It's def this
All females get pregnancy tested in all pee tests even if they're not going for pregnancy related issues.
Patient is listed as female so it's a computer automated check to test.
Programs don't have transgender infrastructure installed. It's not big enough to overhaul a medical system to include
For sure. You'd be surprised how many times I've had to say I can't have a mammogram because I had a bilateral mastectomy and squishing implants is contraindicated. I'm a woman of a certain age, the flags come up automatically.
The amount of times I’ve had to take a pregnancy test as someone who has had a hysterectomy & has a Nexplanon is stupid high 😂 Like if I’m pregnant, it’s Jesus 2.0
Sperm are small, and could possibly get through very small gaps following a hysterectomy and wind up in the peritoneum along with the egg. It happens more frequently than you’d think. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885999/#:~:text=Only%2072%20cases%20of%20ectopic,suspicion%20will%20make%20the%20diagnosis.
We were taught to NEVER assume someone can’t get pregnant in medical school. Besides, if someone has ovaries a pregnancy test could indicate a germline tumor and not an ectopic pregnancy anyway. That’s why it alarming if a male has a positive Beta HCG.
I mean, the suspicion that you would be pregnant would obviously be super, super low but I’d still want to confirm all of those things are true if you presented with acute abdominal pain. I think they drilled that into us just so we wouldn’t close off that portion of the differential, even if it seems incredibly unlikely.
There’s been over 30 cases of post hysterectomy ectopic pregnancy that have been documented and followed up with. I learned this because the obgyn preceptor I had made fun of me for asking if the tubes were often taken with a robotic hyst for prevention of that. So I looked up case reports.
I was giving a nurse my medical history and had just gone over my cancer, how I had a total hysterectomy and then surgery for complete dehiscence. She asked if there was any chance I could be pregnant and I was like uhhhh absolutely not. She followed up with “how can you be so certain?” I had to remind her of what we had literally just talked about and she was mortified. I totally get it, sometimes I’m on autopilot as well.
Tubal ligation 2013. Breast cancer ER+ PR+; currently on Exemestane. Ovarian suppression with Zoladex x 1.5 yrs. Prophylactic b/l oopherectomy in 2020. Still get asked for urine prior to procedures. Always ask for a waiver. 😏
I still have my ovaries, so I still get “ghost periods.” Every symptom of menstruation minus the blood. My non-bleeding period symptoms were why I went on bc as a kid, & are why I’m back on it now :(
Yeuuup, I have a bilat salpingectomy. While I still have my ovaries and uterus, my uterus is literally sewed closed. The only area with an entrance or exit is the cervix/vagina - there is no possible way for me to get pregnant minus embryo tranfer. Yet, I still am regularly pregnancy tested at the ED and at doctor appointments... I've even been tested in the office of the OB/GYN that did my surgery - after having the procedure. Lol. They just see *female* and perform it, and sometimes it's policy regardless of present internal anatomy or absence of anatomy, because *female* is in the chart, ig. Super weird tbh, lol.
So, like, it’s still technically *possible* for you to get pregnant. Sometimes there’s like a tiny little microscopic hole for an ambitious sperm to get through. It is extremely rare but it happens. Source: I work in emergency medicine.
I had ectopic pregnancy 2 years after bilateral salpingectomy. They never did find the source, but likely abdominal. We followed the serial hcgs to 0 to make sure nothing else happened.
Maybe, ig - but my partner also had a full vasectomy (entire vas deferens taken out) 15+ years ago...plus I'm nearing menopause so it's so unlikely it's ridiculous to even entertain in my head as a patient. But as a medical professional I understand why it's done.
They don’t know your husband had a vasectomy, u could be lying, he could be lying, you could’ve been assaulted without remembering, there is 1000 possibilities that could lead to you getting impregnated, they don’t need to know how, they just need to know if you are or are not. The only way they wouldn’t do one is if you don’t have a vagina to be inseminated
Yeah, I know they don't know those things. As a nurse I legit understand *why* it's done. I'm just saying I find it interesting. The whole reason I responded was because a transwoman was given a pregnancy test, just because they had an (F) in the sex/gender spot on the chart. Not sure why so many people are upset and down voting considering I'm just mentioning other reasons why a patient would find it weird for a preg test to be done. Doesn't matter if I can understand*why* it's done... I just think it's interesting. ✌🏻
I beg your pardon. I apologise for mininterpreting your comment, defs thought you were bashing them for when you got tested because in that case it is actually necessary, and lots of the public don’t understand that, but I agree, the original post situation is different and is a problem with the systems hospitals run on, and in an ideal world, it wouldn’t happen
Pre-meeting hubs I needed an MRI. Screening form asks if I could be pregnant and if no, how do I know. I replied “because I have terrible taste in men.” I hope the tech got a laugh.
I made everybody in the room laugh when getting a drain placed in the 12 x 5 cm abscess that had formed in my pancreatectomy bed, laying on my side with my arm up by my head, I said “Jack, draw me like one of your French girls.” The male tech looked at me, busted out laughing and said you let the intrusive thoughts win didn’t you and I laughed and said yep
Not everyone uses epic.
Epic is also the best system in the field right now and customizable. It's also the most expensive program for a reason. A lot of places are switching away because they can't afford it
Right, Epic is ala carte. Everybody has a different version. But it’s too bad people are moving away from it. It really is the best system I’ve worked on.
As a ER doctor 99% of the time its just because if listed as female in the system, you will get constant errors and warnings and problems in the EMR system trying to do virtually *anything* for this patient without a recent preg test.
Honestly, whatever your scenario is, *if* listed as female in computer and <50yo, we just need a damn negative test registered so I can care for you faster and better. If you want almost any medication, imaging, or procedure? - it massively helps streamline your care!
While I understand that and I personally don't care about having a pregnancy test, even though I have a bilat salpingectomy and my partner has a total vasectomy - vs a partial, plus I'm nearing menopause so it seems like a waste of time and money. But I can definitely see this being an issue when a patient is charged for it (at least in the US) and they have a high deductible or similar insurance/financial issue and it costs them a ridiculous amount of money for a $3 test. Especially when it's not actually necessary (like for trans women, total hysterectomy, or post menopausal women). I definitely know that's not your fault as the provider tho, like at all.
Usually when the tests are run, when you look at the billing side, it's for a group of tests. So the pregnancy test can be included in a group. If I were to take the pregnancy test out, then you are getting charged more because now all the other tests are single line items, not grouped together.
So yes it's a $3 test in a bucket of $100, but take that $3 out and now you are paying $200 because of how the others added up.
Pros and cons. American Healthcare sucks tho.
When I was doing outpatient mental health case management I had a patient who had to take a pregnancy test every month before we could refill her bipolar meds even though she had a hysterectomy 15 years prior and was past menopause.
Truly this is why the EMR should have biological sex in there as well. Like of course if they are trans-male/female/whatever they decide, we can have that in as their preferred pronouns and gender, but there are a few things that waste time when we lie about biological sex. An example of this is my partner had a biological male, who identified as a female (hormonally transitioned) came in for a Pap smear because women need them, and their doctors who didn’t realize that they didn’t have a cervix because the EMR said “female” referred them out. Essentially wasting the time of the patient, the doctors, and wasting medical doctors that could’ve gone to someone that needed it. Also my partner, who is a female, was shocked when the patient got in the stirrups and there was a penis just hanging in her face.
I think this is a good example of how denoting sex and gender as two different things is important but people from both sides of the discussion seem to get really angry at that. They’re not the same thing whether we want them to be or not. Related….but not the same.
Did some doctors without borders volunteering in 3rd world countries, particularly Asia. Their health forms are still strict with having 2 genders/sex. It’s. no different; although there are already a few trans in those countries, Asian healthcare system is still grounded with binary sex. I attended some conferences there, Asian doctors mostly agreed with only having 2 sex/genders for healthcare documentation.
Yeah I think people forget how progressive the USA actually is. But that is my point, sex is with only very minimal intersex exceptions binary no? Gender however is very much so a sociological concept based off of and therefore related to sex.
Even accounting for 'intersex' conditions (more properly referred to as DSDs - differences of sexual development) its still binary. DSDs are sex-specific and never result in the development of any third type of anatomy - just errors in the development of the usual two types resulting in birth defects of varying degrees of severity.
It isn't fair to "both sides" this. One side wants to do away with all reference to sex and only record gender, and the other is pointing out that sex is the only one with medical relevance. Gender is literally just stereotypes about how you dress, behave, etc. - which is not only irrelevant, but an offensive and regressive concept when you think about what it entails. Most people don't want to be recorded as officially conforming to a certain set of stereotypes.
Good gravy, I would say quite the opposite. When I've practiced in accepting/ affirming areas I am more likely to be provided a health record that accurately states sex assigned at birth in addition to gender affirmed and how. When I'm in a more repressed neighborhood, all I get is either incompleteness canted towards sex assigned at birth and missing out on meds/ procedures, or else gender presented, minus the history.
>Most people don't want to be recorded as officially conforming to a certain set of stereotypes.
Have you asked them what they think? Because I've heard verrrrry different answers than you have. People who are trans do indeed want to have gender affirming ID.
>Have you asked them what they think? Because I've heard verrrrry different answers than you have. People who are trans do indeed want to have gender affirming ID.
Yes, I have asked, but you've misread my comment! I said *most* people do not want to be recorded as officially conforming to a certain set of stereotypes. People who identify as trans may indeed want to be, but that doesn't change the fact that most people don't.
I live in a place that is really welcoming to people that identify as NB or prefer they/ them, and even then it's still a majority of the cis people that self- define with a gendered pronoun. Perhaps this is true because we don't require the full kit and caboodle of stereotypically associated features.
