Disclosures. Overview: How did I get Here? Pfizer Safe Medical Designs (SMD) MLM Medicus, LLC. Current Concepts in Caring for Transgender Patients

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1 Disclosures Pfizer Safe Medical Designs (SMD) MLM Medicus, LLC Current Concepts in Caring for Transgender Patients No financial relationships relevant to this presentation to disclose UCSF Controversies in Women s Health Symposium Nikko Hotel December 9, 2016 Maurice Garcia, M.D., MAS Associate Professor Department of Urology University of California San Francisco 2 Overview: Transgender terminology, epidemiology Care guidelines; Criteria for surgery Surgery overview: M to F & F to M Genital GCS in U.S. today Insurance Coverage How did I get Here? 2007: Offered orchiectomies to trans women; learned about health care disparities in pop. Involved with UCSF s COE for trans health Fellowship in Andrology / Neurourology (UCSF, Lue) Made case for why UCSF should invest in this; mission statement 2013: Fellowship training in London, UK Founded UCSF s genital GCS program (GU Reconstruction, Plastic Surgery, Ob-Gyn and Colorectal Surgery) 3 4

2 Terminology Gender is a complex internal sense of being male, female, or other (more than binary anatomy) Gender identity sexual orientation (!) Sexual identity is who you go to bed with, whereas gender identity is who you go to bed as Gender identity is a fundamental expression of who you are 5 6 Transgender: Term for people whose identity, expression, behavior, and general sense of self does not conform to what is associated with their birth-sex, in the place they were born Gender identity Disorder: Historical term, reflecting the history of a pathologized view of transgender people 2012: (Diagnostic and Statistical Manual of Mental Disorders, DSM V, changed term to Gender Dysphoria 1973: DSM declassified homosexuality as a mental disorder Gender is a multi-dimensional spectrum Gender dysphoria: Term for the discomfort / distress caused by a discrepancy between the person s gender identity and their sex assigned at birth 7 8

3 Gender non-conforming: Refers to the degree to which a person s gender identity, role or expression differs from the cultural norms prescribed for the male or female sex Being transgender or gender non-conforming is a matter of diversity, not pathology Gender affirming surgery (GAS): Surgery to make a person s body in-line with their identified-with gender (Sex-reassignment surgery) Epidemiology Incidence and prevalence grossly underestimated (studies count only people presenting to gender clinics) Gender non-conformity among (F to M) people is relatively invisible in Western cultures All countries that currently provide genital GAS report a steady increase (2-4X) in patients presenting for GAS (2016) 0.6% US Pop. Identifies as transgender = 1.4 million people (!!) 9 10 Treatment and Need Gender dysphoria can be alleviated with treatment (therapy + hormones + surgery Time Prevalence Focus on helping the patient explore their gender identity-- find a gender role that is comfortable for them Treatment is individualized; may not require surgery Now: 0.6% pop. 11 Patients may prioritize surgeries differently Genital vs. Chest vs. Fecial Feminization vs. Voice surgery 12

4 Professional Care Guidelines The World Professional Association for Transgender Health (WPATH)*, est as HBIGDA International, multidisciplinary, professional association whose mission is to promote evidencebased care, education, research, advocacy, public policy, and respect in transgender health WPATH Standards of Care Guidelines v.7.0 WPATH: Most established & only international professional association for transgender healthcare SOC Guidelines and criteria are recognized by all major U.S. healthcare professional organizations (e.g. AMA, APA, DHHS, U.S. Dept. of State*) and ~all major U.S. health insurance companies * (U.S. Dept. of State governs legal name and gender changes on U.S. Passports) Guidelines flexible; Outlines care and Tx. criteria (*Formerly the Harry Benjamin International Gender Dysphoria Assoc.) Criteria for Genital GAS Surgeries: M to F > 1 year of mental-health care / therapy > 1 year hormone therapy > 1 year social-transition (life full-time in identified-with gender) 2 referral-letters from mental-health professionals recommending genital GAS Psychologist, Psychiatrist, MFT SOC outlines core elements of a referral letter Male to Female genital gender affirming surgeries 15 16

5 Bilateral orchiectomy Peri-Testicular Fat-Pedicle Sparing Trans-scrotal Technique Unequivocal medical benefit Discontinue Sprionolactone / other androgen blockers Lower Estrogen dosage ( 12-16X OCP!) lowers estrogen s cardiovascular risks Smokers + DVT hx. + High baseline estrogen dose If done correctly no risk to vaginoplasty later 17 Fat pedicle preserved to support Labia Majora at vaginoplasty (Garcia et al, 2015) 18 Patient Expectations Penile Inversion vs. Penoscrotal Flap Scrotal flap Penile flap Great Wall of Vagina; Artist: Jamie Artist: McCartney Jamie McCartney; (U.K.) UK All vaginas are different (no gold standard) Limited tissue available Less prominent labia majora Vaginal depth is not visible / does not define a vagina (Garcia, M., Thomas, P, et al, 2015) 19 20

6 Dissection of neovaginal cavity Perineal Incision Netter Atlas of Human Anatomy 6 th Ed. Plate 358 (Garcia et al, 2015) Bilateral orchiectomy Penile skin tube: separation from penis 23 24

7 Urethra shortened / dissected from corpora Clitoroplasty Clitoroplasty Glans Incision 27 28

8 29 Separation of NVB from Corpora

9 Corpora divided / stump oversewn Clitoris sutured to corporal stump Clitoris Over-sewn corporal stump Proximal urethral stump Urethra stump transected, spatulated, and edges oversewn Penile skin tube inverted end is over-sewn Clitoris Urethral plate Urethral lumen 35 36

