Caring for The Transgender Patient
In 2016 BMC established the Center for Transgender Medicine and Surgery. With the unified structure, patients have a single point of contact for their care needs. We are the first center in New England to provide such a comprehensive program and we are a leader nationally in delivery of transgender medical care.
Joshua Safer, MD is here to explain the unique needs of this ever growing community and that The Center for Transgender Medicine and Surgery at Boston Medical Center follows the WPATH (World Professional Association for Transgender Health) Standards of Care and the Endocrine Society Guidelines for the care of transgender patients.
Joshua Safer, MD
Dr. Joshua Safer is an Endocrinologist and the Medical Director for the Center for Transgender Medicine Surgery at Boston Medical Center.
Melanie Cole (Host): In 2016, Boston Medical Center established the Center for Transgender Medicine and Surgery. With a unified structure, patients have a single point of contact for their care needs. This is the first center in New England to provide such a comprehensive program and be a leader nationally, in the delivery of transgender medical care. My guest today is Dr. Joshua Safer. He’s an Endocrinologist and the Medical Director of the Center for Transgender Medicine and Surgery at Boston Medical Center. Welcome to the show, Dr. Safer. What does transgender mean?
Dr. Joshua Safer (Guest): Thank you very much, happy to be here. Transgender references people who have a gender identity which is different from their external body parts, from the sex that was reported for them at birth based on those body parts.
Melanie: In the spectrum of transgender identity, when is this something that’s likely to manifest itself?
Dr. Safer: Transgender individuals report being transgender across a range of ages. We don’t really know why that is. Is it just language, or ability to understand what’s going on with them? If you think about it, you have a gender identity different from the body you have as you look around. When is it that you might think that that’s something that you might speak up about? We have small children who identify as transgender with great confidence, who end up being transgender, indeed. They’re quite accurate. And then we have individuals who identify as transgender later either in adolescence or in adulthood. I would say that as people gain more language, those who wait until adulthood to understand they're being transgender are going to be fewer in number and we will see more kids being able to identify themselves.
Melanie: What are some of the barriers to healthcare for this community?
Dr. Safer: The barriers for transgender individuals for health care remain enormous. The biggest one reported by transgender individuals is that they can’t find medical providers who are able to care for them, either because they aren’t knowledgeable enough, or they don’t feel comfortable actually doing that job, but then, in addition, it is still the case that many state insurance does not cover some of the care and there are still plenty of medical institutions independent of knowledge, where transgender individuals will suffer some discrimination.
Melanie: So what would you like to tell, even other medical centers, about caring for the transgender individuals, and working with this community in a compassionate way?
Dr. Safer: In that gender identity is a biological phenomenon, the care for transgender individuals is part of the domain of conventional medicine, and we all should be doing whatever we need to be doing depending on our specialty. The actual care is relatively straightforward for most practitioners within their specialty and the interventions, especially the hormone interventions, are very safe. Therefore, really it’s a matter of educating the medical community so that medical care is generally available.
Melanie: And what about creating that welcoming environment, about adding a transgender option to check boxes, or the way that you frame certain questions, or even the way that you create that environment – the people that work alongside of you – in dealing with the community?
Dr. Safer: Part of education of the medical community and part of the environment of medical institutions must include actually being respectful of transgender individuals, and understanding what some of the options are so that appropriate language can be used. That includes everything from being comfortable with the use of pronouns, with understanding that a person who is identifying with a certain gender identity is going to want to be referred to with the appropriate pronoun, and having staff who are hip to this reality and appropriately defended it.
Melanie: And what about the World Professional Association for Transgender Health? Tell us about some of the guidelines that you see that are now being implemented.
Dr. Safer: WPATH, which you just referenced, is just a big international organization for medical professionals doing transgender care, have guidelines to help practitioners, which go over typical diagnostic criteria, typical treatment regimens, and typical concerns for those treatment regimens so that practitioners can be appropriately careful.
Melanie: So then when people are thinking about actually going through with some of the services that we are here to discuss – female-to-male transgender individuals – tell us about hormones – or going male-to-female – tell us about what the hormones are intended really to do. How do they work?
Dr. Safer: The difference between men and women from a hormone perspective mostly boils down to testosterone levels. Men and women have clearly similar estrogen levels – Estrogen is the female hormone. People think that estrogen and testosterone are opposite, or a situation where men have about ten times as much of the male hormone testosterone. Therefore, for transgender men, for female-to-male, the treatment regimen is really giving them testosterone, just as we do for any man who does not have enough testosterone, following those same regimens, with those same safety protocols, etcetera. For transgender women, the hormone regimen is a little bit more complicated because what we’re really doing is shrinking the testosterone for that woman from the male range down to the female range. If she has the surgery where her testes are removed, then the testosterone level falls, and we’re simply giving her some estrogen. That’s pretty straight forward, but if we’re doing this with medicines alone, then we need to include some medicine to help bring those testosterone levels down.
