The Evolving Standards of Care / Public Perceptions Of

Education, Execution and Safety: Improving Outcomes after GCS

Marci Bowers, MD 345 Lorton Avenue Suite#101 Burlingame, California 94010 Phone: (650) 570-2270 FAX: (650) 570-2283 www.marcibowers.com @marcibowers76 Disclosures

• No financial relationships or conflict of interest to disclose ASCCP 2018

Seattle/ Obstetrics and Gynecology

 University of Wisconsin (Bachelor of Science)  University of Minnesota (MD)  University of Washington (Residency)  Swedish Medical Center Ob/Gyn (Chair)  Polyclinic

 Mills-Peninsula Medical Center (SF)  Mt. Sinai Medical Center (NY) Disclosures: none

Intro

 Gender Politics: a comment  Review of FTM and MTF Gender Confirmation Surgeries (including Video)  Improving Outcomes Following GCS Surgery  Histology of the Neovagina and primary care considerations  Screening Implications following GCS

 Questions

What is a Man? Woman?

 Chromosomes?  Genitalia  Hormones?  Gender expression

 Intersex  Ambiguous genitalia/ “Hermaphrodite” • Congenital Adrenal Hyperplasia • Klinefelter’s (47XXY) • Androgen Insensitivity Syndrome (AIS) • Hypospadias • Male=Female until 2nd trimester • Incidence: 1/2000 live births • Public lack of awareness: addicted to binary

Real World Order Gender Spectrum

 Gendr Exprssion: Male Androgynous Female  GENITALIA: Female Intersex Male  SEXUALITY: Male Bisexual Female  One Five Ten

Transgender: Brain diversity

Clinicians View of the Transgender Patient

 Helping to unlock the mysteries of the human experience through insight into sex roles, gender stereotyping, global militarism, aggression, male violence, etc., etc.

GRS History

 Biblical Eunuchs  855 A.D. Pope John/Joan  Berlin, Germany: 1910 Magnus Hirschfeld: “Transvestitism” and “transsexualism”  Berlin: 1911 Steinach/Hirschfeld/ Gonadal Transplantation  1930 Lili Elbe (Dutch Painter) World’s “First Transsexual”  1933 Nazi’s destroy Dr. Hirschfeld Laboratory: LGBT population becomes template for Holocaust  1938 DES Discovery

GRS History

 1952 Christine Jorgensen / Copenhagen, First American Transsexual  1953 Dr. Harry Benjamin  1953 Dr. Georges Burou / Penile Inversion Technique / Casablanca  1962 Erickson Educational Foundation

GRS History  1969 Dr. Stanley Biber / SRS  1971 Johns Hopkins Closes SRS Program  1979 Trinidad, Colorado dubbed “Sex Change Capitol of The World”  2003 Dr. Marci Bowers joins Dr. Biber / GRS in Trinidad  2010 Dr. Bowers Relocates to San Francisco Bay Area  2014-16 Dr. Bowers helps establish Transgender surgical teaching in Israel, NY © 2018 – Marci L. Bowers ASCCP 2018

Landmark 2009 NCTE Study

 Violence/Bullying  More than half of transgender and gender non-conforming people who were bullied, harassed or assaulted in school because of their gender identity have attempted suicide, according to just-released findings from the National Transgender Discrimination Survey, conducted by the National Gay and Lesbian Task Force and National Center for Transgender Equality.  “… my suicide attempt had a lot to do with the fact that I felt hopeless and alone in regards to my gender identity.” — Survey respondent » NCTE

ACOG Committee Opinion December 2011

 “Ob/Gyn’s should be prepared … to facilitate quality healthcare for transgender individuals, both in assisting with transition services as well as providing preventative healthcare”

American Medical Association

 “Resolved that our AMA support public and private insurance coverage for treatment of Gender Identity Disorder [gender Incongruence] as recommended by a physician”: 2009--- Resolution 22

