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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 © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 What is a Man? Woman? Chromosomes? Genitalia Hormones? Gender expression © 2018 – Marci L. Bowers ASCCP 2018 Intersex: Genital Diversity 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 © 2018 – Marci L. Bowers ASCCP 2018 Real World Order Gender Spectrum Gendr Exprssion: Male Androgynous Female GENITALIA: Female Intersex Male SEXUALITY: Male Bisexual Female One Five Ten © 2018 – Marci L. Bowers ASCCP 2018 Transgender: Brain diversity © 2018 – Marci L. Bowers ASCCP 2018 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. © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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” © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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) © 2018 – Marci L. Bowers ASCCP 2018 Stanley Biber, MD © 2018 – Marci L. Bowers5/4/1924-1/16/2006 ASCCP 2018 Pierre Brassard, MD(Montreal) © 2018 – Marci L. Bowers ASCCP 2018 Ako Takamatsu, MD (Tokyo) © 2018 – Marci L. Bowers ASCCP 2018 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+/- © 2018 – Marci L. Bowers ASCCP 2018 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) © 2018 – Marci L. Bowers ASCCP 2018 1. MTF: Facial Feminization Surgery (FFS) (courtesy J Deschamps-Braley) © 2018 – Marci L. Bowers ASCCP 2018 1. FFS: Tracheal Shaving © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 2. Body Modification: Breast Augmentation © 2018 – Marci L. Bowers ASCCP 2018 3. Genital Surgery: Embryology Gonadal Ridge Ovary/testicle Genital Tubercle Glans Penis/clitoris Labioscrotal Folds Labia/Scrotum © 2018 – Marci L. Bowers ASCCP 2018 Genital Surgery: Vaginoplasty Hypospadias © 2018 – Marci L. Bowers ASCCP 2018 Genital Surgery: MTF Vaginoplasty Penile inversion (99.5%) plus scrotal graft Colovaginoplasty © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 Genital Reassignment Surgery (MTF Vaginoplasty) © 2018 – Marci L. Bowers ASCCP 2018 2010 © 2018 – Marci L. Bowers ASCCP 2018 2012 © 2018 – Marci L. Bowers ASCCP 2018 2011 © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 2016 © 2018 – Marci L. Bowers ASCCP 2018 Gender Confirmation Surgery for the FTM © 2018 – Marci L. Bowers ASCCP 2018 1.FTM Body Modification: Chest Surgery © 2018 – Marci L. Bowers ASCCP 2018 2. FTM Genital Surgery Metoidioplasty versus Phalloplasty © 2018 – Marci L. Bowers ASCCP 2018 2a.Ring Metoidioplasty © 2018 – Marci L. Bowers ASCCP 2018 2b. Scrotoplasty © 2018 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers ASCCP 2018 3c. Phalloplasty © 2018 – Marci L. Bowers ASCCP 2018 Results Orgasm Ability to micturate while standing Erection Complications Cost: $70,000+ Phalloplasty $15,000 Metoidioplasty © 2018 – Marci L. Bowers ASCCP 2018 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? © 2018 – Marci L. Bowers ASCCP 2018 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: ? © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 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 © 2018 – Marci L. Bowers ASCCP 2018 Do we offer HPV vaccination for women with neovagina? YES © 2018 – Marci L. Bowers ASCCP 2018 Granulation Tissue © 2018 – Marci L. Bowers ASCCP 2018 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” © 2018 – Marci L. Bowers Trinidad I ASCCP 2018 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 © 2018 – Marci L. Bowers Las Vegas TG Empowerment 2011 “It’s a Girl!” © 2011 – Marci L. Bowers ASCCP 2018 © 2018 – Marci L. Bowers Las Vegas TG Empowerment 2011 © 2011 – Marci L. Bowers ASCCP 2018 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
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