UBC Objectives: Family Medicine, UBC Objectives: Care of Men, & UBC Objectives: Behavioural Medicine & Resident Wellness
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
I spent a day in my first primary care transgender clinic and now I absolutely cannot wait to graduate from residency and begin practicing as a trans-affirming physician. I learned today that there is still a shocking degree of stigma that transgender patients face by medical professionals when opening up about their dysphoria with their birth-assigned gender.
My third last patient of the day today, a 54 yo male to female transgender patient, was presenting to clinic for assessment of whether or not she is a candidate for hormone therapy. We spent quite a bit of time diving into her medical and social history, and I learned about how she first had wanted to come out at about 19 years of age, but in a twist of events, she fell in love with a woman (she had never felt romantic toward a woman before), and they formed a partnership that lasted almost 30 years. She had assumed the more masculine role in this relationship, but she was okay with that, because it worked for them, and that's just the way it was. Long story short, her partner moved away a couple of years ago in search of a different life, and she didn't want to leave her life in Vancouver. After all, she had a very secure pension lined up through her employer, and to move now would be to give up a lot of security, not to mention the rest of the life she built for herself. Vancouver is her home. About a year after her partner left, and after a steamroller incident which left her unable to work for 6 months, thoughts about her gender identity began to resurface. It gnawed in her mind with more and more ache, and eventually she couldn't bear to ignore it. She felt like a woman, this is who she is, and to deny herself this fundamental truth was to live a half-life. She gathered up all her courage and went to her family doctor of 15 years in search of self-actualisation.
She sat down, made herself as vulnerable as one can by baring her deepest darkest secret, and in return, the family doctor laughed and told her he didn't believe being transgender was a "real" thing. She immediately welled up in tears and said she could never bear to see him again. She went home, and in a state of frank crisis she took the gun she had at home and put her lips around it. She couldn't bear the agony and wanted it to end. In this state of utter craziness, there was a part of her that didn't want to release the trigger, and instead her index finger dialled an SOS call to a help line she knew about. Someone answered the call, and talked her into putting the gun down. She came to her senses, and it wasn't many days before she was back to work as her ankle injury was healed enough to resume her usual duties.
One night at work shortly after her return, when no one else was still around, her boss mentioned to her how her and her partner were going through divorce. The feelings resonated in my patient's heart as she knew that piercing pain that still lingered from when her partner moved away. One thing led to another, and this full-blown heart-to-heart led to my patient opening up about her state of being transgender. Much to her surprise, her employer actually had many friends within the queer community! And within the next week, all of the women at work were regularly organising lady nights with her and would take her for nights out on the town, dressing her up and giving her makeovers. She felt like a woman and she felt accepted. The community connections she developed eventually led her to Three Bridges, where she sat in front of me, now with courage restored to climb to the peak of her Maslow's hierarchy.
OMG was my mouth gaping open this whole time?
We bonded, her and I, sometimes laughing, sometimes coming to tears as we shared in her experiences over the years. I think mostly she had the opportunity to affirm herself while I learned invaluable lessons about the power a physician can have in their relationship with patients, for better or worse. No doubt, the cumulative impact of many peoples' words can have significant impact on how people feel in this world, on the nature of people's interpersonal relationships, and on the values that shape cultural identity, promoting or demoting one's sense of belonging in their community. Prior to this patient encounter, I did understand that physicians are oftentimes in a position of relative power in society, with voices that are often heard, listened to, and honoured as reasonable and truthful ones. But I didn't appreciate the extent to which this power was borne out in the physician-patient relationship. Patients seek help from physicians in some of their weakest, most vulnerable states, be they physical, mental, emotional, or spiritual, and because of this, there is a saliency in the response physicians have that can further harm or instead heal. As a resident physician I am constantly striving to learn the right way to do things (the most reliable way to diagnose, the most effective way to relieve symptoms, etc.), and much less frequently do I stop to critically consider how my actions can perpetuate harm. There is an inherent power dynamic in the physician-patient relationship, and thanks to my patient today, I am all the more mindful of the degree of harm that parallels the benefit in that relationship. May I never forget this as I progress toward greater physician independence and correspondingly increased patient dependence and vulnerability to my actions.