Insurance Coverage

 National Health Plans (Canada, Cuba, Argentina, Brazil, Europe, Iran, Israel)  Insurance (Microsoft, Intel, IBM, Google, Ebay, State of California, State of Minnesota, Colleges and Universities)  2004 (1/500 Fortune 500)  2009 (40/500 “ “ ) 9%  2015 (70%) Number of companies offering Transgender surgery coverage  States (13)  Medicare (2014)

Stanley Biber, MD

WPATH Standards of Care (SOC)

 Psychological Evaluation  One Year Cross sex Hormone Therapy  One Year Desired Gender Role  Legal Age of Majority : 18 years old+/-

Surgery Options

 FTM  MTF 1. Mastectomy (“Chest Surgery”) 1. FFS (Facial Feminization Surgery) 95% 40% 2. Hysterectomy (“hysto”) 60% 2. Chondrolarygoplasty (Tracheal 3. Metoidioplasty (“Bottom Surgery”) Shave )20% 10% 3. Augmentation Mammoplasty (BA) 4. Phalloplasty (“Bottom Surgery”) 50% 5% 4. Vaginoplasty/ Neocolporrhaphy 5. Testicle Implants (“Scrotoplasty”) 80%(GRS/SRS) 10% 5. +/- Labiaplasty 10% 6. Vaginectomy +/- 5%

© 2018 – Marci L. Bowers ASCCP 2018 Gender Confirmation/Affirmation Surgery 1. Facial Feminization Surgery (brow, rhinoplasty, tracheal shave) 2. Body Modification (breast Augmentation, Mastectomy, fat transfer, etc) 3. Genital Surgery (GRS)

1. MTF: Facial Feminization Surgery (FFS) (courtesy J Deschamps-Braley)

1. FFS: Tracheal Shaving

3. Genital Surgery: Embryology

Gonadal Ridge Ovary/testicle Genital Tubercle Glans Penis/clitoris Labioscrotal Folds Labia/Scrotum

Hypospadias

Genital Surgery: MTF Vaginoplasty

 Penile inversion (99.5%) plus scrotal graft

 Colovaginoplasty

Genital Reassignment Surgery (MTF Vaginoplasty)

2010

2012

2011

2016

Gender Confirmation Surgery for the FTM

2. FTM Genital Surgery

 Metoidioplasty versus Phalloplasty

2a.Ring Metoidioplasty

Results

 Orgasm  Ability to micturate while standing  Erection  Complications  Cost: $70,000+ Phalloplasty  $15,000 Metoidioplasty

Results (GRS) n=1486 MTF

 Orgasm (exceeds 90%)  Depth (15+cm)  Lubrication +/-  Complications: Granulation tissue, vaginal stenosis, tissue necrosis

 How do we care for these patients once surgery is complete?

Care of the Postop Patient

 Rule #1 If they have a body part, follow usual screening protocols  Breast: Mammogram  Prostate: Prostate exam/PSA  Cervix: pap smear  Vagina: ?

Do we screen FTM patients for HPV/dysplasia?

YES 3rd most common cancer globally Trans men are underscreened Esp. MSM Testosterone does NOT increase cancer risk

Gyn exam of the Postop MTF

 Annual visual exam with HPV screening if suspected  Pap every 3-5 years  Treat granulation tissue with excision and silver nitrate

Histology of the Neovagina

 ?Metaplasia  10% histologically similar to cis-vagina  Lacking in glycogen  Bacterial flora more mixed with lesser predominence of lactobacilli  pH is alkaline  More prone to bacterial shifts seen commonly as Bacterial vaginosis  At risk for HPV similar to cis-female

Do we screen the neovagina for HPV?

 Lawrence et al (Int’l J Transgenderism 2001):  SCC and Adenocarcinoma reported

 Hernon et all (J Fam Plann Reprod Health Care 2014; 161-164)  MRKH, AIS, etc: incidence of VAIN and VIN low but unknown  Symptoms: clear of bloody discharge and poistcoital bleeding

Granulation Tissue

What is the Future of Gender?

