Addressing the needs of gender-expansive patients is basic health care, yet many PCPs aren’t sure where to begin. Offering evidence that withholding treatments has far more potential for harm than providing them, UCSF medical and surgical gender-affirming specialists discuss how to navigate conversations, identify individual needs and devise appropriate plans. Learn to manage common complications following surgery and simple steps to initiating hormone therapy.
today's session is primarily about dr Butler who will introduce herself, who we're very excited, has joined UCSF and is launching her vaginal plastic services here. Um I just want to introduce myself and give you a very quick overview of the spectrum of services we offer and then turn it over to dr Butler. Um So I'm the medical director for a Gender affirming health program, which is kind of a yeah, loosely knit consortium of specialists across the UCSF health system providing a range of services. And what I'm gonna do here is share my screen with you. And this is our program website which is transparent dot UCSF dot E. D U. And you can learn you and your patients can learn about a range of services that we offer are different team members and providers as well as the different services we offer and going through the surgical pre op assessment process, et cetera. So this might be a useful resource for folks to evaluate. And uh the only other thing I wanted to share with you is just put a couple of quick slides up to set the stage and let me go in here and screen share this. And while I'm doing that I can let you know that. So I'm a my department affiliation is family and community medicine. I provide um primary care as well as hormone therapy consultations for patients and so we can do hormone therapy consultations for patients who get their primary care elsewhere. And then our kind of core team here serves to help support and navigate patients out to our various specialty services that we offer here and also provide um peri operative assessment support and psychosocial support. So I just want to kind of quickly put a couple other things up here that were topics that were brought up of interest. And you know one is just this is what we really try to do here at UCSF. And also does this based on the feedback I hear from patients which is create a culturally appropriate setting. There's lots of different things that really make patients feel very comfortable when they're trans and coming in, you know, starting with just the waiting room atmosphere. Are their posters? Are their pamphlets as their information? Is there a sign about using which bathroom, whichever bathroom you want? Is there a sign that indicates that this is a place where trans and gender. Expansive people will feel comfortable. Do this. Are the staff trained as well to kind of just have the right kind of attitudinal uptake and kind of buy in about feelings and attitudes towards people who are trans. Do you have systems in place that allow you to record and then use the patient's chosen name and pronoun appropriately because if you don't use that the patient is probably not going to come back to your clinic. Do you have clear policies that patients if they do feel that they were discriminated against or if there were any issues that came up. Do they have some kind of recourse you have referrals that you can share with patients to help link them to other services in the community. Taking a sexual history and understanding how queer and trans people have sex and that sex often means a lot more than penal vaginal intercourse. And asking questions about patients of what organs are involved in the kind of sex you have. Um as well as asking patients what terms they like to use for their organs. There's a lot of us were taught in our medical training to just say, do you have sex with men, women or both? And because they're non binary people who identify as neither male nor female. And also because there are men who have vaginas and women who have penises that becomes much more important to take a more detailed and sensitive sexual history. The other thing I like to put up there is from the provider perspective, this concept of cultural competency versus cultural humility. So cultural competency means that you have kind of basic knowledge and attitudinal understanding maybe you have some empathy that you're able to exhibit towards a particular group, um particularly like a minority group, but humility takes it a step further and really making no assumptions and assume that you know nothing with every patient who walks in to see you. So you might have gone to a training and you learned about terminology or transgender and non binary, this or that. But then somebody comes in to see you and they tell you something that totally is not a line with what you've been taught. The most important thing is that you're there to take care of that patient. And so having that culturally humble approach and for that particular patient respecting their kind of outlook and approach is really the right way to go. So, just a very quick overview. These are full range of gender affirming treatments and procedures and we offer pretty much all of them here at UCSF. Now, a range of surgical procedures and dr Butler will talk about some of that. And then we have other procedures like hair removal and speech therapy. We offer both of those services here at UCSF. And then some other things I like to just put out there, is there a bunch of other things that people do with their body that aren't really medicalized but still may come up in a medical context, like tucking your genitals back to appreciate approximated more feminine genital contour or packing um in your underwear with a penile prosthesis binding the chest. Some of these