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Transgender trauma patients: What surgeons need to know

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Seek out training on treating transgender patients

Education on the care of transgender and gender nonbinary population is lacking in both medical schools as well as surgical residencies, and it is often left to individual surgeons to seek out their own training. Unfortunately, this leaves many uncertain how to ask a patient about his/her/their history without making the patient uncomfortable. If we don’t ask the right questions, some patients may not disclose information that could be very detrimental to their care. Documentation in EHRs can be made difficult if the software doesn’t include transgender female, transgender male, and gender nonbinary options in addition to the binary choice of female or male. This can contribute to the misgendering and distress of the patient.

Asking which pronouns a transgender individual uses can be a big first step because it allows that person know that you are being respectful. Be prepared for pronouns you may not be used to: Some may use she/her or he/his, and some may use they/their, ze/hir, ze/zir or xe/xyr. It is important to have appropriate registration forms, gender neutral bathrooms, and respect and discretion from every individual provider for all of our patients. Providers should seek out education and training so that the patients aren’t forced to do the educating themselves. As trauma and acute care surgeons, we are used to caring for a diverse patient population with many unique needs. However, we don’t know enough about the trauma and surgery risks in the transgender and gender nonbinary population as only a limited research has been done. Studies such as this by Dr. Mandell et al. are encouraging and hopefully more will follow.

Andrea Long, MD, is an acute care surgeon and an assistant clinical professor at University of San Francisco, Fresno.


 

FROM THE JOURNAL OF TRAUMA AND ACUTE CARE SURGERY

The likelihood that a trauma or acute care surgeon will encounter or treat a transgender patient in an emergency setting is increasing every year.

The number of patients who self-identify as transgender and who have undergone both medical and/or surgical gender-affirming treatment is on the rise. The trend has accelerated since private insurers, Medicare, and Medicaid are now covering some of the costs (JAMA Surg. 2018 Feb 28. doi: 10.1001/jamasurg.2017.6231).

Dr. Samuel Mandell, a trauma surgeon at the University of Washington Harborview Medical Center, Seattle

Dr. Samuel Mandell

However, health issues pertaining to transgender individuals are rarely covered in medical schools, and little has been reported in the medical literature about how to care for this population in a trauma setting. A review article published online in the Journal of Trauma and Acute Care Surgery provides some early recommendations for managing transgender patients in the trauma bay (2018 Feb 27; doi: 10.1097/TA.0000000000001859).

Lead author Samuel Mandell, MD, FACS, a trauma surgeon at the University of Washington Harborview Medical Center, Seattle, and his colleagues quote an estimate of 1 million transgender people in the United States. These individuals, many of whom have experienced gender dysphoria, in addition to stigma and negative psychosocial sequelae, may or may not have sought medical treatment. Medical interventions range from hormonal treatments to craniofacial plastic surgery and/or genital surgery.

“As transgender patients are more likely to be victims of assault and intimate partner violence or suicide, they are at increased risk for traumatic injury,” Dr. Mandell and coauthors said. More than 60% of the transgender population has been subjected to assault and more than 40% have attempted suicide. A recent study found that 42% of transgender individuals had a history on nonsuicidal self-injury (Psychiatr Clin North Am. 2017;40:41-50). The research team based their recommendations on managing transgender trauma patients on their own experience, and suggest some topics for future research

The authors searched the MEDLINE database for articles with the key words “trauma” or “injury” and “transgender/transsexual,” in addition to “surgery” and “transgender.” While the search yielded 388 articles, only 6 were relevant to acute care surgery or physical trauma/injury in the transgender population. “No articles were identified that addressed trauma/injury from the perspective of caring for the injured transgender patient,” Dr. Mandell and coauthors said.

The researchers recommend that the trauma surgeon begin if possible by working to establish patient-provider trust. “During surgical consultation, it is important to be aware that any transgender patient may have limited or negative interactions with general health care providers due to the significant discrimination this population faces,” the investigators wrote. Among the steps they suggest for the initial encounter with transgender patients are respectful questions about gender identity, asking what name they prefer, as well as what pronoun should be used.

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