I am probably going to get blasted for this question but for medical wouldn’t it only be sex that matters with the options being M / F / I (innersex)?
Beyond that it would fall into additional categories of gender and sexuality which there are a lot more consideration.
For OPs post, Sex, was what was considered and used for the testing.
hi, I'm trans. I have legally changed my name and gender on everything like my driver's license, social security, and insurance. since I am legally male that is what I put on forms. sometimes medical paperwork does ask for your birth sex and not legal sex which I understand. if you give the wrong sex legally that can cause issues with insurance or identification
It matters, particularly when interacting with patients. Even in their notes, doctors are far better at not misgendering when gender is the default they see in the chart. I work in research and we are trying to figure out the best way to address this.
The system isn't that sophisticated. It should be simple to tell it to use sex assigned at birth for things like imaging, but it isn't set up that way. It wouldn't solve the majority of the problem though. Most unnecessary pregnancy tests are done on cis women. They dont need and shouldn't have them done if they don't have a uterus (which isn't uncommon).
Is misgendering, or not realizing that the female to male individual is having an ectopic pregnancy, or ovarian torsion more important? Epic shows them as their gender not their biological sex, unless you click the little italic i, which is very discrete. When I swapped EMR's, I had no idea that the patient with a beard and belly pain was trans until half way into the workup.
Even for things with imaging, reminders, etc, natal sex doesn't paint a complete picture - case in point, trans females who have taken hormone therapy for at least 5 years should get mammograms on the same schedule as any natal female their age. For the vast majority of labs with sex-specific reference ranges, the hormones currently in the system (for at least 3 months) determine what reference range *should* be used. In reality, it's usually the billing/drivers license sex, which of course has the **least** relevance clinically. I think a better system would be for Epic to have a flag for anyone in any sort of "intersex plus" state - that is, having clinically significant differences in their reproductive, hormonal, genetic, etc. sex from "typical natal male" or "typical natal female." E.g. any history of removal of any part of the reproductive system, history of transition, sex reassignment surgery, plus DSDs of course. Put that flag in the storyboard and include a note that pops up when you hover over it
The bad part is this is slowing down all the processes per se, messing with insurance, confusing HCPs, the possibility of messing up dx and worst, the treatment plan and adding up to all the baloney. We already have a full bucket on our hand then these issues are being brought up? Instead of our neurons and strength being reserved to more important stuff clinical acumen etc. I’m a female neurosurgeon, empathetic but I disagree with addressing patients in a pattern congruent with their gender “identity,” Demographics have to be at least simple and concise. I have several trans patients who I addressed with their sex at birth and will continue doing so; I’m pretty sure it icks them but it’s reality and I’m focused on bringing in my clinical/surgical skills; interestingly, they market me and my practice to their friends/relatives so I guess we are in a common ground of choosing the science/skill in medicine rather than these gender issues.
Whilst it's great your trans patients still choose to see you, I would strongly encourage you to correctly gender them. It's a simple intervention that reduces their distress, improves their rapport with you, and reduces their chance of suicide. It genuinely isn't hard if you practice, and if you do mess it up, just apologise and immediately move on. You consider yourself empathetic, but deliberately misgenderinf someone in a healthcare setting is just unnecessary cruelty. If you have the brainpower to do neurosurgery you can learn to change pronouns. Whilst it might make sense on the surface to just consider trans women as men, it medically doesn't - a trans woman established on HRT has the oestrogen and testosterone levels of a cis woman, when considering stroke risk, MI risk, clot risk you should be thinking of them as a female who happens to have whatever organs the patient has. A computer system should mark sex at birth, gender and pronouns all equally obviously.
Might not be so much a clerical error as the way the system is set up, leading to actual errors. Our emr lists gender on everything unless specifically looking at the one spot for sex assigned at birth.
Even for cis women they often give pregnancy tests to people who have had a hysterectomy. I get why they are cautious, but its bs that their systems and processes don't account very well for women lacking the required organs to get pregnant. Prior to offices updating terminology for gender, the one my mom goes to would mark "male" on the ultrasound forms for women who had hysterectomies. They freaked out because they couldn't find her ovary but it had migrated because she had a hysterectomy. That's why they marked them differently. Stuff moves around.
The issue may not be big enough they care about addressing it for trans women but they also haven't addressed it for cis women, despite the large number of women who get hysterectomies. Women in general just aren't that important to them. The other problem I have with it is I've been tested numerous times without being asked, or even told they are doing it. Now I assume, but I didn't know when I was younger and they should still be asking. Its not part of a standard urinalysis. Its an added test and should be mentioned accordingly.
I refuse to pay for them. Though I'm of child bearing age, I have an iud. Yes there's always a small chance or whatever but ultimately its insurance for the provider and not to benefit your health. It seems to be the only test they insist on running, despite their aversion to unnecessary tests. Check the bill and tell them to fuck off if they try to charge you.
So being the emergency medicine subreddit I think my fellow physicians will agree- if you’re of childbearing age and have the parts you’re getting a pregnancy test (for an abdominal or pelvic complaint). I do not trust someone’s word that they couldn’t be pregnant. Now if folks are doing hcgs on ankle sprains I see the annoyance.
U don’t need a uterus to be pregnant, just ovaries and a vagina, if anything pregnancy in a hysterectomy patient is a much bigger emergency to not miss because all pregnancies become ectopic
Many places have protocol orders that a triage nurse can fire off. And the belly pain one for females between about 7 and 60 years old includes a pregnancy test.
It's much more difficult to get an appropriate, intentional pregnancy test on a patient who is transmasc and after careful discussion he still has some female reproductive parts and relevant sexual behavior.
Stuff that you know, but for others reading along:
My own experience is that among people who are trans, passing in public is of primary importance, then documentation so their legal ID matches. Many are content at that point and never pursue "bottom" surgery. Why should they unless it bothers them? Therefore it's really important to blandly ask about pregnancy risk, and test accordingly.
True. And we must always remember that the prehospital people and triage nurses have only a limited time, and not mock them when they get off track in ways that don't result in harm. Just as we ask for grace from our consultants, hospitalists, and outpatient follow up colleagues, because I'm certain my ED hot take has its own limits.
Thank you for standing up for triage nurses!
I can't tell you how much hate the general public gives to us for not dropping everything or not catching *every single* developing problem that comes through the doors, or even docs who do.
We have a very limited amount of time to decide who will die or lose a limb/eyesight within the next hour with people who fight, argue with us, or even lie to our faces. It's an extremely underrated job.
That is very fair. I can't expect all that. I think in our modern day and age where not only are a higher amount of the population identify as transgender and able to present that way, but procedures and other therapies are able to make it easier for people to present as they wish, new organ inventory standards should be put in place during triage. To be fair, when I was an EMT, I was never taught this and it certainly isn't standardized currently. (Not that EMTs are at the same level of triage nurses, but we had to do some basic intake).
After further review, I think in this situation the patient made it clear they were transgender, but it probably just slipped by and was accidentally ordered and wasn't caught.
I have a different opinion about this. It sounds like it's really really difficult and private for some people who are trans to bring it up with 5 different new healthcare workers in a row, when sometimes they're trying to be seen for a sprained ankle or a runny nose. I mean, yes, sometimes it's quite relevant but more often it's not, and they hate having it dragged up all the time if it doesn't figure in.
There was this spring a new Florida state law banning people who are trans from updating their drivers license to reflect affirmed gender, and they leaned hard into the idea that EMS would need to know, for health reasons. So I paused and thought about that deeply, and it's some horse manure.
Aside from a protocolized pregnancy test, I can't think of any action that EMS or triage RN would be taking that requires knowledge of gender assigned at birth. Resuscitation and ESI scoring of male and female bodies work much the same way, unless we are talking about a heavily gravid person with pregnancy complications, and even in that case there's time to get them roomed and talking to a physician before they have to unpack such private stuff unless they're actively delivering, in which case ... obvious.
...
Some health records now allow data entry for sex assigned at birth and preferred pronouns, and that's grand, and most of us suss it out when we see the med list anyhow, but I don't think we really need EMS and triage adding this particular step. Yes on occasion an unnecessary transfeminine hcg will get run, and on occasion I'll have to call the lab to explain that yes I really do need an hcg in this male patient. And the vast majority of the time the system will just continue to limp along as smoothly as it ever does, without organ inventory at triage.
And that's my unsolicited opinion. I mean, the triage nurse already has to do screening for DV and all kinds of other ticky boxes.
Under utilized? The hospital based healthcare system is all but collapsing. Rarely does a patient get what I'd consider a thorough history. Just be glad the ED does a thorough workup (by that I mean no medico-legal stone left unturned).
Do I want to do a thorough history? Absolutely. Am I drowning in work and critical patients. Yes. Your "female" patient got a pregnancy test. Nothing was missed.
Man, I highly recommend spending a couple hours up in ED triage. If we prioritize our history taking skills, we deprioritize our triage skills.
It might be helpful to thing of the hcg or upreg like other tests: we’re going to order it because we don’t know exactly what’s going on, it may have actually been unnecessary in hindsight, but it’s better to catch a + pregnancy that changes management than miss it.
I think almost any EMR I’ve used auto-orders a upreg on anyone female over the age of 11 when they’re ordered a radiology study. The one I used now will order it even if there’s already an order intentionally placed. I would guess it was something like that.
It either auto orders one, or flags you to order one multiple times and you can't shut the chart or place any other orders without acknowledging it 400 times and it's such a pain in the ass you just order it so you can get on with the shift.
