Quality care for the transgender patient

Wendy B. Stern, MD, a member of the AAO-HNS Diversity and Inclusion Committee, interviews Jeffrey H. Spiegel, MD, Chief of the Facial Plastic Surgery Program and Professor of Otolaryngology-Head and Neck Surgery at the Boston University School of Medicine, regarding caring for transgender patients.

Wendy B. Stern, MD

Dr. Stern: How did you first become interested in working with transgender patients?

Jeffrey H. Spiegel, MD

Dr. Spiegel: About 20 years ago, a transgender woman came to see me and asked if I could help her to look more feminine. I explained that while I knew how to do facial surgery, I did not know exactly what to change. I checked the very limited literature and told her what I suggested. To my surprise, she desired to go forward, and we went ahead and did a cranioplasty plus several other procedures. She was happy with the outcome and went off, leaving me thinking this was probably a one-time interesting case. But she sent someone else, and that continued, and now we see dozens of people for facial feminization surgery each week. Additionally, I found it fascinating that there was so little information available about how we determine gender when we look at someone’s face. As an academic surgeon, I began doing research on that. It has been extremely gratifying to learn more about this and discover how fundamental gender is to our understanding of beauty and attractiveness.

Dr. Stern: I imagine there are many hurdles to overcome in order to provide high quality care, starting with the mechanics of the office or clinic. Did you in-service your staff specifically for working with the transgender community?

Dr. Spiegel: Absolutely. I have learned so much from interacting with thousands of transgender women over the last 20 years and regularly teach my own staff, hospital staff, and people at conferences how to most effectively care for transgender patients. To be honest, it’s truly just common sense. I think that any transgender patient who seeks my care is heroic in their willingness to face the challenges they’ve been given and to take active steps to live their best life. That being said, there are many specific ways to make these patients comfortable in your office.

Dr. Stern: How can physicians who are unfamiliar with transgender and LGBTQ healthcare imperatives improve their ability to welcome, engage, and care for this community?

Dr. Spiegel: Perhaps the best way is to recognize that acceptance and respect are the key. If you have the skills to enable a person to look better, you can improve their health. Caring for transgender patients allows you to use all of your skills to truly and deeply help people. I think the key is to treat LGBTQ patients exactly as you would any other patient; that is, each individual has a unique medical history that contributes to their needs and treatment plan, but all of your patients are reaching out for assistance.

Dr. Stern: I know that the use of language plays an important role in developing relationships and caring for LGBTQ patients. What other dynamics should we be sensitive to? How do we finesse our history, physical examination, and counseling?

Dr. Spiegel: If you have a person whose legal name seems inconsistent with the way they are presenting, it’s a good idea to ask the person what they “go by.” Most EMR software can put in a “goes by” or “nickname” in the identification data fields. Then, use the pronouns (e.g., she, he, they) most consistent with the person’s identity. You’ll make some mistakes in the beginning, but people can tell if you are being rude or if it was an innocent error. If you slip up, just apologize and correct yourself without making a big deal about it. I assume that each of us wants all patients who come to our offices to feel welcomed and cared for in a professional environment. Being respectful and treating all people the same is an obvious part of that.

As far as our medical records, being transgender, for example, is simply one component of a person’s medical history and should be documented as such. For example, “Patient X is a 35-year-old transgender woman.” This would mean they were born with male anatomy but identify and likely present as a woman. I also make sure that my transgender patients understand the many healthcare prerequisites that need to be considered before undergoing transformative surgery, such as adjusting hormones around the time of surgery and the type and duration of hormone treatment that will effect what type of surgery they’ll need. As a result, I coordinate care with their medical doctors. I also work with the patients’ therapists and mental health professionals to determine appropriateness and timing of surgery.

Dr. Stern: Education has always been central to what we do. Any recommendations?

Dr. Spiegel: Education is key. I give lectures regularly on how to best serve the transgender population, including coaching employees on how to address their needs. Ultimately, it all comes down to understanding, caring, and empathy. Plus, you need a sense of personal pride in yourself and your office. When you take pride in your own work, you strive to provide the best experience for everyone who comes to see you. I have included some references for those who might be interested below.

Spiegel JH. Facial Feminization for the Transgender Patient. J Craniofac Surg. 2019 Jun 7.

Spiegel JH. Challenges in care of the transgender patient seeking facial feminization surgery. Facial Plast Surg Clin North Am. 2008 May;16(2):233-8, viii.

Spiegel JH. Phonosurgery for pitch alteration: feminization and masculinization of the voice. Otolaryngol Clin North Am. 2006 Feb;39(1):77-86.