All right everybody, well welcome to today's TCAA webinar titled the trauma patient who is transgender or gender expansive special considerations for the trauma team. This is being presented by my friend and yours Justin Millicy. All participants are going to be in listen-only mode and if you have any questions for Justin please type them into the chat box and then we will review as many of them as we can once Justin is done with his presentation. My name is Steve Wyman. I am the trauma education and injury prevention coordinator at St. Joseph's University Medical Center in Patterson, New Jersey and I serve as a member of the TCAA's education committee and it is my privilege to be moderating today's session. Let me tell you a little bit about Justin. He has got a phenomenal history behind him. Justin is a master's prepared nurse with over 38 years of experience. Justin has presented today's topic around the country numerous times and I've been a witness to this a couple of times and tell you you're in for a treat today. In addition to being a presenter, Justin has served as an author and contributing author on several books on the subject of transgender and gender expansive care and this includes the Emergency Nurses Association's Sheehy Manual for Emergency Care and the Emergency Nursing Core Curriculum. Justin served as chair and contributing author to ENA's LGBTQ toolkit for emergency care settings and he was on the work group and he also authored the Society for Pediatric Nurses Caring for the Transgender Patient. In 2017, we had the privilege of Justin presenting the first resolution on transgender care at the Emergency Nurses Association's General Assembly and pleased to say it passed. Justin has also authored on the Emergency Nurses Association's topic brief care of the gender expensive the gender expansive and transgender patient in the emergency care setting and I was also privileged to work with him in September of 2023 when he published a paper in the Journal of Emergency Nursing titled The Gender Diverse and Transgender Patient, A Special Population in Trauma Care. So Justin holds a master's of science in nursing. He currently works as clinical editor for Elsevier Clinical Solutions and his clinical background is expansive including emergency, trauma, pediatrics, and nursing education. It is my privilege to introduce and turn the mic over to Justin. Well thank you. Thank you Steve and hello everybody. It is wonderful to be here with everyone to talk about this topic that to me is very very important and is becoming more important every single day. If you've been watching all the changes that have been that have been going on throughout not only the country but throughout the world. So I thought this was a perfect timing to do this to do this topic. Let's go right here. Okay so here is that's the educational statement for you all as far as getting your contact hours for this. Let me just kind of take a look at that. And of course you know you can't have a presentation without objectives right? So hopefully by the end of this presentation we're going to you'll be able to discuss the incidents and some of the balance in some of the common causes of injury in a patient who's transgender or gender diverse. We'll describe hopefully we'll describe some special considerations when performing that primary and secondary you know survey on the trauma patient and the special considerations when performing those interventions. So now what I want you to do is I'm going to show you a picture here and I want you to keep this picture I want you to keep this picture in your head as we go through this journey because I'm going to get back to it a little bit later as I go on. I also want to tell everybody here I consider this a safe place okay I consider this a safe place to talk about this topic to open up because as I say it is a it is a huge topic right now especially with all the changes so this is a safe place to discuss this. So I'm going to start out by just asking you a question and you're going and you're this is going to be a poll all right so this question is have you ever met someone who you knew was transgender? Give a few minutes to uh seconds there for you all to answer that. I think have you ever known anybody who you knew um was transgender? Okay so there we go that's a that's a uh you know that that's a pretty good you got about almost um over you know over 60% um say yes and then you've got about uh 37% so that's a you know that's a that's a pretty um that's a pretty good distribution um as we go here so let's just continue on. Oh why can I continue on here all right all right I'll start out by saying you know I'm going to quote this from um you know from my my my friend and colleague Andrew Solomon who wrote a wonderful book several years ago called Far From the Tree and you know he said the gender is among the first elements of self-knowledge you know and it starts very very early so it's just that first you know element of self-knowledge so let's talk about some of the terms that you often hear when we talk about gender diverse care when we talk about um care of a transgender patient there's a whole vocabulary out there okay there's a whole lot of terms and those terms change frequently sometimes daily um these terms will change so it's a lot of keeping up when we talk about that so we're going to talk about some of these terms um that you uh that I'm just kind of putting up here uh that you may see so we're just going to kind of go through um each one of these just to go through so the first we're going to talk about is the biologic sex or the sex assigned at birth okay so very often it's known as the sex assigned at birth it is not synonymous with gender identity it is not synonymous they are two completely different things um that we have to think about that so you know we talk about the biological sex you know that's that's the way the baby is made right um you've got um an x chromosome it always starts out with an x right because everybody starts out as female and if that if that um future being is going to stay female the x stays there's another x however sometimes this funky y chromosome comes around and it just kind of gets there and it's it's going to go where the x is and then you got