 “Nature loves entropy”  “The natural world is punctuated by diversity: embrace it and the world may finally find peace”

Trinidad, Colorado

 Santa Fe Trail  Elevation 6025 Ft  A ‘Western Victorian Town’  Coal/Natural Gas  Arts  ’Sex Change Capital of the World’

 Red Deer or the Southwestern US

“It’s a Girl!”

Outcomes

 Factors Associated with Satisfaction or regret following Male- to-female Sex reassignment surgery”  Lawrence AA  ArchSexBehav.2003 Aug; 32 (4); 299-315  “Longterm assessment of the Physical, Mental and Sexual Health among Transsexual women”  Weyers, S  J Sex Med 2009 Mar; 6 (3) 752-60. E pub 2008 Nov. 17

Complications (GRS):

• Wound separation/dehiscence (3-9%) • Necrotic Tissue (5%) • Poor cosmetic result • Bleeding (7 units/1250 surgeries) • Infection (rare) • Fistula (0.6%) • Urinary difficulties (rare) • Anorgasmia (less than 10%)

Healthcare Implications

 Prostate Evaluation/ PSA  Mammography  Pap Smears  Bone Density  ?HPV Vaccination (Gardisil)

© 2011 – Marci L. Bowers ASCCP 2018 Why Discuss Transgender?  Transgender Persons increasingly visible  Transgender persons throughout history  Parallels other Civil Rights struggles including those of Religion, Women’s Rights and the Struggle for Racial Equality  Treatment allows for reduction in teen suicide, anti-social and self-destructive behavior  Generational Demand for Honesty in Sexuality and Gender  Provides insight into what it is to be human

Gender Queer

 Agender  Gender neutral  Polygender  Gender ambiguous  Gender Fluid  Multigendered

Is gender Fixed?

 How does altered gender attitudes impact healthcare decision- making?  What happens when gender identity changes?  How will shifting gender notions affect aging populations? 20- 50-80  How will changing bodies impact healthcare demographics and treatment?  Will surgery be necessary if gender considered less static?

Video: Male-to Female Vaginoplasty

Technique

 De-infibulation  Exposure of underlying clitoral body  Excision of overlying scar tissue  Transection of suspensory ligament of clitoris to allow downward mobilization of clitoris  Obliteration of potential space above suspensory ligament  Sewing of free Clitoral edges to labial skin  Restoration of pseudolabia with edge to edge closure below

Definitions

 Gender Expression and [Sexual] Dimorphism  Gender Identity

 Genitalia  “Gender Identity Disorder”/Gender Dysphoria

 Transgender: an umbrella term encompassing any aspect of non-biological gender expression, incongruence between any of the above

Binary Model of World Order

Male Female Black White Good Evil

California Department of Managed Healthcare (DMHC)

 Advocacy by Transgender Law Center (TLC) on April 9,2013 orders California Health Plans---covering 22.5 million Californians--- to remove blanket exclusions of coverage based upon gender identity or gender expression allowing medically necessary coverage for transgender persons in California.

Estrogen : Risks

 Thrombosis/Thromboembolism  Hypertension  Lipid Changes (Triglycerides)  ?Malignancy  ?Bone Density

Patient Demographics: MTF (n=432/1296)

 Weight: 86% BMI<30  Sexual attraction: 40% Hetero, 28% lesbian, 27% Bisexual, 5% asexual/other  52% with partner

 Marital status: 65% single, 28% currently married (23 % with children)  Average age: 41 (range 16-74)

Transgender Challenges

 Access to Care  The U.S. Department of Health and Human Services has confirmed that it views a 2010 law prohibiting sex discrimination in health care services as protecting from discrimination based on gender identity and gender stereotyping.

Surgery for the MTF