“Imaging needs of transgender patients have historically not been on the minds of radiologists and their staff,” says Justin T. Stowell, MD, senior consultant and assistant professor of radiology at Mayo Clinic in Florida, who also sits on the ACR Commission for Women and Diversity, where he leads a gender-focused workgroup. “Even pre-pandemic, these patients had limited access and often felt discouraged from coming in for healthcare services in general. Many just don’t trust physicians who often may be uneducated about transgender health issues.”
During a time of unprecedented attention to systemic social injustices and healthcare disparities — putting the inequitable treatment of marginalized populations center stage — radiology has an opportunity to serve the transgender community through staff training, collaboration with colleagues, and a heightened awareness of transgender patients’ needs and experiences.
By definition, transgender and gender-diverse individuals have a gender identity which does not align with the sex assigned to them at birth. Gender identities not congruent with sex assigned at birth are often included within the broader social classification of lesbian, gay, bisexual, transgender, and queer (LGBTQIA+) people, however, gender identity and sexual orientation are not the same.1
Conversations around transgender care aren’t happening as often as they should, according to Linda Moy, MD, professor of radiology at NYU Langone Health and specialty chair for the ACR Appropriateness Criteria® (ACR AC) for Breast Imaging. The ACR AC are evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition — and an upcoming iteration will include transgender breast imaging guidelines for the first time.
Radiologists and referring clinicians may only see or be aware of a small number of transgender patients in their community, Moy says. But that does not negate the need to address transgender health issues. “The ‘this doesn’t apply to me’ way of thinking by clinicians presents a huge obstacle,” she says. “Transgender patients constantly face barriers to screening and other healthcare services because of stigma, discrimination, and patients’ fears of being balked at,” Moy adds. Ignorance and insensitivity around medically relevant services for these patients may start at the front desk, with an RT, or with a referring physician.
“There are incredible unconscious biases that exist in our society,” Moy says. “The goal in radiology — especially in screening — is always to make all patients comfortable and relaxed,” Moy stresses. “We are the portal that will potentially take the patient to other services.”
And this matters to patient outcomes. Gender-affirming therapy may influence an individual’s risk of developing sex-specific cancers such as breast and prostate cancer. In addition, transgender patients still require routine age-based screening based on applicable recommendations.
The value of radiology in connecting transgender patients with other services in the healthcare value chain must be taught earlier in medical training, says Baer Karrington, a 2021 MD and MScPH candidate at NYU Langone and NYU Grossman School of Medicine, which is one of the only medical schools to include an objective structured clinical examination focusing on transgender patient care. Many transgender patients end up doing their own research to find out what services they will need. “That becomes more difficult when it comes to finding the appropriate preventive care or screening,” Karrington says. “Transgender men, for instance, have much lower rates of cervical cancer screening compared to cisgender women, despite continuing to need this screening if they have a cervix.”
Karrington is pursuing adolescent medicine with a focus on gender-affirming care and served as a patient representative in the creation of the new ACR AC on Transgender Breast Cancer Screening. “Transgender patients have already fought to get surgery, to get their hormones, and even to get people to use the name of their choosing. When they get to radiology, they may then be charged with determining, on their own, the types of studies they need and what their risk factors are. That is not fair,” Karrington says.
“Unfortunately, a lot of what drives our decision-making in healthcare may be what insurance companies pay for,” Stowell says. “If you are a transgender woman, but your driver’s license or other legal documents list ‘male’ — services can be denied. The insurance company will likely say breast cancer screening is not recommended for men,” Stowell notes.
Beyond insurance coverage, screening and intake forms also matter. Take a patient-centric approach in revising your forms, Stowell suggests. “This is something patients will see during their first encounter with an imaging group. There should be spaces on forms for sex assigned at birth, gender identity, and appropriate pronouns,” he says.
Simple changes to screening forms could capture information about transgender patients that guides appropriate care recommendations, Stowell says. Because of their central place in patient care, radiologists have an important part in defining what is appropriate for transgender patients, says Frances Grimstad, MD, MS, an attending in the division of gynecology at Boston Children’s Hospital and a clinical instructor at Harvard Medical School.
“If I send a transgender woman who has had a vaginoplasty in for a pelvic US and the imaging practice misidentifies the patient, she may be screened incorrectly,” Grimstad says. “When the radiologist interprets the scan, he or she won’t understand that this patient should not have a uterus. It isn’t because it is surgically absent, rather that it was never there to begin with. Similarly, the radiologist may not realize that there should be a prostate.”
Having all the facts about a transgender patient means realizing that requiring patients to disclose irrelevant personal information could be unnecessarily problematic, Stowell says. Some patient forms call for an organ inventory (listing what organs you have), Stowell notes. “Why is that necessary? Maybe just a surgical history would be enough,” he says. “There are also questions like, ‘If you are a woman, could you be or become pregnant?’ Take out the word ‘woman,’” Stowell suggests. “The question is only there so the radiologist can explain the potential risks of radiation to a fetus, if necessary.”