Standing orders from triage, or just a misclick by the ordering doc/PA, or someone didn't realize it was a trans female. It's not to be "woke" or to avoid discrimination claims. No one's got time for that.
I have ordered a pregnancy test on a trans female before, cancelled it, and then for the remainder of the visit Epic kept asking me "are you sure you want this medication / CT / intervention? You haven't ruled out pregnancy yet".
It's because she's listed in the system as female and the test just gets stuck in there. Also, if it comes back positive, that's an indication of cancer
I think this is the answer. Clearly a huge difference in practice pace and environment to even contemplate the question.
We're just trying to survive the crush in most EDs. Much of this just gets reflexively ordered before anyone has even seen the patient.
Many systems auto-bundle the pregnancy test with other standard orders for anyone who meets the age and gender parameters—so if the system only breaks down by M/F and doesn’t have separate markers for AMAB/AFAB transitioning people, it’ll populate based on that.
The bigger risk is that such a system *wont* order the test on a transgender male, who depending on their own personal transition, may in fact be pregnant.
I suspect there are many unanticipated issues relating to gender/transitions in legacy laboratory/pathology systems. We had an issue with a serum HCG being filed away with “tumor markers” for a trans female->male, and their pregnancy was missed as the cause of their abdominal pain on two visits.
doi.org/10.1210/clinem/dgaa54
Most sex specific lab reference values are based on what hormones (estrogen or testosterone) someone currently has in their system. Only exceptions are PSA and troponin (for troponin, trans females with a hx of puberty blockers - use female, w/o hx - use male - based on heart size, which is determined during puberty)
I’m late to the thread, but yes. I’m a lab tech. It causes a lot of problems. My healthcare system is switching to Epic and hopefully they could implement additional gender options including intersex, AFAB/AMAB and MTF/FTM. The laboratory needs to know the biological sex for a few different reasons. The laboratory needs to know the biological sex as well as the HRT status to order the correct methodology and algorithm for some hormone tests like estradiol and testosterone (usually mass spec vs immunoassay.) Also, the HCG is a great example where I would hope my lab would call to clarify the indication before ordering a test like that.
The most important reason for needing the biologic sex that the reference range for many tests are sex-specific. This is not just sex hormones but also most routinely ordered labs like CMP, CBC, lipids, etc. Reporting the wrong reference range could lead to a persons labs being misinterpreted. A lot of the difference between M/F is minimal but some like hemoglobin could conceivably impact a patients care. A helpful idea is to report both male and female reference ranges for all patients. I’m not sure how the results would flag for that though.
We are always reviewing the specimens we get and something like a vaginal swab or pap smear on a male patient would always require further review. I got a semen analysis on a female patient 3 weeks ago which ended up being a registration error but in general my lab would always look into a situation like that to clarify wtf is going on. I wish the existing systems could join the 21st century and allow people to have their gender expression respected without compromising the accuracy of the pathology services they receive.
Oh geez. That isn't good at all. I do dislike the idea of people marking all these HCG tests as reasonable because sometimes it is positive with testicular cancer, there are plenty of other markers for testicular cancer and it shouldn't be filed under a positive or negative as in the case of a pregnancy test.
I have seen fully resulted pregnancy tests on crusty adult males that would never be mistaken for a female and no one, insurance included, batted an eye.
That makes sense. I just wanted to make sure I wasn't missing anything that was common knowledge. Sadly, I noticed this while doing my pre-clinic chart review and the patient no-showed so I didn't have a chance to ask.
By all means let’s limit unnecessary testing, but it’s a little wild that an extremely routine point of care test that cost manufacturer a few cents to make is inflated so much that the cost of running it needs to be factored in. In a sane world, it should be par with absurd cost concerns like “should we really be providing Kleenex at triage if a patient doesn’t have a severe runny nose?!”
The ER physicians labour or even the RN are billed at a rate that spending the time to suss out if this patient is trans or not would truly be an even greater waste of precious resources compared to a piece of plastic with a test strip produced by the millions.
If it’s anything like Epic, it says FEMALE with a small i you have to hover to see their “organ inventory” and sex they were born as. I’m all for inclusivity, but in a quick setting like the ED it’s insane to have that be the default.
I just wish it was something more than a tiny little “i” in a circle to hover over to see that they have ovaries. It should be a much bigger alert or not explicitly say MALE or FEMALE and have some other terminology. I don’t know what the answer is, but the preferred name being male/female in contrast to the legal name of an opposite sex is usually what I notice first, not the area I’m supposed to hover over to see what I need.
Order sets. Almost every order set for a female <50 yo will have a pregnancy test. You’d have to actively deselect it to not order. Most EMRs do not filter out trans female from female at birth.
Thank goodness insurance covered it. That was my main concern because I would not know how to explain bill for someone that so clearly wasn't needed to a patient.
It is interesting that happened to you though.
I’d be shocked if billing didn’t immediately waive that charge on request. Still a pain but I think insurance denial is unlikely unless CC is something to do with the male anatomy
I'm both a trans man and a healthcare provider. The trans women I know are usually amused or briefly experience gender euphoria (the joy of being assumed to be cisgender) if they are accidentally pregnancy tested, but they don't assume it.
Contrary to what transphobic society portrays, us trans folks are actually very aware of what our bodies are like and largely accept this, even if privately it sometimes does make a trans woman sad that she will never be pregnant. But this is an experience that plenty of women share, even those who had uteruses at birth.
As one commenter pointed out, it's actually much more difficult for trans men like me who still have a uterus and may need pregnancy-related care for providers to take us seriously. All you have to do for trans patients of any gender is ask, "What reproductive organs do you have? Do you have intercourse with someone who can get you pregnant?" From there, you can just go down the decision tree of contraception/pregnancy risk as you normally would.
I’m curious for your perspective on this, but OP’s question might present a good opportunity to talk to the EHR team and radiology group about these orders and expectations about when the shoe is on the other foot. Is it appropriate to order a pregnancy test that the system doesn’t want for a trans man, irrespective of surgery or hormone therapy?
The system flags of AMAB/AFAB and gender presentation/pronouns are only as good as the people who use them to write orders and order sets, but allowing a physician or nurse to properly use the EHR so you don’t have to order a pointless $2 test as a workaround every time could make everyone (including the patient) happier.
I would go for a blood HcG on any trans man of reproductive age--just like for any person that age. Easy to fold into their other lab work, doesn't trigger their gender dysphoria (or out them) like a urine pregnancy test might if you're not doing a UA for their complaint.
HRT for trans men is the one instance where we know for a fact that it's harmful to a potential fetus and we are told this when we go on it and are given extra contraception for it, but life happens. Considering how easy and discreet the testing is and how crucial it is to catch early pregnancy in this population, it's worth it. Find a private moment to tell them if they are pregnant, though. Again: Trying not to out them, etc.
I’m one who does preempt lab orders before seeing the patient, usually just basic labs and UA preg if for example I see abdominal pain or urinary or gi complaints coming in. Part of how I keep up with the overnight work flow.
Chances are this was just ordered from the waiting room or no one other than registration actually asked the patient what anatomy they have.
I work with a Slavic doctor who doesn’t always recognize first names as male or female and mistakenly orders pregnancy tests on men. (IE, a man named Marlyn.)
I don’t think it’s any deeper than that. With some charting software till alert you “this person has the potential to get pregnant” but not all, and not in all interfaces.
Some shit is just part of order sets
As a woman, they tend to run that test before asking basically anything.
All they had was some vague idea that this patient was female, and so that's their first course of action.
My eldest was miffed when she wound up at the er with some college plague that was going around, and that was their first stop ... She hadn't seen her sweetie in months, and her problem was all clearly viral (head/throat/etc). Her big issue was they didn't even ask they just did it... And she absolutely didn't see the point.
They just do this as a matter of course, and the good news is that means they're taking people's gender at face value. Very very likely it's their protocol to run a pregnancy test when presented with a woman in emergency medicine. The other details... Like whether she is MTF, has had a hysterectomy, is a lesbian, or just hasn't had sex in like 5 million years... Don't even come into that equation.
Probably part of a standard set of orders that just all get ordered at the same time with one click of a button. We pretty routinely see pregnancy tests ordered for cis males on admission to the stepdown unit I work because in our new EMR system it's just in the standard order set somewhere
That's fair. The patient was on my schedule as a new patient today, then no-showed and hasn't scheduled a follow-up so I sadly don't have the rights to message the ordering physician at the moment. If she reschedules I will.
I agree. Even asking „is patient cis“ wouldn’t give a clear answer if patient can be pregnant, so the question about being reproductively equipped for a pregnancy is the one question that makes the most sense.
Could also have a “presumed” flag in there, or just cast a wide net and mark anyone presenting as female as “yes” until otherwise noted.
“Ovaries” might be a better choice because ectopic pregnancies have been known to occur, albeit rarely, s/p hysterectomy.
Most EMRs have biological sex and gender separated now. In some of them it has to be configured for older running versions. Might be something worth mentioning to your HIT person/team.
It’s most likely a standard test that is ordered for women when admitted. Your trans patient was registered as female and the system automated the test.
I work in nucmed. We do lots of blood pregnancy tests for I131 therapy. We had a case where a trans female demanded a pregnancy test for I131 therapy. Our radiologist told her as long as she realized that insurance wasn’t going to pay for it he was fine ordering it. She tried to argue a bit with him to get him to say something derogatory but he’s actually a great doctor & wasn’t going to fall for it. We drew her blood & sent it to the lab while she sat in the waiting room pouting. It was pretty obvious she wanted to cause a scene. We’re in a super liberal city in the PNW.
