Laura Douglass, MD (she/her) discusses transgender health and gender affirming surgery. She discusses the importance of transgender and nonbinary health and how to provide gender affirming care. She also provides an overview of Gender Affirming Surgery. All right, good afternoon and welcome to temples medicine. Grand rounds, it's great to be back in Ernie. We seem to go in and out of Ernie but pretty back here and hopefully within not too long a time we can have all of us down here which I think is a lot of fun. Um Today's topic is really important and it's very relevant when um Larry Kaiser was the dean of the medical school, he um recognized the temple service to the L. G. B. T. Q. Plus community was not super good and we had some very enthusiastic folks who tried to identify ways in which we could be a better and more sensitive institution and many of those ways really were successful and we got to a good ranking on various scores of equity, which I think is really great and I think that um like society in general we've tried to make things as good as we can but there's still a lot of areas we're still struggling with and one area that we did not have a service for which we now do is in gender affirming surgery, which is an area that I think um we're overdue getting there but it's my pleasure. Dr Laura Douglas is going to talk about transgender health and gender affirming surgery. Dr Douglas. Great, thank you so much for that introduction. So there's a lot to cover today so I'm gonna try to be as efficient as possible um and then hopefully we'll have time for questions at the end of the presentation, just set this up here. Okay, so first and foremost I have no disclosures. So the objectives for today's lecture. So first is to discuss. Oh, okay, perfect, that's nice. Okay, so first, the objectives for this presentation today is first to discuss the importance of transgender and non binary health. Second is to discuss how to provide gender affirming care. I hope to offer some practical tips and tricks that you could literally use in your practice starting today um to over to give a general overview of gender affirming surgery and then particularly to talk about our program here at Temple. And I do need to give a shout out, especially to the internal medicine residents here that a lot of this has been driven by resident interest in getting the training and the education, particularly I've worked with your colleague dr Brandon Wolf feld, who actually started the transgender medicine elective. So I've actually already worked with a few of you um rotating through our clinic and joining us in the gender affirming surgery clinic. So, I think this is a great opportunity to kind of build off that. Um and offer further education. So, first question how many adults identify as transgender in the United States? So this is actually more difficult to accurately estimate than you would think and that's because population based national surveys never measured gender identity. So really the best data that we have is based off of smaller state level population based surveys. And so um looking at some of the smaller state level data, really the best estimate that we have right now is that about 0.58% of adults in the United States identify as transgender, which is about 1.4 million people. But of course we have to recognize that these surveys are self reported. So it's likely that the true prevalence is higher than this. And then here, particularly in our state of Pennsylvania, we actually rank pretty low on um on the list of states, in terms of the prevalence of transgender adults in our state, we rank about 35th with about 0.44% of the population identifying as transgender. This equates to about 44,000 transgender individuals. And of course, very relevant to our practice here in north Philly. It's important to recognize that adults who identify as transgender or more racially and ethnically diverse in the general U. S. Population. So that's something you'll definitely see here working in philadelphia. So why is this important health care? Why should any of us care about this? So this is the national transgender discrimination survey on health. This was the first ever comprehensive national transgender discrimination study. And this was actually a while ago. This was back in 2008. So take uh take some of these numbers with a grain of salt that this was A few years ago. So, some interesting um stats that I pulled from this. So about a third of patients postponed medical care when they are sick or injured because they fear discrimination due to their transgender status. About a half unable to afford medical care. About 19% were refused care due to their transgender status. About a quarter have been subjected to harassment in the medical setting and about half had to teach their providers about trans care. And also important to recognize that there is a higher prevalence of HIV in the transgender population at this time. It was 2.6 versus 0.6 in the general population and uh something very serious to consider is that the rate of suicide attempts are much higher in the transgender population, about 41% have attempted suicide in the past versus 1.6% in the general population. So this was a more recent survey. Again, take this with a grain of salt. This was in 2015, this was pre-ordordable care act. And this was the largest survey examining experiences of transgender people in the United States. This was almost 28,000 respondents from all 50 states. So you'll kind of see similar themes here, 55% of those seeking coverage for gender affirming surgery that year were denied and about a quarter of those seeking coverage for hormones were denied. About a third had at least one negative experience with a health care provider related to being transgender and about a quarter did not see a doctor when they needed to because of fear of being mistreated. And some other important statistics that came from this survey that are related to health. Um, but not directly related to health care is that there's a much higher unemployment rate in the transgender population at that time, it was about five times the national average, about 15%,, And about a third have experienced homelessness at some point in their lives. And of those who did experience homeless, about a quarter of them avoided staying in a shelter because they feared being mistreated as a transgender person. And for good reason because 70% of those who did stay in a shelter reported being mistreated either being harassed, sexually physically assaulted or kicked out. There's also a much higher rate of sexual and physical assault um, in the transgender population. So all things to keep in mind. So this was an interesting study that I looked at that reported on the experiences of transgender non binary folks in two large emergency rooms in new york city. So here you see that about 45% witness medical personnel gossiping, mocking or telling jokes about transgender folks and anecdotally. Um what I'll say in my experience in both my residency training where we built a gender affirming surgery program and also here at Temple building a program is that there's certainly some novelty with this and a lot of people are very curious and um sometimes people would congregate outside