THE PRACTICE OF EMERGENCY MEDICINE/ORIGINAL RESEARCH

“Sometimes You Feel Like the Freak Show”:

A Qualitative Assessment of Emergency Care
Experiences Among Transgender and
Gender-Nonconforming Patients
Elizabeth A. Samuels, MD, MPH*; Chantal Tape, BA; Naomi Garber, BA; Sarah Bowman, MPH; Esther K. Choo, MD, MPH
*Corresponding Author. E-mail: elizabeth.samuels@yale.edu, Twitter: @LizSamuels.

Study objective: Transgender, gender-variant, and intersex (trans) people have decreased access to care and poorer
health outcomes compared with the general population. Little has been studied and documented about such patients’
emergency department (ED) experiences and barriers to care. Using survey and qualitative research methods, this study
aims to identify specific areas for improvement and generate testable hypotheses about the barriers and challenges for
trans individuals needing acute care.

Methods: A survey and 4 focus groups were conducted with trans individuals older than 18 years who had been to an
ED in the last 5 years. Participants were recruited by trans e-mail listservs; outreach to local trans organizations; and
lesbian, gay, bisexual, and transgender periodical advertisements. The interview guide was reviewed by qualitative
research and trans health content experts. Deidentified participant demographic information was collected with a
standardized instrument. All discussions were captured on digital audio recorders and professionally transcribed.
Interview coding and thematic analysis were conducted with a grounded theory approach.

Results: Among 32 participants, 71.9% were male identified and 78.1% were white. Nearly half (43.8%) reported avoiding
the ED when they needed acute care. The factors that had the greatest influence on ED avoidance were fear of
discrimination, length of wait, and negative previous experiences. There were 4 overarching discussion themes: system
structure, care competency, discrimination and trauma, and avoidance of emergency care. Improvement recommendations
focused on staff and provider training about gender and trans health, assurance of private gender identity disclosure, and
accurate capture of sex, gender, and sexual orientation information in the electronic medical record.

Conclusion: Efforts to improve trans ED experiences should focus on provider competency and communication training,
electronic medical record modifications, and assurance of private means for gender disclosure. Future research
directions include quantifying the frequency of care avoidance, the effect of avoidance on trans patient morbidity and
mortality, and comparing ED patient outcomes by gender identity. Further research with increased inclusion of
transwomen and people of color is needed to identify themes that may not have been raised in this preliminary
investigation. [Ann Emerg Med. 2018;71:170-182.]

Please see page 171 for the Editor’s Capsule Summary of this article.

Readers: click on the link to go directly to a survey in which you can provide feedback to Annals on this particular article.
A podcast for this article is available at www.annemergmed.com.
0196-0644/$-see front matter
Copyright © 2017 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2017.05.002

SEE EDITORIAL, P. 189.
INTRODUCTION
Approximately 1.4 million transgender individuals live in
the United States.1 Transgender, gender-variant, and intersex
(trans) individuals face distinct health inequalities compared
with their cisgender peers, regardless of sexual orientation
(Appendix E1, available online at http://www.annemergmed.
com).2 This includes disproportionately high rates of sexual
and physical assault,3,4 psychiatric disorders,4,5 substance
dependency,6 homelessness,2 HIV infection,7,8 and death by
suicide and homicide.9 Addressing these disparities is impeded
by lack of medical school, residency, and continuing medical
education training in lesbian, gay, bisexual, trans, queer, and
intersex (LGBTQI) patient care,10-13 creating gaps in provider
knowledge and comfort caring for LGBTQI patients.14

170 Annals of Emergency Medicine Volume 71, no. 2 : February 2018

Samuels et al Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Editor’s Capsule Summary
What is already known on this topic
Transgender, gender-variant, and intersex (trans)
people may have difficulty accessing health care and
may experience discrimination when they do.
What question this study addressed
This qualitative study used focus groups of trans
adults with at least one emergency department (ED)
visit in the past 5 years to understand their
experiences with ED care.
What this study adds to our knowledge
The 32 adults who participated described many
issues that make them avoid ED care and made ED
care, when sought, suboptimal. They made
recommendations about privacy issues, staff training,
and improving the flexibility of electronic health
records to capture nontraditional gender
identifications.
How this is relevant to clinical practice
This article sensitizes physicians to issues faced by
trans patients and educates them so that they are
better equipped to provide excellent, compassionate
care.
Community surveys have documented emergency
department (ED) avoidance, experiences of discrimination,
and poor provider knowledge about trans health,15-17 but
reasons for avoidance and characteristics of transgender,
gender-variant, and intersex patient ED experiences have
not been fully characterized.
Database studies about trans patient health outcomes are
logistically difficult because relevant gender information is
not routinely captured in the medical record. For a deeper
understanding of trans patient ED barriers and experiences,
we conducted a survey and series of focus groups with trans
people who had recently sought emergency care.
Importance
There is little known about trans patient ED barriers
and experiences. This investigation explores these patients’
ED experiences, elicits themes that characterize interactions
with the health care system, and identifies specific areas that
can be improved.
Goals of This Investigation
We used qualitative research methods to understand
trans patient care barriers and experiences at every point of
Volume 71, no. 2 : February 2018
contact, from triage through clinician encounters and
diagnostic testing, with an aim to identify barriers and
generate specific suggestions for improvement.
Methods of Measurement
Focus group discussion questions were drawn from
questionnaires about trans health, barriers to care, and
health care experiences. The interview guide underwent
piloting and cognitive testing with qualitative research
methodology and trans health content experts. The study
principal investigator (E.S.) met with local trans leaders to
discuss study scope, goals, relevance, and participant
recruitment. They also reviewed the interview guide to
ensure that questions were understandable, accurately asked
what was intended, and were appropriate. Questions were
revised according to the piloting process to optimize face
validity. The interview guide was iteratively modified
during the course of interviews as themes emerged that
merited further exploration.
Eligible individuals identified as trans, gender variant,
gender queer, or intersex were aged 18 years or older and
had visited a Rhode Island ED within the previous 5 years.
Rhode Island has 12 EDs, one Level I trauma center. There
are an estimated 4,250 transgender individuals in Rhode
Island,1 which is one of 19 states that prohibits
discrimination based on sexual orientation or gender
identity.18 There is a statewide trans organization that has
successfully advocated for mandated insurance coverage for
trans health services,19 the initiation of an annual Trans*
Health Conference at the Warren Alpert Medical School of
Brown University, and the establishment of trans-specific
health clinics.
Participants were recruited through announcements
disseminated by trans community organizations and
e-mail listservs; lesbian, gay, bisexual, and transgender
community organizations and e-mail listservs; an
advertisement in the monthly statewide LGBTQI
magazine; and flyers distributed at local LGBTQI
businesses and the local Rhode Island Pride celebration.
Some participants independently recruited others through
their social network. Participants received $40 in
compensation for completion of a survey and focus group
discussion.
Participants were assigned unique study identification
numbers and completed an anonymous survey (Appendix
E2, available online at http://www.annemergmed.com) with
questions about sex, gender, sexuality, sociodemographics,
and health exposures, access, and utilization. Age was not
asked to reduce identifiability. The survey was designed to be
descriptive of the study sample. Whenever possible, we used
questions from previously validated or well-established
Annals of Emergency Medicine 171
Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients Samuels et al

survey instruments. Most questions were multiple choice. Table 1. Demographics.

