A Culture-Centered Approach to Improving Healthy Trans-Patient–Practitioner Communication: Recommendations for Practitioners Communicating withTrans Individuals

ABSTRACT

The following manuscript explores trans individuals’ lived experiences with practitioners and the types of advice they suggested be provided to practitioners treating trans patients to improve the trans-patient–practitioner relationship. Thirteen semi-structured qualitative interviews were conducted with individuals who self-identified as trans. Interviews were analyzed using thematic analysis (Braun & Clarke, 2006; Owen, 1984). Data analysis revealed that changes in practitioner’s communication behavior during office visits as well as modifications to office logistics and e-health particulars would contribute to a healthy communication environment. Interviewees explained that these variations may potentially improve trans-patient–practitioner communication. We conclude by offering practical and theoretical implications as well as areas of future research for trans health communication.

Healthcare has a substantial impact on a person’s life and potentially affects an individual’s overall happiness (Angner, Ray, Saag, & Allison, 2009). Practitioners play a key role regarding the kinds of physical and behavioral treatment patients receive, and their communication with patients truly matters (Ledford et al., 2010; Logan & Kreps, 2014). In the case of transgender individuals, some practitioners are less familiar with appropriate communication for interacting with this patient population (Burrill & Fredland, 2011; Jucks & Bromme, 2007). This is especially problematic for the approximately 700,000 people comprising the transgender (trans) population in the United States (Gates, 2011). Transgender can be defined as an individual whose sense of self conflicts with the heteronormative binary that limits ways of being. Indeed, trans individuals traverse, bridge, and/or blur the boundaries of sex and gender by not conforming to the social expectations of the body they were born with because their inner conviction and mental image of the self does not match their body (Brown & Rounsley, 1996; Feinberg, 1996; Gressgard, 2010; Meyerowitz, 2002). Individuals who identify as trans typically fall into one of two categories male-to-female (MTF) or female-to-male (FTM). Additionally, there are a range of experiences that trans individuals have regarding their own transition and identity avowal. In other words, some individuals often feel engaging in hormone replacement therapy (HRT) is enough to affirm their gender identity, whereas others might embark on sexual reassignment surgery (SRS).

Regardless of gender identity, anyone can have good or bad healthcare experiences. This includes transgender individuals as well as cisgender individuals, or those whose gender identity matches their sex at birth (Wentling, Windsor, Schilt, & Lucal, 2008). However, it is especially concerning that 71% of trans patients reported experiencing mistreatment in the healthcare context (Kosenko, Rintamaki, Raney, & Maness, 2013). Such negative experiences function to communicatively “produce, maintain, repair, and transform” reality regarding the nature of trans-patient–practitioner communication (Carey, 1989). We are interested in the construction of healthy co-cultural communication between trans patients and practitioners. Co-cultural communication is the study of communication between traditionally marginalized and dominant group members (Orbe, 1998). Healthy co-cultural communication encompasses positive and affirming interactions between traditionally marginalized group members and dominant group members in the health environment. For trans patients, healthy co-cultural communication involves having a practitioner who communicates in a respectful and attentive manner thereby producing and/or maintaining a positive health context. With the goal of learning how practitioners can deliver better transgender healthcare from the perspective of trans-persons, we took a culture-centered approach to health communication and interviewed 13 self-identifying trans individuals (Basu & Dutta, 2009; Dutta, 2007). Many scholars have applied Dutta’s (2007) culture-centered approach to health communication within various context-specific areas (DuBois, 2013; Dutta, Anaele, & Jones, 2013; Ephraim, 2013; Gao, Dutta, & Okoror, 2016). By bringing together the communicative foundations of Carey (1989), the co-cultural explanations of Orbe (1998), and the focus on cultural differences via Hopson (2011) and Allen (2011), we extend Dutta’s (2007) culture-centered approach to include the trans community. Other important transgender health researchers collected data through anonymous online surveys (Kosenko et al., 2013) or through a content analysis of terminology from PubMed articles (Redfern & Sinclair, 2014). Our approach is unique as we actively sought trans individual’s participation and foreground their narratives at the center of this exploration—both important elements in a culture-centered approach (Basu & Dutta, 2009; Dutta, 2008). Additionally, we position the trans individuals in our study as community members rather than “participants” in an effort to humanize these individuals and illuminate their voices and experiences as co-cultural community members (Hughes & Heuman, 2006). The interviews produced rich narratives regarding how trans individuals described being communicatively treated by practitioners and the small and large changes they felt practitioners could employ to create a positive, comfortable healthcare atmosphere. To this end, the following research questions are proposed:

RQ1:

Regarding trans-patient–practitioner communication, how do trans patients characterize communication with their health practitioners?

RQ2:

What types of communication do trans patients recommend practitioners implement to strengthen patient–practitioner communication and trans healthcare overall?

Literature Review

Theoretical Framework: A Culture-Centered Approach

We adopted a culture-centered theoretical approach to examine trans-patient–practitioner communication in this study. Dutta and Basnyat (2008) explain that the utilization of a culture-centered approach to health communication is a culture-driven process, which engages in meaning-making through dialogue with community members. Hopson (2011) explains, “the term culture consists of one’s values, beliefs, norms, and practices; it lends to the creation of our identity; and informs our respective worldviews” (p. 23). With this in mind, together researchers and trans individuals co-create meaning regarding communicative experiences within a specific cultural context.

