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Gender: Terminology and Transitioning

October 4, 2017 Alix Komar, MD Relevant Financial Disclosure(s) Alix Leader-Cramer, MD

• I have no relevant financial disclosures

2 Objectives

• Appropriate and up-to-date terminology

• WPATH recommendations for transition

• Hormonal/surgical therapy options

3 Terminology

• Sex or “Natal Sex”

4 Terminology

• Sex or “Natal Sex”

• Gender or Gender Identity

M F M M

F “trans”-gender M F “cis”-gender F

5 Terminology

• Sex or “Natal Sex”

• Gender or Gender Identity

• Gender Expression

6 Terminology

• Sex or “Natal Sex”

• Gender or Gender Identity

• Gender Expression

• Sexual Orientation Sexual orientation is who you go to bed with… Gender is who you wake up as.

- - Norman Spack, M.D.

7 Psychiatric Diagnosis

• Gender Identity Disorder − Outdated diagnosis name • Pathologized gender

• Gender Dysphoria − DSM-5 • Removed from sexual disorders category • Distress due to one’s gender not required

Coleman E et al. Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7 Diagnostic and Statistical Manual of Mental Disorders (5th edition) Diagnostic and Statistical Manual of Mental Disorders (4th edition) 8 Medical Therapy Who is WPATH?

• World Professional Association for Transgender Health − Mission: to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health.

− Helps to facilitate communications between providers caring to transgender individuals

− Publishes the Standard of Care and Ethical Guidelines for treating patients • Currently Version 7

Coleman E et al. Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7. International Journal of Transgender Health 201;13:165-232 Hembree WG et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009;94:132-154 10 Initial Assessment

• Patients should be the age of majority and able to consent to treatment

• Mental Health Assessment − Assess patient’s gender identity/diagnose gender dysphoria • Persistent and documented history – one referral from a mental health professional − Assess/diagnose/treat concomitant mental health disorders • Must be well controlled − Assess family and social support systems

• Physical Health Assessment − Preventive care • All medical conditions must be well controlled

• Provide information on hormone therapy/surgery options

• Perform the initial assessment

• Discuss the expected effects of therapy in detail − Includes options for fertility preservation

• Confirm patient capacity to consent

• Perform ongoing monitoring and including physical and labs − Assess hormone effectiveness and look for side effects

• Communicate with patient’s PCP and/or mental health providers

• Provide statement that patient is under medical care that includes masculinizing/feminizing hormonal treatment

• Goals − Suppress sex characteristics associated with patient’s natal sex − Induce characteristics of desired gender

• Types of Hormones − Transgender female transition • Estrogens to induce female secondary sex characteristics • Anti-androgens: progestins, spironolactone, GnRH agonists, finasteride − Transgender male transition • Testosterone to induce male secondary sex characteristics

Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol 2013;210:16-26 13 Transgender Female Hormone Effects

Image from TransHealth Connection – Ontario Rainbow Clinic 14 Transgender Male Hormone Effects

Image from TransHealth Connection – Ontario Rainbow Clinic 15 Is Hormone Therapy Effective?

• ~80% improvement − gender dysphoria − psychological symptoms − quality of life − sexual function

Murad MH et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf) 2010;72:214-31. Van Kesteren PJ, et al. An epidemiological and demographic study of transsexuals in The Netherlands. Arch Sex Behav 1996;25:589-600 16 Gender Affirming Surgery What’s In A Name?

Sex Gender Gender Gender Reassignment Reassignment Confirmation Affirmation Surgery Surgery Surgery Surgery

18 Surgery Requirements – Chest Surgery

• Persistent and documented gender dysphoria − One referral from a qualified mental health provider

• Capacity to make informed decisions and consent

• Age of majority

• Mental and physical health concerns are well controlled

• Hormone Therapy − Not required for FtM transition − Not required, but 12 months recommended for MtF transition • Allows for maximum breast growth and improves aesthetic outcome

Coleman E et al. Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7 19 Surgery Requirements – Genital Surgery Including hysterectomy, oophorectomy, and orchiectomy

• Persistent and documented gender dysphoria − 2 referrals from qualified mental health professionals who know the patient well

• Capacity to make informed decisions and consent

• Age of majority

• Mental and physical health concerns are well controlled

• 12 continuous months of hormone therapy − Or as appropriate for patient’s gender goals

• For genital altering surgery: − 12 continuous months of living in a gender role that is congruent with their gender identity

Coleman E et al. Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7 20 Transgender MtF Surgical Options

• Breast/Chest Surgery • Facial Feminization Surgery − Augmentation/mammoplasty − (implants/lipofilling) Hairline correction − Forehead recontouring • Genital Surgery − Brow lift − Penectomy − Orchiectomy − Rhinoplasty − Vaginoplasty − Cheek implants − Clitoroplasty − Lip lift/lip filling − Vulvoplasty − Sliding genioplasty (chin recontouring) • Voice Feminization Surgery − Mandibular angle reduction (jaw − Cricothyroid approximation recontouring) • Hair Removal Procedures − Chondrolaryngoplasty (tracheal shave) − Laser − Electrolysis • Gluteal Augmentation

Coleman E et al. Standard of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, version 7. International Journal of Transgender Health 201;13:165-232 Vujovic S et al. Transsexualism in Serbia: A twenty-year follow-up study. J Sex Med 2009;6:1018–1023. 21 Facial Feminization Surgery

Facial Feminization Team, Marbella, Spain 22 Feminizing Genitoplasty Techniques

• Bilateral Orchiectomy

• Vaginoplasty − Penile shaft skin ± scrotal skin graft − Colon/ileum

23 Transgender FtM Surgical Options

• Breast/Chest Surgery • Virilizing Surgery − Subcutaneous mastectomy − Liposuction − Chest contouring − Voice surgery − Pectoral implants

• Genital Surgery − Hysterectomy − Bilateral salpingo-oophorectomy − Metoidioplasty − Phalloplasty − Vaginectomy − Scrotoplasty with testicular prostheses − Penile prosthesis

• Hysterectomy/BSO − Vaginal hysterectomy? Yes!! − Necessary with other surgeries • Metoidioplasty

Obedin-Maliver J, Light A, de Haan G, Jackson RA. Obstet Gynecol. 2017 Mar;129(3):457-463 25 Phalloplasty

• Techniques: − Radial Forearm • Preserves sexual sensation, not bulky • Conspicuous scar − Anteriolateral Thigh • Preserves sexual sensation, very bulky • Better scar − Musculocutaneous Latissimus Dorsi • No sexual sensation, medium bulk • Hidden scar

http://brownsteincrane.com/alt-phalloplasty-photos/ http://brownsteincrane.com/rf-donor-site-photos/ 26 What Are the Most Common Surgeries?

James SE, et al. The Report of the US Transgender Survey. Washington, DC: National Center for Transgender 27 Equality. 2016. How Successful Is Surgery?

• Paul McHugh - 1979

De Cuypere G, et al. Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies. 15: 2006; 126-133. Brauer G, et al. Suicidality among trans people in Ontario: Implications for social work and social justice. Service Social. 591; 2013: 35-62. 28 Title Calibri 40pt Secondary Title Calibri 24pt

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