Questions about factors affecting emergency care avoidance Demographic No. (%)*
were on a Likert-type scale of 1 to 4. Novel items were Gender identity*
developed for gender identity, preferred pronoun, health care Woman 4 (12.5)
access, ED avoidance, and experiences of harassment because Man 15 (46.9)
Transgender 14 (43.8)
validated questions were not identified. Participants Male to female 4 (12.5)
completed the survey on a handheld tablet immediately Female to male 18 (56.3)
before the focus group discussion. Gender queer 8 (25.0)
Transsexual 4 (12.5)
Focus group discussions were facilitated by the study Gender variant 3 (9.4)
principal investigator, supported by another research team Androgenous 4 (12.5)
member (E.S., C.T., N.G., S.B., E.C.). Discussions lasted Questioning 1 (3.1)
approximately 2 hours and were captured on digital audio Sexual identity*
Heterosexual 7 (21.9)
recording equipment, professionally transcribed verbatim, Gay 5 (15.6)
deidentified, and entered into qualitative data management Lesbian 3 (9.4)
software (NVivo; version 10; QSR International Pty Ltd, Bisexual 3 (9.4)
Queer 11 (34.4)
London, UK). Pansexual 3 (9.4)
The study protocol was approved by the Rhode Island No label 5 (15.6)
Hospital Institutional Review Board. Preferred pronoun*
He, him, his 24 (71.9)
She, her, hers 7 (21.9)
Primary Data Analysis They† 4 (12.5)
Survey responses were analyzed and reported as Ze, zir† 3 (9.4)
proportions of total responses. Initial codes for the Hir† 2 (6.25)
Racial identity*
qualitative analysis followed the interview guide topical
White 25 (78.1)
framework. Five research team members refined the coding Black 3 (9.4)
structure by coding initial transcripts, identifying additional Asian or Pacific Islander 3 (9.4)
codes through group discussion, and modifying existing Native American 3 (9.4)
Hispanic 9 (29.1)
codes. Coding categories were routinely reevaluated to Non-Hispanic 23 (71.9)
ensure that each coder had the same understanding and to Education‡
identify codes needing revision or clarification. The final None 0
<9th grade 0
coding classification scheme was applied to each transcript Some high school 2 (6.3)
by at least 2 independent team members (E.S., C.T., N.G., Graduated high school/GED 1 (3.1)
E.C.); discrepancies or ambiguities were resolved through Some college 11 (34.4)
Technical degree 2 (6.3)
discussion. An integrated set of codes was applied to each
Associate’s degree 2 (6.3)
transcript with NVivo. After all transcripts were analyzed, Bachelor’s degree 9 (29.1)
codes were summarized into major themes and subthemes. Graduate school 5 (15.6)
The study team collaboratively agreed on a final thematic Employment
Unemployed 9 (29.1)
framework and identified illustrative quotes that Part-time job 5 (15.6)
represented the range of responses relevant to each theme. Full-time job 10 (31.3)
More than one job 6 (18.8)
RESULTS Retired 1 (3.1)
GED, General education development.
Characteristics of Study Subjects *Total N¼32. For questions with asterisks, participants may select more than one
Thirty-two individuals participated in 4 focus groups. answer.
†
All participants completed the intake survey. Participant ‡
Gender-neutral pronouns.
Highest level of formal schooling.
demographics are detailed in Table 1. Most participants
were white (78.1%), preferred male pronouns (71.9%),
and identified as female to male, transgender, or male. 31.3% had been sexually assaulted. Most participants had
a primary care provider (96.9%) and were insured
Main Results (96.9%), but only 21.9% had insurance plans that
Experiences of harassment and assault were common. covered sex affirmation or reassignment health services
The majority of patients (84.4%) had experienced verbal (Table 2). Nearly half of participants (43.8%) reported
harassment, 43.8% had been physically assaulted, and avoiding the ED when they needed acute care. Most

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Samuels et al Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients

Table 2. Health exposures, access, and use. patients: “You’re standing there [with] a bunch of other
Question Topic No. (%) people behind you, and you’re going, ‘Yeah, I’m a
History of harassment or assault* transgender woman..’ So right there, now you opened
Verbal harassment 27 (84.4) yourself up to a lot of attention.” (no. 29, transwoman)
Sexual harassment 14 (43.8) Patient names and identifying documentation were
Physical assault 14 (43.8)
Sexual assault 10 (31.3)
frequently scrutinized, especially when inconsistent with
No previous experiences 4 (12.5) information in the existing medical record or insurance
Cigarette smoking documentation. This presented significant obstacles for
None 24 (75.0)
Some days 3 (9.4)
individuals who had not legally changed their name or
Every day 4 (12.5) gender designation. ED staff were frequently observed to
Alcohol use be confused and uncomfortable with these discrepancies.
Never 10 (31.3) Many participants believed some clarifying questions
Monthly or less 12 (37.5)
2–3 times/wk 8 (25.0) were invasive or dismissive. To avoid these situations,
>4 times/wk 2 (6.3) many participants described disclosing only when
Substance use absolutely necessary: “You’re thinking.should I lie in
Cannabis 19 (59.4)
Cocaine 5 (15.6)
this moment? You’re already vulnerable.” (no. 24,
Amphetamine-type stimulants 11 (34.4) transman)
Inhalants 5 (15.6) Communication was often characterized by repetitious
Sedatives 8 (25.0)
Hallucinogens 10 (31.3)
questioning. Staff roles were confusing, and many
Opioids 6 (18.8) participants were uncertain about with whom to share
Has a primary care provider 31 (96.9) information. One participant asked, “What person in all of
Has health insurance 31 (96.9) this chaos do I tell? What—who—who needs to know?
Insurance coverage 7 (21.9)
for sex affirmation/reassignment health services Because I feel like I don’t really want to have to repeat
Health services use myself 12,000 times.” (no. 7, transman)
Primary care provider visit in last year 27 (84.4) Rooming was a commonly mentioned concern. Some
Therapy or counseling† 30 (93.8)
Hormonal treatment† 24 (75.0)
thought being in a private room, when other patients were
Sex affirmation/reassignment surgery† 14 (43.8) in shared rooms, was stigmatizing. Others felt relief. Fears
Ever needed emergency care and did not go to ED 14 (43.8) about having a roommate included being placed in a room
*Total N¼32. For questions with an asterisk, participants may select more than one incongruous with their gender identity, inability to
answer.
†
Ever received this type of treatment.
maintain privacy, and discrimination or harm if their
gender identity was exposed. Bathroom access was not
commonly mentioned, and participants noted that most
EDs had gender-neutral bathrooms they could use.
survey questions were completed, but only 18 of 32 Participants offered suggestions to improve privacy at all
answered the question about factors affecting ED stages of care (Table 4). At triage, they recommended
avoidance. The factors that had the greatest influence on having private areas for sharing sensitive information or
ED avoidance were fear of discrimination, length of wait, waiting to discuss gender identity until privacy was
negative previous experiences, and use of primary care ensured. For EDs with shared rooms or rooms split by
provider (Figure). There were 4 overarching themes in curtains, they suggested using whiteboards as private
the focus group discussions: system structure, care communication aids.
competency, discrimination and trauma, and avoidance Communication improvements were suggested at
of emergency care. Each discussion concluded with multiple levels (Table 4) and emphasized improved
solicitation of suggestions to improve trans patient communication within the care team. This included
emergency care. receipt and review of primary care provider referrals and
Theme 1: System Structure. Throughout the ED visit, information sharing about name, gender, and pronouns
participants described an overwhelming lack of privacy, to promote consistent use among all care team members
repetitive questioning necessitating repeated assertions of and minimize repeated questioning and gender assertion.
gender identity, and documentation inconsistencies that Participants suggested electronic medical record or intake
produced feelings of embarrassment, frustration, and forms modifications to include nonbinary gender options
disempowerment (Table 3). Triage was described as a and fields for preferred name and pronouns. In addition
public process, often resulting in outing themselves to other to the electronic medical record, they suggested that