The goal of the culture-centered approach involves “foregrounding the voices of cultural trans individuals . . . to open up legitimate spaces . . . for marginalized group members” to share personal narratives within the context of their lived experiences (Dutta & Basnyat, 2008, p. 443). Moreover, Koenig, Dutta, Kandula, and Palaniappan (2012) explain that these voices are important as the United States’ population is becoming more diverse. Thus, it becomes vital for practitioners to explore how cultural context impacts how “health meanings are constructed and employed in practice” (Dutta, 2008, p. 1). Therefore, trans individual’s health narratives are key for understanding how to improve trans-patient–practitioner communication in a diverse cultural society (Basu & Dutta, 2009). Research examining trans-practitioner communication from a culture-centered approach, that centers trans individuals’ communication experiences, is likely to help scholars and practitioners to understand this unique population, meet their health needs, and improve their overall health outcomes.

With this culture-centered contextualization in mind, we situate individuals as cultural bodies who transport their personal identities, social identities, and cultural experiences into the healthcare environment (Allen, 2011; Hopson, 2011). This is especially true for trans patients in communication with practitioners. Personal identity refers to individuals’ opinions and interpretations of themselves, the identity they declare, and overall characteristics they correlate with their individuated self. Social identity is formed during interactions with cultural and ethnic group members including age, class, race, region, occupation, sexual orientation, and gender identities. Identity also incorporates health identity. Health identity refers to the overall sense of self in terms of the physical, mental, and emotional, and it also includes one’s personal and social identities (Ross, Scholl, & Castle Bell, 2014). Indeed, identity is complex and messy (Hopson, 2011). Identity is “a discursive text read by interactants . . . ; there are various meanings attached to [individual’s] bodily texts . . . ; [and] individuals behave differently toward foreign or unfamiliar bodies . . . [they] encounter in public or private spaces” (Jackson, 2006, p. 2). This is true for trans patients in the health context. We contend that improving trans-patient–practitioner communication involves understanding how such communication also impacts their personal, social, cultural, and health identities.

Improving General Patient–Practitioner Communication

Previous health communication literature has explored ways to improve practitioner–patient communication across several vital health topics including end-of-life communication (Kendall & Arnold, 2008), strategic communication and cancer prevention (Kreps, 2008), diabetes prevention (Serrano, Leiferman, & Dauber, 2007), health literacy and communication across cultural differences (Heuman, Scholl, & Wilkinson, 2013; Weathers & Castle Bell, 2013), practitioner perspectives of health communication (Villagran & Weathers, 2015), and language use (Jucks & Bromme, 2007). Research also advises practitioners on ways to improve patient interactions and decrease health disparities (Dutta & Kreps, 2013; Gibbons et al., 2011; Kreps, 2006; Pauley, 2011; Redfern & Sinclair, 2014). Although previous literature adds to the larger discussion surrounding practitioner–patient communication, as Horvath, Iantaffi, Grey, and Bockting (2012) maintain, little research has examined trans individuals’ narratives regarding their specific healthcare interactions.

Our contribution to the literature through this study is unique. We conducted semi-structured interviews in a computer-mediated or non-computer-mediated face-to-face context with trans patients. These interviews centered trans individuals’ narratives regarding their health experiences and their goals for improving trans healthcare. Although some of the studies we cite in the following section also provide trans individuals’ perspectives on health, they do so through very different data collection methods: anonymous online surveys, fill-in-the-blank questions, and content analyses of health documents. In this regard, their scholarship laid the groundwork for our research. However, interviews produce “profound narratives [which] form a living discourse . . . [and] descriptive stories [which] disclose life beyond a time and place” (Hopson, 2011, p. 4). Interviews are invaluable for learning about this sensitive population.

In the following text, we present previous trans health research and demonstrate the problematic nature of trans health communication. This section reviews previous literature thematically according to the order a trans patient would come to encounter the health context. We begin by discussing stigma surrounding trans patients and their fear of discrimination. Next, we consider the role of e-health. Thereafter, we review research for creating a trans-friendly office environment. Subsequently, we examine the need for physicians to have trans-specific health knowledge. Finally, we conclude by discussing personal communication changes practitioners should make when interacting with this sensitive health population.

Stigma and Fear of Discrimination in the Health Context

Trans patients begin their search for a competent sensitive practitioner with personal knowledge regarding their stigmatized, traditionally marginalized, co-cultural social identity location. Stigma can be referred to as the communication process of excluding or degrading a person, or group of people, based on their minority status (Poteat, German, & Kerrigan, 2013). In the trans community, stigma performed often appears through acts of discrimination or displays of homophobia (Drabble, Keatley, & Marcelle, 2003) and/or transphobia (dislike or hatred of and sometimes hostility toward trans individuals) (Heath, 2006). Unfortunately, many trans individuals are treated negatively in the health environment.

In one study, Kosenko et al. (2013) asked 152 trans-adults whether healthcare providers had mistreated them in an online questionnaire. Results revealed that several practitioner behaviors communicate discrimination and stigma, including gender identity insensitivity, clear verbal or nonverbal demonstrations of being uncomfortable, verbal abuse, denying patients healthcare services, less-than-quality care, verbal cruelty, and forcefully suggested actions for healthcare. Unfortunately, these negative, potentially harmful, and stigmatizing health experiences have been well documented in literature (Coker, Austin, & Schuster, 2009; Kosenko et al., 2013; Lim, Brown, & Kim, 2014; Poteat et al., 2013; Redfern & Sinclair, 2014; Roberts & Fantz, 2014; Snelgrove, Jasudavisius, Rowe, Head, & Bauer, 2012).

The stigmatization of trans community members constitutes discrimination for this health community. Indeed, negative healthcare interactions can affect both the mental and physical health of a trans patient. For example, Lim et al. (2014) explain that experiencing such discrimination has devastating consequences for trans patients, including “greater health risks, decreased life expectancies, and fewer opportunities to obtain necessary medical care” (Nordmarken & Kelly, 2014). Moreover, Strongin, Silva, and Smiley (2014) also emphasize the detrimental physical and mental health effects that result from discrimination. In fact, displays of stigma, fear of discrimination, and practitioner homophobia (Drabble et al., 2003) are key reasons that some trans individuals avoid or do not receive proper healthcare. However, some trans patients are underserved because they are refused care. Deschamps (2014) revealed that 29% of trans patients were refused healthcare. To date, the trans community remains one of the most underserved populations in the United States (Kosenko et al., 2013; Poteat et al., 2013; Redfern & Sinclair, 2014; Roberts & Fantz, 2014; Snelgrove et al., 2012).

