Transgender Patients In the ED

This patient population presents unique challenges – both clinical and practical – within the emergency department setting. Here’s a crash course in how to treat these patients with competence and sensitivity.

A 58-year-old patient presented to triage with a chief complaint of “vaginal discharge”. History obtained by triage staff: PMH includes HTN, breast cancer in remission, borderline DM. PSH includes lumpectomy, breast augmentation, cholecystectomy. Vitals: HR 105, BP 108/65, T 39.1, RR 20 Weight 136 kg/300 lbs. On examination, you find an obese patient who appears uncomfortable. Patient reports that the discharge started a “few weeks ago” and is “foul smelling,” “getting worse” and is associated with pelvic pain. The patient is registered as a female; she has notable facial hair and a deep voice. Her lower abdomen is very tender to palpation with guarding and rigidity, she is ill-appearing. After gentle further questioning, you obtain additional surgical history of MtF Gender Reassignment Surgery, including creation of a neovagina from a colon graft. She reports that she was reluctant to present sooner due to past negative experiences in the medical system and maltreatment due to being a transgender person. External vaginal examination reveals evidence of necrotic tissue, speculum exam is deferred for fear of perforation. Broad spectrum antibiotics and fluid resuscitation are started and the surgical team is paged STAT.

Transgender Patients in the Emergency Department
Since Caitlyn Jenner made her public debut, the issues of transgender patients have been all the buzz. It is hard to know the exact size of the transgender population as the CDC and US Census Bureau don’t ask. And people don’t always report. LGBT demographer Gary Gates came up with one oft-cited estimate of the country’s transgender population: 700,000, or about 0.3 percent of adults [1]. This number was arrived at based on studies performed in Massachusetts and California.

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Transgender people may be disproportionately seen in EDs due to increased risk of mental health concerns (suicidality and depression) and post-op complications from gender reassignment surgery. According to a recent article in JAMA [2], transgender people are “more likely to postpone medical care because of lack of insurance and encounters with discrimination.” Unlike the celebrity case of Caitlyn, transgender patients are twice as likely to be unemployed and 4X more likely to live in poverty compared to the general population, thus being at risk for limited access to health care.

Many of us received cultural competency training in medical school with relation to race, gender, and socioeconomic status but transgender patients may not have been on the radar of medical institutions until more recently. We do know the importance of establishing good rapport with patients – improved acceptance of treatment plans, compliance with medications, better patient satisfaction scores, and decreased medicolegal risk. Using terms and pronouns offensive to the patient can cause conflict and harm the doctor patient relationship. If you are unsure how to sensitively handle these patients, you are not alone! Here is your crash course in social, mental health, and physical health concerns of transgender patients.

Taking the History
Given that Facebook now allows users to choose almost 50 different gender options [5] to identify themselves, you may find yourself struggling to know how to address the patient in front of you. It’s probably best to simply use their name and then ask them how they’d prefer to be addressed [4].

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Since there are unique medical risks associated with being a genotypic male or female, it is important to know this information for the medical record, but it should be ascertained in a sensitive manner. For instance, “What gender do you currently identify yourself as?” “What gender were you identified as at birth?” “Have you had any gender-specific surgeries?”

Although we are curious by the nature of our medical profession, it is important to ask questions that are relevant to the medical history and avoid unnecessary probing that is irrelevant to their care. If a transgender patient is in the ED for a sprained ankle, it is not necessary to know if they have a penis or a vagina. If they are there for abdominal pain, knowing about prior surgeries and presence or absence of reproductive organs is relevant and necessary to assess. If the patient is on hormonal therapy, it is also relevant as it can affect certain disease risks. If a transgender patient is hesitant to answer questions, it is helpful to tell them why you want to know. Be sensitive to the fact that certain parts of the history and physical may be very difficult for the patient. A transgender male may not like to think about having a uterus and fears of getting a speculum exam may be unusually distressing for them.

The period of time when one is changing from one gender to the other is considered a gender transition. A transgender patient may be anywhere along the journey toward transitioning when you see them in the ED. This may simply involve different clothes and a new hairstyle or other modes of gender affirmation. Changing one’s name is common, but legal changes of name may be more difficult and costly. Hormonal and surgical therapies are likewise expensive and at times contraindicated and therefore may not be an option for the patient. If a patient has not undergone such therapies, it doesn’t mean that they are less serious or certain about their chosen gender.

