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    ED Trans Care – The Transition Process

    Special Populations

    Last Updated Feb 05, 2021
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    Background

    Transition

    When speaking about the care of transgender patients, the term transition is used to denote the process by which the patient alters their body, hormones, and/or gender expression to match their gender identity. This can occur socially, medically and surgically. A transgender person’s health trajectory is typically defined by their transition, which does not look the same for everyone.

    Gender Dysphoria

    It is impossible to discuss the process of transition without also discussing gender dysphoria. According to the DSM-V (5th ed.; DSM–5; American Psychiatric Association, 2013), gender dysphoria is “a marked incongruence between one’s experienced/expressed gender and their assigned gender”. This can manifest in many ways and can be very distressing for patients. The only definitive treatment for gender dysphoria is transition, although counselling and psychiatric treatment can also help alleviate symptom burden.

    It is important to note that while gender dysphoria is listed in the DSM-V, being transgender is not in itself a mental health issue or diagnosis. Patients can only be diagnosed with gender dysphoria if their identity causes “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. Transgender people who grow up in supportive homes and societies will often experience little to no gender dysphoria due to reduced stigma and increased access to appropriate medical care.

    Progress and Continued Understanding

    There has been great progress in recent decades in patients’ ability to access the appropriate resources to transition. In a recent survey of trans youth in BC, 83% currently lived in their “felt gender” at least half the time, and 50% full time. Those who had transitioned were 50% more likely to report good or excellent mental health. Transition is the widely accepted treatment for gender dysphoria. In the ED, we see patients are at all stages of the transition process. It is important to understand the steps in a transition and support patients in accessing the resources they need to do so.

    The Transition Process

    There are three main components of a potential transition: social, medical and surgical. A trans person may choose to complete one, some, all or none of these.

    Social Transition

    A social transition is a process by which a patient begins to present as their desired gender and can occur without any medical or surgical intervention. Social transitions often involve changing names and pronouns, dressing differently or changing hair and makeup habits. You may sometimes hear patients describe this time in their lives as when they began “living as” their true gender. These social interventions are especially common as isolated treatment choices in transgender youth whose goals may not include more definitive hormonal or surgical treatments. A social transition alone can often greatly relieve many symptoms of gender dysphoria. For 20-40% of transgender people, this is the only intervention they desire.

    Healthcare providers must recognize patients who have undergone a social transition and interact with them in their self-identified gender. This is especially true in cases where their stated gender identity and name conflict with those listed on their documentation. This is a very common problem, especially when legal identification is required, as this is very difficult to change. Failure to use a patient’s chosen name and gender identity can greatly stigmatize and traumatize patients by triggering feelings of gender dysphoria.

    Medical Transition

    For about half of trans people, their transition will also include medical treatments. Pre-pubertal children may receive “puberty blockers”, like leuprolide injections. These suppress puberty and its permanent changes to allow further workup, combat dysphoria, or allow children to develop the appropriate ability to consent to non-reversible treatments.

    In patients able to provide informed consent (including medically mature minors), estrogen or testosterone can be used as a lifelong treatment to generate secondary sexual characteristics more congruent with their gender identity. Other treatments may be used as adjuncts, such as finasteride for those people assigned male at birth who do not want to experience male patterned baldness.

    A medical transition can easily be overseen by primary care providers, although endocrinology or the gender clinic are often involved due to lack of provider training and comfort. It is not uncommon to see these medications on the medical record of your transgender patients, and recognizing them can be an essential step in providing safe care.

    Surgical Transition

    For a smaller proportion of trans people, surgeries are a part of the transition process. We refer to these as gender affirming surgeries or gender confirming surgeries. They bring a person’s primary sexual characteristics in line with their gender identity. There are many different surgical procedures that transgender patients may receive.

    Generally, surgical transitions can be divided into “top” and “bottom” surgery. These are the terms most often used by patients to describe their surgical transition. Top surgery consists of breast reductions or augmentation. It may be easier to access, as many general surgeons can perform it, but not all surgeons are willing to do so. Bottom surgery includes orchiectomy, vaginoplasty, hysterectomy, phalloplasty, etc. and is often much more difficult to access. While many gynecologists and urologists can perform hysterectomies and orchiectomies, constructive surgeries such as vaginoplasties and phalloplasties are only performed by a few surgeons in this country, who have universally long waitlists. As such, accessing these surgeries can be a lengthy, complicated, expensive, and exhausting process for trans people.

    Although gender affirming surgeries are not always necessary to achieve each trans person’s gender goals, they can dramatically improve some patient’s gender dysphoria.

    Transition Endpoint

    Many genderqueer individuals seek an endpoint outside of the binary of male and female. These patients may proceed through some, all or none of the processes listed above. They may modify their gender in ways that are outside of cultural expectations and norms. It is important to keep this in mind when interacting with patients, and not to assume that their end goal is a specific or typical gender presentation.

    Notes on the Transition Process

    Transgender Youth

    When caring for a transgender child or teen, no matter what stage of transition they are in, confidentiality is even more important than usual. Unfortunately, it is common that children who come out as trans (either intentionally or unintentionally) immediately face profoundly negative consequences, including loss of family support or access to shelter. A more detailed social history is often warranted to explore the extent to which they are out to their family and friends, and if those people are supportive. Be extra mindful of enforcing confidentiality contracts, interviewing without parents in the room. Inform others (including other ED staff) of a transgender child’s identity only if relevant to the patient’s presenting complaint and with their explicit consent.

    Referrals

    In some cases, the ED is the first contact that a transgender child may have with the healthcare system, representing an opportunity in this child’s care. If you see a transgender child who has not yet begun their transition but wishes to do so, or is experiencing significant gender dysphoria, it is important to offer timely referrals to the gender clinic at BC Children’s Hospital or to another trans competent provider. This is especially relevant for peri-pubertal children, as some elements of transition are time sensitive in this age group. Parental education and support might be helpful, including sharing resources and assessing a child’s safety in the home.

    Mental health screening may also be considered at this time, especially for eating disorders. Trans youth are significantly more likely to experience eating disorders, including using their weight to modify their bodies to be more congruent with their gender identity.

    Mental Health and Transition

    Most transgender people go on to live happy, healthy lives. However, due in part to our cultural climate and pervasive experiences of stigma and discrimination, being trans is strongly associated with many psychosocial issues including depression, self harm and suicide.

    30-40% of trans people report at least one suicide attempt. Those with an unsupportive family (which 70% of trans youth in Canada report) have an even higher risk. Furthermore, homelessness and substance use are common in trans youth, often secondary to familial rejection. An appropriate transition combined with access to safe and gender-inclusive care can drastically reduce the negative mental health outcomes experienced by transgender patients.

    Access to Appropriate Resources

    Access to appropriate primary care is severely lacking for transgender patients. Only about 15% of trans youth in BC report having a family doctor they feel comfortable discussing their needs with. This can profoundly affect access to transition services such as medications or timely referral for gender affirming surgeries, and place patients at increased risk. As a result, it is also not uncommon for patients to be using non-prescribed hormones from friends, relatives, or unregulated online sources. Without the guidance of a trusted professional or a regulated pharmacy, the quality, dosing and safety of these unsupervised treatments can substandard. Our role in the ED is to ask our patients if they have access to a sustainable supply of medication and refer them to someone who can provide it if they do not.

    Although less relevant to the ED, transgender people also need appropriate primary care screening, like colonoscopies for trans women and pap tests for trans men. We can remind our patients of this when we see them, as we would with any other patients noted to have improper access to primary care.

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