(Reuters Health) – The negative experiences of transgender and gender nonconforming patients in U.S. emergency departments could be avoided with better training for doctors, suggests a new study. Based on survey responses from 240 transgender and gender nonconforming people, researchers say negative experiences were often attributable to doctors’ lack of knowledge.

“The biggest recommendation that came out from what we saw and what participants actually said was training,” said Dr. Makini Chisolm-Straker, the study’s lead author from the Icahn School of Medicine at Mount Sinai in New York. Training of medical staff “should be systematic and it should be required.”

People who are transgender or gender nonconforming identify as a gender different from the sex assigned at birth, or do not identify their gender as explicitly male or female. “Basically, I wanted to find out from trans folks across the U.S. what their experience was in emergency departments,” Dr. Chisolm-Straker told Reuters Health.

For the new study, researchers surveyed transgender and gender nonconforming adults who visited U.S. emergency departments between 2012 and 2014. Participants were recruited from health centers serving the lesbian, gay, bisexual and transgender communities, Facebook, a national conference and word of mouth.

Two themes that emerged from the surveys were self-efficacy, which focused on the person’s need to speak up for themselves, and power inequity, which dealt with the dynamic between patient and provider. Regarding self-efficacy, the researchers found, people who had others advocate on their behalf—such as a primary care doctor or family member—felt respected. People who had to advocate for themselves didn’t have positive experiences and some didn’t feel like they could speak up.

As for power inequity, the survey responses revealed, doctors were often unprepared to account for their patients’ needs as related to their gender identity. One respondent recalled a junior doctor saying, “I don’t understand your body. I will just consider you female, but who knows what those hormones you are taking could be doing to you.”

Patients shouldn’t need to teach their doctors about transgender or gender nonconforming healthcare, but they often do, said Dr. Chisolm-Straker. “When patients had to teach their clinicians about medicine, there was a bad dynamic,” she said. “It became clear the clinicians were uncomfortable.”

Respondents also recalled healthcare providers using the wrong names or pronouns. Some people also felt like they were being put on display or that their gender identity was unnecessarily the focus of conversation.