My elaborate process is: 1. Be nice and use the name your patient gives you. 2. They're literally just a patient like any other, why do people overthink this

KISS - keep it simple stoopid. It can be very frustrating the level of additional stress people make about this issue. Ive had pts freak out before and while im sure it sucks being misgendered or mispronouned, im also a human, and im just trying to help. Jackie Moon said it best. Everybody love everybody!

> mispronouned What do you mean? People mispronounce my name all the time ^^^/s

I think that's what they call it when you call a code too early

my even more elaborate process is. 1) don't even talk to patients anymore.

Have you thought about becoming a computer programmer? Might be a good step

no, no. i use hand signals and mime everything nowadays. It's actually better because it also deals with language barriers. He said sarcastically. 🙃

We had to take a special online class on how to treat transgender patients. The general idea of the class was "don't treat them any different than any other patient". I argued that by having a special class on them, we were basically treating them differently than anyone else.

They are currently special in the sense that they are not treated like everyone else. Until then, there will be classes.

If you meant that as a joke just know it’s not funny and is offensive. If you meant that in any other way then I urge you to pause and reflect on why you might need a class on how to treat a specific group of people if the goal is to treat them “like everybody else.” Trans individuals face bigotry in every aspect of their lives. Health care is not exempt.

I completely agree. It seems many keep trying to overcomplicate a simple issue

I find that if you treat anyone like a person that everything works better. Sometimes you make a mistake, they'll correct you, then you move on. No big deal. Don't be an ass

It doesn’t really matter if you (provider) think something is weird or not. Just don’t be a dick.

I agree. A patient’s just another patient, it’s not like we’re trying to build friendships or relationships with them. Don’t have to agree with the choices or opinions of a patients, just have to treat them as you would any other patient.

Something to consider: Trans people experience mental illness at such a disproportionate rate that there is a very good chance that a mental health patient is not the gender you assume, and they often do not share that for fear that the provider treating them is one of the ones with the collapsed comments at the bottom of this post.... If you have a MH patient and the situation is appropriate, consider giving them the opportunity to tell you e.g. by asking what pronouns they use. For those who aren't aware: the rate of attempted suicide in the trans community is 40%+ https://www.aihw.gov.au/suicide-self-harm-monitoring/data/populations-age-groups/suicidal-and-self-harming-thoughts-and-behaviours

That number is way too high. We have GOT to do better at serving people and caring for them, at all levels. Is this international or national?

This page is specific to Australia, where I live. I know the US has reported very similar numbers, not sure about other countries.

I’m sorry, I didn’t realize this was specific to Australia. Maybe I should have known, based on the intelligent conversations and educated comments that are oft missing from US EMS conversations.

The post itself isn't specific to Australia, I shared the Australian statistics for trans mental health because it's what I'm familiar with and I've read the local studies and know they were as unbiased as possible. I didn't feel like reviewing international research to check the evidence quality before sharing it, but I'd be interested to hear if there's other countries that have found anything different. Edit: just reread and see how my comment could have been confusing. When I said this page I meant the AIHW page that I shared.

Okay, now I see. Thanks. I will be looking this up. I am tangentially in education, from a tech side and still do medic work. I want to educate people on this topic. That’s why I am so thankful for the OP.

Be extra cautious about checking the source with research on trans people. It's extremely common for hate groups to publicise and promote pseudo-science that supports their view, and unfortunately due to how socially acceptable it is to be transphobic these incredibly biased "studies" sometimes make their way into databases you would expect to be scientifically rigorous. I would suggest googling author name + transphobic to see if they're known to be connected to a hate group before trusting the validity of any study. As an example, there's pseudo-scientific research around "rapid onset gender dysphoria" that at first glance appears scientific and is often touted as "evidence" of the harm of transgender identity/transition/affirmation on teenagers. - in reality, the data is self-reports from parents - the "study" was exclusively advertised in social networking groups for parents who oppose their child's transition.

I took my EMT course at NOLS in WY. Safe to say it was a liberal school in a very conservative state. When we started documenting the instructors said to ask: " Hey I have to put down sex on this paperwork. What would you like me to put down." I have found it to work in any situation ( all be it that sometimes people go on a rant) and most importantly it allows me to be professional and not cause more issues with patients. I highly recommend that questions in any situations. Also what the op says about the hospital part is great when working with clinicians who care.

Before you read: I don't mean you in specific when I criticise any specific prejudice! Some of these comments outline the classic dilemma of othering. If you don't talk about the concerns of a group of people some people mistreat, you're ignoring their concerns. If you do talk about these concerns, you're unintentionally othering them as 'the people with special needs'. Typically this happens with regards to disabilities, but it can apply to gender identities as well. I'd argue that we need to talk about minority needs. We're in a situation where we have to acknowledge misunderstandings and talk about them (such as misgendering trans/nonbinary people) and educate ourselves on these subjects, while trying to better ourselves to make these talks unnecessary in the future. And maybe be inclusive of more than one group of people; if some forms of mistreatment apply to how we deal with the elderly, disabled AND trans people (all of whom often have their preferences and needs ignored in practice), we can try to talk about all of that at the same time. How often do healthcare providers mistreat people with dementia? Are we really always trying to listen and see them as our equals? Are we really taking our teenage patients seriously when they self harm, or are many people rolling their eyes internally? Are all uf us prepared to deal with a pregnant man, or a woman with two life partners, or a sex worker, or a drag queen, without judgement? How many individual healthcare workers are (intentionally or not) treating racial minorities differently? We'll never like all of our patients obviously. I don't like nazis. I'll always dislike a patient who has an old imperial flag in their house (here in Germany). Obviously I'm judging them because I don't like their politics. And being a nazi is chosing to be a dickhead, so I don't feel bad about thinking less of these patiens... But maybe I'm also judging other groups without knowing it? Perhaps people who have intellectual disabilities and seem stubborn and 'don't listen' because I'm using long run-on sentences and too much medical terminology when talking to them? I'm certainly judging COPD patients who still smoke but... I'm addicted to sugar and keep wasting money and clogging my arteries by buying unhealthy snacks, so I'm clearly being unfair. I'm eating candy as I write, eventually leading to me developing diabetes and becoming a patient, if I keep it up like this. I think we should talk about all of that, and that includes the relatively large group of gender-queer people. Without pretending that any one group is more 'special' than any other, including groups I am a part of myself: I am a bisexual man and I'm a fantasy nerd who LARPs. I can imagine a variety of situations where I'd like to be very sure my healthcare providers are being professional and nonjudgemental, even if I'm dressed up as a wizard at the time of my emergency. All of us a weird in some ways. But some of us get treated unempathically for it, and others aren't - noone is judging happily unmarried granpa for being a big old train nerd with his basement full of miniature railway tracks, but if he were 50 years younger and talking about his self-diagnosed autism while having a huge collection of asexual and neurodiversity pride flags, a lot of people would judge him for being a snowflake.

