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Alpert AB, Mehringer JE, Orta SJ, Hernandez T, Redwood EF, Rivers L, Manzano C, Ruddick R, Adams S, Sevelius J, Belanger E, Operario D, Griggs JJ. Transgender People's Experiences Sharing Information With Clinicians: A Focus Group-Based Qualitative Study. Ann Fam Med 2023; 21:408-415. [PMID: 37748898 PMCID: PMC10519763 DOI: 10.1370/afm.3010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 05/07/2023] [Accepted: 05/10/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE Investigating transgender people's experiences sharing health information in clinical encounters may yield insights for family medicine clinicians. METHODS This was a qualitative study using a community-based participatory research approach and interpretive description methodology. Seven qualitative focus groups were conducted with 30 transgender adults living in North America. We used purposive sampling to ensure diversity. The focus groups were transcribed verbatim, and 2 investigators independently reviewed and coded each transcript, then they mutually reviewed the transcripts, reconciled their coding, and summarized the codes into themes. Themes were reviewed with community members, participants, and uninvolved clinically oriented investigators for member checking and peer debriefing. RESULTS Four themes were noted: (1) transgender people often perceive clinicians' questions as voyeuristic, stigmatizing, or self-protective; (2) patients describe being pathologized, denied or given substandard care, or harmed when clinicians learned they are transgender; (3) transgender people frequently choose between risking stigma when sharing information and risking ineffective clinical problem solving if clinicians do not have all the information about their medical histories; (4) improving the safety of transgender people is difficult in the context of contemporary medical systems. CONCLUSIONS Transgender people often must choose between stigma and potentially suboptimal care. Improvements in medical culture, policies, procedures, and data collection tools are necessary to improve the quality and safety of clinical care for transgender people. Institutional and systems changes may be required to safely and effectively implement sexual orientation and gender identity (SOGI) data collection in clinical settings.
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Affiliation(s)
- Ash B Alpert
- Yale Cancer Center, Yale School of Medicine, New Haven, Connecticut (A.B.A.);
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island (A.B.A., E.B.)
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York (A.B.A.)
| | - Jamie E Mehringer
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York (J.E.M.)
| | - Sunshine J Orta
- University Health Services, University of Rochester, Rochester, New York (S.J.O.)
| | - Tresne Hernandez
- University of Rochester School of Medicine and Dentistry, Rochester, New York (T.H.)
| | - Emile F Redwood
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York (L.R., E.R., C.M., R.R.)
| | - Lexis Rivers
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York (L.R., E.R., C.M., R.R.)
| | - Charlie Manzano
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York (L.R., E.R., C.M., R.R.)
| | - Roman Ruddick
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, New York (L.R., E.R., C.M., R.R.)
| | - Spencer Adams
- Transgender Cancer Patient Project, Ashland, Oregon (S.A.)
| | - Jae Sevelius
- Western Michigan University, Kalamazoo, Michigan (J.S.)
| | - Emma Belanger
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island (A.B.A., E.B.)
| | - Don Operario
- Department of Medicine, University of California San Francisco, San Francisco, California (D.O.)
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia (D.O.)
| | - Jennifer J Griggs
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.G.)
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan (J.J.G.)
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Alpert AB, Rivers L, Manzano C, Ruddick R, Adams S, Obedin-Maliver J, Harvey RD, Griggs JJ, Operario D. Debunking Sex and Disentangling Gender From Oncology. J Clin Oncol 2023; 41:3791-3795. [PMID: 37235816 PMCID: PMC10860932 DOI: 10.1200/jco.22.02037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 03/05/2023] [Accepted: 03/28/2023] [Indexed: 05/28/2023] Open
Affiliation(s)
- Ash B. Alpert
- Center for Gerontology, Brown University School of Public Health, Providence, RI
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY
| | | | | | | | | | - Juno Obedin-Maliver
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, CA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, CA
- The PRIDE Study, Stanford University School of Medicine, Palo Alto, CA
| | - R. Donald Harvey
- Departments of Hematology and Medical Oncology and Pharmacology and Chemical Biology, Emory University School of Medicine, Atlanta, GA
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Jennifer J. Griggs
- Department of Internal Medicine, Hematology & Oncology Division, University of Michigan, Ann Arbor, MI
- Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Don Operario
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, GA
- Department of Behavioral and Social Sciences, Brown University, Providence, RI
