July-August 2020 • Vol. 29/No. 4 237
Justin Omar Barredo, MSN, is Registered Nurse, Holy Name Medical Center, Teaneck, NJ.
Room Assignments, Gender Identity,
and Gender Expression: A Case Study
on Caring for Transgender Patients
Justin Omar Barredo
According to the 2015 U.S.
Transgender Survey, 33% of
transgender people reported
having at least one negative experi-
ence in health care within the past
year (James et al., 2016). This includ-
ed refusal of treatment, verbal
harassment, physical or sexual
assault, or having to educate health-
care personal on transgender care to
receive proper treatment. As the
number of people in the United
States who identify as transgender
has doubled to 1.4 million from a
decade ago, more attention should
be paid to caring for transgender
individuals (Flores et al., 2016). This
case study explores barriers trans-
gender people may face in health
care along with nursing care consid-
erations.
Case Description
Andrew, a 48-year-old male,
enters an emergency room (ER) with
a fever. The receptionist asks for the
patient’s driver’s license to begin the
admission process. Immediately the
receptionist no tices a discrepancy
between the patient’s name, physi-
cal appearance, and gender listed on
the license. The driver’s license iden-
tifies a person named Anna as a
Caucasian female with long blonde
hair and no facial hair. Andrew is
bald and has facial hair. The recep-
tionist says, “Excuse me. I noticed a
discrepancy with your appearance
and the picture on the driver’s
license. Do you have another form
of ID?” Andrew explains he is a
transgender male. He states he never
Case Study
Transgender people face potential healthcare barriers, including
communication issues, violations to HIPAA, inappropriate room
assignments, and failure of standards of care. Appropriate nursing
care considerations for transgender patients are explored.
updated his driver’s license because
he never had time. The receptionist
replies, “Thank you for the clarifica-
tion.”
A few minutes later, the triage
nurse comes out to the waiting area
and asks for “Anna.” As the nurse
repeats the name a couple of times,
Andrew realizes the nurse was call-
ing for him. He reluctantly stands
up and follows the nurse into the
triage room. Chatter and some
laughs are heard among people in
the waiting room. The receptionist
pulls the nurse aside. Outside the
room, Andrew can listen to the
receptionist tell the nurse the
patient is a transgender male. The
triage nurse reenters the room and
immediately apologizes. Andrew
accepts her apology but states, “I am
a man. Please use male pronouns.”
With the admission completed,
the nurse asks if she can place
Andrew in a cohort ER male room
temporarily, as all the private rooms
are taken at the moment. He states
that is fine. She prints his identifica-
tion bracelet with his legal name
and walks him to his ER room. The
triage nurse gives bedside report to
the ER nurse, informs her Andrew is
a transgender male, and asks her to
refer to him using male pronouns.
The ER nurse conducts a head-to-
toe assessment, assesses the pa tient’s
vital signs, and confirms Andrew is
in atrial fibrillation after an EKG.
The ER nurse reports to the ER
physician that Andrew is a 48-year-
old transgender male with a fever
and burning on urination. She dele-
gates to her nursing assistant the
collection of a urine sample for uri-
nalysis, urine culture, and urine
human chorionic gonadotropin test
from Andrew. A couple of minutes
later, the nursing assistant hands
Andrew a urinal and requests a urine
sample. Embarrassed, Andrew tells
her he needs a collection hat for his
urine. The nursing assistant be –
comes confused and asks why.
Andrews explains he’s a transgender
male. The nursing assistant, still
con fused, asks if he has a penis.
Andrew again requests a hat. The
nursing assistant confronts the ER
nurse at the nursing station and
asked why she didn’t tell her the
patient is “passing off as a guy.” The
ER nurse quickly apologizes in
embarrassment and says she forgot.
A hospital custodian overhears the
conversation and asks the nursing
assistant if the patient was gay. The
nursing assistant says she doesn’t
know but he’s transgender.
July-August 2020 • Vol. 29/No. 4238
The ER physician assesses Andrew
and explains he might have a uri-
nary tract infection (UTI) due to
being biologically born female.
Andrew interrupts the physician,
saying he was assigned female at
birth. The ER physician is taken
aback and apologizes. He continues
to assess Andrew. During the assess-
ment, Andrew redirects his eye con-
tact past the ER physician. The ER
physician turns around to find the
roommate peeking through the cur-
tains. The ER physician asks the
roommate to excuse them, as they’re
having a private conversation. The
roommate awkwardly returns to his
bed. The physician finishes the con-
versation and goes to admit Andrew
due to a possible UTI and atrial fibril-
lation.
