Transgender Transgender Health:Health:

My Right SelfMy Right SelfLauren MeadeLauren Meade

March 10, 2010March 10, 2010

My Right SelfMy Right Self

MazzoniMazzoni Center Center, Philadelphia’s LGBT Health , Philadelphia’s LGBT Health CenterCenter

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

DiversityDiversity Socioeconomic statusSocioeconomic status LanguagesLanguages Levels of acculturationLevels of acculturation Unique ways of Unique ways of

understanding illness and understanding illness and health carehealth care

Sex, race, ethnicity, sexual Sex, race, ethnicity, sexual orientation, and gender orientation, and gender identityidentity

Committee on Understanding Committee on Understanding and Eliminating Racial and and Eliminating Racial and Ethnic Disparitiesin Health Ethnic Disparitiesin Health Care. Care. Unequal Treatment: Unequal Treatment: Confronting Racial and Ethnic Confronting Racial and Ethnic Disparities in CareDisparities in Care. . Washington, DC: The National Washington, DC: The National AcademiesPress; 2002.AcademiesPress; 2002.

Cultural CompetenceCultural Competence

““the ability of individuals the ability of individuals to establish effective to establish effective interpersonal and interpersonal and working relationships working relationships that supersede cultural that supersede cultural differences”differences”

Cooper LACooper LA, Roter DL. Patient-provider , Roter DL. Patient-provider communication: The effect of race communication: The effect of race and ethnicity on process and and ethnicity on process and outcomes of healthcare. In: Smedley outcomes of healthcare. In: Smedley BD, Stith AY, Nelson AR, eds. BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Unequal Treatment: Confronting Racial and Ethnic Disparities in Racial and Ethnic Disparities in HealthcareHealthcare. Washington, DC: The . Washington, DC: The National Academies Press; 2002:552–National Academies Press; 2002:552–593.593.

Transgender Transgender HealthHealth Jake is a 32 yo FTM on ‘T’ for Jake is a 32 yo FTM on ‘T’ for

2 years and requesting a 2 years and requesting a referral for top surgery.referral for top surgery.

GOALSGOALS Give a conceptual framework Give a conceptual framework

for transgender peoplefor transgender people Promote dignity and safety for Promote dignity and safety for

transgender peopletransgender people Describe the different Describe the different

behavioral, medical and behavioral, medical and surgical options in transition surgical options in transition of genderof gender

Sex and GenderSex and Gender 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.

Hembree et al Endocrine Treatment of Transsexual Persons:An Endocrine Society Clinical Practice Guideline J Clin Endocrinol Metab 94: 3132–3154, 2009

TranssexualTranssexual

Transsexual people identify as, or desire to live and be accepted as, a member of the gender opposite to that assigned at birth

TransgenderTransgender

TransgenderTransgender is a more recent is a more recent term referring to gender-term referring to gender-variance broadly understood.variance broadly understood.

Trans-activisimTrans-activisim TransphobiaTransphobia

Transgender termsTransgender terms

Female-to-male (FTM) transsexual person refers to a biological female who identifies as, or desires to be, a member of the male gender.

Male-to-female (MTF) transsexual person refers to a biological male who identifies as, or desires to be, a member of the female gender

Joan of arc, put to death for dressing in mans clothing

Hatshepsut, 1479 B.C

Ann Bonny and Ann Bonny and Mary Read 1720Mary Read 1720

1 of over 500 soldiers who fought in the Civil War

Billy Tipton TrioBilly Tipton Trio

PrevalencePrevalence

Prevalence is not easily studiedPrevalence is not easily studied 1/2000 prevalence in New Zealand 1/2000 prevalence in New Zealand

people who changed gender marker people who changed gender marker on passportson passports

Veale JF. Prevalence of transsexualism Veale JF. Prevalence of transsexualism among New Zealand passport holders. among New Zealand passport holders. Aust Aust N Z J Psychiatry. 2008 Oct;42(10):887-9N Z J Psychiatry. 2008 Oct;42(10):887-9

GID and Gender GID and Gender dysphoriadysphoria

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.

