Dr. Hamlin
Presenters: Kimberly Horstman, MD, and Taylor Rosenbaum, MD
This PHM 2023 session aimed to educate hospitalists about the continuum of gender-affirming care, the side effects of medications, the physical aspects of transition, and patient referral to resources regarding gender-affirming care. As hospitalists, there is a high likelihood we will all care for gender-diverse or transgender patients, so we should be familiar with medications and side effects. This is not a negative spin on treatment—gender-affirming care is a positive thing. The presenters touch on the benefits of gender-affirming care in the reduction of self-harm.
As a reminder, the presenters discussed the different modalities ranging from legal (changes to driver’s license) to medical (Gonadotropin-releasing hormone agonists to block puberty and hormone therapy) to surgical. The presenters remind us that in prepubertal patients, legal and social affirmation are the only interventions and that medical transition cannot begin until a patient achieves a sexual maturity rating of two.
The presenters discussed the variety of medical and surgical transition options and the effects a hospitalist may see while caring for a gender-diverse or transgender patient. Gonadotropin-releasing hormone analogs may cause effects including injection inflammation, decreased bone growth and density, hypertension with certain blockers, and very rarely, idiopathic intracranial hypertension. In patients using estrogen, hospitalists should monitor for the occurrence of deep vein thrombosis (especially with concurrent tobacco), migraines, gallstones, hypertriglyceridemia, and elevated transaminases. In patients on estrogen undergoing laboratory monitoring of creatinine, hemoglobin, and alkaline phosphatase, the upper limit of normal is defined by the standard male reference range value. Hemoglobin’s lower limit is determined by the female value. In patients using masculinizing hormones, the hospitalist should monitor for polycythemia, migraines, hypertension, hair loss, acne, metabolic syndrome, and sleep apnea. In laboratory monitoring, male reference values should be used due to increased muscle mass. If the patient menstruates, the female lower limit of hemoglobin should be used as a reference range.
The presenters touched briefly on surgical interventions such as top surgery (mastectomy for masculinization or augmentation for feminization) and its complications including infection, seromas, and possible numbness. Other physical aspects of gender-affirming care include binders (articles of clothing to make the chest appear flat) which can cause chest and back pain, skin irritation, numbness, bruised or fractured ribs, or overheating and dehydration. Patients who use affirming accessories including packers and gaffs are at risk for urinary tract infections.
In the physical exam of a patient who is transitioning or undergoing any aspect of gender-affirming care, a hospitalist must be transparent, and talking through components of the exam can be helpful. Patient consent should always be obtained, and it can be helpful to discuss patient-preferred terminology for genitalia to avoid distress. Anxiolysis may be appropriate if significant dysphoria is present, and aside from the physician and chaperone, people in the room should be limited.
Physicians caring for gender-diverse patients should use resources including the World Professional Association for Transgender Health, the Endocrine Society, and the University of California San Francisco Center for Transgender Excellence. Patients can be provided with referrals to the Trevor Project, the Gay & Lesbian Alliance Against Defamation or GLAAD, and many more.
Key Takeaways
- Pediatric (and all) hospitalists will care for transgender and gender-diverse patients.
- Understanding the transition process, identification of affirming medications and their side effects, and familiarity with physical changes brought on by medications can help guide care in these patients.
- Performing a sensitive physical exam can help foster trust in the medical system.
- As hospitalists, we aren’t often involved in the medical aspects of affirming care but is important to be knowledgeable about the process and resources for patients.
Dr. Conley Hamlin is a first-year pediatric hospital medicine fellow at Norton Children’s Hospital/University of Louisville in Louisville, Ky.