The ER nurse informs Andrew he
will be admitted to the cardiac
telemetry unit. She notes a private
room may not be available and asks
if he would like to share a room with
another male patient. Andrew indi-
cates he would rather have a private
room. The nurse informs Andrew he
might be held in the ER until a pri-
vate room is made available. Andrew
agrees and asks the nurse to excuse
him as he will use the men’s rest-
room to get the urine specimen.
After the conversation with the
ER nurse, Andrew’s roommate asks
to speak with the charge nurse. The
charge nurse walks into the room
and the roommate demands to
change his roommate because he
refuses to share a room with a “she-
male.” Andrew returns to his room
and the charge nurse tells him his
bed has to be moved into the hall-
way. He asks why and the charge
nurse redirects the conversation by
stating they’re trying to find him a
private ER room. Seven hours later,
Andrew is still on a stretcher in the
hallway. The ER nurse tells him he is
being transported to the cardiac
telemetry unit.
Andrew is transported to his new
private room on the cardiac teleme-
try unit. The ER nurse gives bedside
report to the unit nurse and explains
Andrew is a transgender male. The
nurse welcomes Andrew to the unit
and takes his vital signs. As the
nurse continues her assessment, she
explains she has to apply a heart
monitor to assess the patient’s atrial
fibrillation continuously. As the
nurse prepares to apply the heart
monitor, she notices the patient is
wearing a chest binder. She asks him
to remove the chest binder, but
Andrew states he would rather not.
Confused, the nurse asks why he is
wearing it. Andrew says it is to flat-
ten his chest so people do not mis-
take him for being female. The
nurse apologizes but explains the
chest binder interferes with applica-
tion of the electrodes and will dis-
rupt cardiac monitoring. Andrew
agrees to remove the chest binder.
As the nurse completes her assess-
ment, Andrew asks if he can use a
razor to shave his head for the
morning. The nurse recommends
avoiding all razors because he is tak-
ing an anticoagulant and could
bleed excessively if he cut himself.
Andrew then asks if he could use
makeup; the nurse agrees, stating
this is not against hospital policies.
An hour later, a phlebotomist
enters the room and explains she
will take some blood for laboratory
testing. She asks the patient to state
his name and date of birth; he iden-
tifies his birth date and indicates his
name is Andrew. The phlebotomist
reverifies his name band, which does
not match with his stated name.
Andrew realizes his name band has
his legal name, explains he has not
changed his name legally, and pro-
vides the phlebotomist with his dri-
ver’s license. The phlebotomist rever-
ifies the name but is taken aback by
the different appearance of the pic-
ture in his license. She asks the
patient’s nurse to verify she is taking
blood from the correct patient. The
nurse assures the phlebotomist that
this is the correct patient.
After 3 days in the hospital,
Andrew has no more fevers and
reports reduced burning with urina-
tion. He is discharged home with a
prescription for antibiotics.
Discussion
Lambda Legal (2016) cited possi-
ble challenges to transgender pat –
ients, including inappropriate be –
havior, violations of the Health
Insurance Portability and Accounta –
bility Act (HIPPA), improper use of
name and pronouns, inappropriate
questioning, challenges in bath-
room use, inadequate room assign-
ments, and failure of standards of
care. This case study explored differ-
ent issues possibly experienced by
transgender patients in the hospital.
One of the biggest problems Andrew
faced was inappropriate communi-
cation and interaction. The 2015
U.S. Transgender Survey found 24%
of 27,715 respondents reported hav-
ing to educate their healthcare
providers on transgender people
(James et al., 2016). In the case
study, for example, the nursing
assistant did not understand the
meaning of transgender male. If a
staff member does not understand
the meaning of transgender, he or
she should ask the patient. However,
all nurses should remember all ques-
tions should be related to the
patient’s health and should be
nonabrasive and nonjudgmental.
Additionally, nurses and all health-
care professionals should become
educated in use of a few common
terms in transgender culture to
avoid misconceptions (see Table 1).
Another barrier unique to trans-
gender persons is proper identifica-
tion. The discrepancy with Andrew’s
license is common; only 11% of the
27,715 respondents of the 2015 U.S.
Transgender Survey had their pre-
ferred name and gender on all iden-
tification (James et al., 2016). Quest –
ioning the discrepancy is appropri-
ate, as the receptionist and phle-
botomist did. Still, admission forms
and identification bracelets should
include an option of gender identifi-
cation and preferred names, respec-
tively, to prevent discrepancies.
