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Helping Medical Providers Understand Transgender Healthcare

In Pelvic Floor Physical Therapy by Stephanie PrendergastLeave a Comment

 

As Pride Month comes to a close we share a guest blog from our longtime colleague in San Francisco, Dr. Heidi Wittenberg. Recently Dr. Wittenberg has decided to dedicate 100% of her career to working with transgender persons and we are honored to be working with her. PHRC has always been LGBTQ friendly and supportive, now we are excited to offer more specific services to help transgender and gender nonconforming persons achieve their pelvic health goals. We will be posting more about the role of pelvic floor physical therapy later this summer. Today, we start with a post from Dr. Wittenberg intended to help medical providers better understand transgender medical care and certain challenges this community faces.

 

Transgender Care for Medical Providers

By Dr. Heidi Wittenberg

 

In just the last three years, an American Olympic Gold-medalist announced her new gender identity and appeared on the cover of Vanity Fair (Caitlyn Jenner), a film about gender confirmation surgery was released (The Danish Girl), and an openly transgender woman won an Emmy (Laverne Cox) while another won election to the Virginia state legislature (Danica Roem). Despite President Trump’s proposed transgender military ban and rescinding transgender student bathroom rules, it is clear that increasing national recognition of transgender individuals represents a social phenomenon that is both cultural and political.

 

Yet despite this emerging awareness and acceptance, from a health perspective, the estimated 1.4 million Americans who identify as transgender represent an underserved population that continues to suffer from stigma, discrimination, and a lack of coverage and access to health care.

 

Mental health vulnerabilities

 

While increasing public familiarity will likely reduce feelings of stigma and isolation in the long term, currently transgender individuals suffer high rates of life-threatening mental health conditions, particularly substance abuse and depression.

 

  • 29% suffer substance abuse (3-fold greater than the general population)
  • 41% have been diagnosed with clinical depression
  • 40% have ever attempted suicide
  • 10% have attempted suicide within the last 12 months

 

In parallel with these daunting statistics are some observations that offer considerable insight into how familial and medical recognition can ameliorate these vulnerabilities. For example:

 

  • 80% of transgender children and adolescents have thought about suicide or have attempted suicide if their parents were not supportive – but less than 4% if their parents were supportive
  • Issuing identification documents that correspond to the individuals gender identity can prevent 230 suicides per 1000 patients
  • Access to hormone therapy decreases suicidal ideation by 48%.

 

Improving Access to Health Care

 

Unfortunately, the healthcare setting itself can be a barrier for transgender people seeking medical care. Just under a quarter of transgender patients report having to teach their provider about being transgender and 15% report having been asked unnecessary and intrusive questions about their status as a trans person. Although far less frequently, patients still report being abused, assaulted, harassed, or refused care for being transgender.

 

Specific Steps for Medical Providers

 

  • Be willing to see transgender patients. While you feel you may not be adequately equipped, most trans patients realize that there are not many actual specialists in transgender care.
  • Better understand the components of an individual’s identity/experience
    • Gender identity is one’s internal sense of feeling of being a woman, man, another gender, or a combination that is irrespective of physical or anatomic appearance
    • Gender expression is a person’s external manifestation of femininity and/or masculinity
    • Sexual identity refers to the male or female classification of individuals that is assigned at birth
    • Sexual orientation refers to an individual’s enduring physical, romantic attraction to another person
    • Emotional orientation refers to an individual’s emotional/spiritual attraction to another person
  • Learn how to address trans patients in person, on the phone, in registration forms, and in the EMR.
    • Even in an OB/GYN office, do not assume that your patients want to be addressed as she/her/hers and that their partners are male.
    • Train yourself and staff to ask for their preferred name and the pronouns by which they want to be addressed. This may be different than ID and insurance cards.
    • The easiest option is to always refer to someone by their name.
  • Registration forms need to have additions:
    • Name you prefer to be called.
    • Pronouns you identify with: (she/her/hers); (he/him/his); (they/them/theirs); (Other____)
    • If appropriate for the specialty: Partner: Male, female, non-binary or other
  • Become familiar with the World Professional Association for Transgender Health (WPATH) Standards of Care for Health of Transsexual, Transgender, and Gender Nonconforming People. WPATH creates and frequently updates evidence-based standards of care to help guide health professionals in caring for transgender individuals. There are also now a multitude of transgender conferences and 2017 had its inaugural US PATH conference.

 

Transgender surgery

 

Many patients are beginning to seek out surgical care to aid in their transition, though not all transgender individuals have had or want gender confirmation surgery. Most surgeons follow the WPATH guidelines to determine eligibility for surgery which include persistent, well documented gender dysphoria and the capacity to make a fully informed decision and to consent for treatment. The individual has to have lived the gender role they identify for at least 12 continuous months.

 

Transgender surgery involves a multitude of options. Patients may have “top surgery” in which the chest is surgically shaped to conform with the gender identity of the patient. A patient may also elect to have “bottom surgery”. For female-identified patients this may include surgical creation of a vagina and for male-identified patients, the creation of a phallus from existing genital tissue or with a skin graft.

 

Female to Male Surgical Options:

 

– Facial Reconstructive Surgery: enhancement of brow and chin

– Top Surgery: bilateral breast reduction for more male anatomical appearance.

