Case Studies

Case Study 1: Alex

You have a new patient named Alex who is in for a prenatal checkup, and the front desk staff lets you know that Alex has a support person named Beth, and both are in the exam room waiting. You walk into the exam room to see Alex (short brown hair) wearing the exam gown and sitting on the exam table, and Beth (long blonde hair) wearing a dress and sitting in the extra chair. You greet the two and say, “Hello! You must be Alex, it’s great to meet you. You must be Beth. It is always so nice to see sisters supporting each other, especially for something as exciting as pregnancy. Before we get started, are there any burning questions you have for me?”

Beth, the support person at the appointment, says, “We’re not sisters. He is my husband. I’m a little confused–when Alex called to set up the appointment, he was told that this office had experience with trans people.” You apologize profusely for the mistake and continue with the appointment. A few times, you stumble over your language, as you are used to saying things like, “When a woman is in the first trimester,” and, “many women have these symptoms,” though you do try to correct yourself. Even with your apology, correcting yourself, and using the correct language to refer to the patient and his wife throughout the rest of the visit, it is tense. Later that day, the front desk staff asks if anything odd happened in the visit, as Alex asked if he could see a different provider going forward, or to have his records so that he could go to a different office.

• How could you have greeted the patient/support person differently? [“Hi, my name is _____, you must be Alex and you must be Beth, unless you decided to sit in the wrong spots haha. I’m excited to get started, but how about you tell me a little more about you.”]
• If the patient had been a woman, why might the greeting that was used still be offensive and alienating? [Bisexual and lesbian women have babies.]
• Even though you apologized and made corrections, it was still a tense appointment that the patient did not feel good about. Why might an apology not be enough? [Apologizing is important, but it does not undo the harm that was done.]
• Aside from being alienated by the language that you used, why might the patient seek out a different provider for their pregnancy care after this experience? [Beth specifically mentioned that the couple was looking for a trans competent provider. Alex may have pregnancy-related questions that are specific to being trans.

Case Study 2: Scout

You have a new patient come in for abortion care named Scout. The patient’s pregnancy has been confirmed at 6 weeks, and the patient has opted for medication abortion. You go in to the room to meet with the client, give them information about how medication abortion works, answer any questions, and give them the medication. When you enter, you introduce yourself and say, “Sometimes women can have complicated feelings about accessing abortion. I just want to let you know that you know best what you need, and we support you no matter what.” Scout says, “I’m not a woman, I’m agender. I thought I put that on the intake form with my pronouns?” You look at the chart to see a sticky note that says, “agender, they/them pronouns.” Confused, you say, “I’m sorry, I didn’t see that. What’s agender? And I guess I’m a little confused why you’re here for abortion care if you’re not a woman?” Scout sighs and says, “I don’t really want to get into it. I’d really like to just get this over with. The chart confirms I’m pregnant. I have the required parts.”

You want to ask more questions about this “agender” thing, but as the schedule is tight today and the chart does confirm that Scout is pregnant, you go into your regular spiel of explaining how the medication abortion works and the instructions for the patient to follow. You notice that as the appointment goes on and you explain what symptoms most women have and concerning symptoms to look out for, that Scout looks increasingly upset. You ask, “Sweetie, are you okay? If you’re having second thoughts or you’re feeling scared, I’m here to help.” Scout replies, “I’m just not having a good day. I’d like to get this over with. I know that I don’t want to be pregnant anymore.”

You finish the appointment. Later that day, the front desk staff who checked out the patient approaches you and says, “What happened in that appointment? When I asked Scout if they wanted to schedule an appointment for birth control, they said ‘only if it wasn’t with you,’ but I didn’t see anything in the chart from you about them being difficult, and otherwise they were nice as could be.” You reply, “That’s weird. She said some confusing stuff during the appointment, but I thought maybe it was just stress? She mentioned that she wasn’t having a good day.” The front desk staff member replies, “Ahh, that would be why Scout was upset. They’re trans, they use they/them pronouns.”

• What could you have done differently to not alienate the client? [Used inclusive language, not continuously misgender them.]
• What are some negative outcomes that Scout may experience because of how they were alienated in this appointment? [Lack of continued access to all healthcare, lack of access to contraceptives, lack of access to safe abortion care if it is needed in the future.]
• Why would it be inappropriate to ask Scout about “that agender thing” in an abortion appointment? [While it is good to verify with patients what language is affirming for them, it is not appropriate to ask invasive questions that do not relate to the appointment. Ex: it is appropriate to ask what pronouns a patient uses and what medications they take, including gender-affirming hormones, to check for negative medication interactions. It is not appropriate to ask the patient what their gender “means” and if they have plans to have gender-affirming surgeries if it is not pertinent to know for the care you are providing.

Case Study 3: Celina

Celina is a transgender woman being examined for an infection in her hand. The nurse has never taken care of a transgender person before and finds himself very curious about Celina. He repeatedly catches himself staring at her. While taking Celina’s vitals, the nurse asks, “You know, at first I thought you were a real woman. Do you take hormones? Have you had the surgery yet?” Celina angrily responds, “I don’t think that has anything to do with my hand.”

• Why did the nurse upset Celina?
• What could the nurse have done differently?
• How could the nurse practitioner apologize?

This case scenario came from “Learning to Address Implicit Bias Towards LGBTQ Patients: Case Scenarios” from the National LGBT Health Education Center, The Fenway Institute. Additional cases can be found here. 

Case Study 4: Carmen

Carmen is having her annual physical exam with Dr. Jones, an openly gay physician. Dr. Jones recently skipped his health center’s training on LGBTQ care because he believed he already knew everything about LGBTQ health. Dr. Jones asks Carmen, “Are you sexually active with men, women, or both?” Carmen says, “I am sexually active with one woman.” Hearing this, Dr. Jones skips the questions about condom use. Unbeknown to Dr. Jones, Carmen’s partner is a transgender woman.

• How does this case demonstrate the importance for every team member to receive training in LGBTQ health care delivery?
• How could the doctor rephrase his question to ensure effective communication?

This case scenario came from “Learning to Address Implicit Bias Towards LGBTQ Patients: Case Scenarios” from the National LGBT Health Education Center, The Fenway Institute. Additional cases can be found here.

Case Study 5: Dawud & Imran

Dawud is meeting his pregnant wife, Imran, at the health center for a prenatal appointment with the midwife. Dawud is transgender and is in the process of transitioning from female to male. The midwife, along with a midwife in training, enters the room and sees Dawud. The midwife says to Dawud: “Hi, you must be Imran’s sister, it’s nice to meet you!” Dawud, upset, responds, “No, I am her husband.” The midwife looks startled and mumbles “Oh, sorry.” The trainee notices that Dawud and Imran are visibly uncomfortable, but does not say anything.

• Why are Dawud and Imran upset?
• What could the midwife have said instead?
• How can the midwife in training talk to the midwife preceptor about the interaction?

This case scenario came from “Learning to Address Implicit Bias Towards LGBTQ Patients: Case Scenarios” from the National LGBT Health Education Center, The Fenway Institute. Additional cases can be found here.