Behavioral Health Assessments and Referrals for

Gender-Affirming SurgeryRuben Hopwood, MDiv, PhD

Coordinator, Transgender Health Program, Fenway HealthVisiting Researcher, The Danielsen Institute at Boston University

Our RootsFenway Health Independent 501(c)(3) FQHC Founded 1971 Mission: To enhance the wellbeing of

the LGBT community as well as people in our neighborhoods and beyond through access to the highest quality health care, education, research and advocacy

Integrated Primary Care Model, including HIV services

The Fenway Institute Research, Education, Policy

617.927.6354 lgbthealtheducation@fenwayhealth.org

www.lgbthealtheducation.org

3

Technical Questions? Please call WebEx Technical Support: 1-866-229-3239

You can also contact the webinar host, using the Q&A panel in the right hand part of your screen. To see the panel, you may need to expand the panel by clicking on the small triangle next to “Q&A”

Alternatively, e-mail us at lgbthealtheducation@fenwayhealth.org

Sound Issues? Check if your computer speakers are muted

If you can not listen through your computer speakers: Click on the “Event Info” tab at the top of the screen Pick up your telephone, and dial the phone number and

access code.

When the Webinar Concludes When the webinar concludes, close the browser, and

an evaluation will automatically open for you to complete

We very much appreciate receiving feedback from all participants

Completing the evaluation is required in order to obtain a CME/CEU certificate

CME/CEU InformationThis activity has been reviewed and is acceptable for up to 1.0 Prescribed credits by theAmerican Academy of Family Physicians. Participants should claim only the creditcommensurate with the extent of their participation in this activity.

Physicians

AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 Credit™ toward the AMA Physician’s Recognition Award. When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

Nurse Practitioners, Physician Assistants, Nurses, Medical Assistants

AAFP Prescribed credit is accepted by the following organizations. Please contact them directly about how participants should report the credit they earned. • American Academy of Physician Assistants (AAPA)• National Commission on Certification of Physician Assistants (NCCPA)• American Nurses Credentialing Center (ANCC)• American Association of Nurse Practitioners (AANP)• American Academy of Nurse Practitioners Certification Program (AANPCP)• American Association of Medical Assistants (AAMA)

Other Health Professionals Confirm equivalency of credits with relevant licensing body.

Webinar Slides You can download today’s slides from the webinar

section of our website They will also be available on the evaluation page that

appears when you close your browser at the end of the webinar

Within the next week, today’s presentation will be archived and available for free CME credit in the “webinars on demand” section of our website

Today’s Faculty

9

Ruben Hopwood, MDiv, PhDCoordinator, Transgender Health Program, Fenway HealthVisiting Researcher, The Danielsen Institute at Boston University

Continuing Medical Education Disclosure Program Faculty: Ruben Hopwood, MDiv, PhD Current Positions: Coordinator, Transgender Health Program,

Fenway Health; Visiting Researcher, The Danielsen Institute at Boston University; Director, Hopwood Counseling & Consulting

Disclosure: No relevant financial relationships.

Gender confirmation medical treatment is considered ‘off-label’(This includes medications and surgeries)

It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staffdisclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potentialconflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interestor who agree to an identified resolution process prior to their participation were involved in this CME activity.

Ethical Standards

11

This course supports the ethical standardsrelated to equal treatment and access to care fortransgender populations under APA PolicyStatement: Transgender, Gender Identity, &Gender Expression Non-Discrimination, Adoptedby the American Psychological AssociationCouncil of Representatives August, 2008.

Learning Objectives:

12

Participants will be able to…1. Define and differentiate the key eligibility criteria

for sterilizing and non-sterilizing surgeries2. Describe three situations that may negatively

impact outcomes and/or access to surgery3. Outline the basic information needed in a surgical

referral letter

Information NOT covered today

13

Surgery on minors (under age 18) Photographs/images of completed surgical procedures

[consider looking online at sites such as transbucket.com for images of completed surgeries]

Surgeon lists/referrals [patients may be restricted by insurance to particular surgeons, check WPATH, transcaresite.org, and other trans resources]

Financing options, fund-raising, insurance coverage

Overview of Training

14

DSM-5 Gender Dysphoria – highlights Limited surgical options review Eligibility criteria overview (WPATH, SOC, v.7) Brief assessments Referral letter content overview

