Acute Clinical Care for Transgender Patients: A Review

Sexual Assault Nurse Examiner Knowledge and Confidence in Providing Care for Transgender Patients Following Sexual Assault

The transgender population experiences disproportionate rates of sexual assault (SA) compared with the cisgender population. Sexual assault nurse examiners (SANEs) have specialized education to provide care to victims of SA across the lifespan; however, training related to the care of transgender individuals following sexual assault is not always represented in SANE education. This leads to a lack of knowledge and confidence in providing care to transgender victims and can result in inequitable care and poor outcomes. To explore forensic nurses' knowledge and confidence in the care of the transgender population following SA, a descriptive, cross-sectional survey design was employed and distributed to two professional forensic nursing organizations. A total of 240 survey responses were received. The majority of participants reported that content related to transgender sexual assault (TGSA) was not part of their SA education. Nearly 60% perceived their knowledge and confidence in providing TGSA care as "beginner" or "developing" and almost all "agree" or "strongly agree" that additional TGSA education would be beneficial to them. As over half of participants have provided care to a TGSA patient and more than 80% expect to provide care in the future, it is imperative include standardized content related to TGSA care as part of core SANE curriculum and to offer continuing education to address the gap in current SANE TGSA knowledge and practice.

Nuances of gender affirming therapy for transgender women with spinal cord injury

CASE DESCRIPTION

56-year-old transgender woman with new spinal cord injury (SCI) on gender affirming hormonal therapy (GAHT) with estrogen and spironolactone.

FINDINGS

After her injury, estrogen and spironolactone were discontinued, for blood clots and hypotension, respectively. Alternative options were explored.

CLINICAL RELEVANCE

Little is known about GAHT in SCI for transgender women. Shared decision making should be used to navigate risks, benefits, and alternative options.

Identifying Strategies for the Use of Gender and Sex Language in Clinical One-Liners

Purpose: The "one-liner," commonly used in clinical communications, summarizes a patient's identity, presenting condition, medical history, and clinical findings. Imprecise, inconsistent use of gender and sex information in one-liners threatens the provision of affirming care to transgender, nonbinary, gender-expansive, and intersex patients and may exacerbate health care disparities. This study aimed to generate guidance for communicating gender and sex information in one-liners. Methods: This is an explanatory sequential, equal status mixed methods study of transgender, nonbinary, gender-expansive, and intersex people and clinicians caring for this population. Survey participants rated one-liners on a five-point Likert-type scale of appropriateness, considering affirmation and clinical utility, and provided open-ended comments. We conducted two focus groups with survey respondents to explore survey results and performed a thematic analysis of survey comments and focus group transcripts. Results: Survey respondents included 57 clinicians and 80 nonclinicians. One-liners containing patient pronouns were rated most appropriate, and appropriate patient descriptors included self-described gender identity or gender-neutral terms. In scenarios where patient sex information was not pertinent to the chief concern (CC), one-liners containing no sex information were rated most appropriate. Four themes were identified: inclusion of sex information based on relevance to the CC, accurate patient representation, influence of clinical setting, and risk of harm from inaccurate one-liners. Conclusion: This study generated data to support the appropriate use of gender and sex language in one-liners. Clinicians, educators, and trainees may use these findings to compose one-liners that are affirming and clinically useful for patients of diverse gender and sex identities.

Endometriosis in Transgender Men: Bridging Gaps in Research and Care-A Narrative Review

Endometriosis is a debilitating gynecological condition commonly seen in individuals designated female at birth; however, there has been limited research focused on its prevalence and impact among transgender men. This narrative review aims to fill a critical knowledge gap by exploring the epidemiology, clinical manifestations, management strategies, and quality-of-life implications of endometriosis among transgender individuals who identify as male. Specifically, this study seeks to estimate the prevalence rates and describe the symptoms experienced by transgender men undergoing testosterone therapy. Additionally, it addresses the diagnostic challenges posed by hormonal treatments and the lack of culturally competent healthcare services for this population. Recent molecular studies indicate that hormonal imbalances, such as increased estrogen synthesis and progesterone resistance, are significant factors in the persistence of endometriosis symptoms despite testosterone therapy. Moreover, evidence suggests that testosterone therapy may not always suppress endometrial activity completely, contributing to the persistence of symptoms in some individuals. Endometriosis in transgender men requires personalized approaches that consider both testosterone therapy and its interactions with endometriosis, as well as fertility preservation and the psychosocial aspects of treatment. This review emphasizes the necessity of taking an inclusive approach in both research and clinical practice to improve healthcare outcomes for this underserved population. The results demonstrate how continued research, education, and healthcare services tailored specifically to transgender men are necessary to better understand and treat endometriosis, thus improving both their overall health and quality of life.