the male okay so that's the genetic makeup and as I said that's that phenotype um type of expression that they're good that they're have so I said it's often known as the birth sex or the sex assigned at birth that you may see now current terminology we're going to talk about that this is actually relatively recent Fenway or the National Education Institute for Gender Affirmative Care or Transgender Care through the Fenway Institute does have a glossary and that's you see the Fenway 2024 up there um that has the latest terms and they update that very very frequently so the current terminology is assigned female at birth or assigned male at birth or afab or amab I know your brains are kind of going you know you know trying to keep that up but as I said these terms you know and you know these terms expressions do tend to tend to change very very frequently and you got to keep up with that because something can be so five minutes ago right or so yesterday because there's a new terminology that's come up so let's start out with gender the perception of a person's sex on the part of society as a man a male or a female woman or something else okay that's gender okay who is the perception biologic sex is the biologic makeup the chromosomes the x and y chromosomes gender is that perception that person that person identifies with you know on that part of society who do they feel um you know who do they identify with me so that's that's just kind of the difference right there but when we talk about gender identity it's that internal um sense of self as man woman both or neither we're going to get into talking about um non-binary um identity here in just a minute okay so gender you know so gender of course is just how that person views you know how that not views but the perception of self um within society we get to gender identity that's the internal um sense of whether that person identifies as a man woman both or neither and it usually develops very very early by age three and it remains relatively stable over a lifetime so once that you know once that child reaches a certain age and they you know you know they are identifying as they understand who they are um they they just kind of understand that okay um i have these parts okay but i'd like to do this or i like to express myself this way they they internalize that as i it's it's as i said it's just kind of hard to to kind of think about that but it's very very early on um children um will actually develop that and it stays pretty stable as i say you know over a period of time so you know it's that internal person of self the woman um uh or neither as i said it's not synonymous again with biological sex we talked about develops i think i just put an extra slide in there and i apologize for that gender expression so gender expression takes a little further this is how the person is going to express their gender okay i identify as this then so to show that and to express it this is how i'm going to express it in everyday life within the context of the culture and of society okay so this is how they're going to express themselves when we talk about transgender transgender is actually you know this is an umbrella term you know they talk about the person's got a gender identity but it is not fully with that assigned sex at birth you know that they have a gender identity but it's just not you know it's just not with this or it's not with this and so there's many diverse identities and expressions um for somebody who is transgender there's no one way um there's no hard and set rules to be transgender right uh so they have that you know so they have that some very diverse identities and as i said it's not usually um in congruence um with their um assigned sex at birth so this is the child or the you know the child's growing up and they were born they were an assigned male at birth but they don't feel like a male they inside it's like you know it would be like the child saying i feel like i was born in the wrong body my body is a boy but i don't feel like a boy okay i feel like a girl and that is how i want to express myself because that is who i identify with and you know many you know not everyone but you know but you know many um of these individuals they are going to take that a step further they're going to seek you know medical um interventions taking hormones you know gender affirming hormone therapy and taking that a step further and having surgical procedures done to align not only their body but their minds okay so they will have these procedures done so a couple of other um you know just to kind of clarify when we talk about um a transgender individual we return to them as a trans woman or a trans um man and i forgot to take that mtf that ftm there off of the slide i apologize with that that was just to kind of show you all how you know you know how you know which way um that they identify when you hear a trans woman woman it's always going to be who they identify as not how they started biologically who they identify as so a trans woman or trans feminine started out um as a male with the sex assigned at birth and now has um affirmed continue to affirm their gender identity as a woman or trans feminine that's another um that's another term that we sometimes use so it is who the person is affirming to be not how they started a trans man same thing this is the individual who um the decided the assigned sex at birth um was female but identifies as male okay so that's trans masculine now non-binary okay this this is you know now we're kind of getting into some of those gray areas okay so these are the gender identities that are outside their gender binary um so to speak we talked about male female yeah both neither maybe something else as i said this changes this has been changing daily um there's all sorts of new all sorts of new concepts and all sorts of new ways that people are identifying as new terminology it's coming out every single day and so genderqueer a kind of synonymous um when we talk about um um with genderqueer uh because they don't fully you know identify they don't identify as male they really don't identify as female they identify as something in between okay so that's when we might use the term genderqueer um gender um diverse that's become a more