Perspective

15

Surgery can be life-saving and is life-changing Some people experience significant discomfort with

their bodies, some do not – be aware of internal bias The need to affirm one’s gender

identity can supersede other health concerns

You may be the ‘last hurdle’ in a person’s gender confirmation journey

Be aware of power differentials present

Bockting, et al., 1998; Hendricks & Testa, 2012

Overview of DSM-5 criteria

16

DSM-5 Gender Dysphoria (F64._)

17

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration …

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability

.0 adolescence & adulthood .8 other gender identity disorders .9 unspecified

Overview of Surgical Options

18

Brief Overview: Feminizing Surgical Options

19

Breast surgery: augmentation mammoplasty (implants/lipofilling)

Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty

Non-genital, non-breast surgery & more: facial feminizations surgery (FFS), liposuction, lipofilling, voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction & removal, and other aesthetic procedures

Brief Overview: Masculinizing Surgical Options

20

Chest (top) surgery: subcutaneous mastectomy, creation of a male chest

Genital (bottom/lower) surgery: hysterectomy/oophorectomy, urethral lengthening with a metoidioplasty or a phalloplasty, vaginectomy, scrotoplasty, erectile device, and/or testicular implants

Non-genital, non-chest surgery: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures

WPATH Eligibility Criteria

21

Criteria non-sterilizing Surgery: Breast*/Chest (‘Top’)/FFS…

22

Persistent and well documented gender dysphoria Age of majority Capacity to make a fully informed decision and

consent to treatment Any significant mental health or medical concerns are

reasonably well controlled

* recommended trans-feminine people have 12 months of hormone treatment before augmentation for natural breast development

(WPATH, 2011. SOC, v. 7)

Criteria for Sterilizing Surgery: Gonadectomy

23

ALL previous criteria plus: Any significant mental health or medical concerns

are well controlled 12 continuous months of hormone therapy as

appropriate to the person’s gender goals (unless the person has a medical contraindication or is otherwise unable or unwilling to take hormones)

(WPATH, 2011. SOC, v. 7)

Criteria for Genital Reconstruction

24

ALL the previous slides plus: 12 continuous months of living in a gender role

that is congruent with the person’s gender identity*

* It is recommended that individuals have regular visits with a mental health or other medical professional before and after surgery. Documentation of this criteria is expected and may be verified by other outside sources. Criteria may also be varied based on health insurance [and surgeon’s requirements].

(WPATH, 2011. SOC, v. 7)

AssessmentThe root of the word assessment is from the Latin

assidere: to sit beside

25

26

Long-Term (End of surgeries)/Reassessment

Ongoing Supports & Needs Assessment Restart Surgical Referral Process (Optional)

Peri/Post Surgical Care

Routine Medical Care/Recovery Emergency Care/Coordination of Care

Waiting Period

Health Issues/Stability/Finances Reassessment/Supports/Treatment

AssessmentFunctional

Bio/Psycho/Social WPATH/Insurance Resources & Preparation

OPT

ION

AL

Mental Health Basic Assessment

27

What surgery & what surgeon; Finances Gender identity, dysphoria, history, development,

impact on functioning and any stigma/trauma; coping; Imagined/hoped for/understood impact of surgery; Differential assessment that gender dysphoria is not

secondary to, or better accounted for by, other diagnoses or conditions;

Systemic supports Planned pre/peri/post surgery, hormones, pain medications,

FMLA, multi-stages, complications, recovery needs

Functioning – areas to assess

28

Eating Depression Self-harm/Self-care Anxiety Substance use/abuse Alcohol use/abuse Autism spectrum Domestic violence Family relationships

Age & Health Sexual health & function Isolation Suicidality Minority stress impact History of trauma and

discrimination Homelessness Work/School

Assessing Realistic Expectations

29

Aesthetic and functional outcome Sexual functioning and

expectations Complications, healing, multi-stage

procedures, swelling, allergies Time expectations and recovery

realities Financing surgery & associated

costs Exacerbation sexual trauma &/or

DID FMLA procedures and options

Distance travel and self-care Flying home with implants Dilating at work and long-term Body waste elimination

complications Denials, and appeals tolerance SOFFA responses Religious, spiritual concerns Hot flashes, blood clots, and

