Gender Affirmative

1Gender dysphoria; a conflict between assigned gender at birth and persons actual gender. Transgender (gender affirming) surgery; a medical operation for trans-people. Aim: alters the physical body to unify it with true inner self. William Institute finding: In the U.S. there are about 700,000 transgender people. Each trans-people’s journey is unique.
2The Mount Sinai Center for Transgender Medicine and Surgery (CTMS) offers advanced care for transgender and non-binary people. CTMS specializes in: medical care, gender-affirming surgeries, behavioral health services, and other support services. CTMS program is trans-friendly; tailored & customized to cater for the transgender population CTMS surgeries are system wide & most patients are based in NYC, across the country and internationally. CTMS models it for others at every level, such as John Hopkins, NYU, & Montefiore.
3Interview summary with Dr. Erick Eiting & David Kriser on 04/12/2020 What is the proper up-to-date name for describing transgender-specific surgeries?  Gender affirmation surgery (GAS) is preferred to gender reassignment What is the pre-surgical screening process for gender affirmation? What criteria does the patient need to qualify for this surgery? GAS is a safe procedure. It requires medical clearance & 2 letters of behavioral health clearance. A risk-assessment on possible side effects are done such as stricture assessment. A pre-meeting with the multidisciplinary team is vital. Who are the “go-to-people” in case of a series of sentinel events? Visit CTMS and approach our specialists in urology, behavioral health, plastic surgery, and endocrinology, and more! CTMS offers primary care and social work to ensure patient’s safety and comfortability.  
4Who pays for these surgeries let’s say if the person is uninsured or doesn’t have the means of paying out-of-pocket for the surgery, yet suffers from dysphoria self-image and wants Mount Sinai New York eye and ear to perform gender affirmation how would one go about this process? CTMS had a band blocking coverage for GAS, but halted in 2015. In 2016, a transgender program was developed to offer GAS as a hospital service than a charity care. GAS is performed to all persons with or without medical insurance at CTMS. CTMS utilizes the Medicaid offered to the NY State. What are some of the barriers that patients (pt) experience post operatively? Why do they end up in the ED (Emergency department) or why don’t they come into the ED? Prolonged recovery from weeks to years is a major challenge among patients. The nature of the surgery such as transforming the physical anatomy is the main cause. Emotional distress and prolonged recovery among transgender patients lead to isolation and suicide cases. Fear of discrimination and stigmatization is the main reason transgender pts do not go to the ED.
5What are the reasons the transgender population go to the ED? Trauma among transgender population is the cause of ED visits. Most transgender people are victims of violence such as sexual assault. Mental health issues are another reason. Therefore, learning to communicate to transgender goes a long way than assuming the EMR is right. Treat them with respect and love!
6In your opinion, what would the end goal and vision to solve this dilemma and reach as many patients by promoting the care and guidance needed in order for the transgender population to stay medically and psychosocially healthy and intact? Enabling the emergency room to be a safe space for transgender population is vital. Provision of video visits and enhancing access to telehealth for patients will ensure no one is left behind. Therefore, any patient in the outskirts of Brooklyn State Island or Queens can access a trans-friendly ED; a safe and center of excellence. What is the gender “Etiquette rules” on how this population would like to be addressed and what are some examples of things you should never say or avoid saying to these patients? Use of relevant pronouns like “they and them” to address others should be a norm to avoid discrimination and upsetting transgender people. Interact with best of intentions and enquire the preferable name someone want to be identified with. Avoid referring to them with their birthnames.  
7Interview with Dr. Safer, J. of CTMS on 07/12/2020 Why do people come to the Center for Transgender Medicine and Surgery (CTMS) for care? The CTMS at Mount Sinai health facility offers a trans-friendly environment and a health system with extensive experience. It is a center of excellence. The majority of GAS surgeries at Mount Sinai CTMS happen at NYEE (most happen here), Union Square, and all the other campuses. What do you think some of the barriers for the transgender population? The EMR system. If a wrong gender marker or name is entered, it causes multiple confusion that results in problems.  For example, a transgender woman comes to our pharmacy picks up her first dose of medication/hormones and it has the letter “M” next to the sex then pharmacist calls her “sir,” this can trigger and upset the transgender patient. Errors caused by staff towards the transgender patients. In case of errors made by the staff, Mount Sinai offers education to the staffs on use of proper pronouns towards transgender patients. Therefore, an effort approach solves occurrence of errors by asking for the preferred name and entering it in UPPER CAPS to assist people referencing them to use the correct pronoun. Another standard way is to ask people their sex or their gender identity or simply ask them what’s the sex on your original birth certificate or your gender at birth  
