Cultural Competency Series: Transgendered Patients

In light of much media coverage and an obvious lack of knowledge demonstrated on social media sites, our first post for cultural competency is on Transgendered patients. Our hope is to educate others on this important topic so that they can better understand the patients under our care and the laws implicated or suggested in our country.

Important Definitions

It first is important to understand some important vocabulary differences:

Gender Identity: One’s innermost concept of self as male, female, a blend of both, or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth.

Gender Expression: external appearance of one’s gender identity, usually expressed through behavior, clothing, haircut or voice, and which may or may not conform to socially defined behaviors and characteristics typically associated with being either masculine or feminine.

Sexual Orientation: a person’s sexual identity in relation to the gender to which they are attracted; the fact of being heterosexual, homosexual, or bisexual. There are some transgendered people who are sexually attracted to their own sex as well as some that are attracted to the opposite sex. There are some married couples that may appear heteronormative, where for one example, a female to male transgendered person who now presents as a male (and may be legally recognized as a male) is married to a biological female.

Transgender: an umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as straight, gay, lesbian, bisexual, etc.

Gender Dysphoria: clinically significant distress caused when a person’s assigned birth gender is not the same as the one with which they identify. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the term – which replaces Gender Identity Disorder – “is intended to better characterize the experiences of affected children, adolescents, and adults.”

Gender Transition: the process by which some people strive to more closely align their internal knowledge of gender with its outward appearance. Some people socially transition, whereby they might begin dressing, using names and pronouns and/or be socially recognized as another gender. Others undergo physical transitions in which they modify their bodies through medical interventions.

Drag Queen: a man who dresses up in women’s clothes, typically for the purposes of entertainment.

Drag King: a woman who dresses up in men’s clothes, typically for the purposes of entertainment.

Crossdresser (sometimes formerly called “Transvestite”): the term cross-dressing denotes an action or a behavior without attributing or implying any specific causes for that behavior. It is often assumed that the connotation is directly correlated with behaviors of transgender identity or sexual, fetishist, and homosexual behavior, but the term itself does not imply any motives and is not synonymous to one’s gender identity, however many will refer to a gay man dressing in women’s clothes as a drag queen and use the term crossdresser for an identified straight male who enjoys wearing women’s clothing, most often for sexual fetish purposes. If the purpose was entertainment, then it would be a drag queen scenario, and if it were about gender identify, then they would likely identify as a transgendered person.

FTM, MTF- Stands for “female to male” and “male to female.”

Cisgender: Often shortened to “cis,” cisgender is a term used frequently in the intersectional, feminist, LGBT+, and transgender communities. It is an adjective used to describe someone whose gender identity matches their body and the gender assigned to them at birth– in other words, someone who is not transgender, nonbinary, or intersex. (i.e. A male who is born male, and is heterosexual is a cisgendered male or heterosexual cisgendered male to be more specific.)

ICD-10-CM Codes:

F64.- Gender identity disorder (Category):

F64.0 Transsexualism (Gender identity disorder in adolescence and adulthood, or Gender dysphoria in adolescents and adults. )

F64.1 Dual role transvestism Use additional code to identify sex reassignment status (Z87.890) [Excludes1: gender identity disorder in childhood (F64.2), Excludes2: fetishistic transvestitism (F65.1)]

F64.2 Gender identity disorder of childhood (Gender dysphoria in children) [Excludes1: gender identity disorder in adolescence and adulthood (F64.0), Excludes2: sexual maturation disorder (F66)]

F64.8 Other gender identity disorders

F64.9 Gender identity disorder, unspecified (Gender-role disorder NOS)

F65.1 Transvestic fetishism (Fetishistic transvestism)

Z87.89- Personal History of other specified conditions (Category):

Z87.890 Personal history of sex reassignment

  • Keep in mind that the decision to go through complete and full sex reassignment surgery is a private and individual choice. Some patients may chose to “go all the way” while others may chose to go through hormonal treatments only and not have full surgery for sex reassignment. There are multiple reasons for this such as personal preference, successes or unsuccessful outcomes of these surgeries, as well as cost. The surgery itself does not make one “transgendered.”

