surgeon urges colleagues to reconsider views

 

Portola Valley, CA, USA. A prominent gynecologic cancer surgeon believes other surgeons should make an effort to better meet the needs of transsexual patients transitioning from female to male.

 

 

“Transsexual patients face enormous barriers in life, and those continue into their medical treatment. They endure stigma and misunderstanding even when they go to their physicians for medical care,” O’Hanlan said.

 

Most hysterectomies, or removal of the uterus, are performed through large abdominal incisions or through the vagina, O’Hanlan explained. She has observed in her practice that patients making the transition from female to male, who have not had children and are taking testosterone to assist the transition, have vaginal walls that are too thin to safely perform the procedure through the vagina.

 

Minimally invasive forms of hysterectomy have seen increased use at various clinics around the US and overseas. However, the changing practices has received minimal attention as the default procedure for F2M patients.

 

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Laparoscopic hysterectomy, removal of the uterus through several small abdominal incisions, rather than through a large abdominal incision or the vagina, is an option for F2M patients.

 

However, O’Hanlan noted, total laparoscopic surgery is underutilized and few gynecologic surgeons know how to perform it. She reported that about 15 percent of hysterectomies are performed laparoscopically, and only five percent are total laparoscopies.

 

“Transsexual patients are being denied the optimal care they need because doctors are unfamiliar with this procedure,” O’Hanlan said. “The pain and complications of traditional large incisional surgery are simply unacceptable given that laparascopic surgery can be used in so many cases.”

 

In their article, O’Hanlan and her colleagues described the outcomes for 41 transsexual patients during an eleven-year period. They were compared to 552 other patients who underwent total laparoscopic surgery. They note that “culturally appropriate gynecologic care of transsexual patients has been identified as an important goal by the American College of Obstetrics and Gynecology and in Special Issues in Women’s Health.” Standards for care have been well-established by The World Professional Association for Transgender Health (WPATH), the article said.

 

“Transgendered persons frequently experience social and economic marginalization once they begin transition, but after their transition, most transsexuals typically establish and maintain partnerships and have a stable socioeconomic status,” the article said. However, O’Hanlan added, the process is quite expensive, and cannot be covered by medical insurance due to an “unfortunate and baseless” amendment to the Americans with Disabilities Act (ADA).

 

Transitioning within WPATH standards requires ongoing psychotherapy, which can be costly. Similarly, the hormone injections essential to quality of life for these patients are not covered by most insurances because of the ADA. “Because of that amendment to the ADA, the surgeries and medicines used for gender identity disorder are specifically excluded from most insurance policies. It’s a crying shame that Americans citizens are marginalized by this policy and are prevented from getting the medical care they need,” said O’Hanlan.

 

“The transgender diagnosis is a very serious medical reality, and patients deserve compassionate treatment that will carry them forward toward their deserved future as an accepted, valued member of our society.”

 

An expert on health issues facing lesbians and gay men, O’Hanlan was president of the Gay and Lesbian Medical Association and wrote the group’s report “Homophobia as a Health Hazard.” She has been active in urging professional organizations to confront discrimination in medicine against lesbians, gay men, and transsexuals.

 

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O'Hanlan's co-authors for the study were were Suzanne L. Dibble, DNSc (University of California at San Francisco) and Mindy Young-Spint, MD (University of California at Davis).

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Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals. Katherine A. O’Hanlan, Suzanne L. Dibble, Mindy Young-Spint. Obstet. Gynecol., Nov 2007; 110: 1096 - 1101.

 

Abstract

 

Objective. To compare the results of laparoscopic hysterectomy, salpingo- oophorectomy, and incidental appendectomy for female-to-male transsexuals with those of female patients.

 

Methods. Retrospective chart abstraction of all patients undergoing total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and appendectomy since September 1996. Significance from analysis of covariance or 2 was set at .05.

 

Results. Five hundred ninety-three patients underwent total laparoscopic hysterectomy, oophorectomy, and appendectomy. Forty-one were identified as transsexual, 552 as females. The transsexuals were significantly younger (mean 32 years compared with 51 years, median 32 years compared with 49 years, P<.001), with lower parity (mean 0.05 pregnancies compared with 1.34 pregnancies, median 0 pregnancies compared with 1 pregnancy, P<.001), yet had similar body mass index and height. Transsexuals’ surgeries had shorter operating times (mean 74 minutes compared with 120 minutes, median 57.5 minutes compared with 116 minutes, P<.001), with less blood loss (mean 27 mL compared with 107 mL, median 20 mL compared with 50 mL, P<.001) and lower uterine weight (mean 118 g compared with 167 g, median 89 g compared with 140.5 g, P<.001). The total complication rates (12.2% compared with 8.3%), as well as the reoperative complication rates (4.9% compared with 4.3%) were not significantly different.

 

Conclusion. Total laparoscopic hysterectomy offers appropriate surgical outcomes for those patients identifying themselves as transsexual.

 

 

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