This was a great segment and certainly very helpful. One topic which was not discussed was the appropriate way to ask transgender patients about an "organ inventory." The majority of transgender patients I have seen in the ER do not identify themselves as transgender. This becomes a problem when dealing with something like abdominal pain or even dysuria since the biologic male and female anatomy present very different considerations. This becomes even more complicated if they have had (for example) vagina plasty but continue to retain a prostate.
I agree with the points Ilene has made. Starting with a more open ended question like she suggested is a great idea. In addition, I would emphasize framing your questions. Starting out with something like, "because you are having abdominal pain, it's important for me to know about your reproductive organs. Have you had any of your pelvic organs removed or changed?" This same line of questions could apply to a cisgender patient as well, e.g. a patient may or may not have had a hysterectomy or oophrectomy in the past, which changes your differential for RLQ pain. To make sure that your or the patient didn't misunderstand, finish up with confirmation, "So this mean you have a uterus and two ovaries, is that right?"
Great question and always tough. I think starting by asking "have you had any surgeries to align your body with your gender?" and then specifically asking which surgeries is the best place to start. The majority of patients will not have had any "bottom surgeries," and you will know they have the organs that were present at birth. If tell you they have had oophorectomy or hysterectomy, that is easy. If they are transfeminine and have had a vaginoplasty, typically, the prostate is not removed, and the option of prostatitis and need for prostate cancer screening still exists. You bring up a really good point, and I think this is something that is easy to forget, but certainly important to provide the patient with care. At that point, I'd say something like, my understanding is that the vast majority of the time, the prostate is not removed with a vaginoplasty, and an infection (or malignancy) in the prostate could be dangerous to you. In this situation, ...whatever you are worried about or need to do.
probably the second discussion I have heard on this topic since I began med school in 1978. the first was by the urologist at my med school who I guess was a pioneer in such surgery and treatments. 1978-80. the second is this one. It is interesting that these are the only two that I can recall. either I've been avoiding this topic, or , I suspect these lectures and discussions are infrequent.
I think it's easier, more comfortable for us to discuss tPA for stroke, or a deWinters ecg, or the latest TTM trial than it is to discuss transgender concerns, surgeries, and more. maybe I am wrong.
Thanks for listening. Before I started studying and speaking on transgender health, I too had only heard one organized lecture on this in medical school. Now thinking back to what I was told in that lecture, as with much of medical education, 80% of what I heard is not what I would teach people today. This is a subject that is rapidly evolving, and some of what we have told you today we may very different in just a few years. Thanks for taking the time to stay up on the topic.
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Jim J. - July 17, 2021 10:33 AM
This was a great segment and certainly very helpful. One topic which was not discussed was the appropriate way to ask transgender patients about an "organ inventory." The majority of transgender patients I have seen in the ER do not identify themselves as transgender. This becomes a problem when dealing with something like abdominal pain or even dysuria since the biologic male and female anatomy present very different considerations. This becomes even more complicated if they have had (for example) vagina plasty but continue to retain a prostate.
Any tips on how to politely approach this?
Clinton C. - July 19, 2021 6:57 PM
I agree with the points Ilene has made. Starting with a more open ended question like she suggested is a great idea. In addition, I would emphasize framing your questions. Starting out with something like, "because you are having abdominal pain, it's important for me to know about your reproductive organs. Have you had any of your pelvic organs removed or changed?" This same line of questions could apply to a cisgender patient as well, e.g. a patient may or may not have had a hysterectomy or oophrectomy in the past, which changes your differential for RLQ pain. To make sure that your or the patient didn't misunderstand, finish up with confirmation, "So this mean you have a uterus and two ovaries, is that right?"
ilene c. - July 18, 2021 11:39 AM
Great question and always tough. I think starting by asking "have you had any surgeries to align your body with your gender?" and then specifically asking which surgeries is the best place to start. The majority of patients will not have had any "bottom surgeries," and you will know they have the organs that were present at birth. If tell you they have had oophorectomy or hysterectomy, that is easy. If they are transfeminine and have had a vaginoplasty, typically, the prostate is not removed, and the option of prostatitis and need for prostate cancer screening still exists. You bring up a really good point, and I think this is something that is easy to forget, but certainly important to provide the patient with care. At that point, I'd say something like, my understanding is that the vast majority of the time, the prostate is not removed with a vaginoplasty, and an infection (or malignancy) in the prostate could be dangerous to you. In this situation, ...whatever you are worried about or need to do.
tom f. - July 19, 2021 5:14 PM
thank you Drs. Claudius, Coil, and Janeway.
probably the second discussion I have heard on this topic since I began med school in 1978.
the first was by the urologist at my med school who I guess was a pioneer in such surgery and treatments. 1978-80.
the second is this one. It is interesting that these are the only two that I can recall.
either I've been avoiding this topic, or , I suspect these lectures and discussions are infrequent.
I think it's easier, more comfortable for us to discuss tPA for stroke, or a deWinters ecg, or the latest TTM trial than it is to discuss transgender concerns, surgeries, and more. maybe I am wrong.
but thank you, team
tom
Clinton C. - July 19, 2021 7:02 PM
Thanks for listening. Before I started studying and speaking on transgender health, I too had only heard one organized lecture on this in medical school. Now thinking back to what I was told in that lecture, as with much of medical education, 80% of what I heard is not what I would teach people today. This is a subject that is rapidly evolving, and some of what we have told you today we may very different in just a few years. Thanks for taking the time to stay up on the topic.