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Mental Health Concerns
Gender dysphoria is a psychiatric diagnosis that is defined in the DSM-5 with the following diagnostic criteria [6,7]:

• Strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage.
• Adolescents and adults may have a preoccupation with getting rid of primary and secondary sex characteristics, and they may believe that they were born as the wrong sex.
• Patients report significant distress or impairment in social, occupational, or other important areas of functioning.
• These symptoms must be present for at least 6 months.

According to a large poll of transgender adults, their lifetime rate of suicide attempt is 41%. Over half reported experiencing rejection by family members. One fifth had been refused healthcare by a medical provider because they were transgender. Work discrimination was reported by 90% and 20% had been homeless at some point. Joblessness can result in being uninsured. Delaying necessary medical care due to fears of discrimination was reported by 28%. The vast majority reported that they had been harassed or bullied at some point in their lives [8]. Keeping these stats in mind will help physicians treat these patients with sensitivity and respect.

Legal Issues and Controversies
Several controversies have arisen in recent years surrounding transgender issues. For example, should insurance companies cover hormonal and surgical treatments? The transgender community maintains that these therapies are medically necessary for the overall wellbeing of the patient [3]. Beginning in 2014, Medicare recipients can seek authorization for gender reassignment treatments by submitting documentation from a doctor and mental health professionals stating that surgery is recommended in their individual case. There have been several cases of prisoners seeking treatment for gender reassignment. Bradley Manning was sentenced to 35 years in prison for espionage after leaking several documents while serving in the US Army. After sentencing, Bradley announced that she was now Chelsea and won the right to hormonal therapy while in prison [9]. And in 2012, a judge in Massachusetts ruled that a civilian prisoner could have sex reassignment surgery paid for using tax-payer dollars while incarcerated for killing his wife, using the Eighth Amendment ban on cruel and unusual punishment as a reason. He had apparently tried to commit suicide and to castrate himself while serving time [10].

Even more controversial is the transgender child. According to the AMA Journal of Ethics, although the signs of gender idendity disorder can be seen in children, there is disagreement about the appropriateness of treatment in minors. This is due in part to the fact that studies have found that most children with gender dysphoria will not carry those feelings into adulthood [3,16,17]. When Vanderbilt University and London’s Portman Clinic tracked children who reported transgender feelings, they found that 70%-80% of them spontaneously lost those feelings without medical or surgical treatment. Given the gravity of prescribing hormone therapy for minors, and the potential liability associated with it, it is recommended that you seek your hospital’s legal counsel for guidance in these matters.

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The treatment option for the pediatric  gender dysphoria population entails the use of gonadotropin-releasing hormone agonists to halt the development of secondary sex characteristics [11]. There have been several well-publicized cases of children who transitioned at young age [12,13,14]. YouTube star Jazz Jennings was diagnosed with gender dysphoria at the age 4 and was already living in the role of a female by the age of 6 [14,15]. She made the 2014 Time magazine 25 most influential teens list and has her own television show called All That Jazz premiering on the TLC network this year. California has passed laws allowing children to use whichever bathroom at school they feel most comfortable with and to play on the sports team of the gender that they prefer.

Hormone Therapy
A study polling transgender adults found that about 75% were taking hormonal therapy [18]. Hormonal therapies aim to suppress the sex characteristics of the natal sex and induce those of the gender preferred by the patient.

MtF hormone therapy consists of anti-androgens such as spironolactone and cyproterone acetate as well as GnRH agonists. Estrogens and progestins may be used as well [19,20]. Hormonal therapy aims to induce breast growth, decreased muscle mass, redistribute body fat and lessen body hair. Beard growth is still likely despite these therapies. Changes to the voice also may not occur. Thromboembolic disease may be seen at higher rates in those undergoing certain types of estrogen therapy [21].

