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Transgender Health: My Right Self

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

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Transgender Health: My Right Self

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  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

  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.

  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.

  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

  6. Sex and Gender • Sexrefers 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 identityis 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

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

  10. Ann Bonny and Mary Read 1720 Hatshepsut, 1479 B.C 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. 2008 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

  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?

  18. Preferred Gender Pronoun • Visit • Documentation • Other health care providers ie nurses and consultants • Casual discussion

  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?

  20. 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?

  21. Transitioning • Appearance • Cross sex hormones • Surgery

  22. FTM Dress: clothing Mechanical: binding and packing MTF Dress: clothing, make-up, wigs Mechanical: tuck or taping Minor procedures: waxing, electrolysis, botox Transitioning: Appearance (mostly reversible)

  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

  24. 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.

  25. 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

  26. Dr Melissa Johnson SRS Mastectomy

  27. Keyhole MastectomyCourtesy Dr. Melissa Johnson

  28. Double Incision MastectomyCourtesy Dr. Melissa Johnson

  29. Metoidioplasty and Testicular Implants

  30. Vaginoplasty with Labiaplasty

  31. 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

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

  33. 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

  34. 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

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