Toward a Better Understanding of Cardiovascular Risk in the Transgender and Gender-Diverse Community: A Global Call to Action

On World Heart Day 2022, the Mexican Society of Cardiology, the Inter-American Society of Cardiology, and the World Heart Federation collaborated on a public call to action regarding the increased risk of adverse cardiovascular health outcomes in transgender and gender diverse (TGD) individuals. The aim of this article is to unpack the numerous factors that contribute to this, such as the social stigma faced by members of the TGD community, their reduced access to clinical care, and the scarcity of research regarding the unique needs of their community, which makes it difficult for clinicians to provide individualized medical care. Decreasing the incidence of adverse cardiovascular events among TGD individuals requires interventions such as educational reform in the medical community, an increase in inclusive research studies, and broader social initiatives intended to reduce the stigma faced by TGD individuals.

Ethical considerations for the nursing care of Transgender patients in the Intensive Care Unit

There is more discussion than ever surrounding the health and care needs of Transgender communities. However, there is limited research on the care of Transgender patients in the Intensive Care Unit which can contribute to knowledge gaps, inconsistencies and uncertainties surrounding health care practices. This article is not intended to address all of the specific needs of Transgender patients in ICU, but to explore the ethical considerations for caring for a Transgender woman in the ICU. In doing so, this article will explore some specific considerations around gender affirming care, challenging discrimination, physiological changes, and systems change to enhance care.

Management of Urologic Complications After Genital Gender-Affirming Surgery in Transgender and Nonbinary Patients

Transgender and nonbinary (TGNB) patients are a population with unique urologic needs that are often overlooked in urologic training. Most urology residents think that learning to take care of this population is important in their training; however, there is much variation in this educational content within urology residency programs. This review provides information on the current state of teaching regarding the unique needs of caring for TGNB patients as urologists and overviews some basic principles that every urologist should know.

Cardiovascular disease in transgender individuals

The population of people identifying as transgender has grown rapidly in recent years, resulting in a substantive increase in individuals obtaining gender-affirming medical care to align their secondary sex characteristics with their gender identity. This has established benefits for patients including improvements in gender dysphoria and psychosocial functioning, while reducing adverse mental health outcomes. Despite these potential advantages, recent evidence has suggested that gender-affirming hormone therapy (GAHT) may increase the risk of cardiovascular disease. However, owing to a paucity of research, the mechanisms underpinning these increased risks are poorly understood. Moreover, previous research has been limited by heterogenous methodologies, being underpowered, and lacking appropriate control populations. Consequently, the need for evidence regarding cardiovascular health in LGBTQ + individuals has been recognised as a critical area for future research to facilitate better healthcare and guidance. Recent research investigating the effect of transmasculine (testosterone) GAHT on cardiovascular disease risk points to testosterone effecting the nitric oxide pathway, triggering inflammation, and promoting endothelial dysfunction. Equivalent studies focussing on transfeminine (oestrogen) GAHT are required, representing a crucial area of future research. Furthermore, when examining the effects of GAHT on the vasculature, it cannot be ignored that there are multiple factors that may increase the burden of cardiovascular disease in the transgender population. Such stressors include major psychological stress; increased adverse health behaviours, such as smoking; discrimination; and lowered socioeconomic status; all of which undoubtedly impact upon cardiovascular disease risk and offers the opportunity for intervention.

Cardiovascular Risk Factors in Transgender People after Gender-Affirming Hormone Therapy

INTRODUCTION

In the last decade, healthcare for the transgender population has increased considerably in many countries thanks to depathologization movements and the easier accessibility of medical assistance. The age at which they request to start gender-affirming hormones (GAHs) is increasingly younger. The cardiovascular risk associated with hormonal treatment is a novel research field, and the published studies are heterogeneous and inconclusive. Our objective is to determine the metabolic impact of GAHs in the transgender people treated in our Gender Identity Treatment Unit.

METHODS

We designed a pre-post study to analyze changes in anthropometric parameters (weight and body mass index), analytical determinations (fasting blood glucose, glycated hemoglobin, and lipoproteins), and blood pressure control in the transgender population treated with GAHs in Puerta del Mar University Hospital. These variables were collected before and one year after hormonal therapy.

