Chief Complaint: Rash
Andrew is a 16-year-old transman (female-to-male, FTM) presenting with a red, painful rash of his bilateral inner thighs. On exam, you note an area in the inguinal region concerning for cellulitis. Upon questioning him alone, he reports that he began using a “STP” device 2 weeks ago. “What is a STP device?” He answers that it is a stand-to-pee device that he straps on with a waist harness in order to urinate standing, as other males do. STP devices are used by some FTM who have not had bottom surgery. They can cause skin irritation/breakdown if ill-fitting.
Transgender is an umbrella term for those whose gender identity (a person’s sense of their own gender as male, female, or some other gender) differs from their biologic sex (typically assigned at birth based on chromosomes or anatomy). Population estimates for transgender youth is not well defined. One study estimates that 0.7 to 3.2% of 13 to 18 year olds identify as transgender.1 A study from 2017 estimated that 1 in every 250 adults are transgender. 2
What’s in a name? Definitions.
There are many terms you may hear when discussing gender. Transgender can refer to an individual or a larger community, and it is an umbrella term for those whose gender identify differs from their biologic sex and from conventional notions of gender. Alternatively, cisgender is someone whose gender identity DOES match up with our cultural notions about gender. Gender identity: A personal conception of oneself as male, female, both, or neither, experienced in self-awareness or behavior. Gender expression: A person’s outward expression of gender. Gender dysphoria: Discontent a person may feel about the biological sex they were assigned at birth.
Gender and sexuality
Gender and sexuality can be viewed on a spectrum and considered fluid rather than being binary entities. They are not either/or concepts. One can be biologically male, identify with a feminine gender identify (as female), and can be attracted to and have sexual relationships with males, females or both. Gender play is a passing interest that involves playing out different gender-typical roles. Gender nonconforming youth behavior is more persistent, consistent and insistent. It is cross gender expression, wanting other gender body parts, or not liking one’s gender or body.
Transgender youth, mental health, and healthcare access
Transgender adolescents have a 2 to 3-fold increased risk of depression, suicidality, anxiety, and mental health treatment. 3 Given these risks, it is important to understand that identifying as transgender is not in and of itself a mental health disorder. It is social stigma, familial rejection, and social isolation that contribute to the higher rates of mental health issues. Research shows that with acceptance and access to healthcare to help transition, youth are protected from gender dysphoria and reactive depression. 4 Lack of access to accepting and transgender friendly health care services is also a barrier to health for transgender youth. One study revealed that 52% of patients who presented to an ER experienced trans-specific negative experiences, while another showed that 13% of transgender patients were denied equal treatment in an ER setting due to their gender identity/expression. 5,6
How should we communicate with our patients? Language is important so that we can communicate with our transgender patients in a way that is respectful and affirming.
Conversations can start with something as simple as asking, “Do you feel more like a girl, boy, neither, both?” “What name or pronoun fits you/do you prefer?” When examining a patient, use non sex-specific terms. Going back to the initial patient vignette, one may say to Andrew, a FTM teen, “I need to perform a genital exam,” instead of “I need to perform a vaginal” exam. Use the word “chest” vs. “breast,” “genital” vs. “vaginal or penile.” When speaking with transgender patients, ask questions necessary to assess the issue, but avoid unrelated probing. “What’s your anatomy and what surgeries have you had? I need to know this information in order to best treat you.” If you have a patient who presents with a broken finger, it is unnecessary to ask about their reproductive anatomy.
What might we expect from a patient who is transitioning?
Chief complaint: Chest pain, shortness of breath, and URI symptoms
Jenny is a 17-year-old transwoman (male-to-female, MTF) on estrogen therapy. She has a PMH of moderate persistent asthma. What is her risk of a pulmonary embolus?
Phenotypic transitioning occurs in phases: reversible, partially reversible, irreversible, and surgical. The reversible portion of transition includes the adoption of preferred gender hairstyles, clothing, play, perhaps a new name and suppression of biologic gender puberty using GnRH analogues (defined below). The portions of the reversible phase that do not involve suppression of puberty will sometimes occur before the age of ten. Some children may begin GnRH analogues at around age 12 or 13, when they are still Tanner Stage 2, and initiate hormones several years later. GnRH analogues lead to fully reversible changes, provide extra time for psychotherapy and a relief of their gender dysphoria. They prevent secondary sex characteristics that would have required more invasive intervention later. Partially reversible changes are brought about with hormone therapy, which is offered in most centers around age 15 or 16, and irreversible changes with surgery, typically not before age 18.