10 37 Opening for Clitoris & Urethra marked on skin above vaginal opening 38 Creation of a clitoral skin hood 39 40

11 Redundant lateral scrotal skin resected to form Labia Majora Neovagina packed / Dressings Major Complications Bed-rest POD #5 (+SQ Heparin / SCD s) Vaginal packing POD #5 Dilation and Douching starting POD #5 Foley DC POD #6 DC Home POD #6 More than 50% discharged on Ibuprofen only Intra-op rectal injury: <2% (0/61) Delayed recto-vaginal fistula: <0.5% (0/61) Loss of clitoris: <1% (0/61) Return to OR (bleeding, urethral) <1% (1/61) Blood transfusion post-op (1/61) Minor Complications Granulation tissue (25%) Tear at posterior fourchette (15%) 43 44

12 45 Bisected Cadaver Pelvis Intestinal Vaginoplasty Very limited penile-scrotal skin or vaginal stenosis Neurovascular bundle Neoclitori s Neovagina Segment (~20-30 cm) of Ileum or Colon brought to introitus Weight / BMI critical Risks (surgical, mucus) Benefits (+++ depth) 46 Zero-Depth Vaginoplasty Same but no vaginal cavity is constructed Good choice for: Patients for whom dilation / douching overly burdensome No desire for receptive vaginal intercourse H/o rectal radiotherapy (e.g. HIV + anal cancer) Benefits: Faster recovery Common questions: Clitoral orgasm? yes! (~ all by 6 weeks) Erogenous sensation in / around vulva: yes Quality of orgasm? better than pre-op (!) Average vaginal depth? cm (4-5.5 in.) What happens if I stop dilating? vaginal stenosis Self lubricating? No! (*+ejaculate) Should always be offered / discussed 47 Satisfaction? Very high; Regret? Very rare (Garcia et al, 2013) 48

13 Pre & post surgery challenges Sexual function can be complicated by postoperative challenges Hormone (therapy) fluctuations Cancer treatment Aging (!) Sexual function can be complicated by postoperative challenges Delayed wound healing Strictures (vaginal, urethral) Loss of part/all of neo-clitoris Surgeries: F to M Female to Male genital gender affirming surgeries mo. Female to Male Genital GCS Stage I Phalloplasty - Metoidioplasty (+ urethra = 2 stages; - urethra = 1 stage) - Radial Forearm (sensate, +urethra) (With Plastic Surgery) - Anterior Thigh (sensate; +urethra) Metoidioplasty (clitoral release/ lengthening) - Suprapubic (insensate; - urethra) - Lattisimus Dorsii (insensate; - urethra) (Urology or Plastic Surg.) 4-6 mo. Stage II (2-5 hrs) +/- Combine with Laparoscopic hysterectomy Urethral join-up Vaginectomy Glansplasty Testicular prosthesis placement (Rt.) Transposition of Clitoris to base of phallus (safe!) Stage III (2-3 hrs) Penile prosthesis placement (Inflatable > Malleable) (Garcia et al, 2014) + urethra = 2 stages - urethra = 1 stage 52

14 53 Antero-Lateral Thigh (ALT) Pedicle Flap Supra-Pubic Phalloplasty Pedicle-flap of pre-pubic skin tubularized No urethra Donor site = tummy (good cosmesis; no graft) Clitoris CAN be transposed to base for optimal sensation CAN have a penile prosthesis CAN stand to void if gets metoidioplasty 54 Buccal Mucosa Graft Penile prosthesis Common questions: Can achieve orgasm with phallus? YES for majority after radial-forearm flap phalloplasty Median cutaneous nerve single clitoral nerve Even better with clitoris buried in phallus shaft Does moving clitoris to phallus base reduce its sensation? No!! (Garcia et al, 2013) Satisfaction? (very high) Regret? (very, very rare) (Garcia et al, 2013) 55 56

15 Evidence Based Research & Education Medical student teaching & curriculum Cadaver labs Teaching events local public & at Universities Basic research projects Histologic studies to validate surgical techniques Development of surgical devices specific for these surgeries Penile prosthetics Surgical instruments Devices for patient use Educational Apps. Free (ios) from UCSF Soon: Trans Pelvic Health App - Educational materials - Biofeedback - Research SECTION HEADING Insurance Coverage for GCS? Jan 1, California enacted anti-discrimination legislation that prohibits health-insurance exclusionary provisions re. transgender health care (Barclays California Code of Regulations, Article 15.1, ) Includes MediCal Onus now on insurance companies to provide services June 2014: MediCare policy covers GCS.but no eligibility criteria / billing codes infrastructure yet Result is sudden need for GCS and expertise 59 Role of the Surgeon Reality: majority of long-term complications / sequellae are natural GU domains Sexual function / prosthetics placement / replacement Urinary infections, strictures Routine urology (GU tract access via new genital anatomy) Collaboration with related physicians and surgeons who also provide care: Collegial, multi-disciplinary support Urology & Plastic Surgery Psychiatry / Mental Health Primary Care Endocrine; ObGyn; Dermatology; Geriatric Med (!) 60

16 Role of the Academic Medicine Train care providers and surgeons specialized in transgender care Add to peer reviewed literature advance field (can t always be private sector this is how I do it ) Clinical outcomes research (standards, quality metrics, guidelines) Basic research (much we don t know; new devices) Conclusions Large need for transgender surgical care today Fascinating field!! Vulnerable (and very grateful) patient population Pts. increasingly well-cared for in community (mental, medical care) --> patients ready for surgery Patients & this evolving field need expertise from from all fields of medicine Professional guidelines (qualifications to practice) Thank you! Questions? maurice.garcia@ucsf.edu 63