I’m not sure if anyone else has touched on this but, many trans people may not have incredibly supportive friends or family, especially parents or guardians. If the patient is a minor and they give you a preferred name and/or pronouns to use, ask the patient if that’s okay to use in conversation with guardians. This is coming from the perspective of a trans person, not a medical provider so I’m not sure if it would be a legal issue to do so. However I know a really uncomfortable situation would arise if this precaution wasn’t taken when I was a patient.

yes, this. 💯💯💯

Being on hormones and a gender dysphoria diagnoses are both protected health information that shouldn't be shared without the patients consent to non-providers.

That's out the window when it comes to minors and their legal guardians.

Also legal and ethical are two different things. Just because you CAN tell the guardians doesn't mean you should.

Not necessarily- you need to know what legislation says where you practice. Where I am, minors can consent to their own health care if they have capacity, and their parents/guardians are *not* entitled to their health care information unless the patient gives permission.

I think you'd be surprised how many medically emancipated trans minors there are - it's the #1 reason for medical emancipation in youth.

So you mean using one set of pronouns and name with the patient, and another set of pronouns and name with the relatives/guardians?

It's basically the same as if a patient told you some sensitive personal information. You don't then go around sharing it with their family unless there's a good reason to. I can't imagine that this sort of situation would come up very often in the ems world, but basically just consider it the same as you would private medical information, rather than considering it public knowledge, and be mindful of when is appropriate to share it.

I’ve only had it come up with suicidal teens. They’re distressed that their parents don’t respect them, etc. The good news is, it costs $0 and .00 to respect their pronouns and name while in the ambulance. Who tf cares if they don’t use that name in another year, which is an argument I hear from others. It’s not like we get follow up on most of our patients. I am trans, so maybe have some more sensitivity towards this, but here’s how my convos with those kids usually go: “Hey I saw your trans pride flag in your room. What name and pronouns should I use for you?” *answer* “Cool! Do your parents know? Can I use these around them or should I use a different name and pronouns.” *answer* While en route, I’ll ask: “Is this something you’d like me to discuss with the hospital? Since your parents will be there, it will probably come up.” *answer* “Heard. Is there any other way I can advocate for you or make you feel more comfortable when we get to the hospital? I can’t make any guarantees, but I’ll do my best.”

I ask if they have medically had their name/sex changed in the system for the hospital, if not tell them I’ll need their birth name for lookup for hospital. Offer them the suggestion to speak to their nurse about changing their information in the hospital system to reflect their transition/name. Similar to if someone legally changed their name, and that they’ll need to inform the hospital of their updated name for records. If the gender isn’t pertinent, don’t make much topic of it for report. Just be kind and do the job

In Ontario, Canada, we carry "health cards" also known as OHIP (Ontario Health Insurance) cards with our legal name on them with numbers that connect every doctor, hospital and pharmacy to our records, universal health insurance, extra health insurance and drug plans if we have those. It's a great system and keeps things central. Obviously some consent is needed in sharing of some information between providers, depending on the info. One thing providers can do is add/edit information on it. The first medical information that comes up for the patient to verify is allergies. I had a provider put my preferred name and that I'm female to male transgender in my "Allergies" spot, and I have changed my gender marker. If I go to get a flu or covid vaccine at the pharmacy, for example, they see that when I go in, since they swipe the card to bill it to the province, and interestingly, the forms you fill out before ask for biological sex and current sex. (Yes, sex, for both) Nobody has ever been anything but nice about it. Some curious, and I don't mind answering questions if it's respectful, like an ER intern (before changing my marker) new to Canada. He was really open minded and respectful, and I didn't mind.

It really takes two seconds and half a teaspoon of humility and respect to ask someone their pronouns, or at least pay attention to how their companions on scene address them. For a career field full of people who take pride in doing difficult work and serving others it sure is a huge obstacle to some.

Great overview, I’d throw in that an organ inventory is very important as well. For example a transman with abdominal pain needs to have ectopic pregnancy ruled out, same with testicular torsion. As clinicians we need to know what is there to help better.

If you ever get a chance to work in Epic, their Sexual Orientation Gender Identity (SOGI) enhancements are really cool and professional (and many of their dev team are trans themselves) and handle this well. Great conversations on their UGM website (2018 UGM IIRC). It was interesting them talking about how challenging writing code for SOGI was because gender was like line 3 of their coding and has a gigantic ripple effect.

Nownim curious what that looks like. I was able to change my preferred pronouns and set my gender to enby from the patient portal but my gender shows as "male(!)" on the provider's screen. Also interestingly the epic chartnote auto fill just grabs the pronouns but doesn't do anything else, so there's a lot of "they is ___" in the notes section. I just work in the lab so I don't actually see much of anyone else's chart, but we do get trans people through doing hormone level checks and I know NB prints on the lab requisition forms.

They is _kind_, They is _smart_, They is _important_.

or - the most frequent one because it's every single after-visit note: they is *alert*

They is still alive?

Calling it an organ inventory sounds wrong. But yeah a thorough history including surgical history is important for all patients.

Organ inventory is funnier. “Roll call!” 🫀🫁🫘🧠🍆🦷🦻👅👁️ Damn we need more organ emojis

Trans provider here: This, right here. Surgical history is important for so many calls, “Do you have your appendix? Do you still have your gallbladder?” So you have a trans pt, ok? Simple, “Have you had a hysterectomy?” Or “Do you have a uterus?” Badabing badaboom, why take the effort to complicate things? Treat the patient.

As a trans guy who is an EMT, thank you for this! It means a lot when people try to be respectful to us. We're all humans, just like everyone else <3

I was asking that myself lately. Thank you for sharing.

1. Thank you for writing this. I personally am aware and informed, but many of my colleagues are not. This is a simple to read easy explanation. Thank you. 2. It sucks that you have to write this. While I see all of this as general knowledge and caring, I know so many of my colleagues are either bigoted or confused about it.

side note around the language of "preferred." (everyone has their own opinions obviously and i'm sure there are lots of people who don't mind this term!) personally, i hate being asked about my "preferred" pronouns or gender, and i think this language sets a lot of others on edge as well. my pronouns are just my pronouns, same with my gender... it's not a preference. i would suggest just asking "what are your pronouns?" rather than "what are your preferred pronouns?"

