Being Trans in the NHS [Re-release] (21 June 2023)

SPEAKER_00 0:00

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SPEAKER_02 0:24

Hello and welcome to another episode brought to you by the Trainees and Members Committee of the Royal College of Physicians of Edinburgh. My name is Dr. David Ryan. My pronouns are he and him. And today to celebrate LGBTQ Plus History Month, I'm delighted to present a special episode on transgender awareness within the NHS. And while there's a breadth of LGBTQ experience in healthcare that we could draw on in this podcast today, uh we will focus specifically on transgender awareness within the NHS today and consider how we can make healthcare more inclusive and welcoming of diversity. I'm honored to be joined by Dr. Xander Hughes, who is an SHO currently working in intensive care at St. George's Hospital in London. Dr. Hughes has done extensive work on inclusivity for transgender people within the emergency department at St. George's Hospital and has spearheaded several innovations to promote transgender awareness within the NHS. So Dr. Hughes, thank you so much for joining us today, and I'll pass it over to you to introduce yourself to our listeners today.

SPEAKER_01 1:26

Thank you very much for having me. So as Dr. Ryan said, uh my name is Zan Hughes. Uh my pronouns are they, them, and I'm an SHO currently working in ITU at St George's Hospital in London.

SPEAKER_02 1:42

So Dr. Hughes, uh there's a growing interest in transgender within medicine, but a lot of this focus is on specialist transgender clinics, for example, gender identity clinics. But I guess that's a podcast for another day because our focus today will be on the more day-to-day experience of transgender people both accessing and working within healthcare settings, as this is uh I guess for for many of us, how we will interact with transgender colleagues and patients. But before we delve into this in a more detail, would you mind describing some of the terminology that come up when we talk about trans issues? Yeah, sure.

SPEAKER_01 2:20

So just kind of as a jumping off point, can't really explain what transgender means without explaining what gender is. Um so gender is a social construct which attributes qualities of maleness, femeness, or kind of a neutralness uh to actions and likes and dislikes that people have and and their gender can be divided into their identity and their expression, so how they feel on the inside and how they express that. And then once you've got a vague handle on that, you can then think about the difference between transgender and cisgender. So if we think back to kind of GCSE chemistry, we remember trans and cis bonds, um, cis being on the same side as and trans being across. Um with gender. So cisgender just means somebody that identifies the same gender as they were assigned at birth. That letter that you get on your birth certificate sticks with you throughout your life. And then transgender is the concept of moving away from across towards an alternative gender to the one that you were assigned at birth. So that might be transitioning from being male at birth to being female. It might be transitioning from being female at birth to having an androgynous appearance and identifying as agenda. It can encompass a lot, and trying to boil it down to just a few words can can be quite difficult.

SPEAKER_02 3:56

And how would you distinguish between gender and sex in terms of the their concepts and definitions?

SPEAKER_01 4:05

Yeah, so that's a really good question, and um and something that that causes a lot of confusion, I think. So sex is kind of the more scientific um portion, it it's a combination of your uh genetics, your um internal and external genitalia, your hormone profile, and your secondary sexual characteristics. And it's just worth mentioning that that whilst we often think of sex as a binary, that there is an a growing understanding that it's uh kind of a bimodal distribution. So the vast majority of people will fall into male or female at birth, but actually there's a wide variety of kind of alternatives. So people whose karyotype is not XX or XY is actually XO, XXY, etc., or who might have varying genetics, that means that their internal and external genitalia don't match, or with what we would commonly assume, or that their hormone profile is different to that that you you would assume they would have based on their genetics. Whereas gender is much more about how people feel about their appearance and uh how they identify, um, and is a lot more personal in terms of uh it's there's a degree of kind of self-determination in it where obviously you can't change your genetics, you can change your appearance to a certain degree.

SPEAKER_02 5:44

Thank you so much for uh Dr. Hughes for uh for sharing those those definitions with us. And I know one of your main research interests is in pronouns and increasing inclusion for transgender people within within the NHS. Um so can you tell us more about pronouns and why are they important for transgender folk?

SPEAKER_01 6:05

Yeah, so and this and this is a thing that comes up quite frequently when you start talking about trans stuff, is you know, what what is a pronoun and what why will the trans people never ever shut up about it? So again, think back to school, pronoun is word that you use instead of the proper name for someone. So instead of constantly using someone's first name, you use she, he, they, or in some cases a neo-pronoun such as z uh or here, and there's a wide selection of alternatives. Now, commonly you know we use pronouns without really thinking about it, and it's not yet common practice to ask someone their pronouns when you introduce yourself. Kind of my thoughts on the matter is that um pronouns are the same importance to a person and their identity as their name and should be retreated with a similar level of respect. So um I'm all for normalizing introducing yourself with your pronouns as well as your name. And you'll see like a lot of people now have that in their Twitter bio, in their email signature, their name and their pronouns. It means that we don't have to play a guessing game based on kind of appearance of what pronouns we use for people, and it it's just a lot more respectful than um taking a punt and possibly getting it wrong.

