Skip to main content

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.


  • 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 


1. Bourns, A. Guidelines and Protocols for Hormone Therapy and Primary Health Care for Trans Clients. Toronto, ON: Sherbourne Health Centre; 2009
2. Diagnostic and statistical manual of mental disorders. All Authors / Contributors: American Psychiatric Association.; American Psychiatric Association. DSM-5 Task Force.
3. Cicero, Ethan Collin, and Beth Perry Black. "“I Was a Spectacle… A Freak Show at the Circus”: A Transgender Person’s ED Experience and Implications for Nursing Practice." Journal of Emergency Nursing (2015).
4. Bauer, Greta R., et al. "Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey." Annals of emergency medicine 63.6 (2014): 713-720.
5. McNeil J, Bailey L, Ellis S, et al. Trans Mental Health Study 2012. Edinburgh: Scottish Transgender Alliance, 2012
6. Snelgrove, John W., et al. "“Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients." BMC health services research 12.1 (2012): 1.
7. Obedin-Maliver, Juno, et al. "Lesbian, gay, bisexual, and transgender–related content in undergraduate medical education." Jama 306.9 (2011): 971-977.
8. Moll, Joel, et al. "The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know?." Academic Emergency Medicine 21.5 (2014): 608-611.
9. Transgender Law Center. (2016). 10 Tips for Working with Transgender Patients. Accessed online February 24, 2016 from:
10. Scheim, Ayden I., and Greta R. Bauer. "Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey." The Journal of Sex Research 52.1 (2015): 1-14.
11. Grant, Jaime M., et al. "National Transgender Discrimination Survey Report on health and health care." National Center for Transgender Equality and National Gay and Lesbian Task Force. Washington, DC (2010): 1-23.
12. Centre for Addiction and Mental Health. (2012). Criteria and Information For Those Seeking Surgery. Accessed online February 25, 2016 from
13. Writing Group for the Women's Health Initiative Investigators. "Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial." JAMA 288.3 (2002): 321-333.
14. Gooren, Louis J., Katrien Wierckx, and Erik J. Giltay. "Cardiovascular disease in transsexual persons treated with cross-sex hormones: reversal of the traditional sex difference in cardiovascular disease pattern." European Journal of Endocrinology 170.6 (2014): 809-819.
15. Curtis RJ. Should trans men have a hysterectomy? Gender Identity Research and Education Society. (2015). Accessed March 9, 2016 from        
16. Gender Reassignment Surgery in Montreal. Accessed March 8, 2016 from
17. Selvaggi, Gennaro, and James Bellringer. "Gender reassignment surgery: an overview." Nature Reviews Urology 8.5 (2011): 274-282.
18. Rotondi, Nooshin Khobzi, et al. "Nonprescribed hormone use and self-performed surgeries:“do-it-yourself” transitions in transgender communities in Ontario, Canada." American journal of public health 103.10 (2013): 1830-1836.
19. Rainbow Health Ontario. (2015). Changing the Sex Designation on Your Birth Certificate, Driver’s License, and OHIP Card. Accessed February 24, 2016 from
20. Bauer G, for the Trans PULSE Project. Trans Ontarians’ Sex Designations on Federal and Provincial Identity Documents: A Report Prepared for the Canadian Human Rights Commission. 15 November 2012. Accessed February 27, 2016 from content/uploads/2012/11/Trans-PULSE-Sex-Designations-on-IDs-Report-for-CHRC-2012.pdf
21. Rashid, Mamoon, and Muhammad Sarmad Tamimy. "Phalloplasty: The dream and the reality." Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India 46.2 (2013): 283.
22. Horbach, Sophie ER, et al. "Outcome of Vaginoplasty in Male‐to‐Female Transgenders: A Systematic Review of Surgical Techniques." The journal of sexual medicine 12.6 (2015): 1499-1512.
23. Khobzi Rotondi, Nooshin. "Depression in trans people: A review of the risk factors." International Journal of Transgenderism 13.3 (2012): 104-116.
24. Rotondi, Nooshin Khobzi, et al. "Prevalence of and risk and protective factors for depression in female-to-male transgender Ontarians: Trans PULSE Project." Canadian Journal of Community Mental Health 30.2 (2012): 135-155.
25. Rotondi, Nooshin Khobzi, et al. "Depression in male-to-female transgender Ontarians: results from the Trans PULSE Project." Canadian Journal of Community Mental Health 30.2 (2012): 113-133.
26. Bauer, Greta R., et al. "Suicidality among trans people in Ontario: Implications for social work and social justice." Service social 59.1 (2013): 35-62.
27. Ialomiteanu, A., et al. "CAMH monitor eReport: substance use, mental health and well being among Ontario adults, 1977–2013." CAMH Research Document Series 40 (2014).
28. Afifi, Tracie O., et al. "Child abuse and mental disorders in Canada." Canadian Medical Association Journal (2014): cmaj-131792.
29. Hughes TL, Elinson M. Substance use and abuse in lesbian, gay, bisexual, and transgender populations.J Prim Prev. 2002;22:263-298.
30. Reback C, Simon P, Bemis C, Gatson B. The Los Angeles Transgender Health Study: Community Report. Los Angeles, CA: UCLA Press; 2001.
31. Nuttbrock, Larry, et al. "Gender abuse, depressive symptoms, and substance use among transgender women: a 3-year prospective study." American journal of public health 104.11 (2014): 2199-2206.
32. Controlled Substances and Tobacco Directorate. 2012. Canadian Alcohol and Drug Use Monitoring Survey. Ottawa, Ontario: Health Canada Accessed March 19, 2016 from
33. Marcellin RL, Bauer GR, Scheim AI. Intersecting impacts of transphobia and racism on HIV risk among trans persons of colour in Ontario, Canada. Ethnicity and Inequalities in Health and Social Care 2013;6(4):97–107.
34. National Coalition of Anti-Violence Programs. (2013). 2012 Report on Lesbian, Gay, Bisexual, Transgender, Queer, and HIV-Affected Intimate Partner Violence. Accessed online March 19, 2016 from
35. 16 x 9 “The Fight for Trans Rights”, Global TV, Dec 5 2015
36. The Trans Murder Monitoring Project. (2015). Transgender Day of Remembrance 2015 – Trans Murder Monitoring Update. Accessed online March 13, 2016 from
37. House of Commons, The Challenge of Change: A Study of Canada’s Criminal Prostitution Laws, Report of the Standing Committee on Justice and Human Rights (Ottawa: Government of Canada, December 2006). Online: Government of Canada