RESULTS

A total of 227 transgender people were recruited between 2017 and 2020, 97 (40.09%) transwomen and 136 (59.91%) transmen. The average age at which GAHs began was 18 years. Weight, body mass index, and blood pressure increased significantly in both genders. Transmen showed a more atherogenic lipid profile, with a decrease in cholesterol LDL (p < 0.001) and an increase in triglycerides (p < 0.001). The risk of developing prediabetes or diabetes did not increase one year after treatment, although non-specific alterations in carbohydrate metabolism were detected, such as an increase in glycated hemoglobin in transmen (p = 0.040) and fasting blood glucose in transwomen (p = 0.008). No thromboembolic processes or cardiovascular events were reported during the first year of treatment.

CONCLUSION

In our setting, transgender people developed changes in their metabolic profiles in the first year after hormonal treatment. Both transmen and transwomen showed early alterations in lipid and carbohydrate metabolism, slight elevations in blood pressure, and a tendency to gain weight. This makes lifestyle interventions necessary from the beginning of GAHs.

Management of transgender patients in critical care

As clinicians working in critical care, it is our duty to provide all of our patients with the high-quality care they deserve, regardless of their gender identity. The transgender community continues to suffer discrimination from the media, politicians and general public. As healthcare workers we often pride ourselves on our ability to safely care for all patients. However, there remains a distinct lack of understanding surrounding the care of critically ill transgender patients. This is likely in part because the specific care of transgender patients is not included in the Faculty of Intensive Care Medicine's, Royal College of Anaesthetists', Royal College of Physician's, or Royal College of Emergency Medicine's curriculum. There are several important considerations relevant for transgender patients in critical care including anatomical changes to the airway, alterations to respiratory and cardiovascular physiology and management of hormone therapy. Alongside this, there are simple but important social factors that exist, such as the use of patient pronouns and ensuring admittance to correctly gendered wards. In this review we will address the key points relevant to the care of transgender patients in critical care and provide suggestions on how education on the subject may be improved.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Emergency Medicine Considerations in the Transgender Patient

Transgender patients are at high risk for poor health outcomes and many harbor fear of healthcare settings secondary to prior discrimination, perceived sensationalism, clinician unfamiliarity, and unwanted exams. It is essential to approach transgender patients without judgement and with empathy. Asking open ended questions with explanation as to why your questions are pertinent to their specific care will help create rapport and trust. Through a basic working knowledge of terminology, types of hormone therapy, non-surgical techniques, garments, and surgical procedures typically encountered by such patients, and their respective potential side effects and complications, clinicians can provide quality care to transgender patients.

Headache prevalence in transgender and gender diverse youth: A single-center case-control study

OBJECTIVE

Assess the prevalence of headache in transgender and gender-diverse adolescents, comparing prevalence with and without exposure to gender-affirming hormone therapy.

BACKGROUND

Transgender and gender-diverse youth are an understudied group in whom we can study the effects of sex steroids on adolescents' development of headache. We hypothesized that transfeminine adolescents treated with estrogen would have higher odds of headache than those not treated, and that transmasculine adolescents treated with testosterone would have lower odds of headache than those not treated.

METHODS

This retrospective case-control study analyzed all patients seen at the Boston Children's Hospital Gender Multispecialty Service clinic from 2007 to 2017. Cases were defined as patients with headache, controls as those without headache, and exposure as treatment with gender-affirming hormone therapy (i.e., estrogen or testosterone). A computerized search identified cases that were then validated by chart review.

RESULTS

Fifty-two of the 763 transgender and gender-diverse patients seen were confirmed to have headache. Of 273 transfeminine patients 45% (123/273) received estrogen treatment. Transfeminine patients receiving estrogen were more likely to have headache than those not receiving estrogen (7% [9/123] vs. 1% [2/150]; odd ratio [OR] 5.84 (95% confidence interval [CI] 1.24-27.6), p = 0.026). Of 490 transmasculine patients, 46% (227/490) received testosterone. Transmasculine patients receiving testosterone were more likely to have headache than those not receiving testosterone (12% [28/227] vs. 5% (13/263); OR 2.71 (95% CI 1.37-5.4), p = 0.005).

CONCLUSION

Among transfeminine and transmasculine youth, those who received gender-affirming hormone therapy had higher odds of headache compared to those not taking gender-affirming hormone therapy. Further prospective studies to guide headache care of transgender and gender-diverse youth and adults are needed. Our results could be generalizable to other pediatric gender management clinics and may be worth discussing with patients considering treatment.