SPEAKER_02 7:31

And can you tell us about the work you did with the emergency department at St. George's Hospital on pronouns and increasing kind of staff awareness of these?

SPEAKER_01 7:42

Yeah, so um I was lucky enough to work in AE during pride season um with some very enthusiastic um seniors, one in particular who was very keen uh to do some work to increase staff awareness of what pronouns are and why they're important, to begin building on that to make it our AE a more accessible place for trans people, particularly teenagers and young people. We've got a big pediatric AE, and you know it's it's important for the young people coming to us that they they feel listened to and and understood and respected. And the first step of that is to get staff to understand why pronouns are important and how to ask about people's pronouns before moving on to kind of the next steps. So what we did was kind of questionnaire across various staff groups within A and E, asking people what their knowledge and understanding about pronouns was. So do they know what they are? Do they know why they're important? Do they know how to ask, even you know, do they commonly ask people what their pronouns are? And a lot of the responses were kind of not really thought about it, not sure why it's important, kind of on that vein. We then used Pride Week as kind of a springboard to get up loads of posters. Um actually involved a friend of mine who's a graphic designer to create small cartoon style instructionals on asking about pronouns, the kind of do's and don'ts. And we did some teaching sessions with staff, just short kind of 10-15 minutes, quick fire, what are pronouns, how do you ask, what do you do, what don't you do, and then re-questioned everyone and and saw what they'd learned and what they wanted to learn for the future. And and the responses were really positive. Generally speaking, people were saying, you know, yeah, actually, I thought this wasn't important, but I've realized actually it's a simple thing that can make quite a lot of difference. It's you know surprisingly easy to understand. It seems like this big confusing mess, but actually, once you once you get down to it, it's not it's not that hard. We should find ways to include this in our uh in our standard kind of information gathering at the front door. So part of the reason that we did it in A and E is because A, you know, you get a lot more footfall uh than you know one ward. But then also if you can get people's pronouns right at the front door and they are admitted, that's the chance of you getting that to follow them through is much higher if you start in A and E than trying to kind of start up on a ward and go backwards. And we were actually lucky enough to have the results and an abstract accepted to the Royal College of Emergency Medicine for their scientific conference in the autumn and got some really positive feedback from that. So really good.

SPEAKER_02 10:49

And Dr. Hughes, would you share some of the key learning points from this work with our audience? Kind of what would you like them to take home from this research and how can they implement it within their own clinical practice?

SPEAKER_01 11:02

Yeah, so I think the the key things with working with colleagues who are transgender and also when you come across patients who are transgender is to listen, find ways of asking pronouns that feel normal and natural to you, and then if you make a mistake and misgender a colleague or a patient, just uh apologize and move on. Um, the same as you would if if you get their name wrong, you know, if you call them Jack and their name's Tom and they say, My name's Tom, you say, Oh, I'm so sorry, Tom, as I was saying, and then you continue. Um, and just you know, practice that. And especially with with colleagues more than patients, obviously, because you spend a lot more time with them, and just get used to correcting yourself. And if you find yourself talking to a uh another colleague about about that trans colleague and and getting their gender wrong, get used to correcting yourself even when they're not around. Um, and it'll make it a lot easier for you to get it right when it is important, and just have some compassion for for yourself and for for them and think about what questions you would and wouldn't want to be asked about your personal life.

SPEAKER_02 12:20

The other area we wanted to explore today was your experience of being out and transgender within the NHS. How would you characterize this experience?