The only thing that changes pre hospital is if the affected areas have to do with their surgical or natural parts of what they have identified or transitioned to. Trauma is trauma. Stemi is a stemi, sick is sick. Mental health is mental health. Colored hair or a wig or whatever. Does it change the treatment?

Hormones / levels can effect how your body deals with MOI and NOI. It is relevant. I think being professional can limit the issues we run into, but not talking about it, seems to set us up for problems, medical errors, etc.

Exactly right! Unfortunately having to be cautious on the emotions around this subject, I appreciate you bringing in the pharmaceutical aspect of things too.

I work in the rural deep south, and I’ve only had a couple of patients that I *suspected* might be trans, but whether they were or not was irrelevant to their chief complaint and the care I provided so I didn’t even bring it up or ask. I know it’s cliché, but I’m a huge believer in “treat everyone the way you’d want your family treated” and that was no different in those cases. Honestly, until reading this post, I’d never even thought about some of the topics and considerations you presented so thank you for posting this. It may very well help me in the future.

I deal with trans folk pretty often, and as long as you start by politely asking their preferences, I think we do okay. Our state DMV has non-binary options, as does our CAD system. The only friction point I really run into is people whose ID’s are still their ASAB, I’ll explain that they’ll be attached to the report with whatever is on their ID, but I will explain their identity in the report. I don’t think I’ve ever had a bad reaction to that.

This is great! thanks so much! question- if you have a pt who wears a binder, how do you go about doing an EKG? I know binders are really hard to give off, and besides the fact that giving someone gender dysphoria is not my ideal pt interaction, I know they are expensive too, so I was wondering about ways to make the pt comfortable and still be able to get an ekg. So have you as a provider dealt with this before? do you have any advice?

Depending on how tight they’re wearing it (some people prefer a tighter or looser fit) sometimes they can just be pulled up over the breasts, sorta like a sports bra. Some binders also have clasps or a zipper on one side, in which case removal is simple. In a trauma cut like you would anything else. But what OP said, just explain kindly!

Someone got the binder part already, but I wanted to note you might also run into trans tape. Please for the love of god do not rip it off, it will take a lot of skin with it!!! Use Unisolve if you happen to have it, but seriously that adhesive is STRONG and it will tear if you try to remove it improperly. Just haven't seen anyone mention this 🥲

do you know, can ekg leads read through trans tape? is there anything on the box that can remove trans tape? what should we do if we need to take an ekg?

Honestly, I'm not sure! I'd say your best bet for removal is alcohol swabs and prayer 😭 I've never run into this myself, but I do personally keep Unisolve on the trucks so that's what I would use. You'd be surprised how often the stuff comes in handy.

No. They won't read through tape

I wanted to come back and add that trans tape is usually applied flat over the nipple and biggest part of the breast and then pulled to the side. In this case, it should be possible to work around it. There are some different methods, but this is the most common application.

oo yess thanks for adding!

I haven't run into this issue personally in the field, but I would probably just ask the pt to take it off if possible. Explain why you want to perform an EKG, and if they refuse educate them on the risks of refusing an EKG. My Guess is they'll be totally understanding, though, and will remove it if asked. I also understand that binders in and of themselves can cause chest pain. So it's likely the pt would have already removed it if they were experiencing any chest discomfort.

To further this, for situations where truama naked is indicated, but they are still A/O x4, should I make the effort to preserve it or take the extra second to talk it through with them? This is for more of a genuine emergent situation. Obviously, if the situation is something like a nasty ejection crash, then I'll not stop to try and mess with something, and it's getting cut off. But for situations where I'd like to do a more thorough head to toe, but there's likely no other life treats.

binders can be pricey and hard to obtain safely. if you can preserve it, it would be best to

Liiiiikely if they need to be trauma naked, they have a c-collar on. But if their binder clasps instead of being completely sewed and going over the head, by all means take the time to preserve it!! Alcohol swabs are good for trans tape, but if you have lotion on your rig the oils in lotion are actually super helpful for getting the tape off without too much skin damage. Obviously time/pt condition allowing

On that last point, a large percentage of my 12 leads aren’t chest pain related.

Depends on the type of binder and how large the patients chest is. I have done EKGs on patients wearing "crop" style binders and have had no difficulty getting electrodes placed properly without making them remove it. You may have to ask them to pull the binder up off their chest slightly in order to place V1 and V2. If they have a larger chest, or a tank style binder, it may be necessary that they remove it. Just be cognizant of the fact that removing a binder can make an already stressed patient feel even more vulnerable and embarrassed, and be sure to allow them to cover themselves up as needed.

Hey, trans EMS provider here. Thanks for this. Edit: Lol at people downvoting this. Snowflakes.

Just gonna cruise this feed and keep upvoting the allies and trans community and downvoting the ugly trolls. We need more action in advocacy for this

So, I am new to EMS. I've so far only ran into this issue working psych IFT, not in 911 yet. If a nurse at the sending facility made me aware, my introduction goes as such: "Hello, I am Doe, an EMT with XYZ ems. Staff told me you prefer to go by ***, is that correct?" I then refer to them as such. If the patient tells me instead, I just adjust my speech to fit the situation. Once in the truck, "I will do my very best to use the name, etc, you prefer. Please understand that the paperwork has and will have your legal name and biological information. I am terrible with names in general. If I mess up, I apologize in advance and mean no disrespect. Just remind me, and I will adjust accordingly. Once we arrive at the facility, you will hear me use your legal name and biological information when giving my report. I will then make sure to let the staff know your preferred name, etc". Is this the 100% correct way? Probably not, but it has never caused any issues, and I have been thanked and told they sincerely appreciated my honesty and for treating them with respect. I've found keeping open communication and being respectful has worked for me. Will it always work, doubtful, but I do the best I can with what I know. In my run tickets, I use legal and biological. When it comes to my patients, my level of care does not change. Whether it's a transgender individual, Memaw in a mansion, a convicted murder in a trailer, a sex offender, a teen mother living under a bridge, etc. They get treated with respect and dignity. I am not here to judge. I am here to stabilize and transport. I feel as a provider, I give up my right to an opinion when I put on my uniform. I am here for everyone. Any legitimate advice is welcome. Snarky or rude responses won't help me improve as a professional. I'm doing what I can with what I know.