Mindfulness and sensitivity in your radiology reports are equally important — as the words you choose may dictate a patient’s comfort level. “A report with unnecessary mentions of ovaries and a uterus can be uncomfortable to a transgender male,” he says. “Some of these patients don’t want to acknowledge these body parts, so unless there is an issue related to them, use pertinent negatives with a neutral statement such as ‘no pelvic mass.’”
Such considerations in transgender patient care will grow through more gender diversity training for radiologists and their support staff, Grimstad says. “For radiologists, if they don’t understand the kinds of surgeries or hormonal therapies common among transgender patients, they will be interpreting images with incomplete information,” she asserts.
“We depend on radiologists to stand up as leaders and ask what a referring physician needs to interpret information appropriately. Referrers have been trained with a very cisgender approach to imaging,” Grimstad says. “The reality is that medicine is moving towards a model where we understand that the sex binary and the gender binary have limited us,” says Grimstad.
Transgender awareness training should be mandatory for your entire radiology staff, Stowell believes. While radiologists must be informed, so should front office staff, coders, and RTs. For example, says Stowell, “Technologists shouldn’t be afraid to ask the patient if there are parts of an exam they aren’t comfortable with.”
Collaboration with referring clinicians might allow targeted delivery of anticipatory guidance prior to imaging so the patient is aware of what is required during an exam and why it may be necessary for diagnosis. “The patient might also be able to help with part of the exam so it doesn’t feel so invasive.”
Raising awareness can start with showing staff a video or providing them with transgender resources they can pass along to colleagues and patients, he says. “Simple things, like wearing rainbow or transgender rights ribbons, or displaying them in your facility’s waiting areas or check-in stations, show that your specialty supports the transgender community,” Stowell says.
Until a national, collaborative push for the equitable care of transgender patients gets more traction, radiology groups must do what they can now to foster change. “As a breast imager, we find the detection of breast cancer to be important among all patients,” Moy says. Outreach efforts encouraging women to come in for screening mammography, however, can be very biased towards cisgender women, she notes.
“Transgender patients who come in have said that they are reluctant to come back — that they weren’t addressed appropriately and felt uncomfortable,” Moy says. “Some RTs, doctors, and even patients in the waiting rooms have biases towards transgender patients. We are dealing with an ongoing process of educating people.” Education and culture change can be slow, but unfortunately in the time it takes a practice to adapt, transgender patients are missing screening after screening.
A host of indicators may define your practice or radiology department as inclusive or exclusionary in the eyes of transgender patients, Stowell says. If a transgender patient has a negative experience at a facility, they may not come back for much-needed follow-up care. It may even discourage them from getting other healthcare services, like a Pap smear or flu shot, Moy says.
Even signage says a lot. “If a facility is called ‘Center for Women’s Imaging,’ for instance — even if you are offering US and other modalities — you’re basically telling transgender men they can’t come in to have their gynecological exams there,” Stowell says. “Similarly, you’re telling a cisgender male with a mammographic issue that he is sitting in a women’s center.”
While you may not need to change the name of your practice, you can make it clear that restrooms are gender-neutral, Stowell says. You can have transgender literature in your waiting rooms — ranging from magazines to pamphlets for transgender help centers. “No one is forced to pick it up and read it, but it lets transgender patients know they are welcome,” he says. Consider your changing area — do patients have privacy? Are your gowns pink, reinforcing the perception of a gendered space?
October is Breast Cancer Awareness Month and has always been associated with pink to show unity among supporters and survivors. “While pink [ribbons] can make cisgender women feel more comfortable or empowered, they may not speak to the smaller number of transgender patients who see that messaging in waiting rooms or through outreach campaigns,” Moy suggests. Rainbow and transgender rights ribbons alongside the pink may seem more inclusive.
Public displays of nondiscrimination policies, LGBTQIA+ affirmative reading materials, and awards of distinction (e.g., the Human Rights Campaign Healthcare Equality Index) can all be nonverbal indicators of a facility’s commitment to inclusivity, fostering open communication, and patient retention.1 These are silent indicators, Stowell says, and transgender patients in your community will look for these things when seeking services.
“Radiology practices are looking to get patients back on track post-COVID-19,” Stowell points out. “Making inclusion part of your brand can only help.” If you want your radiology group to be forward-facing — so, doing the right thing for all patients — an inclusive mindset is key. Radiology is as important for transgender patients as it is for any cisgender patient who needs imaging, Stowell says. “Always be sensitive to what your patient is facing — and to how you present yourself.”
For now, radiology personnel can help break down barriers to care by providing a welcoming clinical environment, practicing cultural humility, and staying up to speed with changing recommendations for transgender care.2
“In moving forward, what radiologists can do is collaborate with other clinicians who are providing care to transgender patients and find out where we can have the biggest influence,” Stowell says. “Imaging is used universally in healthcare, so it makes sense that radiologists be involved early in conversations around improving transgender care.”