SPEAKER_01 12:31

Um, so I think the the long and the short of it is it's a it's a very varied experience. I've already mentioned kind of the importance of pronouns for our patients, but on a on a personal note, I've had kind of from one end to the other of this of the scale of appropriate responses to uh my pronouns. Um so as I said in the introduction to the show, I use they-them pronouns. I have been out as non-binary since part way through medical school. And I going into my foundation year one jobs, was very keen to be out at work and I don't know, maybe a bit young and and overly enthusiastic and bright-eyed and bushy-tailed, and would introduce myself with my pronouns at every opportunity, and was met with a lot of resistance that I really didn't predict. I was expecting people to forget and to not get it. I wasn't expecting some of what I had, which was you know, me saying, hi, I'm I'm the new F1, my name's Zan, my pronouns are they, them, and people saying, we don't have that here. Or why do I care? Or, you know, that's nonsense. I've also experienced this hostility um completely out of the blue when people have read my name badge. So I am lucky enough to have a my name is badge that includes my pronouns. So um it's got you know Dr. Zan Hughes, senior house officer, pronouns, they them. Um it was bought for me by one of my chosen family. That's a term you might hear a lot of LGBT people using. Um, just means kind of that family we formed that are not biologically related to us but but look after us in the way a family does. And I wear it with a degree of pride because it's important for me to be out at work for patients to see that I'm out and to know that trans doctors exist. But I have had instances where apropos of nothing, people have commented on my pronouns and said, you know, that's a load of bull rude word. Or um, you know, I think it's a load of nonsense what these young people are are into these days, or you know, words to that effect, um, including, you know, in the middle of dealing with very sick patients when I've not, you know, I've not launched into some kind of debate on on trans health or anything. It's just someone's looked at my badge and seen my pronouns and decided to take it upon upon themselves to to give me their thoughts. But it's important to know it's not all dame and gleam, it's not all horrendous. As I mentioned before, I had fantastic colleagues in AE who, you know, uh introduced myself with my pronouns and they kind of went, ah, we should have thought of this before. Why haven't we got name badges with pronouns on? Let me get to that, you know, and then gone away and and and and now they're in the process of of sorting that out. And I also had a really heartwarming interaction with a a senior doctor on a night shift in COVID-intensive care of all places, where like four o'clock in the morning, realized I'd never I'd never told him that, you know, we'd been working together for a couple of weeks, not told him that I was non-binary and and and not mentioned my pronouns because after some of the interactions I've had, I'm sometimes a little hesitant to, but you know, seemed like a reasonable human. So I thought I'd crack on um and and kind of did the I I'm non-binary talk. Um, and his response was, oh no, what wait, what are your pronouns? Have I been misgendering you this whole time? Which yes, he had been, and and I said, you know, yeah, my pronouns are they, them. And it kind of went, Oh, I'm I'm so sorry to get that wrong. Uh, you know, I must try harder. And then, you know, didn't make a big fuss about it, just then every time he got it wrong, corrected himself, then apologized and moved on, and and was just generally a good egg about it, and and that sort of thing can can really make a difference. Just understanding that you can be the person that actually listens and and acknowledges that your colleague is is probably getting misgendered quite frequently and and doing your best to not add to that is is important.

SPEAKER_02 17:26

It kind of to coin a phrase that's almost like we need to reach herd understanding as well as herd immunity, of course.

SPEAKER_01 17:34

Yeah, yeah. Yeah, because at the moment it's definitely kind of few and far between that I have that I work with people who who get it, that I say, hi, my name's Anne, my pronouns are they, them, and they just go, Yeah, great, got up. I might forget your name. Okay, cool, that's fine. You know, the easiest way I can explain the importance of pronouns is is treating them with the same respect as someone's name. And you would never say to someone that their name is not important or that their name is not relevant to you, and so saying that to someone about their pronouns should not be acceptable either. And I think it's it's just worth remembering that your kind of two-minute interaction with someone where you misgender them, get their pro you know, by getting their pronouns wrong, or spend five minutes apologizing for for that, um, which can be equally distressing. Um that's five minutes of your day, but if that interaction happens for a trans person every time they talk to a collie, that can happen like 20 times in a day, which is absolutely exhausting, and it means you just can't get on with your day in any kind of functional way because you spend half your life trying to correct people about your gender or or listening to them tell you their thoughts on gender or or whatever it may be.

SPEAKER_02 19:04

Yeah, so I think there's there's a lot of um really interesting insights and a lot of I guess learning that we can take from from your experiences both personally and and professionally as working as um a doctor who's trans within within the NHS. And Dr. Hughes, what would your tips be for doctors and healthcare professionals? Uh what can they do to make transgender patients feel more welcome within healthcare settings?