kind of a broad term um so to speak uh before that it actually was um you know you know it was gender diverse and then lately it's now gender expansive because they thought the term diverse well that's really not that's really not focusing in on that um on who i am so they thought the term that gender expansive expanding that gender um was more appropriate okay gender fluid this is the individual who's if you think about water you know fluid is always in motion right and so they're vacillating kind of back and forth between okay on monday and tuesday i identify as a male but on you know thursday and friday i identify as something else and on wednesday i identify as a female so it's it's ever-changing um so to speak so one day you know a couple of days this another day is this it's just kind of vacillating back and forth demigender okay that's a new term and if you think about demi means half so they're not quite you know they kind of sort of uh identify as a man but not quite but kind of sort of identify as a woman but not quite as i say it's half it's just a little bit more vague so demigender bigender means that these individuals identify as both they identify as both male and female we think of the term by meaning two right agender and this is if you think if you know the term asexual right essentially means without so they don't identify as a male they don't identify as a female they do not identify as anything that is agender cisgender cisgender simply means that the individual identifies with the gender the same as the assigned sex of birth cisgender right there so both male gendered and um male sex assigned at birth okay that is cisgender gender affirmation we talk about affirm we used to talk about transitioning and they thought the word transitioning um it was not you know you know that really wasn't quite you know it's talking about changing almost like they're making decisions to change when they're talking about transition and you have to remember that this is not a choice to them this is not a choice this is who they identify as so gender affirmation means they are going to affirm that gender that they identify with recognizing and confirm that of that gender identity okay so it's called gender affirmation because it allows them to affirm their gender identity by making those outward changes whether it is um in behavior whether it is in the way that person dresses also expression medical treatment with hormones or surgical treatment that's gender affirmation sexual orientation is how um one identifies their physical and emotional attraction to others it is not the same as gender identity it is not the same as gender identity so there's three you know there's attraction there's behavior and then there's the you know the identity is in there but it's not solely it does not solely mean the same thing as gender identity this is just how that person you know is going to be identified so being transgender in other words is not the same as being gay okay being transgender is not the same as being gay um being a demigender is not the same as as being gay or bisexual right um this you know because a transgender a transgender individual they can be of any sexual orientation you can have a transgender individual who um is you know who is attracted uh to that same to that same gender that that person is you can have a transgender man um who is attracted um to female you can have a transgender man who is attracted to a male you can have a transgender man who is attracted to both okay so it can be any um of sexual orientation Some statistics we're going to show you there and this is recent this is from the from the human rights campaign that about 1.6 million people in the United States identify as transgender okay and that's a pretty good number so about you know 1.6 million um and you know globally around the world it's estimated that one percent of adults identify as transgender and also I'm just gonna move this here there we go and two percent of adults um identify as gender fluid but non-binary that you know the or gender non-conforming gender non-conforming means that yes I identify as a male but I'm not going to outwardly express myself as a male because that kind of makes sense right there so you know there's a larger percent of these individuals who um identify as not you know just transgender not transgender necessarily but something else as they're going through nationwide emergency department sample um that was done in 2023 uh showed that um you know that 300 there uh 66,000 over 66,000 ed visits were made by patients who identified as transgender between um 06 and 2018 that's actually the latest statistics that are that are out there right now um so you can see that's a pretty large number you know that you know that that's a pretty large number over that period of time and it just it's increasing um as we go so what's the biggest issue the biggest issue um I'm gonna um quote you here um an aging study but it really was kind of the study that they kind of set the tone here that was done by Bauer in 2009 that showed that you know 21 percent of transgender patients avoided the emergency department due to a perception that their status that their gender affirming status would negatively affect such an outcome okay they're they're afraid to go to get themselves seen if they're ill um in the emergency department in a clinic a doctor's office because they're they're worried they're worried and afraid that their gender status is going to somehow affect their care and negative experiences um specifically related to being transgender were reported by over 50 percent of trans patients so you know over 50 percent um reported um that they had negative experiences so you know and about 54 percent of trans patients reported having to actually educate the providers educate the staff or some or a lot regarding those trans issues in other words they went there for help but they're now the ones teaching the professionals okay that that's not why they came to the ed so they avoid emergency care because of two big things because of fear of discrimination that is number one right up there they do not want to be called out uh they avoid care so when they avoid care um because they're afraid of getting discriminated