things are binding the chest or chronically tucking the testes can result in some medical conditions. And so those are some things to think about. Talk with patients about if they come in with certain symptoms, why do we offer gender affirming care? There's a number of studies have found over the course of years that this stuff improves mental health outcomes and there's been some actually some costing evidence that has been done that shows that this stuff is pretty cost effective. From a health systems perspective, regret rates and medical malpractice risks are actually extremely low, regardless of what might be kind of over over covered in the media, actual reality of this stuff is really low. Um then you bundle it with other services. So patients may feel uncomfortable about accessing gender affirming care, but then um they uh you mean they may feel uncomfortable about accessing non gender affirming care like blood pressure management or diabetes. But when you bring the patient in and you get them uh comfortable with you because you're providing their hormone therapy, you're managing their gender care. And then all of a sudden you built this bridge with them and you can manage other needed services. And the most important thing also is that these services are defined as medically necessary by the World Professional Association for Transgender Health. So these services are not elective and they're they're not cosmetic. These are these are the real deal. So, I'm gonna pause there and I'm gonna turn this over to dr Butler. We're very glad to have her here. I will let her introduce herself. But dr Butler trained here and and we're very glad that she's back and honored uh to have her here and turn it over to you. Dr Butler. It's thank you. Dr Deutsch, um as I mentioned, my name is Christy Butler. My pronouns are she and her. And I want to thank you all for joining tonight. Um My role here is I provide gender affirming genital surgery. I'm a neurologist by training and I'm here to talk to you all about. Give you a brief introduction to the surgical aspect of gender affirming care. I don't have any financial disclosures, although I will disclose that. I have borrowed with promotion with permission some photos from my fellowship institution at Oregon Health Sciences University. So who I am? I'm assistant professor of neurology and also a gender affirming sergeant. I did my six years of training here at UCSF um followed by a one year fellowship specifically in gender affirming care in general reconstruction. I specialize in feminizing procedures such as both such as vaginal plasticky, both open and robotic approaches. Volvo plasticky and maximizing procedures such as material plasticity and associated revisions. And I'll kind of get into the nitty gritty of what all of this means. My agenda today is I want to kind of review why patients might seek surgery and pre surgical requirements specifically medically and social that might be relevant to you as a primary care physician to be familiar with. What are the various surgical options, considerations that patients may be thinking about when trying to choose which genital surgery option they're going for and then postoperative complications and management. I'll say that I'm going to separate both the feminizing and masculine. Izing surgical procedures because um you kind of get into the they can get quite complicated when you try to blend the two together. So I'm going to focus initially on the feminizing procedures and as long as we have enough time I'll get into more than maximizing procedures afterwards. Gender Dysphoria. The GSM five defines the gender dysphoria as the distress of person may experience when their gender identity doesn't match with their assigned sex at birth. This is the RCD 10 code that you will use for any patient that will present seeking any sort of gender affirming care. It's important to note that not all trans or gender diverse individuals suffer from this for Korea, therefore may not be coming to you for other reasons and not necessarily for you care to manage their dysphoria. However, patients can seek care either medically and or surgically. And I know dr Deutsch was going to get into a little bit more of the details as far as the medical management of dysphoria. So why patients basic surgery number one, we've already mentioned to relieve, help relieve their gender dysphoria, secondly, um it can be a way to help decrease their home runs. For example, trans female patients, they can stop their androgen deprivation and also decrease their estrogen dosage helps and also helps increase their comfort in public settings. In addition to some other goals priorities that are patient driven some pre surgical requirements we require to preoperative assessments either by a mental health provider or social worker. And this was deemed appropriate from the world. Professional Association of transgender Health or the W path. We do require that all of our patients being nicotine free six weeks before any surgery. And this is really um more so to have to do with the visor construction and impacts that nicotine can have on wound healing. We do ask that all of our patients have an A one c less than 6.5. Again, to assist with wound healing an optimal nutrition. You may depending on the surgeon, there will be um various requirements in terms of BMI cutoffs for depending on the different types of procedures. And so patients may seek your assistance for healthy ways to lose weight or improve their nutrition prior to surgery. Social support. It's really important to inquire the support system that patients have available. We do ask these are big surgeries. We do ask that patients have somebody be available to them to either help them take care of their daily