Step 6: Ensure transgender and intersex patients are not overlooked

steps This section covers the following steps:

Step 6.1 Make sure your practice understands the meaning of intersex, transgender and gender diverse
Step 6.2 Make sure your practice team understands transgender and intersex patients’ eligibility for breast and cervical cancer screening
Step 6.3 Understand how data audit tools and practice software gender categories can affect patient care
Step 6.4 Consider maintaining a register of transgender and intersex patients
Step 6.5 Consider adjusting your patient information form
Step 6.6 Develop a workflow for handling transgender and intersex patient information
Step 6.7 Build your team’s knowledge about appropriate patient care for transgender, gender diverse and intersex people

It is important that all patients, regardless of gender identity or physical sex characteristics, have access to the screening they need.

Care needs to be taken to ensure intersex, trans and gender diverse patients who are eligible for screening are captured in cancer screening data and reminder systems, and they are provided with appropriate cancer screening reminders.

Step 6.1 Make sure your practice understands the meaning of intersex, transgender and gender diverse

Intersex

“Intersex is a term that relates to a broad range of congenital physical traits or variations that lie between ideals of male and female. Intersex people are born with physical, hormonal or genetic features that are neither wholly female nor wholly male, or a combination of female and male.

Many forms of intersex exist; it is a spectrum or umbrella term, rather than a single category. At least 30 or 40 different variations are known to science. Intersex differences may be apparent at birth. Some common intersex variations are diagnosed prenatally. Some intersex traits become apparent at puberty, or when trying to conceive, or through random chance.”8

According to Intersex Human Rights Australia, intersex clients need the following8:

  • Clear messages that a service welcomes intersex people, and an awareness that intersex status is about variations of biology, not gender identity or sexual orientation.
  • To know that confidentiality will be respected.
  • Services that understand intersex health and wellbeing concerns.

Consider printing and sharing with your practice team the guide to Making your service intersex friendly by Intersex Human Rights Australia.

Transgender and gender diverse

ACON advises the term Transgender and gender diverse describes people who identify their gender as different to what was assigned to them at birth.

‘Gender diverse’ is an umbrella term for any number of gender identities that sit within, outside of, across or between the spectrum of the male and female binary. A gender diverse person might identify outside of the male and female binary by identifying as non-binary, gender-fluid, gender non-conforming, trans masculine, trans feminine, etc.

The transgender experience is independent of sexuality. A transgender person will also have a sexual orientation, whether that is heterosexual, lesbian, gay, bisexual, queer, etc.

Throughout this document, the terms ‘trans and gender diverse’ are used to include the spectrum of gender identities outside of male and female, such as non-binary and transgender.

Step 6.2 Make sure your practice team understands transgender and intersex patients’ eligibility for breast and cervical cancer screening

Patients aged 25 to 74 years, have a cervix and have ever been sexually active, should have a Cervical Screening Test. This includes transgender men and non-binary people who were assigned female at birth and have a cervix, as well as those who have had the HPV vaccination.9

Step 6.3 Understand how data audit tools and practice software gender categories can affect patient care

From June 2019, CAT4 will have the following gender categories:

  1. Male 
  2. Female
  3. Other (Gender other/diverse)
  4. Not stated/inadequately described

CAT4 cervical and breast cancer screening reports will include patients grouped into the categories of Female, Other or Not stated/inadequately described. Patients who are listed as ‘intersex’ in practice software will be grouped into ‘Other’ by CAT4. This means that CAT4:

  • will NOT include patients whose gender is assigned as male in your practice software, even if the patient is eligible for breast and/or cervical screening. These patients need to be manually captured to ensure they have access to the screening that they need
  • will include patients whose gender is assigned as female in your practice software, even if the patient is not eligible for breast and cervical screening (e.g. patients who do not have a cervix). These patients need to be manually captured to ensure that they don’t get reminders for screening that they are not eligible for.
  • will include patients assigned as ‘Other’ or ‘Intersex’ in practice software:
    • Using these categories can be beneficial for capturing patients who identify as male or non-binary, but who are eligible for breast and cervical cancer screening.
    • Using these categories can be problematic for including patients who are not eligible for breast and cervical screening.

Step 6.4 Consider maintaining a register of transgender and intersex patients

Considering the software limitations outlined in Step 6.3, it is recommended that practices maintain a register of patients who identify as trans/transgender, gender diverse or intersex.

This register should be used to cross-check lists of patients who are going to be sent cancer screening reminders to ensure transgender and intersex patients are only sent reminders for cancer screening programs they are clinically eligible to participate in.

Step 6.5 Consider adjusting your patient information form

Your patient information form is an opportunity for transgender, gender diverse and intersex patients to tell your practice:

  • if they are trans, gender diverse or intersex
  • how they prefer to identify
  • the appropriate pronouns to use when addressing the patient.
The following questions are from the registration form used at ACON’s CheckOUT clinic. Consider adding the following questions to your new patient information:
1. What is your current gender identity?
 
  • Female
  • Male
  • Non-binary
  • Different identity (open field here)
2. What sex were you assigned at birth?
 
  • Female
  • Male 
3. Were you born with a variation of sex characteristics (this is sometimes called ‘intersex’)?
 
  • Yes
  • No
  • Prefer not to say
4. What are your pronouns? (You can select more than one)
 
  • She / Her / Hers
  • He / Him / His
  • They / Them / Theirs
  • Other (open field here)

 

Step 6.6 Develop a workflow for handling transgender and intersex patient information

It is important that practices use appropriate and respectful language when communicating with patients. This includes referring to a person using the gender they affirm for themselves using the correct pronouns and titles (e.g. Mr, Ms, Mx).

Before you add the questions that allow trans and intersex patients to identify themselves on new patient information forms, develop a simple workflow for managing trans and intersex patient information. This will ensure:

  • clinicians are aware of the information they need from the new patient information form in a timely way to provide patient-centred communication and care
  • clinicians know how to ask appropriate questions (as per the questions suggested for the new patient information form), and how to add data to practice software if a patient identifies as trans, gender diverse or intersex during an appointment (or is an existing patient) as opposed to via the new patient information form
  • trans, gender diverse and intersex patients are offered appropriate preventative care (e.g. cancer screening reminders)
  • reception and administration staff are confident to:
    • manage trans, gender diverse and intersex patient data in your practice software
    • communicate with trans, gender diverse and intersex patients respectfully and appropriately.

When developing your workflow, use the comments or notes sections of practice software to record how the patient identifies.

For example, if you have a patient who was assigned female at birth but identifies as non-binary, you may assign them to “other” in practice software but must not use this term with the patient.

It is recommended that your practice:

  • uses the notes field to state (for example) “non-binary, uses they/them pronouns, assigned female at birth (AFAB)”
  • includes the patient on your register of trans, gender diverse and intersex patients so they receive cervical and breast screening reminders, where appropriate.

Step 6.7 Build your team’s knowledge about appropriate patient care for transgender, gender diverse and intersex people

Modules 3 and 4 provide information on:

  • how to appropriately discuss gender with trans, gender diverse and intersex patients if relevant to the appointment and only if guided by the patient themselves.
  • sending screening reminders to transgender and intersex patients
  • cancer screening at the point of care for LGBTIQ+ patients.