There are still several barriers to satisfactory trans healthcare. However, researchers are working to resolve these barriers and improve the healthcare atmosphere for trans individuals. For example, Hoffman, Freeman, and Swann (2009) explain that practitioners should be respectful, honest, nonjudgmental, willing to listen, and capable of creating a comfortable environment for trans patients. To this end, Redfern and Sinclair (2014) discuss avenues for eliminating unequal treatment and discrimination for trans individuals. Their recommendations for reducing discrimination and stigmatization are insightful: office personnel and practitioners should utilize correct gender pronouns and gender-inclusive language, work to secure the patient’s privacy during office visits, and empower the trans patient to self-identify as their preferred gender in initial conversations. While these traits are not always innate, practitioners are more than capable of learning culturally competent trans health communication practices.

Transgender e-Health

It is likely that positive trans-patient–practitioner communication begins first with e-health communication. e-Health is defined as “the use of emerging information and technology, especially the internet, to improve and enable health or healthcare” (Neuhauser & Kreps, 2003, p. 12). Trans individuals often research practitioners online before visiting their office for the first time. As a result, practitioners may actually improve trans patient care by utilizing e-health as a communication medium before trans patients step foot in their office. With this in mind, practitioners moving toward healthy trans-e-health communication might decide to identify themselves online as trans-friendly, as having trans medical expertise, or posting Lesbian, Gay, Bisexual, Transgender, Queer (LBGTQ) ally statements on medical profiles, office websites, and affiliated health insurance websites.

Although health communication literature has explored myriad e-health initiatives, as Horvath et al. (2012) point out, little research has explored transgender-focused recommendations in e-health communication. Although trans health research usually includes recommendations for e-health, actual studies centered on exploring e-health are sparse. Horvath et al.’s (2012) research is the sole study reporting findings about transgender e-health. They examined a number of Web pages directed at trans individuals, practitioners, and the general public. The results demonstrated that the Web pages had numerous areas for growth to improve health outcomes, increase perceived credibility, and encourage the search for relevant information (Horvath et al., 2012). Increasing the effectiveness of these health-related websites may ultimately lead to a better health interaction, where both trans individuals and practitioners are better educated on trans health-related risks.

Environmental Office Setting

Researchers encourage practitioners to make environmental changes to improve trans healthcare and overall office atmosphere, and to recognize the sensitive nature of the patient’s situation. Specifically, Goins and Pye (2013), Heuman et al. (2013), and Redfern and Sinclair (2014) all examined the effects of cultural normativity on intake forms for patients. First, Goins and Pye (2013) analyzed 40 intake forms and collected trans patients’ perspectives online through anonymous open-ended survey responses. They reported that trans individuals felt there were limited options to accurately describe their identities. Ultimately, they suggest creating queer-friendly intake forms. Second, Heuman et al. (2013) suggest creating new intake forms that include “transgender” as a gender option. Third, Redfern and Sinclair (2014) contend that patients should have the option to self-identify their gender rather than choose between heteronormative gender binaries on initial paperwork. They maintain that office personnel and practitioners should then refer to the trans patient using their preferred pronouns.

Additionally, Redfern and Sinclair (2014) and Lombarts, Plochg, Thompson, and Arah (2014) explain that environmentally adapting the office to include trans patients may help them feel more comfortable disclosing medical information to their physician. For example, Lombarts et al. (2014) recommend creating gender-neutral bathrooms and office-wide policies protecting trans individuals. Redfern and Sinclair (2014) also provide ways practitioners can create a comfortable, trans-friendly office environment, including displaying posters and decals in the office to illustrate the office is a “trans-friendly safe-zone,” proving trans-pertinent reading materials in the lobby, and installing a unisex or single-stall bathroom. Ultimately, research substantiates that adapting these trans-friendly recommendations may provide a trans-friendly environment/office setting.

Trans-Specific Health Knowledge

Unfortunately, research maintains that practitioners across all disciplines lack proper trans health education (Deschamps, 2014; Redfern & Sinclair, 2014; Roberts & Fantz, 2014; Snelgrove et al., 2012). In fact, Deschamps (2014) revealed that nearly 60% of trans patients feel the need to educate their practitioners on trans identity issues. Unfortunately, a practitioner’s general lack of trans health knowledge creates a barrier to effective trans healthcare (Lim et al., 2014; Poteat et al., 2013; Roberts & Fantz, 2014; Snelgrove et al., 2012). This remains the case although medical students are taught more about trans health in recent years (Dowshen, Nguyen, Gilbert, Feiler, & Margo, 2014; Kosenko et al., 2013; Redfern & Sinclair, 2014; Roberts & Fantz, 2014). However, the responsibility of educating practitioners about trans-related healthcare falls on trans patients (Lim et al., 2014; Poteat et al., 2013; Roberts & Fantz, 2014; Ross et al., 2014).

