POTD: The Transgender Patient

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FAST FACTS

  • A transgender person is someone whose gender identity differs from their sex assigned at birth

  • “Gender identity” is self-identified and different from “sex” (i.e. “Sex is what’s between your legs, gender is what’s between your ears”)

  • Some people identify outside of the male-female binary (gender nonbinary, or gender fluid) and this includes people who identify as both, neither, or in between

  • Transgender identity is not a mental disorder 

  • 28% of transgender patients report postponing necessary medical care due to prior negative experiences

  • 19% of transgender patients reported being denied care because they are transgender


HOW TO GREET THE TRANSGENDER PATIENT

  • “Hello, My name is Dr. ____________. What name do you go by? What pronouns do you use?”


PATIENT HISTORY and EXAMINATION

  • Prepare the patient for difficult questions by contextualizing why you’re asking them

  • Ask about gender-affirming hormones and surgeries if relevant

  • Determine sexual activity and pregnancy risk

  • As with any patient, do not perform invasive physical exams if not medically warranted (i.e., don’t do a genital exam on a patient presenting with a nose bleed)


HORMONES

  • Not every patient uses hormones for a variety of reasons, including lack of access

  • Masculinizing hormone: Testosterone - suppresses menses, increases libido, increases clitoral size, deepens voice, produces male pattern fat, muscle, and hair distribution, increases energy

  • Feminizing hormones: 17-beta-estradiol and anti-androgens such as spironolactone, finasteride, and gonadotropin-releasing hormone analogues

  • Testosterone does not provide a form of birth control


GENDER-AFFIRMING HORMONE THERAPY-RELATED COMPLICATIONS

  • Masculinizing Hormone Therapy

    • Erythrocytosis - can increase risk of VTE and cerebrovascular disease

  • Feminizing Hormone Therapy 

    • Hypercoagulability (VTE)

    • Electrolyte imbalances (hyperkalemia with spironolactone use)

    • Prolactinoma

    • Cardiovascular disease risk increase

  • Non-medically prescribed hormones

    • Patients may take these due to lack of access

    • Shared injectable hormones increase risk of HIV and hepatitis

    • Birth control pills often used in place of prescribed estrogen


ISSUES AFFECTING TRANSGENDER PATIENTS

  • HIV and other STIs

  • Substance abuse (drug and alcohol)

  • Mental health disorders (depression, anxiety, SI)

  • Physical assault

  • Homelessness

Source: Tintinalli's Emergency Medicine, 9th Edition pp 1997-2000

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