Transcript Transgender Health

Transgender Health:
My Right Self
Lauren Meade
March 10, 2010
My Right Self
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Mazzoni Center, Philadelphia’s LGBT Health Center
Hembree et al Endocrine Treatment of Transsexual Persons:
An Endocrine Society Clinical Practice Guideline J Clin
Endocrinol Metab 94: 3132–3154, 2009
Gender Health Clinic, High Street Health Center, Aleah
Nesteby NP
Diversity
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Socioeconomic status
Languages
Levels of acculturation
Unique ways of understanding
illness and health care
Sex, race, ethnicity, sexual
orientation, and gender identity
Committee on Understanding and
Eliminating Racial and Ethnic
Disparitiesin Health Care. Unequal
Treatment: Confronting Racial and
Ethnic Disparities in Care.
Washington, DC: The National
AcademiesPress; 2002.
Cultural Competence
“the ability of individuals to
establish effective
interpersonal and working
relationships that supersede
cultural differences”
Cooper LA, Roter DL. Patient-provider
communication: The effect of race and
ethnicity on process and outcomes of
healthcare. In: Smedley BD, Stith AY,
Nelson AR, eds. Unequal Treatment:
Confronting Racial and Ethnic Disparities in
Healthcare. Washington, DC: The National
Academies Press; 2002:552–593.
Transgender Health
Jake is a 32 yo FTM on ‘T’ for 2 years
and requesting a referral for top
surgery.
GOALS
 Give a conceptual framework for
transgender people
 Promote dignity and safety for
transgender people
 Describe the different behavioral,
medical and surgical options in
transition of gender
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Sex and Gender
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Sex refers to attributes that characterize biological
maleness or femaleness; the best known attributes
include the sex determining genes, the sex
chromosomes, the H-Y antigen, the gonads, sex
hormones, internal and external genitalia, and
secondary sex characteristics
Gender identity is used to describe a person’s fundamental
sense of being a man, a woman, or of indeterminate
sex.
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Hembree et al Endocrine Treatment of Transsexual Persons:An
Endocrine Society Clinical Practice Guideline J Clin Endocrinol
Metab 94: 3132–3154, 2009
Transsexual
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Transsexual people identify as, or desire to live
and be accepted as, a member of the gender
opposite to that assigned at birth
Transgender
Transgender is a more recent term referring
to gender-variance broadly understood.
 Trans-activisim
 Transphobia
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Transgender terms
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Female-to-male (FTM)
transsexual person refers to
a biological female who
identifies as, or desires to
be, a member of the
male gender.
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Male-to-female (MTF)
transsexual person refers to
a biological male who
identifies as, or desires to
be, a member of the
female gender
Ann Bonny and
Mary Read 1720
Hatshepsut, 1479 B.C
Billy Tipton Trio
1 of over 500 soldiers
who fought in the Civil War
Joan of arc, put to death
for dressing in mans clothing
Prevalence
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Prevalence is not easily studied
1/2000 prevalence in New Zealand people who
changed gender marker on passports
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Veale JF. Prevalence of transsexualism among New
Zealand passport holders. Aust N Z J Psychiatry. 2008
Oct;42(10):887-9
GID and Gender dysphoria
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Gender dysphoria is the distress and unease experienced if
gender identity and sex are not completely congruent.
Gender identity disorder (GID) is a DSM-IV-TR diagnosis.
This psychiatric diagnosis is given when a strong and
persistent cross-gender identification, combined with a
persistent discomfort with one’s sex or sense of
inappropriateness in the gender role of that sex, causes
clinically significant distress.
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Newfield et al. Female-to-male transgender quality of life. Quality of
Life Research (2006) 15:1447–1457
Transition
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Transition refers to the period of time during
which transsexual persons change their physical,
social, and legal characteristics to the gender
opposite that of their biological sex. Transition
may also be regarded as an ongoing process of
physical change and psychological adaptation.
Sex reassignment
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Sex reassignment refers to the complete treatment
procedure for those who want to adapt their
bodies to the desired sex.
Sex reassignment surgery refers only to the surgical
part of this treatment.