The Complexity of Trauma for LGBTQ+ People

Trauma care is complex. Acute and critical care clinicians perceive trauma as a skilled response to critical injury or accident that occurs to patients, but trauma exists on many levels. One of those is a grim reality for patients who are lesbian, gay, bisexual, transgender, queer or questioning, and from other sexual and gender minorities (LGBTQ+). A lifetime of trauma through stigma, discrimination, and victimization is too often present. Owing to distrust of the health care system and clinicians, LGBTQ+ experience health and health care disparities.

Improving the inclusion of transgender and nonbinary individuals in the planning, completion, and mobilization of cardiovascular research

Cardiovascular disease is the leading cause of morbidity and mortality globally. Transgender and nonbinary (TNB) individuals face unclear but potentially significant cardiovascular health inequities, yet no TNB-specific evidence-based interventions for cardiovascular risk reduction currently exist. To address this gap, we propose a road map to improve the inclusion of TNB individuals in the planning, completion, and mobilization of cardiovascular research. In doing so, the adoption of inclusive practices would optimize cardiovascular health surveillance and care for TNB communities.

Diagnosis, Treatment, and Prevention of Stroke in Transgender Adults

Purpose of Review

To identify the current state of science on stroke in transgender adults and highlight gaps in need of further research. We will review current research on cerebrovascular risk and disease, hormone therapy, and stroke in transgender individuals. Finally, we will provide a framework for healthcare providers to prevent and reduce disparities through inclusive care practices.

Recent Findings

Transgender people experience unique stroke risk factors, secondary to both psychosocial stress and health-related behaviors. These include higher rates of HIV, tobacco use, stimulant use, and hepatitis C. The use of gender-affirming hormone therapy may lead to an increased risk for ischemic stroke, but the data are limited and require further research.

Summary

Recent research has highlighted the numerous healthcare disparities faced by transgender individuals. Regarding stroke disparities, these are multifactorial and include contributions from health-related behaviors, inadequate access to care, the use of hormonal therapy, and minority stress. Further research is needed to increase access to care and reduce the substantial gap in outcomes for these individuals.

Recommendations to Address the Unique Clinical and Psychological Needs of Transgender Persons Living With Multiple Sclerosis

BACKGROUND

People living with multiple sclerosis (MS) face challenges coping with chronic illnesses, and transgender (TGD) persons living with MS may experience additional unique challenges and barriers to care. Medical biases toward TGD people are widely reported, and best practices in TGD MS care have not been identified.

METHODS

A case report of a TGD person living with MS is reviewed that helped to identify and inform us regarding the unique aspects of their clinical and psychological care needs. We conducted a systematic review of the literature according to the standard methods in PubMed. The literature was reviewed and summarized for relevant topics related to the unique care needs of TGD persons living with MS, and proposed care recommendations were created.

RESULTS

We used the aforementioned case to identify and inform the special care needs and subsequently describe proposed recommendations to achieve inclusive comprehensive care of TGD persons with MS. The importance of providing an inclusive environment, comprehensive care, mental health screening, domestic violence screening, and case coordination are highlighted with the goal of providing best practice recommendations for the comprehensive inclusive care of TGD persons living with MS.

CONCLUSIONS

The lack of published guidance on the care of TGD persons living with MS and our informative case have led to the proposed recommendations for the care of TGD persons living with MS.

Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk

Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.

USPSTF Approach to Addressing Sex and Gender When Making Recommendations for Clinical Preventive Services

Clinical preventive service recommendations from the US Preventive Services Task Force (USPSTF) are based on transparent, systematic, and rigorous methods that consider the certainty of the evidence and magnitude of net benefit. These guidelines aim to address the needs of diverse populations. Biological sex and gender identity are sources of diversity that are not often considered in studies of clinical preventive services that inform the recommendations, resulting in challenges when evaluating the evidence and communicating recommendations for persons in specific gender identification categories (man/woman/gender nonbinary/gender nonconforming/transgender). To advance its methods, the USPSTF reviewed its past recommendations that included the use of sex and gender terms, reviewed the approaches of other guideline-making bodies, and pilot tested strategies to address sex and gender diversity. Based on the findings, the USPSTF intends to use an inclusive approach to identify issues related to sex and gender at the start of the guideline development process; assess the applicability, variability, and quality of evidence as a function of sex and gender; ensure clarity in the use of language regarding sex and gender; and identify evidence gaps related to sex and gender. Evidence reviews will identify the limitations of applying findings to diverse groups from underlying studies that used unclear terminology regarding sex and gender. The USPSTF will use gender-neutral language when appropriate to communicate that recommendations are inclusive of people of any gender and will clearly state when recommendations apply to individuals with specific anatomy associated with biological sex (male/female) or to specific categories of gender identity. The USPSTF recognizes limited evidence to inform the preventive care of populations based on gender identity.

