Doctors and medical schools are being provided with detailed guidelines for accommodating the needs of transgender and gender-diverse medical students. For example, the Perelman School of Medicine at the University of Pennsylvania prides itself on being “an inclusive, welcoming, respectful and mutually supportive community”. Staff must use trans pronouns, must respect the dress and grooming of the students, must not engage in gender stereotyping, must not retaliate, etc.

Nothing in the Perelman School’s guidelines advises patients how they should react to transgender students. A recent article in The Lancet by a student and a faculty member at Harvard Medical School deals with this issue. Its opening gambit is a situation experienced by one of the authors:

“‘Is he wearing a dress? Men shouldn’t wear dresses.’ It was the first comment by a patient during morning rounds …  As the patient started to ask if the student was “really” a man, the attending physician spoke up to say that the patient’s behaviour was inappropriate and would not be tolerated. The attending physician then led the team out of the patient’s room. The unusual aspect of this incident was not the patient’s transphobic comments or TGD erasure, but rather the attending physician’s response. He was prepared to step in as a responsive ally.”

The authors of the article in The Lancet clearly set out how staff should respond to the needs of transgender students – an increasingly important issue, if, as they claim, 1.2% of first year medical students are transgender.

However, the opening anecdote is the only time that the article alludes to the reactions of patients. In this instance, the patient was scolded for being transphobic. Should patients be counselled about their transphobia? What happens if they persist in their bias? Should they be denied treatment or told to go to another hospital?

The problem is not new. Healthcare workers from different race or ethnic backgrounds have to cope with racism. Earlier this year a British hospital launched a “red card to racism” campaign. After a verbal warning and a “yellow card,” vocally racist patients get a “red card” and treatment is withdrawn.

Medical ethicist Daniel Sokol commented in the BMJ that zero tolerance may not always be the best strategy. “The General Medical Council’s duty to ‘make the care of the patient your first concern is not absolute and should be balanced against the moral and employment rights of the clinician to be free from racism in the workplace. However, a patient’s racist behaviour should not automatically lead to a sanction or abandonment at a time of medical need.”