of our patient rooms and kind of, you know, be whispering and talking and saying things that, you know, that we think are affirming like, oh my gosh, she's so beautiful. You would never know that she was trans. Um, and so I definitely have seen this, um, you know, kind of happening in the periphery. Uh, 63% had past experience of staff refusal to use proper pronouns. I thought this number was way overblown. I was like, Oh my goodness, this couldn't happen 63% of the time. But I'll tell you in in building a gender affirming program that it is definitely a common occurrence. Most people do it by accident and when you correct them, they make the proper adjustments. But we've had some people who have refused to call patients by their proper names or pronouns even after they've been uh educated otherwise. And about a third had past experience with visibly uncomfortable providers. It's also important to take a broader view as well of what our transgender patients are facing with every day. If you remember from one of the prior studies, um, that I mentioned, there's a much higher rate of sexual and physical assault, the transgender community. So there is an epidemic of violence. Um, for our transgender folks since 2021 At least 47 transgender or gender nonconforming people have been killed. And that's, that's what we know of. And these are mostly young black trans women and mostly in the south. However, you don't have to look any further than her own city here in Philadelphia in June of 2020 Dominique remmy fells. Her body was found on the banks of the Scougall River where she had been dismembered and with severe trauma to her face and head. And then in September of 2020 Mia Green was murdered by her boyfriend who had shot her in the neck and he actually was pulled over for running a red light or stop sign in the police. Um when they pulled him over found her in the passenger seat bleeding from a gunshot wound to the neck. So I think it's it's part of the context of the challenges of this community that is so marginalized and that's why it's so important for us to recognize this when we're treating transgender folks in the health care setting. So what language should we use? So it's important to recognize that words matter. And I think a lot of the anxiety that health care providers have when working with L. G. B. T. Q. Folks is a lack of familiarity with the terminology and fear of saying the wrong thing. That's what we've actually done a lot of training um in the temple health system and a lot of people mean well and they're just worried that they're going to say the wrong thing and so they don't say anything at all. So learning how to use the proper terminology is like any other skill. It can be learned and it definitely gets easier with practice. So just some basic terminology. So sex is the chromosome or biological genital anatomy. Whereas gender are the attitudes, feelings behaviors and expectations that our culture associates with either males or females. It's important to recognize that most cultures view gender as a binary, that you're either male or female and there's nothing in between. Gender identity is one's inner sense of self as male, female or non binary on a gender spectrum. So you may hear terms like gender, non conforming or gender non binary or gender queer. And this typically um describes folks who don't identify as one or the other on the binary gender identity can be fixed and it can also be fluid so someone's gender identity may evolve over time. Gender presentation is one's expression of gender. So examples of gender presentation might be the name that you go by your behaviors, your mannerisms, your speech patterns, the clothes that you wear, your hair style. So these are all examples of gender presentation. Gender in congruence is the discrepancy between gender identity and the sex assigned at birth and gender dysphoria, which is a diagnosis in the D. S. M. Five is the distress or the anxiety, depression and despair due to this gender incongruity. So the inclusion of gender dysphoria, which actually formally in the D. S. M. Four was gender identity disorder. Of course. This terminology was changed in the most recent update. Uh this inclusion in the diagnostic manual is actually controversial in some transgender communities because it implies that being transgender is a mental illness rather than a valid human identity. Whereas on the other hand, formal diagnosis is typically required in order for people to receive or provide medical treatments like hormones and surgeries, it does provide access to medical care for people who wouldn't have been able to receive it otherwise. So, you know, it's kind of a double edged sword here that it's a technically a medical diagnosis. The term transgender describes an individual whose gender identity does not align with the sex assigned at birth versus cis gender if you think back to your organic chemistry. Um and transgender is also an umbrella term to describe the full range of diversity of gender identities. And sometimes people for short will say trans sexual orientation are the sexual and romantic attractions and behaviors towards others. And it's independent of gender identity. And I think this is a really important difference to recognize. Of course, there is the terminology for intersex or people who are born with disorders of sexual differentiation and these are for folks who are born with ambiguous genitalia and the genitalia just as in for our transgender folks does not predict gender identity. So there's actually a whole other uh debate that goes on about genital surgery for Children for newborn who are born with the biggest genitalia and whether or not parents should be choosing the presentation, uh, the gender presentation of a child when they're so young when they're newborn and having irreversible genital surgery. So that's actually a whole other whole other topic that I'm sure we could get into in another day. And then of course gender affirming surgery. So what our team provides. So these are surgeries that better align physical characteristics with gender identity and pronouns, pronouns are important. So pronouns are words that refer to a particular person or persons in the 1st, 2nd or third person and gender is often implied with our pronouns. So the most common pronouns that you'll see are she? Her and he him but commonly are non binary folks will go by. They them. There are also less commonly used. Um, pronouns you might see Z or there are some other pronouns that can be used. So in terms of when you're talking with a transgender patient, when you're caring for transgender patients, it's always important that you address patients by their name. It's important when you're looking at Epic or the medical chart that the name they go by may differ from the legal name. Okay, The name that's on their insurance card. And this is also called their debt name. So luckily Epic is probably the most progressive of all of the systems, All the electronic systems that we have here um, in our health system that actually allows us to put in quotation marks, the name that a patient goes by. If it's different from their legal name and as you probably have noticed an epic on the left side and the toolbar, there's a little purple box now