10/19/2018
Disclosures Gender Realignment Surgery Below the Belt Surgical Options: Married to Hologic
I speak really fast HEIDI WITTENBERG, MD FPMRS I have way too many slides FEMALE PELVIC MEDICINE & RECONSTRUCTIVE SURGERY/ UROGYNECOLOGY/ GENDER REALIGNMENT SURGERY
MOZAIC CARE INC
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MoZaic Care Inc San Francisco
Mang Chen Heidi Wittenberg
55 Francisco St, Suite 300 San Francisco California 94133 415-395-9895 Phone/ 415-395-9897 Fax Mozaiccare.com
Journey Background Negative Experience in Healthcare Had to teach their provider about transgender 24% 1.4million Transgender = 0.6% of US population people 41% have been diagnosed with clinical depression Asked unnecessary or invasive questions about 15% transgender status HIV- 15% white transwomen, 24% black transwomen
29% substance abuse. 3x> US population Refused transition related care 8%
40% ever attempted suicide/ 10% attempted suicide <1yr Verbally harassed in healthcare setting 6%
>80% have thought about suicide or attempted suicide if Refused non-transition relatedcare 3% parents were not supportive BUT< 4% if their parents were Provider physically rough or abusive 2% supportive Physically attacked by someone during visit 1% Concordant ID documents prevent 230 suicides/1000TG Sexually assaulted in a health care setting 1% Access HRT decreases SI 48% One or more experiences listed 33%
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Unmet Need for Gender Affirming Services Insurance Denials for -78% respondents wanted hormones one day Transition-related Care but only 49% had ever received them -Surgery USTS 2015 25% denied coverage for hormone therapy Transgender Men Have Had Surgery Want it Some Day 55% denied gender affirmation surgeries.- USTS 2015 Top Surgery 36% 61% Denials for Transgender-related Surgeries Metoidoplasty 2% 25% 56%
54% Phalloplasty 3% 19% 52%
Transgender Have Had Surgery Want it Some Day 50% Women 48% Breast 11% 40% Augmentation 46% 44% Vaginoplasty 12% 54% Overall Medicaic Medicare Private Other Multiple Only Only Insurance Insurance Insurance Facial Surgery 6% 39% Only Only
Status of Transgender Care Components of an individual's in this Underserved Population identity/experience Evolving of Standards of Care
WPATH ( World Professional Association of Transgender Health) Assigned sex refers to the classification of individuals at USPATH (US Professional Association of Transgender Health) birth as male or female.
UCSF Transgender Health transhealth.ucsf.edu Gender identity is one's internal sense or feeling of Fenway Institute Transgender Health fenwayhealth.org being a woman, a man, or another gender. This is not visible to others. Gender expression is a person's external manifestation DSM Category- Transgenderism is categorized as a mental health dx of femininity and/or masculinity. Sexual orientation refers to an individual's enduring Paucity of Research physical, romantic attraction to another person. Emotional orientation and/or emotional/spiritual Insurance Coverage Obstacles attraction to another person.
Need for Transgender Health Professionals.
