Gender transition is a difficult journey with goals that are different for each patient. University of Minnesota Health providers offer transgender and nonbinary patients the resources they need, including counseling, surgical care and adolescent services.
Though less than a year old, the Comprehensive Gender Care initiative has set a high standard for gender care in the Twin Cities area. The University of Minnesota Health initiative is dedicating human assets, material and institutional resources to meet that standard. Given the complex medical, psychological and social needs of transgender and nonbinary patients, myriad elements have to interact seamlessly for the program to function: impeccable medical care, perceptive counseling, useful wraparound ancillary services, and coordination both within the program and with referring physicians.
“We are trying to ensure that when anybody comes out to their provider, anywhere in the system, and seeks additional services for their transition, we have the staff dedicated to be able to provide services,” says Ejay Jack, MSW, MPA, University of Minnesota Health Transgender Community Liaison and Care Coordinator.
“Everybody’s transition is different, so we have various specialties that ideally provide the services that each person is looking for. We want our patients to be able to move seamlessly from specialty to specialty.”
That’s why Jack, together with Nicholas Kim, MD, a University of Minnesota Health plastic surgeon and Assistant Professor in the Division of Plastic & Reconstruction Surgery at the University of Minnesota, helped develop the care program.
Some patients may approach the University of Minnesota Health care initiative from another system or from within the same system and request a particular service, such as breast augmentation. Others may be at the beginning of their transition journey or less sure of their goals. Wherever patients are and however they identify, the University of Minnesota Health staff starts each conversation with care and compassion. Many times, patients turn to University of Minnesota Health for their primary care needs, too, responding to the affirming care they receive.
Comprehensive Gender Care team members (left to right) Katie Spencer, PhD; Joseph J. Pariser, MD; Kate Wedin, RN; Lisa Butcher, MA, CCC-SLP; Nicholas Kim, MD; Ejay Jack, MSW, MPA
Such an immediate, affirming response is particularly important for transgender and nonbinary patients, who have often experienced discrimination or even harassment when trying to access medical care, not just gender-specific care. According to the National Center for Transgender Equality’s 2015 U.S. Transgender Survey, a third of transgender people have experienced harassment, refusal of care or other negative treatment when attempting to access health care, and almost a quarter avoid seeking health services because they fear such experiences.
Compassion goes far beyond a warm voice or the use of the correct pronoun, though such elements are essential. As Jack says, providing necessary procedures with minimal barriers — including financial barriers — is important advocacy work.
“It’s incredibly important to obtain coverage for procedures,” Jack says. “Minnesota case law provides coverage for gender-affirming surgeries. Dr. Kim’s work has been crucial in that area.”
Compassionate advocacy extends to internal diligence, such as working to educate staff if a patient is misgendered, as well as external efforts, Jack says.
“As our program grows, we’re advocating for patients to access external services, and our physicians are providing referrals,” he says. “We submit prior authorization for procedures, and if that’s denied, we work with patients to access services.”
Impeccable Medical Care
Though physicians with the University of Minnesota first started offering surgeries for transgender people in the 1970s, the current iteration is designed to be a comprehensive program, with a surgical component that includes a range of procedures offered by a multidisciplinary team of surgeons.
Dr. Kim, for example, completed a fellowship in gender surgery in Belgium, under the guidance of Professor Stan Monstrey, MD. Drawn by University of Minnesota Health’s “lifespan approach” to gender care, Dr. Kim came primarily to perform phalloplasty and vaginoplasty procedures, he says. A plastic surgeon, Dr. Kim works in conjunction with urologists and other specialists to plan and perform each operation. As of now, Dr. Kim and his colleagues perform vaginoplasty regularly, with phalloplasty offered in the near future. The University of Minnesota Health gender care initiative is the only one in the Twin Cities that currently performs lower surgeries.
“We have performed multiple penile inversion vaginoplasties,” Dr. Kim says. “By next year, we also hope to offer other forms of vaginoplasty, including intestinal and peritoneal vaginoplasties.”
In penile inversion vaginoplasty, the surgeon creates a neovaginal cavity between the prostate and the rectum, Dr. Kim says.
“We line the cavity with inverted penile shaft skin and supplemental skin grafts, usually taken from the scrotum, but sometimes from the abdomen,” he explains. “In the same procedure, the urethra is feminized, shortened so that the stream points downward instead of forward, and the penile tip is refashioned to make a clitoris. And then there is the external vulvar part of the procedure, as well as exterior feminizing cosmetic surgery.”
University of Minnesota Health surgeons perform revision surgeries when needed for patients who have had procedures elsewhere, Dr. Kim says. Of those, some were performed long ago and others abroad.