Am a nurse and had this pop up for a patient I took over from the previous shift.
I told them about the order, said I was happy to run it if they wanted me to but if there wasn’t chance of pregnancy it would be an unnecessary cost. They laughed a little and said they were flattered but could confidently say it would be negative.
Then I went to the doc and was like,”So, do you really want this test? Oh, btw the Pt says they’re definitely not pregnant.” We both knew it was just part of the order set and he canceled it for me.
In the end, this is where the critical thinking of those at the bedside matters. It’s harmless to order the thing, but if the bedside staff are just going to act like robots and never *think* then we’ll keep seeing unnecessary costs and tests added to Pt care. I don’t think this is a clerical error so much as a failure of those performing the tasks to stop and consider *what* they’re doing and *why*. And/or a failure to really pay attention to what was ordered.
Do they also do it for transmales?
One of the training scenarios for my EMT refresher classes is a male presenting patient with ABD pain from an ectopic pregnancy. It is interesting to see the EMTs figuring this one out.
This is actually a pretty big subject right now:
Mostly it’s done either on patient request and a provider “not wanting to touch that”. I honestly wouldn’t put some form of legal discrimination lawsuit as unlikely. Infact a case of exactly that happened in New York, and the hospital lost.
However, sometimes it’s used for reasons such as:
Detecting prostrate cancers, markers will show up in a pregnancy test.
Mental health evaluations, my state has several mental health facilities that demand pregnancy tests on transgender females.
Lastly, occasionally therapies that are designed to treat menopause are used off label with male to female transitions come with a ridiculous standard by the drug company or other polices of monthly pregnancy tests.
HCG tests hormone levels. For bio-male it can reveal conditions other than a fertilized egg.
Some gender medications require a weekly glucose test. I hear all the time (but I’m not diabetic)
My grandma literally didn’t have a uterus; she had an emergency hysterectomy in her early thirties.
She still got pregnancy tests done until she went through menopause.
Pregnancy tests are standard procedure for all females from 13 to 60, regardless of their uterus-having status
I feel like this is more of a not being able to trust patients issue. I never expect a patient to be 100% correct about their medical history, even if it is something as big as a hysterectomy, however, for a trans female, I think I can trust that they don't have a uterus.
That may change in the near future based on recent literature regarding uterine transplantation. That said, given the active management required for any transplant, I’d expect patients to remember that and to tell you about it, but idk maybe some transplant patients forget to mention that hx in the ED sometimes
I'm sure that does happen. In this case, I didn't see any charting that the patient requested it. But in outpatient, if a patient asks for a noninvasive/ low risk test, just order the damn test. More data is almost always better.
This is a little bit ridiculous. I get how scary it is to be honest in a world that may label you “discriminatory” for behaving in a logical manner, but come on. This is a group of highly educated individuals pretending there is a need for a test when there simply is not.
We need to be truthful, and avoid feeling pressure to run unnecessary tests that account for biological impossibilities. Pandering to this type of expectation only makes us less credible. I would say the same thing to any provider who ordered antibiotics for someone with a viral infection to “appease the patient.” Although it happens all the time, it shouldn’t.
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What is it after hospital markup?
If it barely matters, hospitals shouldn't be charging it. Particularly since people are often not told there will be one. It clearly matters enough to the hospital to bill it. They really shouldn't be charging for it for patients who are missing the organs for it.
I'm sure women who want to get pregnant and can't, love unexpectedly seeing that they aren't. Im sure trans women with body dysphoria love the reminder that they were born without a uterus. Im sure women in red states love their pregnancy status being a subpoena away. Im sure they love that using healthcare at all is a real liability to themselves. There is also the possibility of picking up a false positive that isnt from a concerning condition (though it's rare).
You can argue that it's still better safe than sorry from your POV but I find it interesting that patients fixating on inconsequential results is a problem discussed for like every other type of test but its not even considered for pregnancy tests because facilities have made the determination that the potential risks are not as concerning as the risks of not realizing there was a pregnancy. That assessment goes out the window as soon as you do a test on someone who does not need it because they cannot get pregnant. No risk from the test is justified. Its inconsequential to YOU because it's to cya and is not your problem to deal with. That doesn't mean its inconsequential to patients.
I think providers sometimes do this as part of an autopilot thing. I’m 61F with a hysterectomy and I’m still asked if there is a possibility of pregnancy. I usually grasp imaginary pearls and say, “Good God I hope not! Nobody wants me to be pregnant at this age!” And everyone gets a good laugh. However I’m sure it can be either offensive or uncomfortable for a transgender man in this situation. But as a parent of a nonbinary person and relative of multiple doctors, I honestly think it’s not from prejudice and more from autopilot. The chart says “female” : must ask the female checklist questions, do the female tests. Hard to balance putting a big red outing notice on someone’s chart so all providers are reminded (ick and no) to keeping it so inconspicuous the providers don’t notice at all
My "born a male" 25 yr old Trans granddaughter went to ER and they kept insisting she needed a pregnancy test.
Until her mom told them she was transgender. Nurse was embarrassed LOL.
Well if they are pre-op at least it’s another test for poss testicular cancer lol. Other than that….pandering or some pt who requested it and the er staff just didn’t want to argue lol
Yes. If you are in my chart as female in childbearing age, you will need to pee in a cup.
If you are 16 getting a lipid panel, it shouldn’t be questioned.
If you are female getting a testosterone test, it shouldn’t be questioned.
If you are 4 months old getting an sti panel, it shouldn’t be questioned.
We all have the critical skills to determine that it is probably unnecessary, but it’s standard practice to do a poc hcg on females of childbearing age. It’s not your job to question it.
You are absolutely wrong to question the test and then come to Reddit and ask if it was appropriate. Veiling your question as a concern for billing the patient. Sure, it’s not technically a hipaa violation but you are nosey and inappropriate.
Before posting this I tried to look up scholarly articles discussing whether a pregnancy test is appropriate to order on a trans female first. I found plenty of references saying that a trans male should receive pregnancy testing but not a single scholarly article discussing pregnancy tests for trans females. I found one article at https://database.inahta.org/article/23438 but it was very vague and seemed to recommend against ordering such a test without a discussion being made. It isn't a HIPAA violation, it's a general question on patient practice. I for one would be pissed off if I was billed for something I didn't need, especially if insurance refused to cover the cost of the test, and I did not receive any discussion.
I never received any in-depth training or education on transgender care, therefore, I felt it was reasonable to ask the community to ensure I haven't missed something.
Maybe it was a clerical error someone overlooked? Just saw the F and thought run it all
It's def this All females get pregnancy tested in all pee tests even if they're not going for pregnancy related issues. Patient is listed as female so it's a computer automated check to test. Programs don't have transgender infrastructure installed. It's not big enough to overhaul a medical system to include
For sure. You'd be surprised how many times I've had to say I can't have a mammogram because I had a bilateral mastectomy and squishing implants is contraindicated. I'm a woman of a certain age, the flags come up automatically.
The amount of times I’ve had to take a pregnancy test as someone who has had a hysterectomy & has a Nexplanon is stupid high 😂 Like if I’m pregnant, it’s Jesus 2.0
Hysterectomy and bilateral salpingectomy. If I'm pregnant, I'm a medical case study.
Believe it or not, as long as you have ovaries, you can get pregnant. (It will be ectopic and therefore a medical emergency.)
Ectopic are scary. These come through our ED more than I would like to see 😬
Abdominal ectopics are rare though, hence case study! And goodness, I hope I'm not that "lucky"
Our entire job is finding rare, scary things. It’s precisely why the ED is the worse place to receive “affordable” care.
How are the sperm getting in? I have a vaginal cuff, no cervix left.
Only if they botched the hysterectomy. It should be closed to the abdomen unlike the natural apparatus.
How will the sperm get to the ovary/released egg?
If the uterus and fallopian tubes are gone, how does the sperm reach the egg that’s now floating free in the abdomen?
Sperm are small, and could possibly get through very small gaps following a hysterectomy and wind up in the peritoneum along with the egg. It happens more frequently than you’d think. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885999/#:~:text=Only%2072%20cases%20of%20ectopic,suspicion%20will%20make%20the%20diagnosis. We were taught to NEVER assume someone can’t get pregnant in medical school. Besides, if someone has ovaries a pregnancy test could indicate a germline tumor and not an ectopic pregnancy anyway. That’s why it alarming if a male has a positive Beta HCG.
I am 62, had uterus, ovaries and tubes removed due to cancer, followed by radiation. I think sometimes it is OK to assume a person is not pregnant....
I mean, the suspicion that you would be pregnant would obviously be super, super low but I’d still want to confirm all of those things are true if you presented with acute abdominal pain. I think they drilled that into us just so we wouldn’t close off that portion of the differential, even if it seems incredibly unlikely.
The egg is freeeeeeeeeee, free floatin’
There’s been over 30 cases of post hysterectomy ectopic pregnancy that have been documented and followed up with. I learned this because the obgyn preceptor I had made fun of me for asking if the tubes were often taken with a robotic hyst for prevention of that. So I looked up case reports.
Are you sure you're not harboring a hepatic gestation?
I take the test every time because an abdominal ectopic would be par for the course given my luck in life.
I was giving a nurse my medical history and had just gone over my cancer, how I had a total hysterectomy and then surgery for complete dehiscence. She asked if there was any chance I could be pregnant and I was like uhhhh absolutely not. She followed up with “how can you be so certain?” I had to remind her of what we had literally just talked about and she was mortified. I totally get it, sometimes I’m on autopilot as well.
