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Surgery – and an Environment – that Breaks New Ground

February 01, 2018

Yale was the first medical center in New England to provide gender affirming surgery for male-to-female transgender patients and remains the only site in Connecticut to offer the procedure. The Director of the Gender Affirming Surgery Program, Dr. Stanton Honig, is most proud of the environment that his team has created.

“We have worked very hard to make our center a place where transgender patients feel comfortable, because that’s what they deserve,” said Dr. Honig. “One of the things that you have to realize is this population historically has not been treated well by the medical profession.”

The Program provides training for everyone – from the clinical receptionists who answer the phones to the attending physicians – to create a welcoming environment for transgender patients.

“A lot of our patients haven’t received proper healthcare for most of their lives,” said Meghan Curran, RN, assistant patient services manager for the Department of Urology. She described an all-too-common scenario in a doctor’s office of a transgender woman wearing a dress and getting the “third degree” when her driver’s license showed a different first name and gender – and never making it past the waiting room for her appointment.

Listening to his patients was what led Dr. Honig to begin offering gender affirming “bottom” surgery. A reconstructive urologist, Dr. Honig began performing the surgeries when patients themselves requested them. “The best way to explain it is: each part of the operation is something that we already do in reconstructive urology,” he explained. The
inverted skin of the former penis becomes a vagina. Making a new clitoris with good sensation is similar to other operations we do on the penis. Dr. Honig has been performing the operations together with a plastic surgeon, and together, they are dedicated to providing state of the art surgical care.

The Program follows the guidelines of World Professional Association of Transgender Health (WPATH). Patients must be 18, have care letters from mental health professionals attesting that they understand the procedure is irreversible, and understand the risks and nature of the surgical transition. Patients must also be on continuous hormonal therapy
and dress in the gender that they feel most comfortable for at least one year. Most, said Dr. Honig, have been living as transgender women for much longer.

Dr. Honig is also Director of Yale’s Male Reproductive Health Program and can assist his patients to freeze their sperm to preserve their ability to have biological children, if they so desire. Care is long-term, in keeping with
the patients’ unique needs. For example, the women will need the same prostate screenings as male patients following their surgery. Care is also holistic and includes an assessment by the team’s social worker, Fentyshia Daniels, LMSW. The discrimination that transgender patients frequently experience causes many to be separated from family, suffer economically, or experience mental health challenges like depression and substance abuse. When counseling her patients, Ms. Daniels starts with basics, such as connecting patients to transportation, housing and other necessities. She also tries to “think outside the box” to help patients build a support network of extended families and friends. Soon the program will provide a patient support group.

The Gender Affirming Program surgery team is also working to arrange affordable patient lodging near the medical center. Many patients travel from out of state to have the surgery at Yale and all must return for follow up visits within a week after the procedure.

“We’re continuing to learn and improve our technique, and we’re dedicated to being a state of art center for gender affirming surgery,” Dr. Honig said. He travels to share experiences with other urologists performing gender affirming surgery and expands the field through his leadership on the American Urological Association’s transgender education working group.

An estimated 1.4 million adults in the United States identify as transgender. Though they will choose from a variety of surgeries, or choose no surgery at all, the need for more urologists trained in gender affirming surgery is clear, particularly as changes in insurance reimbursement have made the surgery a possibility for more people, especially in
Connecticut, explained Dr. Honig.

But he also emphasized that training clinicians in the interpersonal side of the practice is every bit as important as passing on technical and surgical knowledge. “It used to be called gender confirming surgery. Nobody needs to confirm their gender! Patients affirm their own gender and call it gender affirming surgery because that’s what it is. Affirming,” he said.

Submitted by Eliza Folsom on March 02, 2018