Ensuring OB/GYN Care is Gender-affirming Care

Massachusetts General Hospital is committed to safe, inclusive, gender-affirming care for transgender patients. The Transgender Health Program offers comprehensive primary care, hormone management, and case management, and links patients to gender-affirming behavioral health and surgical services as needed. This multidisciplinary, collaborative team has also developed an educational program to teach gender-affirming care to trainees and providers throughout Mass General.

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That philosophy extends throughout the hospital and clinics, and across the Department of Obstetrics & Gynecology, which provides affirming preventive care, fertility services, hormone treatments, and surgery to transgender patients. "Physicians sometimes have preconceived notions about what patients need, but having an open mind is incredibly important," says Milena Weinstein, MD, a gynecologic surgeon at Mass General, director of the Fellowship in Female Pelvic Medicine and Reconstructive Surgery Program, and associate professor at Harvard Medical School.

Routine OB/GYN Care for Transgender Health

Transgender and gender nonbinary adults often face discrimination, stigma, and violence. They are affected by health disparities including more chronic health conditions and higher rates of problems related to HIV infections, substance use, and sexual and physical violence. A nationally representative survey by the Center for American Progress in 2020 found that 28% of transgender adults reported postponing or avoiding necessary medical care in the previous year due to fear of discrimination. "As a medical community, we've [historically] done a poor job of accepting and treating transgender individuals," says Dr. Weinstein.

Gender-affirming OB/GYN care encompasses a wide range of activities and initiatives. Some efforts are seemingly small things, such as establishing gender-neutral bathrooms and taking steps to ensure providers use patients' preferred names and pronouns.

Caregivers are also paying closer attention to experiences that can be upsetting or even traumatizing for transgender patients who have experienced discrimination in medical settings. For patients who do not identify as female, for instance, being in a gynecologist's waiting room can be a gender-discordant experience, says Carey M. York-Best, MD, division director, benign gynecology and obstetrics at Mass General. Simple efforts can go a long way to put those patients at ease. "We try to utilize hall access to enter exam rooms more discreetly or offer telemedicine appointments if the reason for the visit doesn't require a physical exam," she adds.

Individuals who still have gynecologic organs, especially a cervix, should continue to get routine Pap smears. However, the current guidelines state that annual gynecology visits for routine screening are no longer recommended if patients are healthy and not experiencing gynecological symptoms, Dr. York-Best explains. "We encourage everyone to see their primary care provider [PCP] for routine care like Pap smears," she says. "Patients often have a closer relationship with their PCP, which can be comforting during these procedures. This can be especially true for transgender patients connected to a PCP through the Transgender Health Program."

Still, Dr. York-Best and her colleagues happily provide a full suite of care to patients with gynecologic organs, tailored to their unique needs. That may include providing hormones or placing an IUD to suppress menstruation; treating conditions such as abnormal PAP smears, fibroids, ovarian cysts, and endometriosis; or providing contraception, including permanent birth control with laparoscopic salpingectomy or bilateral tubal ligation. People who have had a hysterectomy typically don't need to see a gynecologist unless they have problems. "Most commonly, those problems are vaginal dryness and urogenital atrophy, especially if the ovaries have been removed," Dr. York-Best says.

For patients who have transitioned from male to female, gynecological care can look quite different. "There isn't a need for a routine Pap smear, and it's an uncommon population for us to see on a routine basis," Dr. York-Best says. "But these patients sometimes need to see a gynecologist if they are experiencing painful sex, pelvic floor dysfunction, or bleeding."

Transgender Surgery: Options and Innovations

Another cornerstone of gender-affirming care at Mass General is the Transgender Surgical Program, a collaboration with specialists from the Division of Plastic and Reconstructive Surgery, the Department of Urology, and the Department of Obstetrics and Gynecology. A surprisingly wide range of surgical options are available to transgender patients. "When patients come for a consultation, it's important to think about their goals," says Dr. Weinstein, who provides hysterectomies and related surgeries for female-to-male patients.

For some patients, having a phallus with penetrative sexual function is important. " For others, urination while standing may be an important goal—in which case, we focus on urinary function. Other patients want to prioritize both," she says.

For many transgender patients assigned female at birth, menstruation is a very triggering experience that is not always fully suppressed by hormonal treatments. "Often the motivation for having a hysterectomy is to avoid cramps or bleeding," she adds.

People fully transitioning from female to male require at least three pelvic surgeries, and sometimes as many as eight, Dr. Weinstein says. She provides removal of the uterus, fallopian tubes, and ovaries. She also performs vaginectomy, the removal of vaginal skin and closure of the vagina—a procedure performed in preparation for phalloplasty or for those patients who desire closure of the vaginal canal without the intention of having a phalloplasty or metoidioplasty.

To reduce the number of surgeries, Dr. Weinstein developed a technique to offer hysterectomy and vaginectomy in one procedure. This combined procedure is more surgically challenging and therefore rare, and not offered elsewhere in the Boston area, she says. But her patients appreciate the option to have one less surgery. "We've been able to do this safely, and for patients who are ready to proceed with both steps, it's really something they value," she says.

Reproductive Care and Family Building Options

Reproductive health care is another important facet of OB/GYN care. The LGBTQ Family-Building Program at the Mass General Fertility Center offers a variety of individualized, gender-affirming care for patients seeking to grow their families. The program provides options including donor sperm, donor eggs, gestational carriers, and reciprocal IVF, in which one partner's oocytes are used to create embryos and the other partner then carries the pregnancy. The program also provides fertility preservation ahead of gender-affirming hormonal treatments or surgery.

As with other gender-affirming care across the Mass General system, providers in the Fertility Center start from the belief that each patient comes in with unique experiences and goals. That individualized care is key to the success of the fertility program, as well as to the broader mission of gender-affirming care throughout the organization. Our obstetrical team is also able to provide gender-affirming care through pregnancy with either our midwifery or physician providers.

A Commitment to Gender-affirming Health Care

Many transgender patients have been subjected to discrimination and trauma and let down by the medical community. Providing OB/GYN care to patients who do not identify as women can add complexity and delicacy, Dr. Weinstein says.

"Gender dysphoria has a lot of triggers, and confirmation of anatomy that's incongruent to a person's identity can be tricky for providers," she says. "Vaginal exams can be traumatic for anyone. Add a layer of dysphoria, and these exams can feel like torture."

To help put patients at ease, she often takes steps such as allowing patients to perform self-exams to obtain their own vaginal swabs. In some cases, she foregoes vaginal exams completely. In a study accepted for publication that she presented at the annual meeting of the World Professional Association for Transgender Health, Dr. Weinstein and her colleagues found that performing hysterectomies without a prior vaginal exam in the office did not increase the risk of negative outcomes. It's important to note that these patients were examined in the operating room prior to the procedure. Dr. Weinstein is also undertaking an effort with colleagues to revise patient intake questionnaires to better capture the needs and concerns of transgender patients. Such steps are the beginning, not the end, of improving care, she says. Providers must actively stop to check their internal biases and question whether procedures and policies can be improved to better meet the needs of this at-risk population.

Also important, Dr. Weinstein adds, is the effort she and her colleagues make to put themselves in the shoes of patients who, too often, have been misgendered and disrespected by the medical community—whether intentionally or not.

"Transgender patients are often very frustrated. It's important not to take that personally," she says. "When caring for patients, listening is critical. I learn just as much from my transgender patients as they learn from me."

Learn more about the Female Pelvic Medicine and Reproductive Medicine Program

Refer a patient to the Fertility Center