Increasing Equity in Pain Management, Substance Use Disorder Treatment, and Linkages to CARE

PATIENT PERSONA: Destiny

Destiny is a single 42-year-old transgender Latina woman who works at a clothing store. Growing up, Destiny experienced severe bullying related to her gender expression, including physical violence in school. At 16 years old, when she told her parents that she is transgender, they were not supportive of her, and she left home to stay with friends. She was unable to complete high school and has worked ever since in restaurants and stores to support herself. Destiny has been on gender-affirming hormones (estradiol) since she was 18 years old. She underwent facial feminization surgery at 26 years old, breast augmentation surgery at 31 years old, and vaginoplasty at 36 years old. Her surgical care team prescribed oxycodone for pain management after vaginoplasty. Post-operative dilations triggered Destiny’s PTSD related to a sexual assault she experienced at 19 years old when she was working at a restaurant. In the context of this distress, she began overusing prescribed oxycodone, then started obtaining this from the street. Her opioid use progressed to intranasal then IV heroin and fentanyl. She has had two opioid overdoses thus far with resulting hospitalizations. Due to behavioral health workforce shortages, she has not yet been connected to stable outpatient psychopharmacology and psychotherapy services. She mistrusts most providers, due to concern that they will not provide gender-affirming and culturally responsive care. She is open to considering medication assisted therapy for opioid use disorder.

Reflections and questions

■ What are Destiny’s intersecting identities and lived experiences? ■ What are the different advantages and disadvantages that Destiny brings to the care setting? ■ How might recognizing Destiny’s intersecting identities help you to see Destiny as a whole person and thus provide more patient-centered and culturally responsive care? ■ What systemic and structural inequities contributed to Destiny’s current situation? ■ How might these inequities affect Destiny’s trust in, and engagement with clinicians and the healthcare system? ■ Did you notice any implicit biases arise while reading this persona? ■ What strategies can you use to acknowledge and reduce any implicit biases?

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