To this point, several scholars maintain that practitioners need trans-specific or trans-focused education and/or, at the very least, the ability to access trans-friendly practitioners (Coker et al., 2009; Dowshen et al., 2014; Redfern & Sinclair, 2014; Roberts & Fantz, 2014; Snelgrove et al., 2012). Dowshen et al. (2014) recommend improving trans-specific expertise by providing lectures on this content area during medical school. Redfern and Sinclair (2014) provide a list of comparable areas practitioners should be prepared to address, such as hormone therapy, bodily procedures, cross-sex hormone side effects, and mental health issues. If no access to training or workshops related to trans healthcare are available, there are an abundance of resources practitioners can access (Coker et al., 2009). A simple search through books, websites, and organizations (e.g., WPATH) can produce information helpful to improving a practitioner’s care for trans individuals. The need for trans-practitioner education is well documented in scholarship.

Further, Snelgrove et al. (2012) interviewed physicians regarding their perceptions of barriers to trans healthcare. Physicians reported that they struggled with not having trans-specific health knowledge required to treat patients and shared that they often did not know where to refer trans patients for specific procedures or health concerns. Ultimately, they recommend incorporating trans healthcare into medical schools through a “trans-friendly” model, which would include “the basics of medical transitioning assessment and treatment, and overall healthcare issues relevant to the trans population” in medical training (p. 11). Adopting such a “trans-friendly” mindset has the potential to positively shift the trans-patient–practitioner relationship. By adopting a trans-friendly culture-centered approach and considering all aspects of trans individuals’ identities (personal, social, and health), practitioners can begin to improve healthcare for these patients.

Practitioner Communication Changes

Not only do practitioners need stronger trans-medical expertise, they also need to make several personal communication changes while interacting with this health population (Coker et al., 2009). As already discussed earlier, scholarship documents several actions practitioners can take to improve the healthcare experience for trans individuals (see: Deschamps, 2014; Dowshen et al., 2014; Hoffman et al., 2009; Redfern & Sinclair, 2014). Although these actions communicate acceptance, practitioners also need to make personal behavior changes when communicating with trans patients (Hoffman et al., 2009; Lombarts et al., 2014; Redfern & Sinclair, 2014; Snelgrove et al., 2012).

Lombarts et al. (2014) recommend that practitioners preserve a level of professionalism and sensitivity to maintain and develop good relationships with trans patients. Namely, practitioners should appear comfortable interacting with trans patients. Pauley (2011) advises physicians to reduce the practitioner–patient power disparity and to empower patient advocacy—which should lead to more effective communication and health outcomes. Further, Redfern and Sinclair (2014) and Snelgrove et al. (2012) encouraged practitioners to refrain from imposing their opinions regarding the morality of a trans patient’s gender identity or the decisions related to their trans status. They suggest that practitioners who refrain from this are able to communicate respect and empathy and explain that practitioners should separate their personal perspectives from their professional behaviors.

Our study extends the earlier literature by offering new ways of improving trans-patient–practitioner health communication interactions. We focus on the growing e-health initiatives, the environmental office setting, and trans-specific health knowledge. With a culture-centered approach, situating trans community member’s narratives at the center, practitioners are provided with practical advice on changing their communication to enrich trans patients’ experiences.

Methodological Framework

Positionality

The first author, who conducted all interviews, member checks, and respondent validation for this particular paper, self-identifies as queer and as an LGBTQ community member, and performs her identity as gender nonconforming. In terms of her clothing and appearance, she presents as androgynous and masculine, which functioned to establish rapport and made interviewees more comfortable disclosing personal trans-related information. Ultimately, the first author sought to create a safe space where trans individuals could share their lived experiences during the interview process. She is also very active in the trans community, both personally and professionally. Further, interviewees referred future interviewees (discussed later in sampling procedures). This empowered her to establish rapport and created a sense of trust more immediately; interviewees already knew she could be trusted before sitting down to discuss this important topic. The second author is a cisgender individual. She identifies as an intercultural communication scholar who is passionate about being sensitive to the ways in which difference matters in everyday co-cultural communication between dominant and traditionally marginalized group members.

Our unique membership positions enabled us to interrogate the data from an in-group and out-group perspective (although the first author does not identify as trans, she is an LGBTQ community member). Specifically, as we discussed the data, we were able to, as Geertz (1985) explains, “present a more credible, more fleshed-out picture or explanation of [data] observation” (p. 10). Our membership enabled us to examine the data from a researcher-centered etic perspective as well as a participant-centered emic perspective (Geertz, 1985).

Participant Recruitment and Study Sample

A convenience snowball sample was used to locate 13 self-identifying transgender interviewees to participate in this study (Keyton, 2010; Lindlof & Taylor, 2011). In accordance with snowball sampling, the first author interviewed a trans individual from this specific population. Thereafter, this first trans individual recommended another trans individual to be interviewed. Facebook, the telephone, and e-mail were the primary sources of contact with potential trans community members. Recruitment continued in this manner until all interviews were completed. To ensure confidentiality, trans individual’s names were changed to pseudonyms. Individuals were eligible to participate if they were 18 years or older, if they self-identified as a trans individual, and if they visited a physician at least once, before, during, or after the start of their medical transition process.

Of the 13 interviewees, 29 was the average age of all trans-individuals. The trans community members represented five geographic locations including California, North Carolina, New York, Texas, and Washington State. Regarding the transition process, all trans individuals disclosed that they started HRT between 1 month and 10 years before participating in this study. One MTF individual had undergone hair removal and SRS and another had her SRS scheduled. Five of the FTM individuals had completed a double mastectomy (top surgery) and two of the five FTMs had a hysterectomy. The average amount of income of the trans individuals that chose to disclose was $40,000. The trans community members who did not identify as a student had various occupations: a Web application developer/computer programmer, a museum worker, a performer, a clinical psychologist, an occupational therapist, a restaurant server, unemployed, and retired. A majority identified their ethnicity as white or Caucasian, while two trans individuals identified as Latin or Hispanic, and one trans individual identified as Palestinian American.

