Sex & Gender in Acute Care Medicine

1. Sex & Gender in Acute Care Medicine Chapter 13C: Emergency Care for the Transgender Patient

2. Chapter 13C: Special Populations – Emergency Care of the Transgender Patient Elizabeth Samuels and Michelle Forcier

3. Case Study, Part One • A 32-year-old presents with shortness of breath • The patient is listed as male in the electronic medical record (EMR) but appears to be female, with long hair, makeup, and a long skirt • The physician first thinks they’ve entered the wrong room and says, “Is this John Jones’s room?”

4. Case Study, Part One • The patient states that it is the right room • The physician asks, “Has he stepped out?” • The patient clarifies, “I am John Jones.” • She is withdrawn and makes poor eye contact during the interview • She appears to be in mild respiratory distress and complains of chest pain and difficulty breathing

5. Introduction • “Transgender” is a broad umbrella term used to describe individuals whose gender identity or gender expression differs from the gender they were assigned at birth* • Transgender (aka trans) individuals continue to be the most marginalized in the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, despite some gains in civil rights *See Glossary of Terms included in text for detailed descriptions of gender terminology

6. Introduction • Trans patients have unique medical and mental health needs and face significant barriers to care, primarily due to discrimination and lack of insurance coverage • Trans people of color experience some of the highest rates of unemployment, poverty, harassment and health inequalities • Transwomen and trans people of color are at especially high risk for HIV

7. Introduction • The transgender community has been disproportionately affected by psychiatric disorders, assault, tobacco and substance use • Trans individuals are much more likely to attempt suicide than the general population • These disparities are linked to the chronic stress of social stigma, discrimination and violence, denial of rights, and internalized shame

8. Introduction • As social discourse progresses, trans individuals are presenting to medical providers in greater numbers • At present, most medical students and residents receive little or no training on trans health • EM providers can more competently care for all patients by incorporating a developmental approach to gender that ensures equal access to all patients, regardless of gender

9. Background • Most trans patients present to the ED for problems unrelated to their gender identity • They may also present for problems that are gender related such as pain, depression and suicidality, injury from assault, or complications from gender transition adjuncts • The foundation for competent care is understanding that there is a broad range of gender identity and expression

10. Background • The gender spectrum is an aspect of both biodiversity and human development • Differentiating between gender and sexuality is an important development concept that informs care for all patients • Gender relies on the interplay of biological, psychosocial, and cultural factors • As well as specific social expectations and norms • Everyone experiences gender

11. Background • Individuals’ understanding of their gender identity and expression is a necessary part of child and adolescent development • Both identities and expression may change throughout a person’s lifespan • Gender is usually assigned at birth as either male or female based on external genitalia • Chromosomes, hormones, gonads, and secondary sex characteristics are also used to assign gender

12. Background • Historically, intersex infants born with “ambiguous” genitalia would have surgery shortly after birth • To make genitalia less ambiguous • To achieve a desirable cosmetic outcome • For many, this practice has created significant distress when they were assigned a gender incongruous with their gender identity

13. Background • More recently, intersex infants have not been assigned a definitive gender at birth • They have instead been allowed to grow and mature to see how their gender evolves • Understanding biologically intersex persons has helped inform our understanding that gender depends more on neurodevelopment than gonads and secondary sex characteristics

14. Background • Epidemiological estimates of the prevalence of transgenderism vary wildly and are often methodologically flawed • Many rely on counts of individuals who have sought medical or surgical treatment and are thus underrepresentative • The fluidity of gender identity as well as widespread transphobia make accurate studies difficult to obtain

15. Background • Current estimates show 0.6% of individuals born assigned male and 0.2% individuals born assigned female would like to pursue hormones or surgery for gender transition • The process by which one actualizes gender identity is called transitioning • Some may transition through reversible measures (attire, hair styling, binding their breasts)

16. Background • Others may opt for partially reversible hormone therapies or irreversible surgical interventions • In 2013, the American Psychiatric Association removed Gender Identity Disorder from the DSM-V • Rather than pathologize gender nonconformity, the APA shifted the focus to gender dysphoria

17. Background • Universally, medical and mental health societies reject reparative therapies that attempt to convert a transgender individual to cisgender • These are regarded as illegitimate, ineffective, and harmful • Insurance companies are incrementally expanding coverage for transition-related medications and surgeries