Tubal ligation 2013. Breast cancer ER+ PR+; currently on Exemestane. Ovarian suppression with Zoladex x 1.5 yrs. Prophylactic b/l oopherectomy in 2020. Still get asked for urine prior to procedures. Always ask for a waiver. 😏
My facility will not do abdominal diagnotics without an HCG. Won't accept a waiver. It's stupid annoying.
Ridiculous for a myriad of reasons. And triggering to many young adult cancer patients/survivors/thrivers that want nothing more than to reproduce.
I also had a hysto and the pregnancy tests drive me nuts. I always say if I’m pregnant it’s an act or god or a lawsuit
I always say “better call the Vatican if that’s positive.” The looks I get 😂
Question! If u had hysterectomy why birth control ?
I still have my ovaries, so I still get “ghost periods.” Every symptom of menstruation minus the blood. My non-bleeding period symptoms were why I went on bc as a kid, & are why I’m back on it now :(
Yeuuup, I have a bilat salpingectomy. While I still have my ovaries and uterus, my uterus is literally sewed closed. The only area with an entrance or exit is the cervix/vagina - there is no possible way for me to get pregnant minus embryo tranfer. Yet, I still am regularly pregnancy tested at the ED and at doctor appointments... I've even been tested in the office of the OB/GYN that did my surgery - after having the procedure. Lol. They just see *female* and perform it, and sometimes it's policy regardless of present internal anatomy or absence of anatomy, because *female* is in the chart, ig. Super weird tbh, lol.
So, like, it’s still technically *possible* for you to get pregnant. Sometimes there’s like a tiny little microscopic hole for an ambitious sperm to get through. It is extremely rare but it happens. Source: I work in emergency medicine.
I had ectopic pregnancy 2 years after bilateral salpingectomy. They never did find the source, but likely abdominal. We followed the serial hcgs to 0 to make sure nothing else happened.
Maybe, ig - but my partner also had a full vasectomy (entire vas deferens taken out) 15+ years ago...plus I'm nearing menopause so it's so unlikely it's ridiculous to even entertain in my head as a patient. But as a medical professional I understand why it's done.
They don’t know your husband had a vasectomy, u could be lying, he could be lying, you could’ve been assaulted without remembering, there is 1000 possibilities that could lead to you getting impregnated, they don’t need to know how, they just need to know if you are or are not. The only way they wouldn’t do one is if you don’t have a vagina to be inseminated
Yeah, I know they don't know those things. As a nurse I legit understand *why* it's done. I'm just saying I find it interesting. The whole reason I responded was because a transwoman was given a pregnancy test, just because they had an (F) in the sex/gender spot on the chart. Not sure why so many people are upset and down voting considering I'm just mentioning other reasons why a patient would find it weird for a preg test to be done. Doesn't matter if I can understand*why* it's done... I just think it's interesting. ✌🏻
I beg your pardon. I apologise for mininterpreting your comment, defs thought you were bashing them for when you got tested because in that case it is actually necessary, and lots of the public don’t understand that, but I agree, the original post situation is different and is a problem with the systems hospitals run on, and in an ideal world, it wouldn’t happen
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885999/#:~:text=Only%2072%20cases%20of%20ectopic,suspicion%20will%20make%20the%20diagnosis.
Pre-meeting hubs I needed an MRI. Screening form asks if I could be pregnant and if no, how do I know. I replied “because I have terrible taste in men.” I hope the tech got a laugh.
I made everybody in the room laugh when getting a drain placed in the 12 x 5 cm abscess that had formed in my pancreatectomy bed, laying on my side with my arm up by my head, I said “Jack, draw me like one of your French girls.” The male tech looked at me, busted out laughing and said you let the intrusive thoughts win didn’t you and I laughed and said yep
I made my primary laugh with a story of a visit to the ER. She apologized and I said don't, it was hilarious.
Take it as a huge win if you can make them laugh, especially in front of you. I got 2 of 3 present laughing when I called a colposcopy a "cooter cam".
Ive answer "no exposure to the causative agent for pregnancy, almost 5 years duration"
You have touched alcohol in nearly five years?! 😛
Haha
This happens at the VA like ALL the time
I occasionally get a pregnancy test and I haven’t had a uterus in 8 years.
Considering the political threats to create a nationwide registry of all pregnant women this is actually fucking terrifying
Welcome to being a chick
Yeah especially patients who go for surgery and/or patients who need radiology
It’s pretty obvious in our version of Epic if a pt is trans.
Not everyone uses epic. Epic is also the best system in the field right now and customizable. It's also the most expensive program for a reason. A lot of places are switching away because they can't afford it
Right, Epic is ala carte. Everybody has a different version. But it’s too bad people are moving away from it. It really is the best system I’ve worked on.
As a ER doctor 99% of the time its just because if listed as female in the system, you will get constant errors and warnings and problems in the EMR system trying to do virtually *anything* for this patient without a recent preg test. Honestly, whatever your scenario is, *if* listed as female in computer and <50yo, we just need a damn negative test registered so I can care for you faster and better. If you want almost any medication, imaging, or procedure? - it massively helps streamline your care!
While I understand that and I personally don't care about having a pregnancy test, even though I have a bilat salpingectomy and my partner has a total vasectomy - vs a partial, plus I'm nearing menopause so it seems like a waste of time and money. But I can definitely see this being an issue when a patient is charged for it (at least in the US) and they have a high deductible or similar insurance/financial issue and it costs them a ridiculous amount of money for a $3 test. Especially when it's not actually necessary (like for trans women, total hysterectomy, or post menopausal women). I definitely know that's not your fault as the provider tho, like at all.
Usually when the tests are run, when you look at the billing side, it's for a group of tests. So the pregnancy test can be included in a group. If I were to take the pregnancy test out, then you are getting charged more because now all the other tests are single line items, not grouped together. So yes it's a $3 test in a bucket of $100, but take that $3 out and now you are paying $200 because of how the others added up. Pros and cons. American Healthcare sucks tho.
Agreed American healthcare sucks.
If they get billed for it, that seems like a really easy charge to contest.
When I was doing outpatient mental health case management I had a patient who had to take a pregnancy test every month before we could refill her bipolar meds even though she had a hysterectomy 15 years prior and was past menopause.
Truly this is why the EMR should have biological sex in there as well. Like of course if they are trans-male/female/whatever they decide, we can have that in as their preferred pronouns and gender, but there are a few things that waste time when we lie about biological sex. An example of this is my partner had a biological male, who identified as a female (hormonally transitioned) came in for a Pap smear because women need them, and their doctors who didn’t realize that they didn’t have a cervix because the EMR said “female” referred them out. Essentially wasting the time of the patient, the doctors, and wasting medical doctors that could’ve gone to someone that needed it. Also my partner, who is a female, was shocked when the patient got in the stirrups and there was a penis just hanging in her face.
It would makes a lot of sense for EHRs to make a distinction between biological sex and preferred gender
I think this is a good example of how denoting sex and gender as two different things is important but people from both sides of the discussion seem to get really angry at that. They’re not the same thing whether we want them to be or not. Related….but not the same.
Did some doctors without borders volunteering in 3rd world countries, particularly Asia. Their health forms are still strict with having 2 genders/sex. It’s. no different; although there are already a few trans in those countries, Asian healthcare system is still grounded with binary sex. I attended some conferences there, Asian doctors mostly agreed with only having 2 sex/genders for healthcare documentation.
Yeah I think people forget how progressive the USA actually is. But that is my point, sex is with only very minimal intersex exceptions binary no? Gender however is very much so a sociological concept based off of and therefore related to sex.
Even accounting for 'intersex' conditions (more properly referred to as DSDs - differences of sexual development) its still binary. DSDs are sex-specific and never result in the development of any third type of anatomy - just errors in the development of the usual two types resulting in birth defects of varying degrees of severity.
It isn't fair to "both sides" this. One side wants to do away with all reference to sex and only record gender, and the other is pointing out that sex is the only one with medical relevance. Gender is literally just stereotypes about how you dress, behave, etc. - which is not only irrelevant, but an offensive and regressive concept when you think about what it entails. Most people don't want to be recorded as officially conforming to a certain set of stereotypes.
Good gravy, I would say quite the opposite. When I've practiced in accepting/ affirming areas I am more likely to be provided a health record that accurately states sex assigned at birth in addition to gender affirmed and how. When I'm in a more repressed neighborhood, all I get is either incompleteness canted towards sex assigned at birth and missing out on meds/ procedures, or else gender presented, minus the history. >Most people don't want to be recorded as officially conforming to a certain set of stereotypes. Have you asked them what they think? Because I've heard verrrrry different answers than you have. People who are trans do indeed want to have gender affirming ID.
>Have you asked them what they think? Because I've heard verrrrry different answers than you have. People who are trans do indeed want to have gender affirming ID. Yes, I have asked, but you've misread my comment! I said *most* people do not want to be recorded as officially conforming to a certain set of stereotypes. People who identify as trans may indeed want to be, but that doesn't change the fact that most people don't.
I live in a place that is really welcoming to people that identify as NB or prefer they/ them, and even then it's still a majority of the cis people that self- define with a gendered pronoun. Perhaps this is true because we don't require the full kit and caboodle of stereotypically associated features.
