A central role of the ED is to provide a safe place for those seeking medical help. This is especially important for marginalized populations. Unfortunately, the data shows that our ED’s are not the safety net they should be for people of diverse sexualities and genders. A 2014 survey of 408 transgender people in Ontario showed that 52% had trans-specific negative ED experiences, including hurtful or insulting language, denial of their identity, and even outright refusal of care. The result of these experiences is that 21% of transgender people surveyed had avoided ED care because of the perception that their gender presentation would negatively affect the encounter.

One reason for these poor interactions is a lack of knowledge and training.

Numerous North American studies show that medical school and residency programs provide minimal teaching on these topics. A provincially funded study by BC’s Health Equity Commission in 2021 found “the number one barrier to care identified by study participants was a lack of health care providers knowledgeable in intersectional issues”. They identified healthcare provider education as one of three key areas of action.

Providing safe and respectful care to transgender patients, who are often severely marginalized by our society, forms the basis of a system that will encourage transgender patients to seek care when they need it most. In lieu of formal training, here are some basics to get you started:

There are three main descriptors used when talking about gender and sexual diversity: Assigned Sex, Gender, and Sexuality. Gender can be further divided into gender identity and gender expression.

Sex

Sex is a physician-assigned characteristic based on a set of phenotypic criteria, primarily the external genitalia observed at birth and associations with sex chromosomes. We treat assigned sex like a binary characteristic, but it is more accurate to treat sex as a continuous spectrum with a strongly bimodal distribution. 2% of people do not meet these simplified criteria. We have historically assigned these people the label “intersex” as their genitalia do not conform to the phenotypic binary.

Variations in sex can occur for a variety of reasons including Turner syndrome, congenital adrenal hyperplasia (CAH), receptor abnormalities, and hormonal exposure in utero. Some of these conditions are apparent at birth due to phenotype (e.g. most people with CAH are assigned intersex) while others are not (e.g. most people with complete androgen insensitivity syndrome are assigned female at birth despite having XY sex chromosomes). For this reason, the traditional genetic and phenotypic binary of sex is fraught with contradiction and does not accurately describe the diversity of human biology.

Gender

Gender is a social concept traditionally based on the binary of “masculine” and “feminine”. Although many cultures, including some Indigenous peoples in Canada, have conceptualized other genders beyond this binary. In recent years, the understanding of gender has expanded in the public consciousness thanks to the efforts of activists and scholars. It is now widely acknowledged to be a spectrum divided into two components: gender identity and gender expression.

• Gender Identity
  • Gender identify is a term used to describe how masculine or feminine a person feels. For most, their assigned-at-birth sex and gender identity match. We say that these people are cisgender. For others, their assigned-at-birth sex and their gender identity do not match. We say that these people are transgender (abbreviated “trans”). A trans man is someone whose gender identity is masculine, but whose assigned sex is female. A trans woman is someone whose gender identity is feminine, but whose assigned sex is male.
  • Furthermore, there are people who feel their gender is somewhere between or outside of the poles of the masculine and feminine binary. Some of these people identify as gender non-conforming, although this term comprises a number of distinct identities including nonbinary, genderqueer, agender, and gender fluid. There is a growing body of evidence that gender identity is multifactorial, and at least partially innate. The details of this are beyond the scope of this clinical summary, but suffice to say that gender identity is a complex concept with cultural, environmental, and innate characteristics.
• Gender Expression
  • Gender expression is the way your gender is presented or performed externally. It is usually demonstrated through the way a person looks and acts, including through clothing and grooming. A person’s gender expression may closely align with the binary of male/female, and it may not.

Sexual Orientation

Sexual orientation describes a person’s romantic and sexual attractions. This includes terms such as lesbian, gay, bisexual, pansexual, asexual, and straight, among many others. It is most accurate to consider sexual orientation as completely distinct from gender or sex. While sexuality is believed to be a strongly innate characteristic, it may evolve over the course of a person’s life. Terminology may change, but wholesale changes in sexual orientation rarely occur. Attempts to externally change a person’s sexual orientation have been recognized as harmful by numerous health organizations.

The following are a list of terms often used in discourse around gender and sexuality:

Queer

Previously used as a slur for people who did not conform to the gender and sexual norms of the time, this word has been reclaimed by members of the LGBTQ+ community and is now used by some as a blanket term to describe this population.

LGBTQ+

This is an acronym for lesbian, gay, bisexual, transgender, and queer. The “plus” signifies all of the diverse identities contained within the queer community but not listed in the acronym. This acronym is widely seen as inclusive while also short enough for common use, although LGBTQ2S+, explicitly including two spirit, is also commonly used in Canada.

Two spirit

An identity within some Indigenous communities that describes the spiritual embodiment of both masculine and feminine traits within one person. This term has both a historical and religious context. Knowledge of this identity and its long history in the Indigenous community is a part of providing culturally competent care.

Pronouns

A person’s pronouns are the parts of speech used to denote their gender. Standard English includes the binary “he/him/his” and “she/her/hers” as well as the gender neutral “they/them/theirs”. Recently, alternative pronouns such as “xe/xem” and “zie/zim/zis” have been proposed and are beginning to be used by some.

The following are incorrect or offensive and shouldn’t be used, especially in a professional setting:

• “A transgender” or “transgendered” – transgender is an adjective and should not be used as a noun. Instead, we say “a transgender/trans person”
• “Hermaphrodite” – we now use the word intersex to refer to people with ambiguous phenotypic sex, given the unkind history behind this word.
• “Transvestite”, “transsexual” or “tranny” – these are historically discriminatory slurs and are inappropriate. They are sometimes used by people with the transgender community in a self-referential or facetious way but should not be used by others, especially health professionals, given their history and the ongoing marginalization faced by transgender people.
• “Sex change” or “sex change operation”– we no longer refer to the process of transitioning genders as a “sex change” as it is inaccurate. The surgical process by which a person transitions is known as a gender affirming surgery.

1. Trans Care BC – Resources for patients and providers.

   
   

2. BC Children’s Hospital Gender Clinic

   
   

1. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Ann Emerg Med. 2014;63:713-720.e1

   
   

2. Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, Gay, Bisexual, and Transgender–Related Content in Undergraduate Medical Education. JAMA. 2011;306(9):971–977. doi:10.1001/jama.2011.1255

   
   

3. Moll J, et all. The Prevalence of Lesbian, Gay, Bisxual and Transgender Health Education and Training in Emergency Medicine Residency Programs: What do we know?. Academic Emergency Medicine 2014;21:608–611 © 2014

   
   

4. Health Equity Collaborative. (2021). Believe Me: Identifying barriers to health equity for sexual and gender diverse communities in British Columbia.