18. Caring for the Transgender Patient • Trans patients may have had prior difficult or stigmatizing experiences in health care settings • Fear of stigma may prevent patients from disclosing important health information • It is best to avoid assumptions and directly ask each patient the preferred name, title, gender, and pronouns

19. Caring for the Transgender Patient • This information should be shared with the entire clinical team so it is used consistently • Using correct names and pronouns conveys respect and helps build trust between patient and provider • It is common to care for patients before their name or gender have been legally changed on their ID or health insurance

20. Caring for the Transgender Patient • EMRs often limit to two gender options and do not have space for preferred name or pronoun • Not having this information can lead to awkward and alienating interactions • IOM, WPATH, and other organizations recognize the need to adapt EMRs to collect information on gender identity, sexual orientation, preferred name and pronoun

21. Caring for the Transgender Patient • Differentiating between gender and sexuality allows ED clinicians to show build trust with patients and collect a more thorough history • Understanding common methods of transition and being aware of poorer health outcomes in trans patients is essential to providing culturally competent care

22. Caring for the Transgender Patient • Gratuitous curiosity about the transgender experience is unprofessional and has no place in patient care • When clinically appropriate, screen for depression, suicidality, substance use, and interpersonal violence • Ask about specific behaviors rather than the gender of their sexual partners to determine pregnancy, STI, and HIV risk

23. Caring for the Transgender Patient • Prior or concurrent hormone use or surgeries may alter your differential diagnosis • Many transgender individuals have not had surgery because of disinterest, lack of access, or cost • Those who have should be specifically asked what structures were removed or created and whether these procedures were done in medical settings

24. Caring for the Transgender Patient • Hormone use or surgeries are especially relevant are in cases of abdominal pain, genitourinary concerns, sepsis, or chest pain • For example, a transwoman with lower abdominal pain who has not had an orchiectomy may have testicular torsion • Physical exams can be uncomfortable and psychologically difficult for many patients, including transgender patients experiencing body dysphoria

25. Caring for the Transgender Patient • Clinicians should approach each individual with clear, respectful communication and boundaries • Explain why you may want to do more sensitive genital or breast/chest exams and what you’re looking for • Obtain explicit consent for exam procedures • For persons with severe dysphoria or histories of abuse, a relaxant or conscious sedation may provide some relief

26. Caring for the Transgender Patient • Establishing a hospital nondiscrimination policy may help ensure trans-friendly care • All providers and staff should be educated on how to treat trans patients with professionalism and respect • Hospital workers should keep a patient’s gender identity private unless relevant or necessary for that patient’s care

27. Caring for the Transgender Patient • Individuals not involved in direct patient care should not be included for voyeuristic or nonmedical purposes • Hospitals should allow individuals to use bathrooms and rooms based on their asserted gender • Hospitals can also provide unisex bathrooms

28. Case Study, Part Two • The patient reports that her symptoms began ~6 prior to arrival at the ED • Review of systems is negative for fever, cough, leg swelling, travel or long trips • She has no prior history of asthma, COPD, cancer, heart disease, or pulmonary embolus • She is not prescribed any medications • She is a one pack-per-day smoker

29. Case Study, Part Two • On exam, she is afebrile, tachycardic, in mild respiratory distress with accessory muscle use and oxygen saturation of 91% on room air • Her heart rate is 120 with a regular rate and rhythym • Her abdomen is soft and nontender but as you lift up the gown, you note voluntary guarding • She has male pattern face and body hair • No acanthosis, straie, or rashes

30. Medical Therapies for Gender Actualization • Patients prescribed hormones have persistent gender dysphoria and/or a strong desire to be another gender • Barriers to therapy include limited access to care, fear of discrimination, lack of insurance or insurance coverage, and prohibitive cost • Barriers are often circumvented by taking pro-hormone supplements or purchasing hormones from unlicensed providers

31. Adolescents • Most transgender adolescents who have begun puberty continue to identify as transgender into adulthood (80-90%) • To avoid worsening dysphoria from pubertal physical changes, trans adolescents may halt or delay puberty with gonadotropic (GnRH) analogues or puberty “blockers” • GnRH analogues are completely reversible and may be stopped at any time

32. Adolescents • Hormone blockers prevent development of secondary sex characteristics (breasts, menses, face/body hair, etc.) that would require future mediations with hormones or surgery • Risks or adverse outcomes from puberty blockers are uncommon

33. Adolescents • Initiating hormone blockers in early puberty • Allows individuals more time to explore and understand their gender • Gives parents time to come to terms with their child’s evolving gender identity • Allows families to create a safe, healthy approach to disclosure and support

