1. Transgender Health: My Right Self
Lauren Meade
March 10, 2010

2. My Right Self 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
Kyle and Erin
I started to think more about the transgender population about 3 years ago when our new NP at HSHC had transgender health as her subspecialty interest in primary care. She had recently graduated from Mass General NP program in primary care where she did her thesis on access to services for the transgender community. And, as expected there are limited services for transgender folks. She came to me and to the medical director to talk about offering trans health services at HSHC. And this is what has inspired a new direction within my expertise in primary care.
This talk is partly from the experiences of our trans patients at HSHC and supplimented by the literature and by a educational booklet put out by the Philadelphia LGBT health center.

3. Diversity 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.
Diversity not just in sex, race, ethnicity, sexual orientation or gender identiy

4. 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.
In anticipation of the promise of cultural competence
training, the Office of Minority Health has put forth standards
for cultural competence that include training of health care
providers,5 and the Accreditation Council on Graduate Medical
Education (ACGME) has required that physicians-intraining
demonstrate sensitivity and responsiveness to a patient’s
culture as part of its professionalism competency

5. 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
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

6. Sex 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

7. Transsexual
Transsexual people identify as, or desire to live and be accepted as, a member of the gender opposite to that assigned at birth
Transgender – social sciences literature

8. Transgender
Transgender is a more recent term referring to gender-variance broadly understood.
Trans-activisim
Transphobia

9. Transgender 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
The nominclature in the transgender world is basic and helpful. A trans man is a man who is biologically female and identifies as man
A trans woman or MTF is a biological male who identifies as a woman. Allie and her partner.

10. for dressing in mans clothing 1 of over 500 soldiers
Ann Bonny and
Mary Read 1720
Hatshepsut, 1479 B.C
Bloodlines may have had something to do with it. On a cenotaph at the sandstone quarries of Gebel el Silsila, her chief steward and architect Senenmut refers to her as "the king's firstborn daughter," a distinction that accents her lineage as the senior heir of Thutmose I rather than as the chief royal wife of Thutmose II. Remember, Hatshepsut was a true blue blood, related to the pharaoh Ahmose, while her husband-brother was the offspring of an adopted king. The Egyptians believed in the divinity of the pharaoh; only Hatshepsut, not her stepson, had a biological link to divine royalty.
Still, there was the small matter of gender. The kingship was meant to be passed down from father to son, not daughter; religious belief dictated that the king's role could not be adequately carried out by a woman. Getting over this hurdle must have taken great shrewdness from the female king. When her husband died, Hatshepsut's preferred title was not King's Wife, but God's Wife of Amun, a designation some believe paved her way to the throne.
Hatshepsut never made a secret of her sex in texts; her inscriptions frequently employed feminine endings. But in the early going, she seemed to be looking for ways to synthesize the images of queen and king, as if a visual compromise might resolve the paradox of a female sovereign. In one seated red granite statue, Hatshepsut is shown with the unmistakable body of a woman but with the striped nemes headdress and uraeus cobra, symbols of a king. In some temple reliefs, Hatshepsut is dressed in a traditional restrictive ankle-length gown but with her feet wide apart in the striding pose of the king.
As the years went on, she seems to have decided it was easier to sidestep the issue of gender altogether. She had herself depicted solely as a male king, in the pharaoh's headdress, the pharaoh's shendyt kilt, and the pharaoh's false beard—without any female traits. Many of her statues, images, and texts seem part of a carefully calibrated media campaign to bolster the legitimacy of her reign as king—and rationalize her transgression. In reliefs at Hatshepsut's mortuary temple, she spun a fable of her accession as the fulfillment of a divine plan and declared that her father, Thutmose I, not only intended her to be king but also was able to attend her coronation. In the panels the great god Amun is shown appearing before Hatshepsut's mother disguised as Thutmose I. He commands Khnum, the ram-headed god of creation who models the clay of mankind on his potter's wheel: "Go, to fashion her better than all gods; shape for me, this my daughter, whom I have begotten."
In various times and places, Transgendered people have been trusted, and/or looked up to.
Several groups in history that we know of have been given extra clout because of a transgendered connection:
Both Egyptian and Babylonian pharaohs and kings were given spiritual connections while engaging in transgendered behavior.
American Indians valued members of their tribe who were transgendered as being 'twin souled' persons having the 'wisdom of both' and thus valued as leaders.
The eunuchs of the Biblical times were often valued, trusted, and considered a vital part of the social and political structure.
Joan of Arc, a 17 year old peasant girl, transgendered her way to both Sainthood, and having a major hand in the creation of the state of France.
There are at least a dozen saints honored on the Catholic Calendar who were transgendered.
Though largely 'written out' of history, transgenders have often served in the militaries of various nations.
At least 400 women, for instance, fought as men in the U.S. Civil War. Their service, when discovered, was largely respected, and honored at the time, by the veterans who shared the battlefield experience.
Billy Tipton Trio
Joan of arc, put to death
for dressing in mans clothing
1 of over 500 soldiers
who fought in the Civil War

