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Transgender care

October 2022—I read with great interest your article “Transgender care, in and beyond the lab” (July 2022). In the article Gabrielle Winston-McPherson, PhD, talks about her desire to improve health outcomes, identify problems in the preanalytical process, develop training material, assemble data and information prior to implementation, address informatics challenges, and ensure proper allocation of limited resources—all of which is laudable and appears to align perfectly with our mission as pathologists. The writer reminds readers that the topic has landed in the middle of court cases, state laws, and policy debates, with “words like ‘controversial,’ ‘issue,’ ‘politics,’ ‘traditional family values,’ and ‘beliefs’ awkwardly mixed in with medical realities.”

“But strip away the rhetoric,” the article continues, “and labs continue to be charged with the same, enduring task: how to provide the best care to patients.”

Given that I agree with these premises, I am left to wonder whether my divergence from the views expressed elsewhere in the article could be ascribed to mere matters of technical implementation.

If a patient is transgender, nonbinary, or gender fluid, the article says, it’s important for physicians to know whether they’re on gender-affirming hormones. But this point is not necessarily limited to people who identify as transgender because we should always strive to append reference intervals that are as specific, accurate, and clinically useful as possible, to the extent we can. Dina Greene, PhD, makes this point in the article when she says “We do stuff like this all the time” and cites the example of therapeutic ranges for the drug tacrolimus that reflect the specific use of the drug and the clinical context (liver versus kidney transplant). Given the small size of the transgender population and its heterogeneity, accomplishing this would pose its own methodological challenges.

Dr. Greene said the following comment could be appended to test results: “Please note that these are transgender reference intervals specific to people on gender-affirming therapy. If the patient is not on gender-affirming therapy, please use sex assigned at birth to interpret these results.” Another possible comment: “For transgender individuals on hormone therapy, use adult cisgender male for transgender men or people on masculinizing therapy; use adult cisgender female for transgender women or people on feminizing therapy.” I find this verbiage cumbersome and confusing, especially given that the goal of a laboratory report is to relay data in a manner that is concise and as immune from miscommunication as possible. Instead of a straightforward comment directed at a patient’s taking a particular steroid, we have a paragraph about transgender patients who may or may not be on “gender-affirming therapy.” Instead of simply referring to a female taking testosterone, we have “transgender men or people on masculinizing therapy” (assuming I understood that correctly).

Including these comments in a laboratory report, in my view, is a misappropriation of our roles as laboratory physicians and scientists, which is to report our objective findings. Furthermore, we might do well to remember that it is our clinical colleagues who order tests with specific questions in mind and who, with their patients, must ultimately decide, using the results we provide, how best to proceed clinically. Our role in this process is best served by providing results, reference ranges, and commentary that are as accurate, concise, and objective as possible—and nothing more. These results are useful to the extent they reflect reality and provide guidance to the clinician and patient to assist them in making the clinical decisions they must make together. Trying to do anything else, including helping the doctors metaphorically see things our way, is inappropriate.

Dr. Winston-McPherson says misgendering a patient is a common problem among phlebotomy staff—for example, using an incorrect pronoun or title. She suggests that a transgender person’s possible hesitancy to return to the laboratory for sample collection as a result of a perceived negative interaction with a phlebotomist be considered a “preanalytical variable.” For reference I unearthed my Henry’s textbook, which defines preanalysis as all the complex steps that must take place before a sample can be analyzed. The text provides a relatively comprehensive list of possible sources of preanalytical error; it includes “patient-related variables (diet, age, sex, etc.), specimen collection and labelling techniques, specimen preservatives and anticoagulants, specimen transport, and processing and storage.” Nowhere is the use of a correct pronoun or anything remotely similar listed as a preanalytical variable.