against so what happens that just continues a cycle where they avoid health care and when they avoid health care they avoid um getting things checked when there's a problem and they may not know there's a problem and so by the time they actually do get to the point where they need that medical help the problem is just kind of has just kind of blossomed and gotten larger and larger and larger because they were afraid to actually go uh to that facility or to that clinic or doctor's office to get that um check because they are afraid of discrimination and also a prior negative experience you know they had a bad experience coming to the ed going to a doctor's office that they felt horrible about it they're not going to want to go back okay so those are the two big things fear of discrimination and having had a bad experience prior to now um we which brings me to another point here gender-related medical misattribution and invasive questioning or grmmo or grmmq also known as the trans broken arm syndrome this is a very very hot topic so in this situation this is the provider um they they have misconceptions as to the cause of that transgender patient's health problems they're jumping to conclusions they're making assumptions when they know that that person is transgender so it can take on two forms you can have that causal misattribution aspect in other words uh well this person is obviously coming in um you know you um for this for this problem and the cause um is obviously their um their medical affirmation so this obviously has to be caused by their affirmation process okay this sprained ankle this abdominal pain um this shoulder pain this eye pain is caused obviously is caused by their gender affirmation process okay that's that's being biased okay we talk about um we talk about um not being biased and that's a big bias right there and also invasive questioning aspect and or all you know otherwise known as um the cookie jar effect right so they're going to be asking questions about that when it has nothing to do with why that patient's there okay they're invasive and they're really not those questions are really not going to be contributing to making medical diagnoses the patient comes in with a sprained ankle and they start asking about their hormones that they're taking um their gender affirming surgery um that's going how long have they been it has nothing to do with that um when they go through that oh sorry so what are some best practices here that we can think about as far as that the best practices are you know ask how they want to be addressed just ask how this patient wants to be addressed my overall point in all of this by the time we're done is that these patients need and should be treated with the same dignity and respect as any other patient i can't emphasize that enough the same dignity and respect as any other patient now obviously there may be issues um that are going to be related to that affirmation process um and if those come up we have to develop that relationship with them and communicate effectively with them to tell them why we need to know some of that information but if it's not if it's not needed don't go there so addressing the patient you know you we we have these these expressions good morning ladies thank you sir these are some of the responses we don't even think about right we just say but a huge impact can be made by simply saying just good morning and thank you you don't have to add the ladies you're not to add the sir habits become habits believe me i know that i i completely get that habits form and sometimes we don't even think about it when we say it that's called you ever heard of unconscious bias everybody's guilty of it's at some point um in their life probably several points in their life we don't we're not even we're not thinking about we're not even we're not thinking about it but we're saying something that's actually maybe perceived as bias you're just you know just saying good morning or just saying thank you ask their name simply ask their name not what is your real name what is your preferred name no no no no no no no ask their name let them tell you what their name is ask what they want to be called you know when i if i triage a patient or i get a patient that i know is um that i know is gender expansive i'm simply going to say what's your name and what do you like to be called you know just casually what do you like to be called introduce yourself you know absolutely introduce yourself and you know the pronouns pronouns that's a big topic too and so we want to do is you know ask the patient what their pronouns are not their preferred not their chosen when you ask for preferred pronouns this is what's going to go through the patient's mind well now i feel like i'm cornered and i have i have to make this decision now on whether to give them my legal pronouns or whether i give them the pronouns that i identify with okay they have they feel like they're forced to make a choice and it's not a choice okay i'll offer my pronouns you know i will offer my pronouns you know i'm hi i'm my name is uh justin and my pronouns are he him and his how can i best address you things we may not think about but we should be thinking about as we're going along so using that patient's um we call it chosen then chosen is better than preferred chosen is actually if you have to if you have to put um if you have to put an adjective before that chosen is actually better to use than preferred it's been shown to be you know and using that patient's chosen name and pronouns is shown to be very protective it shows the patient wow this person um is you know this person um is very respectful uh this person is respecting you know is respecting my gender identity and i feel safer neutral pronouns change daily they can be z here i'm just kind of giving you some examples of what you may see and they was they can change very very daily you know a lot you know a lot a large percentage of these patients may just say they them are there in fact in my in my large um company that i work for l severe i actually sit on the style alignment committee and the style alignment committee is always thinking of ways to be inclusive to be inclusive in in the materials and the um you know the stuff that we publish and