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Requesting or obtaining a standard laboratory test for a health concern might seem like a basic task for most people. However, for transgender patients, those whose gender identity does not match the sex they were assigned at birth, and who are already socially marginalized, even that seemingly simple act can be a huge challenge. Transgender patients meet with a variety of healthcare barriers ranging from healthcare professionals’ lack of education to information systems not offering enough variation in gender options.  

While healthcare has made strides in educating its clinicians and accommodating transgender patients, many problems still exist in and out of the laboratory. How can laboratories lead the way in helping this patient population get better treatment? The answer lies in educating staff, updating information systems, and finding creative workarounds.  

Facing the challenges 

“Being a gender diverse person in this world is difficult,” says Dina Greene, PhD, DABCC, an associate laboratory director with LetsGetChecked, and a clinical associate professor in the department of laboratory medicine and pathology at the University of Washington.  

Transgender and non-binary people are often on edge, worrying how they will be treated in any context, Dr. Greene says, but it can be even more problematic in a healthcare setting, particularly in phlebotomy, where names are often called out publicly. Events such as “Calling people by their dead name or insisting people have to use a [specific] name or identity to get their blood drawn or looking at someone who is very male-presenting and questioning why they are getting prenatal screening or a pregnancy test” can be off putting at best and have a huge impact on this patient population’s comfort and willingness to get care, she says. 

Other challenges include how labs handle tests that appear incorrect because the patient’s stated gender doesn’t match the test. Dr. Greene explains, “If you have a urine pregnancy test come in on a male, does your intuition cancel that test? What are your reference intervals for prostate screening antigens?”  

Laboratories need to put processes into place that don’t cancel samples on sex discrepancies, she urged. The same goes for tissue samples taken from transgender patients  in anatomic pathology, Dr. Greene says. A transman might need a cervical biopsy or pap smear. A transwoman might have an orchiectomy. And all genders should have their tissues appropriately tested for cancer risks. 

Limiting assumptions 

Another good starting place, says Dr. Greene, is to limit assumptions at any stage in the process about gender diverse people. “Trans people need healthcare like cisgender people do. When does a cis person need a CBC? When does a cis person need their hormones checked? When something’s wrong. Let’s not make it about cis or trans, but about what does this person need?” 

Part of the problem is that doctors and even laboratory staff, who received their medical training decades ago, or out of the U.S. are likely to have less education on gender diversity, according to Matthew Krasowski, MD, PhD, a clinical professor of pathology at the University of Iowa Hospitals and Clinics. Trainings should become mandatory for laboratories and doctor’s offices alike. 

“Healthcare centers and labs can ensure their front-end people have gender diversity training, that they are only using last names to call out people in the waiting group, or that they have backup protocol if people don’t want to use names as an identifier such as date of birth and medical record number,” Dr. Greene says. 

Changing values 

Physicians and laboratory professionals need education that helps them understand how laboratory values can look different in patients who are receiving hormones for gender-affirming care, according to Dr. Krasowski. “Creatinine is one of those tests where [gender affirming hormone therapy] may change where the patient is on the reference range. It may say you’re in kidney failure when you’re not, or say your kidneys are fine when they’re not.” 

While it’s only a few tests that are likely to look abnormal if the laboratory does not know that a person is transgender—tests for creatinine, hemoglobin, and liver enzymes, for example—having the ability to note that a patient is transgender will stop likely flags or concerns, Dr. Krasowski notes. 

“Labs could help doctors recognize that there are alternative reference ranges for transgender patients on gender affirming hormone therapy,” says Jeffrey SoRelle, MD, assistant professor in the department of pathology at UT Southwestern Medical Center in Dallas, Texas. “Whatever hormones the patient is on can just correspond to their preferred gender, and that will help identify who is within range and who is out.” 
 

Updating information systems and health records

One of the problems that is not an overnight fix, is that many electronic medical records (EMR) vendors and laboratory information systems have not yet accommodated the necessary changes that would solve some of the problems. 

“Laboratory information systems and electronic health records are not built to be very flexible. They are built to follow logical rules that say if this, then that, so you can get improper rejection of a sample,” Dr. SoRelle says. 

“Only the large EMR vendors have the ability to look and if there’s a mismatch between legal sex, sex assigned, or gender identity, they can identify those and put a test comment that this lab may be affected by hormones,” Dr. Krasowski says. “That’s probably the easiest first step in some ways.” 

Workarounds

Even with the existing limits, there are always workarounds that laboratories and other healthcare clinics can put into place. In phlebotomy departments or anywhere that a patient is called by the legal name on their intake forms, an alternate and trans-inclusive way to do this is to assign a number, or call out a patient’s last name, instead. “It’s kind of impersonal, but not horrible,” Dr. Krasowski says. 

Another approach that some clinics have taken is to create separate laboratory tests for transgender patients for things like testosterone, estradiol, and creatinine. “Whoever orders that test would then supposedly have the information that this patient is on hormones or gender affirming care. It’s probably unworkable for a lot of labs, but for a few it would be good,” Dr. Krasowski says. 

At the very least, through education, whether through in-service trainings, presentations, or continuing education credits, every laboratory can make strides at removing barriers for transgender patients.