(Originally published in Doximity Op-Meds, a platform for physicians, on May 11, 2023. Published here in its original form with a selected Bibliography/further reading at the end.)
*Written consent was obtained from the patient to tell this story. Names and details have been changed to protect their privacy.
As a queer, Chinese, female colorectal surgeon, I wear my pride in the form of a rainbow caduceus symbol on my white coat lapel. Working in downtown Manhattan, in my particular field, I had many gay patients see me for various anorectal ailments. I cared for transgender patients with anal cancer and helped manage patients with complications from gender-affirming surgery. I would proudly mention my wife in front of a queer patient in a show of solidarity. I was the first in my practice to change our intake form so that it asked for preferred gender pronouns instead of the sex of the patient. But how crucial my background was didn’t become real until my personal experience and knowledge of LGBTQ+ culture helped a transgender patient.
Sam* (they/them) had seen me in the office for a few months for a persistent anorectal issue. We tried stepwise therapy, and the symptoms were gradually getting better. Toward one of their last visits, I mentioned that they wouldn’t have to see me anymore, and asked if there was anything else I could do for them. They paused and said, “Well, this chest pain is still bothering me.”
Because we had a longitudinal patient-physician relationship, Sam had been comfortable enough to share with me that they were assigned female sex at birth and presented as transmasc or lesbian and had a female partner. Sam required a couple of procedures for their anorectal issue, one of which involved surgery in the ambulatory center. The morning Sam arrived to complete paperwork before surgery, I made a note on the chart that they preferred ‘they/them’ pronouns. Our medical records still default to male/female and he/she, with no option for anything else. Sam appreciated this small gesture of inclusivity and acceptance.
I was paged overhead a while later while coming out of surgery for a different patient. I went to the patient holding area and asked what the problem was. The nurses told me that Sam had refused a urine pregnancy test. A urine pregnancy test is standard pre-surgical procedure, generally so that there is no unintentional harm to an unknown fetus by anesthesia medications or radiation. However, I understood immediately what this was about. Sam didn’t engage in sexual intercourse that would result in pregnancy. I told the nurses this, but they said they had to do a urine pregnancy test or else cancel the surgery. I told them I would discuss this with the patient. Still, if the patient refuses a urine pregnancy test and accepts the potential risks to a hypothetical fetus, I would document that, and we would proceed with surgery. I went into Sam’s room and explained the situation. Sam said there was no chance they could be pregnant and expressed frustration that they weren’t being ‘trusted’ about that. I explained that it wasn’t necessarily about trust but medico-legal implications and that the hospital always has to CYA. I said that if they refused the test, and accepted the risks associated with that, then I would write that in the chart, and we would proceed. That is exactly what we did.
Because of this interaction, Sam trusted me with their medical issues, which is how we ended up discussing chest pain in a colorectal surgeon’s office. As a subspecialist, my practice is broad-based colorectal surgery but otherwise limited in scope. I’m not a family doctor or an internist, but I help when possible. Most of the time, it’s mental health issues.
“Chest pain?” I asked. Chest pain was a little outside of my purview.
“Yeah,” Sam replied. They told me that this had been going on for years. They’d gone to their PCP multiple times and had been prescribed NSAIDs. They’d seen a cardiologist who ruled out a cardiac problem. They went to a pulmonologist and had X-rays done. They were left with the diagnosis of costochondritis, an inflammation of the joints of the rib cage. But the pain medication wasn’t helping, and they said it sometimes hurt to breathe or to bend over.
I said, “Can you show me where it hurts?”
They pointed at a spot right in the middle of their chest, below the sternum. My first thought, as a surgeon, was to wonder if anyone had checked out their esophagus or stomach. But the pain was not triggered by eating. My second thought was that costochondritis doesn’t happen right in the middle of the chest.
My assistant was in the room, so I said, “Can I see it? I want to make sure there isn’t anything visible.” Sam looked down at their chest and slowly lifted their t-shirt. I noticed some bandages around their chest. I visually inspected the spot that Sam pointed to, on top of the xiphoid process. There was no bruising, noticeable lumps or masses, or skin changes.
