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Mayo Clinic's Transgender and Intersex Specialty Care Clinic provides a home base for transgender patients and those with differences of sexual development

Oct. 16, 2020

Mayo Clinic established the Transgender and Intersex Specialty Care Clinic (TISCC) in 2015, based in Endocrinology, Diabetes, Metabolism, and Nutrition in Rochester, Minnesota. The clinic provides for the mental health and hormonal and surgical needs of transgender patients and those with differences of sexual development. Mayo Clinic is one of the first major academic medical centers to offer multidisciplinary transgender care, including a gender-affirming surgery program. The surgical program started in 2016 with breast and facial procedures; vaginoplasty surgery was introduced in 2017.

The TISCC has seen more than 500 patients since 2015, with more than half coming from the five-state region, and one-third coming from central and southern Minnesota. The Mayo surgical team has performed approximately 150 vaginoplasties in patients ranging in age from their 20s to 70s. Not all transgender individuals choose to have surgical procedures to achieve gender congruence.

"The transgender population faces major challenges in assessing and obtaining appropriate health care," says Todd B. Nippoldt, M.D., Endocrinology, Diabetes, Metabolism, and Nutrition, at Mayo Clinic in Rochester, Minnesota, and the co-medical director of the TISCC.

Mayo Clinic believes that all patients are best served with a multidisciplinary approach. "We offer transgender patients a home base for their care where they are appropriately cared for and respected", adds Dr. Nippoldt.

"Some people erroneously think transgender patients make a choice to change their gender. Rather, it's about confirming their identity and wanting to live authentically. Being transgender indicates diversity, not pathology. Our goal is to relieve the distress associated with the incongruence between their gender identity and physical body," adds Cesar A. Gonzalez, Ph.D., L.P., Psychiatry and Psychology, at Mayo Clinic in Rochester, Minnesota.

Patients in the TISCC see behavioral health and endocrinology providers first. Those providers evaluate and optimize any social, mental health or medical issues. "Before initiating hormonal or surgical therapies, patients must meet World Professional Association for Transgender Health (WPATH) standards of care, which outline the steps necessary to achieve the best outcomes," says Caroline J. Davidge-Pitts, M.B., B.Ch., Endocrinology, Diabetes, Metabolism, and Nutrition, at Mayo Clinic in Rochester, Minnesota, and the co-medical director of the TISCC.

WPATH standards vary for each surgical procedure and may include letters of approval from the patient's mental health professional, prior hormonal therapy and at least one year of living as the gender with which the patient identifies. Each patient's case is discussed at the multidisciplinary TISCC case conference, and a patient proceeds to surgery only after consensus that all issues have been addressed and optimized.

In pursuit of evolving equity, diversity and inclusion, Mayo Clinic has made great efforts not just to use the correct patient-affirmed pronouns but also to modify the medical record — from how patient names are listed to what normal ranges are for gender-specific lab reports.

Studies show that after hormonal therapy and gender-affirming surgery:

80% of transgender individuals report significant improvement in their gender dysphoria
80% report significant improvement in quality of life
78% report significant improvement in psychological symptoms
72% report significant improvement in sexual function

Jorys Martinez-Jorge, M.D., Plastic and Reconstructive Surgery, at Mayo Clinic in Rochester, Minnesota, says: "TISCC patients feel like they're trapped in the wrong body, which affects all aspects of their lives. They just want to live life like I do. We can give that to them through medical care and technologies, and it's professionally and personally rewarding."

Allied health in the Transgender and Intersex Specialty Care Clinic

Katie L. Ubl, M.S.W., sees pediatric and adult patients in the TISCC for initial consultations and ongoing counseling. "I see patients who transitioned genders years ago and want help with ongoing hormonal therapy and finding gender-affirming therapists," Ubl says. "I also see patients who have never talked to anyone about their gender confusion and distress and have taken the brave step to initiate the conversation about it. I guide them through a gender narrative and discussion of their gender identity and expression, and sexual identity. Other patients have had behavioral and hormonal therapy for years and want to talk about gender-affirming surgery. I'm here to listen to their stories, ask questions, and offer resources and guidance."

Ubl works closely with her behavioral health colleagues and the medical team in the TISCC. "All of our voices are equal, and we thrive on collaboration," she says. "We're passionate about caring for our patients. To do that, we not only collaborate with each other and the larger Mayo community but also with other similar clinics. There's a small number of transgender clinics, so we work together to make sure patients have the best possible access to supportive care.

"I'm humbled every day by our patients' resiliency and tenacity. They can't escape the incongruence between what's in their minds and the bodies they inhabit. Simply going out in the world can be a source of serious anxiety. I haven't seen anywhere else the kind of resilience required for them to show up to appointments, work, and for their friends and family. They motivate me and my colleagues to be our best every day. We learn from them and are committed to honoring the ongoing need for awareness of and sensitivity to the transgender community."

Justine S. Herndon, P.A.-C., Endocrinology, Diabetes, Metabolism, and Nutrition, at Mayo Clinic in Rochester, Minnesota, sees patients in the TISCC for medical management, as well as for initiation and monitoring of their hormone therapy before and after gender-affirming surgery. "It's important to be affirming when working with patients who have some medical mistrust," says Herndon. "Like all of our patients, transgender patients are unique individuals, and we tailor our care to their needs."

Herndon was part of a study team that presented TISCC data on perioperative outcomes of vaginoplasty in transgender women at the 2019 Endocrine Society annual meeting.

Being a transgender-friendly and affirming provider is inherent in the Mayo Clinic values. "I'm personally and professionally enriched by working with these patients, listening to their stories, determining how we can help them reach their goals and seeing the positive changes in their lives," concludes Herndon.

Outreach and education

The TISCC shares its expertise with health care providers in local communities who see patients who have had gender-affirming surgery at Mayo Clinic. In addition, the Mayo Clinic School of Continuous Professional Development offers Principles in the Care of Transgender and Intersex Patients, an annual continuing medical education course.

10 tips to become a transgender-friendly provider

Most health care providers have had little or no formal training in addressing the needs of transgender patients, which can contribute to the stress that members of the transgender community may develop through stigmatization, avoidance, discrimination and prejudice.

If you have a question about your patient's gender nonconformity, don't be afraid to ask.
Ask patients their preferred names and pronouns, and use them during encounters. If you make a mistake, apologize and continue.
The preferred name and pronoun often will differ from what is in the medical record. Many transgender people haven't changed their names and genders legally. Ask the patient if you can use this preferred name and pronoun in the medical record. Many patients have access to their medical records, and your sensitivity should be reflected in the notes.
If possible, intake forms should include an option to disclose transgender status.
Sensitivity training should be required for all staff members who interact with the patients. The Center of Excellence for Transgender Health at the University of California, San Francisco has published a helpful online course called Acknowledging Gender and Sex: Supporting Health Care Providers in Serving Transgender Patients and Clients.
Public restrooms should include a unisex option.
Have local transgender resources, such as support groups, available to help guide the patient if needed.
Include transgender health topics as part of medical school and training programs to increase the competence of future leaders in transgender health care.
Provide faculty development in transgender health. Many national and international meetings include transgender health topics, and more online resources are available.
Phone a friend: Identify qualified providers in your area who can answer transgender-related questions.