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Critical Values is the go-to resource for the entire laboratory team, providing insight and information on the latest research, information, and issues within pathology and laboratory medicine. The print and online magazine invites submissions on topics including, but not limited to, advocacy, education, technology, global health, workforce, workplace best practices, and leadership.

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ASCP Staff Advisers

E. Blair Holladay, PhD, MASCP, SCT(ASCP)CM
Chief Executive Officer 

Critical Values Staff

Molly Strzelecki  Editor 

Susan Montgomery  Contributing Editor

Martin Tyminski  Creative Director  

Jennifer Brinson  Art Direction and Design  

Our Recent Articles

The Honor that is a Sampheah

Nov 18, 2022, 00:24 AM by Julie Papango

It was August of 2009, a Monday with 90 percent humidity. I arrived in Phnom Penh, Cambodia. Though only a three-hour flight away from my homeland, the Philippines, I felt like I had travelled light years to an unchartered planet. There I was, carrying only 10 kg of luggage, my security briefing packet, and tons of anxiety. As a person of transgender experience, this is a constant dilemma every time I go to new surroundings. There are cultural and political contexts that I need to be aware of for my safety. Afterall, this is the place that I will call home for the next six months, and where I was tasked to help set up a tuberculosis lab in a regional Hospital three hours from the capital near the Vietnam border. I was greeted by a man in his mid-50s, who welcomed me by touching his palms together in his chest in a prayer like manner, and a radiant smile as he said, “chom reab sour.” “Welcome” in Khmer. I replied with a smile and suddenly I felt excited despite the anxiety. 

Fast track to a month later, I was learning to speak Khmer and we were discussing greetings with my teacher. I asked what the palms in a prayer-like manner is called and what is it for. “Sampheah” she said, “it is the way we show honor and respect.” She also explained how, the higher the palms, the more respect is shown. An example is when they are greeting an elderly or mentor, they place it on their chin and while praying, they hold their hands together on their foreheads. 

This was a validating moment for me because I realized that most of my colleagues greet me with their palms on their chin. I never had that level of respect back home where I was constantly reminded with heckling and stratifications caused by discrimination and prejudice just because I am a person of transgender experience. 

Addressing challenges, finding equilibrium  
Being a medical laboratory scientist, I have the privilege of having access to information on how to safely undergo my journey of transitioning to being my authentic self. From hormone replacement therapy, understanding the purposes of a laboratory test, interpreting results, to advocating my needs to my medical provider to have the safest avenue to treatment. Unfortunately, most people of transgender experience are denied or rather do not seek medical care for fear of rejection and prejudice from a healthcare system that is not aware of the specific needs of us as a community and as individuals. A 2015 survey with transgender and gender non-conforming individual showed that 19 percent of the 6,450 participants were denied getting medical care because of their gender identity and expression. An updated survey is being conducted until November 21, 2022.1 If only the medical community knew the Sampheah, to give that honor and respect to this demographic of patients. Maybe we can create tools that can alleviate suffering, bridge the gap, and provide safe treatment. 

This is just one facet of the plethora of challenges regarding the lives lived by people of transgender experience. On November 20, Transgender Day of Remembrance (TDOR) is commemorated to honor the lives of transgender and gender non-conforming people who were killed the past year. This was founded in 1999 to commemorate the murder of transgender woman Rita Hester in Allston, Massachusetts. In 2021, 375 transgender and gender non-conforming people were killed, a 7 percent increase from 2020.2 

These data do not include people who died because of not getting proper medical care. When we do not address the medical care needs of transgender and gender non-conforming people, we become accomplices to the deaths and suffering of this minority group.  Studies have shown that receiving gender affirming care reduced mortality rates significantly.3,4,5 Also, there are studies that people receiving HRT has higher mortality rates compared to their cisgender counterparts.6,7,8,9,10 This makes it a double-edged sword because we want gender-affirming care while mitigating the risks brought about by medications and procedures that help us align with our inner selves. It is a never-ending limbo on finding equilibrium between access and monitoring. 

Creating equity through the laboratory 
So how can we as laboratory professionals be an ally to our transgender and gender non-conforming patients? To answer the How we should first ask the Why. Often, it causes confusion on how we interpret results. There are also discrepancies that need to be clarified for billing and reimbursements. Lastly, providing the best laboratory testing and interpretations would guide other healthcare professionals in providing the best care.  

