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.
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.
– Flap failure – 1-2%
– Urinary fistula – 41%
– Urinary stricture – 17%
– 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%
– hypersensitivity or the loss of sensation
– pelvic pain
– loss of skin graft/necrosis
– inadequate depth
– 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.
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