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Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Figure. Reported influence of factors resulting in avoidance of emergency services. Numbers in bar total are number of responses
about degree of influence factor has on avoidance of emergency care. PCP, Primary care physician.
preferred name and gender identity be reflected on
hospital bracelets.
Theme 2: Care Competency. All participants had
experiences with providers who lacked experience,
knowledge, and competency about gender identity or
transgender care (Table 3). Many described encounters in
which staff and providers did not understand the meaning
of transgender. As one participant (no. 17, transman)
explained, “[I]t’s been so ingrained, that male and female
binary system, where, you know, there’s a slew of questions
that are asked males and there are a slew of questions that
are asked females. And I think it’s sort of programmed that
way. They can’t deal.” Another added, “[U]sually [the]
response is, like, ‘So you’re a girl who wants to be a guy?’
I’m like, ‘No, I already identify as a guy..’ [I]t doesn’t
make sense to them.” (no. 27, transman)
This knowledge gap was frustrating for many
participants, and many described feeling burdened by
assuming an educational role. One participant (no. 23,
transwoman) explained, “[I]t seems like we have to
educate them all the time, and be very patient. Very
patient.” Another participant (no. 20, transman) added,
“I gotta educate you on something that I feel like
should’ve been already part of your training.”
Participants described feeling objectified, “like the freak
show” (no. 10, gender queer). Participant 2 (transman)
elaborated, “If you’re the ‘out’ trans person in the ER,
and there’s 8 residents on who have not seen a trans
person before, everyone wants to run into the room to be
part of that evaluation.” Some did not feel it was their
responsibility to educate providers and would even
withhold information to avoid negative experiences.
174 Annals of Emergency Medicine
Samuels et al
Others felt that identifying as trans and educating
providers might help other trans individuals in the
future.
Lack of staff and clinician knowledge about sex and
gender had a perceived influence on every level of patient
care. Participants described providers as rarely asking about
gender identity and reported inconsistent use of preferred
name or pronoun. Many perceived neglecting to
acknowledge gender identity as disrespectful and
dehumanizing. This was underscored by inconsistent use of
correct names and pronouns, depending on perceived
gender and whether patients had “outed” themselves as
trans. “Before I said anything, there was no problem with
the pronouns. They got the right pronouns. But after I
outed myself, then it caused a lot more problems with the
pronouns.” (no. 7, transman) These types of experiences
generated mistrust and lack of confidence in care quality.
Participant 22 (transwoman) asked, “Sort of makes you
wonder, if they can’t get your gender identity correct, what
else along the way is being misconstrued. What else are
they screwing up behind the scenes that you don’t know
well? Or what other information isn’t getting passed along
properly?”
After gender disclosure, participants described a wide
spectrum of questioning. One participant (no. 19,
transwoman) commented, “Once you disclose.it becomes
question after question.. [T]hey feel like it’s just open
season, like they can just say whatever they want, ask
whatever they want, whether it’s appropriate or
inappropriate.” Relevance of inquiry to clinical care had
many wondering whether physicians were “trying to get to
something that’s clinically relevant or are [they], like,
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Samuels et al Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Table 3. Discussion themes about system structure and care competency.
Subthemes
Theme 1: System Structure—Emergency care system
is not designed for safe and private gender
disclosure and fosters disempowerment and
mistrust between providers and patients.
“Routine” ED practices (such as being treated by several
physicians, being asked questions repeatedly at
various stages in care, or being put in a certain type of
room) are often interpreted as discriminatory/unsafe.
Key sites of dangerous disclosure include triage,
registration, and examination rooms that are shared or
lack privacy.
System requires repetitious disclosure of gender identity
to multiple people unknown to patients.
Existing documentation systems, including the electronic
medical record and identification bracelets, often
reflect sex rather than gender identity, which results in
misgendering, misnaming, and inappropriate or
repetitive questioning.
Theme 2: Care Competency—ED staff and providers are
often not experienced, knowledgeable, or competent
about gender identity or transgender care.
Providers perceived as not knowing how and when to ask
about gender identity.
When it is relevant to ask about gender identity is not
known by providers and variable among patients,
putting the onus on patients to identify what
information is relevant for patient care.
Trans patients frequently educate their providers about
gender or trans health within the setting of receiving
care.
Volume 71, no. 2 : February 2018
Quotes
“Um, so I think it’s knowing that you’re going to have to explain yourself over and over
and over again. Um, and you just—it’s, like, exhausting thinking about it before you
even go and it’s kind of, like, the determining factor of is it serious enough to have to
go through all that just to have something checked out?”
“At any one time you—I’ve seen upwards of 10 staff members in that little area. And you
might not want to say something to one person, let alone 10.”
“There’s no way to have a conversation that the person next to you doesn’t hear.”
“Go to that window, everybody hears everything around you, you know.”
“And I think that the, the lack of privacy in the ED is just—it makes it terrifying because
so many different people see you and there’s curtains rather than doors.”
“You know I’m often very uncomfortable about what I’m hearing in the next curtain, and
that drives me to not say stuff. Not only about my gender but a, a whole host of
things.”
“What person in all of this chaos do I tell? What—who—who—who needs to know?
Because I feel like I don’t really want to have to repeat myself 12,000 times.”
“They’re whispering, ‘Is that the right person? Who are we looking for? We’re looking for
this person.’ Then they started calling me my female name. I’m like, ‘I’m not a
female. I’m male.’ ‘Uh, can we see your bracelet again?’ I’m like, ‘What the hell?’ You
know?”
“And it was just, just really stressful and so, it still is stressful even with all the legal. I
mean, like, ’cause, like you, I haven’t, um, my insurance still says female, but, uh, my
license says male and that can be confusing still too. And, um, so e-either way it just,
it doesn’t really matter. Uh, it’s just I don’t think anybody wants to even step through
the door.”
“They’re kind of uncomfortable ’cause they’re looking at you one way and then you have
to tell them, you know, ‘I’m trans,’ and I don’t, don’t really wanna tell them that
because you just wanna tell them, you know, I’m male. But the way they look at you
and when they see your registration that’s kind of really uncomfortable.. They kinda
looked at me funny because they didn’t know how to react to that sorta thing.. It was
really awkward and uncomfortable and everybo—I felt everybody was, like, staring at
me and my face was turning all red and I just—it was a horrible experience.”
“If I’m someplace that I—I don’t feel safe, I don’t feel comfortable because someone’s
either, you know, insisting on calling me the wrong name, pronoun, whatever. Even if
I’m really, seriously sick, I’m probably not gonna feel comfortable sharing details of
that, especially if it’s got anywhere to do with, you know, parts of your body that are
directly impacted by being trans. I may not be as forthcoming with the necessary
details. Therefore, I might not get the right care, and it’s—and this is my own personal
opinion, it’s partly on me, because I don’t want to share that information. But it’s
also partly on whoever, those providers and support people, nurses, even people
doing transport, whatever. Because I’m not comfortable enough to share those
details.”
“Although it’s probably uncomfortable for me, I’m to the point where it’s less