needs when they're recovering from surgery. Um and just kind of check in. So it's important to just be familiar with what are the resources available if patients don't have immediate social support um in their day to day so that you can kind of get a direct patients stable housing, patients need a safe clean space to recover, especially when patients are having to dilate after surgery, after vaginal pastie and then hair removal. Again, depending on the surgeon and depending on which procedure we're talking about, patients may require various hair removal is in various parts of their body. So what are the different feminizing surgical options? They can vary between facial feminization, breast augmentation, boy surgery, Lauren capacity or trickle shave, body contouring. And then we talk about body bottom surgery, which is what I do. So that can be anything from a simple archaic to me to a vaginal plastic, which is creation of the external vulva with the canal or available plastic, which is creation of the external canal, external genitalia without the canal. So, I like this schematic. This was done by an artist. Her name was Hillary Wilson. Um It's color coded in cartoon form and I think really nicely demonstrates what it is we do. So, um patients who are seeking vaginal class year bible class D. They start obviously with the penis and scrotum, the scrotum here highlighted until we get we remove and then we'll use later use that as a skin graft to line the vaginal canal. We then deconstruct the penis, leaving the penile skin to behind and we will get rid of all of the erectile tissues keeping the neurovascular bundle attack. This is what's going to help maintain patient's sexual sensation and ability to orgasm. The clitoris is then made from the glance the urethra is shortened. That scrotal skin that was removed as then so into the penile skin tube and then gets inverted in words as you can see over here to line the canal. I want to point out that the prostate does remain in place. So some patients do get confused. They think that we remove the prostate. The prostate does stay in place after a national class city. And so I recognize that there there is some controversy in regards to screen for prostate cancer. However, there have been case reports of patients who have been on hormones since 13 age years and who have gone on to develop prostate cancer. So I just encourage you to keep that in mind um when deciding to uh screen or make that shared decision making decision with your patients about prostate cancer screening. Yeah. And then this I just wanted to provide a kind of a real life view of what it looks like. So this is a patient compliments of dr do get O. H. S. U. Patient pre operatively. This is immediately post operatively. This is with packing in place in the vagina couple of drains. You can see there's a lot of swelling. This is that patients six months later. So how does a patient choose between vaginal plastic bubble plasticky? There's several considerations for them to keep in mind. One is the fact is their anatomy, you know, do they have used a need um for canal and that need may not necessarily have to do with any sort of sexual reasons they may feel like they need a canal to feel more feminine and that's okay. Um, other things to consider our patients willing to undergo lifelong dilation with a vaginal plastic patients need to maintain lifelong donation in order to keep the canal open. We don't know. Um Uh there's no evidence to say that patients can stop after a certain number of years. In fact, even after 10 years, patients will still experience closure of the canal. They do stop dilating. So as of now, we encourage patients to dilate lifelong velvet class. Cities do have a shorter hospital stay. Doesn't require any hair removal. I will say that the recovery is about the same. We still ask patients to take off about 6 to 8 weeks um from work to recover from after available. Plasticky. And then other things to be considered would be contra indications for vaginal pastie or creation of that canal and that would be prior pelvic radiation, prior rectal or prostate surgery and then loosely um for some patients inflammatory bowel disease. This is mostly a soft contra indication for patients seeking robotic national Plasticky and that's because we do go inside the abdomen and instead of creating the canal lining from just scrotal skin, we create the top of the vagina using a peritoneal flaps. Some complications to be aware of. Common complications include things like granule ation tissue or little pink areas that haven't healed correctly wound breakdown, particularly in areas that under a lot of tension and stress in the posterior wound vaginal bleeding, which is typically indicative of strangulation tissue in the canal Urinary retention, which happens in about 10% of patients urinary tract infections, which I would say is more common. Um and females after vaginal plastic because the urethra is shorter and with the dilation practices, it just introduces more bacteria to the area. And then less commonly would be things like wooden infection and DVT when you should call a surgeon. Um you can always call the surgeon in some patients back. I will say that it is my practice to follow my patients for at least six weeks every week for six weeks after vaginal classes. So hopefully a lot of this will be caught by then before they actually reach you. But so you can always call for any reason. So patient happens to be coming in for any reason here on the left. But definitely if there's any evidence of obstruction and urinary retention and you're unable to place a catheter, uncontrolled bleeding. Federal infection. These are emergencies. Non emergent would be for any reason to go back to the operating room. So urethral