Basics of Transgender Patient Care

Introduction

In the United States, over 1.6 million people identify as transgender - with the vast majority of those patients being under the age of 30. With advances in LGBTQ medicine and the culture surrounding gender identity overall, transgender or transitioning patients are becoming more and more common in the prehospital realm. While this topic is hotly debated and highly controversial, it is important to maintain a high index of suspicion for underlying medical issues while being respectful and polite with patients. It is important to build a rapport with patients and leave any personal beliefs we have at the door when it comes to patient contact.

This article is not intended to be an exhaustive discussion on the psychological components; that is a discussion for another time and for someone far more educated than I. This article is not intended to be a place for debate of personal discussions or beliefs on the matter. This article intends to provide the current evidence-based clinical pearls regarding transgender care and hormone therapy, and what considerations there are for emergency medicine when encountering these patients.

Glossary & Terms

Per the Advocates for Transgender Equality Foundation, a transgender person is any person who feels that their gender identity is different from their assigned-at-sex birth. The feeling of having distress as a result of gender identity mismatching one’s assigned sex at birth is the feeling of gender dysphoria.

Gender is a social term for how one views oneself in the world and how they fall into gender roles. This is a complex term that cannot be fully discussed here. However, advocates have established that sex (which is assigned at birth and is purely biological) is separate from gender.

Gender dysphoria is a feeling typically described as mental anguish and like one is an imposter in their own body as a result of the aforementioned mismatch. Patients will seek gender-affirming care such as hormonal therapy and surgical intervention in order to make their gender expression match their gender identity.

Gender expression is the outward, external projection of how one presents to the world. For instance, clothing is one of the ways we express gender - and wearing a dress may be one way that a transgender male-to-female (MTF) patient expresses their preferred gender identity.

Deadnaming is the use of a person’s ‘old’ name that runs counter to their preferred gender identity. Using someone’s old assigned name is often distressing for them and worsens their gender dysphoria. Make sure to collect both the patient’s ‘old’ name and their current preferred name when documenting information. It is important to avoid mixing up patient files at the hospital when registering patients, and health records are often stored under ‘old’ names when a patient is first transitioning.

Hormone therapy is the use of gender-affirming hormones such as estrogen and testosterone in order to make someone’s gender expression and bodily features match that of their preferred gender identity. There are risks that come with hormone therapy, and it is important for clinicians to conduct a full, tailored assessment when it comes to patients on hormone therapy.

Surgical transitioning is the use of surgical intervention to match one’s gender expression and bodily features match their preferred gender identity. An example of surgical intervention is breast removal for those transitioning from female to male.

Patients will choose the extent to which they transition. Not all patients will choose to go through with surgical transition, with many patients being satisfied with hormonal therapies only. High cost and recovery times can also stop many transgender patients from pursuing the most extensive transition options.

Gender pronouns are the basic ways that we address one another. We use pronouns in common language everyday. Examples of pronouns include he/him/his and she/her/hers. Patients who are choosing to express a different gender identity will often make their pronouns known so that they can be correctly referenced.

Best Practices for Interacting with Transgender Patients

As I have stated above, transgenderism is a hotly contested and controversial topic in every realm of society - medicine included. The role of this article is not to enter into a debate. The main goal of our care is to establish a trusting relationship with our patient, recognize and address life threats, and help ensure a proper continuum of care.
Part of establishing a healthy rapport is ensuring that you have an open and trusting communication line with the patient. The best way to do this is to ask the patient what their preferred pronouns are, basic details about their gender identity if applicable, and then follow through with using their preferred pronouns.

Do not make it a point to use “biologically correct” terminology if your patient has expressed a preference on how they will be referred to. For the vast, vast majority of our complaints, the sex assigned at birth is not pertinent. Attempting to force a patient to use “biologically correct” terminology can be needlessly distressing for patients and damage rapport.

For instance, there is minimal difference between biological males or females when treating someone with a broken arm or with a STEMI. However, we will discuss assessment needs later on in this article.

Hormone Therapy Clinical Pearls

There are two main types of hormone therapy - feminizing and masculinizing hormone therapy. Hormone therapy is a complex and somewhat risky procedure but is often necessary to ensure that patients do not experience worsening gender dysphoria. The main treatment for gender dysphoria at this time is medical/surgical transitioning. Both therapy options are commonly provided through a variety of subcutaneous/intramuscular injections and hormone patches that remain in place.