that has pronouns, so that was hours and hours of meetings um really pushed forward by the L. G. B. T. Q. Task force, which there are a lot of members in the Department of Internal Medicine that were part of this. Um and it was amazing how much work went into creating a little one centimeter box with 15 characters. So that is clear when people look at the computer system, the name of patient goes by and their pronouns. Unfortunately epic doesn't talk to centris city and eccentricity is where a lot of the scheduling the billing goes and it isn't what radiology sees or lobotomy sees. So it's this kind of constant whack a mole in terms of the the electronic medical records that we're using. So good examples, this is all about practice, Right? You getting comfortable with using these terms? So, hi, my name is dr Douglas and I use she her pronouns, what name do you go by and what pronouns you use? That's the first thing I say when I walk into the room, when I'm seeing one of my and then if there's any confusion, a good way to ask if you're unclear is the name, you go by different from from the name on your insurance card, or you can ask, what is your current gender identity and what sex were you assigned at birth. So, if there's any doubt, ask so terms to avoid, um certainly there are some outdated terms, um things like transsexual, transvestite, tranny, of course, these are words that we really shouldn't be using um gender identity disorder I had mentioned was in the prior D. S. M. For this, of course, is implying that something was wrong before. And there's a really big push in the gender affirming care is to not pathologize our patients. Okay, it's always important to respect the language that a patient uses to describe their own identity experience or body parts, and I'll say that there is there is a generational difference. I see patients who are in their sixties or seventies, who have transitioned recently, that, you know, live their whole lives as a cis gendered person and then transition later because a lot of them tell me, hey, back in the fifties and sixties, you couldn't be trans. I didn't feel safe transitioning. And so I have this older generation of folks who aren't necessarily a lot of them say to me, I don't know what these things are like pronouns and all these terminology. And then I see a totally different generation of are much younger folks who are coming through who are supported by their families at a very young age. So we see people who are in their early twenties and there's definitely a different a generational difference in the terms uh that some of our patients use. So it's important to respect what your patients are comfortable, what terminology of patients are comfortable to use. So in terms of anatomy, anatomical terms and physical exam if you need to examine one of your patients. So it's important to provide a safe and inclusive environment. And again, going back to using terms that patients are comfortable with. So you can always ask what names or terms is a patient does the patient prefer to use to describe their body? So this is actually a nice chart um that offers other terms that you can use um instead of saying breast, you can refer to the upper body or for the penis. You can refer to the erogenous erectile tissue with the external genitals. Um Some trans men refer to the vagina as the front hole or the internal genitals. So there are ways to be more neutral, more neutral terminology for an atomic terms, because a lot of our an atomic terms are very gendered, whereas genitals really don't have a gender per se. Um, so some important considerations when you're doing a physical exam. So first are to consider the physical changes due to hormonal therapy. So there are a lot of secondary sex characteristics that may be different hair distribution, um body fat distribution. All these things changed for folks who are on hormonal therapy of course after surgery, Anatomy may be radically different. So always important to take an organ inventory um For for our folks, it's also important to recognize that for our trans men and for our non binary, masculine identifying patients that they may bind their chest. So, you know, say for cardiology or pre op assessment and they need to get an E. K. G. Need to be very sensitive that exposing someone's chest that might have that might be bound maybe a very sensitive part of the physical exam. Also for a lot of our trans women, they may also tuck their genitals. So um important to recognize some of these different aspects on a physical exam and that you're particularly sensitive about this. So especially for a pelvic exam, um if you remember I had mentioned there's a much higher rate of sexual and physical assault in the transgender population, pelvic exams can be incredibly anxiety provoking. So some tips and tricks for the pelvic exam. Number one, take an organ inventory, especially if they're post surgical which organs. Um does the patient have to keep it focused. Of course, if someone's coming to see you for upper respiratory symptoms, you don't need to do a genital exam. Um so make sure your exams are focused that you're doing these exams for a good reason. It's always important to discuss the exam or procedure beforehand. So patients know what to expect and to explain each step in a clear and direct manner and a lot of folks actually really benefit from having a support person. I know that's a little tricky these days with covid and visitors being allowed. Um But allowing a support person or allowing them to have music playing in the background, some folks like to use a mirror and they actually want to watch the physical exam along with you and some folks want to look at their genitals. So um again patient preference. Um some people may benefit from an oral benzo before a pelvic exam and what I thought was a very clever trick, especially for our trans men who have been on hormone therapy, there is a lot of vaginal atrophy. So for a pelvic exam to do a very important say pap smear or cervical cancer screening, it's important that you get a good pelvic exam so you can actually use topical vaginal estrogen. Um It's local therapy, it's not absorbed systemically, it shouldn't affect any of their other uh treatments, their testosterone treatments. Um And this actually helps improve a lot of comfort for a speculum vaginal exam for a trans man and then of course specimen self collection. I know there's been a lot of data just cis gendered folks as well that if for, you know, say S. T. I. Screening um that patients may even be able to help self collect specimens. So no one gets it right all the time. I learn something new every day. There's new terminology. A lot of this is fluid. A lot of this is evolving. So mistakes happen. It's really important to apologize, correct and don't overcorrect, don't make it a bigger deal than it needs to be and then move forward. So you might say something like she. Sorry, he needs an extra blanket or my apologies. I use the wrong name. I see you go by Samantha or thank you for correcting me. I will use she her pronouns. No need to believer it and also be an advocate. So if you hear other people using the incorrect names or pronouns correct others directly and kindly. So just a friendly reminder that Adrian