Transgender Care in the ED Part 1 EMRAP November 2025

Jan Shoenberger, MD, and Jailyn Avila, MD

• Cisgender: a person who is the same gender that they were assigned at birth 
• Transgender: a person who is a different gender than they were assigned at birth 
• Cis and trans: adjectives describing a person’s gender (eg, transwoman)
• Non-binary: a person who does not identify as a man or woman, typically using “they/them” as their preferred pronouns 

Best practices for initial interactions:

• “I’m Dr. X, my pronouns are he/him (she/her, etc), what pronouns may I use to refer to you?”
  • If you mess up, apologize, correct yourself, and move on. 
• “May I share your preferred name/pronouns with the staff and/or registration?” 
• Pins or badges highlighting your pronouns can greatly help trans patients feel more comfortable and trusting of the healthcare system. 

Medications/hormones used by trans individuals:

5-alpha reductase inhibitors (eg, dutasteride, finasteride) are used to block testosterone.

• May cause orthostatic hypotension 

Spironolactone is used at high doses (100-300 mg/day) to block testosterone and for its estrogenic effects. 

• May cause orthostatic hypotension and potassium derangements, particularly when initiated

Estrogen can be taken orally, topically, or parenterally.

• Oral estrogen increases the absolute risk of venous thromboembolism (VTE) 2-fold but overall risk remains less than 1%. 

Testosterone: high doses will also block estrogen and will lead to voice changes by thickening the vocal cords. 

• Places the patient at the same risk for cardiovascular complications as a cisgender man 
• Can increase hemoglobin and blood viscosity 

PEARL: Medications and hormones are often vitally important to trans individuals. It is helpful to recognize the potential side effects or risks they may face and work with them to mitigate these effects.

Transgender Care in the ED Part 2 

Jan Shoenberger, MD, and Jailyn Avila, MD

Gender-Affirming Surgeries:

• Vocal cord tightening/shortening: This may limit the size of endotracheal tube (ETT) that can be used for intubation; consider sizing down. 
• Cricoid/thyroid approximation: This may obliterate the cricoid membrane, limiting the ability to perform a surgical airway in an emergency. 
• Top surgery (breast reduction or augmentation): Watch for standard post-surgical complications. 
• Metoidioplasty: Enlarges the clitoris and releases it to create a phallus to allow for urinating standing up. This may limit the ability to catheterize for urine. 
• Phalloplasty: Creating a neopenis from skin grafts. Use of a foley catheter may be contraindicated and the patient may require suprapubic catheterization after discussion with urology.
• Vaginoplasty: Inversion of the penile shaft and scrotum, which may be prone to surgical complications like fistulas. 

Non-Surgical 

• Binding: using elastic binders to reduce the appearance of breasts
  • The binder may place the patient at increased risk of hypoxia or difficult ventilation during procedural sedation. You may need to discuss temporarily removing the binder beforehand. 
• Tucking: using special underwear or tape to minimize the appearance of the penis and testicles. 
• Early on, this may place the patient at an increased risk of testicular torsion. 

Surgical history

• Surgical history should be obtained when it is clinically relevant and not because of curiosity. Explain to your patients why asking about specific surgeries is clinically relevant for their condition or symptoms. 

Mental Health

• Gender dysphoria: Distress caused when an individual’s gender does not align with their gender assigned at birth.
• The inability to transition and treat gender dysphoria can create significant mental and emotional distress and higher rates of suicide.
• Trans people unfortunately see higher rates of violence and trauma.

Allies can help with their colleague’s transition in the workplace and support them by encouraging the use of appropriate pronouns with your colleagues. 

PEARLS: Trans patients may have slightly different medical risks based on their prior medications and surgeries; however, the first step in providing excellent care is to be supportive and create an environment that they can trust and be open in.