Diana Bowen: Hi, my name's Diana Bowen, and thank you for having me. I have no disclosures.

So my talk is really expanding on the last two talks, to try to give you some practical tips on how to make any gender diverse patient coming to your clinic have a great affirming equitable experience. And so, I kind of broke it down into just the general clinic experience, and then some specifics with urologic concerns outside of bottom surgery.

So why am I talking about this? Well, like Dr. Figler, we created at Northwestern, a program that's comprehensive about four years ago, surgeon led, but we understood very quickly, we needed to touch all aspects of care. And so, I'm drawing from some of these lived experiences with patients and our health system, to hopefully give you some knowledge about that.

I think that, just like the explosion of bottom surgery, there's an explosion of transgender legislation. But it really doesn't matter whether you're in a state that has gender expansive legislation, or gender restrictive legislation going on, there's increasing acceptance nationally, culturally. And so, you will be seeing gender patients, and they deserve to get great urologic care.

I won't belabor this because Dr. Figler went through this, but it has to be in the scope of the fact that, most of these patients have had either a negative healthcare experience. They don't want to see a doctor because they're afraid, or they have to report teaching their doctor about their own care.

When I think about the clinic experience, I kind of broke it down into three different domains. There's the overall physical environment, there's the workforce, and then there's patient information.

And so, the physical environment matters. Patients coming into your office, seeing perhaps, an all gender restroom for a single stall, that's important. Seeing a waiting space that may have magazines or posters that are not just cis heteronormative. And potentially, even going as far as to have safe space signage, which we developed at Northwestern, and offered to all the different departments, as an opt-in to put in their waiting room.

For workforce, I'll get into this in a little bit, but terminology and pronouns are really important, and not just for you, right? A patient may see three, four other people before they get to you. And so, educating your work staff about these issues is important, through cultural competency trainings. And then, how do you get this information through intake sheets, and through the EMR?

Before I get into those, things to keep in mind, I think it's important that affirming care goes just beyond your gender diverse patients. You most likely have staff that are gender diverse, they may not be out to you, and the same goes for patients not being out to you as well. So I think that putting some of this language into daily use is a really good idea.

We put together some cultural competency trainings when we started this program for the whole institution, Northwestern. It was a big undertaking, but we focused on terminology because we found that people were really hungry for terminology, and ways to use language. Right? And that was the feedback we got. They just want resources.

And so, we provide these resources, and I'm happy to provide any of these for you. Things like staff tip sheets, where you give them the language to say, "Hi, my name is so and so. I use these pronouns." Everybody's scared about what people will say back to them. Right? And so, giving them language to address those concerns, like this is a question we ask everyone because, and so on. I think those are always helpful.

You can modify your intake forms that can be additive. It doesn't need to change dramatically, but putting in things like a preferred name and optional pronouns, as well as after legal sex, gender identity, also optional.

The EMR is a bear, but it can also be a tool, like in most things. And so, there's actually good studies showing most TGD patients would like their preferred name and pronoun documentation to be part of it. You can contact your EMR provider for the latest updates in the SOGI data. And I'll touch on organ inventory.

So is, we use EPIC. This is obviously a fake patient, but you can see here in that top left, you have the patient's legal name, and then in quotations you have their preferred name, and then female with an I, showing that it doesn't match up with their legal sex.

The patient can put that in through MyChart, or you can do it in your encounter. And that lets everybody, again, PSRs, the MAs, the nurses, know how to address the patient. And right here is an example of all the different options they have to choose from, and they can also put in their pronouns.

And I think in the future, organ inventories are going to be really important, as patients start to come in and not just identify as transgender or female. They want to s=ay, "I'm female, well, but I have a prostate." And so, that's important for cancer screenings going forward.

So lastly, we'll talk about urologic care. So again, outside of bottom surgery, any urologic complaint, right? Patients will come in with stones, phimosis, hydrocele. And so, it's important to collect a detailed information history, about their bottom surgery history, or any gender affirming interventions, especially hormones. But you can't assume that they've had these things. The majority of patients have not had bottom surgery.

Genital exams are very, very anxiety producing, provoking for patients. And so, I find that letting the patient know at the beginning of the encounter, "Hey, we're going to do an exam later on. This is why we're going to do an exam. Are you okay with that?" Let’s them process it a little bit, and tell you about any bad experience they've had. And I think that spending the extra time to do that is really important for these patients. Because many have had negative experiences in healthcare.

I see a lot of patients with lower urinary tract dysfunction. When you start a program, people start coming to you. And so, I think that it's multifactorial. A lot of patients avoid public restrooms, so they hold their urine. There's common coexisting mental health disorders. Hormones can trigger or compound existing problems. And so, I think being aware of all of those different factors, in addition to what you would normally do with any patient who came in with this problem, it's important.

Also important to know that a lot of trans women will do something called tucking, where they push the testicles up into the inguinal canal. And so, you could see maybe, things like testicular pain, orchitis UTIs, and you just have to kind of think about it a little bit differently and know that that exists. There's no real literature though, to go off of.

Cancer screening. So there's no WPATH. WPATH, Dr. Figler referenced. There's no guidelines specific to prostate cancer screening. You would think that it would be much lower with the hormones that patients are on, orchiectomy, but it's not zero. And so, we treat patients just by the AUA guidelines, as you would any patient. But there has been some kind of buzz about lowering the PSA cutoff, because of the issues with hormones.

Sexual function is a talk in and of itself, and I would encourage you to go to, you can Google it, the WPATH guidelines, there's a great section on it. They talk about gender affirming hormone treatments, and when you start to see sexual side effects, and things like that, as well as patients pre and post bottom surgery. It's a great resource if you see a patient like this.

And finally, fertility, any in the urologic sphere, right? Patients who are assigned male at birth, AMAB, should really be offered fertility preservation before starting hormone therapy. But they can still bank if they've started hormones by coming off of those. Cryopreservation is an option, and they should know that.

So my major takeaways are that, have an awareness that TGD patients are going to seek care for basic urologic issues, and they don't all follow the same path. So ask them, and if you make a mistake, apologize, it's not a big deal. Move on. They'll appreciate that.

Utilize all the resources that are out there. WPATH, the AUA has great resources, the Core Curriculum, Updates.

Find champions to refer to in sexual health, pelvic floor physical therapy, people you know that are affirming. And if you don't think you can manage it, maybe it is best handled with a multidisciplinary approach. And there are programs that are sprouting up everywhere. So that's the good news.

These are some resources for you that are available in the PowerPoint.

And then, you can always email me, or our program director at the Gender Pathways are happy to help you out with resources. Thank you.