Wednesday, August 28, 2013

Transcription Problems

By apparent coincidence, I have had two transgender patients come in recently, within spitting distance of when Pvt Chelsea Manning (nee Bradley Manning) came out as a trans woman. Such patients are not all that uncommon. But though these two were unconnected to each other and didn't even have similar complaints, we wound up having a similar issue in each case.

Each of those patients felt the need to lie to me.

I don't mean that they reported a different sex than what they were born with. That's neither a lie nor a problem. It doesn't matter to me what name or pronouns you use; just state your preference and I'll follow your lead. In the ED we hardly care what the box on your drivers license says or whether it matches your chromosomes.

What we do care about is figuring out why our patients are sick. And the fact is that physical organs are relevant to your medical care, even more so than your surgical history or your medication list. So if you decide to fib to us, and claim outright that your presenting gender matches the equipment you're carrying around, that is a problem. Sometimes it won't wind up affecting anything. But sometimes, not telling us the complete story can lead to delays in care, or even a dangerous missed diagnosis.

Just for example, if you come in complaining of low abdominal pain, we start considering various problems from appendicitis to urinary tract infection. If your chart says Male at the top, then the list also includes things like testicular torsion or epididymitis. But if you happen to be a preoperative trans man, we've got to make a critical shift in our thinking. We need to forget about scrotal issues and shift instead to stuff like PID or ovarian cysts or ectopic pregnancy.

(A ruptured ectopic, just for the record, is a surgical emergency. Missing it would be life threatening. It's a good thing for everybody that we didn't miss one.)

I understand that trans people are at high risk for abuse and disrespect. I'm sure it must be difficult to discuss such a personal issue with a stranger you've only just met. But we're here to help. You came to the ED and literally put your life in our hands. If you trust us with your health, why wouldn't you also trust us with that one other detail?

It upsets me both personally and on a professional level, to learn that people even in great need might feel they have to hide that information from us. I wish I had some idea what to do about it.