uses they them pronouns or her name is Aria. The name in the chart is different because it is her legal name, but she goes by aria. So be an advocate. So how can we treat gender dysphoria? So it's important to recognize that not all transgender individuals experience gender dysphoria, but for those that do gender. Dysphoria can be treated in the treatments are effective and medically necessary and also highly individualized what helps manage one person. Dysphoria may not be exactly what helps another patient's dysphoria. So the four pillars of treatment are the social support and counseling for a change in gender expression and gender role psychotherapy, hormone therapy. And of course our topic for today, gender affirming surgery. So I do want to touch on hormone therapy. Of course. This is an area that is well within your wheelhouse um to be able to provide hormone therapy um to our patients um But specifically with the kind of surgical lens to the hormone therapy. So hormone therapy typically the physical changes are most noticed after two years beyond hormone therapy. So some changes that you can expect on feminizing hormone therapy is breast growth which is very variable, decreased erectile function, decreased testicular size and it actually increased ratio of body fat to muscle mass. Whereas for masculine izing hormone therapy you may notice a deepened voice clitoral enlargement which again is very variable. A growth in facial and body hair cessation of menses, atrophy of breast tissue and a decrease creation to muscle mass. So for feminizing hormone therapy regimens typically consist of an estrogen formulation plus an anti androgen. And I'm sure you probably already know this better than myself as a surgeon. Um in terms of the homogeneous city. So the oral estradiol is the most highly drama genic. Whereas our transdermal estrogen um is the least homogenic. So really the transdermal estrogen um should really be offered um to folks who are smokers or who have a personal family history of E. T. And then of course bilateral mastectomy is also one way to manage hormone therapy. This is performed via a single midline pino scrotal incision. We modify our technique a little bit. Then we would say for like a cancer surgery to minimize scarring of the scrotal tissue in case a patient in the future ever decides to move forward with vaginal pastie. We want to minimize scarring of the scrotal tissue because that scrotal skin is used as a graft in the future and they can immediately stop the anti androgens. Folks hate the spironolactone. They are all so happy to be able to stop the spiro once they have or key ectomy, there's currently no good evidence on the role of progestin. And then for testosterone. Again, various formulations topical testosterone can actually increase clitoral mega li and there is a much greater effect to promote desired secondary sex characteristics than estrogen. So, in terms of risks, I really want to talk about the risk of venus problem bolic disease while in estrogen therapy because this affects some of our counseling uh surgically. So it's really with the available data that we have right now, it's not clear if there's truly an increased risk in the piri operative period while on estrogen therapy. So the dogma forever in the surgical culture has been that folks have to stop their estrogen therapy before surgery. No ifs ands or buts about it because of the risk of VT that of course there's always the baseline risk of E. T. E. While in estrogen. And that this risk was assumed to be higher in the peri operative period. But unfortunately there have been no direct studies actually looking at this and the studies that do exist. There is a lack of well designed high quality studies, most of them are retrospective, but there is new evidence emerging, which is exciting and it's leading to a very slow cultural shift away from strict cessation of estrogen in the peri operative surgical period. So this was a study um actually one of our urology residents was part of this patriot Patrick Young here. So give a little shout out to him when he was at Mount Sinai Medical School, this was retrospective. Um but they identified um no increased risk for BT while on estrogen therapy. So there is this slow shift currently happening worldwide and right now based off of the available evidence that we have right now is that we're asking folks to stop their estrogen two weeks before surgery and of course you the appropriate use of preoperative DVT prophylaxis and that we actually start their estrogen for them when they're in the hospital post operatively, once we have prophylactic measures, once we have the sub cue heparin started and most importantly, early ambulance station, we have folks emulate post op day one, we drive them out of bed at eight o'clock in the morning, get them amputating and then we're happy to start transdermal estrogen patches while they're admitted post op and ultimately this is shared decision making and a lot of gender affirming care is really being um advocated in the informed consent model. So we tell our folks, we tell them what the risks and benefits are, what we do and don't know about the risks and that some folks are very very sensitive to their hormones and we're essentially forcing hormone withdrawal menopause um for our focus on estrogen and mental health is really important for the surgical recovery. So if patients are really sensitive and they say to us, you know what, I don't think I can be off of my estrogen, um you know, that's just not gonna be good for my mental health. And we haven't informed, we have informed consent um discussion about what those risks are. And we've offered low dose estrogen regiments for our folks who really wouldn't be able to tolerate coming off of hormones. So more importantly, time to talk about gender affirming surgery. So first question is how common is gender affirming surgery? How many folks are actually having surgery? So the U. S. Transgender survey, again, remember this was in 2015. So this is pre affordable care act. At that time, 25% had one or more gender affirming surgeries. The second study is a health claims database. So take this with a grain of salt. This study was skewed to higher earning employed patients. So these are folks who have insurance um Um either commercial or employee-based insurance plans. And if you remember there's a much higher rate of unemployment um and lack of insurance coverage in the transgender population. So again grain of salt 13.2% had one or more gender affirming surgeries and mastectomy was the most common and foul opacity was the least common surgery. And then this is data from a review article that was assessing trends in health care utilization of trans patients. So this is looking at the overall um um prevalence of gender affirming surgery. And you'll see here that actually gender affirming surgery is more common in trans men. And at first when I read this article I was like what? That doesn't make sense to me because the majority of the patients that I'm seeing are trans women seeking bottom surgery vaginal classy. But then I have to remember that gender affirming surgery isn't just genitals and the most common surgery if you remember from just the prior slide is mastectomy. Top is