– Hysterectomy: with or without ovaries depending on family history, fertility concerns, patient preference.

– Metoidioplasty: involves elongating the clitoris by cutting the chordae tendinae, reconstruction of labial skin into a phallus. This can include: urethral elongation within the phallus, vaginectomy, and V-Y advancement for scrotoplasty.

– Phalloplasty: includes all the above with metoidioplasty but instead of just elongating the chordae tendinae, the dorsal nerve and vessels are dissected and attached to a graft nerve and vessels of the neophallus harvested from radial forearm, anterior lateral thigh, latissimus dorsi. The graft allows for a larger phallus.

 

Phalloplasty Complications:

– Flap failure – 1-2%

– Urinary fistula – 41%

– Urinary stricture – 17%

– Scarring

– Infection

– UTI

– unresolved gender dysphoria

 

Female to Male Surgical Options:

 

– Facial Feminization Surgery: brow shave, hairline lowering, rhinoplasty, revision of philtrim, eyelids, chin and jaw revision.

– Tracheal Shave

– Vocal Cord Surgery

– Breast Augmentation

– Vaginoplasty: Penectomy, bilateral orchiectomy, creating a vaginal orifice, grafting skin or, less commonly, a portion of colon for vaginal lining.

 

Complications of Vaginoplasty:

– wound breakdown common

– bleeding/hematoma – 4-8%

– urinary retention – 10%

– UTI – 4%

– granulation tissue – 15%

– need for revision/re-operation – 10-20%

– fistula – 4%

– Infection

– hypersensitivity or the loss of sensation

– anorgasmia

– pelvic pain

– loss of skin graft/necrosis

– inadequate depth

– scarring

– stenosis

– prolapse of the graft lining

– rectal or urethral injury

– excessive erectile tissue

– urethral stenosis

– mental health issues

– unresolved gender dysphoria

 

Common issues that arise after surgery:

 

Currently there are only a few transgender surgeons in the country but this number is starting to balloon. A common pitfall in post-surgery care is that most patient’s live far from their surgeons and do not always have the economic means to return for care, nor are they able to find a transgender specialist near them. Surgeons are doing as much as they can with phone consults but frequently local providers can help with common, less complicated issues that require an office visit. Additionally, surgeons are happy to discuss with local providers any concerns or questions. Many patients use their family practitioners, gynecologists, plastic surgeons and dermatologists for issues preoperatively and postoperatively after a gender affirming surgery. Though not ideal, this is currently commonplace until there are more transgender surgeons and specialists available.

 

  • UTI – treat same as cis-gender patient
  • Urinary retention – place a catheter. Already has a catheter? Check patency.
  • Bacterial vaginosis or yeast infection. Treat with pH correctors, recommend douching every day with over the counter solutions, or treat as you would cis-gender patient.
  • Granulation tissue – treat with silver nitrate
  • Scars – mederma or scar creams. For anything requiring surgery, patient can return to the surgeon.
  • Anything more involved, the patient needs to return to their surgeon or find a surgeon closer to them.
  • For physical therapy, I recommend assessing patients as you would any cis-gender postoperative patient for pain or incontinence. Just note that their bone structure will be that of their natal gender. I assess patients for scarring or issues that need my expertise of medications, injections or surgery.  I rely on the expertise of the physical therapists to assess and treat muscle, nerve, ligament or scar issues after surgery. Stay tuned to this blog for more detail about pelvic floor physical therapy for gender confirmation surgical rehabilitation.

 

Moving Forward

 

As more patients who identify as transgender are empowered to seek out care, insurance companies are starting to cover transgender-related health services including hormone therapy and mental health services. Encouragingly, most California plans have coverage and those that do not are under legislative pressure to cover these services.

 

As providers we can create an inclusive, supportive environment for transgender patients to welcome them from the first contact with the office throughout the entire visit. For most of their care, you would treat them as you would any of your cis-gender patients.

 

More about Dr. Wittenberg:

 

 

Heidi Wittenberg, M.D. obtained her Bachelors in Genetics at the University of California, Berkeley, a Masters Degree in Applied Physiology and MD from the Chicago Medical School. Her residency was at Johns Hopkins in Baltimore, Maryland. In 1999, Dr. Wittenberg moved to San Francisco, and continued to pursue urogynecologic advances. She developed and directed the Comprehensive Pelvic Medicine and Continence Center, and chaired the Multispecialty Pelvic Physiology Conference at California Pacific Medical Center.  She developed the pelvic medicine center at Urogynecology Center of San Francisco. In 2013, she was in the vanguard of first board certified specialists in Female Pelvic Medicine and Reconstructive Surgery specialists. Dr. Wittenberg was performing hysterectomies for trans-male patients, and was recruited by Dr. Curtis Crane to train and perform sexual reassignment surgeries such as vaginoplasties and metoidioplasties in order to help the transgender community. In 2018, Dr. Wittenberg became director of MoZaic Care, a gender confirming surgical group. Dr. Wittenberg travels on surgical missions to Guatemala and does surgical missions in San Francisco for the underserved. For this latter work, she received the Congressional Operations Access Unsung Hero Award in 2011.

 

Contact for Dr. Wittenberg:

For more info:  MoZaic Care | San Francisco | Mang Chen, Heidi Wittenberg

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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