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Transgender Health in the ED


Trans awareness is currently at an all time high, helped by portrayals in award winning shows such as Orange is the New Black and Transparent, and also by the recent public transition of Caitlyn Jenner. 

Transgender health is also an emerging area of research, and has also been getting more publicity, including in the world of Emergency Medicine. Trans people make up an estimated 0.5% of the population, and as frontline healthcare workers it is important that we learn about some of the special needs of our trans patients so that we can create an inclusive environment and provide great care. An Ontario study found that because of negative experiences that trans people had with the healthcare system, 21% had avoided the ED despite feeling that they needed emergency care.



Definitions:

  • Gender identity refers to one's internal perception of being a boy/man, girl/woman, or something in between. 
  • Sex describes one's phenotype, and often refers to the configuration of one's genitals. 
    • Because most peoples' gender identity matches their sex, these two terms are often mistakenly used interchangeably.
  • Cisgender refers to when one's perceived gender matches their phenotypical sex.
  • Transgender refers to when one's perceived gender does not match their phenotypical sex.
  • Non-binary is an umbrella term for anyone who does not identify with static binary gender identities.
  • Trans is an umbrella term for people who are not cis. It includes people who are non-binary as well as trans-men and trans-women. 

Dos and Don'ts:

  • Do use the pronouns that match the patient's felt gender.
  • Do ask the patient how they would like to be referred and what pronouns to use if you're unsure. 
  • Don't ask questions about anatomy and genitalia that are not relevant to the encounter.
  • Do explain why you're asking certain questions.
  • Don't make the encounter about the patient's trans status unless it is relevant to why they are there.
  • Don't use just the presence of a trans person as a training opportunity for learners.
  • Don't disclose a person's trans status to anyone who does not explicitly need to know.

Hormone Therapy:

  • The goal of hormone therapy for trans women is to reduce the effects of testosterone and induce secondary female sex characteristics (ex: breast and hip development).
    • Spironolactone, cyproterone and progestins are utilized to  block androgens +/- LH. 
    • Luprolide (Lupron, a GnRH analog) in trans youth blocks the onset of puberty. 
    • Estrogen to initiate feminization: 
      • Exogenous estrogen increases risks of breast cancer, strokes, heart disease and venous thromboembolism, although the risks are lower with the use of transdermal estradiol.
  • The goal of hormone therapy for trans men (with testosterone) is to induce virilisation (increased muscle mass, hair growth, deeper voice). 
    • Side effects are noted to include polycythemia, insulin resistance and mood changes.

Surgical Options:

  • For trans women, options include feminizing surgeries such as breast augmentation and tracheal shaving, as well as genital surgeries; orchiectomy and caginoplasty (a gender confirmation surgery).
    • Approximately 15% of trans women have genital surgery.
  • For trans men options include masculinizing surgeries such as mastectomy (top surgery) and genital surgeries; metoidioplasty or phalloplasty (both gender confirmation surgeries). 
    • About 1.5% of trans men have genital surgery.

Trans Health Issues

  • Most trans people will present with medical conditions that have nothing to do with being trans, however, if they present with conditions such as abdominal pain it is important to clarify anatomy, and any potential surgeries that they have had.
  • There is a large burden of substance use and mental health in the trans population:
    • In Ontario, 43% of trans people have attempted suicide, and 10% have in the past year.
    • Rates of alcohol and substance use is 4-10 times greater than the general population. 
  • Trans people experience some of the highest rates of violence in our society:
    • 20% have been physically or sexually assaulted, 34% verbally threatened or harassed. 
    • In intimate relationships, trans people are twice as likely to be physically threatened or intimidated.
    • Approximately 20% of Canadian trans women participate in sex work, which increases risks for violence. 
    • Worldwide, a trans person is killed nearly every day.

Take Home Points

  • It is important to utilize pronouns that correlate to the patient's felt gender, and if you're unsure, to ask the patient how they would prefer to be referred. 
  • Trans people may be on a multitude of medications or therapies, and so it is important to be cognizant of how these will influence their baseline risk for various disease entities. 
  • It is important to be cognizant of the potential for violence and abuse within this population, and to ask appropriate questions when concerns are identified or raised. 



Dr. Stephanie Barnes is a 3rd year Emergency Medicine Resident at the University of Ottawa, with a special interest in public and global health initiatives. 


Edited by Dr. Shahbaz Syed, PGY-4, Emergency Medicine resident at the University of Ottawa 










References


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