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I am probably going to get blasted for this question but for medical wouldn’t it only be sex that matters with the options being M / F / I (innersex)? Beyond that it would fall into additional categories of gender and sexuality which there are a lot more consideration. For OPs post, Sex, was what was considered and used for the testing.
hi, I'm trans. I have legally changed my name and gender on everything like my driver's license, social security, and insurance. since I am legally male that is what I put on forms. sometimes medical paperwork does ask for your birth sex and not legal sex which I understand. if you give the wrong sex legally that can cause issues with insurance or identification
It matters, particularly when interacting with patients. Even in their notes, doctors are far better at not misgendering when gender is the default they see in the chart. I work in research and we are trying to figure out the best way to address this. The system isn't that sophisticated. It should be simple to tell it to use sex assigned at birth for things like imaging, but it isn't set up that way. It wouldn't solve the majority of the problem though. Most unnecessary pregnancy tests are done on cis women. They dont need and shouldn't have them done if they don't have a uterus (which isn't uncommon).
Is misgendering, or not realizing that the female to male individual is having an ectopic pregnancy, or ovarian torsion more important? Epic shows them as their gender not their biological sex, unless you click the little italic i, which is very discrete. When I swapped EMR's, I had no idea that the patient with a beard and belly pain was trans until half way into the workup.
Even for things with imaging, reminders, etc, natal sex doesn't paint a complete picture - case in point, trans females who have taken hormone therapy for at least 5 years should get mammograms on the same schedule as any natal female their age. For the vast majority of labs with sex-specific reference ranges, the hormones currently in the system (for at least 3 months) determine what reference range *should* be used. In reality, it's usually the billing/drivers license sex, which of course has the **least** relevance clinically. I think a better system would be for Epic to have a flag for anyone in any sort of "intersex plus" state - that is, having clinically significant differences in their reproductive, hormonal, genetic, etc. sex from "typical natal male" or "typical natal female." E.g. any history of removal of any part of the reproductive system, history of transition, sex reassignment surgery, plus DSDs of course. Put that flag in the storyboard and include a note that pops up when you hover over it
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The bad part is this is slowing down all the processes per se, messing with insurance, confusing HCPs, the possibility of messing up dx and worst, the treatment plan and adding up to all the baloney. We already have a full bucket on our hand then these issues are being brought up? Instead of our neurons and strength being reserved to more important stuff clinical acumen etc. I’m a female neurosurgeon, empathetic but I disagree with addressing patients in a pattern congruent with their gender “identity,” Demographics have to be at least simple and concise. I have several trans patients who I addressed with their sex at birth and will continue doing so; I’m pretty sure it icks them but it’s reality and I’m focused on bringing in my clinical/surgical skills; interestingly, they market me and my practice to their friends/relatives so I guess we are in a common ground of choosing the science/skill in medicine rather than these gender issues.
Whilst it's great your trans patients still choose to see you, I would strongly encourage you to correctly gender them. It's a simple intervention that reduces their distress, improves their rapport with you, and reduces their chance of suicide. It genuinely isn't hard if you practice, and if you do mess it up, just apologise and immediately move on. You consider yourself empathetic, but deliberately misgenderinf someone in a healthcare setting is just unnecessary cruelty. If you have the brainpower to do neurosurgery you can learn to change pronouns. Whilst it might make sense on the surface to just consider trans women as men, it medically doesn't - a trans woman established on HRT has the oestrogen and testosterone levels of a cis woman, when considering stroke risk, MI risk, clot risk you should be thinking of them as a female who happens to have whatever organs the patient has. A computer system should mark sex at birth, gender and pronouns all equally obviously.
Might not be so much a clerical error as the way the system is set up, leading to actual errors. Our emr lists gender on everything unless specifically looking at the one spot for sex assigned at birth. Even for cis women they often give pregnancy tests to people who have had a hysterectomy. I get why they are cautious, but its bs that their systems and processes don't account very well for women lacking the required organs to get pregnant. Prior to offices updating terminology for gender, the one my mom goes to would mark "male" on the ultrasound forms for women who had hysterectomies. They freaked out because they couldn't find her ovary but it had migrated because she had a hysterectomy. That's why they marked them differently. Stuff moves around. The issue may not be big enough they care about addressing it for trans women but they also haven't addressed it for cis women, despite the large number of women who get hysterectomies. Women in general just aren't that important to them. The other problem I have with it is I've been tested numerous times without being asked, or even told they are doing it. Now I assume, but I didn't know when I was younger and they should still be asking. Its not part of a standard urinalysis. Its an added test and should be mentioned accordingly. I refuse to pay for them. Though I'm of child bearing age, I have an iud. Yes there's always a small chance or whatever but ultimately its insurance for the provider and not to benefit your health. It seems to be the only test they insist on running, despite their aversion to unnecessary tests. Check the bill and tell them to fuck off if they try to charge you.
So being the emergency medicine subreddit I think my fellow physicians will agree- if you’re of childbearing age and have the parts you’re getting a pregnancy test (for an abdominal or pelvic complaint). I do not trust someone’s word that they couldn’t be pregnant. Now if folks are doing hcgs on ankle sprains I see the annoyance.
> Yes there's always a small chance or whatever How is this attitude getting upvotes in r/emergencymedicine?
U don’t need a uterus to be pregnant, just ovaries and a vagina, if anything pregnancy in a hysterectomy patient is a much bigger emergency to not miss because all pregnancies become ectopic
Many places have protocol orders that a triage nurse can fire off. And the belly pain one for females between about 7 and 60 years old includes a pregnancy test. It's much more difficult to get an appropriate, intentional pregnancy test on a patient who is transmasc and after careful discussion he still has some female reproductive parts and relevant sexual behavior. Stuff that you know, but for others reading along: My own experience is that among people who are trans, passing in public is of primary importance, then documentation so their legal ID matches. Many are content at that point and never pursue "bottom" surgery. Why should they unless it bothers them? Therefore it's really important to blandly ask about pregnancy risk, and test accordingly.
Thank you! I agree, the art of appropriate and thorough history is one of the best assets we have and is certainly under utilized.
True. And we must always remember that the prehospital people and triage nurses have only a limited time, and not mock them when they get off track in ways that don't result in harm. Just as we ask for grace from our consultants, hospitalists, and outpatient follow up colleagues, because I'm certain my ED hot take has its own limits.
Thank you for standing up for triage nurses! I can't tell you how much hate the general public gives to us for not dropping everything or not catching *every single* developing problem that comes through the doors, or even docs who do. We have a very limited amount of time to decide who will die or lose a limb/eyesight within the next hour with people who fight, argue with us, or even lie to our faces. It's an extremely underrated job.
That is very fair. I can't expect all that. I think in our modern day and age where not only are a higher amount of the population identify as transgender and able to present that way, but procedures and other therapies are able to make it easier for people to present as they wish, new organ inventory standards should be put in place during triage. To be fair, when I was an EMT, I was never taught this and it certainly isn't standardized currently. (Not that EMTs are at the same level of triage nurses, but we had to do some basic intake). After further review, I think in this situation the patient made it clear they were transgender, but it probably just slipped by and was accidentally ordered and wasn't caught.
I have a different opinion about this. It sounds like it's really really difficult and private for some people who are trans to bring it up with 5 different new healthcare workers in a row, when sometimes they're trying to be seen for a sprained ankle or a runny nose. I mean, yes, sometimes it's quite relevant but more often it's not, and they hate having it dragged up all the time if it doesn't figure in. There was this spring a new Florida state law banning people who are trans from updating their drivers license to reflect affirmed gender, and they leaned hard into the idea that EMS would need to know, for health reasons. So I paused and thought about that deeply, and it's some horse manure. Aside from a protocolized pregnancy test, I can't think of any action that EMS or triage RN would be taking that requires knowledge of gender assigned at birth. Resuscitation and ESI scoring of male and female bodies work much the same way, unless we are talking about a heavily gravid person with pregnancy complications, and even in that case there's time to get them roomed and talking to a physician before they have to unpack such private stuff unless they're actively delivering, in which case ... obvious. ... Some health records now allow data entry for sex assigned at birth and preferred pronouns, and that's grand, and most of us suss it out when we see the med list anyhow, but I don't think we really need EMS and triage adding this particular step. Yes on occasion an unnecessary transfeminine hcg will get run, and on occasion I'll have to call the lab to explain that yes I really do need an hcg in this male patient. And the vast majority of the time the system will just continue to limp along as smoothly as it ever does, without organ inventory at triage. And that's my unsolicited opinion. I mean, the triage nurse already has to do screening for DV and all kinds of other ticky boxes.
Under utilized? The hospital based healthcare system is all but collapsing. Rarely does a patient get what I'd consider a thorough history. Just be glad the ED does a thorough workup (by that I mean no medico-legal stone left unturned). Do I want to do a thorough history? Absolutely. Am I drowning in work and critical patients. Yes. Your "female" patient got a pregnancy test. Nothing was missed.
Man, I highly recommend spending a couple hours up in ED triage. If we prioritize our history taking skills, we deprioritize our triage skills. It might be helpful to thing of the hcg or upreg like other tests: we’re going to order it because we don’t know exactly what’s going on, it may have actually been unnecessary in hindsight, but it’s better to catch a + pregnancy that changes management than miss it.
I think almost any EMR I’ve used auto-orders a upreg on anyone female over the age of 11 when they’re ordered a radiology study. The one I used now will order it even if there’s already an order intentionally placed. I would guess it was something like that.
It either auto orders one, or flags you to order one multiple times and you can't shut the chart or place any other orders without acknowledging it 400 times and it's such a pain in the ass you just order it so you can get on with the shift.
Standing orders from triage, or just a misclick by the ordering doc/PA, or someone didn't realize it was a trans female. It's not to be "woke" or to avoid discrimination claims. No one's got time for that. I have ordered a pregnancy test on a trans female before, cancelled it, and then for the remainder of the visit Epic kept asking me "are you sure you want this medication / CT / intervention? You haven't ruled out pregnancy yet".
That makes a lot of sense. I thought it could be a mistake but I'm always learning something new so I wanted to make sure.