comfortable for me than it would be for someone who’s maybe, like, just starting out
their whole process or transition or whatever they’re going through. So I would rather
be kind of the guinea pig, and almost take one for the team that way. Next time
those students come across someone in any of our situations, they are better
equipped to address it or respectfully, um, know how to speak to someone or about
someone.”
Annals of Emergency Medicine 175
Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Table 3. Continued.
Subthemes
There is dissolution of professionalism when providers “They don’t have to like me or accept what I am or anything else, but they’re—I’m there
and staff are confronted with nonbinary gender identity
that results in shame and avoidance of care among
transgender patients.
“I just think sometimes often we? I? just get ‘othered’ so often in these sorts of
curious?” (no. 10, gender queer) Questioning was
frequently thought to be inappropriate and irrelevant to
reasons for seeking emergency care. Participant no. 11
(transman) described receiving “inappropriate questions
about where I was in my transition; essentially, doctors
asking me what I plan on doing to my genitals when that’s
not why I was there to be cared for.”
Encounters in which participants were comfortable
talking to providers and staff were characterized by respect
for privacy, relevant questioning, and provider recognition
of knowledge gaps. Participant 12 (transman) recounted a
positive experience: “I think I felt comfortable, uh, really
talking to the nurse, talking to my doctor, ’cause I was at a
private setting. And because they weren’t asking stupid
questions that just didn’t seem relevant. Like my doctor
even—he had no idea, when I said this is the surgery I had,
this is the name of the surgery. He was, like, ‘Well, I’ve
never heard of that.but I treat infections.’ He didn’t ask
any questions that he didn’t need to. And, um, so that
made me feel comfortable, just to be able to talk—tell him
everything that’s going on.”
Provider and staff competency training about gender
and trans health was emphasized as the most important area
for improvement (Table 4). Participant suggestions for
training included online modules, inclusion in clinical
curricula, and continuing medical education presentations.
Theme 3: Discrimination and Trauma. Most participants
shared accounts of overt discrimination experienced or
witnessed in the ED, which produced fear and anxiety,
avoidance of emergency care, and mistrust of emergency
providers (Table 5). Many individuals described instances in
which their gender identity or anatomy was scrutinized and
mocked. One participant recalled a nurse asking, “‘Do you
have a dick between your legs?’ ‘No.’ ‘Then there you go.’” A
participant further recounted, “One woman came in, and
she’s, like, um, ‘What do you have underneath the covers? If
we have to do anything, are we gonna see something we’re
not used to?’” (no. 20, transman) At times the mockery was
shared publicly: “The EMT and the hospital staff were
176 Annals of Emergency Medicine
Samuels et al
Quotes
for a medical reason.. They’re professionals. They should at least respect who I am
while I’m there, you know? And if that means calling me ‘her,’ then that’s what it
should be.”
situations, that like it—you know, just the idea that, like, we’re human beings. Like,
you know, it’s nothing really crazy about this whole idea of transgender. It’s just a
little more complicated, but that doesn’t mean we should be treated badly—poorly
because of it.”
talking about my gender, my biological parts, um, at, like, at
the desk. And I could hear it in my room, and I knew that
the patients, like, next to me could hear it, and the people in
the hallway could hear it.” (7, transman)
Some participants not perceived as transgender by staff
had transphobic comments shared with them about other
patients. One recalled a certified nursing assistant bragging
about forcing a trans patient to expose her genitals to
another staff member. Another outed themselves as a
transman after hearing staff mocking a transwoman. Many
participants expressed helplessness and fear about being
outed to their local community through the process of
receiving emergency care and subsequent risk for harm
(Table 3). To prevent these types of experiences, many
individuals avoided gender disclosure unless it was
absolutely necessary.
Participants thought rainbow stickers, signs, or medical
pins were a simple way that EDs or providers could
communicate to patients that they could safely disclose
their gender or sexual identity (Table 4). To further
minimize unintentional trauma and discomfort during the
ED visit, participants emphasized clear and patient
communication when providers perform sensitive tests or
examinations, such as genital or rectal examinations and
pelvic ultrasonography. Recommendations included
explaining to patients the purpose of examinations or tests,
what is entailed, and willingness to discuss alternative
testing to minimize discomfort.
Theme 4: Avoidance of Emergency Care. Lack of privacy,
poor provider competency, fear of discrimination, wait
times, and cost of care were the most commonly mentioned
care barriers (Table 5). These findings were consistent with
survey responses (Figure). The unpredictability of these
factors compounded anxiety about seeking care. “I feel like
it’s like tossing.things in the air, and you just don’t know
how things are gonna land. Like you just never know what
providers you’re gonna get. You don’t know if they’re
gonna be trained or not trained. You don’t know what
intake’s gonna be like.” (no. 1, transman)
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Samuels et al
Table 4. Suggested solutions address lack of privacy, communication, provider competency, and advocacy supports.
Subthemes
Privacy could be improved by having private areas for
information sharing at triage, intake forms that
could be completed by the patient, and whiteboards
for sharing sensitive information in EDs with shared
rooms or beds separated by curtains.
Intake forms and the electronic medical record should
collect sex and gender information.
Patients should be asked about what name they
prefer to be called, their gender identity, and
preferred pronouns. This should be captured in the
medical record and hospital identifiers.
Communication needs to be improved between
outpatient and emergency providers and within the
emergency care team to minimize redundant
questioning and need for repetitive assertion of
gender identity.
Providers in all roles need required training in
nonbinary gender identities, sexual identity, and
delivery of appropriate and high-quality care to
transgender people.
Symbols or signifiers of being lesbian, gay, bisexual,
and trans friendly such as rainbow stickers or
medical pins can indicate that an ED is a safe place
to receive care.
Additional advocacy infrastructure could be an on-call
advocate who could accompany individuals to the
ED or any medical appointment.
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Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Quotes
“I think that there needs to be a place for you to disclose safely.”
“[I] think just having, like, a whiteboard. Like, in each area and when the patient’s
brought in, say, ‘You know, if there’s anything you’re asked during your stay here, you
know, that you don’t wanna answer verbally, you can write it on the whiteboard and show
it us.’“
“I think the easiest, most discrete way to do it would just be on the intake forms. Um, you know,
add a couple more options—under gender. Um, and then make sure that information gets to the
people who follow in the process.”
“[The clinic’s] intake form is probably a model that you should look after. It literally covers
everything, including blank spaces for you to fill in things about your—your sexual identity, your
gender identity, your gender expression, the difference between the two, and whether or not
they can outwardly call you a certain thing or not. It’s really, really inclusive.”
“My personal belief is that we should be asking every patient that ends up in front of us what their
name [is], what they wanna be called.”
“Um, it would, it fi-fix things not only for trans folks but a whole host of other folks. And I think that
we should announce pronouns for people or, or how they wanna be referred to. You know some
people wanna be referred [to] by their first name. Some people wanna be referred [to] by Mr.