Interviews

Qualitative interviews were employed as the method for data collection. Interviews are beneficial for understanding trans individual’s perspectives and lived communicative experiences with practitioners (Maxwell, 2013). Each of the 13 interviews lasted between 30 and 75 minutes, for an average of 60 minutes. Trans individuals were interviewed either through Skype or FaceTime, or face-to-face. Although we hoped to conduct all interviews in a face-to-face format, it was difficult to locate a large number of trans community members in the same geographical location. Therefore, of the 13 interviews, 2 were interviewed face-to-face, while 11 were interviewed via Skype or FaceTime. Not only did these online mediums physically enable more trans members to participate in this study and therefore verbalize their health experiences, but online interviews may also have created an avenue for traditionally stigmatized individuals to participate comfortably. A handheld digital recording device was used to audio-record all interviews, regardless of the interview medium (Skype, FaceTime, face-to-face). All interviews were fully transcribed yielding a total of 327 pages of data. We interviewed and immediately transcribed data throughout the interview process.

The first author utilized a semi-structured interview schedule, which allowed for unplanned additional follow-up questions throughout the interview process (Ross et al., 2014). After beginning the interview conversation with basic demographic questions, the first author asked the trans individuals about passing as their preferred gender: “Tell me about the first time you realized you passed as your preferred gender at the doctor’s office/in the health context.” Thereafter, we focused on communication with practitioners and trans individual’s feelings about being at the doctor’s office, such as: (a) In your life today, how would you describe your communication with health professionals?; (b) Describe how you feel comfortable in the health context; (c) Tell me about your overall goals when you visit the doctor’s office or interact with health professionals; (d) Please share the first conversation you had with a doctor or nurse about transitioning and your desire to go through the process; and finally, (e) Please share an experience in a health environment that left you feeling or like it was harassment or discrimination, if you’ve had one at all. We were particularly interested in trans individual’s conversations with practitioners. As such, our interview questions were followed with probing questions to evoke storytelling to provide trans individual’s narrative accounts of patient–practitioner interactions.

Saturation

Trans community members were recruited and interviewed to saturation, or until interviews produced no new categories, information, or thematic ideas and until themes recurred, repeated, and were forcefully emphasized across trans-individual’s interviews (Creswell, 2009; Maxwell, 2013).

Forms of Proof

Researchers employed two forms of proof to be sure that the study results accurately reflect trans individual’s perspectives: member checking and/or respondent validation. Engaging in forms of proof prevents selective observation, when a researcher sees what they want to see (Creswell, 2009). Member checking and/or respondent validation involve asking members of the population about their thoughts regarding study results. Throughout verification process, trans-individuals were approached to verify and help interpret the findings, to correct and add to the researchers’ insights, to expand their responses, and to check researcher perceptions. This process helps to interpret findings, to clear up researcher (mis)understandings, and to ensure that the researcher is not imposing his/her own viewpoints on the data (Creswell, 2009; Maxwell, 2013; Patton, 2002).

Methods for Data Analysis

Thematic Analysis

Thematic analysis was employed to discover common themes within all interviews that exhibit the interconnected thoughts of the study (Creswell, 2009). The first author and the second author equally analyzed all data in this study. We completed data analysis procedures separately and then together, discussed, interpreted, and interrogated our results. Our data analysis included two types of thematic analysis: Braun and Clarke’s (2006) six-step process, which provided clear steps for data analysis procedures, and Owen’s (1984) thematic analysis, which helped authors to identify themes that repeated, recurred, and those that trans individuals forcefully emphasized. By using two analysis techniques, we were able to critically analyze our data to its fullest extent, revealing all possible themes. Both procedures together contributed to a meaningful data analysis process.

Beginning with Braun and Clarke (2006) methods, the researchers first established a relationship with the data by transcribing, reading, and rereading the transcripts. Second, we developed preliminary codes by documenting noteworthy features of the data in a systematic way on transcript margins. Third, the researchers searched for themes by organizing the initial codes into potential themes. Fourth, the potential themes were cross-examined with the data to establish codes. Fifth, we used trans individual’s definitions to label and define each of the themes. Finally, we produced the report by distinguishing exemplars for each theme.

Additionally, the authors relied on Owen’s (1984) thematic analysis procedures (repetition, recurrence, and forcefulness) to identify and isolate thematic categories. Specifically, recurrence involves examining more than one transcript to locate similar evidence of meaning. Repetition refers to “the duplication of key words and phrases” across the data (Ross et al., 2014, p. 8). Finally, forcefulness refers to being “attentive to vocal inflections and dramatic pauses that stress or subordinate some utterances” during communication (p. 8). Forcefulness was marked throughout the interview transcriptions by italics, exclamation points, and marked pauses in response.

Results

We were interested in the types of communication that trans patients recommended practitioners should implement to strengthen trans-patient–practitioner communication and trans healthcare overall. Trans individual’s lived experiences in the healthcare context informed the types of care they hoped to receive from practitioners. Data analysis produced two major themes: (a) advice for practitioners and (b) office procedures.

Advice for practitioners includes four subthemes: (a) communication behavior modifications, (b) acknowledge trans status only when necessary, (c) employment of preferred pronouns, and (d) ask only health-related questions. The office procedures theme encompasses two major procedural changes: (a) adjust intake forms and (b) modify online material to reflect trans-friendly or trans-focused expertise. These thematic categories emerged organically through conversations with trans individuals when they were asked the following interview questions: (a) “Please share the first conversation you had with a doctor or nurse about transitioning and your desire to go through the process?”, (b) “How would you describe your communication with health professionals?”, and (c) “Please share an experience in a health environment that left you feeling like it was harassment or discrimination, if you’ve had one at all?”

Advice for Practitioners

Communication Behavior Modifications

Trans individuals suggested that practitioners and staff should make several key communication changes to improve the overall trans-patient–practitioner interaction. Trans individuals explained that enhancing the healthcare environment involves practitioners and office staff modifying their communication behaviors.