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Alpert AB, Mehringer JE, Orta SJ, Redwood E, Hernandez T, Rivers L, Manzano C, Ruddick R, Adams S, Cerulli C, Operario D, Griggs JJ. Experiences of Transgender People Reviewing Their Electronic Health Records, a Qualitative Study. J Gen Intern Med 2023; 38:970-977. [PMID: 35641720 PMCID: PMC10039220 DOI: 10.1007/s11606-022-07671-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/06/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND The 21st Century Cures Act and the OpenNotes movement have brought patients immediate access to their electronic health records (EHRs). The experiences of marginalized people, including transgender people, accessing and reviewing their EHRs could inform documentation guidelines to improve patient-clinician rapport and reduce harm. OBJECTIVE To investigate the experiences of transgender people reviewing EHRs. DESIGN Qualitative study using community-engaged research and an interpretive description methodology. Participants were recruited via social media, snowball sampling was employed, and purposive sampling was used to ensure diversity in terms of age, race/ethnicity, and other factors. In focus groups, participants were asked to discuss their experiences reviewing their EHRs and, for those participants who were clinicians, their experiences reviewing other clinicians' documentation. PARTICIPANTS Thirty transgender adults aged 20 to 67 years, including 10 clinicians. APPROACH Digital audio-recordings of focus groups were transcribed verbatim. Content was analyzed to identify emerging essential elements and analysis was continued until no new themes emerged (i.e., saturation). KEY RESULTS Four themes were noted. (1) Using the wrong name, pronoun, or gender marker for patients is common in the EHR, erodes trust, and causes trauma. (2) Various aspects of clinicians' notes contradict, blame, or stigmatize patients, across multiple axes of oppression. (3) Limitations of EHR capabilities create barriers to quality care. (4) Certain medical customs set the stage for marginalizing, objectifying, and pathologizing transgender people. CONCLUSIONS Transgender people experience harm via various aspects of EHR documentation, suggesting that changes must be made to improve patient-clinician relationships and reduce ill-effects for patients.
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Affiliation(s)
- Ash B Alpert
- Department of Health Services, Policy & Practice, Center for Gerontology and Healthcare Research, Brown University School of Public Health, Box G-S121-6, Providence, RI, 02903, USA.
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA.
| | - Jamie E Mehringer
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Emile Redwood
- Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY, USA
| | - Tresne Hernandez
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Lexis Rivers
- Transgender Cancer Patient Project, Ashland, OR, USA
| | | | - Roman Ruddick
- Transgender Cancer Patient Project, Ashland, OR, USA
| | | | - Catherine Cerulli
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
- The Susan B. Anthony Center, Rochester, NY, USA
| | - Don Operario
- Department of Behavior and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer J Griggs
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Alpert AB, Gampa V, Lytle MC, Manzano C, Ruddick R, Poteat T, Quinn GP, Kamen CS. I'm not putting on that floral gown: Enforcement and resistance of gender expectations for transgender people with cancer. Patient Educ Couns 2021; 104:2552-2558. [PMID: 33745786 PMCID: PMC9320277 DOI: 10.1016/j.pec.2021.03.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/25/2021] [Accepted: 03/05/2021] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Understanding barriers to care for transgender people with cancer is necessary to increase oncologic care access. Little has been published regarding the experiences of transgender people with cancer. We sought to explore these experiences, assess barriers to oncologic care, and elucidate potential solutions. METHODS Using an interpretive descriptive approach, we conducted two group interviews with transgender people who had been diagnosed with cancer and one with physicians who treat patients with cancer. Two investigators independently analyzed verbatim transcripts and, together, refined themes, resolving disagreements with consensus. Member checking and peer debriefing were used to confirm and elaborate on findings. RESULTS Seven people who had been diagnosed with cancer and five physicians who treat people with cancer participated in group interviews. Themes included: (a) experiences with cancer may uniquely impact transgender people; (b) enforcement of clinician and systemic gender expectations creates barriers to cancer care; and (c) resistance to gender expectations may facilitate care. CONCLUSIONS Gender expectations create barriers to oncologic care, which can be resisted by patients, clinicians, and institutions. IMPLICATIONS FOR PRACTICE Clinicians and institutions should create gender-inclusive oncologic spaces, demonstrate allyship, and support patient autonomy to decrease barriers to care for transgender people with cancer.
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Affiliation(s)
- Ash B Alpert
- Department of Medicine, Division of Hematology and Medical Oncology, University of Rochester Medical Center, Rochester, NY, USA.
| | - Vikas Gampa
- Department of Medicine, Massachusetts General Hospital, Cambridge, MA, USA
| | - Megan C Lytle
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Roman Ruddick
- Transgender Cancer Patient Project, Martinez, CA USA
| | - Tonia Poteat
- Department of Social Medicine, University of North Carolina, Durham, NC, USA
| | - Gwendolyn P Quinn
- Department of Obstetrics and Gynecology, Perlmutter Cancer Center New York University Langone Health, New York, NY, USA
| | - Charles S Kamen
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Affiliation(s)
- Ash B Alpert
- Division of Hematology and Medical Oncology, Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Roman Ruddick
- San Francisco State University, San Francisco, CA, USA
- Transgender Cancer Patient Project, Martinez, CA, USA
| | - Charlie Manzano
- San Francisco State University, San Francisco, CA, USA
- Transgender Cancer Patient Project, Martinez, CA, USA
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