Experiences and Perspectives of Transgender Youths in Accessing Health Care: A Systematic Review

IMPORTANCE

Transgender and nonbinary youths have a higher incidence of a range of health conditions and may paradoxically face limited access to health care.

OBJECTIVE

To describe the perspectives and needs of transgender youths in accessing health care.

EVIDENCE REVIEW

MEDLINE, Embase, PsycInfo, and the Cumulative Index to Nursing and Allied Health Literature were searched from inception to January 2021. Qualitative studies of transgender youths' perspectives on accessing health care were selected. Results from primary studies were extracted. Data were analyzed using thematic synthesis.

FINDINGS

Ninety-one studies involving 884 participants aged 9 to 24 years across 17 countries were included. We identified 6 themes: experiencing pervasive stigma and discrimination in health care, feeling vulnerable and uncertain in decision-making, traversing risks to overcome systemic barriers to transitioning, internalizing intense fear of consequences, experiencing prejudice undermining help-seeking efforts, and experiencing strengthened gender identity and finding allies. Each theme encapsulated multiple subthemes.

CONCLUSIONS AND RELEVANCE

This review found that transgender youths contend with feelings of gender incongruence, fear, and vulnerability in accessing health care, which are compounded by legal, economic, and social barriers. This can lead to disengagement from care and resorting to high-risk and unsafe interventions. Improving access to gender-affirming care services with a cultural humility lens and addressing sociolegal stressors may improve outcomes in transgender and nonbinary youths.

Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents

Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.

Overview of Medical Management of Transgender Men: Perspectives from Sri Lanka

Transgender medicine is an evolving field of medicine due to the rising awareness of individuals with a non-binary gender identity. Individuals with nonconforming gender identities have been on the rise in many societies and it is becoming an increasingly discussed issue. Their management is multidisciplinary, which includes mental health, endocrine therapy, and surgery. Although their general healthcare needs are similar to those of the general population, special considerations in primary and preventive care are also necessary in relation to the gender-affirming medical issues. Their quality of life is largely affected by psychological, social, and economic difficulties they face due to acceptance issues in the society and healthcare. This review explores the primary care, medical, and surgical management of transgender men with perspectives from Sri Lanka.

On the Basis of Gender: A Medical-Legal Review of Barriers to Healthcare for Transgender and Gender-Expansive Patients

Transgender individuals will seek medical intervention for transition-related services as well as medical treatment for general health needs similar to cisgender individuals. However, people in the transgender community face unique barriers to treatment such as the lack of knowledge among health-care professionals, insurance coverage, and legal protections. This paper reviews barriers, major legal cases, and federal policy related to the health needs for transgender and gender expansive individuals. The authors call for a social work response at the macro and micro level. Advocacy for health care access for transgender individuals is a social justice issue social workers are uniquely positioned to work toward. At the micro level, social workers must help educate and advocate for their clients to bring transgender-sensitive practices to the health care system.

Headache in transgender and gender-diverse patients: A narrative review

OBJECTIVE

To summarize the unique aspects of managing headache in gender minorities and current research in this area including the potential relationship between gender-affirming hormone therapy (GAHT) and headache.

BACKGROUND

The study of headache in gender minorities is intrinsically important. Gender minorities are medically underserved, and their medical care to date has been limited by socioeconomic disadvantages including stigma and an unsupportive clinical environment. Despite the rising population of transgender and gender-diverse adults and youth, headache research has also been limited. Knowledge of hormonal effects on headache in cisgender patients raises the question of possible effects of GAHT on transgender patients.

METHODS/RESULTS

The manuscript is a narrative review of current best practices in treating transgender patients, including the use of appropriate terminology and ways to create a supportive environment. It also contains current guidelines on GAHT and reviews drug-drug interactions and secondary headache related to hormone therapy. We also review transgender headache research and related research on hormonal effects on headache in cisgender individuals.

CONCLUSION

Creating a supportive environment for transgender and gender-diverse patients and being knowledgeable about GAHT are key to providing quality headache care. This review identifies further research needs for this population including the epidemiology of headache disorders in sexual minorities and the potential effects of GAHT on headache disorders in transgender patients.

The process of transitioning for the transgender individual and the nursing imperative: A narrative review

AIMS

The objectives of this study were to bring the experience of the transitioning process for the transgender population to the nursing profession and address the lack of knowledge to promote improved patient outcomes.