Lambda Legal (2016) suggested hos-
pital staff could ask gender identity
and sex assigned-at-birth as part of
the admission profile. Adding an
optional field for nicknames and
pronouns also would help commu-
nication for transgender patients.
This may be a common occurrence
for transgender people. According to
Lambda Legal, transgender patients
should be addressed using names or
Case Study
July-August 2020 • Vol. 29/No. 4 239
Room Assignments, Gender Identity, and Gender Expression: A Case Study on Caring for Transgender Patients
TABLE 1.
Glossary of Transgender Terms
Term Definition
Sex Classification of a person as male or female based on appearance of external anatomy
A person’s sex is determined by chromosomes, hormones, internal and external reproductive organs,
and secondary sex characteristics.
Gender Identity Personal sense of one’s own gender
Gender identity may not always match the sex assigned at birth. People may identify themselves as
man, woman, or non-binary.
Gender Expression External manifestation of a gender
This is embodied by a person’s name, pronouns, clothing, haircut, behavior, voice, and body
characteristics. Gender expression can be described as masculine or feminine.
Sexual Orientation Person’s physical, emotional, or romantic attraction to another person.
Terms straight, gay, lesbian, bisexual, and queer describe a person’s sexual orientation.
Transgender Umbrella term when sex is different from a person’s gender identity or gender expression
The terms female, male, woman, or man following transgender usually describes the gender identity or
expression. Transsexual is an older term used to describe people undergoing transition through
medical interventions (surgical or medical).
Cisgender Describes people who are not transgender
Non-binary or
Genderqueer
Used by those whose gender identity or gender expression is not categorized as male or female
Transition Change over time from one gender to another
Transition may include coming out, using a different name or pronouns, change in gender expression
or identity, hormone therapy, and surgery.
Source: Gay & Lesbian Alliance Against Defamation, 2016
TABLE 2.
Words and Phrases to Avoid
Avoid Preferred Rationale
Transgenders or a
transgender
Transgender people or a
transgender person
Transgender is used properly as an adjective to describe a
person, not as a noun.
Transgenderism Being transgender Transgenderism often has a negative connotation. It may be used
by anti-transgender activists to describe being transgender as a
condition.
Biologically/genetically
born male/female
Assigned male/female at birth Using the term biologically or genetically undermines a person’s
gender identity.
Sex change Transition This phrase produces the incorrect impression that surgery is
required for a transgender person to transition.
Passing/posing/pretend –
ing as male/female
Visibly/not visibly transgender Using the phrase passing as may imply inauthenticity (being
something other than the person is). Transgender people live their
gender identity as authentic.
Tranny, she-male,
he-she, it, and shim
Use the person’s preferred
name and pronoun.
Many transgender people find these terms offensive and
dehumanizing. Use their names and ask them what pronoun is
appropriate to use.
Source: Gay & Lesbian Alliance Against Defamation, 2016
July-August 2020 • Vol. 29/No. 4240
Case Study
pronouns they deem appropriate. In
the case study, Andrew overheard
the receptionist and the emergency
physician using the wrong pronoun.
Using phrases such as biologically
born female and passing as a male can
be offensive as they undermine a
person’s gender identity. See Table 2
for examples of terms to avoid and
words preferred by a transgender
person.
Lack of communication between
staff in the case study created awk-
ward encounters for the patient. For
example, the ER nurse called for
Anna instead of Andrew in a room
full of people. This attracted atten-
tion in the waiting area because
Andrew’s gender identity did not
match Anna’s feminine name.
Sharing information of patients
with other personnel is also inap-
propriate and a violation of HIPAA,
affecting the patient’s right to priva-
cy and confidentiality (Lambda
Legal, 2016). Andrew’s nursing assis-
tant told a hospital custodian, who
was not involved with patient care,
that he is a transgender male.
According to Lambda Legal, “Pri –
vacy can be especially important to
transgender patients who may not
want their transgender status dis-
closed for personal or safety rea-
sons” (p. 6).
Transgender people have the
right to receive care without dis-
crimination or harassment due to
gender identity or expression
(Lambda Legal, 2016). According to
James and coauthors (2016), 6% of
over 27,000 surveyed transgender
people reported being abused ver-
bally in a healthcare setting. In one
account by Hanneman (2017), an
anonymous transgender male stated
the doctor kept referring to him as
she in front of other staff members
despite correcting him multiple
times. Samuels and colleagues
(2015) reported numerous transgen-
der participants in their study feel-
ing “like a freak show” (p. 174). In
Andrew’s situation, the ER nurse was
right to separate Andrew from the
roommate who used inappropriate
language and slurs. However, it may
have been more appropriate to con-
sider both patients’ accommodation
preferences rather than move
Andrew first.
