EM Approach to Transgender Patients

Authors: Anna Condino, MD, MPH (EM Resident Physician, University of Washington Emergency Medicine Residency, Seattle, WA) and Jeff Riddell, MD (EM Attending Physician / Medical Education Fellow, University of Washington Emergency Medicine Residency, Seattle, WA) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)

Case Part 1:

You are just coming on shift, and the first free patient on the ED board is Frank Smith, 37 year old man with leg pain, triage level 4. You glance at normal vital signs and then walk into his room. There, you see a tall woman sitting on the edge of bed in shorts and a t-shirt. You double check the patient’s name band and indeed, it says, “Frank Smith.” You begin by saying, “Hello, I’m Doctor Jones, and I’ll be your doctor today. How do you prefer to be addressed?” The patient says, “Nice to meet you. I am Sarah Smith – please call me Sarah.”

Introduction

Transgender people have a gender identity that differs from the sex which they were assigned at birth and are estimated to represent 0.5% of the U.S. population (1,2). They may or may not have undergone medical treatment to affirm their gender identity and/or alter their physical appearance. They identify as female or male based on their internal sense of self. Some people identify as “non-binary” or “gender non-conforming”, which means a gender identity outside of male or female. Many transgender patients experience discrimination and discomfort with the health care system (1,6), thus ED providers must be comfortable and competent treating transgender patients.

Our patient in this scenario is a transgender woman. This implies that she was born a boy, but identifies as a woman.  This is abbreviated “trans woman.” Familiarity with the terminology used by the transgender community is essential to setting a respectful tone throughout the patient interaction; more information can be found here: http://transhealth.ucsf.edu/trans?page=guidelines-terminology.

The doctor here handles their initial confusion correctly by a) checking they have the right patient, the same as one might if you expected a 20 year old and walked in and saw an elderly person and b) introducing themselves and their role, and then asking the patient “How do you prefer to be addressed?” This allows the patient to state her preferred name and sets the tone for a respectful encounter and increases patient satisfaction (3).

A follow up question should be: “Which pronouns do you prefer?” This helps clarify if the patient wants to use she/her, he/his, or they/their. Often, legal names may still appear on insurance documents, medical records, and ED track shells, which leads to the patient being mis-gendered – as Sarah was in this scenario. It is important to communicate to other providers that will be taking care of the patient their preferred name and pronouns, and document in the medical record the correct gender and name so that future providers will use the correct terms. The first line of your HPI about Sarah might say: “This is a 37 year old transgender woman named Sarah who presents with a chief complaint of leg pain …”

Other times, a provider may not discover that a patient is transgender at all if they have had a legal name change, nobody has documented it previously, and in the course of history and treatment the patient’s gender identity, birth sex or medical treatments aimed at gender affirmation are not disclosed or discussed.

Key Points:

• Familiarity and appropriate use of terminology used by the trans community is essential to a respectful clinical encounter with a trans patient.
• “How do you prefer to be addressed?” and “What pronouns to do you prefer?” are questions that can be used to establish a gender-affirming patient encounter.
• “How do you describe your gender identity?” and “What sex were you assigned at birth?” are questions that are appropriate to determine a patient’s biological sex and if it differs than their gender identity.
• Ideally these questions are part of a triage process and incorporated into your EMR.

Case, part 2:

You take a history and discover Sarah twisted her knee running 4 days ago, noticing initial swelling, and over the past day the swelling has spread to her upper calf, which now has a constant ache. She denies falling and/or striking the knee and has been able to walk, albeit a bit painfully.  Her medical history includes only mild asthma. For medications, she reports albuterol as needed and hormone therapy. She reports no surgical history. She is a non-smoker with no personal history of DVT. On exam, you see a mildly swollen right knee and upper calf without erythema or bruising.

Medical Issues specific to Trans patients

Transgender patients have a unique set of medical issues related to gender affirming surgical and medical therapies that ED providers must be aware of. Several different therapies are discussed below; some patients will have had none at all, and some will have had both surgical and medical interventions (1).

A key component of any clinical encounter with a trans patient is using gender affirming language and having a culturally sensitive approach to the history and physical examination. This includes all providers using the patient’s preferred name and pronouns throughout the visit and having extra sensitivity when performing a genital exam, if indicated, on a trans patient. Remember, a genital examination will not be required for complaints such as Sarah’s. If you do determine a genital exam is necessary, remember to approach this with particular sensitivity, and trans populations often experience discomfort and anxiety with these exams and have had prior poor interactions with health care providers (4,5,6).

Hormone Therapy

Transgender people often take hormones therapy to promote gender-affirming body characteristics and suppress characteristics of the birth sex. The extent to which trans women will have female secondary sex characteristics and trans men will have male secondary sex characteristics depends on the duration of therapy and the age at which therapy is started (7). Sometimes these therapies are provided and monitored by a medical professional, and other patients will obtain hormones from the internet or through other means.