top surgery. So and in my opinion and what some of the authors um had kind of hypothesized is that all a lot of us is due to access that there are more plastic surgeons are more surgeons who can offer top surgeries whereas bottom surgeries are much much more specialized and you need a very specifically trained skill set um to access those surgeries. So um top surgery is likely easier to access. Um So I thought that was interesting and then if you even look at the breakdown in genital surgery. Again it is more prevalent and trans men and I'm like wait, this really doesn't make sense to me again, access, the most common procedure is hysterectomy. Again, most G. O. I. N. S. Are able to offer hysterectomy. So again this is a matter of access that I think in my opinion um it's likely that these folks can access hysterectomy um more easily because there are more surgeons who have the skills And for trans women for genital surgery, about 5- 13% prevalence. So this is a study from the american Society for plastic surgeries that was looking 2016 to 2017. So this was right at the beginning of affordable Care Act and gender affirming surgeries increased by 155% of 289% increase in transgender men and a 41% increase for transgender women. And between 45 to 54% of transgender women desire bottom surgery in the future. So we actually don't have more updated data on a nationwide basis right now. So I'd be really curious to see what the increase in access to these surgeries with both health insurance and also an increasing group of surgeons who can offer these surgeries. You know, see these numbers have likely increased. So in terms of surgical requirements. So I will refer you to the World Professional Association of transgender Health or the W path. And this document here. The standards of care is a great document. They actually talk a lot about primary care and hormone therapy but specifically in regards to gender affirming surgery. They have proposed criteria for surgery. Um this is the most recent version is version 7.0 and the version 8.0. Is actually supposed to come out later this spring. And there will likely be revisions to these criteria because the movement is about increasing access um to these surgeries. So there are some kind of strict criteria here and there's been some controversy debate about gatekeeping uh for folks in order to attain these surgeries. So I think you're gonna see um some revisions in these criteria in the coming months. So in the green box are your basic criteria. Um This is specifically looking at material capacity file past your vaginal class is so full reconstructive genital gender affirming surgery. So persistent, well documented gender dysphoria. The capacity to make an informed decision the age of majority and that any medical or mental health concerns are well controlled. This is a chart. Looking here, um you can see in the first column is your chest or breast surgery. Then you have, you're gonna check to me is like your hysterectomy, hysterectomy or or key ectomy. And then you have your full genital gender affirming surgeries. Material, plastic foul, plastic vaginal plastic. And you can see as you kind of increase the level of complexity of these surgeries That there are more requirements. So, for the genital surgeries. There's an additional requirement at 12 months of hormones and this was proposed as a period of potentially reversible treatment before undergoing an irreversible surgery. Um there are I would say hormone therapy is partially reversible. There are some changes that can't be reversed once you stop hormone therapy. Um and then you see when you get to the most complex surgery, some of the full genital gender affirming surgeries that there's this additional requirement for the 12 months living in the gender role. And so the rationale for this according to the W. Path, was to provide a period of time for patients to experience and socially adjust fully in their gender role because this can affect a person's life personally socially from a family perspective from a job. Perspectively economically financially, legally. So this was to really ensure that these surgeries aren't done in isolation or um in secret um isolated from the rest of their identity presentation. And then you also see here the the increase in the number of letters of mental support that are required to obtain these surgeries. And there's a lot of controversy about letters. Um And this is where a lot of the controversy is about in terms of gatekeeping um for decreasing access to these surgeries. All right, so some preoperative considerations that I think will be very relevant to you all um in primary care and internal medicine. So first these are just are specific things that we're thinking about before surgery. So number one, we're following the w criteria because that's what insurance follows. So we have to make sure that we check all the boxes when we um submit to insurance so that these surgeries are approved. And it should be interesting that when the W path requirements likely change how quickly or how slowly insurance companies will be to change the requirements as well. Um Everyone gets a nicotine a drug screening regardless of history. And that's because we have good data that nicotine use increases the risk of complications and graft failure, medical history. So B. M. I. Another super hot topic and gender affirming surgery. We all know that B. M. I. Is not the greatest measure of a person's health. B. M. I was studied and cis gendered white folks um are a lot of our patients are on hormone therapy. What are the changes that happen to um the body mass distribution on hormone therapy? There's a lot of hard to be about B. M. I. And wait in the gender affirming surgical community. Again increasing about increasing access, I will say from a surgical perspective, um There are certain things that we can and cannot accomplish for people based on their body size and shape. And so again an informed consent model. Talking about expectations what we can achieve reasonably and what we can achieve safely diabetes. So right now our requirement is a hemoglobin. A one c of 7.0 or less. Um Again to um to decrease the risk of wound infections and complications of HIV and hepatitis should be well controlled again for risk of wound infection and wound healing. Mental health super important. And we have our our program psychologist, Dr Jeff Grant here in the office who is part of our team. So mental health really important for the surgical surgical preparation and recovery. So any mental health issues should be stable and controlled. La lot of our folks have coexisting anxiety and depression related to their dysphoria. A lot of folks have pTSd related to a lot of the trauma they had experienced in their lives and that's all okay, we don't expect them to be perfect. It's just there. They should be well controlled and should have a plan post operatively. Again, this is all about not pathologize because there are some folks who have gender dysphoria and don't have any anxiety and depression. And those letters, especially letters of mental health, can feel like a hoop to jump through. So again about not pathologize ng um and substance use disorders should also be well controlled and we have specific requirements