stenosis or narrowing of the urethra matus, um significant regulation tissue that's not easily managed at the clinic. Any aesthetic concerns, difficulty dilation, dilating, or vaginal stenosis or any evidence of a fistula. Official, I would say it was probably the most dreaded complication of a vaginal class city Because we're creating a space between the rectum and the bladder. There's always potential for causing injury to either of these structures and then potentially risking a fistula for me, this unfortunately occurs about 1% of cases, but just something to be aware of. So what you could potentially manage in your office if someone comes to you with graduation tissue and I'm going to highlight this graduation to show these little pink areas here. These are very easily managed with just some silver nitrate a chemical sticks, you just place right on the graduation tissue. I usually have patients place some gauze and then that's it. Some patients will require several rounds of treatment. So every couple of weeks, if they're still there, you can just treat um uh and then but typically will heal In a couple weeks time and this is most commonly shows occurs probably, I would say 4-8 weeks after post operatively wound breakdown. As I've mentioned, there are areas this area is under the most tension. The posterior wound because we're bringing skin from here and bringing it down here. So it's not uncommon for this to kind of break down very easily managed just with some dry gauze. I have patients play some dry gauze after urinating or after showers in about four weeks. This all heals on its own. And then urinary retention. I want to point out just a little bit of difference in anatomy. So women who have undergone vaginal plasticky will have their, your soulmate is closer to the vagina than an assist female. And so I just wanted to point that out to you. If you happen to have patient who's in urinary retention and you need to place a catheter, um You want the easiest way, you can follow the outlines of the incisions, find the vaginal canal and then the opening, right about the actual amount will be your urethra Mutis. And then lastly, I thought it might be helpful to have an idea of what a typical speculum exam would look like after vaginal plasticky. Um It's not typically required to do regular speculum exams. After vaginal plasticky patients who do complain of bleeding and their vagina, we will often do a speculum exam to look for granule ation tissue or if they're complaining of signs or symptoms of official, we will do a speculum exam if you're comfortable. Um And the patient is comfortable. You can go ahead and do a speculum exam, you want to make sure that um because this is not as elastic as a cyst female, you just want to use a lots of lubrication and being very careful when you're opening. It's not going to stretch the way assist female will, so typically it will only really accommodate um you know, opening just ever so slightly. Um And so you just kind of want to ask the patient look for cues and then adjust accordingly. Um The other thing I want to point out is that you can notice that this is a patient actually who got a robotic graduate classes. So the top of the vagina was peritoneum. Um It really does epithelial eyes in and looks very nice like a normal epithelium. Okay, so um masculine sing surgical options. So similarly patients may seek facial facial vascular ization, uh mastectomies, hysterectomies, hysterectomies, vaginal economies and then again more bottom surgery material plasticky follow plasticity, plasticity implant placements and it can be a combination of all of these that patients may seek. Not every patient goes for all this is just to give you a sense of the baseline. So patients who have been on testosterone treatment, you'll get more of a serialized clitoris looks, so that enlargement of the clitoris. This is the baseline that we're dealing with. So you have a Libya menorah here, labia majora. There is the option in terms of creating a phallus that we can create what's called a micro flat phallus using um a tortilla plastic material is greek meaning towards male genitalia. And basically what we do is we cut this dispensary ligament to kind of bring out the phallus more and then we'll cover it using one of the labia menorah, there's the option to do a re throw lengthening procedure which is what you see here. So that allows patients to be out of the tip of the phallus is not a guarantee that they will stand to pee. Um or they can do a simple majority of plastic, in which case we just bring out the phallus. But they pee from the Ortho topic need is you also have the option of creating a scarred um or not. Similarly. The other option is fallow. Plasticky follow plastic is creating an adult size phallus and this is typically done from some sort of donor site. Donor sites can vary based on surgeon comfort um and patient morbidity and a multitude of factors. It can be from the anterior lateral thigh, the radio forearm, the abdomen, autism store side of the back, groin or lower leg. And again, patients have an option of either doing agree through lengthening procedure or a non urethral lengthening procedure, surgical considerations. So there's a lot I think patients have to think about in terms of what they want when they're thinking about Maskell izing genital surgery, one is the anatomy. Do they want their urethra lengthened or do they not? Do they want to retain their vagina or do they not? Um do they want to maintain their fertility meaning? You know, do patients want to maintain their uterus and their ovaries? So there's a multitude of priority is that patients can present with these are all important things for patients to think about when trying to decide between a material plastic