DESIGN

This study used a narrative review using the literature matrix method. Because of the dearth of trans specific literature, editorials and monologues were included.

DATA SOURCE

A broad search was undertaken across all databases including CINAHL, PubMed, PsycINFO, Ovid MEDLINE, ProQuest Nursing & Allied Health and Google Scholar. Literature from June 1994 to May 2020 was appraised. Non-peer reviewed literature and published texts were procured via Google Alerts.

REVIEW METHODS

Selection for inclusion was based on credibility and relevance from a variety of social science disciplines. A narrative analysis was used to identify common themes, incongruencies in schools of thought and perspectives that require consideration.

RESULTS

Analysis of the literature revealed the following themes: (a) literature and terminology evolution, (b) transitioning as a process, (c) medicalization of transitioning, (d) generational views on transitioning and (e) needs during transition.

CONCLUSION

This review highlights key issues about the transitioning process imperative to nursing when meeting the needs of the transgender population.

IMPACT

This review addresses the lack of trans specific literature and lack of consistency in the literature about the understanding of the transitioning process for the transgender population. Main findings? Terminology to explain the transitioning process is ever evolving. Future studies about transitioning need to go beyond the medical lens. Generational views differ in the approach to transitioning, and there are needs unique to this population required during the process. Where and whom will the research impact? The review has significant implications for change in health delivery, nursing policy and formulating nursing practice and education to improve trans competent care.

Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems

Recent advances in electronic health records and health information technology are providing new opportunities to improve the quality of care for transgender and gender diverse people, a population that experiences significant health disparities. This article recommends changes to electronic health record systems that have the potential to optimize gender-affirming care. Specifically, we discuss the importance of creating an anatomical inventory form that captures organ diversity, and of developing clinical decision support tools and population health management systems that consider each patient's gender identity, sex assigned at birth, and anatomy.

Caring for Transgender Patients: Complications of Gender-Affirming Genital Surgeries

Patients who undergo gender-affirming genital surgeries may present to the emergency department for their postsurgical complications. In this paper, we briefly describe the transfeminine and transmasculine genital procedures, review the diagnosis and management of both common and potentially life-threatening complications, and discuss the criteria for hospitalization and time frame for surgical consultation and referral.

A Call for LGBTQ Content in Graduate Medical Education Program Requirements

A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.

A rapid review of gender, sex, and sexual orientation documentation in electronic health records

Objective

The lack of precise and inclusive gender, sex, and sexual orientation (GSSO) data in electronic health records (EHRs) is perpetuating inequities of sexual and gender minorities (SGM). We conducted a rapid review on how GSSO documentation in EHRs should be modernized to improve the health of SGM.

Materials and Methods

We searched MEDLINE from 2015 to 2020 with terms for gender, sex, sexual orientation, and electronic health/medical records. Only literature reviews, primary studies, and commentaries from peer-reviewed journals in English were included. Two researchers screened citations and reviewed articles with help from a third to reach consensus. Covidence, Excel, and Atlas-TI were used to track articles, extract data, and synthesize findings, respectively.

Results

Thirty-five articles were included. The 5 themes to modernize GSSO documentation in EHRs were (1) creating an inclusive, culturally competent environment with precise terminology and standardized data collection; (2) refining guidelines for identifying and matching SGM patients with their care needs; (3) improving patient-provider relationships by addressing patient rights and provider competencies; (4) recognizing techno-socio-organizational aspects when implementing GSSO in EHRs; and (5) addressing invisibility of SGM by expanding GSSO research.

Conclusions

The literature on GSSO documentation in EHRs is expanding. While this trend is encouraging, there are still knowledge gaps and practical challenges to enabling meaningful changes, such as organizational commitments to ensure affirming environments, and coordinated efforts to address technical, organizational, and social aspects of modernizing GSSO documentation. The adoption of an inclusive EHR to meet SGM needs is a journey that will evolve over time.

A comparison of perioperative safety for breast augmentation in cis- vs. trans patients

Background

Gender-affirming surgery provides a psychosocial benefit to transgender women. However, increased medical complexity within the transgender population has limited access for some transgender women. This study compared patient population comorbidities and 30-day peri-operative safety following primary augmentation mammoplasty between cis- and transgender women.

Methods

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database between 2007 and 2016. Transgender patients were identified using ICD-9 &10 codes for gender dysphoria. Categorical variables were compared using chi-squared and Fisher's exact tests while independent t-tests were used for continuous variables. Statistical significance was set at P<0.05.