of six months free of that substance. Again, having a plan um to get more people to surgery. So psychosocial assessment so important. This is something that I've learned and I'll talk about this in terms of lessons learned um in building the surgical program um is the importance of social supports for recovery that no one can recover from these surgeries by themselves. So it's really important to have good social support and as I mentioned earlier in the lecture, um their higher rates of homelessness is that that folks have safe and stable housing for recovery. And that's a barrier for a lot of our patients. Um and having somewhere private to recover somewhere private that they can say dilate their vagina for instance. Um hair removal is something that we recommend specifically for vaginal classy um peri operative hormone therapy management we had already touched upon and the importance of pelvic floor physical therapy, both pre imposed stop, especially for our vaginal plastic patients were essentially barreling through the pelvic floor to create a vaginal canal. Um there's some emerging data on the benefits of this and something that we're trying to build here at temple. So in terms of gender affirming surgery is just a brief um overview of the different types of surgeries from head to toe, even though I'm a urologist. So I do mostly I do bottom or genital gender affirming surgeries. I have to remember. It's not all about me. So there are other gender affirming surgeries. So craniofacial and chest body surgery. So craniofacial surgery, feminization is much much much more common than Matthew Ization. So a lot of times we're talking about facial feminization here. So this typically requires fracturing of the cranial facial bones and plating. This can also include tracheal shave and vocal feminization, masculine ization is much more is much less common. Um And typically where involves placement of implants to augment the cranial facial skeleton. So here are some pictures here. Some examples for facial feminization a lot of times. It's reducing the brow bone in the forehead, a prominent forehead. Um So here's some examples of that and then also softening the jaw line of the mandible and the chin. So those are probably the more common procedures that are done as part of facial feminization. Here's some examples. So you can see the difference here in the forehead, in the brow bone once it's been softened here. And this is a patient who underwent full facial feminization. So you can see the difference in the brow bone, the nose, the jaw and the chin here. So in terms of chest and body surgery. So for feminizing procedures, estrogen hormone stimulation does cause some growth, but a lot of folks go on to breast augmentation was commonly with implants, um possibly fat grafting for masculine masculine izing chest surgeries. This mastectomy with nipple construction and of course body contouring may include fat grafting, liposuction or excision of tissues. So here are some examples here is a Chess master analyzation procedure where you can see here there's some surgical scars here with nipple reconstruction and here is breast augmentation. So now to talk about genital or bottom gender affirming surgeries. So are feminizing genital gender. Affirming surgeries are vaginal classy. The alternative is a Volvo classy or shallow depth vaginal classy. I'll um explain that a little bit later. Um in or key ectomy. And then our masculine izing bottom surge our material plastic. So mature. Real classy is using um the enlarged clitoris due to the testosterone stimulation. Using the enlarged clitoris to create a small neo palace. Um that you can also do urethral lengthening. You don't always have to do your thing. So it's with or without urethral lengthening. This typically allows a person to urinate standing up. But typically this new palace is um except in rare circumstances is not large enough or long enough for penetrative intercourse. Then of course you have full foul classy whether without urethral lengthening, scrotum, plastic creation of a scrotum with testicular prostheses, placement of the penal prosthesis to allow a phallus to be rich enough for penetrative intercourse. And then also hysterectomy with or without your ectomy. Imagine ectomy. So um so all of these surgeries, especially masculine. Izing surgeries is typically staged are feminizing surgeries. Typically we can do in one surgery. Um And for our masculine. Izing surgeries for full file opacity can be up to three stages um depending on how a patient recovers. So I wanted to specifically just touch upon vaginal plastic because this is what our strongest experience has been here at temple is vaginal pastie. So what is vaginal pastie? It is the creation of the external female genitalia technically the vulva and vaginal canal which is technically with the term vaginal class describing if desired. So not all folks desire a vaginal canal. So they might have reasons as penetrative intercourse isn't important to them. They don't want to dilate for the rest of their lives. Certainly for folks who've had um pelvic cancers, radiation surgeries, prostate cancer. This surgery of full vaginal canal is actually quite risky. Um and so we may actually not recommend a full vaginal canal for some folks. So daniel cassie is actually a bunch of procedures that are all rolled together. So first we do the bilateral or key ectomy if they haven't already had it done and then we create the vaginal canal. So we have to find that sweet spot in between the urinary, track the urethra and the prostate and the G. I tract, which is the rectum. And this is the most technically challenging and also the riskiest part of the surgery because of risk of injury to the rectum, which thank goodness, is quite uncommon. It happens less than 5% of the time. But this is what keeps up gender affirming surgeons, you know, the night before surgery before doing these cases is the risk of rectal injury. And then we use a combination of penile skin plus a free Squirtle skin graft to line the vaginal canal once we've created the canal, we can use additional skin grafts and the lower abdomen, groin or thigh as needed if there's not enough skin. And you can also use peritoneal flaps, a robotic approach, which is kind of the new hot topic and gender affirming surgery. Um and also intestinal segments. We also do connect to me or I like to describe it more as a penile disassembly that we're not amputating, were actually disassembling everything and reconstructing. So for the clitoral class, you were actually using the glands of the penis to create the clitoris and we're maintaining it on its dorsal neurovascular bundle to maintain sensation to allow the ability to orgasm after surgery. And then urethra plasticky where you actually shortened the urethra. We take the urethra off of the erectile bodies of the phallus and we shorten it so that a person can urinate sitting down and then of course, Libya Classy So one of the most technically challenging um aspects from an aesthetic point of view is creating that definition between labia majora and labia majora. So preoperative counseling is really important. It is really important to set realistic expectations. And this is um, this is an image that I showed