and a fellow plasticky, you know, things to consider ability to stand to urinate. Like I said material plastic is not guaranteed their desire to use the phallus for penetration. Its length is important and girth are important to them. And then the various risks and complications follow. Plasticky has extremely high risks and complications. That's compared to mature capacity just because there's a lot more tissue manipulation you're adding on the complexity of flaps and micro an Eskimo sees. Uh And so the risk factor goes up significantly and then lots of patient decides on follow plasticky where they're going to take the donor site from. So I mentioned the more common donor sites that patients will use. Thanks to think about our length, thickness, sensation, scarring comorbidities. So, you know, patients who decide to use their thigh uh one that it may not be a candidate. It depends because if I tends to be thicker, tends to be longer. The sensations decrease because there's less nerves as compared to, say, a forearm. Um but but the forum, there's obviously a more obvious scar that's more present and visible on day to day. Life is compared to the guy complications. Um So, so much feminizing surgery, you get complications but like I said, there are much higher risk. So wound issues again breakdown degranulation tissue. Um you can get urinary retention either from a structure or middle stenosis, flap loss, which again is the more dreaded complications. So if something happens where the flap dies, Patients can lose their fellas completely, fortunately complete flat losses. Flat loss is only about 2% of cases compared to partial flat glass, which happens about 7% of cases urinary fistula most likely to the skin. You can get a retained vaginal remnant if the vagina is not completely removed or if it reopened realizes and that can end up leading to urinary complications, urinary incontinence, pulling um infection, um wound infections in addition to infections of the vaginal remnant bleeding or hematoma and DVT. And whenever you have a patient present who's had any sort of um mask analyzing general surgery. Always always always contact the surgeon. The anatomy is just a little bit more complex and there's a higher risk patient presents with urinary attention. If you tried to place the catheter with causing more injuries, it was recently reconstructed and causing more fischelis. So it's easier if someone presents with urinary retention for example, just have that patient go back to their surgeon or go to a place where they have a urologist where they can place this for pubic tube. It's safer. So that's just a small introduction to the surgical aspects. There's obviously a lot more that we could talk about and behalf of the UCSF gender affirming team. I just want to thank you all for participating and allowing us to be here today to give you this brief introduction. It really does take a village in terms of providing an affirming care for an affirming society. And I think if we all work together. we can achieve that. Thank you dr Butler. Um that was very informative and I certainly uh took several new learnings away from that. So very much looking forward to working with you. Um and so I understand that there were some other requests for some other topics and so I have a little bit of a potpourri of topics to um speak with folks. I think I'll probably try to take just about 10 minutes and then we can turn it over to Q. And a. um One thing that I want to say just in response to something dr Butler actually didn't say which I agree with her not seeing this was this concept of holding hormone therapy pre operatively and um there's no basis for that recommendation, I see it routinely done. But actually if you look at professional society guidelines around both um uh menopause as well as even highly photogenic hormones like ethanol, estradiol used in contraception and ACOG guidelines regarding peri operative use of hormonal contraception. There is no recommendation to routinely hold those on any patients. Uh The only time ACOG recommends holding oral contraceptives if if the patient is going for major surgery with planned prolonged immobilization and these surgeries don't really meet that criteria. The other thing is sometimes I see surgeons telling patients to hold or reduce their estrogen dose for two weeks before surgery. The three homogenic effect of estrogen if you do believe it exists and this is questionable about what role it plays actually is six week window And so having somebody make a dose change for two weeks, doesn't actually have any effect on outcome, even if there is an outcome effect. But it can precipitate significant mood swings and depression for a patient who is about to undergo a major major surgery that also often involves gannett ectomy. So there's gonna be a lot of hormone swings going on with the patient. So I'm in total agreement with not recommending that. So thank you. I'm going to re share my screen now and we'll just kind of from the current slides. So there were some questions about initiating tailoring hormone therapy. You know, my approach to initiating and tailoring hormone therapy is very individualized. It is not identity based. So I hear sometimes people talking about things, you know, what's your approach to non binary hormone therapy versus binary hormone therapy. But the thing is is that your goals with regards to hormone therapy and other gender for me treatments and interventions do not really have anything to do necessarily with your identity. They're just very individualized. So there might be somebody who identifies as non binary, but is seeking the maximum degree of masculine izing effects and even wants falla plastic. Whereas there might be somebody who identifies squarely