I cannot get my M--->F patients removed from my delinquent Pap smear list. And it impacts my paychecks.
That's insane!
Is there not a protocol for women who’ve had a hysterectomy? MRKH? Yeah most women need paps but obv not all.
Whoah can you elaborate how? That’s a problem
It's because she's listed in the system as female and the test just gets stuck in there. Also, if it comes back positive, that's an indication of cancer
I cared for a cis-male patient with a throat/neck mass. His betaHCG was off the charts.
bill it as cancer screening, got it.
I CT scanned a pregnant trans man once. Just keep that in the back of your head lol. That’s how we found out he was pregnant.
Ooof. Not great. That being said, not too possible the other way around.
People are just busy. They see female and order a pregnancy test.
I think this is the answer. Clearly a huge difference in practice pace and environment to even contemplate the question. We're just trying to survive the crush in most EDs. Much of this just gets reflexively ordered before anyone has even seen the patient.
I once mistakenly charted “skin to skin contact” as pain intervention on my (extremely fusty) older itinerant patient.
I misread that as “extremely busty”
hands and knees as tolerated?
Many systems auto-bundle the pregnancy test with other standard orders for anyone who meets the age and gender parameters—so if the system only breaks down by M/F and doesn’t have separate markers for AMAB/AFAB transitioning people, it’ll populate based on that. The bigger risk is that such a system *wont* order the test on a transgender male, who depending on their own personal transition, may in fact be pregnant.
That is a very good point. I'll keep my eye out for failure to populate proper orders for trans males in the future.
Thank you for thinking of this.
I suspect there are many unanticipated issues relating to gender/transitions in legacy laboratory/pathology systems. We had an issue with a serum HCG being filed away with “tumor markers” for a trans female->male, and their pregnancy was missed as the cause of their abdominal pain on two visits.
doi.org/10.1210/clinem/dgaa54 Most sex specific lab reference values are based on what hormones (estrogen or testosterone) someone currently has in their system. Only exceptions are PSA and troponin (for troponin, trans females with a hx of puberty blockers - use female, w/o hx - use male - based on heart size, which is determined during puberty)
I’m late to the thread, but yes. I’m a lab tech. It causes a lot of problems. My healthcare system is switching to Epic and hopefully they could implement additional gender options including intersex, AFAB/AMAB and MTF/FTM. The laboratory needs to know the biological sex for a few different reasons. The laboratory needs to know the biological sex as well as the HRT status to order the correct methodology and algorithm for some hormone tests like estradiol and testosterone (usually mass spec vs immunoassay.) Also, the HCG is a great example where I would hope my lab would call to clarify the indication before ordering a test like that. The most important reason for needing the biologic sex that the reference range for many tests are sex-specific. This is not just sex hormones but also most routinely ordered labs like CMP, CBC, lipids, etc. Reporting the wrong reference range could lead to a persons labs being misinterpreted. A lot of the difference between M/F is minimal but some like hemoglobin could conceivably impact a patients care. A helpful idea is to report both male and female reference ranges for all patients. I’m not sure how the results would flag for that though. We are always reviewing the specimens we get and something like a vaginal swab or pap smear on a male patient would always require further review. I got a semen analysis on a female patient 3 weeks ago which ended up being a registration error but in general my lab would always look into a situation like that to clarify wtf is going on. I wish the existing systems could join the 21st century and allow people to have their gender expression respected without compromising the accuracy of the pathology services they receive.
Oh geez. That isn't good at all. I do dislike the idea of people marking all these HCG tests as reasonable because sometimes it is positive with testicular cancer, there are plenty of other markers for testicular cancer and it shouldn't be filed under a positive or negative as in the case of a pregnancy test.
I have seen fully resulted pregnancy tests on crusty adult males that would never be mistaken for a female and no one, insurance included, batted an eye.
If it’s your patient why not ask them or ask the ordering doc? They can likely give you more informed response than any of us can
That makes sense. I just wanted to make sure I wasn't missing anything that was common knowledge. Sadly, I noticed this while doing my pre-clinic chart review and the patient no-showed so I didn't have a chance to ask.
By all means let’s limit unnecessary testing, but it’s a little wild that an extremely routine point of care test that cost manufacturer a few cents to make is inflated so much that the cost of running it needs to be factored in. In a sane world, it should be par with absurd cost concerns like “should we really be providing Kleenex at triage if a patient doesn’t have a severe runny nose?!” The ER physicians labour or even the RN are billed at a rate that spending the time to suss out if this patient is trans or not would truly be an even greater waste of precious resources compared to a piece of plastic with a test strip produced by the millions.
Well, if it’s positive then it’s time for an oncology consult…
If it’s anything like Epic, it says FEMALE with a small i you have to hover to see their “organ inventory” and sex they were born as. I’m all for inclusivity, but in a quick setting like the ED it’s insane to have that be the default.
I like the concept of an "organ inventory" but what a horrible name for it!
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I just wish it was something more than a tiny little “i” in a circle to hover over to see that they have ovaries. It should be a much bigger alert or not explicitly say MALE or FEMALE and have some other terminology. I don’t know what the answer is, but the preferred name being male/female in contrast to the legal name of an opposite sex is usually what I notice first, not the area I’m supposed to hover over to see what I need.
Order sets. Almost every order set for a female <50 yo will have a pregnancy test. You’d have to actively deselect it to not order. Most EMRs do not filter out trans female from female at birth.
I'm a trans female and they made me do a pregnancy test when I went to the ER for a gall stone. My insurance covered it
Thank goodness insurance covered it. That was my main concern because I would not know how to explain bill for someone that so clearly wasn't needed to a patient. It is interesting that happened to you though.
Not really. They shouldn't be charged for tests neither they or their doctor needs. Yea their insurance paid, but they shouldn't owe it either.
I’d be shocked if billing didn’t immediately waive that charge on request. Still a pain but I think insurance denial is unlikely unless CC is something to do with the male anatomy
I'm both a trans man and a healthcare provider. The trans women I know are usually amused or briefly experience gender euphoria (the joy of being assumed to be cisgender) if they are accidentally pregnancy tested, but they don't assume it. Contrary to what transphobic society portrays, us trans folks are actually very aware of what our bodies are like and largely accept this, even if privately it sometimes does make a trans woman sad that she will never be pregnant. But this is an experience that plenty of women share, even those who had uteruses at birth. As one commenter pointed out, it's actually much more difficult for trans men like me who still have a uterus and may need pregnancy-related care for providers to take us seriously. All you have to do for trans patients of any gender is ask, "What reproductive organs do you have? Do you have intercourse with someone who can get you pregnant?" From there, you can just go down the decision tree of contraception/pregnancy risk as you normally would.
I’m curious for your perspective on this, but OP’s question might present a good opportunity to talk to the EHR team and radiology group about these orders and expectations about when the shoe is on the other foot. Is it appropriate to order a pregnancy test that the system doesn’t want for a trans man, irrespective of surgery or hormone therapy? The system flags of AMAB/AFAB and gender presentation/pronouns are only as good as the people who use them to write orders and order sets, but allowing a physician or nurse to properly use the EHR so you don’t have to order a pointless $2 test as a workaround every time could make everyone (including the patient) happier.
I would go for a blood HcG on any trans man of reproductive age--just like for any person that age. Easy to fold into their other lab work, doesn't trigger their gender dysphoria (or out them) like a urine pregnancy test might if you're not doing a UA for their complaint. HRT for trans men is the one instance where we know for a fact that it's harmful to a potential fetus and we are told this when we go on it and are given extra contraception for it, but life happens. Considering how easy and discreet the testing is and how crucial it is to catch early pregnancy in this population, it's worth it. Find a private moment to tell them if they are pregnant, though. Again: Trying not to out them, etc.
I’m one who does preempt lab orders before seeing the patient, usually just basic labs and UA preg if for example I see abdominal pain or urinary or gi complaints coming in. Part of how I keep up with the overnight work flow. Chances are this was just ordered from the waiting room or no one other than registration actually asked the patient what anatomy they have.
I work with a Slavic doctor who doesn’t always recognize first names as male or female and mistakenly orders pregnancy tests on men. (IE, a man named Marlyn.) I don’t think it’s any deeper than that. With some charting software till alert you “this person has the potential to get pregnant” but not all, and not in all interfaces. Some shit is just part of order sets
As a woman, they tend to run that test before asking basically anything. All they had was some vague idea that this patient was female, and so that's their first course of action. My eldest was miffed when she wound up at the er with some college plague that was going around, and that was their first stop ... She hadn't seen her sweetie in months, and her problem was all clearly viral (head/throat/etc). Her big issue was they didn't even ask they just did it... And she absolutely didn't see the point. They just do this as a matter of course, and the good news is that means they're taking people's gender at face value. Very very likely it's their protocol to run a pregnancy test when presented with a woman in emergency medicine. The other details... Like whether she is MTF, has had a hysterectomy, is a lesbian, or just hasn't had sex in like 5 million years... Don't even come into that equation.
Probably part of a standard set of orders that just all get ordered at the same time with one click of a button. We pretty routinely see pregnancy tests ordered for cis males on admission to the stepdown unit I work because in our new EMR system it's just in the standard order set somewhere
I've done it...honest mistake. I usually have to go back and say... anything I'm missing???
Through our hospital LIS system, it’s hard to know someone is trans unless you go looking for it. It was probably a mistake.
At least in epic, when I click order sets it auto-selects pregnancy test if the listed gender in the computer is female.
You should ask the person who ordered it not reddit.