For example, Jared, a 36-year-old graduate student who has been on HRT for one month described his experience:

I got to a doctor and it would just like, I mean they were essentially like, “What the hell is this?” They asked me like, just disrespectful questions about my gender, “So what were you born?” But like the tone and the way that they asked was definitely snarky and judgmental.

Jared encountered practitioners who were invasive, inappropriate, and who needed to modify their communication tone and messages to create a comfortable health environment.

Pejorative comments like these were common among study trans individuals. Ariel, a 24-year-old who has received hair removal treatment and SRS and has been on HRT for 18 months disclosed, “The first three therapists I went to and told them, they were just kinda like, ‘No, you’re not that. It’s not true. You can’t have that. That’s wrong.’ [or] ‘No, that’s not right. You have something else going on.’” The first few therapists Ariel attempted to seek care from turned her away with denial that her transgender status existed.

Trans patients were also taken aback by verbal messages practitioners uttered like, “Well it’s my job as a Christian to save you.” For example, Kevin, a 34-year-old clinical psychologist who has received top surgery and has been on HRT for three and a half years, shared his worst experience: “I had a psychiatrist that asked me . . . really invasive questions about my sexual history [such as] . . . what don’t I like about a penis going into my vagina?” Kevin’s psychiatrist proceeded to violate the level of comfort by asking Kevin incredibly personal questions about his sexual history. As a final example, Wade, a 20-year-old student who has been on HRT for one and a half years and has received top surgery shared, “I went to go see one doctor who was my main doctor and he told me I was crazy and I should go find God.” Many trans individuals shared that their practitioners asked them similar questions and acknowledged that treating trans patients went against their faith. It is therefore necessary to educate practitioners regarding the types of communicative adjustments they can make to avoid insulting trans patients and making them uncomfortable.

Ultimately, trans individuals felt practitioners and their staff needed to make necessary communication behavior adjustments to improve the healthcare interaction. The following three subthemes represent the types of specific behavioral changes that trans individuals suggested practitioners should make: (a) acknowledge trans status only if relevant, (b) preferred pronoun usage, and (c) asking only health-related questions.

Acknowledge Trans Status Only If Relevant

One way practitioners can shift their personal behavior in the office is to acknowledge a trans individual’s trans status only if it is relevant to the current healthcare visit. Otherwise, interviewees recommended practitioners recognize their preferred gender identity. This specific subtheme emerged through conversation when trans individuals were asked two probing questions: “What are your goals when you visit the doctor’s office?” and “Do you want doctors to acknowledge your trans identity?”

Conner, who self-identifies as a white 29-year-old and has been on HRT for four months, stated: “I prefer doctors bring up my being trans, [only] if it’s necessary to what I’m going to see them for.” Conner does not feel his trans identity has a place in his healthcare conversation unless a health concern arises that is related to his trans identity. Larry, who self-identifies as a white 43-year-old FTM student and has been on HRT for five years and has received top surgery and a hysterectomy, also shares Conner’s sentiments: “There [are] certain times that it’s relevant. I mean, if I’m going in there because I have a pain in my pelvic region, then yes, by all means lets discuss the fact that I’m a transgender male.” Unlike Conner, Larry is more specific regarding when health procedures merit practitioners discussing his identity.

Preferred Pronoun Usage

Many trans individuals face being referred to by their biological pronouns on a daily basis. In a practitioner’s office though, trans individuals expected a higher level of understanding. During dialogue with interviewees, trans-individuals organically expressed their preference for practitioners to use pronouns that aligned with their preferred gender. This result emerged as trans individuals described negative health experiences where they were “outed” and their biological gender was revealed usually to a waiting room full of people. It also emerged when probing questions were asked: “What does an ideal doctor visit look like?” or “Will you share an experience where you felt you had to educate your practitioner?” For example, Linda, a retired police officer in her 50s who has been on HRT for three years and has scheduled her SRS, explained: “I want to be called she, you know . . . when they call me from sitting out in the lobby . . . I don’t want them to say ‘hey transgendered Linda, will you come over here.’ No, I want [them to use] she [or] ma’am.” Calling a trans individual by non-preferred pronouns essentially discloses their personal identity to those around them in the waiting room and creates an uncomfortable health environment.

Similarly, consistently using preferred pronoun is also important. Jaston, [sic] a Palestinian American 25-year-old who has been on HRT for 20 months, gives practitioners a piece of advice, “Stay in line with [using] the pronouns that I prefer . . . treat me like a normal human being. Get to the point and don’t try to prescribe me anything that I don’t need.” Thus, alternating pronouns while treating trans-individuals may make them feel discomfort, out of place, and marginalized.

Using the preferred pronouns when talking with or addressing a trans individual can be vital for practitioners. Another behavior change that trans individuals suggested was how to and what types of questions to ask. In the following text, the subtheme, ask only health-related questions, is defined and exemplars are provided to demonstrate what trans individuals urge practitioners to change.

Ask Only Health-Related Questions

It is natural for any human to be curious about something they do not know very much about. However, certain questions are appropriate to ask trans individuals and others are not. This subtheme includes instances where trans individuals discuss which questions practitioners should and should not ask as well as the appropriate way to ask sensitive questions. These data emerged organically as trans individuals and the researcher discussed “experiences in the health context that make you comfortable or uncomfortable” and “positive and/or negative health experiences.”

According to Jaston, a Palestinian American 25-year-old who has been on HRT for 20 months:

And I guess like (pause) for-for . . . doctors, you know, people in the-the-the health field. Dealing with trans people, ask the simple questions first. Like, “What do you identify with?” You know, “What pronouns do you prefer?” And let (pause) I guess, don’t get too- I know this sounds kinds of weird- but don’t get too nosey as far as . . . emotional, you know, transitioning, and stuff like that. And that’s like- that’s something that I’ve known . . . other trans people to kind of get uncomfortable about.

