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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY December 2017 | Archived Issues

Providing Care for Transgender People

Maurice Garcia, MD, Director of the Cedars-Sinai Transgender Surgery and Health Program

The most recent census-based population studies estimate that 1.4 million adults and 1.6 million adolescents in the United States identify as transgender. There has been a slow but steady movement toward greater social acceptance of diversity within our society. This has led to people of diverse sexual orientations — and more recently, diverse gender identities — being visible and better represented in the media, census studies and health policy. Changes over the past five years in California healthcare legislation and federal Medicaid and Medicare policies have eliminated the use of exclusionary insurance policy clauses in both commercial and public health-insurance plans, which previously denied transgender-related care and gender-affirming surgery (GAS).

In addition to California, an increasing number of states prohibit such exclusionary clauses. Owing to decades of commercial and federal health insurance plans not providing coverage, genital GAS performed in the United States has been limited to the private-practice sector. Today, very few surgeons are trained to competently perform genital GAS. As a consequence, there is a relatively sudden and significant need for transgender care. While other domains of transgender care such as mental health (psychiatry), hormone management (endocrine) and gynecological care have clear parallels in traditional cisgender medicine, genital GAS techniques are unique relative to traditional genito-urinary surgery and, hence, expertise in genital GAS is most in need today.

Cedars-Sinai recognizes the need for transgender care, especially amid the large and diverse community of Los Angeles. In January 2014, Maurice Garcia, MD, was recruited to found and direct the Cedars-Sinai Transgender Surgery and Health Program. The interdisciplinary clinical and research program leverages the breadth of expertise already present within Cedars-Sinai to ensure that the program can provide comprehensive care across the spectrum of disciplines relevant to the care of the transgender patient.

Garcia is a reconstructive urologist who came to Cedars-Sinai from the University of California, San Francisco (UCSF). He completed his residency training in urology at UCSF, and after fellowship training (andrology, sexual medicine and neurourology) and completion of a two-year master's degree in clinical research, also at UCSF, he joined the UCSF faculty in the Department of Urology. In 2013, he spent several months in London to complete fellowship training in genital GAS. In January 2014, he founded and led the genital GAS program at UCSF, which at the time was the only academic center program to offer genital GAS in the Western United States and only one of three in the nation.

The rollout of a transgender care program is not without challenges. For our institution to be welcoming to patients, it is essential that our physicians, nurses and staff are familiar with this patient population and educated about basic terminology and patient needs. One of the biggest pitfalls for us, as an institution seeking to be welcoming to transgender patients, is misgendering patients — addressing transgender patients using pronouns (she, her; he, him) that would apply to their birth-sex but not to the gender with which they identify after starting their gender transition.

A cisgender person is someone whose birth-sex/body and gender identity are in alignment, whereas a transgender person's birth-sex/body does not reflect the gender they identify with. Misgendering happens because we use secondary sex characteristics as cues to determine the gender of the person before us. For transgender people, changing the "sex" of their voice or their physical features is challenging. Being referred to with the wrong pronouns is very wounding to most transgender patients and perceived as a rejection of who they are. Misgendering can also happen when we address a transgender person by their birth name (i.e., pretransition).

While any patient may change their legal gender and name, many have not completed that sometimes lengthy process before they present at our center for care. Misgendering can be perpetuated by incorrect pronouns in other clinician's notes. Misgendering in all of these ways is inadvertently facilitated by our electronic medical record, which always lists the legal gender and name (typically what is listed on the health insurance records).

Garcia and colleagues from the transgender services task force have organized interactive educational lectures by leaders from local transgender community centers for our campus faculty, students and staff to learn more about how to interact with transgender patients in a culturally sensitive manner. The task force is also working on strategies to prevent misgendering of our transgender patients. The electronic medical record banner, the most prominent place listing a patient's gender and name, should reflect the patient's gender identity and preferred name.

The expertise that the Transgender Health and Surgery Program brings together from the Cedars-Sinai community creates unique opportunities to expand patient care. For example, cisgender women who have lost most or all vaginal depth due to a history of surgical and/or radiotherapy treatment for some gynecological cancers can be offered intestinal vaginoplasty — a well-proven technique offered to transgender women wherein an intestinal segment is harvested to line the obliterated vaginal cavity (cisgender) or newly created vaginal cavity (transgender).

Other transgender surgery expertise that can be translated for use among nontransgender patients includes vaginal reconstruction for women suffering from aftereffects of female circumcision (or female genital mutilation). Garcia has already established contacts within local communities that are home to such victims. Men whose genitalia have been affected by major physical trauma (including battle-related injuries among veterans) also benefit from transgender surgery expertise that focuses on urinary tract and sexual functions. The Transgender Health and Surgery Program also offers unique opportunities for research collaboration at Cedars-Sinai, particularly via the sharing of tissues, clinical data and research expertise.

The expectation is that the Transgender Surgery and Health Program will grow and contribute widely to the medical center's educational mission. Cedars-Sinai offers transgender surgery and health-related education to medical students, residents and fellows. As the program expands, it will increasingly contribute to both our campus and to healthcare on a regional, national and international level, through education, peer-reviewed publications and contributions to professional organizations. Garcia, for example, is author of the American Urologic Association's inaugural core curriculum dedicated to transgender care; he is a founding member of the multidisciplinary American Society for Gender Surgery; and he provides surgical training courses across the country. He was recently invited by the Ministry of Health of the State of Jalisco, Mexico, to contribute content, lectures and educational materials for the development of what will be Mexico's first transgender surgery academic program.