and Mrs. so-and-so. I think, you know, if we just make it standard that we become more patient
centered in our communication with patients [and] then things go better for everybody. And
that, I think, far surpasses the needs of trans folks.”
“On the bracelet. Like, you know, your legal name, and then your preferred name. That would, I
think, [alleviate] some doubt, even for people outside of the transgender community.”
“I feel like just increasing communication with—before you walk in the room, here’s the form, you
read this brief synopsis before you go in, so you don’t have to explain to 5 different nurses
during shift rotation before they settle on which one’s yours—because that ends up taking up
half an hour where they could be treating people.”
“Yeah, and so it’s, like, all right, so once you explain it and do that, like, information, education
moment with that first person, how does—can—how can that be communicated again—and
again, and again, so you don’t have to do it to every—person you meet?”
“There needs to be appropriate communication between the people that take care of you, um,
how they treat you directly. And they need to learn to interpret whether your gender variant or
whether you’re female transgender but identify as female. Or whether you identify as
transgender, or what [this] specific language means, so that they know what to do with that
information once you give it to them.”
“I think there should be more training for everyone from front desk, to triage, to doctors, to nurses,
to medical assistant, to the whole gamut.”
“You know, my gender identity, and what pro—and that kinda stuff should not be just talked about,
um, openly like that. And I would put that under education for staff, understanding that this is
private, medical, personal information.”
“Something to put under education—is like when taking a, like, sexual history, understanding that
even nontrans patients, like, that might be partners of trans patients, like, if it says, you know,
do you have sex with women, men, or both—and they check off women, that doesn’t necessarily
means a biological woman.”
“We desperately, desperately need, um, training for ultrasound techs. Especially techs that are
doing transvaginal ultrasounds.”
“Having an understanding that certain procedures are going to be more stressful and anxiety
provoking for people—gender identity, um, variants, because, um, things like pelvic exams,
breast exams, uh, you know, uh, colonoscopies, things like that that might just be a little bit
annoying to people who are cisgendered can be very anxiety provoking.”
“When I see rainbow flags, I’m, like, this place is cool.”
“So as an option, it could be nice for the providers, if they’re not—if they’re unsure of something,
but they don’t wanna offend the patient by saying, ‘Well, like, why don’t you explain all of this to
me?’ in the moment. They could go to whoever’s on call as the trans advocate and just say,
‘Okay, like, this—this part I just am not sure about. Can you clarify for me so I don’t embarrass
this person?’“
Annals of Emergency Medicine 177
Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
Table 5. Discussion themes about discrimination, trauma, and avoidance of emergency care.
Subthemes
Theme 3: Discrimination and Trauma—Experiences
receiving emergency care are generally anxiety
provoking and traumatic.
Experiences of discrimination and mockery produce
feelings of worthlessness, objectification, shame,
and fear for personal safety.
Loss of control of gender disclosure produces feelings
of anxiety and fear over personal safety during and
after the clinical encounter.
Fear of mockery and physical violence results in
anxiety and avoidance of gender disclosure.
Theme 4: Avoidance of Emergency Care—
Participants sought alternative sources of care
because of fears of discrimination, previous
negative experiences, and concerns unrelated to
gender identity.
Fear of discrimination is based on previous bad
experiences and fear of disclosure of gender
identity.
Cost and wait to be treated are common cited
concerns, but not as significant as fear of
discrimination.
Barriers to care overcome by support and
encouragement from a relative or friend or
because of emergency care need.
178 Annals of Emergency Medicine
Samuels et al
Quotes
“When you work in the [health care] environment, you hear the gossip and you hear what they say
about other trans people, their patients. I actually had a CNA brag to me about making a trans
woman expose her genitalia in front of another CNA to prove that this person had a penis. I
didn’t even know what to do.. I had to walk out of the room. I didn’t say anything.. All I could
think was wow! Like, I live in this community and I could be at that hospital and I could be forced
to do the same thing, and what am I going to do? You know? And that’s terrifying.. The rumors
and the gossip that goes on behind closed doors is scary. It’s really scary.”
“They brought me to get x-rayed. While I was on the table getting x-rayed, they went and got other
folks in the department. So while I was laying on the table getting x-rayed, there were now 5
folks in the x-ray window, like, behind the room, watching me, laying on the table, being helpless
and in pain while I was getting x-rayed. Like, pointing, laughing.”
“I had a massive seizure. I wake up at this hospital.and I’m so afraid.. The stuff I hear is just,
like, Rhode Island is such a closed community there. Like, I just feel like I would be beat to
death if anybody found out there. Um, and I wake up there and my wife is there already. And my
mother’s there already and I’m thinking, ‘How long has this been and what did they do to me
when I was being bused over here?’ Because usually, you know, they’re cutting your clothes off
and I’m thinkin’, ‘Oh my God! Did my packing fall out?’ you know? I was so stressed out
afterward and then being all foggy still from the seizure. It was just absolutely horrible. I still
think about who were the ambulance drivers? What did they see? What did they know? I mean,
it’s still kind of haunting.. It’s such a small town and it’s really gossipy and everybody knows
each other. And, so it’s almost like ‘if one person knows, everybody’s gonna know’ kinda thing,
and it would just—I’m not out to people at all. Um, there’s certain parts of my job that I would
probably be violently attacked if people knew, um, if they found out now. So I worry all the time,
you know, oh maybe they’ll run into that ambulance guy and they’ll say, ‘Hey, hey’ to his buddy,
ru-ru-ru, you know? It’s just always a fear for me now.”
“Sometimes I would rather deal with them misgendering me, and mispronouning than having to
be my own advocate. I have, so many times, just been, like, ‘Yep, that’s my name’ when they say
the wrong name or say ‘she’ because I am almost too nervous to bring up trans because I’m
afraid of a more violent, or a more negative reaction.”
“I feel like it’s, like, tossing.things in the air, and you just don’t know how things are gonna land.
Like, you just never know what providers you’re gonna get. You don’t know if they’re gonna be
trained or not trained. You don’t know what intake’s gonna be like.”
“When you’re that vulnerable, that’s the worst time to have to worry about people reacting to you.”
“Um, you know I have insurance, so it’s not that bad, but I still have a pretty sizeable copay when it
comes to emergency rooms.”
“If I go to the ER, they’ll treat me, but, like, if I need to go home and take medicine, then, like, I
can’t even afford it.”
“And so I don’t wanna go and spend, you know, 12 hours to—for them to give me some painkillers
and tell me to call my doctor in 3 days, when I could just wait it out and go to my doctor.”
“So, like, if I’m sick, I’ll try to, like, wait until, like, okay, is it 4 in the morning? Okay, that group of
people are going this way, this group—you know what I mean? I try to just slip in and slip out.”
“It’s just stressful and it’s just a lot of time and a lot of money.”
“I don’t go until somebody makes me, mainly my wife.”
“And so then, if I had to go, I would’ve probably only gone if my partner was with me.”
“I think a lot of times we end up there because we haven’t sought care prior to things becoming
urgent or emergent. I think—I—I mean the number of trans guys I’ve brought with vaginal
bleeding to the emergency department that, that would have never belonged there 14 days
earlier.”
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Samuels et al Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients

