Beyond Binary: Critical Care Through a Transgender Lens

It all started with a crucial question from a colleague working on an ECHO HD data collection form design: "Should we include gender options alongside sex on this data collection form?" This seemingly simple query opened a much broader discussion about the importance of inclusive data collection in medical research, particularly when it comes to understanding the long-term health outcomes of transgender individuals. 

The decision to include both sex and gender on data entry forms has become increasingly significant in cardiovascular research. While traditional research has primarily focused on biological sex, there are compelling reasons to consider a more inclusive approach that accounts for the complexities of gender identity. Current evidence suggests that transgender individuals, especially those on long-term hormone therapy, may have different cardiovascular risk profiles compared to cisgender people. By capturing both sex assigned at birth and gender identity in medical data collection, we can better track and understand these potential long-term effects(1). This is particularly crucial in studies using echocardiography to measure heart data, where sex-based variations are already well-documented, but gender-based differences in transgender individuals remain understudied. 

This conversation took me back to the beginning of my journey, from the bustling streets of India. As a doctor from a middle-class Indian Muslim family, I found myself juggling two equally demanding aspects of my life: my medical profession and my internal gender identity conflicts. My journey of self-recognition and transition began in 2011. It wasn't an easy road, but it led me to where I am today – advocating for transgender inclusion in healthcare while pursuing my passion for critical care medicine(2). 

Landing in the UK as an International Medical Graduate (IMG) during a global pandemic was, to put it mildly, a challenging experience. There I was, fresh off the plane, immediately donning full PPE to work in the ICU. Fully covered from head to toe, the only way to identify a person was through their voice and self-introduction. This led to some interesting moments of gender perception – my voice didn't always match what people expected when I introduced myself. It was a stark reminder of how deeply ingrained our assumptions about gender can be, even in a professional medical setting. 

Despite these initial challenges, my journey as a transgender doctor in the UK has been largely positive. I've found incredible support and acceptance among my colleagues. For the first time in my career, I felt I was in a truly safe workplace – a dream that had seemed distant not too long ago(3,4). 

One of the most rewarding experiences has been the opportunity to contribute to medical research that directly impacts transgender healthcare. I volunteered to provide blood samples for a study at King's College Hospital, which has become the world's largest investigation of blood tests in individuals on hormone therapy(5). This study underscores the growing recognition within the medical community of the need for transgender-specific health data and reference ranges, and I'm proud to have played a small part in this groundbreaking research. 

My advocacy extends beyond research participation. Recently, I've had the opportunity to teach foundation trainees about global health inequalities, with a focus on transgender healthcare. These sessions serve a dual purpose: not only do I share my lived experiences and discuss the barriers transgender patients face, but I also use this as an opportunity to collect data on the trainees' perceptions of transgender healthcare in the UK. By teaching through my own experiences of the struggles I've faced as a transgender person seeking healthcare in the UK over the past four years, I'm able to provide a personal perspective on these issues. The data I'm collecting from these sessions will be used to conduct a needs-based analysis, helping to project and address gaps in transgender healthcare education and provision. 

I've also been invited to speak at the Royal College of Psychiatrists and the Association of Anaesthetists, sharing my experiences as a transgender person in medicine(2,6,7). These opportunities have allowed me to contribute to important discussions, like those around the Cass Review on care for children and young people with gender dysphoria. It's been a bit surreal, to be honest – one minute I'm intubating patients in the ICU, the next I'm advising on national healthcare policies. These experiences have reinforced my belief in the power of visibility and advocacy within the medical community. 

However, even in a progressive healthcare system, there's still work to be done in understanding and addressing the unique health needs of transgender individuals. I've observed how the lack of understanding about transgender health issues can impact patient care in the ICU. Something as crucial as hormone management for a transgender patient on long-term therapy can be overlooked in the midst of managing critical illness. It's not just about remembering to give estrogen or testosterone – it's about understanding the complex interplay between hormone therapy, critical illness, and overall patient wellbeing. 

Creating an inclusive environment within the ICU team itself is equally important. As a transgender doctor, I've faced my own challenges in navigating professional spaces. But I've also found incredible allies and supporters along the way. By being visible and open about my identity, I hope to pave the way for other transgender individuals in healthcare, showing that there's a place for us even in the high-stakes world of critical care. 

So, to my colleagues in ICM and beyond, I invite you to join me on this journey towards more inclusive practices in critical care. Let's work together to ensure that our ICUs – and indeed, our entire healthcare system – truly serve and represent the diverse population we care for. This means: 

1. Advocating for more comprehensive education on transgender health issues in medical schools and postgraduate training. 

2. Supporting research that considers the full spectrum of gender identities. 

3. Developing policies that protect and support transgender healthcare professionals and patients alike. 

4. Creating a culture of openness and acceptance in our ICUs and hospitals. 

Remember, a safe and inclusive workplace isn't just about policies; it's about the small, everyday actions that make everyone feel seen and valued. It's about asking the right questions on our data collection forms, considering the unique needs of each patient, and fostering an environment where every healthcare professional can bring their whole self to work. 

Let's make our ICUs a place where diversity is celebrated as much as a successful extubation. Together, we can reshape critical care to be more inclusive, effective, and compassionate for all. After all, in the world of critical care, the only thing we should be discriminating against is poor hand hygiene. 

References:  

1. Cardiovascular disease in transgender people: a systematic review and meta-analysis | European Journal of Endocrinology | Oxford Academic [Internet]. [cited 2024 Sep 8]. Available from: https://academic.oup.com/ejendo/article/190/2/S13/7596368 

2. ‘On being me’- understanding mental health of LGBT people [Internet]. [cited 2024 Sep 8]. Available from: https://elearninghub.rcpsych.ac.uk/products/Understanding_mental_health…;

3. As a transgender doctor a safe workplace was a distant dream for me until now | News from Newham [Internet]. [cited 2024 Sep 8]. Available from: https://www.bartshealth.nhs.uk/news-from-newham/as-a-transgender-doctor…;

4. Gender pronouns: our language is evolving and so too must our workplace | #TeamBartsHealth blogs - Barts Health NHS Trust [Internet]. [cited 2024 Sep 8]. Available from: https://www.bartshealth.nhs.uk/blogs/gender-pronouns-our-language-is-ev…;

5. Mills L. Trans study in London becomes the world’s largest investigation of blood tests while on hormones [Internet]. King’s College Hospital NHS Foundation Trust. 2023 [cited 2024 Sep 8]. Available from: https://www.kch.nhs.uk/news/trans-study-in-london-becomes-the-worlds-la…;

6. www.rcpsych.ac.uk [Internet]. [cited 2024 Sep 8]. Congress 2024: building empathy and understanding. Available from: https://www.rcpsych.ac.uk/news-and-features/blogs/detail/presidents-blo…;

7. tsig-newsletter-autumn-2022.pdf [Internet]. [cited 2024 Sep 8]. Available from: https://www.rcpsych.ac.uk/docs/default-source/members/sigs/transcultura…;