From Male to Female Preparation and Surgical Tips

Transcription

1 From Male to Female Preparation and Surgical Tips Sexual Medicine Society of North America April 7, 2016 Dana A. Ohl, MD, FECSM Professor of Urology Head, Division of Andrology and Urologic Health University of Michigan

2 Disclosures None Presented by:

3 Gender Dysphoria (DSM V) Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person s gender identity and that person s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b).

4 Demographics 2001 survey (U.S. surgeons) 1170 genital reassignments per year 1 63% MTF, 37% FTM data % of the U.S. population is transsexual 2 (300, M individuals) Category Self-defined transsexual man/woman Diagnosed with Gender Identity Disorder Underwent genital reassignment surgery Lifetime prevalence Total population 1: ,951 1: ,976 1: , Horton, MA. The Prevalence of SRS Among US Residents Gates, GJ. How many meople are lesbian, gay, bisexual, and transgender?, UCLA, ucla.edu/wpcontent/uploads/gates-how-many-people-lgbt-apr-2011.pdf

5 More videos from the BBC EUROPE 8 January 2015 Last updated at 14:01 ET Russia says drivers must not have 'sex disorders' Russia has listed transsexual and transgender people among those who will no longer qualify for driving licences. Fetishism, exhibitionism and voyeurism are also included as "mental disorders" now barring people from driving. The government says it is tightening medical controls for drivers because Russia has too many road accidents. "Pathological" gambling and compulsive stealing are also on the list. Russian psychiatrists and human rights lawyers have condemned the move. The announcement follows international complaints about Russian harassment of gay-rights activists. In 2013 Russia made "promoting non-traditional lifestyles" illegal. Valery Evtushenko at the Russian Psychiatric Association voiced concern about the driving restrictions, speaking to the BBC Russian Service. He said some people would avoid seeking psychiatric help, fearing a driving ban. The Association of Russian Lawyers for Human Rights called the new law "discriminatory". It said it would demand clarifications from the Russian Constitutional Court and seek support from international human rights organisations. But the Professional Drivers Union supported the move. "We have too many deaths on the road, and I believe toughening medical requirements for applicants is fully justified," said the union's head Alexander Kotov. However, he said the requirements should not be so strict for non-professional drivers. Mikhail Strakhov, a Russian psychiatric expert, told BBC Russian that the definition of "personality disorders" was too vague and some disorders would not affect a person's ability to drive a car safely.

6 Public interest Relative frequency of Google searches for transgender in the state of Michigan, Jan 2007-Apr 2015

7 Vocabulary Biological or Genetic Sex reproductive anatomy and secondary sex characteristics (male or female) Gender Identity - psychological identity along the gender spectrum (masculine, feminine, agender ) Sexual Orientation preferred gender of sexual partners Transgender - identify as, or desire to live and be accepted as, a member of the biological sex opposite to that assigned at birth - transman, transwoman, gender variant, and/or gender incongruent are now preferred terms - Use pronouns for target gender

8 World Professional Association for Transgender Health (WPATH) Membership : patients, providers, networks, support groups Being Transsexual, Transgender, or Gender Nonconforming is a Matter of Diversity, Not Pathology Standards of Care Version 7 from 2011 definitive treatment guidelines for providers

9 WPATH Standards of Care Designed to protect both patient and provider Lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment. Roadmap to surgical sex reassignment

10 WPATH SOC v7

11 Requisites for Sex Reassignment Surgery Consolidation of gender identity; continuing mental stability Age 18* Chest surgery (mastectomy, breast augmentation) 12 months continuous hormone therapy for breast augmentation 1 letter of readiness Genital surgery (vaginoplasty, phalloplasty) 12 months successful continuous real life experience 12 months of hormonal therapy 2 letter of readiness from mental health professionals

12 WPATH - SOC A departure from the SOC may be justified by: A patient s unique anatomic, social, or psychological situation An experienced health professional s evolving method of handling a common situation A research protocol Lack of resources in various parts of the world The need for specific harmreduction strategies

13 Male to Female (MTF): Penile Inversion Vaginoplasty Natal male genitalia Marking scrotal-perineal flap

14 Male to Female (MTF): Penile Inversion Vaginoplasty Dissection down to bulbospongiosus m. Orchiectomy

15 Male to Female (MTF): Penile Inversion Vaginoplasty Degloving of the penis Retraction of penis into perineum

16 Male to Female (MTF): Penile Inversion Vaginoplasty Isolation of the neurovascular bundle Bundle and neoclitoris lifted off corpora

17 Male to Female (MTF): Penile Inversion Vaginoplasty Isolation of urethra and bulbospongiosus m. Mid-urethral transection

18 Male to Female (MTF): Penile Inversion Vaginoplasty Penile skin bisected Neoclitoris formed and anchored

19 Male to Female (MTF): Penile Inversion Vaginoplasty Penile shaft skin pulled posteriorly Penile inversion to form neovagina

20 Male to Female (MTF): Penile Inversion Vaginoplasty Urethra and flaps sutured into place Construction of labia majora Vaginal packing

21 Male to Female (MTF): Penile Inversion Vaginoplasty

22 Tips for a Successful Program Mental Health team is the key Our patients enter the program via mental health Mental Health professional guide patients through the process Must have two separate evaluations Surgeons have contact with the patients only after they are well into the process Presented by:

23 Tips for a Successful Program EMPHASIS ON MULTIDICIPLINARY CARE Therapist Primary care (incl hormones) Specialty care Second opinion Surgical Referrals Plastic Surgeon Urologist Gynecologist ENT Other providers (electrolysis, speech therapy) Program coordinator tracks all patients Mental Health Team Readiness for surgery Core Team Surgical Transition

24 Tips for a Successul Program Learning Curve

25 Tips for a Successful Program Standards of Care Presented by:

26 Tips for a Successful Program Keep an Open Mind

27 What Tin Man REALLY Wanted Presented by: