The medic making a difference to the care of trans patients

Medical students are taught about some of the rarest diseases, yet do not learn something as important as how to care for trans patients.

This needs to change, says intensive care specialist Luke Flower, whose work to improve their care has been recognised with an international award.

Shortly after leaving medical school, as a junior doctor Luke Flower encountered a transgender man who had been admitted to one of his wards. The response of his colleagues was disappointing.

“Everyone seemed to find it so awkward discussing their gender, who they were, how to ask them,” he recalls. So he did what none of the consultants seemed able to do. “I said, ‘Hi, I’m Luke, what are your pronouns?’. Their face suddenly lit up and we had this really nice conversation.”

Pronouns, for those unfamiliar with their significance, reflect how we identify our gender identity – and how we wish others to recognise it. A trans man, for example, may prefer the pronouns he, him and his, while many gender non-binary people use they, them and their.

Luke accompanied the patient as he was transferred to a new ward. There, the nurses seemed confused, insisting to Luke that this was a male ward, for men. Eventually Luke took the lead nurse into a side room and explained that this patient was a trans man – in other words, male – and the recommendation was that he should be placed on a male ward.

It was obvious to Luke that the patient could tell what was happening. Luke apologised, but says “the saddest thing is they were like, ‘Oh, no, this is normal. This is what I expect’.”

Fortunately, despite their resignation at the familiarity of the situation, the fact that Luke had taken time to ask the patient their pronouns and was now using them helped improve their experience significantly.

“What amazed me is that all the complex medical things we do for patients, it’s simple things like that that make a difference.”

Luke is a trained medical doctor specialising in intensive care. He is currently taking time out of his medical career to study for a PhD in acute hypoxaemic respiratory failure under Professor Charlotte Summers at the Victor Phillip Dahdaleh Heart and Lung Research Institute, Cambridge. On 9 January, he was awarded the inaugural Kathleen Ferguson Award for Inclusivity by the Association of Anaesthetists ‘in recognition of his work with a range of NHS Trusts to improve awareness and understanding of transgender patients’ healthcare needs’.

Luke Flower receives his award from Dr Kathleen Ferguson (Credit: Association of Anaesthetists)

Luke Flower receives his award from Dr Kathleen Ferguson (Credit: Association of Anaesthetists)

Luke says he became interested in equality, diversity and inclusion (EDI) due to his own personal situation. Although he is a cis-gendered male (that is, someone whose gender is the same as their sex assigned at birth), he is also gay. He trained at medical school in Bristol, where he was not out about his sexuality, only beginning to open up once he moved to London.

As anyone who identifies as LGBTQ+ will tell you, coming out is not something you do just once in your lifetime. For Luke, it was a decision he had to make every day, “especially if you're working in anaesthesia, when it may just be you and the consultant for a whole day and it's this decision at the start of the day: is this the kind of person where it can be very awkward if they ask about my girlfriend?”

He became involved in the Intensive Care Society, which was beginning to recruit for an working party look at EDI matters.

“I thought it’s all or nothing, so I threw my hat into the ring!”

In 2021, he hosted a webinar for the Society as part of its Pride celebrations, which asked the question: how can we improve the experiences of LGBTQ+ staff and patients in ICU? One of the speakers was Dr Kamilla Kamarudin, a transgender GP and activist. Luke describes himself as being “blown away” by her story and shocked that he hadn’t heard more about the issues she, and those like her, faced.

Luke decided to organise a session for the Intensive Care Society’s National State of the Art Congress on the care of trans patients in intensive care and anaesthetics, and began looking for data or published research on the topic. He was shocked to draw a blank.

Together with Dr Stuart Edwardson from NHS Lothian, he decided to address this, organising a webinar for the Association of Anaesthetists on improving peri-operative care for transgender patients (that is, care for before, during and after surgery), with speakers from the USA, Australia and the UK.

Three hundred people signed up for the webinar. Registrants were sent a short survey, the first question of which asked what they hoped to get out of the webinar.

“We did have some not very nice comments before, which surprised me,” he says. One anonymous respondent replied I want to know how I would be able to get out of care for a patient. Another said I would refuse to care for a transgendered patient.

“I think if anything that inspired us a bit more to do it!”