34. Feminizing Hormone Therapy • Feminizing hormone therapy typically includes a combination of estradiol and an antiandrogen • Sublingual, transdermal, or intramuscular (IM) estradiol is recommended to decrease risk of venous thromboembolism (VTE) • Antiandrogens block testosterone effects on male pattern hair growth and have some effect in reducing endogenous testosterone

35. Feminizing Hormone Therapy • Prolonged estrogen use has been associated with testicular damage but the effect of hormone therapy on sperm production is inconsistent • These therapies are not considered effective birth control • Risks and side effects of feminizing hormones include VTE, cardiovascular disease, and elevated liver enzymes, among others • For the transgender woman, the benefits of feminization typically outweigh potential risks

36. Masculinizing Hormone Therapy • Testosterone is the primary masculinization therapy for asserted male patients • It is typically given IM or topically • Providers should discuss sterile needle use and caution against needle sharing • Masculinizing hormones increase the risk of alopecia, polycythemia, sleep apnea, weight gain

37. Medical Therapies for Gender Actualization • The changes of transition, including shifting hormones, may create some changes in mood and affect • Most trans patients report feeling more emotionally stable after hormonal treatment • Goals of hormone therapy include achieving desired physical characteristics, improved confidence and comfort in their own physical habitus, and minimizing risks/side effects

38. Surgical Methods for Gender Actualization • Surgeries of the chest are commonly referred to as “top” surgeries, while those involving genitalia are referred to as “bottom” surgeries • Not all trans patients seek surgery, often due to personal choice or prohibitive cost • Chest binders or wraps are non-surgical methods used to promote the appearance of a male chest

39. Surgical Methods for Gender Actualization • Similarly, instead of or prior to phalloplasty, transmen may use packers (prosthetic testicles and penis) or “stand-to-pee” devices • Transwomen uncomfortable with their genitals may desire an orchiectomy or construction of a neo-vulva and vagina • Prior to or instead of surgery, transwomen may tuck their genitals to create a female type vulva profile

40. Surgical Methods for Gender Actualization • Common complications include postoperative infection and dissatisfaction with cosmetic outcomes • In a small cross-sectional study, almost half of those undergoing genitourethral reconstruction had bladder symptoms, including incontinence • In another study, nearly a quarter of individuals were dissatisfied with their sexual function

41. Surgical Methods for Gender Actualization • Some individuals may seek procedures from unlicensed providers • Complications range from poor cosmetic outcome to disfigurement, multisystem organ failure, transmission of HIV or Hep C from contaminated needles • Case reports underrepresent incidence of self-injection of silicone and other substances for breast, gluteal, or facial augmentation

42. Case Conclusion • The patient is asked to identify gender, name, and pronoun preferences • The patient reports that she is a transgender woman early in her transition from male to female • She has not been able to change her birth certificate so her ID has her birth name on it • She tells you she has been taking oral estrogen pills that she gets from a friend’s prescription

43. Case Conclusion • You have high suspicion for pulmonary embolism given concurrent oral estrogen use and cigarette smoking • CT pulmonary embolus study reveals bilateral submassive, segmented pulmonary emboli • You discuss your findings with the patient and initiate heparin • Upon request, the patient is given a private room

44. Conclusion • Transgender patients have unique medical and mental health needs • Discrimination, stigma, and socioeconomic status create disparities in trans health outcomes • EM providers can help address disparities by treating trans patients with respect and by understanding the medical and surgical methods of transition that may be key to a correct diagnosis and care plan

45. Gaps in Knowledge • Long-term effects of hormone blocking and adjunctive hormone therapies • Relative risk of pulmonary embolus in MtF individuals taking estrogen • Effect of feminizing hormones on breast cancer risk • Frequency of postsurgical complications • Incidence of cardiovascular after initiation of testosterone therapy

46. Gaps in Knowledge • Incidence of diabetes mellitus and PCOS after initiation of testosterone therapy • Barriers to ED care; opportunities to improve ED care for gender nonconforming persons • Clinical and cultural competency for EM physicians and physicians in training • Effect of masculinizing hormones on bone density • Effect of masculinizing hormones on incidence of breast, cervical, ovarian, or uterine cancer