Estrogen therapy is essentially giving estrogen (estradiol) to a biologically male patient to feminize their body. This is done for male-to-female transgender patients (MTF). This helps them match their preferred gender identity and express themselves as they wish. These hormones are synthetic but are identical to ovary-produced human hormones. Estrogen therapy helps patients build secondary sex characteristics associated with females, including breast development, vocal pitch increase, a decrease in body hair, and facial feature changes.

Patients who are being given estrogen therapy will often take an antiandrogen such as spironolactone. Antiandrogens are intended to stop the body’s natural production of testosterone to allow for estrogen therapy to take effect. There’s little sense in providing estrogen if the body is going to produce testosterone to counter its effects.

Clinical pearl: It is important to remember that estrogen is a natural procoagulant. We should assess patients receiving estrogen in the same way that we consider the possibility of embolism forming in patients receiving birth control. After all, many birth control medications have some amount of estrogen in them. A 2013 review found that patients who receive both estrogen therapy and smoke are at an up to 70 percent increased risk of venous thromboembolism formation versus control group patients (Blondon et al., 2013). Ensure that you maintain a high index of suspicion for thromboembolic conditions such as pulmonary embolism and DVT when assessing these patients.

Estrogen therapy increases the risk of all cardiovascular events such as STEMI, NSTEMI, and coronary artery disease. Maintain a high index of suspicion with any potentially suspicious complaints such as epigastric/abdominal pain, nausea, unexplained vomiting and dizziness, visual changes, shortness of breath, and especially chest pain.

Testosterone therapy provides bioengineered testosterone to patients to help masculinize them so that they can match their preferred gender identity. This is done for female-to-male transgender patients (FTM). Testosterone helps increase muscle density and amount, deepen vocal pitch, masculinize the face (somewhat), and change the distribution of adipose tissue.

With time, periods will stop. It can take a variable amount of time for menstruation to cease once testosterone therapy is initiated. These patients may still receive oral contraceptives, which can be synergistic with testosterone hormone therapy and increase the risk of thromboembolic conditions.

Clinical pearl: It is important to remember that patients who only have hormonal therapy and have not had a surgical hysterectomy are still capable of becoming pregnant, especially at the beginning of their hormone therapy. These patients may still ovulate and engage in penetrative vaginal sex. As a result, these patients remain at risk for ailments like ectopic pregnancy, ovarian torsion/cysts, or other OBGYN complaints. Ensure that you approach the topic of OBGYN complaints and the possibility of pregnancy with tact and respect. Emphasize to the patient that you will only ask medically necessary questions to ensure that their care is handled correctly.

Surgical Transitioning

MTF: Male to female patients typically receive a penectomy (surgical removal of the penis) and bilateral orchiectomy (removal of the testicles). Vaginoplasty follows in which a neovagina is created and requires frequent dilation to avoid closure (University of California, San Francisco, n.d.).

FTM: Female to male patients typically receive ‘top surgery’ (mastectomy or surgical removal of the breasts) in addition to voice feminizing surgery and phalloplasty (surgical creation of a penis).

Surgical transition will usually be accompanied by lifelong hormone therapy.

The major takeaway for post-op surgical patients is that, just like any other surgery, these are open wounds and are prone to all of the same risks that any surgical wound is open to. Surgery on the lower extremities and lower half of the body are particularly prone to infection due to increased warmth and moisture.

Ensure that you maintain a high index of suspicion for any sepsis or general infection findings. In addition, make sure to monitor patients for thromboembolic events post surgery as PE, embolism, and stroke. We create the risk of embolism forming anytime we undergo a surgical procedure.

Conclusion

The main goal of the EMS clinician in the prehospital realm is to establish a safe, secure rapport with transgender patients while addressing life threats as necessary. In many scenarios, a patient’s biological sex assigned at birth is not pertinent to our treatment or assessment. Ensure that you maintain tact and respond kindly with transgender patients, and avoid practices such as deadnaming when interacting.

References

Blondon, M., Wiggins, K. L., Van Hylckama Vlieg, A., McKnight, B., Psaty, B. M., Rice, K. M., Heckbert, S. R., & Smith, N. L. (2013). Smoking, postmenopausal hormone therapy and the risk of venous thrombosis: a population‐based, case–control study. British Journal of Haematology, 163(3), 418–420. https://doi.org/10.1111/bjh.12508

Understanding Transgender People: The Basics | A4TE. (n.d.). https://transequality.org/issues/resources/understanding-transgender-people-the-basics

University of California, San Francisco. (n.d.). Vaginoplasty procedures, complications and aftercare | Gender Affirming Health Program. UCSF. https://transcare.ucsf.edu/guidelines/vaginoplasty