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Saul Harari, MD
Pathologist
New York Community Hospital
Brooklyn

In reply: We read with interest the concerns outlined by Dr. Harari. Embracing gender diversity in medicine requires a learning curve. We understand there might be confusion around nomenclature, and we respect that it can be complex. However, we believe adopting appropriate language is a baseline requirement for respecting transgender and nonbinary people. We do not believe that the verbiage is cumbersome, but rather it is new. Language evolves, and it is our responsibility as medical providers to maintain a cultural awareness of the patients we serve. The recent incorporation of sexual orientation/gender identity fields in electronic health records is an example of how the practice of medicine and associated medical records adapts at a broad level to changes in cultural norms and language.

As laboratory directors and pathologists, we are responsible for ensuring our reports are medically sound and respectful and offer interpretation to the person reading the material. Clinicians and patients read pathology reports. We agree that the specific details of a pathology report may be confusing to people outside of health care, but stress that there is universal competency related to understanding one’s own gender. A transgender man who is appropriately utilizing testosterone is not a “female taking testosterone.” He is a man receiving appropriate medication. As such, it is an error to dictate differently on a pathology report. We are not speaking metaphorically; we are speaking about the lived experiences of human beings. We want to ensure that patients are respected for their identities across the health care system.

Our understanding of preanalytical error is not stagnant but iterative. Like other quality standards, it must adapt to new challenges. We believe that respecting people’s gender identity is a preanalytical issue. As Dr. Harari mentions, phlebotomy is one of the “complex steps” that must be completed before samples are analyzed. Indeed, all components of the blood collection process have long been recognized as a part of the preanalytical phase. This includes mutually respectful interactions between patients and phlebotomy staff. To this point we reference CLSI GP41, which states that “during the blood collection process the phlebotomist should establish a rapport and gain the patient’s confidence.” We believe this guidance is sound and applies to all our populations, including those who are gender-diverse. Moreover, the recent editions of Tietz state that “preanalytical error should be assessed with a focus on patient outcomes and prevention of patient harm.” The chapter emphasizes that laboratorians should identify situations where patient outcomes may be affected and focus on the most critical errors. Failure of our front-end team to respect a patient’s gender can lead to failure to get necessary testing and can have a dramatic impact on patient outcomes.

Dina Greene, PhD, D(ABCC)
Clinical Associate Professor
University of Washington
Associate Laboratory Director
LetsGetChecked

Gabrielle Winston-McPherson, PhD, D(ABCC)
Associate Director, Chemistry
Henry Ford Health System
Detroit

Matthew Krasowski, MD, PhD
Clinical Professor and Vice Chair
Clinical Pathology and Laboratory Services
University of Iowa
Hospital and Clinics