Table 5. Continued.
Subthemes Quotes

Primary alternative to emergency care is being treated
by a primary care physician whom they already
trust.
“And, um, I was, like, hit by a car and the only part I can—the only thing I remember—but I called
my mother and I said, ‘Mom, can you bring me over to my primary care doctor?’ And she’s, like,
‘What happened?’ ‘I got hit by a car.’ And she’s, like, ‘I’m bringing you to the emergency room,’
and I wouldn’t tell her where I was until she agreed to bring me to the pri—my primary care
doctor. And, ’cause at that time I was negative $200.00 a month.”

Although most participants had mistrust and often dislike
for physicians—“a lot of providers don’t really have a bedside
manner. It’s more of a graveside manner, or just no manner”
(no. 26, transwoman)—most also had a primary care
provider they liked, trusted, and preferred to consult before
going to the ED. Many of the instances in which individuals
reluctantly sought emergency care were at the urging of their
primary care provider or a close family member.
Individuals without a primary care provider sought care
only when absolutely necessary. A few participants
described knowingly delaying treatment for asthma
exacerbations and respiratory and intestinal infections
because of previous negative experiences. Participants also
described not seeking treatment after minor accidents
and injuries, including lacerations, burns, sprained ankles,
and low-speed motor vehicle crashes. Although many
participants reported previous physical or sexual assault,
they did not mention avoiding emergency care after such
incidents.
There were various perspectives on the development of
an advocacy infrastructure, such as an on-call advocate who
could accompany trans individuals to the ED (Table 4).
Some thought this might help decrease isolation, minimize
barriers caused by fear of discrimination, and relieve
pressure to self-advocate. Others worried that the presence
of the advocate would out them as trans, potentially
limiting their ability to decide when and to whom to
disclose their gender identity.
LIMITATIONS
This study provides rich information about barriers and
facilitators to emergency care for trans patients, yet there
are several limitations. First, although the study sample is
sufficient for hypothesis generation, it is not possible to
make generalizable conclusions, given the small study size,
overrepresentation of individuals with access to a primary
care provider, exclusion of those who had never sought
emergency care or did not speak English, and
underrepresentation of trans people of color, transwomen,
and participants who identified as intersex. Participants in
our study were 80% white, whereas larger population
surveys estimate that 55% of transgender adults are white,
16% are black, 21% are Hispanic, and 8% are Asian or
Pacific Islander, Native American, or multiracial.20 Nearly
80% of our sample used masculine pronouns, a larger
proportion compared with respondents to the US
Transgender Survey, the largest survey of transgender
individuals (27,715 people) to date, in which 37% used he/
his pronouns, 37% used she/her pronouns, and 32%
identified as transwomen and 3% as intersex.16
Most survey questions were completed by study
participants, but nearly half (43.8%) skipped the questions
about factors impacting ED avoidance. These questions
were in the middle of the survey, and participants answered
questions after this question group and about more
sensitive topics, such as substance use and assault.
Questions about ED avoidance were the only items on a
Likert scale and may have been skipped because of lack of
question clarity, lack of participant opinion, or participant
discomfort, resulting in a response bias.
Our sampling method may have introduced bias by
selecting for individuals who were already engaged with
trans organizations or had access to pertinent e-mail
listservs. The disproportionate participation of white and
transmale individuals is likely related to the demographic
composition of organizations targeted for outreach, word-
of-mouth participant referrals, and outreach limitations
because of cost and time constraints. These factors may
have resulted in omission or underreporting of some
barriers and overreporting of others. Furthermore,
inclusion of participants who had visited an ED in the last
5 years could have introduced recall bias among those who
had not been to the ED in several years before the study.
Our research format also had benefits and drawbacks. For
some, talking in a group may have created a comfortable
environment in which they could find mutual support and
build on others’ comments. Many participants mentioned that
they found significant mutual support through the group
discussion, which minimized feelings of isolation and facilitated
participation. For some individuals, however, group
discussions may have been uncomfortable, so they either did
not participate or may have limited their participation. Group
facilitators balanced the conversation to minimize dominance
from one or a few participants; however, focus groups are

