SGEM#442: I’m on the Right Track Baby I Was Born This Way

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Reference: Kruse et al. Systematic Review, Quality Assessment, and Synthesis of Guidelines for Emergency Department Care of Transgender and Gender-diverse People Recommendations for Immediate Action to Improve Care. WJEM December 2023

Date: May 30, 2024

Guest Skeptic: Dr. Kay Dingwell is a rural emergency physician working in Prince County, PEI with a special interest in gender-affirming care and improving the care of trans and gender-diverse patients.

Case: A 16-year-old nonbinary youth on testosterone blockers and oestrogen has come into your emergency department (ED) having twisted their ankle while playing soccer. You learn they are ordering hormones online as they do not have any gender-affirming primary care. You don’t see a large number of trans patients in your ED and you wonder if there might be specific recommendations that can guide your care of this adolescent.

Background: In North America, trans and gender diverse (TGD) people make up 0.3% to 0.6% of the overall population, and up to 4.1% of the adolescent population according to Statistics Canada [1] and The Williams Institute in the US [2].

It has been shown in previous research that TGD individuals have both high ED avoidance due to discrimination, as well as a high need for emergency services due to the impacts of minority stress on this population [3,4].

Trans individuals are at higher risk of experiencing violence, adverse substance use, homelessness, and mental health challenges, among other challenges which may impact their health. These patients often report negative experiences when accessing emergency care, and there is an established lack of research to guide their care in the emergency department.

A group of researchers, including members of the queer community, set out to perform a systematic review, quality assessment, and synthesis of clinical practice guidelines and best practice statements on the care of transgender and gender-diverse individuals at any stage of accessing emergency department care.

Clinical Question: What clinical practice guidelines (CPGs) exist to inform the care of transgender and gender diverse (TGD) patients in the emergency department?

Population: Transgender and gender-diverse populations of any age, in any setting, region, or nation. It included both medical and paramedical care within these groups.
- Exclusions: Not a guideline or best practice statement, or guidelines/BPS not relating to TGD patients or ED care, full text not available, or not in English
Intervention: There was no intervention. The study looked at implementing clinical practice guidelines (CPG) and best practice statements (BPS) for the care of TGD individuals in ED.
Comparison: The guidelines and statements were assessed against quality standards using the AGREE-II and AGREE-REX criteria, rather than comparing different types of care or interventions against each other.
Primary Outcome: The identification and assessment of the quality and applicability of guideline recommendations relevant to ED care of TGD people.

Authors’ Conclusions: “This is the most comprehensive review of clinical practice guidelines and best practice statements for ED care of transgender-diverse populations to date and reveals several important actionable recommendations for the care of TGD people in the emergency department.”

Quality Checklist for Therapeutic Systematic Reviews:

The clinical question is sensible and answerable. Yes
The search for studies was detailed and exhaustive. No
The primary studies were of high methodological quality. Unsure
The assessment of studies were reproducible. Yes
The outcomes were clinically relevant. Yes
There was low statistical heterogeneity for the primary outcomes. No
The treatment effect was large enough and precise enough to be clinically significant. No
Conflicts of Interest: There were no financial conflicts of interest or sources of funding to declare.

Key Results: The initial search identified 1997 articles, with 291 moving on to full-text review after the application of inclusion criteria, resulting in a further 190 being excluded. Of the remaining studies, seven articles had a total of ten recommendations that were relevant to any stage of emergency care. They analyzed these using the AGREE-II tool to assess the methodological quality, and then the AGREE-REX tool to assess the quality and strength of the ten guideline recommendations, eight of which ended up being recommended for use by the assessors as two had no consensus.

The eight recommendations include four on sexual health, one on primary care access, one on training ED staff in culturally competent care of TGD patients, one on substance use, and one on mental health.

Primary Outcome: Eight Recommendations

Transgender people in high-prevalence areas should be offered HIV testing if having blood tests for another reason. In very high prevalence areas, offer testing regardless of the need for a blood draw otherwise. (European Centre for Disease Prevention and Control et al 2018, Palfreeman et al 2020)
Using a trauma-informed approach, offer Pre-Exposure Prophylaxis (PreEP) to TGD persons in the ED. (PanAm Health Org. et al 2014)
Offer non-occupational post-exposure prophylaxis (nPEP), sexually transmitted infections (STI), and pregnancy prevention counselling to TGD victims of sexual violence or if otherwise an urgent need is likely. (PanAm Health Org. et al 2014, Tan et al 2017
Immediate referral of a TGD person to HIV care is recommended following an HIV-positive diagnosis to improve linkage to anti-retroviral therapy. (Zuniga et al 2015)
Create a medical home for TGD children and create an equitable referral pathway from ED for those using it for primary care. (Bell et al 2021)
Healthcare providers in the ED must be trained in culturally competent care and have skills to treat TGD persons. (PanAm Health Org. et al 2014)
Using a trauma-informed approach, assess TGD people for substance use disorder symptoms and refer to TGD-focused treatment programs from the ED. (PanAm Health Org. et al 2014)
Risk-reduction and safety should be prioritized for TGD patients with acute gender dysphoria presenting to the ED. Consider hospitalization in extreme cases to prevent self-harm and consult TGD-competent care as needed. (Strang et al 2018)

1) Search Strategy: They performed a very good search including the gray literature. Research librarians are invaluable for helping with systematic reviews. The limitation to English-only literature is a common, but again present limitation.

