Teena Brandon was a young woman in the USA who, in the throes of a sexual identity crisis, cut her hair and dressed like a man to see if she could pass for one. What began as an experiment turned into a fully fledged alter ego when she/he was accepted as a man named Brandon by a group of young people she met in a bar. As Brandon she had an affair with a young woman who fell in love with her thinking that she was a man. InDecember 1993, two ofBrandon’s male acquaintances raped and murdered her because they discovered her true identity. This abhorrent hate crime captured media attention at the time, highlighting the stigma, discrimination and violence directed at transgender people. The high-profile coverage generated by the case was the inspiration for the award-winning film Boys Don’t Cry. Although the film is violent and brutal, it is also tender and powerful as the triumph of the human spirit shines through in the audacity, pathos and sheer humanity of Brandon.
The extreme violence meted out to Brandon is rare, but there is unfortunately nothing unusual about unequal treatment of and discrimination against individuals who are perceived as different, even in in healthcare settings and despite numerous recent policies issued by the Department ofHealth outlining best practice in ensuring equality and dignity for marginalised groups. Gay and lesbian patients experience lack of understanding and prejudice from clinicians which can result in not only suboptimal care but also humiliation and distress for the patient (Meads et al, 2009). This form of discrimination is all the more surprising when one considers that medical advances in recent years have offered alternatives to individuals who desperately want and need to change their sexual identity. Somehow society, culture and belief systems do not appear to keep pace with what is scientifically or technologically possible. Thus attitudes to transgender patients range from respect and admiration to pity and, at worst, judgemental attitudes and moral opprobrium.
Transgender is a term that refers to a range of nonconforming gender behaviour, including cross dress dressing, drag queens, and transsexuals who generally feel their body to be at odds with their innate sense of gender identity. Transsexuals may medically transition or reassign to the gender that feels right for them; others may choose not to do so. Members of the latter group may have limited contact with health services and consequently experience the added stress of having to assert and prove themselves in the gender of their choice. It is thus not difficult to appreciate how a lack of understanding, and disregard and dismissal of the personal privacy and dignity of the transgender patient, may cause as great a hurt as violence.
Such was a case recently in a London hospital when an elderly and very unwell transgender patient presented to the emergency setting. This patient was in her eighties and had been cross dressing and presenting herself as female for many years. As she became increasingly frail she was less able to maintain her appearance as a woman, and began to appear increasingly male to the extent that the doctors and nurses who were caring for her were confused by her clearly female name but so obviously male appearance.
One of the nursing staff felt great compassion for this elderly woman and made a concerted effort to inform colleagues of the need for a sensitive approach. The staff responded well and care was delivered professionally and with dignity until the patient was transferred to the ward. The ward had been forewarned that the patient was an elderly person who needed a female bed but had a very masculine appearance. This information was either misconstrued or not given due credence, and on arrival on the ward the woman was allocated to a male bay, which caused her great distress. The transferring nurse tried to rescue the situation by returning the patient to the Emergency Department until a female bed was made available, but this did little to lessen the hurt and indignity that had been caused.
Prior to single-sex accommodation becoming mandatory in the NHS, allocating a patient to a mixed bay would not have caused the same level of distress, and possibly the circumstances of this patient would even have gone unnoticed. Unfortunately, single-sex accommodation does not always accommodate those who do not fit neatly into male or female categories. Consequently, gay, lesbian, bisexual, transgender and intersex (LGBTI) patients are likely to experience high levels of anxiety about the possibility of being misidentified (Hughes, 2009). Ageing exacerbates their difficulties. Few older adults will disclose their sexual identity or preferences, because they are the product of an era in which there was no understanding of sexual differences and in which male homosexuality was illegal. Moreover, despite Department of Health policies such as High Quality Care for All:NHS Next Stage Review (Department of Health, 2008) and the National Service Framework for Older People (Department of Health, 2001), elderly patients are still subjected to ageist attitudes, and the hurt and bewilderment that this incurs is compounded when those who should be caring for and about the individual also fail to recognise the importance and centrality of that person’s gender choice and personhood.
Knowledge about LGBTI people is very new (Grossman, 2008). The annual LGBT Health Summits in the UK which began in 2005 are a step in the right direction, in that they are designed to provide an opportunity for professionals, carers and LGBT people themselves to meet to discuss current issues in health and social care. As the population ages and gender reassignment operations become more common, it is essential that healthcare curricula in all disciplines acknowledge and accommodate these developments to ensure that professionals are equipped to respond appropriately and with understanding to transgender people so that these individuals are not depersonalised and subjected to prejudice and humiliating experiences.
The World Professional Association for Transgender Health (WPATH) is an international organisation devoted to furthering the understanding and treatment of gender identity differences. WPATH established and still publishes the Standards of Care (SOC) for the treatment of gender identity disorders, which may be a useful resource for healthcare workers. However, if we are true to ourcommitment to equality and to delivery of person-centred care, we should not need to refer to or rely upon written Standards of Care to make a person feel valued and respected. We just need to remember that our patients are people with feelings and that boys do cry.