BMC to offer gender reassignment surgery
Boston Medical Center plans to become the first hospital in Massachusetts — and one of a few in the country — to offer gender reassignment surgery, responding to a growing and unmet demand for treatment in the transgender community.
The hospital said more than 100 patients have already signed on to a waiting list to be evaluated for surgery — even before it has widely publicized the program. Boston Medical Center has long provided primary care, mental health services, and hormone therapy for transgender men and women, and most of the patients considering surgery are from the Boston area.
Across the country, many hospitals have been reluctant to offer male-to-female and female-to-male genital surgeries, but health care providers said that is slowly changing as insurance coverage expands and public acceptance of transgender people grows.
Surgeons in a new program at the University of Maryland Medical Center in Baltimore are completing one to two such operations a week, and a longstanding surgery program at the University of Michigan Health System in Ann Arbor has seen a rapid rise in interest over the last two years.
“The demand for care from the transgender community is significant and has not been met,’’ said Dr. Joshua Safer, an endocrinologist and medical director of Boston Medical Center’s new Center for Transgender Medicine and Surgery. “It’s a community that has been neglected for years and years.’’
The hospital cares for 300 to 400 transgender patients and refers to the surgery as “gender affirmation surgery’’ — to underscore that the surgery gives patients the appearance of the gender they identify with.
Without a local program, “we just didn’t know what do to with these patients’’ who want surgery, said Dr. Jaromir Slama, the plastic surgeon who will perform the procedures with urologist Dr. Robert Oates. Along with Michigan and Maryland — up until now, the only two comprehensive programs at teaching hospitals — there are a dozen or more surgeons in Arizona, California, Illinois, and Pennsylvania who offer gender reassignment surgery, many in private clinics. But the distance from Boston can be challenging, particularly if complications occur.
“I knew if we did get insurance coverage, we would need to increase the provider pool because there are not enough,’’ said Jamison Green, president of the World Professional Association for Transgender Health, a nonprofit organization based in Chicago.
Starting in late summer, Boston Medical Center will offer male-to-female surgery and may expand the program to include female-to-male surgery, which is more complex.
Patients must be at least 18 years old and have lived for 12 months or longer in their new gender. Before an applicant is accepted for surgery, a multidisciplinary panel at the hospital will review the person’s medical and mental health history, in part to rule out a mental disorder or substance abuse problems.
Boston Medical Center currently provides facial feminization and breast surgery to transgender patients, as do a number of US hospitals.
During the 1960s and 1970s, dozens of US hospitals provided medical treatment to transgender people, including surgery, but Medicare stopped covering most care in the 1980s amid a backlash. Nearly all the programs closed, Green said.
“Doctors did not want to tell their professional colleagues they treated trans people. Their colleagues would say, ‘That is sick,’ ’’ he said.
Medicare lifted that restriction in 2014, and many state Medicaid programs followed, including Massachusetts that same year. The private insurer Harvard Pilgrim Health Care said it has covered gender reassignment surgery since 2010, while Blue Cross Blue Shield of Massachusetts began paying for it two years ago.
The male-to-female surgery typically consists of an orchiectomy, during which the testicles are removed, and a neovaginoplasty, in which surgeons construct a vagina from the male genital tissue. It takes five to six hours, and patients usually recover in the hospital for five days.
One transgender woman who lives in Ayer said that when she began researching reassignment surgery last year, she was stunned to learn it did not exist in Boston, given all its top hospitals. And programs elsewhere often seemed to be in clinics, which makes her uncomfortable.
“We should have been doing this in Boston a very long time ago. We have a sizeable transgender population,’’ said Phyllis, 41, who did not want her last name used because she prefers her plans regarding surgery remain private for now. “I have seen some facilities, and it almost seems like you are going to have this surgery done in a dentist’s office, and that just isn’t right.’’
She could not find appropriate medical and mental health care near her home and now travels to Fenway Health in Boston. Her former psychologist did not want to get involved in writing letters supporting her diagnosis of gender dysphoria, which is typically required for surgery. “There are a lot of professionals out there who are not going to be comfortable taking that step,’’ she said.
The number of transgender people in the United States is unclear, but some doctors estimate about 1 million men and women identify themselves this way. Only a small number opt for surgery, Green said, either because they don’t feel it’s necessary, they do not have access, or are fearful of undergoing an operation. And no good data exist on whether those who do undertake surgery ever regret their decision.
Over the years, Safer at Boston Medical Center said, he has had one patient undergoing hormone therapy transition back to male because he was “failing to pass’’ as a woman. But, he said, “regrets are incredibly rare.’’
Green said one concern as programs expand is making sure the surgery is being done safely and that surgeons are properly trained — a tall order given the scarcity of instruction during medical school and residency. His organization is starting a certification program for providers and plans to hold a training program next fall in Chicago for surgeons to practice on cadavers.
Slama said many components of the male-to-female surgery are done in other types of operations, such as reconstructive surgery for women following genital cancer. He is observing surgeries at the University of Michigan. Boston Medical Center president Kate Walsh said it’s crucial to have teaching hospitals involved because they can train residents and publish papers on how to get the best results.
At the University of Maryland, “we have seen a tremendous increase in the last year because of changes in health insurance coverage,’’ said Dr. Rachel Bluebond-Langner, a plastic surgeon who does both male-to-female and female-to-male reassignment surgery.
Without insurance, a patient might pay $20,000 for male-to-female surgery, while a female-to-male operation is in the $70,000 range, she said.
“It’s a patient population that is incredibly rewarding,’’ she said. “They have historically been marginalized and finally are afforded access to health care that they haven’t had before.’’