For trans women, feminizing hormone therapy typically includes estrogen therapy combined with an androgen blocking therapy such as spironolactone, finasteride, or dutasteride.  The preferred estrogen used is 17-ethyl estradiol, a bioidentical estrogen to that released from the human ovary, either as a transdermal patch, oral tablet, or sometimes a gel; injections are also used (1). Supplemental estrogen therapy, depending on formulation and dose, can predispose to higher rates of thromboembolism in trans women, thus a heightened suspicion for VTE in transgender women taking supplemental estrogen therapy is prudent (8). This is especially true for tobacco smokers. Other side effects of estrogen therapy may include migraines, hot flashes, and possible worsening of autoimmune conditions.

For transgender men, parenteral testosterone therapy is the mainstay of hormone treatment and is used in a manner similar to the treatment of men with low or absent testosterone levels (9). Injection or gel preparations are used. Acne, migraines, and a rise in hemoglobin/hematocrit may be encountered with testosterone therapy.

Binding and Tucking

Binding is using a tight-fitting bra, ace bandage, tape, or other device over the breasts to effect a more masculine chest shape. Prolonged binding can lead to breast pain, skin breakdown, fungal infection, or irritation.

Tucking is moving the testicles into the inguinal canal area or the penis/scrotum posteriorly into the perineal region, held in place by tight underwear, or less commonly, adhesive or tape. This can lead to skin effects, urinary trauma or infections, or testicular pain.

Gender Affirming Surgery

A wide range of gender affirming surgeries are available. Feminizing vaginoplasty, masculinizing phalloplasty/scrotoplasty, masculinizing chest surgery (“top” surgery), facial feminization, facial hair removal, and voice modification procedures are some of the surgical interventions you may elicit on a surgical history; in addition, transgender individuals may undergo hysterectomy, oophorectomy, orchiectomy, and breast augmentation or reduction.

Genital procedures for trans women typically leave the prostate in place. Some trans men retain their uterus and ovaries, thus abdominopelvic complaints should trigger consideration of pathologies associated with these organs. Some interventions are staged, requiring multiple procedures over months or years to achieve the final result. Both feminization and masculinization procedures carry post-surgical risks including bleeding, infection, urethral stricture, fistula, free-flap loss in phalloplasty, loss of sensation. The type of procedure and the time of procedure should be elicited on your history. An appropriate question to ask is: “Have you had any gender affirming procedures?”, if this is relevant to the patient’s complaint. Also be aware that newly reconstructed tissue may be friable; in particular, you should avoid pelvic examination of a neo-vagina unless medically necessary AND deemed safe.

Key Points

• Many transgender people are on hormone therapy to promote gender-affirming secondary sex characteristics. Be aware that trans women may be at an increased risk of VTE and migraine.
• Be aware of binding and tucking and how this may relate to chest and genital complaints, respectively.
• It is important to know the timing and type of Gender-Affirming surgeries to accurately assess for potential complications, if this is relevant to the chief complaint.

Case conclusion

Based on Sarah’s potential increased risk for DVT, you decide to order a duplex ultrasound. This is negative, and you convey your diagnosis of a knee sprain to her with a recommendation for rest, ice, elevation, NSAID therapy, and return to her primary care doctor for a follow up visit if not improved in 1 week. She thanks you for her care.

References / Further Reading

1. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. Available at www.transhealth.ucsf.edu/guidelines
2. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender Health in Massachusetts: Results From a Household Probability Sample of Adults. Am J Public Health. 2012 Jan;102(1):118–22
3. Deutsch MB, Buchholz D. Electronic health records and transgender patients–practical recommendations for the collection of gender identity data. J Gen Intern Med. 2015 Jun;30(6):843-7
4. Peitzmeier SM, Khullar K, Reisner SL, Potter J. Pap test use is lower among female-to-male patients than non-transgender women. Am J Prev Med. 2014 Dec;47(6):808–12.
5. Peitzmeier SM, Reisner SL, Harigopal P, Potter J. Female-to-male patients have high prevalence of unsatisfactory Paps compared to non-transgender females: implications for cervical cancer screening. J Gen Intern Med. 2014 May;29(5):778–84.
6. Rubin R. Minimizing Health Disparities Among LGBT Patients.JAMA.2015;313(1):15-18. doi:10.1001/jama.2014.17243
7. Deutsch MB, Feldman JL. Updated recommendations from the world professional association for transgender health standards of care. Am Fam Physician. 2013 Jan 15;87(2):89-93
8. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Overview of Feminizing Hormone Therapy. Deutsch MB, ed. June 2016. Available at: www.transhealth.ucsf.edu/guidelineshttp://transhealth.ucsf.edu/trans?page=guidelines-feminizing-therapy
9. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Overview of Masculinizing Hormone Therapy. Deutsch MB, ed. June 2016. Available at: http://transhealth.ucsf.edu/trans?page=guidelines-masculinizing-therapy