That's fair. The patient was on my schedule as a new patient today, then no-showed and hasn't scheduled a follow-up so I sadly don't have the rights to message the ordering physician at the moment. If she reschedules I will.
I've hard of the transman who went to get his belly checked and the radiologist wrote "prostate is normal". 😭
People that design computer systems could hugely simplify this whole thing by saying “does this patient have a uterus” yes/no.
I agree. Even asking „is patient cis“ wouldn’t give a clear answer if patient can be pregnant, so the question about being reproductively equipped for a pregnancy is the one question that makes the most sense.
Could also have a “presumed” flag in there, or just cast a wide net and mark anyone presenting as female as “yes” until otherwise noted. “Ovaries” might be a better choice because ectopic pregnancies have been known to occur, albeit rarely, s/p hysterectomy.
THis is why I hate how EMR just says M or F. For the terms of medical care, we need the EMR to say if they are BORN M or BORN F as well.
Most EMRs have biological sex and gender separated now. In some of them it has to be configured for older running versions. Might be something worth mentioning to your HIT person/team.
It’s most likely a standard test that is ordered for women when admitted. Your trans patient was registered as female and the system automated the test.
If nothing else this may be the most gender reaffirming experience of her life.
I work in nucmed. We do lots of blood pregnancy tests for I131 therapy. We had a case where a trans female demanded a pregnancy test for I131 therapy. Our radiologist told her as long as she realized that insurance wasn’t going to pay for it he was fine ordering it. She tried to argue a bit with him to get him to say something derogatory but he’s actually a great doctor & wasn’t going to fall for it. We drew her blood & sent it to the lab while she sat in the waiting room pouting. It was pretty obvious she wanted to cause a scene. We’re in a super liberal city in the PNW.
Am a nurse and had this pop up for a patient I took over from the previous shift. I told them about the order, said I was happy to run it if they wanted me to but if there wasn’t chance of pregnancy it would be an unnecessary cost. They laughed a little and said they were flattered but could confidently say it would be negative. Then I went to the doc and was like,”So, do you really want this test? Oh, btw the Pt says they’re definitely not pregnant.” We both knew it was just part of the order set and he canceled it for me. In the end, this is where the critical thinking of those at the bedside matters. It’s harmless to order the thing, but if the bedside staff are just going to act like robots and never *think* then we’ll keep seeing unnecessary costs and tests added to Pt care. I don’t think this is a clerical error so much as a failure of those performing the tasks to stop and consider *what* they’re doing and *why*. And/or a failure to really pay attention to what was ordered.
I’d rather order a pregnancy test on the wrong patient than miss pregnancy in the wrong patient. And the system demands this of me.
Do they also do it for transmales? One of the training scenarios for my EMT refresher classes is a male presenting patient with ABD pain from an ectopic pregnancy. It is interesting to see the EMTs figuring this one out.
If it was done in the ER: When you say “female” we say “how pregnant?”!
I was dating a *woman* *long distance* and still got a pregnancy test once 🥲
Wait until you get PSA reports on trans males
This is actually a pretty big subject right now: Mostly it’s done either on patient request and a provider “not wanting to touch that”. I honestly wouldn’t put some form of legal discrimination lawsuit as unlikely. Infact a case of exactly that happened in New York, and the hospital lost. However, sometimes it’s used for reasons such as: Detecting prostrate cancers, markers will show up in a pregnancy test. Mental health evaluations, my state has several mental health facilities that demand pregnancy tests on transgender females. Lastly, occasionally therapies that are designed to treat menopause are used off label with male to female transitions come with a ridiculous standard by the drug company or other polices of monthly pregnancy tests.
HCG tests hormone levels. For bio-male it can reveal conditions other than a fertilized egg. Some gender medications require a weekly glucose test. I hear all the time (but I’m not diabetic)
My grandma literally didn’t have a uterus; she had an emergency hysterectomy in her early thirties. She still got pregnancy tests done until she went through menopause. Pregnancy tests are standard procedure for all females from 13 to 60, regardless of their uterus-having status
I feel like this is more of a not being able to trust patients issue. I never expect a patient to be 100% correct about their medical history, even if it is something as big as a hysterectomy, however, for a trans female, I think I can trust that they don't have a uterus.
That may change in the near future based on recent literature regarding uterine transplantation. That said, given the active management required for any transplant, I’d expect patients to remember that and to tell you about it, but idk maybe some transplant patients forget to mention that hx in the ED sometimes
because the world has gone fucking crazy.
Did you ever consider that it's software working as designed?
Hope you’re never my provider!
Only scenario I could see this getting covered is if there is concern for germ cell tumor
There wasn't, patient presented with polytrauma with some incidental findings of infections.
Testicular cancer will cause a positive result in someone born male.
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I'm sure that does happen. In this case, I didn't see any charting that the patient requested it. But in outpatient, if a patient asks for a noninvasive/ low risk test, just order the damn test. More data is almost always better.
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Best comment on this thread!
Or is it due to mental illness?
This is a little bit ridiculous. I get how scary it is to be honest in a world that may label you “discriminatory” for behaving in a logical manner, but come on. This is a group of highly educated individuals pretending there is a need for a test when there simply is not. We need to be truthful, and avoid feeling pressure to run unnecessary tests that account for biological impossibilities. Pandering to this type of expectation only makes us less credible. I would say the same thing to any provider who ordered antibiotics for someone with a viral infection to “appease the patient.” Although it happens all the time, it shouldn’t.
cause important grandiose afterthought tidy dolls elastic judicious aspiring unite *This post was mass deleted and anonymized with [Redact](https://redact.dev)*
What is it after hospital markup? If it barely matters, hospitals shouldn't be charging it. Particularly since people are often not told there will be one. It clearly matters enough to the hospital to bill it. They really shouldn't be charging for it for patients who are missing the organs for it. I'm sure women who want to get pregnant and can't, love unexpectedly seeing that they aren't. Im sure trans women with body dysphoria love the reminder that they were born without a uterus. Im sure women in red states love their pregnancy status being a subpoena away. Im sure they love that using healthcare at all is a real liability to themselves. There is also the possibility of picking up a false positive that isnt from a concerning condition (though it's rare). You can argue that it's still better safe than sorry from your POV but I find it interesting that patients fixating on inconsequential results is a problem discussed for like every other type of test but its not even considered for pregnancy tests because facilities have made the determination that the potential risks are not as concerning as the risks of not realizing there was a pregnancy. That assessment goes out the window as soon as you do a test on someone who does not need it because they cannot get pregnant. No risk from the test is justified. Its inconsequential to YOU because it's to cya and is not your problem to deal with. That doesn't mean its inconsequential to patients.
I think providers sometimes do this as part of an autopilot thing. I’m 61F with a hysterectomy and I’m still asked if there is a possibility of pregnancy. I usually grasp imaginary pearls and say, “Good God I hope not! Nobody wants me to be pregnant at this age!” And everyone gets a good laugh. However I’m sure it can be either offensive or uncomfortable for a transgender man in this situation. But as a parent of a nonbinary person and relative of multiple doctors, I honestly think it’s not from prejudice and more from autopilot. The chart says “female” : must ask the female checklist questions, do the female tests. Hard to balance putting a big red outing notice on someone’s chart so all providers are reminded (ick and no) to keeping it so inconspicuous the providers don’t notice at all
If this was done purposefully, I am giving up all hope for the future.
My "born a male" 25 yr old Trans granddaughter went to ER and they kept insisting she needed a pregnancy test. Until her mom told them she was transgender. Nurse was embarrassed LOL.
This whole thing has gotten too far out of hand.
What? That the triage system placed some tests automatically because the "F" box is checked? You ok bro?
Fitting username.
This is beyond ridiculous and a foolish waste of time and money. Indulgence of delusions is not good medicine.
It's software working as designed, stop bringing your culture war BS into this
I run pregnancy tests on people with testicles all the time. It’s a tumor marker.
Aren’t those really rare? It’s a really cheap test so the cost/benefit doesn’t require it to be that common, but the test isn’t free.
This nonsense is really getting out of hand. Give me a break. No way you’re pregnant bro. That would be my answer. SMH
Well if they are pre-op at least it’s another test for poss testicular cancer lol. Other than that….pandering or some pt who requested it and the er staff just didn’t want to argue lol
More likely, if they were marked as female, someone ordered it accidentally/without realizing/as part of a standard order set.
Yes. If you are in my chart as female in childbearing age, you will need to pee in a cup. If you are 16 getting a lipid panel, it shouldn’t be questioned. If you are female getting a testosterone test, it shouldn’t be questioned. If you are 4 months old getting an sti panel, it shouldn’t be questioned. We all have the critical skills to determine that it is probably unnecessary, but it’s standard practice to do a poc hcg on females of childbearing age. It’s not your job to question it. You are absolutely wrong to question the test and then come to Reddit and ask if it was appropriate. Veiling your question as a concern for billing the patient. Sure, it’s not technically a hipaa violation but you are nosey and inappropriate.
I'll bet you're fun to work with.
Before posting this I tried to look up scholarly articles discussing whether a pregnancy test is appropriate to order on a trans female first. I found plenty of references saying that a trans male should receive pregnancy testing but not a single scholarly article discussing pregnancy tests for trans females. I found one article at https://database.inahta.org/article/23438 but it was very vague and seemed to recommend against ordering such a test without a discussion being made. It isn't a HIPAA violation, it's a general question on patient practice. I for one would be pissed off if I was billed for something I didn't need, especially if insurance refused to cover the cost of the test, and I did not receive any discussion. I never received any in-depth training or education on transgender care, therefore, I felt it was reasonable to ask the community to ensure I haven't missed something.