2) Lack of Evidence: This is an area with extremely limited research to begin with and so this SRMA cast a wide net which resulted in a mix of papers being involved in the final analysis ranging from structured infectious disease recommendations to one paper on care of autistic youth with gender dysphoria and another on the general care of Indigenous youth in Alaska. None of the papers were written with ED clinicians as the target audience, further demonstrating the lack of available guidelines to help emergency physicians in caring for this population. This lack of specific emergency department-focused guidelines indicates a gap in the literature that needs to be addressed for more targeted recommendations.

3) Patient-Oriented Outcomes (POOs): The available guidelines have largely been created in a researcher/clinician-oriented manner, out of keeping with the needs of the community. This is specifically identified as a limitation by the authors as a possible subtle source of research bias that isn’t captured by the AGREE II risk of bias assessment. This is a point that is under-identified in a lot of clinical research, pointed out frequently on the SGEM when studies are time and time again focusing on MOO/LOO/DOO instead of outcomes that matter to patients (POOs), but these authors go even further in discussing that the research question needs to be formulated with community involvement.

4) Quality: Of the 8 recommendations that ultimately arise from this analysis, all but one originate from primary sources assessed as moderate to high quality. The one recommendation arising from a CPG assessed as lower quality (#5 – relating to medical homes for TGD youth) is supported elsewhere by higher-quality evidence across many populations.

One of the 8 resulting recommendations is from a paper specifically about the management of autistic adolescents who also have gender dysphoria, but that this was developed with a very specific population in mind is not reflected in the final recommendation.

5) Queer Involvement: A major strength of this paper is the involvement of members of the queer community in an intentional way, and the group indicated they plan to use this as a launching point for the creation of an advisory panel and ongoing project to create guidelines for identified areas of need.

Extra Special Guest: Dr. Aine Yore is an Emergency Physician, practicing in the Seattle, Washington area for over twenty years, and is herself a transgender woman. She is the former president of the Washington chapter of ACEP and her career focus outside of clinical practice has been largely devoted to health care policy. However, her lived experience as a trans physician, and experience both taking care of trans and gender nonconforming patients and also helping fellow emergency physicians educate themselves on the care of trans and GNC patients led us to ask her to participate in this conversation.

“I’d like to start by congratulating the authors on an excellent paper. Unfortunately, gender-affirming care (GAC) is often an evidence-free zone; the paucity of high-quality literature is striking, which is reflected by the really low rate of the relevance of the articles in this systematic review that were of relevance to trans and GNC patients in the ED. Trans and GNC folk are highly marginalized and I also congratulate the authors in that the recommendations, while limited in their scope, do focus on some of the challenges that most commonly bring trans people to the ED – mental health crises and exposure to STIs. High praise also for including trans and queer individuals in an advisory panel in the crafting of this paper and in training emergency clinicians.”

Listen to the SGEM podcast to hear Aine’s comments and her top five list of recommendations to clinicians on this topic.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion that this is the most comprehensive review and analysis to date of ED care of transgender and gender-diverse people.

SGEM Bottom Line: There are limited high-quality, emergency care-specific guidelines with which to inform the care of trans and gender-diverse patients in the ED and there is a need for more patient-oriented research in this area.

Case Resolution: You assess and treat your patient’s ankle injury as you would for anyone else, but while ensuring that they have appropriate follow-up you learn they have no primary care professional so make a referral from the ED to a primary care team that is appropriately trained in the competent care of gender diverse individuals.

Dr. Kay Dingwell

Clinical Application: The recommendations arising out of this review are largely actionable in any setting. Although the one recommendation to refer to a primary care team is, perhaps a bit optimistic for most of Canada and perhaps elsewhere.

What Do I Tell the Patient? While caring for your patient including while discussing them with other care team members, you use their correct name and pronouns in keeping with the cultural competency training your hospital makes available to staff. You say “Hey I noticed you don’t have a primary care team. I might add something to the effect that I’m worried the HRT you’re ordering off the internet may not be safe, and may not work as well as you want it to… We have a clinic in the community that sees many of our trans and nonbinary patients and they sometimes will pick up patients who we refer to them. Would you like me to send a referral to them for ongoing primary care?”

Keener Kontest: Listen to the podcast to hear this week’s keener contest question. Email your answer to TheSGEM@gmail.com with “Keener” in the subject line. The first correct answer will win a cool skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

Statistics Canada. Canada is the first country to provide census data on transgender and non-binary people. The Daily. 2022;(11):16.
Flores AR, Herman JL, Gates GJ, et al. How Many Adults Identify as Transgender in the U.S? The Williams Institute, UCLA; 2016:1–13.
Bauer GR, Scheim AI, Deutsch MB, 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(6):713–20.e1.
Chisolm-Straker M, Jardine L, Bennouna C, et al. Transgender and gender nonconforming in emergency departments: a qualitative report of patient experiences. Transgender Health. 2017;2(1):8–16.