Per the Patient Protection and
Affordable Care Act, hospitals are to
provide equal access to their health
programs or activities without dis-
crimination based on sex (Romero,
2016). Lambda Legal (2016) estab-
lished seven guidelines in order of
priority on how to assign rooms for
transgender patients (see Table 3). In
the case study, the ER nurse first
should have given Andrew the
option of a private room, or a semi-
private room shared with a patient
of his identified gender. This was
addressed by offering a private room
when he was admitted to the car-
diac telemetry unit.
After arriving at the unit, Andrew
faced issues with gender expression.
This included use of a chest binder,
boxers, razor, makeup or personal
belongings that assist with gender
presentation. Lambda Legal (2016)
indicated bringing personal belong-
ings does not apply to items that
can jeopardize a patient’s health.
Additionally, hospital policies may
differ with patient access to personal
belongings. In this instance, the
nurse allowed the use of makeup as
it was not against hospital policy.
The nurse could have suggested
using an electric shaver as an alter-
native to using a razor blade. Finally,
the nurse explained how a chest
binder might interfere with the
TABLE 3.
Room Assignment Policy for Transgender Patients
1. If a transgender patient requests to be assigned to a room with a roommate of the patient’s same gender identity and such
a room is available, the request should be honored.
2. If a transgender patient requests a private room and there is one available, it should be made available to the patient.
3. If a transgender patient does not indicate a rooming preference and a private room is available, the private room should be
offered to the transgender patient. The offer should be explained to the patient as optional and for the purpose of ensuring
the patient’s privacy, safety, and comfort.
4. If a private room is not available and the transgender patient does not wish to share a room with a roommate, the
transgender patient should be assigned to an empty double room with the second bed blocked.
5. If there is no private room or empty double room available, the patient should be assigned to a room with a patient of the
gender with which the transgender patient identifies.
6. If there is no private or empty double room available and a transgender patient does not wish to share a room, other
patients may be moved to make a private room available if doing so would not compromise the health or safety of the
patients being moved.
7. If there is no private or empty double room available, the transgender patient refuses to share a room, and no other
patient can safely be moved to make a private room available, the transgender patient should be allowed to remain in the
Emergency Department or Admitting Office without harassment until a private room becomes available.
Source: Lambda Legal, 2016
continued on page 244
July-August 2020 • Vol. 29/No. 4244
telemetry monitor. Allowing patient
access to personal belongings that
assist with gender expression helps
create a more therapeutic environ-
ment for them.
Conclusion
Education, communication, and
respect are keys to creating a healing
environment for transgender pa –
tients. Andrew had several health-
care experiences that may be com-
mon to some transgender patients.
Nurses and other healthcare profes-
sionals should be educated about
use of appropriate terms and com-
munication strategies for interacting
with transgender patients. This in –
cludes using correct pronouns and
proper identification as indicated by
the patient. Nurses must respect
their patients’ privacy and advocate
for their right to be cared for in a
nondiscriminatory, harassment-free
environment. Finally, nurses must
create an environment that allows
gender expression for transgender
patients. Hopefully, these nursing
care interventions will reduce barri-
ers transgender people may face in
health care and provide better out-
comes.
REFERENCES
Gay & Lesbian Alliance Against Defamation.
(2016). GLAAD media reference guide –
transgender.
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Hanneman, T. (2017). Healthcare equality
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Flores, A.R., Herman, J.L., Gates, G.J.,
Brown, & Taylor, B. (2016). How many
adults identify as transgender in the
United States?
law.ucla.edu/publications/trans-adults-
united-states/
James, S.E., Herman, J.L., Rankin, S.,
Keisling, M., Mottet, L., & Anafi, M.
(2016). The report of the 2015 U.S.
Transgender Survey.
equality.org/sites/default/files/docs/
USTS-Full-Report-FINAL.PDF
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to quality health care for transgender
patients.
sites/default/files/publications/down
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Romero, A.P. (2016). Nondiscrimination in
health programs and activities: Pro posed
rule RIN 0945-AA02.
register.gov/a/2016-11458
Samuels, E.A., Tape, C., Garber, N.,
Bowman, S., & Choo, E.K. (2015).
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Case Study
continued from page 240
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