we're moving away from he or she and using they them were there okay so they are really pushing for that i know i push for that in the clinical skills um that i write and so you're seeing it more and more l severe is very very pro um inclusive um as far as far as that very pro dei now you know we're all going to make mistakes right you know we're going to make mistakes you know to err is human you know we're only you know we're only as good uh you know as we are so if we but we have to remember if we don't ask 100 of these patients 100 of the time all we're doing is furthering the stigma so we've got to be consistent about it if we're doing it 30 of the time 20 of the time and you know if things are perceived wrong it's just it's furthering the stigma so 100 of the time if we 100 of the patients 100 of the time will actually decrease help decrease um that stigma and not further that stigma all right so most traumatic injuries in the transgender population are caused by wait for it of course violence right violence is the number one this scene um from the horrific incident that took place in florida um several several years ago in orlando um where there was the where's the shooting at that club um so that is the number one cause of trauma in this population they're more likely to be victims of assaults number one right there at the top of the list intimate partner violence and suicide in fact um more than about 60 of the transgender population um has been subject to assault you know that's that's a pretty big number and some of the latest statistics are at least 32 deaths from violence were recorded in 2023 at least 32 deaths were recorded in 2023 and the number really didn't change um in 2024 it's it's been pretty consistent um as far as um you know how many deaths from violence actually occurred other risks there are going to include it's going to be behavioral health lots of anxiety depression and thoughts um of suicide did you know that the transgender population um is the population that is the most at risk for suicide the most at risk the highest and that's that's pretty significant when you think about that so some statistics might show you here that 81 percent of transgender adults thought of suicide 42 attempted suicide okay so about half of that amount attempted suicide then that 56 percent of transgender adults did you know they had a non-suicidal or like self-harm you know non-suicidal self-injury over their lifetimes like cutting um a lot of you see a lot of teenagers um will cut will cut themselves and so you see um a lot of the in the adult population as well 56 percent of these uh population so um other issues substance and alcohol abuse sure you know this this is going to be higher that's a higher risk and um so what are the challenges we're thinking about the trauma system and the trauma team what are the challenges so let's go through let's go through our primary and secondary survey we're going to break it down for you right now right so the initial assessment your priorities don't change it is still stop hemorrhage airway breathing circulation disability the whole nine yards we save the life first that does not change so let's talk about airway and breathing tracheal stenosis um it's going to be more common in that affirmed female at birth so this is the um born female and is affirming um their gender as a male these so they've got this narrow uh they have a narrow tracheal lumen and those estrogen receptors actually increase the risk of fibrotic scarring and it's very difficult intubation um so a smaller tube actually may be needed um in these individuals because of that so we talk about tracheal stenosis and um chondrolaringoplasty or the tracheal shave and this is going to be um this is going to be the um gender you know this is going to be the affirming um female the affirming woman the trans woman they go through surgical procedure they have this um they they're they're adam's apple they basically have their adam's apple shaved down and they reduce that thyroid cartilage and what are the complications well you tell me okay we're messing with an airway we're messing with an airway we're messing with edema we're messing with infection all sorts of possible complications right painful swallowing hoarseness laryngospasm so these are just some of the now the statistics actually show that it's not a large percentage of these patients after a tracheal shave will have these problems but you got to be aware of them you got to be aware especially if it's a recent if it's recent and that um that surgical site is still is still healing now so gender affirming hormone therapy so gender affirming hormone therapy um this is testosterone can actually cause sleep apnea um in the trans man okay so they're taking testosterone that can actually cause sleep apnea um with that so that's something else that has to be taken into consideration um for airway and breathing we move to circulation gender for affirming hormone therapy so both of these both testosterone and estrogen cause issues with clotting did they both cause issues with clotting in fact um the testosterone not only causes issues with clotting but also causes polycythemia klr you know increased number of red blood cells they clump together and essentially act like a clot all right so this would be a trans um a trans woman and they're more going to be more at risk if a trans woman's going to be more at risk for a vte a pe in a my ischemic stroke because um it's a pretty well known fact that birth control pills or estrogen does cause um does have the risk of uh clots of blood clots forming okay so that is going to be that's going to be a big risk when you talk about um using you know when they're taking those uh that estrogen supplement blood products massive transfusion it's o negative right you and you know as well as i do the only reason it's o negative and the negative there the rh factor is because we're taking into consideration the um the female patient of childbearing age right so i o negative blood is used when people say oh my goodness well what do we do here what do we do here it's very very simple they do get o negative blood you know that's the universal donor it doesn't matter you know whether they are um you know whether they are a