11. Prevalence Prevalence is not easily studied
1/2000 prevalence in New Zealand people who changed gender marker on passports
Veale JF. Prevalence of transsexualism among New Zealand passport holders. Aust N Z J Psychiatry Oct;42(10):887-9

12. GID and Gender dysphoria
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

13. Transition
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.

14. Sex 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.

15. Transgender Health
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
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

16. Transgender video Gay and Lesbian Advocates and Defenders - GLAD
Mass Transgender Political Coalition
Mass Equality

17. 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?
Do you go by Jane?
What name do you prefer?
Strong jaw.
Jake knows that he is presenting as male with a legal female name and Jake is probably really nervous and anticipated an awkward moment. Vulnerable time for Jake and your opportunity to gain trust and rapport. So how do you do that.
Do you go by Jane?
What name to you prefer?
How can I help you today? Then work it in later.
Once you have established a male identity with the patient then all documentation and discussion involving the patient should maintain his preferred gender.
Samuel Lury - trainer
Don’t ignore the issue.
Body language and non verbal cues are going to be important that this point.
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

18. Preferred Gender Pronoun
Visit
Documentation
Other health care providers ie nurses and consultants
Casual discussion
Documentation can include FTM or trans man but the pronoun reference should always be what the patient has identified.

19. 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.
How do you ask a gender identity history?
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

20. Sexual history How do you ask a 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.
How do you ask a sexual history?
Jake has a female partner. He defines himself as a heterosexual man. Before Jake transitioned he was with his same female partner. When he was still identifying as a woman, he was in a lesbian relationship with his partner.
There is no standard for trans folks around orientations. Prior to transition they may be attracted a one gender and that may or may not change with their preferred gender.

21. Transitioning Appearance Cross sex hormones Surgery
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

22. Transitioning: Appearance (mostly reversible)
FTM
Dress: clothing
Mechanical: binding and packing
MTF
Dress: clothing, make-up, wigs
Mechanical: tuck or taping
Minor procedures: waxing, electrolysis, botox
Packing – creating a realistic bulge in the groin – home made or store bought

23. Readiness for hormone therapy
WPATH (World Professional Association for Transgender Health) Standards of Care (SOC)
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
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 23

25. Assumed increased risk

27. Increased dose of hormones does not increase effect

29. Readiness for Sexual Reassignment Surgery (SRS)
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. 29

30. Dr Spack – Children Hosp Boston

31. Transitioning: Surgery (irreversible)
FTM
Top:
Mastectomy
Bottom:
Metoidioplasty (clitoral release)
Testicle implants
Hysterectomy
MTF
Tracheal shave
Facial feminization surgery
Top: Breast augmentation
Bottom:
Vagnioplasty/
Labiaplasty
Orchiectomy
Hormones plus top surgery for trans men is ideal. Gives all of the external effects that they need to get by in society and with themselves. Very few benefits to bottom surgery. Possible loss of sensation. Unattractive – just does not look like a bio mans penis.
But for MTFs it is the
FTM - Bottom surgery is expensive not many providers and a developing field with earlier poor outcomes and so some healthy caution.
MTF – Bottom surgery is still expensive and not many providers but functional benefits and overall more success. Overall harder to pass without it for folks who are trans women.
Legally changing your gender is reliant on gender reassignment surgery b/c it has to be irriversable.

32. Dr Melissa Johnson SRS Mastectomy
The other closest well known surgeon is in Baltimore.

33. Keyhole Mastectomy Courtesy Dr. Melissa Johnson

34. Double Incision Mastectomy Courtesy Dr. Melissa Johnson

35. Metoidioplasty and Testicular Implants

36. Vaginoplasty with Labiaplasty

37. Trans-specific health considerations
Insurance
Revision of DSM-IV-TR
Review of diagnosis – Gender Identity Disorder
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

38. Legal Issues Identity Documents – Gender Markers Employment
Gender-segregated Facilities Access
Family Formation
Youth
Prison

39. Transgender Health
Jake is a 32 yo FTM on ‘T’ for 2 years and requesting a referral for top surgery.
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
This is a trans man. A man born as female but who identified as a male and is now living his life as a man. FTM stands for Female to Male.

40. Thank you
My Right Self
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