Progress seen in field of transgender medicine

Monitor staff
Published: 8/22/2016 11:56:12 PM

While the field of transgender medicine is advancing rapidly, significant barriers remain for people who wish to make their physical appearance match their gender identity.

So far, just one hospital in New England offers gender reassignment surgery – Boston Medical Center. The cost of surgery can differ by tens of thousands of dollars, depending on how drastically people want to change their appearance.

Still, health experts say things are improving. Being transgender is gaining recognition and acceptance in the United States. Young transgender individuals can transition earlier, and there are many different procedures they can undergo to look how they want.

Transgender individuals can choose from many different medical options, but much is dependent on money and insurance.

Male to female gender reassignment surgery ranges anywhere from $7,000 to $25,000, while the procedure to transition from female to male can be twice as much. That’s because it’s much more complicated to construct and attach a penis than it is to create a vagina, doctors say.

In the past, people had to pay for gender reassignment surgery out of pocket. But under the Affordable Care Act, insurers are not allowed to deny transition-related health care.

Besides the cost barrier, limited choices exist for hospitals providing gender reassignment surgery. The closest place in the U.S. for New Hampshire patients to travel used to be Pennsylvania, but Boston Medical Center recently announced it would offer the procedures. Its waiting list already has more than 100 names on it.

When endocrinologist Jack Turco sees new patients at his transgender health clinic at Dartmouth-Hitchcock Medical Center in Lebanon, they have often spent hours researching beforehand and want access to hormones.

Many patients have the same wish: “I want my outside to match my inside.”

Taking hormones is a necessary first step to start the gender transition process. Estrogen slows the production of facial and body hair and smooths the skin in transgender women, while testosterone speeds up hair production and can lower vocal pitch.

Transgender individuals must continue to take hormones throughout their life to maintain these changes.

There are some risks with hormone therapy, including blood clots and a slightly increased chance of getting some cancers, but overall, the treatment is relatively simple and safe.

However, traces of people’s old bodies remain. Transgender men who don’t have surgery to remove their ovaries and uterus still need to have pelvic exams, and Turco reminds transgender women that they still need to get their prostate checked as they age.

Turco said he doesn’t try to minimize the medical risks for people who have a history of blood clots or heart disease. And the health risks of smoking or chewing tobacco are heightened for people taking hormones.

Still, the chance to have their bodies match their inner identity outweighs everything.

Turco remembers cautioning one patient who had a problem with blood clots about starting the gender transition and being met with this response: “Doc, I’m going to kill myself” if I can’t get surgery.

Still, Turco says everyone is different, and not all transgender individuals opt for gender reassignment surgery or even hormones. Some see themselves falling somewhere on the middle of a gender spectrum, with both male and female elements.

“I’ve had more than a few patients saying, ‘I wasn’t going to have an operation, but society won’t let me hang out in the middle there,’ ” Turco said.

What age

Transgender individuals often start identifying with a different gender at a very young age. As acceptance grows, more are starting to transition earlier in life.

Dartmouth-Hitchcock endocrinologist Benjamin Boh, one of the physicians at the center’s transgender clinic, said he sees patients who are adolescents and adults.

“In the span of the six years I’ve been in the field, the age of presentation for transgender individuals is decreasing dramatically,” he said.

While children can socially transition as young as they want by changing their name, hairstyle and clothes, the question of when to start hormones is trickier. Families and doctors usually wait longer to make sure adolescents are certain before they physically transition.

In some cases, transgender pre-teens use puberty-inhibiting drugs for a few years so they don’t have to go through hormonal changes with the gender they don’t identify with. The blocking can last one to three years and give them extra time to decide if they want to start transitioning to the opposite gender.

For patients born male, blocking puberty can limit their typical growth spurt, the broadening of the shoulders and development of an Adam’s apple.

On the other hand, Boh said, these changes can also dramatically improve a patient’s quality of life. Without treatments, transgender individuals have high rates of depression and substance abuse.

For younger patients, the typical age to start hormone therapy is between 15 and 18, and it comes after meeting with parents and a psychologist, Boh said.

“It’s important that the adolescent is mature enough to understand the implications of lifelong hormone therapy,” Boh said.

It’s “not a decision we take lightly,” he added.

(This story was updated to reflect the correct age range of patients that Dartmouth-Hitchcock endocrinoligist Benjamin Boh treats. Boh’s patients are adolescents and adults.)

(Monitor intern Leah Willingham contributed to this report.)

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