Jaston advocates asking simple questions that are related to the healthcare treatment and to convey interest in the trans person, rather than in the person being trans. Trans-individuals also revealed the challenges that emerge for practitioners when asking sensitive questions. Larry, a 43-year-old student who has been on HRT for five years and has received top surgery and a hysterectomy, describes this discomfort:

We need to let doctors-have doctors know that . . . creating these conversations and saying, “Hey we are gonna have this delicate conversation, I’m gonna ask you some questions. Are-do you have preferred words that you want to use to make this an easier conversation. What do you call this part of your body . . . do you call it anything because you know, hey if we don’t check it something could go wrong and we’re not gonna find it till you’re- you’re way on down the road in third or fourth stage cancer. Whether it is prostate, whether it is . . . cervical cancer or breast cancer, or whatever the case may be.”

Larry ultimately suggests that trans patients and practitioners would benefit by having a shared vocabulary. He insists that such terminology would make these conversations easier and decrease the likelihood of missing or overlooking serious health issues.

Summary

Regarding advice for practitioners, data reveal that practitioners need to make four specific changes when communicating with and caring for trans patients. First, practitioners need to modify their communication behaviors. Second, practitioners should not make offensive or inappropriate comments about trans patients or their lifestyle choices (e.g., religion, sexuality). Third, practitioners should acknowledge a patient’s trans status only if it is relevant to the treatment being given—otherwise, they should treat the patient without mentioning their gender identity. Finally, nurses, staff, and physicians can communicate respect for trans patients by employing their preferred pronouns. If they make a mistake, they should apologize and begin using the correct pronouns.

Office Procedures

Additionally, trans individuals explained that healthcare could be improved for trans individuals by changing the way practitioners’ offices approach the trans community. Specifically, this theme emerged when trans individuals responded to the following interview questions: (a) “Do you feel comfortable in the health context?”, (b) “What makes you feel more or less comfortable or uncomfortable?”, and (c) “Are there specific instances you recall having felt anxiety in the health context? Will you share an experience with me?” Essentially, trans individuals explained that practitioners could create a more comfortable health environment and reduce trans patient anxiety by altering the office organization: adjust the forms and modify online material.

Adjust Intake Forms

Echoing previous research from Heuman et al. (2013), Redfern and Sinclair (2014), and Goins and Pye (2013), we found that a common barrier to feeling comfortable in a practitioner’s office starts with the paperwork, when male and female are the only options. Trans individuals advised changing preliminary intake paperwork so that it includes more than the binary genders.

Harold, a 33-year-old performer who has received top surgery and has been on HRT for seven and a half years, said: “And . . . in Georgia. And it was the first place that I went to where you could put trans as [an option]. I was shocked.” Another trans individual told her practitioner to make this change to office intake forms. Meli, a Pacific Islander and Latin Web developer who has been on HRT for nine months, explained: “I told my physician, that she should do is- or have [transgender] as an option on the intake forms.” Trans individuals without this intake form option expressed the negative environment the lack of options on the form creates. For example, Brandon, a 36-year-old graduate student who has been on HRT for one month, stated: “It’s that intake form, right off the bat, that makes it difficult.” He finds the healthcare environment to be a difficult place to exist because the intake form assumes that his gender does not exist. Ultimately, trans individuals suggested that making this change would help create an inviting and relaxing health atmosphere for trans individuals.

Modify Online Material

It is likely that positive trans-patient–practitioner communication begins first with e-health communication. e-Health is defined as “the use of emerging information and technology, especially the internet, to improve and enable health or healthcare” (Neuhauser & Kreps, 2003, p. 12). Several trans-individuals explained that they did significant research online prior to talking with a practitioner. Simple modifications to practitioners’ websites would help trans individuals find practitioners who will treat them respectfully. One MTF, Meli, a Pacific Islander and Latin Web developer, who has been on HRT for nine months discussed how websites impacted her search for a practitioner:

I think a doctor can also . . . really benefit if . . . they have a website and then they put down their specialties, when they write down, [how they] specialize or [who] they work . . . [like listing] . . . transgender or [listing other specialties like] those that suffer from gender identity dysphoria, gender identity disorder, GID or gender dysphoria. [These types of changes] make those [people], like myself . . . feel comfortable knowing, “Okay, this is somebody I can talk to.”

Ultimately, Meli recommends practitioners add trans specialization to their website profiles so trans patients can locate practitioners who are comfortable with trans healthcare.

Summary

Ultimately, trans individuals specifically suggested that practitioners should make two immediate changes. First, data suggest that practitioners should use in-patient intake forms that include “transgender” as a gender option. Finally, trans individuals expressed the need for e-health communication changes like modifying online material.

We sought to understand how trans patients characterized communication with their health practitioners and the types of communication they recommended practitioners implement to strengthen trans-patient–practitioner communication and trans healthcare overall. Trans individuals indicated the need for practitioners to make personal communication changes when interacting with trans patients. Thematic analysis, member checking, and/or respondent validation specifically revealed two major themes: (a) advice for practitioners and (b) office procedures. The first major theme includes three subthemes: acknowledge trans status only when necessary, employment of preferred pronouns, and ask only health-related questions. The second major theme included two major suggestions for procedural implementation: adjust intake forms and modify online website material.