8 Are these surgeries considered elective, medical or emergent? Most people assume they are elective since it entails changing one’s appearance. Emergent means the surgery is mandatory or else an individual will die. Medical implies that if one does not undergo the procedure, they will suffer medical consequence. Therefore, GAS is considered medically necessary because it leads to gender dysphoria, which affects the emotional and physical domain of transgender patients. What are the main complications with these surgeries that potentially land these patients in the ED? Metoidioplasty records the highest morbidity in GAS. It is a trans-masculine surgery meaning female-to-male (FTM) GAS.  It involves the manipulation of the urethra; extension of the urethra by administering testosterone to a female after puberty. Phalloplasty involves the removal of a tissue from one part of the body to another by a surgeon and makes it resemble a normal-sized penis. The alteration of the urethra leads to possible strictures and concerns. 50 percent of these surgeries leads a patient to the ED because of inability to void urinate. Vaginoplasty; a trans-female, male to female (MTF). Less complicated surgery.  
9Aftercare / Length of stay (LOS)/ follow up for Phalloplasty Phalloplasty LOS takes 5 days, then 3 days for the patient in a skilled facility. For any of our genital surgeries, we insist the patient to stay within 90m from the hospital for 4 weeks. Living within the close proximity to the hospital helps in case of any emergent complications; they have access to us immediately.   What happens to the patients who has a housing situation or are domicile or live in shelters?  GAS is not performed on patients that do not have a 4-week post op plan and a stable housing. CTMS is very helpful for people that have these barriers. CTMS helps people sign up to different programs because a patient needs to be in a private area with its bathroom and not a SNF or shelter.
 Transgender patients are afraid of going to the ED or hospital which delays care when having a complication or after a patient has endured someone misgendering them calling them a “he” when in fact there a trans-female obviously this becomes a trust issue. Fear is the major problem transgender patients are afraid to go to the ED or hospital. For instance, a patient who had undergone a phalloplasty experienced strictures and needed a pubic catheter, on Friday. They waited until Monday to see the surgeon instead of addressing it immediately. Therefore, Mount Sinai addresses fear among transgender patient by offering a safe space and transgender-friendly environment.  
10Problems/Barriers Cultural competence and knowledge of the health provider. Health inequities and discrimination against transgender patients. Limited access to primary care providers due to geographic boundaries. Lack of financial resources for the transgender individual.     Inadequate training among health providers towards the lesbian, gay, bisexual, and trans-gender (LGBT) population (Institute of Medicine, 2011; U.S. Department of Health and Human Services, 2014). This is results in health inequities and discrimination against transgender patients. For example, Reiner et al., (2015) found that 24 percent of transgender adults’ experience discrimination. Discrimination affects their access to healthcare services such as preventive care.   Understanding the experiences of Transgender and Gender Nonconforming (TGNC) persons is essential in developing and implementing a culturally competent and TGNC affirming intervention (McCormick, 2020). For example, the application of John Hopkins nursing evidence-based practice rating scale.    
12Solution Implementation of Quality initiatives WorkshopsUsing visual campaigns to create awareness and educate the public about transgenders Video visits between patient & medical providers 24/7 health care accessPromotes confidentiality Appropriate for post-op period
13Develop universal standards and policies for all health care providers. Implementing annual universal competenciesUtilize pronounsRespectCreating a structure in the ED after post opPromotion of an exceptional trans-friendly patient environmentBeing well informed and prepared
14Mount Sinai’s Healthcare System Goal: rendering quality customer service to all patients.  have a patient centered approach, a trans-friendly gender culture system wide.  Mission: reach beyond the delivery of exceptional patient experiences throughout the entire delivery system. Problem solving needs to begin with “The patient’s initial contact experience and that starts with possibly EMS, REGISTRATION, TRIAGE; it is imperative that all staff are engaged in delivering exceptional care and service to our transgender population.  No individual from the LBGTQ population should be neglected!    
15“It always seems impossible until it’s done.” – Nelson Mandela


Erick A. Eiting, MD, MPH, MMM, FACEP

Vice Chair of Operations Mount Sinai Downtown,

Director of Emergency Physician Recruitment

Medical Director for Quality Center for Transgender Medicine and Surgery,

Associate Professor of Emergency Medicine Icahn School of Medicine at Mount Sinai

David B. Kriser Department of Emergency Medicine

Mount Sinai Beth Israel.

Joshua D. Safer, MD, FACP, FACE is the Executive Director of the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) and Professor of Medicine at the Icahn School of Medicine at Mount Sinai.

Institute of Medicine (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press.

McCormick C. D. (2020). Systematic Review: Barriers to Primary Care for the Transgender Individual. Walden Dissertations and Doctoral Studies. 9191.

Reisner, S. L., Hughto, J. M. W., Dunham, E. E., Heflin, K. J., Begenyi, J. B. G., Coffey‐Esquivel, J., & Cahill, S. (2015). Legal protections in public accommodations settings: A critical public health issue for transgender and gender‐nonconforming people. The Milbank Quarterly93(3), 484-515.

U.S. Department of Health and Human Services (2014). Advancing LGBT health and well-being. Washington DC: HHS LGBT Issues Coordinating Committee;

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