When it comes to interpreting laboratory parameters, because of systems that are set to cater mostly to cisgender male and female, parameters like hormone levels and liver enzymes as examples could be misinterpreted when testing samples from a patient on hormone replacement therapy. Studies have shown that within three to six months of HRT, levels can be compared that of their affirmed gender.11,12,13,14,15,16,17 The other challenge is the restrictive electronic medical record (EMR) and laboratory information system (LIS) that only usually capture sex assigned at birth. When there are flags on test results, a technologist who does not have the full information on the patient could treat it as a critical result, which in a way is good vigilance. However, if we have access to information as to legal gender, sex assigned at birth, and patient history, we could make a more informed decision as to how to proceed with testing and interpretation.  

Studies show that EHR is a great equity tool for LGBTQI and healthcare systems can adopt well-established strategies for data collection.18,19 One way is revising language for inclusivity for in patient-facing materials and forms. The phlebotomy department can include preferred name on their forms to use when addressing patients who are still not able to change their names legally. Also, a compassionate way of informing the patient that for identification purposes of their samples, the identification on their insurance will be the one used. This could be an affirming experience for our patients. Data should be collected in EHRs in the context that is bound on treatment protocols adoption, organizational needs, integrated service development, harm reducing, and trauma informed approaches.20 A Sampheah, to inform our patients that we see them, we understand their needs, and we are here to provide a safe space with their journey. 

EHR could also be adopted to include inventory of a patient anatomy.20,21 Not all transgender people choose to have surgeries to remove organs they don’t feel congruent with. This should be independent of ones assigned sex at birth and legal sex. A transman needing a Pap smear, or transwoman needing PSA could be some examples. 

Lastly, as laboratory professionals, we could be advocates on behalf of our patients. Providing results with attestations that are connected to the patient’s treatment and monitoring status could give a clinician better understanding in interpreting results. Practicing gender-affirming medicine is strictly dictated by standardized assessment protocols, which serve as a form of curriculum and how health professionals learn and teach health advocacy as a form of resistance to protocols identified as creating inequities. This could be an opportunity to view existing protocols, their inherent limitations, and the gaps that are not addressed to be used as learning and teaching tools for advocacy.22 We could also coordinate with human resource departments and local LGBTQI organizations to conduct gender sensitivity training focused on Sexual Orientation and Gender Identity/Expression (SOGIE). 

It has been more than a decade since I first stepped in Cambodia and learned the essence of a Sampheah. I have also attended yearly TDOR ceremonies since 2012. The grief and loss never get lighter. I will be honest that I have not moved on from the grief; I just carry it with me and use them as reminder of the privilege I was given being a person of transgender experience in the laboratory setting. Every day I give Sampheah to all those transgender and gender non-conforming people who are either brutally murdered or died because of not accessing adequate health care. This is my love letter to both my LGBTQI and healthcare communities. To the former, I honor the memories of those before us and I promise to provide a better world for those who come after us. And to the latter, we can do better. We will do better. With an inquisitive mind, a heart open to provide safe care and voices to serve as allies, we will do better. Transgender and gender non-conforming people are more than data, body parts, and an alphabet soup—we are people with individual needs beyond the assigned letters on our birth certificates. And hopefully a day will come where we celebrate the successes in healthcare rather than losses. A day when each one of us can embody the essence of a Sampheah. 

Julie Papango is an ASCP Patient Champion. Read more on gender affirming care, and Julie's story here. And don't miss the Inside the Lab podcast on Transgender Pathology. 

References 

1.National Center for Transgender Equality https://transequality.org/issues/resources/national-transgender-discrimination-survey-executive-summary 

2. Transrespect versus Transphobia https://transrespect.org/en/research/tmm/.  

3. D. M. Tordoff, J.W. Wanta, A. Collin et al Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978 

4.R. Bränström, J. E. Pachankis, Toward Rigorous Methodologies for Strengthening Causal Inference in the Association Between Gender-Affirming Care and Transgender Individuals’ Mental Health: Response to Letters The American Journal of Psychiatry. 2020 Aug; 177(8). pp 769-772 

5. A.N. ALmazan, A.S Keurghlian Association Between Gender-Affirming Surgeries and Mental Health Outcomes JAMA Surg. 2021;156(7). pp 611-618. 

