John Green, 33 year-old Caucasian male

Introduction

            I was assigned to case study 1. The patient in the case study is a 33-year-old Caucasian male who presents to the office to establish new patient care. The patient is a transgender male who transitioned two years ago and fully transitioned with family and socially last year. He had just moved back home to live with his parents after he felt his health was declining, as he had become very weak over the last few weeks. He is unemployed and worries about being a burden to his parents. He has been obtaining testosterone from the internet for the past three months. He has smoked two packs of cigarettes daily for the last ten years and smokes 3-6 marijuana joints every weekend (active green card). He has depressive episodes. He has been HIV+ for the last three years and is virally suppressed demonstrated by his last blood draw six months ago. He takes Biktarvy once daily, which he receives for free via mail. There are several culturally sensitive factors to consider for this patient.

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Patient-Specific Cultural and Sensitive Factors

To begin, the patient is a transgender male. Transgender individuals have no history of having good experiences with healthcare professionals. A qualitative report conducted in 2017 demonstrated that 45.7% of transgender and gender non-conforming patients within the emergency department witnessed medical personnel gossiping, mocking, or telling jokes (Mehta & Warner II, 2021). A zero-tolerance policy for these behaviors must be enacted and practiced in all healthcare facilities if effective and safe patient-centered care is to be delivered.

The healthcare provider must begin the health assessment interview by addressing the patient with their preferred pronoun; it should never be assumed, and the healthcare provider should directly ask the patient how they wish to be addressed (Ball et al., 2019). Beginning the interview this way demonstrates to the patient that their needs are at the forefront of the clinician’s treatment plan. It is essential that the patient feels comfortable and confident with their healthcare provider and plan of care for effective patient outcomes. The prudent healthcare provider should know that transgender individuals have higher unemployment rates, poverty, homelessness, discrimination, psychological distress, HIV infection, substance abuse, suicide, and violence (Mehta & Warner II, 2021). These topics should be discussed during the initial meeting and regularly followed up on.

There are high rates of uninsured transgender individuals or a lack of coverage for transgender-related services (Mehta & Warner II, 2021). The healthcare provider should discuss insurance coverage with the patient, especially since he is unemployed and recently moved back in with his parents. It may be necessary to guide the patient to the local Department of Health Services office to inquire about public assistance. The healthcare provider should also inquire about whether the patient expects to continue receiving his testosterone and Biktarvy through the mail and whether these will continue to be offered for free to the patient. It may be necessary to provide the patient with drug discount coupons. The patient has been feeling weaker over the past couple of weeks, and a more thorough assessment of medication habits is warranted. The patient should be asked if he has been taking the Biktarvy as prescribed. It is possible that the patient is not taking Biktarvy as prescribed, which could lead to the patient being weaker. It is necessary to determine who is prescribing and dispensing the testosterone and Biktarvy for the patient to assess for authenticity and accreditation. Obtaining new labs to assess whether values have changed is also essential.

The patient is prescribed Biktarvy, an antiretroviral medication for the treatment of HIV. Antiretroviral medications can cause adverse effects on the liver, including idiosyncratic reactions, direct cholestatic injury, mitochondrial dysfunction, nonalcoholic steatohepatitis, or isolated hyperbilirubinemia (Parmar et al., 2023). Therefore, ordering liver functioning labs would be necessary when diagnosing the patient’s cause of weakness.

The patient is HIV+, another sensitive issue that the provider must discuss with the patient. Though the patient in the case study is a transgender male, transgender women have a 34.2 times higher risk of HIV infection than the US population (Stevens & Fajardo, 2021). This data is vital to this case as it represents the transgender community and demonstrates how this population is particularly vulnerable. Due to previous poor experiences, the patient may be hesitant to share intimate details about his sexual history; however, the provider must inquire about these details to assess the patient’s current risk status. Building a solid rapport before this conversation would likely aid in a more productive conversation. The provider and patient must come to an agreed-upon treatment plan to manage HIV+ sensitively.

Targeted Questions

How would you like me to address you? What is your preferred pronoun? Is there any information that you feel uncomfortable discussing?
Tell me about your lifestyle prior to moving back with your parents.
Where did you live? Did you live with anyone? Was the location in a safe place?
What did you do for work previously? Do you plan on searching for employment while staying here?
Where do you obtain your prescriptions from? Do you know the prescriber of the medications? What pharmacy do the medications come from? Will you continue receiving the medications for free, or do you need assistance?
What is your relationship status? How many partners have you been with? Is your current partner aware of your HIV+, and do they regularly get tested?

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Mehta, A. H., & Warner II, D. M. (2021). Identifying and addressing barriers to transgender healthcare: Where we are and what we need to do about it. JGIM: Journal of General Internal Medicine, 36(11), 3559–3561. https://doi.org/10.1007/s11606-021-07001-2Links to an external site.

Parmar, K., Mekraksakit, P., Nugent, K., & Nichols, J. (2023). A possible case of bictegravir-associated severe unconjugated hyperbilirubinemia. AIDS Research & Therapy, 20(1), 1–5. https://doi.org/10.1186/s12981-023-00501-7Links to an external site.

Stevens, G. A., & Fajardo, F. J. (2021). LGBTQ+ health research guides at North American health sciences libraries: A survey and content analysis. Journal of the Medical Library Association, 109(3), 406–413. https://doi.org/10.5195/jmla.2021.1189Links to an external site.