FtM hormone therapy largely consists of androgen therapy. Testosterone is given in transdermal or injectable preparations. Levels must be monitored to avoid liver toxicity, hypertension, aggression, acne, and dyslipidemia. Changes expected from testosterone therapy include increased muscle mass, increased libido, increased body hair, thinning of scalp hair, deepening of voice and redistribution of body fat. Testosterone therapy may increase the risk of coronary artery disease [22]. Progestins may be used to induce amenorrhea if a hysterectomy has not been performed. FtM patients who have reproductive organs present may still become pregnant despite androgen therapy.

Sexual Reassignment Surgeries
FtM: There are several surgical options for the FtM transgender patient. One of the first procedures performed which allows them to more easily live in their desired gender role is chest surgery to remove the breasts [23]. A phalloplasty utilizes a radial forearm graft to create an asthetically and functionally appropriate phallus. The neopenis allows for sexual function and voiding in the standing position [23]. First the vaginal lining is removed; a hysterectomy and oopherectomy may be performed at the same time. From the forearm flap, the radial artery is connected to the femoral artery and the cephalic vein is connected to the greater saphenous vein. One forearm nerve is connected to the ilioinguinal nerve and the other to the dorsal clitoral nerve to allow for tactile and erogenous sensation [23]. The labia minora is used to lengthen the urethra and the labia majora are used to fashion a scrotal pouch. Several months later, testicular prostheses and a penile implant may be inserted. One of the major complications of this procedure seems to be long term urinary problems including fistulas [24,25]. This procedure also requires a long hospital stay and obvious scarring to the forearm [23]. These reasons may be why up to 72% of FtM transgender people do not desire this procedure [18].

MtF: Patients who desire surgery may undergo breast augmentation with implants. They may choose to undergo facial feminization procedures such as brow lift, cheek augmentation, lip augmentation, and hair removal. They may also choose bone-shaping procedures such as contouring to the forehead, chin, or jaw and reduction of the Adam’s apple. Genital surgical options include penile inversion, vaginoplasty, and orchiectomy. According to the Gender Affirming Program at the University of Michigan, “Surgeons use a ‘like becomes like’ approach by using parts of the original penis to create a sensate neo-vagina. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.” A neovagina can also be created with a graft from the colon.

TSRoadmap.com [26] offers a detailed financial worksheets and estimates on the all the costs of transition, and estimates that it is typical to spend a total of $40,000 to $50,000 for a mid-range transition, including surgery.

Before Surgery
Doctors typically follow the guidelines  of the World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). This non-profit, interdisciplinary professional and educational organization devoted to transgender health promotes standards of care in the care of transgender patients. Their guidelines state that before undergoing sex reassignment surgery an individual should be:

• 18, or the legal age of consent in their home country
• Have had one year of continuous hormone therapy, except for patients who cannot do so for medical reasons
• One year of living successfully and continuously as a member of the new sex
• Psychotherapy during that year, if recommended by the patient’s mental health professional
• Have knowledge of the cost, risks, hospitalization requirements, necessary aftercare for the surgery
• Know of competent surgeons who can perform the surgery

Post-Op Complications
There is no board certification and no governing body to standardize care or grant accreditation for sexual reassignment surgery. There are many techniques to perform the surgeries and the outcomes can vary greatly.

A Brazilian study that followed 70 patients over 13 years showed a 40% complication rate in MtF surgical patients [27].

Post op complications can include bleeding, hematoma, necrosis, infection, pulmonary embolism, recto-vaginal fistula, prolapse, urethral strictures and fistula formation, nerve damage, and loss of tissue. Be cautious with the tissue in these surgical sites as it may be friable; excessive manipulation may cause damage to the vessels, nerves, and skin. Avoid a speculum examination of a neovagina unless it is deemed both necessary and safe.

Be sensitive to the patient’s distress at the potential loss of their genitalia. Make every effort to contact their surgeon, even if they are at a different hospital or distant location. Your local surgeons who may be called upon to care for complications will need as much information as possible about the patient’s surgical procedure, you can be an educational resource and advocate for your patient. Keep in mind that transgender patients may delay seeking care for post-op complications due to fears of discrimination and mistrust of the medical system.

Physician Opinion
You may feel uncomfortable with transgender patients for a variety of personal and religious reasons. It is important to remember that you don’t have to agree with any patient – or even like them! – in order to provide excellent care. It is our duty as emergency physicians to treat all who walk (or are carried) through our doors. We are unique in the house of medicine in our willingness to see all patients regardless of complaint and ability to pay. We are on the front lines of medicine and should be proud of what that means.