as a binary female, but actually is only interested in uh kind of mid range hormone levels and not undergoing any surgery. So, uh I do kind of take this assessment of goals and vision and plans and try to contextualize that for the patient each time when I'm thinking about doing the initiation this whole concept of starting hormone therapy without a mental health assessment is totally appropriate. And within the scope of primary care, it involves making an assessment for the presence of gender dysphoria and the capacity to provide informed consent and assessing for gender dysphoria is very straightforward. Does the patient have a history that tell you a story that demonstrates persistent, well documented gender dysphoria? That is not complicated by coexisting medical or behavioral health condition? The the patient is actively psychotic. It might not be the best time to do an assessment. And if the patient has maybe a difference of sexual development or some other um uh condition, then that really wouldn't be gender dysphoria. That would be kind of a separate issue of helping to align that patient up. But the main thing is that the mental health assessment is not mandatory. Um I also talked to the patient about their long term goals which don't necessarily have to be clearly defined at the onset of hormone therapy. But I like to get an idea of the fact that the patient either does have long term goals or doesn't know what they are. And something that's really important is that this can be a very dynamic process and patients goals and identities can change over time. And that's okay and there's a value in patients going through that kind of personal journey journey? Um I try to discuss realistic expectations with my patients as well as talk about limitations. Um you know, I had a patient today who came in who uh wants testosterone to make their voice deepened, but it's very anxious about losing any hair on their head. And we talked about that a little bit and they said, well, you know, if I start losing my hair on my head, no big deal because finasteride um and and Rogaine will fix all of that, right? And you know, I said very realistic expectations for them, which was that finasteride and minoxidil can sometimes slow or push back a little bit on androgenic alopecia, but it is not a cure. And I think it is important for patients to have that kind of clear level setting and expectations setting right out of the gate, including that you can't dial a hormone. So I can't say yes, we want voice deepening. No, we don't want care laws. Yes, we want skin to become soft and reduce body here, but you don't want to have any breast development. Those kinds of dials and like approach to customizing hormone therapy. It just doesn't exist. And so patients will get a lot of information from online forums where there's all kinds of information floating around that isn't necessarily accurate. So what do you do if you're going to be starting hormone therapy on your own? Uh you know, what guidelines do you look at the reality is is that this is pretty cookbook when it comes down to, what do you start? How many milligrams? How often do you check labs and it really comes down to, you know, which set of guidelines do you feel most comfortable with? The double standards of care? Actually don't have too much detail on hormone therapy management in their current version, version seven, but version eight will be coming out soon and that will have some detail and the current society guidelines are four years old and they have a lot of really great detail as you are five year old UCSF guidelines, Callen Lorde guidelines, I think they're about six years old. Uh you know, familiarize yourself with a set of guidelines and what seems to fit you and make you comfortable, I would go with it. Most of these have more in common than they have differences. Endocrine society guidelines, a bit more academics and more frequent lab testing. Um UCSF guidelines are kind of uh a little bit more relaxed. Um then the endocrine society guidelines, but these two guidelines are pretty well aligned. Callen Lorde also well aligned but a bit more focused on the harm reduction in a kind of lower resource community setting. And so depending on your patient population and where you're working, you might find one of these guidelines fits you more um general approach to feminizing hormones involved. Some kind of androgen blockade. That's usually spironolactone along with an estrogen. Sometimes a progestin jin might be used probably beyond the scope of what we can talk about in this didactic portion about making decisions about all this. But those guidelines can take you all through that and primary care docs, we experience all kinds of things you've never heard of on a daily basis and we go to up to date or whatever resource you're using and you figure it out and it's really kind of no different for basic management of uncomplicated patients with the gender affirming hormones, masculine izing approach? You generally use one of several forms of parental testosterone, although there is now a new oral form of testosterone that's a little fussy to deal with. And so I actually have one patient who's taking it. But just in general it's parental testosterone. And then there might be some other adjuncts, especially if you're trying to deal with inducing elementary A and you can't get it to happen with just testosterone. You might use some progestin gin. Some patients again for hair issues may use a five alpha reductase inhibitor. Um so what are my clinical endpoints for patients who are seeking what I refer to as the maximum degree of medically appropriate effects. That's how I kind of phrase it for feminizing approach. I target the testosterone into the female range and then I