Results

There were 4,234 breast augmentations identified in cisgender women and 137 in transgender women. Transgender women had a higher frequency of ASA-II and ASA-III patients (P<0.001), diabetes (P<0.001), hypertension (P=0.006), and active smoking status (P<0.001). Despite the higher comorbidity burden and routine use of hormonal therapy, there were no significant differences between populations in major or minor peri-operative complication rates.

Conclusions

Top surgery improves quality of life in transgender women. Despite the more complex pre-operative risk profile in the transgender population, there is no difference in peri-operative safety profiles. Plastic surgeons treating this patient population should consider more liberal surgical indications for reconstructive top surgery compared with cosmetic breast augmentation.

Peripartum Considerations for the Transgender Parturient: A Case Report

Despite efforts by medical and social activists, transgender parturients encounter barriers to adequate and gender-inclusive health care, resources, and support. We present a case of a 38-year-old transgender man presenting for induction of labor at term. Our case highlights the importance of multidisciplinary planning, appropriate gender-related language, and interventions that may ameliorate gender dysphoria during childbirth. Because some transgender men may desire childbirth, we recommend that health care providers become familiar with and respectful of the unique considerations for this patient population in the peripartum setting.

Orthopaedic Care of the Transgender Patient

»

A transgender person is defined as one whose gender identity is incongruent with their biological sex assigned at birth. This highly marginalized population numbers over 1.4 million individuals in the U.S.; this prevalence skews more heavily toward younger generations and is expected to increase considerably in the future.

»

Gender-affirming hormone therapy (GAHT) has physiologic effects on numerous aspects of the patient's health that are pertinent to the orthopaedic surgeon, including bone health, fracture risk, and perioperative risks such as venous thromboembolism and infection.

»

Language and accurate pronoun usage toward transgender patients can have a profound effect on a patient's experience and on both objective and subjective outcomes.

»

Gaps in research concerning orthopaedic care of the transgender patient are substantial. Specific areas for further study include the effects of GAHT on fracture risk and healing, outcome disparities and care access across multiple subspecialties, and establishment of perioperative management guidelines.

Providing Inclusive Care for Transgender Patients: Capturing Sex and Gender in the Electronic Medical Record

BACKGROUND

Providing a positive patient experience for transgender individuals includes making the best care decisions and providing an inclusive care environment in which individuals are welcomed and respected. Over the past decades, introduction of electronic medical record (EMR) systems into healthcare has improved quality of care and patient outcomes through improved communications among care providers and patients and reduced medical errors. Promoting the highest standards of care for the transgender populations requires collecting and documenting detailed information about patient identity, including sex and gender information in both the EMR and laboratory information system (LIS).

CONTENT

As EMR systems are beginning to incorporate sex and gender information to accommodate transgender and gender nonconforming patients, it is important for clinical laboratories to understand the importance and complexity of this endeavor. In this review, we highlight the current progress and gaps in EMR/LIS to capture relevant sex and gender information.

SUMMARY

Many EMR and LIS systems have the capability to capture sexual orientation and gender identity (SOGI). Fully integrating SOGI into medical records can be challenging, but is very much needed to provide inclusive care for transgender individuals.

An Environmental Scan of Sex and Gender in Electronic Health Records: Analysis of Public Information Sources

Background

Historically, the terms sex and gender have been used interchangeably as a binary attribute to describe a person as male or female, even though there is growing recognition that sex and gender are distinct concepts. The lack of sex and gender delineation in electronic health records (EHRs) may be perpetuating the inequities experienced by the transgender and gender nonbinary (TGNB) populations.

Objective

This study aims to conduct an environmental scan to understand how sex and gender are defined and implemented in existing Canadian EHRs and current international health information standards.

Methods

We examined public information sources on sex and gender definitions in existing Canadian EHRs and international standards communities. Definitions refer to data element names, code systems, and value sets in the descriptions of EHRs and standards. The study was built on an earlier environment scan by Canada Health Infoway, supplemented with sex and gender definitions from international standards communities. For the analysis, we examined the definitions for clarity, consistency, and accuracy. We also received feedback from a virtual community interested in sex-gender EHR issues.