Transgender Health
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Jake is a 32 yo FTM on ‘T’ for 2
years and requesting a referral
for top surgery.
FTM – female to male transgender
person
‘T’ – testosterone
“top surgery” – sexual
reassignment surgery
Transgender video
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Gay and Lesbian Advocates and Defenders GLAD
Mass Transgender Political Coalition
Mass Equality
Transgender Health
Jake comes to your practice for his
first visit. You look at his
chart label which states ‘Jane
Smith’ and you look at your
patient who is presenting as
male. What do you do?
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Do you go by Jane?
What name do you prefer?
Preferred Gender Pronoun
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Visit
Documentation
Other health
care providers ie
nurses and
consultants
Casual discussion
Gender identity history
Jake tells you that he has been injecting
testosterone which he orders on
the internet. He started dressing as
a man a few years ago and was
seeing a therapist for a few months
in the beginning which he found
only a bit useful as he was very
comfortable with his decision to
transition to a man.
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How do you ask a gender
identity history?
Sexual history
Jake tells you that he has no significant
medical history and is taking no
other medications. He does not
smoke or use alcohol or drugs. He
is working in IT.
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How do you ask a sexual
history?
Transitioning
Appearance
 Cross sex hormones
 Surgery
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Transitioning: Appearance
(mostly reversible)
FTM
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Dress: clothing
Mechanical: binding and
packing
MTF
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Dress: clothing, make-up,
wigs
Mechanical: tuck or
taping
Minor procedures:
waxing, electrolysis,
botox
Readiness for hormone therapy
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WPATH (World Professional Association for
Transgender Health) Standards of Care (SOC)
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Patient must be evaluated by a mental health professional
with specialized training. Recommended duration is often
interpreted as 3 months OR
Patient must complete “real life experience” for 3 months
Exemption for safety of patient
Informed Consent Model
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Patients must demonstrate understanding of the risks and
benefits of hormone therapy, must be competent to make
decisions about their health and must work in conjunction
with health care providers
Readiness for Sexual
Reassignment Surgery (SRS)
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WPATH (World Professional Association
for Transgender Health) Standards of Care
(SOC)
 Minimum of 3 months psychotherapy
for gender related issues AND
 Diagnosed with Gender identity disorder
(GID) AND
 Deemed ready for surgery from both a
psychological as well as medical
standpoint.
Transitioning: Surgery
(irreversible)
FTM
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Top:
 Mastectomy
Bottom:
 Metoidioplasty
(clitoral release)
 Testicle implants
 Hysterectomy
MTF
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Tracheal shave
Facial feminization
surgery
Top: Breast
augmentation
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Bottom:
 Vagnioplasty/
Labiaplasty
 Orchiectomy
Dr Melissa Johnson
SRS Mastectomy
Keyhole Mastectomy
Courtesy Dr. Melissa Johnson
Double Incision Mastectomy
Courtesy Dr. Melissa Johnson
Metoidioplasty and
Testicular Implants
Vaginoplasty with Labiaplasty
Trans-specific health considerations
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Insurance
Revision of DSM-IV-TR
 Review of diagnosis – Gender Identity Disorder
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Violence
Vulnerable population with decreased access to
healthcare due to discrimination
Poor rates for basic screening and higher rates
of untreated illness
HIV risk behaviors
Legal Issues
Identity Documents – Gender Markers
 Employment
 Gender-segregated Facilities Access
 Family Formation
 Youth
 Prison
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Transgender Health
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Jake is a 32 yo FTM on ‘T’ for 2 years
and requesting a referral for top
surgery.
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Use his desired pronoun in referring to
him
Recognize that trans folks may choose
several venues for their sexual
expression
Do not assume behaviors
Build rapport and when you are not
sure just ask
Thank you
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My Right Self
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Mazzoni Center, Philadelphia’s LGBT Health Center
University of Pennsylvania Department of Fine Arts’ darkroom facilities
American Medical Student Association
The project has been conducted as part of Arthur Robinson Williams' master in bioethics
thesis at Penn's Center for Bioethics.
Diversity Office; Stephanie Houle and Bobby Rodriguez
Aleah Nesteby, NP High Street Health Center