6. C. de Blok, C.M> Wiepjes, D. van Velzen, A.S. Staphorsius et al Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria The Lancet. Diabetes and Endocrinology. 2021 Sept 2; 9(10). Pp 663-670 

7. H. Asscheman, G. T'Sjoen, L.J. Gooren Morbidity in a Multisite Retrospective Study of Cross-Sex Hormone-Treated Transgender Persons Joint meeting of the International Society of Endocrinology and the Endocrine Society:  24 June 2014 

8. H. Asscheman, G. Tsjoen, A. Lemaire, M. Mas, M. Meriggiola, A. Mueller, et al. 2013 venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review Andrologia, 2013 Aug 15; 46 (7)  

9. K. Wierckx, E. Elaut, E. Declercq, G. Heylens, G. De Cuypere, Y. Taes, et al. Prevalence of cardiovascular disease and cancer during cross-sex HRT in a large cohort of trans persons: a case-control study Eur J Endocrinol, 2013; 169 (4) pp. 471-478 

10. C. Bagot, M. Marsh, M. Whitehead, R. Sherwood, L. Roberts, R. Patel, et al. The effect of estrone on thrombin generation may explain the different thrombotic risk between oral and transdermal hormone replacement therapy J Thromb Haemost, 2010; 8 (8), pp. 1736-1744 

11. A.S. Cheung, H.Y. Lim,T. Cook, S. Zwickl, A. Ginger et al Approach to Interpreting Common Laboratory Pathology Tests in Transgender Individuals J Clin Endocrinol Metab. 2021 Mar; 106(3): 893–901.  

12. Hannemann A Friedrich N, Dittmann K, et al.  Age- and sex-specific reference limits for creatinine, cystatin C and the estimated glomerular filtration rate. Clin Chem Lab Med. 2011;50(5) pp.919-926.  

13.Klaver M, de Blok CJM, Wiepjes CM, et al.  Changes in regional body fat, lean body mass and body shape in trans persons using cross-sex hormonal therapy: results from a multicenter prospective study. Eur J Endocrinol. 2018;178(2) pp.163-173 

14.Van Caenegem E, Wierckx K, Taes Y, et al. Body composition, bone turnover, and bone mass in trans men during testosterone treatment: 1-year follow-up data from a prospective case-controlled study (ENIGI). Eur J Endocrinol.2015;172(2). pp. 163-171 

15.T’Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction”. J Sex Med. 2020;17(4). pp. 70-584 

16.A.N.Allen, R.Jiao, P.Day, J.A. SoRelle et al Dynamic Impact of Hormone Therapy on Laboratory Values in Transgender Patients over Time The Journal of Applied Laboratory Medicine, 2021 January ;6(1), pp 27-40 

17.B.P. Ramongane, A.A. Khine Role of clinical laboratories in reporting results of transgender individuals on hormonal therapy Journal of Endocrinology, Metabolism and Diabetes of South Africa, 2021 Oct; 27(1), pp 8-13 

 18.H, A.C. Smart, L.A. Kissock, A.S. Keuroghlian Organizational Strategies and Inclusive Language to Build Culturally Responsive Health Care Environments for Lesbian, Gay, Bisexual, Transgender, and Queer People Journal of Health Care for the Poor and Underserved. Johns Hopkins University Press 2021 Feb, 2(1) 

19.A.M. Morenz, H. Goldhammer, C.A. Lambert, R. Hopwood and A.S. Keuroghlian A Blueprint for Planning and Implementing a Transgender Health Program The Annals of Family Medicine. 2020 January 2020, 18 (1). pp 73-79  

20.C.Grasso, H.Goldhammer, J.Thompson, A.S. Keuroghlian Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems Journal of the American Medical Informatics Association, 2021 November; 28(11) pp 2531–2535 

21.S.L. Reisner, J. Bradford, R. Hopwood et al Comprehensive Transgender Healthcare: The Gender Affirming Clinical and Public Health Model of Fenway Health Journal of Urban Health. 2015 vol. 92, pp 584–592  

22.K. R. MacKinnon, S. L. Ng, D. Grace et al Protocols as curriculum? Learning health advocacy skills by working with transgender patients in the context of gender-affirming medicine Advances in Health Sciences Education. 2020, Vol. 25. pp 7-18