From the American Psychological Association:

Highlights include the following statements:

  • Transgender and gender nonconforming1 (TGNC) people are those who have a gender identity that is not fully aligned with their sex assigned at birth. The existence of TGNC people has been documented in a range of historical cultures (Coleman, Colgan, & Gooren, 1992; Feinberg, 1996; Miller & Nichols, 2012; Schmidt, 2003). Current population estimates of TGNC people have ranged from 0.17 to 1,333 per 100,000 (Meier & Labuski, 2013). The Massachusetts Behavioral Risk Factor Surveillance Survey found 0.5% of the adult population aged 18 to 64 years identified as TGNC between 2009 and 2011 (Conron, Scott, Stowell, & Landers, 2012).
  • The purpose of the Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (hereafter Guidelines) is to assist psychologists in the provision of culturally competent, developmentally appropriate, and trans-affirmative psychological practice with TGNC people.
  • Trans-affirmative practice is the provision of care that is respectful, aware, and supportive of the identities and life experiences of TGNC people (Korell & Lorah, 2007).
  • Because of the high level of societal ignorance and stigma associated with TGNC people, ensuring that psychological education, training, and supervision is affirmative, and does not sensationalize (Namaste, 2000), exploit, or pathologize TGNC people (Lev, 2004), will require care on the part of educators. Students will benefit from support from their educators in developing a professional, nonjudgmental attitude toward people who may have a different experience of gender identity and gender expression from their own.

The full report from December 2015 may be viewed here: https://www.apa.org/practice/guidelines/transgender.pdf

It should be noted that being transgendered is not a whimsical choice that just happens one day. These people are born with a feeling and knowing in their own mind, through gender identity, as the opposite (in a mental identity sense) of what is presented physically on their body. A great deal of emotional and psychological trauma is often endured. There is a lengthy process of counseling, hormonal therapy, and legal battles that ensue for these patients.

Additional Valuable Resources Include: 

Transgendered related topics from Wikipedia

Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People From the UCSF Center of Excellence for Transgendered Health

The Bathroom Bill Crisis Issues in Many States:

A bathroom bill is the common name for legislation or a statute that defines access to public facilities – specifically restrooms – by transgender individuals. Bathroom bills affect access to restrooms for an individual based on a determination of their sex as defined in some specific way – such as their sex as assigned at birth, their sex as listed on their birth certificate, or the sex that corresponds to their gender identity. A bathroom bill can either be inclusive or exclusive of transgender individuals, depending on the aforementioned definition of their sex.

Critics of bills which exclude transgender individuals from restrooms which conform to their gender identity argue that they do not make public restrooms any safer for cisgender (non-transgender) people, and that they make public restrooms less safe for both transgender people and gender non-conforming cisgender people. Additionally, while there is not a single documented case of a transgender person attacking a cisgender person in a public restroom, many transgender people have been verbally, physically, and sexually harassed or attacked by cisgender people in public facilities.

The  LGBT+ community has successfully managed bathroom access for years. It is standard practice in gay bars for example to utilize the restroom that identifies with your current gender expression. This means that men would use the mens room, unless they were presenting as a female (in wig, dress, etc.) and in such cases they would normally utilize the women’s restroom.

For those who argue that one cannot deny their born gender, they should be educated. Transgendered people do indeed exist in this world. It only makes sense that people should use the restroom of their expression. Naysayers have argued that this places risk of women and girls to “perverts” who might then dress in women’s clothing to gain access to women’s facilities for unsavory purposes, however no true transgendered person would have any such inclination. Trans FTM wish to be seen and accepted as men, and MTF trans people wish to be seen and regarded as women.

If you are still unsure, then take a look at the photos below. Each of the “male appearing” folks were born female, and each of the “female appearing” folks were born male. Would you want them being forced to use a restroom based on their physical or birth gender or how they appear/express themselves?

I do not think that most cisgendered men would be comfortable with these trans women entering a men’s room…

 

Nor would cisgendered women would feel comfortable with these trans men entering a women’s restroom. 

Bathroom bills that discriminate against these people must be stopped, but this can only happen through education and learning. Some argue that they should be based on gaining a new legally recognized identification that present the new identified gender, however this process is lengthy, and varies in time from state to state. If a transgendered person is awaiting this legal approval, and going through a transition, (and often taking hormonal therapies simultaneously) then it only stands to reason by all common sense that they should be allowed to use a restroom that matches their physical expression.

Some Videos on How it Feels to Be Transgendered:

Transgendered Patients are at an increased risk as Victims of Hate Crimes and Violence

 

Brian Boyce, BSHS, CPC, CPC-I, CRC, CTPRP is an AAPC-approved PMCC medical coding instructor, and ICD-10-CM trainer and the author of the AAPC CRC® curriculum. He has specialized in risk adjustment from the very beginnings of these models being utilized and has assisted large and small clients nationally. He has special interest in ethics, patient safety, disease management, and management and leadership of people. Brian is a veteran of Desert Storm, where he served on active duty with the US Air Force with a job specialty of Aeromedical Evacuation. He went into physician practice management and medical coding after an honorable discharge. He is the CEO of ionHealthcare®, LLC, a company that specializes in risk adjustment coding & support services. For additional inquiries contact ionHealthcare® at info@ionHealthcare.com.