Thoughts on caring for transsexual patients Authors: Kenn M. Kirksey, RN, PhD, CS, CEN, APN, Gail B. Williams, RN, PhD, APN, and David J. Garza, RN, BSN, San Antonio, Texas

M any e m e r g e n c y nur ses have ca red for homosex- ual or b i sexua l pa t i en t s , bu t wi th t he excep t ion

of t hose work ing in larger e m e r g e n c y d e p a r t m e n t s in me t ropo l i t an areas , p e r h a p s few have worked wi th t r ans sexua l pa t i en t s . I n a d e q u a t e k n o w l e d g e regard- ing t r a n s s e x u a l i s m m a y foster p re jud ice and d i sc r im- inat ion. One au thor n o t e d t ha t m e d i a por t rayals m a y c a u s e nu r ses to be host i le and j u d g m e n t a l t oward t h e s e individuals . 1

T rans sexua l i sm first a p p e a r e d in the med ica l lit- e ra tu re du r ing the midd le of the las t century . 2 In the 1950s i t w a s r e c o g n i z e d as a m e d i c a l condi t ion requ i r ing d i a g n o s i s and in tervent ion. 1 Various theo- r ies have b e e n p o s t u l a t e d r e g a r d i n g this p h e n o m e - non. Lo ths te in s u g g e s t e d tha t th is " g e n d e r - i d e n t i t y d i so rde r" r e su l t ed from l ibidinal confl icts tha t were not reso lved dur ing p s y c h o s e x u a l deve lopment . 9 The m e d i c a l c o m m u n i t y has c h a n g e d its pos i t ion regard- ing t r a n s s e x u a l i s m in r e c e n t years . Stoller 4 no ted tha t p sycho log i c in t e rven t ions are "frui t less ," and there- fore once the d i agnos i s is made , hormonal therapy , electrolysis , a n d p r epa ra t i on for gende r r e a s s i g n m e n t su rge ry should begin . Benjamin 5 c o n t e n d s tha t t rans- s exua l i sm is an incurab le condi t ion and surgery should b e v i e w e d as a l i fesaving in tervent ion. Reas- s i g n m e n t su rge ry w a s once more common. Now, few, if any, i n su rance p r o g r a m s fund such surgery; there- fore all e x p e n s e s are out of pocket . It is c o m m o n for t r ans sexua l s to expe r i ence diff icult ies in socia l adap - ta t ions , and s u b s e q u e n t l y anxiety , depress ion , and su ic ida l i dea t ion develop. Transsexuals , a l though not fully u n d e r s t o o d and a c c e p t e d b y m a n y hea l th care profess ionals , are b e c o m i n g more m a i n s t r e a m in our socie ty . The A m e r i c a n Psych ia t r i c A s s o c i a t i o n ' s Di- agnostic and Statistical Manual of Mental Disorders first i nc luded cr i ter ia d e s c r i b i n g t r a n s s e x u a l i s m in i ts 1980 edi t ion. 6 " A t r ans sexua l pe r son is s o m e o n e who has an una l t e rab le convic t ion tha t he or she be longs

Dr. Kirksey is assistant professor of Acute Nursing Care and Dr. Williams is assistant professor of Family Nursing Care at the Uni- versity of Texas Health Science Center at San Antonio School of Nursing. Mr. Garza is staff nurse, General Medicine, University Hospital, San Antonio, Texas. Reprints not available from authors. J EMERG NURS 1995;21:519-20. Copyright �9 1995 by the Emergency Nurses Association. 0099-1767/95 $5.00 + 0 18/1/68828

to the g e n d e r o ther t han tha t s u g g e s t e d by his or her geni ta l ia ."7

Case study Maria, a 26-year-old Hispan ic woman , was b rough t by a m b u l a n c e to t he e m e r g e n c y depa r tmen t ; she re- por ted seve re shor tness of b r ea th tha t had pe r s i s t ed for the p a s t 8 hours. She w a s p l a c e d in a four-bed room wi th th ree other female pa t ien t s . Initial a s se s s - m e n t r evea led severe dyspnea , d iaphores i s , and cy- anot ic na i l beds on all ex t remi t ies . Ches t auscu l t a t ion i n d i c a t e d expi ra tory w h e e z i n g in the lower lung lobes. The pa t i e n t d e n i e d pain, bu t r e p e a t e d l y no ted tha t she w a s " ha v ing a lot of t rouble b r e a t h i n g . " She repor ted

Stoller n o t e d that p s y c h o l o g i c in tervent ions are "fruitless," and therefore once the d iagnos i s is made , hormonal therapy, e lectrolys is , and preparat ion for g e n d e r r e a s s i g n m e n t surgery shou ld beg in .