Newfield et al. Female-to-male transgender quality of life. Quality of Life Research (2006) 15:1447–1457

TransitionTransition

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 reassignmentSex reassignment

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 Transgender HealthHealth Jake is a 32 yo FTM on Jake is a 32 yo FTM on

‘T’ for 2 years and ‘T’ for 2 years and requesting a referral for requesting a referral for top surgery.top surgery.

FTM – female to male FTM – female to male transgender persontransgender person

‘‘T’ – testosteroneT’ – testosterone““top surgery” – sexual top surgery” – sexual

reassignment surgeryreassignment surgery

Transgender videoTransgender video

Gay and Lesbian Advocates and Gay and Lesbian Advocates and Defenders - GLADDefenders - GLAD

Mass Transgender Political CoalitionMass Transgender Political Coalition Mass EqualityMass Equality

Transgender Transgender HealthHealthJake comes to your practice Jake comes to your practice

for his first visit. You look for his first visit. You look at his chart label which at his chart label which states ‘Jane Smith’ and states ‘Jane Smith’ and you look at your patient you look at your patient who is presenting as who is presenting as male. What do you do?male. What do you do?

• Do you go by Jane?Do you go by Jane?• What name do you What name do you

prefer?prefer?

Preferred Gender Preferred Gender PronounPronoun VisitVisit DocumentatioDocumentatio

nn Other health Other health

care providers care providers ie nurses and ie nurses and consultantsconsultants

Casual Casual discussiondiscussion

Gender identity Gender identity historyhistoryJake tells you that he has been Jake tells you that he has been

injecting testosterone which injecting testosterone which he orders on the internet. He he orders on the internet. He started dressing as a man a started dressing as a man a few years ago and was seeing few years ago and was seeing a therapist for a few months a therapist for a few months in the beginning which he in the beginning which he found only a bit useful as he found only a bit useful as he was very comfortable with his was very comfortable with his decision to transition to a decision to transition to a man.man.

How do you ask a gender How do you ask a gender identity history?identity history?

Sexual historySexual history

Jake tells you that he has no Jake tells you that he has no significant medical history significant medical history and is taking no other and is taking no other medications. He does not medications. He does not smoke or use alcohol or smoke or use alcohol or drugs. He is working in drugs. He is working in IT.IT.

How do you ask a How do you ask a sexual history?sexual history?

TransitioningTransitioning

AppearanceAppearance Cross sex hormonesCross sex hormones SurgerySurgery

Transitioning: AppearanceTransitioning: Appearance (mostly reversible) (mostly reversible)FTMFTM

Dress: clothingDress: clothing Mechanical: Mechanical:

binding and binding and packingpacking

MTFMTF Dress: clothing, Dress: clothing,

make-up, wigsmake-up, wigs Mechanical: tuck Mechanical: tuck

or tapingor taping Minor procedures: Minor procedures:

waxing, waxing, electrolysis, botoxelectrolysis, botox

Readiness for hormone Readiness for hormone therapytherapy

WPATH (World Professional Association for WPATH (World Professional Association for Transgender Health) Standards of Care (SOC)Transgender Health) Standards of Care (SOC) Patient must be evaluated by a mental health Patient must be evaluated by a mental health

professional with specialized training. professional with specialized training. Recommended duration is often interpreted as 3 Recommended duration is often interpreted as 3 months ORmonths OR

Patient must complete “real life experience” for Patient must complete “real life experience” for 3 3 monthsmonths

Exemption for safety of patientExemption for safety of patient Informed Consent ModelInformed Consent Model

Patients must demonstrate understanding of the Patients must demonstrate understanding of the risks and benefits of hormone therapy, must be risks and benefits of hormone therapy, must be competent to make decisions about their health competent to make decisions about their health and must work in conjunction with health care and must work in conjunction with health care providersproviders

Readiness for Sexual Readiness for Sexual Reassignment Surgery Reassignment Surgery

(SRS)(SRS) WPATH (World Professional WPATH (World Professional Association for Transgender Health) Association for Transgender Health) Standards of Care (SOC)Standards of Care (SOC)Minimum of 3 months Minimum of 3 months

psychotherapy for gender related psychotherapy for gender related issues ANDissues AND

Diagnosed with Gender identity Diagnosed with Gender identity disorder (GID) ANDdisorder (GID) AND

Deemed ready for surgery from Deemed ready for surgery from both a psychological as well as both a psychological as well as medical standpoint. medical standpoint.