trans man or a trans woman because the o because the rh factor is not there all right but if it's less emergent i mean type blood specific you know type specific blood is always going to be the best i mean you know we don't always have time for that so um but in lesser severe situations that type specific blood um is going to be um needed or indicated so um for disability we talk about those thromboembolic events like ischemic stroke we talked about that unconsciousness patients unconscious um they're a john doe a jane doe or as we used to use in my former institution uh they were going to be uh they were going to be an alpha beta gamma okay they're going to you know be one of those names that they came in for so that makes that causes a little bit of a challenge right the challenge is you really can't obtain a name or pronouns and if they don't have the wallet if they don't have any identification it's going to be difficult right difficult to obtain a history look at that question at the bottom there does this patient still have their reproductive organs you're not going to necessarily be able to know that especially if there is not somebody that can be called especially if they've not been to that hospital before if they have you can probably look it up in the record okay but if they've not been there you've got to get the you've got to have the other um they have their other chart transferred over it becomes you know it's just a little bit more complicated but in a very tight and critical situation right there, you may not know whether or not that patient still has their reproductive organs. We need to expose environmental control. Okay, this is where we have to think about the fear of discrimination and the stigma of healthcare encounters. You're about to take the scissors and you're about to cut off all the clothes. This can be very stressful, very anxiety provoking for these patients who are conscious or awake. I mean, for any patient, doesn't like their clothes cut off, but it's even more so with this population because remember, they don't want to be called out. It's almost like they feel like they've got to keep everything just kind of hush hush. They don't want to be called out. They don't want to be discriminated against. So this is going to be a big source of anxiety for them. Very stressful, especially in front of seven people. Okay, they're in the trauma bay. There's about seven people all talking at the same time, of course, right? Lots of noise going on. And now we're cutting off the clothes. You know, all these strangers are going to see my body after the clothes have been cut off. So this is where you develop that rapport. Give them their name, ask them their pronouns, explain why their clothes have to be removed. You just, you want to build up that rapport and simply explain to them for your safety. We have to remove your clothes to see if you have any other injuries going on, right? If you have to. Hard to do in the ED. I mean, I get that, right? Not every ED has a private room, but maintain as much privacy as possible. And on the ICU, more and more ICUs have those private rooms now. Okay, so you want to be able to have to maintain as much privacy as possible. You know, that's a big win for them is maintaining that privacy, dignity, and respect. I'm going to say it again and again and again, the same dignity and respect. So the findings may be, let's, you know, you've taken the clothes off. There could be a surgical scars from top surgery. Hey, this could be a trans man that had a bilateral mastectomy done. So you may see some scarring. Sometimes they do what's called the keyhole approach. They make a small incision, it looks kind of like a keyhole, and that's how they do the mastectomy. Okay, so you may see that when they actually, when they have that cut down, you may see the laparoscopic or the big, you know, or the big scar, a laparoscopic scar, big scar, if they've had a hysterectomy done. It's going to be suprapubic. They've had any bottom surgery done, if you've seen that. If they had a phalloplasty done, if they had a vaginoplasty done, and it's been recent, you can sometimes tell, you know, that those procedures have been done. Okay, full set of vital signs in the family present. Remember, you know, they're often different, and heart rate are often different between the affirmed male at birth and the affirmed female at birth. I mean, that's just, that's just the way we're made. So we have to think about the therapy that they're taking. So for the trans woman who is taking estrogen, that may be a lower blood pressure because of that, so lower the blood pressure. If it's a trans, if it's a trans man, the higher blood pressure that they actually may have. So it kind of makes it a little murky. You have to kind of think about that in this context, though, when you're getting that history and when you're doing the assessment on. Presence of the family at the bedside may be a source of stress. When you think about the presence of the family at the bedside, that may be a source of comfort. It may be a source of stress. You always want to ask that patient about that. And, you know, partners should not be excluded from family presence. If there's a significant other partner, absolutely, they should be with your patient there. Now, here's an exception. We talked about violence in number one cause of injury. So if these injuries are from violence and, you know, visiting family members should be screened. They really should be screened before letting them see the patient. A member of that group did the assault on the patient. Did you let them back? You didn't know that. And then we have another potential problem, right? So they really should be screened before they come back. Getting monitoring devices and giving comfort laps. You want to ask for their safety. Does the patient have their reproductive organs? You know, for your safety. And because of the pain that you're having in your abdomen and, you know, because pain in the abdomen can be from this, it can be from this. For your safety, we really need to know whether you still have your reproductive organs. You know, explain the rationale for the pregnancy testing. It can happen, right? The trans man may be having a period. There may be blood