Letters to the Editors
www.AJOG .org
Transgender patients care TO THE EDITORS: We commend the American Journal of Obstetrics and Gynecology editors and Cecile A. Unger for the outstanding comprehensive Expert Review on the care of transgender patients for gynecologists.1 This thorough and concise update highlights the need for all gynecologists to be competent in providing medically appropriate and culturally sensitive care to gender nonconforming and transgender patients. The roles of gynecologists are crucial for this vulnerable population who face significant barriers and obstacles in our health care systems. We want to provide clarification regarding 2011 WPATH guidelines on the process by which a transman would receive a hysterectomy. On page 21, Dr Unger states: “Masculinizing procedures such as mastectomy require documented gender dysphoria and a mental health professional’s referral although hysterectomy and salpingooophorectomy require the same referral as well as 12 months of continuous hormone therapy...” Although we believe that hysterectomy should require only 1 letter of evaluation the WPATH 2011 Standards of Care state: “Two referrals from qualified mental health professionals who have independently assessed the patient— are needed for genital surgery (ie, hysterectomy/salpingooophorectomy, orchiectomy, genital reconstructive surgeries.)”2 The WPATH Standards of Care revision committee has recently begun reassessing the recommendation for 2 referrals and is considering moving hysterectomy to the 1 mental health letter category also recognizing that the gynecologist will counsel patients on the medical implications of surgery. It should be recognized that the WPATH Standards of Care guidelines do not replace an individual clinician’s medical judgment. We also want to clarify that WPATH amended
their guidelines to state 12 months of hormone use are not applicable in cases where hormones are not indicated for the patient.2 In addition, we would like to highlight the importance of addressing gonad retention for fertility preservation at the time of hysterectomy as an option for transmen seeking surgery. The fortuitous attention to mental health letter requirements for hysterectomy will hopefully bring needed attention and support for moving WPATH guidelines to a single mental health letter requirement helping patients face fewer barriers to care. Erica Weiss, MD Department of OB/GYN Kaiser Permanente, San Francisco 2238 Geary Blvd., 5SE San Francisco, CA 94115 [email protected] Jamison Green, PhD Transgender Law & Policy Institute San Francisco, CA [email protected] The authors report no conflict of interest.
REFERENCES 1. Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol 2014;10:16-26. 2. Coleman Eli, et al. Standards of care for the health of transsexual, transgender, and gender non-conforming people 7th version. Intl J Transgender 2013:165-232. ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2014.03.063
MONTH 2014 American Journal of Obstetrics & Gynecology
1
www.AJOG .org
Transgender patients care TO THE EDITORS: We commend the American Journal of Obstetrics and Gynecology editors and Cecile A. Unger for the outstanding comprehensive Expert Review on the care of transgender patients for gynecologists.1 This thorough and concise update highlights the need for all gynecologists to be competent in providing medically appropriate and culturally sensitive care to gender nonconforming and transgender patients. The roles of gynecologists are crucial for this vulnerable population who face significant barriers and obstacles in our health care systems. We want to provide clarification regarding 2011 WPATH guidelines on the process by which a transman would receive a hysterectomy. On page 21, Dr Unger states: “Masculinizing procedures such as mastectomy require documented gender dysphoria and a mental health professional’s referral although hysterectomy and salpingooophorectomy require the same referral as well as 12 months of continuous hormone therapy...” Although we believe that hysterectomy should require only 1 letter of evaluation the WPATH 2011 Standards of Care state: “Two referrals from qualified mental health professionals who have independently assessed the patient— are needed for genital surgery (ie, hysterectomy/salpingooophorectomy, orchiectomy, genital reconstructive surgeries.)”2 The WPATH Standards of Care revision committee has recently begun reassessing the recommendation for 2 referrals and is considering moving hysterectomy to the 1 mental health letter category also recognizing that the gynecologist will counsel patients on the medical implications of surgery. It should be recognized that the WPATH Standards of Care guidelines do not replace an individual clinician’s medical judgment. We also want to clarify that WPATH amended
their guidelines to state 12 months of hormone use are not applicable in cases where hormones are not indicated for the patient.2 In addition, we would like to highlight the importance of addressing gonad retention for fertility preservation at the time of hysterectomy as an option for transmen seeking surgery. The fortuitous attention to mental health letter requirements for hysterectomy will hopefully bring needed attention and support for moving WPATH guidelines to a single mental health letter requirement helping patients face fewer barriers to care. Erica Weiss, MD Department of OB/GYN Kaiser Permanente, San Francisco 2238 Geary Blvd., 5SE San Francisco, CA 94115 [email protected] Jamison Green, PhD Transgender Law & Policy Institute San Francisco, CA [email protected] The authors report no conflict of interest.
REFERENCES 1. Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol 2014;10:16-26. 2. Coleman Eli, et al. Standards of care for the health of transsexual, transgender, and gender non-conforming people 7th version. Intl J Transgender 2013:165-232. ª 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2014.03.063
MONTH 2014 American Journal of Obstetrics & Gynecology
1
