I read with interest the interview with Mark V. Williams, PhD, on health literacy in the January 2012 issue of CLN's Patient Safety Focus (1). I agree that poor health literacy poses a risk to patients. In addition, special patient populations face their own unique risk factors. On behalf of my colleagues in the Department of Pathology and Laboratory Medicine at Emory University, I want to share an experience with your readers that we had involving transgender patients.

Recently, one of our phlebotomists was approached by a transgender patient who had fully transitioned from male to female. The patient was on hormone therapy following sex reassignment surgery; however, all of her medical records still indicated that she was a male. The patient requested that all of her records be changed to reflect completion of her gender reassignment. After learning of this situation, our laboratory leadership decided to invite a transgender patient to connect with front-line hospital staff so that our employees could better understand the needs of these individuals. This discussion made us realize that not only does the transgender population face unique patient safety risks that are not widely recognized but that other special populations also may encounter certain risks.

One such issue is access to competent care. Transgender persons represent one of the most underserved and misunderstood populations in healthcare. Society often stigmatizes transgender individuals, not unlike the way patients with poor reading skills can be shut off from important information about their health. Front-line hospital staff may positively influence the care of these patients simply by putting on a friendly face and responding to their questions and concerns in the same compassionate manner they would use with any patient. Negative interactions, however, could leave transgender patients feeling denigrated and lead them to make poor healthcare choices. For example, in order to avoid such emotionally painful interactions, the patient might decide to obtain medicines and treatments from nontraditional sources or to forgo care completely. In fact, the prevalence of unsupervised hormone use in urban transgender populations reportedly ranges from 29–63%, a behavior that poses a significant health risk (2,3).

Transgender symbol
Transgender patients face unique challenges in the healthcare system. Gender choice on medical intake forms exemplifies just one such difficulty.

Even today, few healthcare professionals receive training in delivering care to special patient populations. A negative first impression for the patient may set the tone for future medical visits, as well as cast doubt about the organization's ability and willingness to care for this individual. To ensure the safety of all patients, it is critical that front-line staff respond respectfully to the needs of each patient, regardless of age, gender, pregnancy status, or race. Training is essential to ensure that employees understand how to interact courteously with all patients.

Another area that can negatively impact the care of special patient populations is one that laboratories have long struggled with: the ability to provide appropriate reference ranges. This is true for pediatric, pregnant, geriatric, and transgender patients. Many laboratory tests report results in terms of age, race, and/or gender-specific reference ranges.

Overcoming Transgender Patient Safety Issues

In an effort to promote safe access to care and descriptive gender assignments, we invited a transgender patient to talk to our hospital's front-line staff. The session was well-attended and included representatives from customer service, phlebotomy, radiology, and the emergency department, as well as our hospital chaplains. The laboratory's goal was to gain information that would help us improve processes related to gender assignment in the laboratory information system.

We first introduced our staff to common transgender terminology and discussed how individuals must be diagnosed with gender dysphoria by a mental health professional before they can start on hormone therapy. We then encouraged staff to participate in a meeting with a transgender individual that was mediated by Emory University's Office of Lesbian, Gay, Bisexual, and Transgender Life. The individual shared his experiences, not only in healthcare, but in the broader context of navigating society as a transgender person now living as a man instead of a woman.

He also answered questions and discussed best practices relating to transgender patients. Some of the issues that surfaced included restroom facilities designated male or female, medical records, and health insurance. Perhaps the most pertinent issue for the laboratory was hospital intake and admission forms. Ultimately, these forms impact the laboratory's ability to display reference ranges reflective of the appropriate population. We discussed choices such as natal or identified gender and legal or preferred name.

Overall, the session was a positive and enlightening experience for all participants. Many attendees lingered after the session ended to thank the patient and other speakers for sharing their experiences and to ask them to speak to individual departments about specific patient safety issues.

In our discussion with the transgender individual, we learned that transgender patients often resist revealing their gender identity. For example, when faced with gender choice on medical intake forms, the vast majority of transgender patients will mark their identified gender, especially because only two choices are available. This creates yet another patient safety issue in interpreting laboratory test results. Patients who have identified themselves in the medical record as female but whose natal sex is male may inadvertently sabotage interpretation of their test results. This information may cause to the laboratory to use the wrong reference range for test results, not to mention leading the clinician to misdiagnose the patient's problem, ordering additional testing and/or unnecessary procedures.

While we specifically set out to improve the safety of our transgender patients, we also were inspired to address deficiencies that extend to other special patient populations.

Our role is to provide a safe, caring environment where all patients can be treated respectfully and competently. We've started this discussion in the laboratory and have seen it propagate throughout our healthcare system, which is developing practices grounded in understanding and responding to the diverse needs of our patients.

A Webcast on Transgender Issues in Healthcare

In order to reach as many people as possible in our hospital system, we recorded and posted the one-on-one presentation by the transgender patient as a webcast on our departmental website. Our hospital is now incorporating this new knowledge into its policies and working to overcome some of the limitations of the laboratory information system.

You can view the webcast at the Emory University website.


  1. Health Literacy is a Patient Safety Issue that is Relevant to Clinical Laboratory Services. Clinical Laboratory News, Patient Safety Focus. January 2012.
  2. Clements-Nolle K, et al. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health, 2001;91(6):915–21.
  3. Sanchez NF, Sanchez JP, Danoff A. Healthcare utilization, barriers to care, and hormone usage among male-to-female transgender persons in New York City. Am J Public Health, 2009;99(4):713–9.

Tiffany K. Roberts-WilsonTiffany K. Roberts-Wilson, PhD, is a clinical chemistry fellow, in the Department of Pathology and Laboratory Medicine, Emory University, Atlanta, Ga.