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Surgery Journey
MtF Surgical Options Genital Reconstruction: Vaginoplasty
THE INS AND OUTS
2 therapist referral letters (+ 1 from hormone-prescriber)
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Mental Health Professional Multidisciplinary Care
Psychiatrist/Psychologist 1. Assess and diagnose gender dysphoria Social Worker 2. Provide information for treatment Endocrinologist 3. Assess co-existing mental health concerns Primary Care Physician Lawyer 4. Referral for hormone therapy Ancillary Specialists 5. Referral for surgery
Gynecologist Urologist Plastics Surgeon
Initial Visit Social Support
History and Physical Medical History
Surgical History Establish Safe Housing Medications Smoking BMI Emergency Contact Support System ****** Fertility Discussion *** Accompanied by friends/family Hair Removal ***
Insurance coverage
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Ideal Vagina Natural
Minimal “upkeep” Sexual intercourse Erogenous Lubrication Convincing
pexel Whitney.org Georgia O’Keefe
Vagina Procedures
Penile Inversion Technique
Colon
Peritoneal Pull Through
Courtesy of Pexel homeandskincandeez.blogspot.com
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Pre-Operative Instructions
Hair removal
No smoking
Hold off on certain medications Hormone adjustment/dc Blood thinners NSAIDs Herbal remedies
Bowel prep day before
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What The E? http://annals.org/aim/article-abstract/2687653/cross-sex- hormones-acute-cardiovascular-events-transgender- persons-cohort-study During the Operation
Cross-sex Hormones- Acute Cardiovascular Events General Anesthesia Transgender Persons Cohort Study, Getahun MD et al, One-Stage Procedure: Penile Inversion Annals of Internal Medicine, Aug 21, 2018 Vaginoplasty
VTE Orchiectomy
Transfeminine pts had a 2 & 8 yr inc risk of 1.5 and 3.2x higher Penectomy
than Cisgender men Construction of Vagina 1.7 to 2.5x higher ompared to Cis gender women Up to 4-5 hours Ischemic Stroke 10x higher than cismen and 4x higher than ciswomen
In the beginning, Before & After
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Before & After Post Op 1 Week
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Post Op Week 2 Post Op Week 3
Day of Surgery Post Op 1 week, 6 months 3 months 1 year
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6 months 6 months
1 year 1 Year
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Series 1 year Series
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After the Operation Dilators
Hospital 3 days Walking Nutrition Pain control
7-10 days Packing and bladder catheter out Re-start hormones Start dilation Start douching
Return to clinic every week x3 weeks
Recovery Taking care of your new vagina
3 months post op: return to work
3 months post op: return to vigorous physical activity Wound care 3 months post op: engage in penetrating sexual intercourse Keep area dry Lots of maxipads 9 months to 1 year post op: final results
Showers
Douching
Dilating
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Complications Hematoma
Wound breakdown - . Hypersensitivity common . Loss of Sensation Bleeding/Hematoma . Anorgasmia Urinary retention . Excessive erectile tissue UTI . Loss of skin graft/necrosis
Granulation tissue . Prolapse . Inadequate depth Need for revision/re- operation . Rectal or urethral injury . Urethral stenosis Fistula . Mental health issues Infection . Unresolved gender dysphoria Scarring Stenosis
Common Post Op Issues Series
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Granulation Tissue
Labioplasty Revisions Complicated Vaginoplasty Revision
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Non-Binary Options Gender NonConforming
Peritoneal Pull Through Variation
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After the Operation Persistent Pain
www.pexels.com Medication
Physical Therapy
Pain Specialist
Surgery
Hypnocdstore.com
Post Operative Considerations
UTI Bleeding Scarring Granulation Tissue Strictures Discharge Douching Dilation Long term Hair Prostate Breast
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And Now FTM Bottom Surgery Hysterectomy & Oophorectomy
Hormone status
Egg Retrieval & Egg Freezing
BRCA status/Family History
Laparoscopic Options
Metoidioplasty Metoidioplasty DOS
= toward more organs
multiple options
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Metoidioplasty Metoidioplasty tailoring
Surgical goals:
Avoid donor site morbidity With or without urethral lengthening Stand to urinate Penetrative sex not a priority With or without scrotoplasty Accept small phallus With or without vaginectomy
Metoidioplasty Metoidioplasty
Surgery technique in brief: Complications Vaginectomy NYU 2016* (7 study review) Phallus release Urethral complication rate: 27% Urethral lengthening Overall complication rate: 43% Phallus skin reconstruction Urethral: fistula, stricture, diverticulum Scrotoplasty Aesthetics/function: anatomy dependent