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Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
subject to the development of dominant “group think,” which
can silence less popular voices or opinions.
Although the interview focused on emergency care
experiences, questions about sexual and gender identity are
very personal, and participants may have been reluctant or
unable to fully answer questions on these topics. Although
participants did share multiple negative experiences, some
individuals may have been reticent to fully divulge in a
group setting or to the research team.
Finally, generalizability of results is limited not only by
study design but also because interviews occurred in
Providence, RI, which may be a more or less trans-inclusive
community compared with other geographic areas or cities.
DISCUSSION
In this study of trans individuals who had sought
emergency care, common themes included system-based
barriers to care, overt discrimination, lack of clinician
competence in trans care, and emotional trauma incurred
from the ED experience. Participants also provided specific
suggestions for improvement that could make the ED a safe
and welcoming clinical environment for trans patients.
Privacy, communication, and provider competency were
priority areas for improvement. Although privacy can be
very challenging in a busy ED, our study underscores that
avoiding discussion of sensitive information, including
gender identity, within auditory range of other patients is
key to improving the patient experience and protecting
patient privacy. For trans patients, this is a means to ensure
patient safety, given the high incidence of transphobic
violence.5,9 Compared with the general US population, our
study sample reported higher rates of lifetime physical
(43.8% versus 2.42%)21 and sexual assault (31.3% versus
19.3% women, 1.7% men).22
Concerns about private rooming were varied. Our study
suggests that access to private rooms may benefit trans
patients, but to avoid stigmatization a private rooming
option should be offered before a patient is assigned to one
if there is no medical necessity and it is not standard
practice.
Many of the barriers and negative experiences
described—cost, wait times, lack of privacy, and repetitive
questioning—are unrelated to gender identity. However,
these issues were further compounded by experiences of
mockery, discrimination, and threats of violence that trans
individuals experience in and outside of the ED. Despite
structural limitations, providers and staff can play a
significant role in fostering an accepting, open, and
comfortable clinical environment. This may mean real-time
education of colleagues and staff, setting expectations for
respectful treatment of trans patients, or addressing
180 Annals of Emergency Medicine
Samuels et al
transphobic behavior, incidents of which were described by
each study participant.
Our findings also highlight the importance of care
team communication and electronic medical record
documentation to ensure consistent preferred name and
pronoun use and minimize repeated questioning.
Participants favored open-ended questions about gender
identity without excess scrutiny and preferred that clinical
questions focus on presenting medical concerns.
Consistent name and pronoun use was reportedly
undermined by the prominence of the legal name on
electronic medical record banners and hospital bracelets,
which are checked and confirmed with each medication
administered, radiographic test, and procedural time-out.
Currently, most electronic medical records do not
accurately record information about sex, gender, sexual
orientation, or sexual practices. Some electronic medical
record contractors23 offer options to display preferred
name in the electronic medical record banner and fields
that accurately collect sex and gender information. The
World Professional Association for Transgender Health
advocates a 2-step process to collect sex and gender
information, asking first about biologic sex and then
gender identity, in addition to collecting data about
pronouns and common gender actualization treatments
and procedures.24
Finally, there is a clear need for provider and staff
training. Education about LGBTQI health is not
widespread in medical and nursing education and needs
to become an expected core competency. Some
professional organizations, such as the Association of
American Medical Colleges,25 the Institute of
Medicine,26 and the American Medical Association27
have taken steps in this direction. In emergency
medicine, the Academy for Diversity and Inclusion in
Emergency Medicine28 of the Society for Academic
Emergency Medicine has made concerted efforts around
LGBTQI emergency medicine curriculum development,
provider education, and research.
No patient should feel “like a freak show.” To
improve the trans patient experience and reduce
avoidance of care for emergency conditions, future
quality improvement efforts should focus on provider
and staff competency and communication training,
electronic medical record modifications, and assurance of
private means for gender disclosure. Building from this
qualitative investigation, future studies should examine
the effect of gender identity on patient outcomes. This
includes quantifying the frequency of care avoidance,
assessing the effect of avoidance on trans patient
morbidity and mortality, and comparing ED patient
Volume 71, no. 2 : February 2018
Samuels et al Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
outcomes by gender identity. For institutions that
implement trans-inclusive policies, evaluation should
include pre- and postassessment of the trans patient
experience, ED avoidance, and trans patient outcomes.
Finally, further qualitative and quantitative research
remains to be conducted with representative inclusion of
transwomen and trans people of color to identify themes
and areas for improvement that may not have been raised
in this preliminary investigation.
Supervising editor: David L. Schriger, MD, MPH
Author affiliations: From the Yale National Clinician Scholars
Program, Yale Department of Emergency Medicine, New Haven, CT
(Samuels); the University Emergency Medicine Foundation,
Department of Emergency Medicine (Garber), Alpert Medical
School of Brown University (Tape), Providence, RI; the Rhode Island
Department of Health, Providence, RI (Bowman); and the Center
for Policy and Research in Emergency Medicine, Oregon Health &
Science University, Portland, OR (Choo).
Author contributions: EAS and EKC conceived the study. EAS, CT,
SB, and EKC designed the interview guide and intake survey and
undertook obtaining institutional review board approval and
participant recruitment. All authors facilitated the focus group
discussions, reviewed and coded transcripts, and participated in
thematic analysis. EKC supervised data collection and analysis.
EAS drafted the article, and all authors contributed substantially to
its revision. EAS takes responsibility for the paper as a whole.
All authors attest to meeting the four ICMJE.org authorship criteria:
(1) Substantial contributions to the conception or design of the
work; or the acquisition, analysis, or interpretation of data for the
work; AND (2) Drafting the work or revising it critically for important
intellectual content; AND (3) Final approval of the version to be
published; AND (4) Agreement to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and
resolved.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE conflict
of interest guidelines (see www.icmje.org). This study was
supported by a Brown University Emergency Medicine Foundation
Resident Research Grant.
Publication dates: Received for publication January 30, 2017.
Revision received April 20, 2017. Accepted for publication May 1,
2017. Available online July 14, 2017.
Presented at the American College of Emergency Physicians
Scientific Assembly October 2015, Boston, MA; and the Gay and
Lesbian Medical Association 33rd annual conference, September
2015, Portland, OR.
REFERENCES
1. Flores AR, Brown TNT, Herman JL. How Many Adults Identify as
Transgender in the United States?. Los Angeles, CA: Williams Institute
UCLA School of Law; 2016.
Volume 71, no. 2 : February 2018
2. Cochran BN, Stewart AJ, Ginzler JA, et al. Challenges faced by
homeless sexual minorities: comparison of gay, lesbian, bisexual, and
transgender homeless adolescents with their heterosexual
counterparts. Am J Public Health. 2002;92:773-777.
3. Lombardi EL, Wilchens RA, Priesing D, et al. Gender violence:
transgender experiences with violence and discrimination. J Homosex.
2001;42:89-101.
4. Roberts AL, Austin SB, Corliss HL, et al. Pervasive trauma exposure
among US sexual orientation minority adults and risk of
posttraumatic stress disorder. Am J Public Health.
2010;100:2433-2441.
5. McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to
discrimination and psychiatric disorders among black, Hispanic,
female, and lesbian, gay, and bisexual individuals. Am J Public Health.
2010;100:1477-1484.
6. Rosario M, Reisner SL, Corliss HL, et al. Sexual-orientation
disparities in substance use in emerging adults: a function of stress
and attachment paradigms. Psychol Addict Behav.
2014;28:790-804.
7. Clements-Nolle K, Marx R, Guzman R, et al. HIV prevalence, risk
behaviors, health care use, and mental health status of transgender
persons: implications for public health intervention. Am J Public
Health. 2001;91:915-921.
8. Marshall BDL, Shannon K, Kerr T, et al. Survival sex work and
increased HIV risk among sexual minority street-involved youth.
J Acquir Immune Defic Syndr. 2010;53:661-664.
9. Remafedi G, French S, Story M, et al. The relationship between suicide
risk and sexual orientation: results of a population-based study. Am J
Public Health. 1998;88:57-60.
10. White W, Brenman S, Paradis E, et al. Lesbian, gay, bisexual, and
transgender patient care: medical students’ preparedness and
comfort. Teach Learn Med. 2015;27:254-263.
11. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay,
bisexual, and transgender—related content in undergraduate medical
education. JAMA. 2011;306:971-977.
12. Moll J, Krieger P, Moreno-Walton L, et al. The prevalence of lesbian,
gay, bisexual, and transgender health education and training in
emergency medicine residency programs: what do we know? 2014;21:
608-611.
13. Jalali S, Sauer LM. Improving care for lesbian, gay, bisexual, and
transgender patients in the emergency department. Ann Emerg Med.
2015;66:417-423.
14. Smith D, Mathews W. Physicians’ attitudes toward homosexuality and
HIV: survey of a California medical society—revisited (PATHH-II).
2007;52:1-9.
15. Bauer GR, Scheim AI, Deutsch MB, et al. Reported emergency
department avoidance, use, and experiences of transgender persons
in Ontario, Canada: results from a respondent-driven sampling survey.
Ann Emerg Med. 2014;63:713-720.
16. James SE, Herman JL, Rankin S, et al. The Report of the 2015 US
Transgender Survey. Washington, DC: National Center for Transgender
Equality; 2016.
17. Brown JF, Fu J. Emergency department avoidance by transgender
persons: another broken thread in the “safety net” of emergency
medicine care. Ann Emerg Med. 2014;63:721-722.
18. Humans Rights Campaign. Maps of state laws and policies. Available at:
http://www.hrc.org/state_maps. Accessed April 4, 2017.
19. Gourlay K. New law: RI health insurers must cover trans health
care. December 3, 2015. Available at: http://ripr.org/post/new-
law-ri-health-insurers-must-cover-trans-health-care. Accessed March
25, 2017.
20. Flores A, Brown T, Herman J. Race and Ethnicity of Adults Who Identify
as Transgender in the United States. Los Angeles, CA: Williams
Institute UCLA School of Law; 2016.
21. Truman J, Langton L. Criminal Victimization, 2014. Bureau of Justice;
August 2015, Revised September 29, 2015, 2014.
Annals of Emergency Medicine 181
Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients
22. Breiding MJ. Prevalence and characteristics of sexual violence,
stalking, and intimate partner violence victimization—National
Intimate Partner and Sexual Violence Survey, United States,
2011. MMWR Surveill Summ. 2014;63:1-18.
23. Institute of Medicine. Collecting Sexual Orientation and Gender
Identity Data in Electronic Health Records: Workshop Summary.
Washington, DC: Institute of Medicine; 2013.
24. Deutsch MB, Green Jamison, Keatley J, et al. Electronic medical
records and the transgender patient: recommendations from the
World Professional Association for Transgender Health. J Am Med
Inform Assoc. 2013;20:700-703.
25. AAMC Advisory Committee on Sexual Orientation GI, and Sex
Development. Implementing Curricular and Institutional Climate
182 Annals of Emergency Medicine
Samuels et al
Changes to Improve Health Care for Individuals Who Are LGBT,
Gender Nonconforming, or Born With DSD: A Resource for Medical
Educators. Washington, DC: Association of American Medical
Colleges; 2014.
26. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and
Transgender People: Building a Foundation for Better Understanding.
Washington, DC: Institute of Medicine; 2011.
27. American Medical Association Advisory Committee on LGBT Issues. Available
at: https://www.ama-assn.org/about/advisory-committee-lgbtq-issues.
Accessed April 7, 2017.
28. Academy for Diversity and Inclusion in Emergency Medicine. Society for
Academic Emergency Medicine. Available at: https://www.saem.org/adiem.
Accessed April 17, 2017.
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Appendix E1. Glossary of terms.