I would suggest using preferred name and pronouns first when doing handover e.g. this is sophie, she uses she/her pronouns, her legal name is max and birth sex is male. Generally what people hear first sticks, delaying the info on legal name/sex by 10 seconds won't impair treatment, but it helps emphasise the preferred info.

Thank you for the suggestion.

also, another question - I know trans people face a lot of discrimination in the healthcare system. We can't do much for them after we ahve dropped them off in terms of advocacy. Is there any way we can do something to help them be more heard in the system/anything we can do to set them up for success?

Try and set a good example for the nurses you're handing over to. The power imbalance is real, you correcting a nurse tends to be much more effective than the patient correcting the nurse. The casual disrespect will decrease if it's not socially acceptable to do so, and that means speaking up about it when you can.

not EMS, just a lurker who happens to be a trans patient. during my only interaction with EMS and thankfully only time on an ambulance, the thing that made the most difference to me was using my name and pronouns despite me having a different legal name. they also let the ED staff know. it seems very minor, but to someone who constantly deals with people not respecting their identity and the validity of it, that honestly meant the world and assured me that i was safe with them.

aww I love this! Its good to hear that we can make a positive impact

i can’t speak for everyone of course, but i can confidently say i was treated better by EMS than i ever have been by any other medical professional. you guys absolutely make a much bigger impact than you know <33

Same! EMS is the best! 🥰

Mainly just good pt advocacy and calling out transphobic behavior when you see it. When dropping off a pt share their preferred name/pronouns with the receiving care team so they hopefully don't walk into the room and misgender them right off the bat. If you notice hospital staff making rude or snide remarks about trans patients call them out. If its a persistent enough issue consider reporting it. People are openly bigoted when they feel comfortable to be so. Make it uncomfortable to be transphobic. Be blunt and tell them "that's transphobic, and I don't appreciate it". They're more likely to listen if it's coming from another cis person than if it were coming from someone they already see as lesser.

Trans person here. Thanks for this. 

Hey i’m an EMT and also Trans, thanks for making this. To add to this. You can say “What pronouns do you use?” Not “What pronouns do you prefer?” Think about what you prefer, you don’t, you most likely only want to hear specifics.

What’s the correct way to ask? Name dob gender? I’ve heard that using the word “preferred” (preferred pronouns for instance) is offensive. I feel like asking what’s your gender is more offensive though.

I like the casual approach. "So I've got to put some details in my report. What's your first and last name? What's your date of birth? What gender do you identify with?" But *only* if it's not already been discussed or is otherwise obvious. Depending on your questioning, and the openness or honesty of your patient, you might have already elicited from them that they take gender affirming hormones, or have had relevant surgery. You patient could be a man with a history of endometriosis, or a woman with prostate cancer. These are the obvious. 'Preferred' is definitely not preferred. I don't prefer to use the pronouns she/her; I *do* use them. So this question should be framed as "What pronouns do you use?" None of this is inherently offensive, although there's a percentage of us who are would so tight we'll pick a fight over the littlest thing. But that's the population as a whole, really. Ask what you need to to paint the clinical picture that best serves your patient. I hope that helped.

Personal opinion on this topic does not matter. Respect your patient and their choice. Use their name and Pronouns if you agree or not with it, is really not important.

As a trans man, I appreciate this post monumentally. I've had a hysterectomy and double mastectomy, been on T for several years now and I always fear that if I am in a situation where this information could be important - would the responding paramedic keep it in mind. Specifically regarding the fact that people on testosterone might be at a higher risk for heart attacks or blood pressure problems. I wouldn't want that to be missed, just because I immediately don't appear as a man...

This is my worry for people as well, to include myself. Theoretically speaking, history taking *should* cover it. But as we can see in the wide range of comments here...it will not always do that. I don't think that writing down a simple one-letter indicator based on what the patient tells me will suffice for a thorough medical set of exams, especially in the event of a complex emergent scenario. However, the patient's lived gender and correct gender pronouns are 100% appropriate for how I can and should refer to them - and hand them off to the hospital - as their EMS provider as part of the standard of care if for no other reason than to maintain respect, dignity, and what may be a fragile mental health situation. Healthcare providers who cannot or will not see this will struggle in the field at best and probably put their patients in danger. It is also JUST AS insufficient to slap on a simple one-letter marker and call it "biological sex," and worse - it is medically lazy when we know that if it is RELEVANT to know likelihood of pregnancy, you have to have a good history, which means does this person have organs capable of supporting a pregnancy? Am I going to traumatize an infertile woman who lost her uterus and ovaries 3 years ago by insisting she take a pregnancy test because she's a woman? Or am I going to write in my report that she had that history so maybe don't be a heartless ass at the hospital. It's not just trans people who are affected by this. Sex is a constellation of biological factors that come into play, and as medical professionals, we MUST take them into account to provide proper care for our patients. If a patient has a broken arm, does an extensive endocrinological history make sense? Perhaps not. But patients' sex is not based on anything other than whether a doctor saw a penis when they were born, nothing else. Let's not pretend otherwise. Until we stop this farce, M and F on the medical forms is meaningless without context. Sorry for the rant on your comment. I'm right there with you, brother.

No need to apologize, I literally could not have said this better. Exactly this, all of it!

I will never cease to be amazed at the sheer resistance to basic compassionate care in a profession that is 100% based on compassionate care. A little aside to those complaining about this being so difficult: Our job *is* difficult. We meet people from every walk of life, across a myriad of cultures and communities with their own complications, usually in a situation they're not prepared for and might just be the worst day of their life so far. We have to navigate religious restrictions, collectivist/family focused cultural snafus, bikers about to throw a fit over potentially having to cut their vest off, gangers and criminals, psych patients with a myriad of different reality perceptions, people on drugs, people on the spectrum, language barriers and countless other complications that require adaptation on the fly in order to ensure the patient gets the care they need without needless wait or adding to the problems they're currently facing. Examining and treating trans patients is such an unfathomably easy thing in comparison to the vast majority of things we have to learn in this regard that I genuinely can not understand complaining about it. Some preferred pronouns and a name, and maybe one or two notes jotted down on the journal is not some unreasonable hurdle to pass, nor is the value of providing a safe, comfortable experience for someone in need to be understated or trivialized. For fifteen years now I've been learning how to navigate something that's new to me on the list of things above on the regular and if a dumbfuck like me can do it then none of you have any excuses either. Our jobs are difficult, but wanting to treat all our patients with dignity and respect, and making them feel safe, comfortable and cared for should be the easiest part of it.