SPEAKER_01 19:34

That's a really good question. I think there's a there's both a lot and a little to be done. Um a lot of there's a lot of deep-seated um longstanding distrust of the health service amongst trans people that will take a lot of work to fix. But also there are some very small things that we can all do that will cumulatively make a big difference. So, like I mentioned um with regards to the research that we were doing, um, is that actually if you can get people's pronouns right at the front door, um, then that makes a huge difference to how they're to their experience of healthcare. Um and that applies as well as uh to pronouns to to preferred names. Um, and this isn't just a trans issue, actually, there are a lot of people who don't go by their legal name for whatever reason. Um, I mean, maybe they're you know they shared a name with a family member and actually they go by a middle name instead or whatever. So actually, having computer systems in hospital that are flexible enough to have both their legal name and then some way of of acknowledging that actually what staff should be calling them is different to that. Um and and having some way on that system of also recording pronouns means that that goes with the patient throughout their their um inpatient stay. Um so yeah, that's important, and I think another thing that we need to be mindful of as healthcare professionals is um appropriate curiosity. So especially as doctors, we're taught um to be curious, and it and it is important to ask the extra question, um, you know, to question what the abdominal scar is from, to to think about kind of all the things that could have added together to put that patient in front of you at that time. But there is a time and a place, and there There is a degree of relevance that needs to be considered. So if a patient comes to you with abdominal pain and you know from their records or from an interaction with them that they're transgender, then of course asking them if they've had any surgery on their abdomen or on their genitals is going to be relevant. Um, you know, do you are they a trans man who still has ovaries and has got an ovarian torsion? Could they be pregnant? Are they a trans woman who's had extensive um surgery on their genitals and actually it could be a complication of that that you need to know about? But if they're if they've come to you with a broken wrist and you happen to find out or know that they're transgender, asking them about surgery on their genitals is 99% of the time not going to be relevant and is in fact very harmful to them and to your relationship with them as a professional to kind of pursue that as a as a line of questioning. And the same goes for things like asking them what their plans for their transition are, unless you are their endopronologist and you're asking them about what hormones they want you to prescribe, or you know, you're the GP that's referring them to the gender specialist, you you kind of shouldn't be asking those questions. It's it's not relevant to why you're seeing them. And it is quite difficult to turn that bit of your brain off because we're so used to to trying to know absolutely everything about our patients, but it's one of the reasons that trans people avoid healthcare is because of this professional curiosity and this desire to know everything, because it's such a personal thing, and there's so much judgment in the media, and so much trauma experienced by trans people related to their gender expression and their identity that that actually the last thing they need is is being scared that their doctor's gonna treat them differently or or cause them harm because of it.

SPEAKER_02 24:15

Yeah, and it sounds like that would be quite stressful.

SPEAKER_01 24:18

Yeah. I mean, I know stories of of you know of trans people that I'm friends with or know through the trans community that you know have had things like gone for mid-cervical smear being asked what their plans for their um genital surgery are, and and it's just not on. Like we need to be as professionals, need to be we need to be better than that. You know, and and I also know stories of kind of of of trans of trans woman who was going in for a knee problem who had uh ask her if her breasts were implants and and where she got them done. And and you know, you wouldn't ask a cis woman that um mid-knee examination, you know. Maybe if if she was coming in for a mammogram for breast cancer screening, you would, and that would be completely fair enough. But if you're looking at her knee, probably not relevant. And alongside that is this need for professionals to educate themselves rather than relying on trans people to do the teaching. Now, I don't for a second mean don't listen to trans people or don't learn from them because actually you can't know about trans people without listening to us. But learn from podcasts like this, go out, read books, um, listen to TED Talks, listen to you know other trans people talking about their experiences where they're they're getting paid or they've done it voluntarily with a full understanding of what they're getting in for. Don't ask your trans patients to spend their appointment time explaining to you what trans means, what it means to be a trans person, what their transition is, how do you go about that, etc. etc. Just be mindful of the relationship you have with the person that you're asking this of. I mean, I set myself kind of rules by which I play at work, and I will answer generic questions from colleagues about transition, about you know, who refers to the gender clinic? Sure, I'll answer that question. I know about that, it doesn't take me a heap of energy to answer that. And I will talk to certain colleagues about my own journey in the same way that they will talk to me about their sick mother or you know, whatever. But if colleagues that I barely know start asking me about my transition, I will not answer those questions. It's not it's a it's a deeply personal thing and it's not to be chatted about lightly with someone you don't trust.

SPEAKER_02 27:05

Um thank you so much, Dr. Hughes, for sharing your insight and and those tips with our audience about how we can make sure that healthcare is accessible and inclusive for transgender people. And that brings our podcast to a conclusion. So thank you very much, Dr. Hughes, for sharing with us your experiences both personally and professionally. Um we acknowledge that there's a range of experience within the LGBTQ plus community that deserves to be covered in depth in future podcasts. And we recognize that while equality is improving, there's still much progress to be made. But we hope that this podcast has been informative for our listeners, and then it will go some way to improve the experience of our LGBTQ patients and colleagues. Thank you again for listening to another episode brought to you by the Royal College of Physicians of Edinburgh.