“Can I press on it?” I asked. Sam nodded.
I placed three fingers on the area, and Sam immediately jerked away. “Ouch!” I pulled back and waited. “Sorry, it’s sensitive,” they said.
“Can I try again?” I palpated once more with a little distraction but noticed they still winced, right over the xiphoid but not over the rest of the rib cage. Done torturing them, I said, “Sorry, I just had to be sure.” I had them pull their shirt down and sit up. A thought was brewing.
“How long have you been binding your chest?”
“Off and on since college,” they said.
“Did the pain start after you started binding?”
Sam thought about it for a minute. “Yes, I think so.”
Somewhere in the back of my mind, I knew that binding long-term could cause skeletal deformities or injuries. Just look at Chinese foot-binding. Also, somewhere in the back of my mind, I knew I had tried binding once or twice in college, which was horribly uncomfortable. Often people did not want to talk about it, ashamed that they had to do this thing to themselves to feel like a truer version of themselves. So I wondered if Sam had brought up the binding to any providers.
“No…” they said.
I didn’t want to poke further, at this point, literally or figuratively, so I said, “As you know, this is the opposite end of what I deal with. But you’ve had a bunch of chest X-rays that don’t show anything, and you’re still having pain, so I’d like to start with a chest CT, maybe even an MRI. I’m looking for some kind of injury to the bones or joints. I’ll also send you to my friend, who is a thoracic surgeon and might be able to help.
Sam was ever cautious and very good about asking about the need for tests and their potential effect on further outcomes/intervention. But at this point, their exasperation at the lack of a diagnosis or pain relief was apparent, and they agreed to my plan.
A few weeks later, a CT scan report popped up on my computer. Sam had a minor fracture of the xiphoid process, right where their pain was. I referred them to a thoracic surgeon, who agreed that the fracture was likely due to years of chest binding. After seeing a pain specialist for injections, the pain was relieved by blocking the nerves to the xiphoid area. This was both diagnostic and therapeutic. Then, Sam underwent surgery to have the xiphoid removed. They are doing well postoperatively.
Reducing health disparities and health inequity in LGBTQ+ care has been widely researched over the past decade. Medical schools and training programs have the best intentions. Most have adopted some curricula surrounding the care of the LGBTQ+ population, usually a one-time session on LGBTQ+ cultural competency. However, this curriculum has evolved into just another box that the institution can check off — what happens when students and trainees start their practices is an entirely different story. LGB patients are 2.17 times more likely to delay obtaining healthcare, while transgender patients are 2.76 times more likely to report unfair treatment and poor quality of care. Some physicians may never have to consider special care or diagnoses for the LGBTQ+ population. Most who do are in primary care, transgender care, or endocrinology. Research has shown that Black men may have better cardiac outcomes when they see Black doctors, and women are more likely to receive guideline-based care with a female cardiologist. Is this true for LGBTQ+ folks as well? LGBTQ+ folks tend to have less access to care, less cancer screening and are more likely to be uninsured.
There are three components to addressing these disparities. One is improving the cultural competency education in medical school and postgraduate training, which a few sites are laudably doing,. The second is to continue increasing the diversity of our physician population because representation matters. Third is for physicians in all specialties to continue cultural competency training even when they are in practice because our world is constantly evolving, LGBTQ+ people are more visible, and we are more aware of the need for culturally competent care.
When I discussed this article with Sam, months after their xiphoid surgery, they expressed that subspecialties should also have continuous training around LGBTQ+ care. Perhaps if one of the cardiologists or pulmonologists had noticed the chest binding and the implications of it, they would have made the diagnosis sooner, and Sam would not have been in pain for years.
Resources
My alma mater, MSU College of Human Medicine, holds monthly DEI grand rounds
Harvard Medical School also has a monthly ‘Addressing Health Disparities’ seminar, the most recent of which discussed advancing health equity for transgender and gender-diverse populations.