in the urine. But you're thinking, oh my gosh, they've got a pelvis break. They've got a urethral tear. They've got some injury right here. They may be having a period, right? We have to think about that. Communication with the lab. Some baseline values, you know as well as I do, that baseline results from the CBC in a female are different than a male. And so there's gotta be communication with the lab because they're going to see this patient that was admitted as a male. They're looking at this and saying, this doesn't really make sense. Okay, this doesn't make sense. This should be for the other way. So it's very, very important to actually communicate that. Those baseline labs may be different. You wanna monitor. Mastectomy scars may be noted during the lead placement that you can see, right? The orogastric or the nasogastric tube, there's really no special considerations for that. Same thing, whether you're doing the SpO2 or the N-tidal CO2, again, it's with any other patient. Remember, any other patient, you are still going to treat them as a trauma patient. The pain assessment and management. Did you know that they experience bias from healthcare providers? Some patients may not get enough of the pain medication that they needed or may not have their pain managed quite adequately. Yeah, there is bias there. That's the problem. They'll experience bias from healthcare providers and then they have inadequate pain management. And you know as well as I do that when pain gets out of control, it causes stress response, oxygen is utilized and utilized and they can become all sorts of, they can start teetering down and having all sorts of issues because of unmanaged pain. So it's very, very important that we manage that like with any other patient. History, keep the conversation clinical. Not go to that trans broken arm syndrome. If it's not the issue, leave it alone, all right? It's not pertinent, don't ask. If this patient's got a fractured femur or they've got some broken ribs, really doesn't have anything to do with their gender affirming status at all. Now, if that patient's got abdominal pain and they've had some abdominal injuries, that's a little bit different. So if this is a trans man, especially, this is where you wanna ask whether they have had, you know, whether they still have their reproductive organs. It's gonna be on case by case, but if it's not pertinent, don't ask. You know, why, you know what I ask about that status? It is, again, a trans man that's got abdominal pain, not a trans man or a woman with a sprained ankle, okay? But you do wanna ask about the organs and pregnancy status. So you wanna ask about it because sure enough, of course, they're about to go get an abdominal CT and the department does not see a documented pregnancy test and they're gonna send that patient right back to you, right? I know that our CT definitely did. So that's something you have to take into consideration because of the imaging, right? Preparation for surgery, you're certainly gonna wanna know that. Head and face. Really no special considerations. The neck, the tracheal shave scar. Either they have that tracheal shave scar at the chest, a recent mastectomy or a mammoplasty that may have been done, the abdomen and flanks, a recent hysterectomy. Obviously, that's very, very important to know, okay? Do they have those reproductive organs? A recent phalloplasty. This is going to be the trans male. If they've had a recent phalloplasty, and phalloplasties, I could do an entire lecture on this. They take a long time to heal. They may have a suprapubic tube. That's another cue. Do they have a suprapubic tube? Because that phalloplasty has got to be able, they've built a new penis, okay? And it's got to be able to heal. And so for a little while, they may have a suprapubic tube. So it's important to know if there's any significant trauma to the abdomen, flanks, or the pelvis. Because if they've just had a phalloplasty, and they just had a big old pelvis fracture, which caused complications, so to speak, or further injury to that surgical site, they may need to have a suprapubic catheter put in place. Pelvis, a significant pelvis fracture. This is where we would get a little bit more concerned, more higher risk if they've had a phalloplasty or a vaginoplasty. This can worsen gender dysphoria, okay? Which we will, we talk about gender dysphoria. That is the negative feelings or feelings of anxiety or depression. As these individuals are going through that affirmation process, they know they're going through the affirmation process, but they feel uneasy. They feel depressed. It can actually lead to further depression. And as I discussed earlier, thoughts of suicide. Yeah, very important to think about. Perineum, think about the anatomy following the gender affirming surgery. The holy catheter may be contraindicated. If they've had a recent phalloplasty or a vaginoplasty, they may have a suprapubic tube. We talked about that. The extremities, skin grafts for phalloplasty from the forearm or the inner thigh is a distinctive scar. So if on their forearm, you see this perfectly square scar area that, or on the inner thigh, that perfectly square scar area that looks like it was a skin graft, that's what you might want to ask about that skin graft because they use that for the phalloplasty. Spectral posterior surface, not a whole lot of special considerations. And of course, just keep reevaluating. Their psychosocial status. Again, this is gender dysphoria. Differing, they know that their identity differs than their sex assigned at birth. And they can have both physically and socially and they just have those feelings of distress or discomfort. You know, that we've got to be aware of that. And that can lead to depression. We talked about suicide. Not all transgender or gender expansive patients experience this. I mean, but some do. So you want that continuity of care. You want to build up that trust. Remember, they're afraid to be called out. They're afraid of being discriminated against. Inclusive, supportive, caring environment. And that's just nursing 101, as far as I'm concerned. So best practices, of course, are people of diverse gender expression should be awarded the same respect and rights as those whose gender identity