Keep your patient comfortable: Inpatient stays

Many aspects of a trans person’s care as an inpatient will be the same as any other similar. However, there are some areas that might be different and some areas where additional sensitivities may apply.

Hospital staff might need to make extra considerations when admitting a trans patient. It is important to understand that trans women are entitled to be treated on a women’s ward and trans men are entitled to be treated on a men’s ward (unless there are exceptional circumstances, as detailed elsewhere in this resource). You should ask non-binary patients where they would feel most comfortable.

For patients who are in hospital for reasons typically associated with men or with women, it might be that you try to accommodate them on a different ward than others under the care of the same team. For example, it is good practice to accommodate a trans man having a hysterectomy on a general medical ward rather than on a gynaecological ward. A patient being on a different ward does not prevent their consultant or their team visiting them during rounds.

It’s important to be aware that some trans people might find it uncomfortable to be on a ward with others. If this is the case, if may be helpful for them to have a bed in a side room if possible. However, it’s important not to make assumptions about what a trans person may or may not want.

In circumstances where it’s not possible to accommodate a trans patient according to their wishes, it is important to explain the situation with them and take additional measures to support them in the space they are accommodated in.

What does NHS guidance say?

NHS guidance states that

“a trans person does not need to have had, or be planning, any medical gender reassignment treatment to be protected under the Equality Act: it is enough if they are undergoing a personal process of changing gender. In addition, good practice requires that clinical responses be patient-centred, respectful and flexible towards all transgender people whether they live continuously or temporarily in a gender role that does not conform to their natal sex.”

p12-13, Delivering Same Sex Accommodation, NHS England (2019)

It goes on to specify that

“Those who have undergone transition should be accommodated according to their gender presentation. Different genital or breast sex appearance is not a bar to this, since sufficient privacy can usually be ensured through the use of curtains or by accommodation in a single side room adjacent to a gender appropriate ward. This approach may be varied under special circumstances where, for instance, the treatment is sex-specific and necessitates a trans person being placed in an otherwise opposite gender ward. Such departures should be proportionate to achieving a ‘legitimate aim’, for instance, a safe nursing environment. 

This may arise, for instance, when a trans man is having a hysterectomy in a hospital, or hospital ward that is designated specifically for women, and no side room is available. The situation should be discussed with the individual concerned and a joint decision made as to how to resolve it. In addition to these safeguards, where admission/triage staff are unsure of a person’s gender, they should, where possible, ask discreetly where the person would be most comfortably accommodated. They should then comply with the patient’s preference immediately, or as soon as practicable. If patients are transferred to a ward, this should also be in accordance with their continuous gender presentation (unless the patient requests otherwise). 

If, on admission, it is impossible to ask the view of the person because he or she is unconscious or incapacitated then, in the first instance, inferences should be drawn from presentation and mode of dress. No investigation as to the genital sex of the person should be undertaken unless this is specifically necessary to carry out treatment.

In addition to the usual safeguards outlined in relation to all other patients, it is important to take into account that immediately post-operatively, or while unconscious for any reason, those trans women who usually wear wigs, are unlikely to wear them in these circumstances, and may be ‘read’ incorrectly as men. Extra care is therefore required so that their privacy and dignity as women are appropriately ensured. 

Trans men whose facial appearance is clearly male, may still have female genital appearance, so extra care is needed to ensure their dignity and privacy as men. 

Non-binary individuals, who do not identify as being male or female, should also be asked discreetly about their preferences, and allocated to the male or female ward according to their choice.”

p12-13, Delivering Same Sex Accommodation, NHS England (2019)

A lot of trans people take measures day-to-day to reduce their dysphoria, and some of these measures might not be possible during their inpatient stay.

These include:

Wearing a chest binder

This is an item of clothing used to compress and flatten a person’s breasts. A binder should not be worn for more than 8 hours a day and should never be worn to sleep in. Binders can restrict breathing, so there may sometimes be clinical reasons to ask a patient to not wear their binder.

For patients who normally bind their chest, it can be distressing to be seen without a binder on – even when wearing several layers of clothing. It’s important that hospital staff are mindful of this and, where possible, try to reduce the number of different members of staff a patient in this situation has to encounter.

Measures to help with dysphoria in these circumstances might include the patient wearing a loose hoodie, or having extra blankets on their bed. If a patient is on a ward, they might prefer to have the curtain drawn when they aren’t wearing their binder.

