She walked into our small conference room staying completely in character. We had earlier propped the door open because the room was stuffy, but we closed it now as a gesture of preserving privacy. She was an actress playing the role of a 60 year old woman seeing her “new” doctor to get her prescriptions refilled.  She had no particular complaints. Her doctor was “new” in that this was the first meeting between this “patient” and this “doctor”. He was “new” in that he was just starting medical school.

  They sat in facing chairs in the front of the room, and she focused her attention completely on the student playing the doctor. She pretended to be unaware of the others in our group, about a dozen other brand new medical students, and myself, the faculty mentor. As mentor, I understood my role to be one of modeling appropriate questions and language within the framework of the standard patient interview, and to let things unfold without interruption. The rules allow for interruption of the interview only by the student doing the interview, in the form of a “time-out”. The student interviewer says “timeout”, and the actress/patient puts her head down while the interviewer listens to the comments from the group. When the interviewer says “time-in,”  the interview continues. As faculty, I can’t call a time-out, and sometimes I find myself squirming quietly in my chair. The beginning of this patient interview was one of those times, a chance for me to model appropriateness, on hold.

   “May I call you Jane” the student interviewer asked in a clear confident voice. “Sure” she says. His very next question was “ What gender do you identify with”. While she made no attempt at glamour, she wore woman’s clothes, and had already said her preferred name was Jane. She answers “female” and crinkled her forehead. I looked around the room and there was no reaction from the students. To me,  it felt like we were checking off a box called “cultural competence” at the beginning of the interview, and now with that box checked, we can move on to gather medical information.                                                       

   The patient reveals herself to be somewhat ambivalent about her need for care. She says, “ I came in today at the urging of my family. I have been out of all my meds for at least 3 months. ” She clearly accepts her aches and pains as, “ what it is to be old.”  We re-fill her prescriptions, and schedule a follow-up appointment. The actress/patient leaves and we discuss the interview. I listen to the other students comments as we go around the room in order. I go last.  I ask if  there was a  connection between what they learned in diversity training during their first week of medical school, and this question about gender in a cis-gender patient?  They all agreed that there wasn’t.

  Over the next week I wonder about how to appropriately ask about gender identity in the context of the patient interview.  I know what gender dysphoria is, but l have to admit I haven’t given much thought to any of this before. My intuition tells me to wait to ask about identity until you are further into the interview.  Deal with the patient’s presenting problems first. I asked a number of my colleagues and no one had a good answer. An Endocrinologist friend of mine  said he deals with most of that in a questionnaire that patients fill out in the waiting room. The medical literature was no help.

    When I can’t get answers from traditional sources like my peers or the literature, I turn to Reddit. I posted a thread on the SubReddit  asktransgender, ( asktransgender.com), basically asking how to make our healthcare system better for trans patients?  I got over a hundred comments in the first 24 hours. What became clear immediately, was that there was no cookie cutter narrative for the transgender patient. Gender is but one aspect of who they are. They talk about “Intersectionality”, that other parts of someone’s background, race, class, spiritual beliefs and so on, all play a role in shaping someone’s identity.The question of how to you ask about gender within the framework of the patient interview becomes a better question of how to  explore your patient’s story with sensitivity, within the limitations of time and trust?

    The Reddit bloggers wrote about bad experiences that make the trans community wary of healthcare encounters. Healthcare workers, including doctors,  must approach these patients with that as the starting point. They wrote about what is known as “broken arm syndrome”, that is, no matter what they complain about to the doctor, the assumption is that it has to do with their transgender identity, or treatment.

  There were a lot of comments  that spun off the comments of others not directly related to healthcare. I learned that gender dysphoria is not something that is fixed, it is not experienced the same way all the time in any given individual. Dysphoria can be extreme. One blogger wrote about being on a bus and looking around and “ feeling somehow alien from myself… I see myself in each and every rider”.  I learned that not everyone wants to transition, but in those that do, our healthcare system makes them wait too long. I read comments about suicide that made my skin crawl, and learned that about a third or more of this group attempt suicide.

    Then I clicked on the names of some of those who replied to me on Reddit, and you can read their other posts in other threads. Down the rabbit hole we go to a world of  role playing video games, internet flirting, advice about do-it-yourself hormone replacement therapy, every combination of gender/sex encounter including a surprising amount of abstinence, and again, thoughts of suicide. Reading these minimally hidden notes felt like an act of social transgression to me, somehow voyeuristic.
    I now think asking about gender identity as the second question in a patient interview shows an awareness of the importance of cultural background in the doctor-patient relationship, but there is a big difference between awareness and sensitivity. Sensitivity would have us reassuring the patient that we will address their healthcare concerns first, and then later in the interview, make time to explore the complexity of their identity.