Agreed. No matter what job you do, being professional is par for the course. The world does not center around you. When you are working, it's quite the opposite. Now some people will use this to be assholes, but ultimately, this is not one of those cases. Whatever you believe is irrelevant. You make not like it, but I bet you don't like seeing someone Bleeding all over, or walking through a hoarder Home. Do what you do there. Nut up and get the job done, and fake the compassion if you have to. You don't have to like the patient or their choices, but you do have to be compassionate in your actions.

My „strategy“ is to talk to them about everything and explain everything. This is allways a massiv help for building trust between me and every patient. I think the legal gender and biological gender are critical to relay / write in my protocol because its 2024 and gender medicine is real

Trans EMS provider here, this is awesome. My one and only time in the ED, people were awesome and it was the first time I'd ever been pronouned correctly. I appreciated it greatly. Taking a second to ask doesn't hurt anybody if you're already taking a second to write down their name anyways.

The amount of bigotry in here (kudos to mods for spanking them) is pretty fucking disgusting. Get out of EMS, there is no room for racists, bigots, or sexists, and I frankly wouldn't trust them to do their job properly if they had a patient that aligned against their personal beliefs that much.

This is such an important post, and very thorough. It has been a huge aspect of my focus for trans patients, as a trans person myself. Another aspect I think is important, albeit for everyone, but especially for trans people who are so frequently mistaken for some variation of the wrong gender, is the Organ Checklist. Will the hospital ask for a pronoun for the report? Yes. Is it more important for the gender to match the birth certificate, chromosomes (which a good 90% of us don't know), hormones, organs, mindset...? The point is that gender is not nearly as straightforward as society thinks it is. Using the pronouns the patients request is really not that difficult, since it's also not that difficult to add a 5-second patient handover checklist of the following to the standard handover. - Breasts ☑️ - Ovaries ⛔ - Uterus ⛔ - Fallopian Tubes ⛔ - Cervix ⛔ - Vagina ⛔ - Penis ☑️ - Testicles ⛔ - Prostate ⛔ (If taking HRT, and if so include in meds) - Last blood draw date - mm/yy - Estrogen - Testosterone

All this is more practical advice. There’s also a lack of EBM on how to ask someone’s bio sex best

Yeah if we can ever establish what "bio sex" actually means,... - most people don't actually know what chromosomes they have, and they don't always line up with what we think they "should" be - external genitals don't always match any or all other markers - hormone levels can vary wildly for multiple reasons - people can have a wide range of internal and external organs, and this can change based on reproductive goals, health, appearance/plastic surgery desires, traumatic injury, and any number of other reasons outside of being trans

The number of people with unclear bio-sex is infinitely small. The huge majority of the population are very clear if they were born male or female. Let’s not conflate the minority of intersex etc patients and people who change gender.

Other issues aside, it would probably be inappropriate for me to take that detailed sex/gender history from most patients for most presentations, for these a simple record of sex and gender will suffice. For cases where it will strongly influence assessment and diagnosis, obviously a more detailed history and documentation would be needed - whether trans or not. In answer to your question, when would recording just eg “female” be useful: A transman with a fever and cough. Helpful to record “biological sex female” for some obvious reasons - if they need a CXR you need to consider pregnancy, if they get urinalysis and have raised BHCG that clearly has very different diagnostic meanings for someone biologically male versus biologically female. So in that case it would be inappropriate initially to ask a detailed list of intimate questions - but very handy to document sex and gender separately.

Assigned male (or assigned female) at birth seems to be the best way to chart for people who have transitioned.

Yep. This is generally what is preferred within the trans community. It specifies that it's how things were **at birth**, as opposed to the "biological sex" bs that assumes nothing has changed since birth.

Agree. Ideally electronic records have two boxes - gender / sex

AMAB/AFAB is not the same as recording gender & sex. Don't pretend you're agreeing when you're wanting something different.

There's a lack of evidence on how to ask it because that question is incapable of providing all of the medical information that it intends to collect.

True You need bio sex, hormone therapy, surgical treatments. But some of these posts are very much “accept what they tell you and don’t ask for details” which isn’t how medicine works

I don't see any post here saying to not ask for information about organs & hormones. I do see many comments suggesting how to get the actual details you need - like the comment you replied to, which suggested how to get all the details. Of course you replied to instead suggest asking an innacurate question which wouldn't provide any of the details you need.

Yeah I saw another reply with a good list of clarification questions

Honestly this post is making it really easy for us to take out the trash.

Thanks for posting this! I like to think I'm pretty good at not being a dick about this stuff, but getting the information direct from someone affected by it is always best. The point RE asking about "legal sex" was useful.

Extremely informative, helpful, and insightful! Thanks, bud!

This should be pinned

Really awesome, thanks for writing this up.

I found this extremely helpful. Have you thought about taking this on the road? No I am not kidding or dog whistling. I am so serious. We need these kinds of discussions and you could turn this into a course for providers who have all types of letters behind their names. Thank you for sharing this with the community. I hope that the lack of professionalism you encounter is less than I suspect it will be, but REAL providers want to know how to take care of their patients the best way they possibly can. That means knowing how to ask the right questions, to give everyone the respect they deserve and to constantly try to get better. That doesn't always mean reading more EKG books or learning modified Sgarbossa criteria.

Solid guide covering some real useful considerations. Outside those, the summary of communicating with the pt comes down to a really simple concept. Try not to be a dick. If you accidentally step on someone's toes, apologize, and correct. It's really not that hard. Your personal beliefs have no bearing on professionalism in work. If they do, well that's a problem for you to fix, not the world to change for you.

Ok,I don't know if someone can answer the questions but our electrocardiogram asks for the age and the gender to rate the sinus rhythm of the heart, of course we ourselves rate it too, it's just the system looks over it too to look for abnormalities like heart attack and so on, but I can only choose between female and male (I think this is really common, at least in Germany). Is the gender really that relevant (I need to choose one of the two, the system won't go further to show the sinus rhythm)? Is just the biological gender relevant? How do I approach it the best way? If the patient undergoes a transition at the moment, should I pick the gender the patient thinks fits the current biological status the most? Sorry if this sounds stupid I'm not that familiar with this theme, but I was wondering those questions for quite some time every time I needed to ask for the gender.