hav ing h a d " seve re a s t h m a as a lit t le girl ," bu t no ep- i sodes du r ing the p a s t 15 years . The p a t i e n t ' s condi- t ion gradual ly improved after admin i s t r a t ion of IV m e d i c a t i o n s and two in t e rmi t t en t pos i t ive -p ressu re b r e a t h i n g t r ea tmen t s . The in ternal m e d i c i n e re s iden t a s k e d two me d ic a l s t u d e n t s to ob ta in a hea l th h is tory a n d perform a comple t e phys i ca l examina t ion . After app rox ima te ly 20 m i n u t e s wi th t he pa t ien t , the two s t u d e n t s e m e r g e d from the room and asked to s p e a k to t he cha rge nurse . The s t u d e n t s r epor ted tha t w h e n t hey a s k e d the p a t i e n t to r emove her u n d e r g a r m e n t s for the gen i ta l i a examina t ion , she had a penis . The nurse looked puzz led b e c a u s e she h a d e x a m i n e d the pa t i e n t on a d m i s s i o n and h a d c lass i f ied her as a "fe- m a l e " p a t i e n t b e c a u s e she looked feminine, h a d fully d e v e l o p e d breas t s , and r e g a r d e d herself as female.

On further a s s e s s m e n t i t w a s no ted tha t Mar ia w a s a p r eope ra t i ve t r anssexua l pa t ien t . She had had

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p sycho log ic counse l ing , had t aken female hormones , u n d e r g o n e electrolysis , and w a s s c h e d u l e d to have g e n d e r r e a s s i g n m e n t su rge ry in 2 months . W h e n she ar r ived in t he e m e r g e n c y d e p a r t m e n t , Mar ia w a s d r e s s e d in a floral d r e s s and sandals . She h a d a fem- in ine- looking face and w a s w e a r i n g eye m a k e u p and lip color. Her facial skin, arms, and legs were w i thou t any t r aces of hair. After the ED staff l ea rned tha t Mar ia had a penis , she w a s i m m e d i a t e l y t ransfer red to ano the r four-bed room wi th th ree male pa t i en t s . The

It is e s t i m a t e d t h a t a b o u t 60% of t r a n s s e x u a l s a t t e m p t s u i c i d e at s o m e t ime .

other p a t i e n t s cal led Mar i a " b a b y - c a k e s , " " s w e e t i e , " and " g o r g e o u s . " Some of t he male staff m e m b e r s (phys ic ians , e m e r g e n c y t echn ic i ans , med i ca l s tu- dents ) m a d e c o m m e n t s a b o u t the pa t ien t . W h e n they were ou t s ide her room, t hey referred to Mar ia as " tha t pe rve r t " or " t h e fag in T r a u m a 1." B e c a u s e of her w e a k e n e d condi t ion , Mar ia r e q u e s t e d he lp to s t a n d at the b e d s i d e to void. The male a ide a s s i g n e d to tha t room re fused to he lp her and s ta ted , " I ' m not go ing in the re w i th t ha t freak." A male nurse he lped the pa t ien t .

In re t rospec t , it wou ld have b e e n preferable to

k e e p the p a t i e n t in a p r iva te or al l-female room and refer to her as " female ."

Rees no ted tha t " t r a n s se xua l s expe r i ence a pri- va t e hell few could imag ine . ' ,s M a n y t r anssexua l indi- v idua l s repor t confl icts wi th the i r own sexual ident i ty , families, and fr iends, and t a u n t i n g b y soc ie ty in gen- eral. They often have difficulty forming close friend- s h i p s and expe r i ence feel ings of despai r .

It is e s t i m a t e d tha t abou t 60% of t r anssexua l s at- t e m p t su i c ide at some t ime. s Knowledge can b e a powerfu l w e a p o n wi th w h i c h to c o m b a t fear. It is h o p e d tha t ED nur ses can l i s ten and learn from pa t i en t s , and care, even w h e n w e do not fully under - s t and . 7

References

1. Thomas B. Gender loving care. Nurs Times 1993;89:50-1. 2. Hoeing J. Transsexualism. In: Gransville-Grossman K, ed. Recent advances in clinical psychiatry. Edinburgh: Churchill Livingstone, 1982. 3. Lothstein L. Female-to-male transsexualism: historical, clinical and theoretical issues. London: Routledge and Kegan Paul, 1983. 4. Stoller R. The transsexual experience. London: Hogarth Press and the Institute of Psychoanalysis, 1975. 5. Benjamin H. The transsexual phenomenon. New York: Julian Press, 1966. 6. American Psychiatric Association. Diagnostic and sta- tistical manual o f men ta l disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980. 7. Eastwood A. Return to gender. Nurs Times 1992;88:49- 50. 8. Rees M. He, she or it? Nurs Times 1993;89:48-9.

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