Transitioning: SurgeryTransitioning: Surgery(irreversible)(irreversible)

FTMFTM Top: Top:

Mastectomy Mastectomy Bottom: Bottom:

Metoidioplasty Metoidioplasty (clitoral release)(clitoral release)

Testicle implantsTesticle implants HysterectomyHysterectomy

MTFMTF Tracheal shaveTracheal shave Facial feminization Facial feminization

surgerysurgery Top: Top: Breast Breast

augmentationaugmentation Bottom: Bottom:

Vagnioplasty/Vagnioplasty/LabiaplastyLabiaplasty OrchiectomyOrchiectomy

Dr Melissa Johnson Dr Melissa Johnson SRS MastectomySRS Mastectomy

Keyhole MastectomyKeyhole MastectomyCourtesy Dr. Melissa JohnsonCourtesy Dr. Melissa Johnson

Double Incision Double Incision MastectomyMastectomy

Courtesy Dr. Melissa JohnsonCourtesy Dr. Melissa Johnson

Metoidioplasty and Metoidioplasty and Testicular ImplantsTesticular Implants

Vaginoplasty with Vaginoplasty with LabiaplastyLabiaplasty

Trans-specific health Trans-specific health considerationsconsiderations

InsuranceInsurance Revision of DSM-IV-TRRevision of DSM-IV-TR Review of diagnosis – Gender Identity Review of diagnosis – Gender Identity

DisorderDisorder ViolenceViolence Vulnerable population with decreased Vulnerable population with decreased

access to healthcare due to discriminationaccess to healthcare due to discrimination Poor rates for basic screening and higher Poor rates for basic screening and higher

rates of untreated illnessrates of untreated illness HIV risk behaviorsHIV risk behaviors

Legal IssuesLegal Issues Identity Documents – Gender Identity Documents – Gender

MarkersMarkers EmploymentEmployment Gender-segregated Facilities Gender-segregated Facilities

AccessAccess Family FormationFamily Formation YouthYouth PrisonPrison

Transgender Transgender HealthHealth Jake is a 32 yo FTM on ‘T’ Jake is a 32 yo FTM on ‘T’

for 2 years and requesting a for 2 years and requesting a referral for top surgery.referral for top surgery. Use his desired pronoun in Use his desired pronoun in

referring to himreferring to him Recognize that trans folks may Recognize that trans folks may

choose several venues for choose several venues for their sexual expressiontheir sexual expression

Do not assume behaviorsDo not assume behaviors Build rapport and when you Build rapport and when you

are not sure just askare not sure just ask

Thank youThank you

My Right SelfMy Right Self MazzoniMazzoni Center Center, Philadelphia’s LGBT Health Center, Philadelphia’s LGBT Health Center University of Pennsylvania Department of Fine Arts’ darkroom facilitiesUniversity of Pennsylvania Department of Fine Arts’ darkroom facilities American Medical Student AssociationAmerican Medical Student Association The project has been conducted as part of Arthur Robinson Williams' The project has been conducted as part of Arthur Robinson Williams'

master in bioethics thesis at Penn's master in bioethics thesis at Penn's Center for BioethicsCenter for Bioethics. . Diversity Office; Stephanie Houle and Bobby RodriguezDiversity Office; Stephanie Houle and Bobby Rodriguez Aleah Nesteby, NP High Street Health CenterAleah Nesteby, NP High Street Health Center