Research Caveats and Future Directions

There are several research caveats for this study and numerous opportunities for future research. Regarding research caveats, one major caveat concerns the two coauthors’ positionalities: neither identifies as trans. Specifically, the second author is a cisgender individual. Although the second author was able to identify themes and patterns, it was necessary for the second author to tack back and forth (Geertz, 1985) between researcher-centered observations and trans individuals’ perspectives regarding what they found meaningful about their daily-lived experiences. This empowered the first author to recognize themes that trans individuals did not explicitly verbally name, which created opportunities for richer member checking and follow-up questions. However, at the same time, the second author lacked community-member-specific knowledge and had to learn a lot about the trans community while coauthoring this exploration.

Similarly, the first author identifies as queer and as part of the larger LGBTQ community. She positions her queer identity as falling under the trans umbrella along with intersex and two-spirit individuals since she presents as androgynous and masculine. However, the first author does not specifically identify as trans. This helped her understand some, but not all, of the deeply personal struggles that trans individuals experience. However, by occupying a queer social location and an androgynous, masculine standpoint, she had more insight into interviewees’ lived experiences than a typical cisgender heterosexual individual. As a result, she was able to ask community-specific probing questions throughout interviews and data verification/interpretation member checking processes. The authors’ positionalities, therefore, offered both limitations and strengths for the study.

A second caveat and area for future research concerns the data produced and the interview questions we asked. The themes generated here were produced organically during dialogue; our interviews were not geared toward asking trans-individuals about their specific advice for practitioners. Studies about trans community member’s e-health and online behaviors and the ways in which they aid patients in locating health practitioners would add value to the growing body of literature. For example, we presented an exemplar regarding website changes practitioners can make to create a comfortable atmosphere for trans patients. This narrative highlighted how websites help trans individuals identify trans-friendly practitioners or practitioners with trans-focused expertise (Snelgrove et al., 2012). Unfortunately, we were able to provide only one exemplar because we did not directly ask about online behaviors and the role they played in the trans individuals health-seeking behaviors. It is very likely that richer data would result from asking specific, targeted questions, which would strengthen the awareness regarding trans-specific healthcare needs.

A third caveat and area for future scholarship to address concerns the data collection process, specifically, utilizing Skype or FaceTime to facilitate face-to-face interviews for individuals who were not in close proximity to the researchers. These two mediums provided “real-time interactions and . . . contributed to a climate of intimacy” in the absence of traditional face-to-face interviews (Lindlof & Taylor, 2011, p. 190). However, technology was also challenging. During several interviews, the Internet connection froze while using Skype or FaceTime requiring the first author to reconnect the call. These instances disrupted the conversational flow. However, despite these technological disturbances, these alternative methods enabled the first author to speak with a greater number of trans community members, from a larger geographic region and enabled interviewer and interviewees to see one another and connect face-to-face, despite the distance (Maxwell, 2013).

Additionally, also regarding data collection process, it may be useful to conduct focus groups and interviews in the same study of this topic. Focus groups may have created an interesting atmosphere and led to discussion and comparison among trans community members that we were not able to capture using solely interviews. It is possible that more complex issues may have been discussed as trans individuals spoke to one another about trans healthcare. On a related note, it would be interesting to include those who identify as intersex and/or two spirited in the study population to learn the myriad ways they contribute to understanding healthcare experiences overall.

Regarding practical implications moving forward, practitioners in every geographic location in the United States can make the following changes to improve the office environment for the transgender community. First, all staff should be required to attend a transgender awareness seminar. This program’s structure would be similar to the SafeZone program held at myriad universities (SafeZone, 2014). Even with the addition of a “trans 101” course in medical school, a SafeZone program could be beneficial in its own ways. Specifically, the “trans 101” medical school course would be a brief seminar on the basics of how to care for a transgender person medically. Alternatively, the SafeZone program is a workshop that familiarizes practitioners with more communicative practices related to how to approach topics such as body dysphoria, use of pronouns, and the appropriate questions to ask a transgender person. In addition, this suggested program would include a segment for practitioners on specific medical treatment for transgender individuals including HRT and SRS. As new research continues to be published, the SafeZone program can be implemented every three to four years to ensure that all healthcare staff stays up to date with how to care for transgender patients.

As a final practical implication, regarding adjusting intake forms, it may be helpful to include a question regarding patients’ preferred pronouns to protect their identity when they are called from the waiting room. Practitioners could also consider adding other additional questions to help trans patients feel more comfortable, such as (a) What sex were you assigned at birth? and/or (b) What gender do you identify with? Another specific change would be to include a disclosure statement about the friendliness of their office to all genders and self-identifying individuals; this could be placed on the office door, on insurance websites, online, and on the intake forms. Together, these practical changes may help trans individuals narrow their search for an open and competent health practitioner.

Conclusion

Although we are making progress in trans healthcare, trans remains a stigmatized social and health identity. Unfortunately, trans patients continue to be excluded and/or marginalized in the health setting. We need to keep moving toward a combination of trans-friendly and trans-focused healthcare, driven by trans-individual’s narratives, achieved through healthy co-cultural communication, and foregrounded through a culture-centered approach. Such progress will aid in the development of trans personal, social, and health identities. Ultimately, trans healthcare awareness will grow as the needs of trans people become more prominent in the healthcare field. Recognizing the unique challenges trans individuals face while communicating with practitioners stands to benefit practitioners and trans patients alike. Our hope is twofold. We envision an atmosphere where practitioners medically understand this underserved population. We aspire for trans patients to receive the care they need, in a relaxed health environment, where they communicate effectively and comfortably with practitioners. Although there is still more work to be done, we are making progress.

Our study positioned trans community members’ narratives at the center creating a space for these individuals to become stakeholders in their own healthcare communication interactions. By providing trans individuals as a marginalized group, a space to voice their concerns with their healthcare experiences, practitioners can gain practical knowledge. An adjustment to practitioners’ communicative behaviors can enable them to better understand the trans population, meet their health needs, and improve their overall health outcomes.