Popular posts from this blog

Tips for Success in your Emergency Medicine Rotation

Our wonderful medical students are preparing to start their first clinical rotations. With this in mind here are some of the top tips for success in your EM rotation
1)Be On Time – show up to your shifts on time, better yet 5 minutes early.That first impression is immensely important.
2)Introduce yourself to the team - “Hi my name is John Doe, I am the medical student on shift today” introduce yourself to the attending, residents, nurses, etc.You will be called on a lot more to help when there is something interesting going on if they know your name.
3)Be goal-oriented – have a goal for each shift, whether it’s a procedure or a type of presentation to see.
4)Don’t just stand there, do something – whenever there is a trauma or code, come to the bedside.Get gowned up for traumas and pay attention.Help with things that are within your scope of practice: chest compressions, moving patient, cardioversion
5)Don’t just stand there, do nothing – there are times in medicine when the best thing to d…

2014 Canadian Guidelines for AF Management: Part 1: Introduction and CCS “CHADS-65” Algorithm

by Ian Stiell MD @EMO_Daddy

In this and subsequent postings we will discuss the latest recommendations for ED management of atrial fibrillation (AF) as presented in the newly published 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. The Guidelines PDF can be downloaded from the CCS website at 2014 Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation
The 2014 Focused Update uses the GRADE system of evidence evaluation as was the case in the comprehensive 2010 AF Guidelines and the 2012 Update. The CCS AF Guidelines Panel is comprised of Canadian cardiologists plus physicians from internal medicine, family medicine, neurology, and emergency medicine. This 2014 Update provides evidence review and recommendations for 8 aspects of AF care, including ED Management (written by myself and Dr. Laurent Macle of the Montreal Heart Institute). The 2014 Update focuses on advances in oral anticoagulant (O…

You CAN reverse that! Reversal of NOAC's and more..

We have seen a large surge of the utilization of New Oral Anticoagulants (NOAC's) in the past few years, as such, it has been a novel challenge when these patients present to the Emergency Department (ED) with life threatening bleeding. Dr. Michael Ho looks to discuss treatment options, and future options in these patients. 
NOACs vs WarfarinDabigatran, Rivaroxaban and Apixaban have seen a dramatic increase in use since their approval in Canada. Dabigatran is a direct thrombin (Factor II) inhibitor, while the latter two are direct Xa inhibitors. These drugs are collectively referred to as novel oral anticoagulants (NOACs). They have also been called direct, or target-specific oral anticoagulants (DOACs or TSOACs) [1]. 
The NOACs have many practical advantages over warfarin: Rapid onset of actionShorter half-lifeLess food and drug interferencePredictable pharmacokineticsEase of use and no requirement for monitoringThe downsides to NOACs are the higher cost to the patient, the inabilit…