All medications have potential side effects and risks, and it is important for providers on the front lines in primary care and urgent/emergency care know what those potential risks are. However, it is important to frame the risks and benefits of treatment for transgender youth in light of the risks of depression, anxiety, and suicide that youth without treatment face. Studies support the mental health of trans youth being much improved with appropriate, early access to health care including the medications discussed below.
GnRH analogues stop puberty. There are few side effects aside from injection pain and withdrawal bleed if menstruating. Estrogens induce the development of female secondary sexual characteristics. The greatest risk for estrogen therapy is the 20-45 fold increase of venous thromboembolism (VTE). 2-6% of hormonally treated MTF patients experience a VTE. Other lower risk, possible complications include prolactinomas, pituitary adenomas, hypertension, hypertriglyceridemia causing pancreatitis, gall bladder and liver disease, and the potential biological female risk of breast cancer. Anti-androgens reduce the effects of endogenous male sex hormones. Most pertinent are spironolactones causing hyperkalemia, hypotension, or ataxia. Testosterone induces the development of male secondary sexual characteristics. Risks include hepatotoxicity, insulin resistance, weight gain, decreasing high-density lipoproteins (HDL), increasing triglycerides and homocysteine levels, and polycythemia. There is a theoretical risk of breast cancer and endometrial cancer (testosterone is aromatized to estrogen), so patients who have chest or genital symptoms need workup appropriate to their anatomy.
Transgender youth flourish
Research shows that transgender people report numerous positive aspects related to successful transitioning. 7 Familiarizing yourself with local resources (medical, mental health, peer and parent support groups) and learning more about transgender youth will help to create a more supportive health care system for trans youth and their families for successful transitioning.
Last words from experts in the field of transgender care
- Lack of trans friendly health services, transphobia, and real or perceived prejudice and discrimination lead to mental health disorders and undertreatment of medical conditions.
- Transgender kids need love and acceptance by family, school, and community, like all teens.
- Using incorrect names or pronouns and misgendering IS a big deal to patients, and we all need to help systems counteract or eliminate this.
Local Physicians Accepting Referrals of Transgender Youth
- Comprehensive care of transgender youth: David Levine, MD, Morehouse Healthcare, 1800 Howell Mill Rd, Atlanta, Georgia 30318, 404) 756-1400
- Comprehensive care of transgender youth: Isabel Lowell, MD, MBA QMed,Website: queermed.com, Email: firstname.lastname@example.org, Office phone: 404-445-0350
- For medications only: Leonidas Panagiotakopoulos-CHOA Endocrinology-404-785-KIDS
- Feminist Women’s Health Center (Atlanta): http://www.feministcenter.org/en/health-wellness-services/trans-health-initiative
- CDC: gov/lgbthealth/transgender.htm
- National Center for Transgender Equality: transequality.org
- The National LGBT Health Education Center: lgbthealtheducation.org
- Center of Excellence for Transgender Health: transhealth.ucsf.edu
- The Fenway Guide to LGBT Health, American College of Physicians: amazon.com/Fenway-Lesbian-Bisexual-Transgender-Health/dp/193051395X
- Transgender Law Center: Health Care Issues: transgenderlawcenter.org/issues/health
- Herman JL, et al. “Age of Individuals Who Identify as Transgender in the United States.” The Williams Institute, UCLA School of Law. January 2017.
- Meerwijk EL, et al. “Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.” Am J Public Health, 2017;107:e1-8.
- Reisner SL, et al. “Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study.” J Adolesc Health. 2015;56:274-79.
- Ryan C, et al. “Family Acceptance in adolescence and the health of the LGBT Young Adults.” J Child Adolesc Psychiatr Nurs. 2010;23:205-13.
- Bauer GR, et al. “Reported Emergency Department Avoidance, Use, and Experiences of Transgender Persons in Ontario, Canada: Results From a Respondent-Driven Sampling Survey.” Ann Emerg Med. 2014;63:713-720.
- Grant, JM et al. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011.
- Riggle, ED et al. “The Positive Aspects of Transgender Self-Identification.” Psychol Sex, 2011;2:147-58