Results

The information sources consisted of public website descriptions of 52 databases and 55 data standards from 12 Canadian entities and 10 standards communities. There are variations in the definition and implementation of sex and gender in Canadian EHRs and international health information standards. There is a lack of clarity in some sex and gender concepts. There is inconsistency in the data element names, code systems, and value sets used to represent sex and gender concepts across EHRs. The appropriateness and adequacy of some value options are questioned as our societal understanding of sexual health evolves. Outdated value options raise concerns about current EHRs supporting the provision of culturally competent, safe, and affirmative health care. The limited options also perpetuate the inequities faced by the TGNB populations. The expanded sex and gender definitions from leading Canadian organizations and international standards communities have brought challenges in how to migrate these definitions into existing EHRs. We proposed 6 high-level actions, which are to articulate the need for this work, reach consensus on sex and gender concepts, reach consensus on expanded sex and gender definitions in EHRs, develop a coordinated action plan, embrace EHR change from socio-organizational and technical aspects to ensure success, and demonstrate the benefits in tangible terms.

Conclusions

There are variations in sex and gender concepts across Canadian EHRs and the health information standards that support them. Although there are efforts to modernize sex and gender concept definitions, we need decisive and coordinated actions to ensure clarity, consistency, and competency in the definition and implementation of sex and gender concepts in EHRs. This work has implications for addressing the inequities of TGNB populations in Canada.

Emergency Care Considerations for the Transgender Patient: Complications of Gender-Affirming Treatments

The transgender population presents a unique challenge for the emergency nurse. There are types of surgeries, medications, complications, and differences in laboratory testing that are unique to transgender people. In addition, emergency nurses are increasingly encountering more transgender patients in the emergency department for care, referrals, and education. Yet, many emergency nurses lack the formal training to care for transgender patients and their families. A complete understanding of the terminology, gender-transforming surgeries, hormonal suppression and augmentation of sexual characteristics, adverse effects, complications of surgeries, and ongoing health risks owing to the altered hormonal milieu and potential risk for acquiring sexually transmitted diseases is important to provide the necessary emergency care for this emerging population.

Prevalence of Human Immunodeficiency Virus and Opportunistic Infections Among Transgender Patients in the Clinical Setting: An All-Payer Electronic Health Record Database Study

We performed a cross-sectional analysis of the prevalence of HIV and opportunistic infections among transgender patients in clinical care. Of 10,160 transgender patients identified, 3.9% had a diagnosis of HIV, compared to 0.32% in the non-transgender cohort (p<0.0001). Transgender patients experience the burden of all opportunistic infection compared to non-transgender patients in this analysis, although prevalence of pneumocystis pneumonia was not significant. This cohort-based, all-payer electronic health record study of HIV patients connected to care revealed that transgender patients have a higher prevalence of HIV infection and opportunistic infections compared to the non-transgender cohort.

Transgender pediatric surgical patients-Important perioperative considerations

Transgender describes a variety of identities in which an individual's gender identity is different from expected based on the sex assigned at birth. In the United States, it is estimated that over 1 million adults and 150 000 youth identify as transgender, with increasing numbers being seen in healthcare and surgical settings. These numbers will continue to rise as visibility and acceptance grow. Current guidelines recommend transition-related surgeries be reserved for older adolescents and adults. However, this is not the only circumstance in which the pediatric anesthesiologist may find themselves caring for a transgender patient. In order to provide the safest and most affirming care, it is crucial that the pediatric anesthesiologist develop a working knowledge of this unique and vulnerable population, including the potential impacts of gender-affirming treatment on their perioperative care.

Sexual Orientation and Gender Identity in Patients: How to Navigate Terminology in Patient Care

OBJECTIVE

The purpose of this paper is to describe how health care providers can improve their practice environments to be more welcoming for patients on the spectrum of gender and sexual identity.

METHODS

Literature searches were performed in WorldCat, PubMed, and nongovernmental organizations and Gallup polls. The years searched were from 2005 to 2018. Key words used included sexual orientation, transgender, and health care. The PubMed MeSH termed searched included gender identity and sexuality, both in combination with patient care.

RESULTS

Terminology that patients use to identify their gender may vary. Understanding the terminology that patients use to self-identify is a first step to becoming more sensitive to the needs of gender and sexual minority patients. Minority patients on the spectrum of gender and sexual identity experience discrimination when accessing health care. Therefore, an accepting doctor-patient relationship especially benefits these patients. When communication competency and fluency is established, health care providers provide a more inclusive, accepting environment. Addressing patients based on their preferences and using inclusive forms and patient handouts are some recommendations that are made to create an open, patient-centered environment.

CONCLUSION

This article provides health care providers with terminology that facilitates communication and the healing environment for sexual and gender minority patients. Understanding and using this may create a more welcoming environment to all patients.