written by Anonymous

The current climate means that, presented with a patient like this, I can tell you I was nervous as hell about saying the wrong thing. I’m not talking about misgendering, it’s easy not to do that… What I mean was that I was terrified of saying anything that hinted I’d observed or considered that the patient might be a transwoman, in case I upset them or attracted a complaint.

I saw a transwoman in the ED the other day. Medical records all said ‘female’. NHS number was new. Nothing from [patient] to reveal natal sex, except ‘I take HRT’. I could see this patient was taking 6x the exogenous oral oestrogen normally taken post-menopause, plus a weekly patch. Formerly took [androgen blocker used in feminisation therapy for males] and had had NHS speech and language therapy.

With patient’s consent I viewed the SCR [Summary Care Records], to record drug history accurately in the notes. In the SCR natal sex was not recorded. All it contained was childhood immunizations and current drugs. No ‘diagnosis’ relating to drug history. No record of any surgery.

A few points.

If this patient was bleeding, I would send group and save. This would go to blood bank with sex erroneously marked as female. I’m not a haematologist but are there risks around this, I don’t know?

If the patient donated blood, is natal sex recorded? 

Patient had [shortness of breath]/cough/chest pain. Was sent in for PE work-up, presumably because the massive doses of oestrogen are a big risk factor.

I did bloods, d-dimer, chest X ray etc.

Investigations were negative for PE but there was an incidental finding on chest x-ray of healed fractures with no history of trauma, which is unusual to see in a young patient.

I was concerned this might indicate reduced bone density, knowing this can be a side-effect of gender reassignment therapy. I discussed this with the patient, without at any point suggesting that I didn’t take patient’s recorded sex at face value. I thought it was in the patient’s best interest to mention the incidental finding in the patient’s discharge letter. 

Anyway, I’m telling you all this because I suppose it highlighted to me a few things about how unhelpful it is from a clinical [point of view] to go down this gender rabbit hole. For the patient, passing and being dissociated from their natal sex is important. They are permitted to have a new name, NHS number and sex on their records. Their wish/need for gender affirmation is prioritised over their clinician knowing something as fundamental as their sex when it comes to diagnosing and treating them.

Also, the current climate means that, presented with a patient like this, I can tell you I was nervous as hell about saying the wrong thing. I’m not talking about misgendering, it’s easy not to do that… What I mean was that I was terrified of saying anything that hinted I’d observed or considered that the patient might be a transwoman, in case I upset them or attracted a complaint.

There was lack of candour and openness, and waryness on both sides, which is not conducive to delivering best clinical care to the patient.

Prior to this encounter I was unaware you could change both your sex and NHS number on your records. I looked into it and I found a discussion on Reddit between some young trans individuals who were exchanging information about how to get a new NHS [number] changed (from what I remember it is easy and I’m not even convinced you need a GRC).

What was also clear, is that their priority in getting new NHS number is so they can actually hide, erase, their sex… it’s all about passing.