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