Recent legislation regarding transgender people's access to public bathrooms could have an impact on the healthcare community, said a perspective published on July 14, 2016, in the New England Journal of Medicine. Several states have debated or passed laws requiring that people use the bathroom that corresponds to their sex "identified at birth." Transgender people have a gender identity that does not match their sex assigned at birth. Approximately 700,000 adults in the United States are transgender, according to a study cited by the authors. One consequence of restricting bathroom access for this population is that it could make a transgender person suppress his or her basic bodily needs. Delaying bathroom use, the authors said, can cause health problems including kidney and urinary tract infections, impacted stools, and hemorrhoids. Some transgender people abstain from drinking all day in order to avoid the need to urinate, the authors said. Transgender people may also fear being physically assaulted if they enter the bathroom they feel more comfortable using. The ongoing public conversation regarding access to bathrooms can also take a toll on the mental health of a transgender person. Beyond bathrooms, the authors noted, the discrimination transgender people face is associated with increased stress, anxiety, depressive symptoms, posttraumatic stress disorder, substance abuse, and suicide. It is also associated with increased risk of bullying, verbal harassment, violence, sexual assault, and decreased healthcare utilization. Simply accepting and acknowledging someone's gender identity in social, legal, and other settings has been found to greatly improve overall psychological health, the authors said. The healthcare community can accomplish this goal through clinical care, research, and advocacy. However, the authors noted, most clinicians lack training in transgender health issues, and some even resist treating transgender patients or make prejudiced and abusive statements toward them. A survey cited by the authors found that 28% of transgender adults experienced harassment in medical settings, 19% reported being refused care, and 28% reported they had to postpone care because of discrimination. Half of those surveyed said they had to teach their clinicians about transgender care. Clinicians can actively support the care of their transgender patients by addressing the risk of physical and verbal assault with them, helping with the emotional challenges related to disclosing gender identity to friends and family, and discussing medical options for gender affirmation, such as hormone therapy. Medical offices and hospitals can welcome transgender patients by asking about gender identity on registration forms and asking how to conduct a physical exam in a way that will be most comfortable for the patient. The American Psychiatric Association in 2013 revised its guidelines to say that being transgender is not a mental disorder and that gender-affirming treatments are a valid form of care. The American Medical Association and other medical societies have called on clinicians to treat all patients, regardless of gender identity. The American Academy of Pediatrics recently repudiated North Carolina's public-facilities law. "Physicians should not underestimate their ability to educate and reassure people who are misinformed and unaware or afraid of the unknown," the authors said.

HRC Recommends: Healthcare organizations and individual providers should commit to providing patient-centered care. Patient-centered care involves respect for the patient's values, preferences, and expressed needs; provision of health information and education; timely access to care; provision of emotional support to relieve fear and anxiety; involvement of family and friends; continuity of care and safe, smooth transitions between healthcare settings; physical comfort; and coordination of care. Risk managers may wish to take an inventory of the organization's existing policies and procedures and ensure that they incorporate patient centeredness and specifically address patients' gender identity. They should also assess how the organization operationalizes patient centeredness for transgender patients and visitors.