Melanie: When you’re also talking with a transgender patient, what about mental health, and even speech and language, because certainly, if female-to-male, that switchover with the voice is really a big deal and can cause some confusion among people. How do you deal with the mental health issues and with speech and language?
Dr. Safer: With mental health issues for transgender individuals are a number of things. First of all, there are multiple mental health concerns that we observe in transgender individuals, which look to be related to the fact that people were being treated in a disrespectful fashion, that there wasn’t language for them to identify themselves, that there wasn’t good care and such, so we see much higher rates of depression and suicide attempts among transgender individuals. As the age comes down of transgender individuals identifying themselves and receiving care, those mental health concerns seem to be less. That’s one story.
The second piece is that it has historically been the case, and it still is the case in many areas of the country, and the world that the entire circumstance was considered a mental health issue, and people had to go to a mental health provider in order to receive a diagnosis of being transgender for any other treatment to be considered. I think we’re observing a shift in that overall framework where it should be the case – I certainly advocate for it this way – it should be the case where you would go to your primary care provider and say, “I think I’m trans, help me out,” and your primary care provider might need some mental health guidance and assistance in making the diagnosis, if necessary – or not, depending on the specification of your primary care provider – so that’s the second element. The third element is even if we are in the perfect future system where if you go to your primary care provider, say that you’re transgender, people are respectful, or you go at an early enough age and get appropriate care, the transition is still a big deal for many people, for their families surrounding them. There’s a mental healthcare component that may be important for individuals in terms of going through the stresses of that very dramatic life change, even in a perfect world where everybody is perfectly respectful. That’s a mental health need. If you want to go on to the voice need, there are two sides of it. For transgender men, things are a bit easier. I said before, differences between men and women from a hormone perspective are really testosterone levels, but that also has impact on tissue. Testosterone actually stimulates increased size of certain tissues, and when you are a transgender man, female-to-male, those tissues are smaller. Specifically the larynx, the soft tissues there are – there’s less there, and you have a higher voice. When you start taking testosterone, even if you do it at a later age, even if it’s beyond the normal age for puberty, you’re still going to have increased size of those tissues and your voice is going to go down a little bit. For many transgender men, that works out pretty well. For transgender women, that is male-female, the opposite is not necessarily so. Simply getting the testosterone down is not enough to cause some of these things that develop with testosterone in their earlier life go away. There are numerous interventions that we have there to get rid of some of that, and that includes, for voice, some transgender women doing voice training to try to get a more feminine sounding voice seeing as the physical structures are not changing as much for that.
Melanie: So, in the last few minutes, tell us about the new Center for Transgender Medicine and what are some of the services? Tell us about your team.
Dr. Safer: We’re very excited with our center here. The big elements are that we have one dedicated phone number so that anybody trans can call in and say, “I am trans, and this is what I need.” It could be somebody saying, “I need everything. I haven’t even told anybody I’m trans. Can I have a primary care provider and a mental health provider? Set me up.” Or, it could be somebody saying, “I have been doing this for years. I have a very supportive medical situation in place, but I need X-Y-Z surgery,” and we can help with that. Or, it could be, “Everything’s been very stable, but I want an expert Endocrinologist to review my protocol,” and we can help with that, too. That’s one of our biggest services. Part of that is the surgery like I just mentioned. The surgery is not widely performed across the country, and certainly not in New England, so we offer most surgeries that most transgender individuals would want, including for transgender women, facial feminization, chest reconstruction, that is breast augmentation, and the creation of female genitalia, that is something called vaginoplasty. For transgender men, we have chest reconstruction also, and we do not have a genital surgery program here, yet. That actually is our one gap, but short of that last gap, we have a very comprehensive program that could really care for most transgender individuals’ needs.
Melanie: So then wrap it up for us, Dr. Safer, with really your best advice for people out there that are considering calling and may be hesitant -- and for other healthcare providers as well -- what you want them to know about caring for the transgender patient.
Dr. Safer: For providers and for individuals out there, if you think you have a transgender patient, or if you are a transgender individual, or think you’re a transgender individual, do not be shy about contacting us. The beauty of our setting up this center is that we can help you at any level. If you’re a primary care provider or a patient who lives far from us, we don’t need to break up that relationship. We can provide advice and let you continue with your primary care provider wherever you are. If you need surgery – if you aren’t sure what you need, reach out to us, and we feel well-equipped to help you.
Melanie: Thank you, so much, for being with us today. That’s really great information. You’re listening to Boston Med Talks with Boston Medical Center, and for more information on the Center for Transgender Medicine, you can go to BMC.org, that’s BMC.org. This is Melanie Cole. Thanks, so much, for listening.