to a lot of to all of our patients in pre op counseling. This is actually from an artist named Jamie McCartney and they took um plastic, plastic plaster molds or casts of over 400 bolas to show that there's beauty and diversity. And so I show this to all of our patients that there's beauty and diversity. There's no two Volvos that look exactly like you don't want revolver to look like someone else is you want your Volvo to be your own. So realistic expectations is really important throughout the entire preoperative counseling process. So what are our goals? So for those who seek a vaginal canal um in terms of vaginal depth, be typically achieve 12 to 14 centimeters which is about 4 to 5.5 inches of vaginal depth. To make this all relative the average depth of of someone who was born with a vagina is about 3.5 to 5 inches. Again this is highly variable to an individual's health. Anatomy appearance. Of course our goal is to create aesthetically pleasing external external genitalia and again highly dependent on a person's existing anatomy the color of the skin, the thickness of the skin, the stretching of the skin, the number of hair follicles. Some people have wider or more narrow pelvises. Some people have a shorter or longer parent and people can look very different just like anyone else. Sexual function of course, is to create a functional vaginal canal for for receptive intercourse if desired and to maintain clitoral sensation. The ability to orgasm. And then for urinary function is to urinate sitting down. So gender affirming surgery at temple. So what we're trying to build here is a comprehensive multidisciplinary team. So our medical team of course involves you all psychology psychiatry, infectious disease under chronology. Social work, case management, pharmacy and speech pathology. Our surgical team consists of both urology, plastic and reconstructive surgery gynecology and E. N. T. So what is the role of primary care physician in terms in the gender of army surgical setting? So number one is providing hormone therapy and then referring patients to us when surgery is appropriate. So of course a medical optimization. Um I have talked about some of the medical aspects that are important to us that we're looking at to help optimize outcomes for our patients. And also for preoperative risk assessment. I will say I have seen some preoperative risk assessments, not from anyone here, but I have seen some preoperative risk assessments that where our patients were mis gendered or the use of the dead name. And again as an advocate just gently correcting and reminding people that this is the name, the patient goes by the pronouns that they use. Um so important to make the whole surgical process affirming, right? So in terms of cancer screening before and after surgery. So again, important for an organ inventory. So things that you all will be thinking about is breast cancer screening for both trans women and trans men prostate and testicular cancer, cervical cancer and endometrial and ovarian cancer. Again, taking organ inventory, which organs do our folks still have vaginal classy? We do not remove the prostate. So trans women still have a prostate in general. A lot of the guidelines and recommendations for cancer screening. There's a lot that we don't know. And so right now most of the guidelines are just screen as you would for anyone with breast tissue or anyone with a prostate or anyone with the cervix or uterus or ovaries. So specifically from a urologic standpoint, the risk of prostate cancer. Um for example, the risk is assumed to be incredibly low because prostate cancer is a hormone sensitive cancer. A lot of our folks are on testosterone blockers are on estrogen. Um but there are documented cases of prostate cancer in trans women. So right now, our clinical guidelines are to screen our trans women as we would for anyone of the prostate, which is typically without any other additional risk factors just start screening around age 50. So I tell a lot of our patients that there's a lot that we don't know that but that I'm hoping now that a lot more people are interested and research searching and looking at these things and trying to answer these questions that in the next 5 to 10 years that will hopefully have answers and evidence based recommendations for these cancer screenings, some great resources. UCSF has a phenomenal website for primary care. If you want to learn more about hormones and the medical management and also Fenway health. There are two kind of pillars in trans care. So our surgical team. So I took over the program. I did my fellowship here 2019 to 2020 and reconstructive urology with mike Metro. And that was actually when the program was first started um Dr Andrew Gasman plastic surgeon. He actually started the program in 2019. He left in late 2020. And I actually stayed on his faculty after my fellowship to continue building this program. Dr Ali Reza comedian. He is a plastic surgeon who actually did additional training, did a gender affirming surgery fellowship in Chicago and he recently joined just a few months ago. And then Dr Michael Metro, my mentor is also part of our team as well. Our care team consists of Dexter Rose who is our program manager. We have dr Jeff grant here who is our program psychologist and we have our surgical coordinator Stacey home Kristin Sims. And just as a plug, we are currently recruiting for a care navigator, a nurse, a program nurse, and also for a mid level provider and NPR P. A. If you know of anyone who might be interested in joining our gender affirming surgical team. So just want to share some lessons learned quickly. I just I do want to save some time for questions. But um some important things that I've learned in building this program. Um Number one is providing an affirming environment and this is a lot harder than it sounds training competent providers. So as you all know, the phone tree is terrible and there are so many different ways that people end up on your schedules, um whether it's the, you know, the 800 number is that McKesson is at the call center. Um and so we've actually had to do trainings for our telephone operators for schedulers for call centers to get their appropriate information. What is the name of asian goes by? What are the pronouns that they use? Um important to train our front desk and check out staff um so that people aren't mis gendered from the moment, someone puts their foot in in our clinic. Um also our outpatient clinic supports our medical assistance in nursing and of course for the surgical part was pre op impact you and our our staff to make sure that on one of the most important and anxiety provoking days of their lives coming in to have surgery, that it's an affirming environment and then also in patients staff. So not only nursing, we did training on the nursing floors, but then again, kind of like this whack a mole is that there are other people who come in day to day lobotomy, radiology, dietary environmental services. Um and those are all opportunities for folks to be mis gendered um or dead names. So, um, you know, our small team, we're doing our best to train everyone that we can, but really it's a health system as a health system issue and the entire health system was not built to be