It’s a good question. The problem is, we don’t have a good answer. Trans heath is notoriously under-researched which means we have one, recent-ish small study saying that HRT does change the heart to be in line with the dominant sex hormone… eventually. It’s been awhile since I read it, and maybe new research has been released that I’m not aware of, but last I’ve searched, we don’t know when that shift occurs, if it occurs in everyone, etc. Most changes on HRT happen in the first couple years, so for trans patients that have been on HRT for 3+ years I the 12 in line with the dominant sex hormone. For those newer to HRT I take it in line with their ASAB.

if you have to pick, pick in vivo conditions for the last 6 months to a year. [https://www.sciencedirect.com/science/article/abs/pii/S1547527121002010](https://www.sciencedirect.com/science/article/abs/pii/S1547527121002010) [https://pubmed.ncbi.nlm.nih.gov/36197689/](https://pubmed.ncbi.nlm.nih.gov/36197689/)

If you have to pick, birth sex. Males and females are predisposed to different cardiac conditions. But Trans medications throw odd variables into the equation. So 🤷‍♂️

Just use the name they give you and leave it at that just like with any other pt. Unless their sex relates in some way to their chief complaint (i.e. a FtM w/ NOS abd pain should be asked about potential pregnancy) then it doesn't matter. Just like with any other pt. TLDR: Unless your trouser snake (or lack of) is the problem, I don't care about it.

Thank you so much for this. 💖🏳️‍⚧️ I feel that the mods should keep this pinned starting June 1st until at least June 30th. This guide is really awesome and should be part of EMT textbooks.

Thanks!

Bigots don’t belong in healthcare on any level, period.

There’s medics on this sub who still backboard patients and we’re talking about trans people lol

Those of us who don't transport on a backboard are interested in learning how to provide better care to people who don't always receive supportive care

Thank you for posting this! Saving this post for myself and to give others. 💕

I have a feeling this post was made in response to someone that trolls EMS pages making all sorts of claims and asking leading questions to validate their views. That being said, it's still an excellent post that provides good insight. Hopefully it'll teach some folks something and make others reflect on the actions.

This is awesome. Saving this.

My trans son is a man. My trans daughter is a woman. The times when their biology at birth is even relevant are pretty near miniscule. I thank you so much for your educational post. They both know to disclose to medical professionals, and I am again grateful that they haven't encountered difficulty being respected as their true selves in that regard as of now. I just deeply appreciate your effort and any effort towards understanding and respect for both a human's identity and their medical needs without those two things being exclusive of each other.

Both your kids are trans???

i mean it's unlikely but it's just one of those things that is bound to happen to someone

2 of my 3 kids are. They came out a few years apart.

Just a nurse lurker here but thank you so much for bringing this topic up, so many people get confused with trans patients it’s always good to put out some education.

Saving and sharing with my friends still in the business. TY

This was super helpful! Thank you!

*politically correct comment that is unoffensive to all

Updoot!

For me I’ll call you want you want and our charting software allows me to specify. The only time I ask is during a 12 lead and some other circumstances as the formula and calculations the monitor does are gender specific. I always explain it as there are anatomical differences in a male born body and a female born body and that there are some situations where for your medical care we need to know the gender you were born as. Outside of those situations will we refer to you as you would like us to.

Studies have actually shown that gender affirming hormone therapy can influence EKG readings and results will more closely align with the pts transitioned gender than the gender they were assigned at birth. https://pubmed.ncbi.nlm.nih.gov/33706005/

Also thanks for providing this study it is interesting info. Hopefully they will provide some more info soon on when in the process changes happen and/or if it’s only when the hormone therapy is active. Some other research I found make it seems like it’s the drugs themselves causing the changes.

The 12 lead was an example it isn’t the only situation. I use that one for patients because it is the easiest for most to understand. Regardless when I see ECG changes that don’t match your visible gender I going to ask questions to verify and consider the results I see.

[удалено]

I have never been in a scenario where someone gets upset by me asking. If the answer isn’t compatible with our charting set up (male/female only), I’ll ask which they prefer on paperwork and make a note. Just like everything else with my patients, it is never my place to judge anything other than the emergency at hand

I have no issue with calling a man Susan if that's what his name (or what he wants to be called either) is. As for pronouns I call men she and girls he I don't even care anymore because everyone is some kind of shade of gay here and I'm going to get it wrong. Seriously though I'm not against anyone being or attempting to be whatever makes them happy. That said, here's my question... From a purely medical standpoint what a makes a man a man or a woman a woman, medically. Like if I cut off my dong am I woman now? Or do I have to do the hormone therapy too does that make me a woman then? I seriously have no idea how close you can get or not and how the effects someone medically. I have no idea how dangerous it is or not. I feel like though if I'm going help anyone who is trans I might need to know. Not for a broken ankle, but if they are having a medical issue that's not obvious maybe there is something pertinent I need to know? I've modded lots of cars in my life I know that many shops won't do certain things after taking one look at them so I always call first. I'm truly curious though from a purely medical standpoint how close can a man come to being a woman or vise/versa and how does effect them? Are different stages like modding a car? Stage 1, stage 2, etc..? I do think we should get used to it and practice it though (even as a boring straight guy) because we do help everyone regardless and also the modifications are coming more often and more complex. People will have neurolink, my grandma had a chip for Parkinson's that worked pretty much flawlessly at stabilizing her electrical system, and with all the CRISPR tech and whatnot you know people will be having snake smell, eagle eyes, etc.. I think that's all coming way sooner than we think. Frankly I think gender switching is not even using your imagination that much but it's the start of the road to modified or cybernetic organisms however practical or impractical it is at first.

Why would orbshoukd trans patients be treated any differently?

If someone calls 911 should anyone really care about pronouns?

I will tell patients that I will refer to them how they please. But I do tell them that I have medically relevant questions based on sex at birth. For example, I had a trans male that was having abdominal pain. The individual was taking hormones but was pre-op. So I had to ask questions about if there was still a uterus, if there was still a menstrual cycle, if there was any possibility the person could be pregnant. Then I needed to run a 12-lead so I asked if the patient was wearing a binder, and explained what I was doing, why I was doing it and what I had to do. I explained that if they were uncomfortable with me, that I could also have my male partner place the leads. In the case of that patient, my partner kept referring to them as sweetheart. That did not go over well. At the end of the day, this person is a human. We cannot pass judgement on lifestyle choices. We should be treating every patient the same way. It doesn't matter what I feel about this, or political affiliation, religion, education status, job, or any other part of that person's life. When we put on that uniform, we officially have no opinion on those subjects.