Cisgender: A person whose gender identity and expression match the gender stereotypically associated with their biological sex; for example, a person born
with female genitalia who identifies as a woman.
Gender identity: One’s basic sense of being a man, woman, or other gender. May or may not be in stereotypical accord with physical anatomy.
Gender variant/gender nonconforming: Someone who does not conform to society’s gender norms or standards.
Gender queer: A gender identity outside the male-female binary.
Intersex: A term used for people who are born with external or internal genitalia that vary from typical male or female genitalia, a chromosomal pattern that
varies from XX (female) or XY (male), or hormonal insensitivity (such as androgen insensitivity syndrome, disorders of sex development).
Sexual orientation: Enduring pattern of sexual and romantic attractions and behaviors toward men, women, or nonbinary genders.
Sex: The genetic, hormonal, anatomic, and physiologic characteristics of male or female persons.
“Out”: People who are out are those who have made public their gender or sexual identity.
Trans: An umbrella term intended to include a wide range of gender identities and expressions, including transgender, gender-variant, gender
nonconforming, transsexual, and intersex.
Transgender: An umbrella term referring to individuals with a gender identity or expression that differs from societal norms for those of their birth sex.
Transsexual: A historic and outdated term referring to those with a gender identity “opposite to” the gender assigned at birth.
Transitioning: The process of changing the body through hormones, surgeries, and other means. Other changes include changing their name and gender
designation on legal documents such as birth certificates, driver’s licenses, social security records, and health insurance.
Two-spirit: A term used by some North American Native peoples to describe individuals who identify with male and female gender roles and expressions.
Modified from Bauer et al.15

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