use, I add back estrogen dial into the cis female range, arguably at the lowest tolerable dose. So yeah, how do I do this? I usually use some combination of spironolactone and estradiol and then between the two of those, usually get adequate degree of testosterone suppression into the female range and then you really just need to add back physiologic estrogen. These kind of high dose estrogen regimens are dangerous. That is when you, that is when you begin to get into the thrombin symbolic risk range, whereas if you're dozing patients physiologically in the safe range, you're probably not going to get anyth rumble of symbolic risk and in well selected patients, um masculine izing patients don't even have to worry about the astra dial, you just target the testosterone in their mail range. One thing that's really important to know about using testosterone for masculine izing therapy is that the dozing is usually higher and more frequent than you might be familiar with when prescribing testosterone to sis nails who have some kind of low endogenous testosterone and that's because you have to effectively do complete testosterone replacement. These are effectively a grown adult males because the kind of physiologic levels of testosterone in people who are physiologically female um is effect is very, very low and doesn't really contribute much to levels. And if a patient is seeking what I refer to as like sub maximal effects or kind of non binary effects, then, you know, really there's a little bit of making your best guess at first. That's kind of based on talking to patients. Do you want to start at a low dose or a super low dose for example. And then for all of my patients, I monitor labs, I show the results to the patient. I talked to them about what these results mean and what's going on in your body. And I monitor the patient for changing goals over time. So, you know, this is a take home slide and this is right out of the protocol. So the cookbook stuff. So I don't want to spend too much time on this, but, you know, it's kind of put it up there so that it's recorded and you can see it. I want to just spend the last couple minutes talking briefly about some cardiovascular and metabolic stuff. And uh you know, the overall philosophy is that the psychosocial benefits of hormones may include some positive lifestyle changes, patients may be more motivated to to change behaviors and improve their lifestyle. And the benefits of hormone therapy generally outweigh any potentially increased metabolic risk. There's probably not much of an increased metabolic risk. Anyway, there's a lot. And what you might see in some of the outcome stuff, looking cardiovascular outcomes. The role of minority stress and the development of these chronic health conditions cannot be discounted. Um and so, uh this is this describes changes that happened to the body's physiology because of chronic stress experience that has nothing to do with hormones has to do with derangement of the adrenal axis and cortisol levels, et cetera. And then other lifestyle factors that are high prevalence and trans and other minority groups also may be contributing. So I'm gonna skip right ahead here because I just want to kind of talk about a couple of key concepts. This is a study that was done retrospective matched cohort study from Kaiser with thousands of patients and they looked at several overall outcomes, ignore this lower part. We really have time to talk about it. But they looked at stroke blood clots and am I comparing transfeminine people to uh cis males and cis female controls. And you can see here everything that I highlighted in yellow, there was a statistically significant increase. So not surprising. And my and stroke were higher among trans women insist women because at some point, these trans women had some testosterone exposure in the past. The the you know, there's a doubling of the risk of metabolic disease compared to cis men among trans women. But if you calculate the numbers needed to harm, which was not done by the paper, but I just added it on here, the numbers needed to harm a very high for all of these. And so the point is is that even if you do think that there is an increased risk in some of these cardiovascular areas. The numbers needed to harm are very high. The number needed to harm by withholding treatment because you're worried about these things is like one. Because the number needed to treat with regards to promote therapy is like one. The last slide I want to put up here is um this is a similar study that was done but it was self reported in the BRF S. S. Which is a national uh self reported health surveillance survey that's run by the C. D. C. And and this they looked in this bi transgender status to see were there increased rates of cardiovascular disease And interestingly, and I'll let you kind of dive into this but I just want to give you the take home interestingly, this study found that trans men had higher rates of my that was statistically significant compared to both CIS men and six women. Whereas the trans women comparing trans women to assist men. There was no statistically significant difference. There was again that difference was seen between trans women and cis women. But that makes sense as I talk to you about before. But the trans women compared to system and there was no difference here. So the take home here is that, you know, there's two conflicting studies, they have different methods and different sources of data but the signals that we're seeing the number needed to harm is probably similar. I didn't calculate it for this study. But the odds ratio, you have to take that into consideration of what the actual number needed to harm and what is the kind of relative versus absolute risk difference look like.