Conditions related to cross-sex hormone use, postoperative wounds, cardiovascular risk, and sexual and mental health concerns in trans people deserve special consideration from emergency physicians 

According to the Center of Excellence for Transgender Health at University of California, San Francisco, the most common reasons for a transgender person to present to an emergency department are similar to those seen in the general population and not secondary to cross-sex hormone use. The following can be areas of special consideration, however, when transgender patients present.

Cardiovascular: Most data demonstrate negligible impact of both estrogen and testosterone therapy on cardiovascular risk. Depending on the route and type of estrogen being used, risk of venous thromboembolism in patients receiving estrogen therapy may or may not be increased. When risk is increased (smoking, use of oral estrogens, use of oral contraceptives as estrogen source), it is minimal and reduced after the first year.

Cross-sex hormone use: Cancer, cardiovascular, and diabetes mellitus screening protocols for trans women (male-to-female) currently taking estrogen and trans men (female-to-male) currently taking testosterone are available at www.transhealth.ucsf.edu/trans?page=protocol-screening.

Postoperative (male-to-female): Transgender women may present with postoperative wound complaints. Vaginoplasty involves the use of penile, scrotal, and urethral tissue to create a vulva and neovagina. Complaints may include bleeding, infection, or graft/flap necrosis, as well as urinary issues. ED care should be supportive, and attempts should be made to refer patients back to the performing surgeon or another local surgeon with expertise in this area. Wound care centers may also be of value. Examination of the neovagina is best performed using an anoscope, inserting and then slowly withdrawing while looking for fistulae or lesions. Granulation tissue and retained lubricant are more common sources of discharge than bacterial vaginosis, and true vaginal candidiasis is very uncommon.

Depending on the route and type of estrogen being used, risk of VTE in patients receiving estrogen therapy may or may not be increased.

Gynecologic (female-to-male): Transgender men who retain their uterus and ovaries may experience pain or bleeding similar to that experienced by women. ED management of such complaints is similar to that of women, with a beta-human chorionic gonadotropin test followed by examination and/or imaging as indicated. Patients may be especially sensitive about examinations and may have an atrophic vagina that requires a smaller speculum. In some cases, a pelvic exam or endovaginal ultrasound may not be possible.

Sexual health: As with any patient who discloses engaging in potentially risky sex practices, some transgender patients may be at risk of HIV/STDs and may be vulnerable to abuse and/or exploitation. Avoid making assumptions about sexual behaviors or partners; regardless of their gender identity, transgender people may be sexually active with men, women, or both and may use their natal genitals during sexual activity.

Mental health: Rates of attempting suicide in LGBT youth are two to three times that of the general population. Substance abuse, including tobacco, alcohol, and other drugs, may also be a concern. All are fueled by the increased stress experienced by LGBT persons due to discrimination.

Social factors: Homelessness, lack of health insurance, and poor social support can affect transgender patients’ access to health care as they can for the general population.