REFERENCES

1. How many people are lesbian, gay, bisexual, and transgender by Gary J Gates, Williams Distinguished Scholar April 2011 The Williams Institute at The University of California School of Law
   Minimizing Health Disparities among LGBT patients Rita Rubin, MA.  JAMA 2015
2. Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People. The World Professional Association for Transgender Health. Version 7.
3. http://transequality.org/issues/resources/transgender-terminology
4. http://www.huffingtonpost.com/dana-beyer/facebooks-gender-identities_b_4811147.html
5. www.glaad.org/references/transgender
6. DSM-V. American Psychiatric Publishing; 5 edition (May 27, 2013)
7. Grant et al. (2011). Injustice at Every Turn:
8. http://www.thetaskforce.org/downloads/reports/reports/ntds_full.pdf
9. http://www.cnn.com/2015/02/13/us/chelsea-manning-horomone-therapy/index.html
10. http://www.cnn.com/2012/09/04/health/massachusetts-sex-change-surgery-inmate/
11. Best Pract Res Clin Endocrinol Metab. 2015 Jun;29(3):485-495..Adolescents with gender dysphoria. Cohen-Kettenis PT, Klink D
12. http://www.cnn.com/2013/06/24/us/colorado-transgender-girl-school/index.html
13. http://www.cnn.com/videos/us/2015/03/17/digital-shorts-parenting-transgender-child-orig.cnn
14. http://abcnews.go.com/2020/video/transgender-11-listening-jazz-18260857
15. https://www.youtube.com/watch?v=k4NUqoAMBSk
16. Dev Psychol. 2008 Jan;44(1):34-45.A follow-up study of girls with gender identity disorder. Drummond KD, Bradley SJ, Peterson-Badali M, Zucker KJ.
17. Child Adolesc Psychiatr Clin N Am. 2011 Oct;20(4):725-32. doi: 10.1016/j.chc.2011.08.004.Guidelines for pubertal suspension and gender reassignment for transgender adolescents. Hembree WC
18. Grant et al., 2010: http://transequality.org/PDFs/NTDSReportonHealth_final.pdf
19. J Clin Endocrinol Metab. 2009 Sep;94(9):3132-54. doi: 10.1210/jc.2009-0345. Epub 2009 Jun Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM; Endocrine Society.
20. Medical Management of Adult Transsexual Persons.Emily L. Knezevich, Pharm.D; Laura K. Viereck, Pharm.D; Andjela T. Drincic, M.D. Pharmacotherapy. 2012;32(1):54-66.
21. Clin Endocrinol (Oxf). 1997 Sep;47(3):337-42. Mortality and morbidity in transsexual subjects treated with cross-sex hormones. van Kesteren PJ, Asscheman H, Megens JA, Gooren LJ.
22. Clin Endocrinol (Oxf). 2010 Jan;72(1):1-10. Effect of sex steroid use on cardiovascular risk in transsexual individuals: a systematic review and meta-analyses. Elamin MB, Garcia MZ, Murad MH, Erwin PJ, Montori VM
23. Sex Reassignment Surgery in the Female to Male Transgender. Stan Monstrey, Peter Ceulemans, Piet Hoebeke. Semin Plast Surg. 2011. Aug 25(3): 229-244
24. Eur Urol. 2005 Mar;47(3):398-402. Epub 2004 Dec 2. Impact of sex reassignment surgery on lower urinary tract function. Hoebeke P, Selvaggi G, Ceulemans P, De Cuypere G, T’Sjoen G, Weyers S, Decaestecker K, Monstrey S
25. Br J Plast Surg. 1988 Mar;41(2):160-4. Phalloplasty using the free radial forearm flap. Matti BA, Matthews RN, Davies DM.
26. Soc Sci Med. 2013 May;84:22-9. doi: 10.1016/j.socscimed.2013.02.019. Epub 2013 Feb 19. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Poteat T, German D, Kerrigan D.
27. Medscape News by Laird Harrison, May 2013 Sex change operations mostly successful