Dual Relationships in Specialty Care: Reflections from the Field

Introduction

The creation of the Oregon Health & Science University (OHSU) Transgender Health Program (THP) was a grassroots effort involving transgender and gender nonconforming (TGNC) community members, local organizations serving the TGNC community, clinicians, administrators, and researchers. The THP, which launched in January 2015, offers comprehensive, affirming, and competent healthcare to TGNC individuals across their lifespan. In 2015 the THP had over 500 referrals for TGNC patients and in 2016 that number grew to over 1500 referrals.

Amy Penkin is a cisgender, LGBTQ community member and licensed clinical social worker who was hired as the THP Program Coordinator in 2015. Her duties include, but are not limited to, workforce education, assisting patients with healthcare navigation, TGNC policy development, clinical alignment of departments offering gender affirming care, and community engagement to ensure program development and services align with community needs. During the first year Amy also helped establish a THP Volunteer program to ensure the program continued to involve the voices of the community the program was serving. That program has also created opportunities to teach TGNC individuals about how to lead trainings for healthcare settings and providers about TGNC patient needs; thus, providing jobs and revenue to a community that faces disproportionate under/unemployment.

Dr. Lewis Raynor is an epidemiologist and a TGNC community member. He works as an Investigator at OCHIN and has affiliate faculty status at OHSU where he is helping build a program that addresses the healthcare disparities faced by sexual and gender minorities. He attends THP monthly meetings where he discusses what he is doing professionally; in addition, to providing his own community–based perspective on how the program can best serve the TGNC community.

Amy and Lewis have had many conversations about the overlap in identities and relationships with regards to the THP. Amy contributed to the creation of the THP and serves now as the program supervisor, but she also is a community member with personal ties to the TGNC community of Portland, Oregon where the THP is based. Lewis is a researcher that works with providers serving the TGNC community, but he is also a community member that advocates for improved healthcare access and utilization for community members in addition, to using the healthcare system himself. Lewis’ recent utilization of healthcare at OHSU forced the both of us to move beyond abstract conversations to intentional ones around the ethical dilemmas our roles with each other and the systems we work within create. We believe that the issues we raise in this essay are experienced by other individuals that work with and coexist in small communities, and we hope this work will help guide other individuals from smaller communities in their attempts to bridge roles.

Program Supervisor and Community Member Amy Penkin’s perspective

The THP program has experienced rapid growth since its onset and the success of this program would not be possible without the continued involvement of and relationships among community advocates and organizations, patients, clinicians, and administrators. What I did not anticipate were the ethical issues that have arisen around my involvement in both the administration of this program and my membership in the community it serves. I have found that it is not unusual for me to engage with an individual who has overlapping personal and professional roles as a colleague, volunteer, community collaborator, friend, family member, and/or patient.

In April 2016, I was contacted by a close colleague of mine from an OHSU clinic who called to discuss a patient who came to the clinic for a consult regarding complications from a surgery received from a provider in another state. My colleague reported that the patient left before completing his appointment and appeared to be distressed, uttering a statement that was construed as a threat of self–harm. The patient’s name and medical record number was provided, which led to the discovery this patient is an academic colleague, collaborator, and a personal friend, Dr. Lewis Raynor.

The context in which I met and built a relationship with Lewis was collegial and often informal. I knew he had encountered barriers to navigating...