HRT ‘Utopia’ and routine revisions

Serious Mental Illnesses*

30

Mental health issues must be well controlled Severe psychiatric disorders and impaired reality

testing warrant further care and additional evaluation and supports throughout the process pre/peri/post

Efforts to manage conditions must be effective to provide sustained stabilization throughout process

No surgery should be undertaken during active psychosis

* Conditions may include: any psychotic disorders, delusional disorders, bipolar disorders, OCD, personality disorders, DID

Surgeon’s Responsibilities

31

Review different surgical techniques available (with referral to colleagues who provide alternative options);

Review advantages and disadvantages of each technique; Review limitations of a procedure to achieve “ideal”

results; surgeons are responsible to provide a full range of before-and-after photographs of their own patients, including both successful and unsuccessful outcomes;

Review inherent risks and possible complications of the various techniques;

Inform patients of their own complication rates with each procedure.

Referral Letters

32

33

Surgery Letters Other Criteria

Augmentation 1 12mos HRT recommended

Top Surgery 1 n/a

Gonadectomy 2 12mos HRT unless reason not

Genital Reconstruction

2

12mos HRT unless reason not12 mos living in congruent gender

FFS/Hair Tx/etc.?

Variable/none – not in SOC reqs

In plain language you must attest that…

34

The patient has clear, reasonable, and realistic expectations for surgery processes and outcomes, cost, recovery, work/school interruptions, and etc.;

The patient has chosen a surgeon and arranged for financing, pre- peri- and post-surgical care, andreasonable plans for complications;

Reproductive* options have been adequately explored and resolved prior to surgery if it will include sterilization.

* Sperm or egg banking if still feasible

Information you must include:

35

Patient’s identity (on insurance and in life if different) Report on bio-psycho-social assessment Overview of any clinical problems and medications Rationale for recommendation and facts* to support Statement on assessed risk:benefits understanding Statement on ability to consent or support needed Summary of patient plans for care & support needs Invitation to communicate with surgeon

*Note: please do not write a defense of your competence to evaluate. The surgeon needs information on the patient’s situation and trusts you to work within your professional competence and boundaries.

Additional information:

36

Statement that patient meets criteria for/is diagnosed with Gender Dysphoria (F64._)

Hormone treatment status or reason for variance Any co-occurring medical, sexual, or psychiatric

diagnoses, including medications (OTC/Rx) Capacity of person to live in their asserted gender –

explain if needed – and length of time if relevant Any steps taken to confirm/consolidate gender & how

this surgery supports further relief/prevention of dysphoria and distress or functioning

Primary Care Provider’s Letters

37

Primary Care Provider’s letters may be accepted by some insurance carriers and surgeons in place of/in addition

to the MHP letter of referral

It is strongly recommended to involve the PCP in the assessment and referral process to assist in the

coordination of medical care and follow-up and to provide medical clearance for surgical procedures.

38

1. American Psychological Association. Guidelines for Psychological Practice With Transgender and Gender Nonconforming People. Am Psychol. 2015 Dec;70(9):832-64.

2. Erickson-Schroth L, editor. Trans bodies, trans selves: a resource for the transgender community. Oxford ; New York: Oxford University Press, USA; 2014.

3. julie graham. Guidelines for psychosocial assessments for sexual reassignment surgery or gender affirmation surgery: Comprehensive assessments and psychoeducation[Internet]. 2013 Nov p. 35. Available from: https://www.sfdph.org/dph/files/THS/TransgenderHealthServices_MH%20Guidelines.pdf

4. Lev AI. Transgender emergence: therapeutic guidelines for working with gender-variant people and their families. New York, NY: Haworth Clinical Practice. New York, NY: Haworth Press; 2004.

5. Singh A, dickey lore m., editors. Affirmative counseling and psychological practice with transgender and gender nonconforming clients. [Internet]. Washington: American Psychological Association; 2017 [cited 2016 Aug 14]. Available from: http://content.apa.org/books/14957-000

Additional Supports Available at

39

Download (free) and read the WPATH Standards of Care, Version 7 from www.WPATH.org

Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016. www.transhealth.ucsf.edu/

Basic letter templates can be downloaded from https://www.fenwayhealth.org/transhealth under the “Provider Support” tab

Thank you!