47. The Transgender Patient Questions 1. You are working as an intern in the ED and are requested to take a full history of a transgender patient. The electronic records identify his sex as female but the gender he identifies with is male and he discloses that he is undergoing sexual transition. Upon questioning, the patient complains of moderate suprapubic pain with bladder and fecal incontinence issues and decreased libido for one month. He reports a remote history of pelvic inflammatory disease. He is currently afebrile with normal additional vital signs. Which is a critical consideration when further assessing this patient? (A) Performing the H&P with respect, courtesy, and a patient-centered approach (B) Current medication use, including steroids and/or hormone therapy (C) Sexual History (D) Inquiring about recent surgeries. (E) All of the above Answer: (E) All of the above Because the patient has indicated that they are undergoing sexual transition, an important differential diagnosis you want to immediately rule out is post-operative infection.. You want to confirm that there is no postoperative bleeding, infection, or sepsis from a possible recent surgery. In many instances, many transgender patients seek hormonal treatment or surgery for gender actualization. Given barriers of cost and stigma, these may be unregulated and unsafe if not conducted by a licensed health provider. Complications from genitourethral reconstructive surgeries includes pelvic floor problems including vaginal prolapse, urinary and fecal voiding, urgency, and emptying issues as well as dissatisfaction with sexual function. Given the patient’s history of previous PID and pelvic pain, sexual history is an important component on the history, regardless of patient’s sex, gender, or sexual orientation. Likewise, medication history, particularly steroids or hormones, is also paramount. In a transman who may have not undergone gender actualization surgery, ovarian cysts and/or torsion are also on the differential (in addition to pregnancy and in this case, recurrent PID). *see next slide for references

48. The Transgender Patient Questions Question 1 References: 1. Samuels E, Forcier M. “Emergency Care for Transgender Patients.” InGregor A, Choo E, Becker B, et al. Sex and Gender in Acute Care Medicine. 2016 Cambridge University Press NY, NY p221-223, 227. 2. WPATH. Standards of Care for the health of Transsexual, Transgender, and Gender-Nonconforming People: The World Professional Association for Transgender Health; 2012. 3. Xavier, J (2000). Final report of the Washington Transgender Needs Assessment Survey. 4. Kuhn et al. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals 5. Kuhn et al. Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals . Fertility and Sterility, 95, 2379-82. http://www.fertstert.org/article/S0015-0282(11)00438-9/fulltext

49. The Transgender Patient Questions 2. A transwoman presents to your ED with concerns about side effects from Spironolactone that she recently initiated as a feminizing hormone. Which of the following is not a potential side effect of this medication? (A) Increased urinary frequency (B) Hypertension (C) Renal insufficiency (D) Rhabdomyolysis (E) Gynecomastia Answer: (B) Spironolactone is a common anti-androgen used for hormone therapy because it blocks the effects of testosterone and its synthesis. Some of its main side effects include hyperkalemia and hypotension. Irregular heart rhythm, renal insufficiency, and rhabdomyolysis are all affected by an increase in potassium (hyperkalemia) from exogenous (diet) and endogenous sources. Hypotension, rather than hypertension, is a common side effect of spironolactone since it is also used as a common treatment for high blood pressure. References: 1. Samuels E, Forcier M. “Emergency Care for Transgender Patients.” Gregor A, Choo E, Becker B, et al. Sex and Gender in Acute Care Medicine. 2016 Cambridge University Press NY, NY p221-223, 227. 2. WPATH. Standards of Care for the health of Transsexual, Transgender, and Gender-Nonconforming People: The World Professional Association for Transgender Health; 2012. 3. Teo, BW, Nurko, S. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/hypokalemia-and-hyperkalemia/

50. The Transgender Patient Questions 3. What is the best way to assess a patient’s gender? (A) Ask all patients what name they would like you to use. You can clarify preferred pronouns by asking, “what pronouns do you prefer?” (B) Ask all patients what name they would like you to use. You can infer what pronouns to use based on whether the patient appears masculine or feminine. (C) Refer to all patients by the name listed on their medical record. You can use this to infer what pronouns to use. (D) a or b Answer: (A) When approaching any patient, it is best to avoid assumptions and rather, directly ask each patient the preferred name or title, gender and pronouns. This information can be noted and shared with the clinical team for consistency and coherence during the course of treatment. This conveys respect, builds trust, and enhances rapport that will aid in helping the patient. References: 1. Grant, et al. Injustice at Every Turn. 2. AJ McGregor, E Choo B Becker. Sex and Gender in Acute Care Medicine. 2016.