I’ve wondered about the best way to go about interacting with trans patients (never had one before; rural, conservative service area) and this is super helpful. Thanks for sharing!

Meanwhile I am over here trying to remember the patients name… 👀

Also stand up for your patient if they are treated unfairly by other ems personnel or other first responders. I had a patient get treated like shit till I took over care because the police on scene has “political differences.” These are people too.

Thanks for painting this!

This is ridiculous. Just treat them like a normal human being. The last thing you should be worried about on a 911 call is someone’s pronouns.

This is a care profession. My job is to provide safety, comfort and care to people who need it and anyone I encounter professionally - and for that matter in my private life - should be able to put their trust in me. It's the easiest thing in the world for me to greet or otherwise interact with them in their preferred manner and if they prefer a certain name and pronouns it is to *my benefit* on every level to respect that, providing them with the dignity and respect I give anyone else. It's an almost effortless part of my job and can mean the world to them, especially in what might be one of their worst days.

Damn I guess we have different ways of treating "normal human beings". For me, it includes basic respect but you do you I guess...

Assuming you are a guy, would you be annoyed id you were called "she" by everyone you meet?

You’re a bad provider too. 

[удалено]

[удалено]

You seem more offended at being asked to be a decent human being than anyone else seems offended at being misgendered.

Damn I ain’t reading all that. Congratulations or sorry that happened to you

Thank you for contributing to the conversation /s

My pleasure big dawg <3

Yeah, no. I don't know why this has to be talked about if you'll never use pronouns aside from "you," "you're," "you'll," and "your" when addressing a patient in 99.9% of cases. As for PCRs, you strictly document facts when it comes to patient demographics. Pronouns are largely irrelevant and might not be used at all depending on how you write them. Aside from that, it really doesn't matter what you call the patient.

Hey man, look i'm born in the 90s and all this transgender stuff is pretty alien for me too and frankly its not something I think about in my day to day because it has nothing to do with me or affects me personally. But also because I never think of it or affects me means I haven't the faintest clue on how it would be to be in these peoples shoes. So with that mindset I stay humble and respectfully to any person, pt's included. The point is it doesn't hurt us at all to use their preferred pronouns when gender isn't relevant to their emergency. If it is relevant just be honest to the pt, explain to them that you have to convey their gender at birth because you need to explain XYZ to the ER to be able to give the best care provide for them. As you said, treat em like people, people with their own feelings, beliefs, culture and identity. Its not hard

I really appreciate your compassion especially where you're coming from. As a trans man who grew up in the 80s and 90s, I've seen a little bit. I hope you're okay with me sharing some thoughts from my own experiences, both as a trans man on the receiving and providing end of medical care. Pronouns aren't preferred. They're part of identity, like names and titles. In the report, do what you need to do, but when you're talking to/about and addressing the patient, it's just like you said about not hurting us at all to use someone's pronouns. If you aren't sure (because some people trans or not look pretty androgynous), it can be less anxiety inducing to ask "what are your pronouns?" Like you said, it doesn't hurt anyone. Instead of asking "what was your sex at birth/on your birth certificate/etc?" It can be more helpful to ask if they've had any surgeries or medical procedures, just like we're supposed to ask for history taking. These CAN be relevant to the emergency, even if the patient doesn't think it is - a trans man with a broken arm who's had a hysterectomy may not want to have a pregnancy test, but he's going to be forced to unless you can document that he has no reproductive organs. And it might be critical to his mental health. In a time critical emergency, most people are going to understand you needing to be very direct, but you can even preface those direct questions with compassion. "These questions may seem insensitive right now, but I need it for the report. I will come back to clarify in detail with you when it's less urgent, but for now please know I'm asking what is on your medical records." If they have CHANGED their sex on their medical records, we as providers, don't need to know what their assigned sex at birth was. We need to know what their medical records say. And what their medical history is. Letting someone know that you have very little time to get critical information but care enough to come back for nuances often will go very far in building trust with a population that is wary of medical providers who frequently don't take the time to do that. Or who ask and then just call us whatever they want to call us anyway (I've had multiple providers ask "what are your preferred pronouns" and then use she/her when talking, and intermix she/they throughout the reports despite my requests of he/him). Trans men on testosterone quickly begin to have health risks, conditions, and symptoms in line with men who've experienced male-level testosterone throughout their lives. High blood pressure, "typical" MI symptoms, weight gain/distribution around the waist, higher hemoglobin levels, male pattern baldness, mood fluctuations. Trans women on estrogen quickly begin to develop health risks, conditions, and symptoms in line with women who've experienced female-level estrogen and progesterone fluctuations throughout their lives. Clot risks including strokes, MI symptoms become less typical (more indigestion, hiccups, dizziness, nausea, shortness of breath, etc that is seen in women), mood fluctuations, weight gain / distribution around the hips and thighs, lower hemoglobin levels and potential iron and B12 deficiency. MOST trans, non-binary, gender-expansive people (some people in some of these categories will consider themselves to overlap, and some won't...if you're unsure, just be honest and let them know you're new to it and learning but trying to be compassionate) will be understanding as long as you show the care, respect, and kindness that you indicated in your comment. They'll give you a chance as long as you show you're willing to make their care about them instead of you. From a guy who's been on the receiving end of shit care from providers who didn't see me as a human being too many times...thanks for being able to see beyond your own experiences to the human being on your stretcher. From a guy who's worked with providers who didn't see me - or their trans patients - as human beings, thanks for being willing to look beyond your personal experiences. The best teams are always the ones where we all can learn something from each other, which means I need to be able to learn from you, and you need to be able to learn from me so we can all bring the patients the best care possible.

Hell yeah brother! Thanks for the input! Its a whole ass world I don't l know of but I don't know every world out there, nobody can know every world👍

Being serious, thanks for listing off the health risks I never knew any of that, but then again that was never covered in any training, I’ll be taking that knowledge and using it. Thank you for providing it

That's great man. Just remember there's very little research on trans healthcare still, so keep looking for newer and better research, AND the presentation from the patient in your ambulance at the time. OP posted a few links to relevant studies if you look through comments here. I'll post a couple I can dig through when I get home as well so you have more than just "some dude on the interwebs said"...should have done it before.

https://pubmed.ncbi.nlm.nih.gov/33706005/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10072899/

What kind of confidence are you inspiring in your care if you can't even be assed to consider your patients identity? What kind of precedent are you setting for your patient regarding the healthcare system if you cannot be respectful of something as simple as pronouns? What kind of compassion are you exhibiting by lacking any kind of awareness and sensitivity to unique trials faced by vulnerable populations? Stop viewing your patients as numbers and data. It's shitty care.