“In the past, many patients underwent vaginoplasty abroad because of the cost in the United States,” he says. “Insurance didn’t pay for it. Nowadays, patients travel to countries with a history of expertise.”
At home, though, patients can be tracked more carefully following surgery.
“The benefit of undergoing gender surgery domestically is that, during the healing process, the patient can be at home with family members and friends,” Dr. Kim says. “Also, we can follow their treatment closely and care for them if there’s a complication.”
Individualized care is also a product of the local, patient-by-patient coordination the University of Minnesota Health care initiative offers.
“Some models push patients through a conveyor-belt type treatment plan,” Dr. Kim says. “But here in the U.S., we collaborate with our patients and discuss what will be best for each individual.”
Seamless Coordination Across the Community
For each patient, the care continuum begins with either a direct call to Comprehensive Gender Care or a referral. When a referring provider calls in, the conversation is a two-way street: University of Minnesota Health providers have a wealth of services to offer each patient, but they also look at the connection as an opportunity to help the referring physician provide the best care he or she can for the patient.
University of Minnesota Health gender care specialists Ejay Jack, MSW, MPA, and Katie Spencer, PhD.
“We welcome any type of referral for gender dysphoria,” Dr. Kim says. “If someone in a rural community has a patient who has gender dysphoria, who perhaps wants to meet with a therapist or explore surgical options, we obtain the patient information and put in those referral orders, depending on what the patient needs and desires. We offer a unique model through which we are hoping to provide a full spectrum of services across each patient’s lifespan.”
When the patient first speaks with a coordinator at the Comprehensive Gender Care initiative, the conversation will be similar, with a focus on the individual patient’s needs and goals.
“The patient will hear trans-competent questions: their legal and their preferred name, where they are in their transition, and what services they’re looking for,” Jack says. “The care coordinator will then enter referrals to specific departments and ensure the patient receives a call back from primary care or urology, for example, so they can get scheduled with that department. We can also connect patients with external resources so they get all the support they need.” Adolescent patients can receive gender care, including counseling and top surgery — though not genital surgery — through University of Minnesota Health. The care coordinator regularly makes referrals for trans-affirming primary care, gynecology and other specialties for young trans- or nonbinary patients, Dr. Kim says.
Whereas some competing systems only make internal referrals, University of Minnesota Health gender care specialists make both internal and external referrals and work closely with independent providers or those from other health systems to make sure patients receive appropriate counseling, hormone therapy and other care. It’s an important distinction and one that fosters communication among physicians and rapid access to treatment for patients.
“One of the main issues that the transgender community has experienced in the past is healthcare inequality,” Dr. Kim says. “It is our goal to reduce any barrier to their receiving care. We feel it’s unfair, when a patient has therapists outside the system, for us to insist on a referral within our own system before moving forward with hormone or surgical therapies.”
At the same time, when patients do choose University of Minnesota Health, they will find cohesive, proactive care and navigation support.
“Historically, navigation of care has been difficult for the trans community,” Dr. Kim adds. “So we bring all the players together at one location or one institution, and we all have the same mission and values. I believe we can provide optimal care.”
“What’s unique about University of Minnesota Health Comprehensive Gender Care is that we have a centralized hub where we coordinate referrals and advocate for patients while helping them navigate our system. Our referrals and physician coordination are highly centralized, making it efficient for both patients and providers.”
— Nicholas Kim, MD, University of Minnesota Health plastic surgeon and Assistant Professor in the Division of Plastic Surgery & Reconstructive Surgery at the University of Minnesota
Setting a Standard
Still growing, University of Minnesota Health Comprehensive Gender Care looks to increase coordination with referring providers across the region, deepening those relationships and serving as a resource for physicians who serve transgender and non-binary patients.
“I’ve met with key players in the Twin Cities area at clinics that provide hormone therapy,” Dr. Kim says. “Our goal is to have a monthly conference in the near future. We’ll discuss select patient cases, especially challenging ones.”
Provider education is essential for trans and nonbinary people to feel safe and welcome when accessing medical services. Often, when transgender patients can access health care, they find themselves having to teach their providers the basics of their health needs — a process that can become burdensome and alienating when repeated frequently. According to the National Center for Transgender Equality, 24 percent of transgender patients say they had to educate medical providers to receive the health care they needed.
By undertaking such important work, University of Minnesota Health providers hope to raise the standard of care for transgender patients across the region.
“We want our neighboring physicians to know we aim to be a one-stop for gender care services,” Dr. Kim says. “Sooner or later, all providers will become competent at caring for transgender patients, just as all providers have learned to become competent with patients who have diabetes. It will become part of the culture. But until that happens, we are looking to serve as a resource for our local community however we can.”
Visit mhealth.org/gendercare to learn more.