Specialty transgender clinic takes whole patient view

The Transgender and Intersex Specialty Care Clinic at Mayo has undergone significant growth in the last year.

In June 2016, the Williams Institute estimated that 0.6 percent of American adults identify as transgender. That’s nearly 1.4 million people. Minnesota is home to about 24,250 transgender adults, according to the study.

However, many transgender adults lack specialized care, and few clinics offer a full range of surgical options.

In 2015, when it opened, the Transgender and Intersex Specialty Care Clinic saw 77 unique patients, according to Caroline Davidge-Pitts, an endocrinologist in the clinic. In 2016, the clinic saw 80 patients. But in 2017, they saw 196 unique patients.

"Our trajectory is going up," she said. In the last two years, the clinic has gone from offering hormone therapy to transgender patients one half-day a week to two days a week. The plastic surgeons in the transgender clinic offer services three days a week, (all of the doctors who work in TISCC treat cisgender — people whose gender identity corresponds with their biological sex) hormone and plastic surgery patients on other days of the week).

In addition to the 120 or so bottom surgeries they hope to complete in the next year, Oscar Manrique, a plastic surgeon in TISCC, estimated that the clinic will perform 80 to 90 breast augmentations and mastectomies, and slightly fewer facial surgeries. Bottom surgery, at least at TISCC,will begin outpacing other forms of surgery.

The complicated surgical procedures Manrique completes for transgender patients, though, are moving faster.

Bottom surgery used to take six hours, he said. Now the team can do one in three and a half.

The clinic offers hormones, surgeries and mental health treatment for trans men, women, and non-binary (not identifying as male or female) or intersex (born with a variation in sex characteristics) patients.

Every insurance offers different benefits, Davidge-Pitts said, but in general, it’s not too hard to get hormone therapy covered.

"Insurances now are seeing, ‘Oh, we don’t have a good excuse for not covering this,’" said Jessi Wangen, a patient at the clinic. Some still do not cover hormones, though. Many don’t offer any coverage for surgeries, even though those, too, are helping to treat gender dysphoria, she said.

Providers in the clinic hold weekly interdisciplinary meetings to discuss patients, Manrique said.

Having psychologists and psychiatrists on staff is important for another reason, Davidge-Pitts said. They want to address any mental health conditions that may exist before beginning treatment.

Cesar Gonzalez, a psychologist who practices within TISCC part-time, said that although gender dysphoria is listed on the current Diagnostic and Statistical Manual of Mental Disorders, recent studies suggest that the actual condition of identifying as a different gender than assigned at birth is not a disorder .

"Some can be transgender or gender diverse who never experience dysphoria," Gonzalez said. "It’s a condition, but not necessarily a pathological condition."

Instead, Gonzalez looks to treat the mental health issues that are naturally more likely to occur from being part of a severely marginalized, small part of the population.

Data from transgender patients in Olmsted County, courtesy of Davidge-Pitts, from 1974-2015 reveals that, during that time, 78 percent of "adult patients seen for gender-related diagnoses" suffered from depression. Sixty-two percent suffered from anxiety.

Gonzalez agreed that the rates of depression, anxiety, and suicidal thoughts are high among the gender-diverse population.

Gonzalez helps trans patients develop coping methods for a world that will, especially as their gender expression changes, often react badly.

Suicidal thoughts in trans patients, he said, do not reduce much after a gender-affirming surgery. Surgery may help a patient feel better about their body, but it doesn’t erase the experience of marginalization, the threat of violence, or the memory of assault.

"A lot of times, physicians want to make physical interventions that don’t translate to social interventions," he said.

A large part of his job, and part of the reason psychologists provide letters before transgender patients begin HRT or receive surgery, is the need to determine whether patients have a support system in place.

"It’s not just the individual who’s changing," Gonzalez said. "It’s also their families, friends, their coworkers — their identity changes as well."

Integrated care

Wangen called her continued experience with the clinic "very affirming."

"Say, if I feel like my hormones should be at a different level," she said. "They’re very responsive to how I felt my body was reacting to things."

The empathetic approach extends to things like using the correct name and pronouns for patients, which may not yet be the name and pronouns on their legal documents.

Wangen is a leader in Southern Minnesota Transgender Support , a support group that holds meetings and connects transgender people in the area to resources.

Other people in the group can feel "timid" about seeking specialized care, she said. "They wonder, ‘Am I going to have a good experience in the hospital? What if the nurses misgender me?’"

Some of the doctors Wangen has worked with have been knowledgeable about transgender issues — but other workers in other clinics may not be. And even though a provider may see habitually misgendering a patient as a small glitch, the patient remembers that treatment, she said.

Growing a community

As part of the SMTS network, Wangen said she’s seen Mayo Clinic and Rochester’s transgender population help each other flourish.

Mayo Clinic actually refers local patients to the support network , she said, where she and the rest of the trans community can provide support outside of the clinic.

SMTS has been here longer than TISCC, and it’s gotten three to four times bigger in the last year.

"We’ve only scratched the surface in attendance," Wangen said. "We piggy-backed on (the clinic)."

It’s especially important to have a group like SMTS around for people who don’t seek medical treatment at Mayo — or at all.

There are varying levels of physical and social transition, Wangen noted — while some people choose to take hormones and get top and/or bottom surgery, not everyone pursues all or any of those things. Some people simply present as their preferred gender. Some people aren’t out.

Surgery, in particular, varies a lot, Wangen said. Most of the members in her group would like some amount.

"If more people could afford it, I think more people would do it," Wangen said. "The barriers to care, as far as financial and social stressors, are huge."

It’s not clear what percentage of transgender people get bottom surgery, Manrique said.

What’s to come at TISCC

The clinic currently offers hysterectomies for trans male patients, but not male bottom surgery, or phalloplasty .

They are training for it, though. Manrique said two surgeons’ final training for female-to-male bottom surgery will take place in San Francisco in July. He hopes to complete a first surgery around September.

"I think at some point, surgeries become more often and surgeons become more trained," Manrique said. "It’s like any other type of procedure, like removing an appendix or breast. … I think as more people are trained, demand will catch up."

Davidge-Pitts said the clinic has three endocrinologists at work now. If needed, she said, they could work an extra day a week, but thinks "we have a good amount of staff … working in the clinic from the demand we have now."

The Transgender and Intersex Specialty Care Clinic offers several other services, such as:

• Speech-language voice therapy.

• In-house non-denominational chaplain.

• Pelvic physician who meets with bottom surgery patients pre- and post-operation

• A gynecologist who visits patients who were assigned female at birth but identify otherwise, so they do not have to seek treatment at a women’s health clinic.