*Frey et al (Hazen): A systematic review of metoidioplasty and RF phalloplasty. Plast Reconstr Surg Glob Dec 2016
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Metoidioplasty Metoidioplasty
Ideal anatomy: Non-ideal anatomy:
Metoidioplasty Option: with Vagina
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Phalloplasty
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Phalloplasty Indications for free flap phalloplasty
Disorders of sexual differentation Bladder extrophy/epispadius Micropenis Severe hypospadius Penile agenesis Traumatic amputation Cancer extirpation Female to male sex reassignment
Phalloplasty Phalloplasty
Surgical Goals: Surgery technique in brief:
Stand to urinate Vaginectomy, Urethral lengthening
Penetrative intercourse Native phallus release, Nerve dissection
Proportional phallus Scrotoplasty
Donor Sites: Phalloplasty
Radial Forearm Urethral anastomosis, Nerve anastomosis
Anterolateral thigh Vessel anastomosis Wound closures
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Phalloplasty Possible donor sites for
Complications: microvascular phallic reconstruction
NYU 2016* 11 Study review
Urethral complication rate 51% Overall complication rate 88% Radial forearm High volume centers: Monstrey (287 patients), Garaffa (115) Anterior lateral thigh Urethral complications: 35-41% Latissimus dorsi Overall complication rate: 70-75%
*Frey et al (Hazen): A systematic review of metoidioplasty and RF phalloplasty. Plast Reconstr Surg Glob Dec 2016
Metodioplasty & Metodioplasty & Phalloplasty Phalloplasty
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Metodioplasty & Metodioplasty & Phalloplasty Phalloplasty
Metodioplasty & Metodioplasty & Phalloplasty Phalloplasty
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Metodioplasty & Metodioplasty & Phalloplasty Phalloplasty
Metodioplasty & Metodioplasty & Phalloplasty Phalloplasty
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Phalloplasty Phalloplasty
Phalloplasty Phalloplasty
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Phalloplasty Phalloplasty - Plastics
X X X X
Phalloplasty - Plastics Phalloplasty - Plastics
X
XX XX
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Phalloplasty - Plastics Phalloplasty - Plastics
X x
Phalloplasty - Urology Phalloplasty - Plastics
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Phalloplasty Phalloplasty
Anterior Lateral Thigh Flap
Good for thin patients
May require multiple stages
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Musculocutaneo us Latissimus Dorsi Phalloplasty
Phalloplasty Delayed Glansplasty
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Implants Implants
After the Operation Post-Operative Recovery
2-3 Overnight Stay for Vaginoplasty Same day surgery for Metoidioplasty www.pexels.com 5-7 Days for Phalloplasty Follow-up visits Compressive Dressings Drains Swelling and Bruising! Medications Wound Care
2 weeks: Back to work for Metas. 12wks Vag. 8-12 wks Phallo 3 months: 80% of results Metas & Vaginoplasties 9 months -1 year: full results
Hypnocdstore.com davidhalperin.net
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Post Operative Status of Transgender Care Considerations in this Underserved
UTI Population Bleeding Paucity of Standards of Care Scarring WPATH ( World Professional Association of Transgender Granulation Tissue Health) Strictures USPATH (US Professional Association of Transgender Discharge Health) Douching DSM Category-Transgenderism Pexels.com Dilation is categorized as a mental health dx Long term Paucity of Research Hair Insurance Coverage Obstacles Prostate Breast Paucity of Transgender Health Professionals. YOU can help make a difference.
Transgender 101 What can we do?
Identify Patients Open your door. Be willing to see them. While you feel you may not be equipped, most of these patients realize Ask there are not many specialists and they are knowledgeable themselves to help you Front desk, back office, and you. Understand the components of an individual’s identity/experience Registration Forms One of the largest barriers for our patients and the easiest for providers to address and change is how we address our patients in person, on the phone, in our registration Name you prefer to be called forms, and EMR. Pronouns you prefer Become familiar with the World Professional Association for Transgender Health (WPATH) Standards of Care for Sex assigned at birth Health of Transsexual, Transgender, and Gender Gender you identify Nonconforming People.
Partner – sex & gender Research: there is a paucity of research and knowledge for transgender individuals.
Pexels.com
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Resources Thank You All!
World Professional Association Transgender Health
Wpath.org
Fenway Institute
Fenwayhealth.org
UCSF
http://www.transhealth.ucsf.edu
www.pexels.com
It’s been a pleasure!
Heidi Wittenberg MD MS FPMRS
Co-Director MoZaic Care
55 Francisco St, Suite 300 San Francisco, CA 94133 415-395-9895 phone 415-395-9897 fax
www.mozaiccare.com
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