and expression conform to societal expectations, right? So that's very important to think about that. And from the American College of Surgeons, Dr. Eileen Buggler, I will quote this here, that as trauma surgeons, we survive to provide optimal care by attending to the physical and psychological and societal needs of our patients. This review raises awareness of critical issues to consider when caring for transgender patients and should be included in our educational programs for trauma fellowship, training, and used as a resource to raise awareness in our trauma centers. In fact, the American College of Surgeons and EAST absolutely endorse this. In fact, if any of you are familiar with the great big red book, Trauma by Feliciano Moore and Maddox, there is a section in there on gender identity. The same thing with courses such as TNCC. There is an entire chapter about the gender expansive patient in there. So it's being incorporated there. You wanna lead by example. You know, lead by example. You know, don't be the person that that patient fears. You wanna lead by example when we take care of that. So, you know, why am I so invested in this? You know, this has been a passion of mine for years, but you know, people ask me, Justin, why are you so invested in this topic? Why is it so important to you? It's important to me because of this guy right here. And, you know, as I'm just gonna kind of show you there, you know, he has taught us, my wife and I, you know, so much over the years when he went through his process, when he was in very, very young and went through that process. We learned a lot. We had to learn a lot. I'll be honest with you. I was very, very new to it and so was my wife. But, you know, he's taught us more than I can think about. Now, you know, he just recently graduated from veterinary school and he is a practicing emergency veterinarian in Holland, Michigan. And another big news right there to the right, you can see that Morgan there on the right has a ring on that finger. So the two of them are getting married this next October. Okay, so he proposed getting married this next October. So as I say, it's a good, you know, it's a great, as I say, journey. That, and we are all very, very proud of him and he will continue to make us proud. And this here is just some references that I just kind of used here if you want that. Does anybody, I guess we can go to, I mean, I guess we can go to the Q&A with that. All right, very good. So again, thank you so much, Justin. Phenomenal presentation as always. Do have a couple of questions in the queue for you. And first of all, congratulations to you, your wife and your son and your soon-to-be daughter-in-law. That's wonderful news. All right, so Wendy Batkins asks, where can we find the Fenway Glossary? You can find the Fenway Glossary, you just do a Google search, just say the Fenway Institute LGBTQIA Glossary. It actually, it is a sub, it is a subsection of Fenway. It is the National Transgender Gender Education Department. I can't think of the entire name here, but you will see that there. It is their education section. And you will find that if you just do Fenway Institute LGBTQ Glossary and you will get that. Great, excellent. And then Cassandra wanted you to maybe quickly go over gender again. It definitely is confusing. And there's a lot of terminology and a lot of emerging and changing terminology there. So is there kind of a quick, kind of a quick index that we can kind of keep in our mind for pearls when it comes to genders and gender classification? Well, that is one of the wonderful things about that glossary that I just told you about, because it has the most up-to-date definitions by the Fenway Institute as far as gender. Another wonderful institution is WPATH. And that is the World Professional Association for Transgender Health. The World Professional Association for Transgender Health. And WPATH actually does have guidelines, okay? They do have clinical practice guidelines. The only ones that I'm aware of that are out there right now is under WPATH. So if you just type in W-P-A-T-H and put in guidelines or care for care, they will actually have those that you can download in a PDF form. It's a huge, huge, huge, huge document, but it covers everything. And we'll also have those definitions in there as well. And it was just updated. Great. And then another question came in. You certainly mentioned the use of O-negative blood for mass transfusion, with a lot of centers going to low-titer O-positive and a lot of pre-hospital assets now going more and more to that. Are there any contraindications for using O-positive blood in these patients? Not the, you know, only, you know, it's only that RH factor that they're concerned about. With that, just like you would be careful about that in a patient who is not gender diverse or transgender, and that patient is a female and they're childbearing age. So that's- They really kind of follow your standard protocols. Exactly. Follow your standard protocols, correct. Excellent. Excellent. Well, we're about running out of time here. A lot of people have asked questions about whether the slides can be available. And in the chat box, there's a link to be able to grab Justin's handout. And then people have asked about being able to review this. And again, in the chat box, comments have been made about this will be available and up on TCA's website, and that'll be available to TCAA members. So Justin, thank you so much for your time and your efforts today. Again, wonderful presentation, and obviously very timely with what's going on in the world today. And thank you. And you're welcome. And you can also add in there, if anybody, you know, wants to contact me, email me, text me, whatever, I am welcome to all of that. I'm absolutely okay with that. So you were- Please feel free to give my contact info to them. Very good. All right, well, everybody have a great day. Thanks for hanging on board with us. And again, Justin, thanks for the wonderful presentation. Okay, you're welcome. Thank you.

transgender care

trauma teams

gender-expansive patients

cultural competence

Fenway Institute Glossary

WPATH guidelines

gender-affirming treatments

communication strategies

preferred pronouns

healthcare discrimination