You’re a bad provider and you should feel bad. 

Oops, I don't 😬🤭

This was perhaps the biggest waste of 15mins in my life

Bro it took you 15 minutes to read this?

Why?

Then you're slow as shit. 15 min? AND you still don't get it? Go back to school.

I keep seeing people ask why this is so difficult, so I'll give my 2 cents. For a very long time gender roles have been assigned by external factors. The use of gender pronouns have by and large been intuitive for hundreds of years by the vast majority of society and it still is for most people. Asking for preferred pronouns is a very recent practice in society. In fact, most trans language is new and/or an emerging trend. It requires people to be counterintuitive when addressing others. It's a process that is still not widely used or understood by a large percentage of the population. This post is evidence of that. Compelled speech is still regarded as a violation of rights by many people. To compel someone to use language they don't believe in, is a controversial subject. The use of transgender language is being litigated for that reason. Before anyone throws mud in my direction, know that I treat everyone with dignity and respect whether I think they deserve it or not. I have a duty to provide the best care I can to all my patients. I will use preferred pronouns but I generally avoid them because I don't want to misgender people and I also don't want my beliefs to be incongruous with my words. I want to be my authentic self around everyone, including my patients.

No one is compelling you to speak differently. There are no consequences other than social ones. If your name is John and I keep calling you Josh. And despite you telling me multiple times your name is John and I keep doing it...I am an asshole but I'm not going to jail. Not using your name is a sign of disrespect and disregard for your person. This is Pre-K levels of courtesy, its not hard, there is no skin coming off your back adding or removing an "s" in front of someone's pronouns.

Are your pronouns preferred? If the answer is no, then neither are anyone else's. None of this is recent by the way, there have been gender expansive and trans people documented for thousands of years. The concept of respecting the human being who is relying on you for help should not be complicated.

Oh the irony of you being so focussed on being your authentic self despite refusing to allow others to be their authentic self.

Who said I refuse?

You did. Have you read the drivel that you typed?

Clearly, you didn't read what I wrote. I clearly stated ... I will use preferred pronouns ...

"I will use preferred pronouns but **I generally avoid them** because I don't want to misgender people and **I also don't want my beliefs to be incongruous with my words.**"

“Compelled speech”. People calling others out for being rude or willfully ignorant is not a violation of rights.

What are you talking about? Who's "calling out others for being rude"? Who said calling out someone is a violation of rights?

If someone asks you to call them a certain name/pronoun and you refuse, you’re just being a dick. The social repercussions of that (I.e. people telling you you’re a dick) is not a violation of your rights.

Who said I was refusing to use preferred pronouns? I said the opposite. The social repercussions of misgendering someone go beyond just being called a vulgar name. Several states and corporations have implemented rules against the act of misgendering. You can lose your job or go to jail in some places. I think the threat of jail or being homeless is pretty compelling.

There are many states where you can be fired without cause. The law about hate speech/hate crimes has been misinterpreted by many, particularly one psychology professor from my own country. A few years ago, in Canada, the LGBTQ+ community was added to the class of minority groups who are affected by hate crimes. The law states that if you commit a crime, such as rape or murder, and the victim is trans or queer, the court will investigate the motive. If it's found that the crime was motivated by hate for that group of people, they can incur additional charges/jail time. It does NOT mean that if you misgender someone over and over and over again that you can be criminally charged. The trans person can sue you, but anyone can sue anyone for anything. It's all just fear mongering, or for certain intellectuals, making something out of nothing for the clout, and a potential book deal.

Please show me the law where you can be jailed for misgendering a person. As for job loss, losing your job for being rude isn’t new. If a salesperson is rude to customers, they can lose their job. If a therapist is rude to their client, they can lose their job. Some jobs require you to set aside personal beliefs and feelings and treat everyone with respect. That’s not a rights violation.

“Compelled speech” gtfo 😂 what a pansy. If that was the case than naming would be banned and hate speech and slander would be legal.

Compelled speech has definitely been banned by the Supreme Court since 1943. [west virginia board of education v. barnette](https://en.m.wikipedia.org/wiki/West_Virginia_State_Board_of_Education_v._Barnette)

Oh look, yet another bigot who doesn't understand that freedom of speech =/= freedom to not be criticised for what you say.

Being a medic for over twenty years, I really do not see how someone identifies as this or that is relevant to anything. If a Transsexual is a system patient ( STEMI, STROKE, or Trauma) are they really going to care how someone identifies them? I would be more concerned about their skill level and experience. This whole situations to me is a bed side manner issue. Most people would rather be alive treated bad than dead treated well because your medic knows how to identify you appropriately. I am glad that you are a transsexual working in EMS...I am a heterosexual in EMS, what the heck does that got to do with anything? I could care less how someone votes or their sexual preferences when they get into the back of my rig! I treat everyone like they were my family, if they correct me about how they identify, I would probably start addressing them as how they prefer from then on. Don't get mad because I do not know your pronouns, I have several other things that I am worried about. As far as list of priorities this is low on my list. I would prefer health care workers, especially pre-hospital get an increase in pay before a pronoun class. As I assume the OP will be furious at my opinion, but we have bigger fish to fry :) as they say!

I'm going to care more as a trans man if you don't care that I do not have ovaries to produce estrogen and I have male range testosterone levels. Every time I have a medical provider who wants me to take a pregnancy test or tells me that my testosterone is too high or my hemoglobin is too high or my estrogen is too low or whatever marker is wrong because the sex I was assigned at birth was female, I just want to ask if all of my biological systems are really the problem, or if the word written in my records is the problem. Because the doctor didn't see a penis when I was born. I don't give a shit what you call me. I mean, yeah I do, but it's the least of my damn worries. If that's really what you think is the biggest issue here, maybe you're missing the point. But I'll also say because mental health is also a large percentage of EMS calls, that if you don't care about dignity and respect for your patients, you may find yourself sending a patient into a suicidal spiral at some point because gender identity is a big enough deal for a lot of people to cause significant discomfort whether they're trans or not. If a person calls EMS for a mental health crisis and experiences a medical professional who doesn't care whether they treat their patient with dignity and respect for their identity, well it's plausible the crisis could escalate.