ensure compliance.29 These trainings and related
identify the patient. materials should be reviewed and revised as necessary
to include specific examples of the circumstances
B. “Minimum Necessary” Standard. under which transgender status and transition-related
services may be considered protected health informa-
We recommend that the hospital include the tion and the application of the Privacy Rule to such
following language in its HIPAA Privacy information.
Procedure Manual:
D. S afeguards. The Privacy Rule requires that hospitals
very physician, [Hospital] employee, and contractor who
E and other covered entities maintain reasonable and
uses, discloses, or requests patient information, including appropriate administrative, technical, and physical
information regarding a patient’s gender identity or expres- safeguards to prevent intentional or unintentional use
sion, transgender status, or other demographic data, on behalf or disclosure of protected health information in vio-
of [Hospital], shall make reasonable efforts to limit disclo- lation of the Privacy Rule.30 Hospital policies should
sure of and requests for protected health information to any be revised, as necessary, to make clear that any dis-
person not directly involved in the treatment of a particular cussion or documentation of transgender status and
patient to the minimum necessary to accomplish the authorized transition-related services, any medical history related
purpose of the use, disclosure, or request, in accordance with to transition, and similar information may involve
applicable federal law and regulations, including minimizing protected health information, and as such would be
incidental disclosures. Procedures appropriate for implement- subject to the hospital’s administrative, technical,
ing this policy vary based on the intended purpose of the use, and physical safeguards. For example, if a patient
disclosure, or request, as provided elsewhere in this HIPAA indicates in an admitting/registration record or in a
Privacy Procedure Manual. subsequent conversation with admitting/registration
personnel that he or she is transgender, reasonable
[ Hospital] will ensure that every physician, [Hospital] and appropriate safeguards (such as keeping the re-
employee, and contractor will have access to protected health cords in a folder where they are not easily accessible,
information only to the minimum extent necessary and or taking care to hold conversations about the pa-
relevant to perform his or her specific job functions, as tient’s status in private) should be in place to ensure
described in this HIPAA Privacy Procedure Manual.28 that no protected health information is intentionally
or unintentionally disclosed or overheard by physi-
cians, employees, independent contractors, patients,
or hospital visitors.
28 Hospitals are already required under HIPAA’s implementing privacy regulation
(the “Privacy Rule”) to limit disclosures of protected health information, including
under the “minimum necessary” standard. These protections apply to transgender
individuals as they would for any other patient. Note that “protected health infor-
mation” includes any health information, including demographic data, that relates to
an individual’s physical or mental health condition, or payment for the provision of 29 45 C.F.R. § 164.530 (b).
health care, and that identifies the individual or for which there is a reasonable basis
to believe can be used to identify the individual. 45 C.F.R. § 160.103. 30 45 C.F.R. § 164.530 (c).TRANSGENDER–AFFIRMING HOSPITAL POLICIES 15
E. Breach. Interim final regulations implementing the A covered entity must document all complaints
HI-TECH Act require hospitals and other covered received, and their disposition, if any.35 Hospitals
entities to provide notification to an individual fol- should review their policies to ensure that a
lowing a breach of that individual’s unsecured pro- proper process is established for documenting
tected health information.31 Generally, a “breach” and responding to complaints, and should ensure
occurs when there is an impermissible use or dis- that transgender patients are made aware of
closure of unsecured protected health information their right to complain about improper uses or
under the Privacy Rule that poses a significant risk of disclosures of their protected health information.
financial, reputational, or other harm to the affected
individual.32 Hospitals should review their policies P OLIC Y G U IDA NCE: INSU R A NCE G U IDE LINE S
to ensure that any “breach” related to a transgender
patient’s protected health information is handled The negative experiences that these model policies aim
in accordance with these regulations and that to eliminate are often compounded by insurance-related
transgender patients are notified if their protected practices that create additional barriers to care. To fos-
health information is inappropriately disclosed. ter a better understanding of the insurance issues faced
Physicians, employees, and contractors should be by transgender patients, this section briefly discusses
trained accordingly. insurance-related practices that affect access to quality
health care.
F. Internal Sanctions. Under the Privacy Rule, a cov- Leading authorities in the medical and policy
ered entity must have in place and apply appropri- communities,36 including the American Medical As-
ate sanctions against members of its workforce (i.e., 35 45 C.F.R. § 164.530(d)(2).
physicians, employees, and contractors) who violate
the entity’s policies and procedures and the Privacy 36 For a full compilation of professional organizations’ statements in support
Rule.33 Hospitals should specify that inappropriate of access to care for transgender patients, see Professional Organization Statements
Supporting Transgender People in Health Care, Lambda Legal (July 2, 2013), http://
use, disclosure, or request of a transgender patient’s
www.lambdalegal.org/publications/fs_professional-org-statements-supporting-
protected health information is both a violation of trans-health. See also, e.g., Am. Med. Ass’n H.D., Resolution 122 (A-08): Remov-
the hospital’s internal HIPAA policies and proce- ing Financial Barriers to Care for Transgender Patients (June 2008), http://
dures, and a violation of the Privacy Rule, and that www.tgender.net/taw/ama_resolutions.pdf (“Whereas, An established body of
such violations will be subject to appropriate disci- medical research demonstrates the effectiveness and medical necessity of mental
health care, hormone therapy and sex reassignment surgery as forms of therapeutic
plinary action.
treatment for many people diagnosed with GID; and . . . Health experts in GID .
. . have rejected the myth that such treatments are ‘cosmetic’ or ‘experimental’ and
G. Complaints. The Privacy Rule requires that covered have recognized that these treatments can provide safe and effective treatment for
entities must provide a process for individuals to make a serious health condition . . . therefore be it . . . Resolved, That the AMA oppose
complaints concerning the entity’s policies and proce- categorical exclusions of coverage for treatment of gender identity disorder when
prescribed by a physician . . . .”); Am. Psychiatric Ass’n, Position Statement on
dures required by the Privacy Rule, and concerning the
Access to Care for Transgender and Gender Variant Individuals (July 2012),
entity’s compliance with such policies and procedures.34 http://www.psychiatry.org/File%20Library/Advocacy%20and%20Newsroom/
Position%20Statements/ps2012_TransgenderCare.pdf (“[T]he American Psychiatric
31 45 C.F.R. § 164.404. Association . . . [r]ecognizes that appropriately evaluated transgender . . . individuals
can benefit greatly from medical and surgical gender transition treatments . . . [and]
32 45 C.F.R. § 164.402. supports both public and private health insurance coverage for gender transition
treatment.”); Transgender, Gender Identity, & Gender Expression Non-Discrimination, Am.
33 45 C.F.R. § 164.530(e). Psychological Ass’n, Council of Representatives (Aug. 2008), http://www.apa.
org/about/policy/transgender.aspx (“APA recognizes the efficacy, benefit and medi-
34 45 C.F.R. § 164.530(d)(1). cal necessity of gender transition treatments for appropriately evaluated individualsYou can also read