Wearing a wig

Some trans women and non-binary people might wear a wig if they are bald or have a receding hairline. Being seen without their wig might make them feel dysphoric. Most people take their wig off before going to sleep and any patient would have to remove their wig for surgery. There are things you can do to reduce the impact of the dysphoria a trans patient might experience when unable to wear their wig, many of these are similar to the steps you can take for a patient who normally binds their chest. That is, try to reduce the number of different members of staff the patient has to encounter whilst not wearing their wig, offer or suggest the option of wearing a hat or headscarf, or offer the option of drawing the curtain around their bed.

Shaving facial hair

Many trans women and some non-binary people shave their facial hair, often more than once a day. This is because of the dysphoria they experience by having stubble or facial hair. It might be that somebody is particularly self-conscious about hair regrowth, and may notice it on themselves (for example by the feel of their skin) even if nobody else does.

If you have a patient who experiences distress in relation to their facial hair, you can support them by ensuring that they have access to shaving facilities as and when they need them. If they’re unable to get out of bed, you could provide them with a bowl of water and a mirror. If they’re unable to shave for themselves, ask them if they’d like someone to help them to shave.

Bear in mind that a patient in this situation might feel self-conscious when you ask them about shaving. One discreet way of offering this kind of support might be to include a razor on a list of personal hygiene items that they’re offered during their stay or for all patients to be offered a list of personal care tasks they can be supported with.

Packing and tucking

Packing is the process of using prosthetics or padding to create a more affirming body shape. For trans men and some non-binary people, this might include using a prosthetic penis or a pair of socks to create a bulge in their underwear. Some trans women and non-binary people may use prosthetic breast forms or padding in their bra.

Tucking is a process used by some trans women and non-binary people to reduce the appearance of a bulge in their underwear. It typically involves tucking their testicles into the inguinal canals and pulling the penis between the legs and towards the back of the body. Most people that tuck hold everything in place with tape, a piece of fabric called a gaff, or very supportive underwear.

As with other garments and actions designed to reduce a trans person’s experience of dysphoria, trans people should only be asked not to pack or tuck if it doing so would have an impact on their clinical condition or their recovery.

If it’s not possible for a trans patient to pack or tuck, the simplest way to reduce the impact of dysphoria is to make sure they have access to an appropriate number of blankets whilst in bed and to a dressing gown for when they’re out of bed.

If it’s not possible for a trans woman or non-binary person to wear their breast forms, your approach to reducing the impact of dysphoria might be similar to that for a trans man or non-binary person who would normally bind their chest but is unable to.

As referenced elsewhere in this resource, it’s important not to make assumptions about who will need a urine bottle and who will need a bedpan. Some trans men and non-binary people may need to use a bedpan rather than a urine bottle, some trans women and non-binary people may prefer to use a urine bottle. This will depend on whether or not they’ve had genital surgery and on what type of genital surgery they’ve had. You won’t necessarily know whether or not a patient is trans, the simplest thing to do is ask them.

If you need to catheterise a patient, it’s important to know if they’ve previously had surgery relating to their urethra. This is true for any patient, not just trans patients. The simplest way to find out about this is to ask the patient or, if they’re unable to answer, to check their medical records. It’s especially important to ask trans men and non-binary people who’ve had a phalloplasty or metoidioplasty with urethral lengthening about any recommendations their surgeon might have given them in relation to future catheterisation. For example, they may recommend a paediatric catheter to prevent damage to the neourethra. Those patients may also have a urethra that takes a less direct route to the bladder. In an emergency, it is a good idea to err on the side of caution and use a paediatric catheter for anyone that’s had a phalloplasty or metoidioplasty.

Be aware that if you need to support a trans patient with any continence-related care, they may be especially self-conscious and it may trigger dysphoria. You might not know they’re trans prior to seeing their genitals – it’s important not to pass comment about them or react in a way that may make them feel any more self-conscious than they already do. Refer to the Keep it relevant: Asking trans people about their bodies section of this resource for other things you can do to reduce the discomfort a trans person might experience during continence-related care.

It’s not uncommon for trans people to experience harassment or abuse from complete strangers when out in the community. This means that they’re at risk of experiencing it in hospital too – from other patients and/or their visitors, or from members of staff. It is important that you have a policy that makes it clear to both patients and their visitors that harassment and abuse toward patients (as well as staff) is unacceptable and that staff know what to do if such a situation arises.

Regardless of other patients’ attitudes towards trans people, be aware that the fear of harassment or abuse might lead to a trans patient might asking for extra privacy. For example, a trans patient might be more comfortable with the curtain pulled round their bed all of the time or during visiting hours. This would also be useful for a trans person who is experiencing dysphoria. However, don’t make assumptions about what a trans patient will or won’t want – ask them.

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