A primer on the needs and the care of the transgender patient in the Emergency Department

The following post is authored by Caroline Davidge-Pitts, a Mayo Clinic physicians who specializes in the care of transgender patients. The purpose of this piece is to serve as a conversation/learning starter and highlight the urgent needs of this population in our Emergency Departments, ICUs, ambulances and healthcare in general. We can and we should do better.

Author: Caroline Davidge-Pitts, MBBCh

The needs of transgender community have recently come into the spotlight due to increased media coverage. Although awareness of transgender issues has improved, the healthcare profession continues to face challenges in transgender medicine. Until recently, patients have had limited access to transgender -related care due to insurance denial. In addition, the transgender community continues to experience minority-stress including stigma, discrimination and prejudice by many uninformed health practitioners resulting in underground medical care. Lambda Legal reports 70% of transgender individuals have suffered some form of maltreatment at the hands of medical providers, including harassment and violence.  Suicide attempts amongst transgender individuals are also extraordinarily high, around 25-43%. The prevalence increases in those who have had a negative experience with a healthcare professional.

The Emergency Department (ED) plays a key role in the health of transgender individuals as for many patients; this may be their first point of care.  A study completed in Ontario, Canada[1] reported out of 408 transgender patients surveyed, 21% will nevertheless avoid the ED due to a perception that they would have a negative encounter due to their Trans status. Fifty two percent reported a Trans-specific negative encounter. It is vital that we increase education and awareness in transgender health in the ED to meet the needs of this underserved population. A survey sent out to Emergency Medicine residency programs in the US, results published in 2014 [2], revealed that only 33% had incorporated LGBT health topics into their curricula.

A transgender or gender nonconforming person has a gender identity that does not conform to sex (chromosomal or anatomical) assigned at birth. A transwoman will have been assigned as male at birth, but identifies as a woman. The converse is true for a transman. Many patients do not feel restricted to male or female and may consider themselves as both or neither. The terms male to female (MTF) and female to male (FTM) are often used by health professionals. Gender identity is quite different from sexual orientation, which includes the sex a person is emotionally and/or physically attracted to. Being transgender indicates diversity and not pathology. The clinical distress that may accompany being transgender (termed gender dysphoria) is what needs to be evaluated and treated by health professionals. Gender dysphoria may arise as a result of internal conflict associated with incongruence between gender identity and sex assigned at birth. This dysphoria is also heightened by minority-stress experienced by transgender people in our western culture. Relief of gender dysphoria is unique for every person. For some, dressing in congruence with their gender identity is enough. For others, hormonal treatment and gender confirmation surgery is necessary. All patients will require a trained mental health professional to establish the diagnosis of gender dysphoria, assess co-morbid psychiatric diagnoses, and evaluate social support structures.

Patients arriving in the ED may be on a variety of hormone therapies. Typical feminizing hormones include spironolactone and estradiol (oral, transdermal or prolong depot release) with doses of estradiol being 1-4 times higher than replacement doses in a postmenopausal female. In addition, some patients will also be taking finasteride and/or progesterone. Masculinizing hormones include testosterone (intramuscular, transdermal patches or gel) in addition to progesterone in some cases. A pregnancy test should be considered in transmen who still have their ovaries and uterus intact. It is often assumed that patients have had genital surgery. This is often not the case, and providers should be sensitive to this during the examination.

My top ten tips to become a trans-friendly and competent Emergency provider:

1. Sensitivity training should be required for all staff that interacts with the patient. Recommended training from UCSF Center of Excellence for Transgender Health:  http://transhealth.ucsf.edu/video/story.html
2. If you are not sure, ask. This reflects empathy.
3. Ask the patient their preferred name and pronoun and use these during the encounter. If you make a mistake, apologize and continue.
4. The preferred name and pronoun will often differ from what is in the medical record as many have not changed their name and gender legally. Ask the patient if you can use this preferred name and pronoun in the medical record. Remember that many patients may have access to their medical record and therefore your sensitivity should reflect in the notes.
5. If possible, intake forms should have an option to disclose transgender status.
6. Public restrooms should include a unisex option.
7. Have local transgender resources available to help guide the patient if needed, e.g., local transgender support groups.
8. Include transgender health topics as part of your training programs. This will increase the competence of our future leaders in transgender healthcare.
9. Provide faculty development in transgender health. Many national and international meetings now include transgender health topics, and online resources are becoming more available.
10. Phone-a-friend, be aware of trans-competent providers in your area that you can contact if you have a question.

References

1. Bauer, G.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, 2014. 63(6): p. 713-20 e1.
2. Moll, J., 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 : official journal of the Society for Academic Emergency Medicine, 2014. 21(5): p. 608-11.
3. www. lambdalegal.org
4. www.williamsinstitute.law.ucla.edu
5. WPATH (World Professional Association for Transgender Health) standards of care 2012
6. Endocrine Treatment of Transsexual Persons. Endocrine Society guidelines 2009

Image from Shutterstock.com, used with permission.