Transgender Care

October 13, 2018

Written by Clay Smith

Caring Well

There was a helpful JAMA Internal Medicine article on caring for transgender patients this past month.  This is a hot button political and religious issue.  All that aside, these patients are coming into our EDs.  We need to know how to expertly and respectfully care for transgender patients.  All of us have different social, political, religious, and cultural backgrounds that impact the way we understand this and other LGBT issues.  So, I not only want to present information but also openly discuss some of the potential struggles we may face may face in caring for these patients. Here is a crash course to help us take great care of transgender patients.

Scope

This is a growing population.  The estimated prevalence is 390/100,000 people in the U.S.  About 33%, in one survey, reported a negative experience with a healthcare provider in the past year.  This may discourage patients from seeking care.  That’s sad and not acceptable.

Terminology

One way to respectfully care for transgender patients is to understand the terminology.  See the figure below.

Asking straightforward questions can help, such as:

• What is your gender identity?

• What is the sex listed on your original birth certificate?

• What gender pronouns do you currently use?

• What is your name?

Some struggle in the use of pronouns that do not accord with the patient’s birth sex. One way to overcome this and respectfully address the patient is to simply refer to them by their preferred name.  It is not uncommon for people to change their name or go by a nickname.  Many names could be used for a male or female.  This is one way to handle this issue of conscience.  Another is to use gender-neutral pronouns, such as “they,” “theirs,” “the patient,” or if they have an advanced degree, “Dr.”  This is a thorny ethical issue for some of us, yet one where we can find ways to make the patient feel respected. Take a look at the terminology the authors have defined below. While we may not agree on all of these definitions, it is a helpful glossary. And we can be cognizant to avoid words that may inadvertently and unnecessarily offend.

Clinical Concerns

General
There are, “higher rates of mental health disorders, substance abuse, and disability,” among transgender patients. Be very sensitive and ask about depression and suicidal ideation. We recently lost a transgender colleague and friend to suicide. It is important to ask.

Anatomy
It is also important for some aspects of clinical care to understand what surgical procedures a patient may have undergone. See figure below. The nature and types of procedures vary by individual choice. It is important to know so we can take into consideration potential complications, such as, “infection or scarring after chest surgery and frequent urinary tract infections, urethral strictures, or fistulas after genital surgery.” About 25% have undergone some type of transgender surgical procedure.

Hormone Therapy
Use of estrogens, antiandrogens, or testosterone by transgender patients may have several adverse effects, drug interactions, or may impact lab values. Below is an outstanding table that summarizes them from the article. Thromboembolic events are increased in male to female transgender patients.

Hospitalization
Respecting privacy is of paramount importance.  It is ideal to allow transgender patients to have a private room whenever possible.

Reconciling Beliefs

Many of us have Christian or other religious beliefs that affect the way we think about LGBT issues.  Sadly, some Christians have been harsh, rude, ungracious, or worse about these issues.  Some countries tolerate and may even encourage violence toward LGBT people. That is not right.  I want to be clear, the majority of Christians are people of good will who may not agree with this worldview but care very deeply about these, their friends and neighbors. The same Christian beliefs that impact my thinking about LGBT issues also invite me to love people and treat them with respect, kindness, compassion, and mercy.  There is a place to discuss the ethical and religious aspects in the right context or in the safety of friendship with a transgender person.  But the ED is probably not the place nor the time.  When a transgender patient presents to the ED, they are vulnerable and deserve the same respect and care as any other patient.  Understanding the nuances of delivering expert care to this population is our job.  This review has helped inform me to do that job a little better.

Source
Acute Clinical Care for Transgender Patients: A Review.  JAMA Intern Med. 2018 Aug 27. doi: 10.1001/jamainternmed.2018.4179. [Epub ahead of print]