L, G. B. T. Q. Or trans friendly. So um really advocating for a cultural change within the entire health system and again, electronic medical records is part of that. There is a sexual orientation and gender identity form that can be filled out. Um that's actually limited to who can actually access it. But this is where you can actually put in a name that a patient goes by and their pronouns. Physical spaces should also be gender neutral. And we've learned that to try to offer as many services within our own institution and that if we can't to find those in the community who do to be a source of referrals and resources for folks who are coming to us and say, oh you need some hair removal before surgery. Here are three genders affirming providers who can do hair removal for you in the city of philadelphia. That's part of the reason why we're building the pelvic floor physical therapy program here at Temple is so that can all be in house. And certainly the more folks that you're taking care of, you know, for primary care and we kind of have them all in house allows for a lot of collaboration taking care of our patients together And the importance of community outreach. So referrals, this is really important to get referrals um to help a preoperative patient readiness and support for post operative support. And it's important to build a good reputation. So currently we have a wait list of over 250 folks for gender affirming surgery. We have over 100 patients waiting for bottom surgery um and the rest of the patients are waiting for facial feminization or top surgery and that's without advertising. We haven't advertised the thing, this has all been word of mouth. Um so building a good reputation. Um so that's been really important for us and we're getting ready to start advertising. Um and we can only imagine how busy we we will be once we start advertising because we are actually the only major academic center in the entire state of pennsylvania that can offer a comprehensive gender affirming surgeries. So we have patients who are coming to us all the way from Pittsburgh because there's no one doing these surgeries in Pittsburgh. So, um and then also for anyone who's interested, we do have our Gender affirming surgery research group that we actually finally got off the ground. There are over 25 interested residents and fellows um spanning different specialties interests and institutions because there are a lot of institutions who don't have gender affirming care. And so we have folks who are working with us from um from my home institution, monte, if you're in the Bronx where I did my residency training um from penn from P. Com from cooper. Um So this is multidisciplinary, multi institution. Um so there's a lot to be done in terms of research. So I'm really happy to collaborate with you all um as well. So, in terms of referrals if you have folks who are interested in gender affirming surgery, the best way to get them plugged into our program is to contact extra rose uh dexter uses they them pronouns and um here are their phone number and their email. If you have any patients who would like to be referred to our gender affirming surgical program. So that's it. Thank you so much. I really appreciate everyone's attention and I'd be happy to answer any questions or comments that you might have. Really appreciate that. I think many of you will see that station. Yeah. Art and culture and NGC and student services in a broader sense of some of these issues because if you have in this world, it's sometimes harder to imagine what the experience. Of course that was beautiful presentation. That's one hour. You can just watch people in the situation that kind of resembles flavor some of the challenges. I do appreciate yet this presentation. That is an absolute principle actually do it too. And I think it's really important for us to retain that curious but you know, not judgment approach to all of our patients and colleagues. And so in time for just one or two questions here. Alright, great talk. Um, the cancer screening. Um, I think alerts that hopefully we all pay attention to, do they do they appropriately get sort of changed over. So that's a great question. The question was, do the epic cancer screening. Best practice alerts. Will they alert for our trans folks? That's actually a great question. And I don't know especially depending which if the if they're registered under the sex they were assigned at birth or if it's registered under the gender identity that they currently identify with. Um We actually probably should sit down with the epic folks because there's a lot of stuff that needs to be built out to make sure as part of an organ inventory um likely as part of the so G. Um form um where you can do an organ inventory that would hopefully trigger that um You know that alert and Nicole strand here. Who on the chat um part of the L. G. B. T. Q. Task force says we'll work on it. Oh yeah. Let me see see Brandon asked the question. Okay so um Brandon's question was in our ideal world where GS. Is standard. I think we can expect to see patients who may have had surgery many years ago and may not be living near agenda for new surgeon. If patient presents with gynecologic complaints like smell filling discharge or just Caronia, let's say would you recommend referring patients to find a specialist or do you think this is something that an internist should be able to handle? I should feel comfortable to do a public exam for a trans woman. And do you have any recommendations or warning or is it generally the same as a pelvic exam for this woman. So certainly I think um it really will depend on what your experience and your comfort is. So post operatively after a vaginal plastic, the lining of the vaginal canal is skin. So you actually should be screening for things more like skin cancers. Um and there's no cervix. So um there's no cervix should be doing a pap smear or anything like that. Um Of course in your routine s ci screenings as well. So you know, in a perfect world, everyone would feel super comfortable, you know, um doing these exams. But um if you're not comfortable and you don't have the experience and absolutely referring um you know, there are a lot more G. Y. N who are who can provide this service as well public exams for trans women that a lot more G lions are becoming comfortable with these exams. Um and not necessarily, you know, only being referred to gender affirming surgeons, you can find a gender affirming gynecologists. Hopefully locally that might increase access for folks. I agree with that. I think it's important for us to acquire. Not familiar with. You feel like this is 100% should take yourself to the place safe zone of your experience. But if you don't, it's no insult the patient, you know something, this is an area that confidence, Respectful of that. 50 years more of us will have the skills and for therapy, a lot of probably started, we wouldn't understand all of the issues that adjustment therapy and so we want to make sure we have our resource to go to that. There is an issue. Thank you so much. Thanks so much for having me. I appreciate it and feel free to reach out to me, email, call me if you have any questions if you want to get more involved. Absolutely happy to have you all.