Before the session, attendees were asked how confident they felt in caring for trans patients – the average score was 3 out of 10. Afterwards, they were asked the same question: the figure increased to 8 out of 10.

Luke followed up the webinar by co-authoring – together with Stuart Edwardson and trans colleagues – a paper in the Journal of the Intensive Care Society looking at the care of trans patients in intensive care. It went on to become one of the journal’s top trending articles of the year and was selected by the Editor-in-Chief as Article of the Year.

“What a lot of people were surprised by is that you just don't know what you don't know. There's a lot of things that are very relevant for the care of all LGBTQ+ people or specifically for trans people, and we're just not taught about it in medical school. We're taught in great depth about very rare diseases like acromegaly, but not something as simple as looking after a trans person.”

One example he gives is around airway surgery, a procedure that some male-to-female transgender individuals undergo to help change their voice. This can have implications for how the intensive care team inserts a breathing tube if the patient needs to be on a ventilator, but because many trans people choose to have this procedure done privately, it may not be in their medical records.

“When you care for these patients, it doesn't matter what your viewpoint is, you're going to have to care for them. You have to have a big enough understanding of the specific healthcare needs of that person to be able to adapt to them.”

Luke says the nicest piece of feedback he received was from a patient in Spain who got in touch to say that they happened to have read the article ahead of an operation and gave it to their anaesthetist. It resulted in the anaesthetist changing their entire peri-operative plan.

Following on from that, on behalf of the Association of Anaesthetists, Luke and Stuart created the first ever guidelines for the care of trans patients in the peri-operative period, which were published in 2024.

Some of these guidelines are technical, for example, around carrying out an airway assessment or navigating a patient’s hormone therapy. Others are practical, such as around chest binding, where some trans men or gender non-binary people use tight strapping before or instead of breast surgery, which may need to be removed in order to ventilate the patient.

But it’s the “really simple stuff” that he thinks is among the most important part of the guidelines – such as understanding and using the correct pronouns.

“It's very easy to do it and it can make a huge difference. If you're in intensive care, you are probably terrified. It's one of the worst periods of your life. Everything's going wrong. The last thing you want is for someone to be continually misgendering you or making you feel uncomfortable.”

There are also challenges around patient privacy, “understanding who they're out to, who they're not out to, being an advocate for the patient when they might not be able, if they're in a coma for example.”

Luke is currently working on a joint project between the Intensive Care Society and the Faculty of Intensive Care Medicine to develop guidelines for the care of trans and gender-diverse patients in intensive care. He speaks regularly at conferences and to universities and NHS Trusts and is pleased with how willing most people are to engage in the subject. On 6 February, he is chairing a session on trans care for the Royal College of Anaesthetists at one of its national conferences.

“The nice thing about having [platforms such as this] is that people will take it seriously because it's coming from the Royal College.”

He is now pushing for care of trans patients to be part of the curriculum for intensive care doctors and anaesthetists. “We have so much to learn for these exams that, understandably, sometimes people don't read outside [of the curriculum], so it would just mean that people will routinely learn it and they'll think, well, this is something I should know.”

Transgender male patient being examined in hospital - stock photo (Credit: rparobe)

Transgender male patient being examined in hospital - stock photo (Credit: rparobe)

Because of the stigma and lack of understanding surrounding trans issues, it is perhaps unsurprising that many trans people have negative experiences of healthcare. A survey by the organisation TransActual UK found that 14 per cent of respondents reported being refused GP care because they were trans, while a staggering 70 per cent had experienced transphobia from their primary care provider.

“A lot of times people have probably lost confidence in the healthcare system. We need to try and rebuild that confidence and say to them, ‘As a community we are here to help you’.”

He acknowledges that it won’t all be plain sailing and that there will always be challenges when you are trying to change systems. Trans rights are often politicised and there can be pushback among the wider society, but, he says, as researchers and clinicians, it is their job to understand the science and understand their patients.

“People are always a little bit scared of change, especially when it's something as politically charged as LGBTQ+ health, and specifically transgender health.

“But at the end of the day, these are our patients, and we need to give them the best care possible.”

Published 3 February 2025

Main image by Nick Saffell

The text in this work is licensed under a Creative Commons Attribution 4.0 International License