He is now she: Addressing the health history changes for a transgender dental patient

Since Caitlyn Jenner has gone public with her transition from male to female, it's likely that many other people will move forward and do the same. Some of these people will sit in your dental hygiene chair, as was the case with me last week. Although I had treated a transgender patient once five years ago while temping, I had no history of a patient relationship with the person.

But last week was different. My patient, the former Ken, had contacted our office the month before to make us aware that he was transitioning to becoming a female. We would now know him as Jessica. She had been inactive for 14 months but had scheduled her recare visit, and I was to be her hygienist. I felt slightly apprehensive when my doctor explained to me the changes that were occurring in Jessica's life. I had been treating Jessica as a male patient for more than six years and knew her, her wife, and children fairly well. (I suppose I did not know her as well as I thought I did.)

That afternoon I went to the reception area and called Jessica's name. I brought her back and began exchanging my normal pleasantries. It was an adjustment to see what I had known as Ken's face and appearance with a longer, feminine hairstyle, smoother skin and makeup, and breasts that were very obvious. She was carrying a purse and garbed in a dress. She sat down and the first thing she did was thank me for being willing to treat her. She said that others in her medical community had shunned her, which I found surprising.

When I updated her medical history, I learned she was taking medications that have aided in the transformation. Sublingual doses of 1-4 mg estradiol per day causes the feminization of physical traits, including skin changes, redistribution of fat, breast development, and decreased muscle mass and strength. It also makes changes in the amount of sweat and to the odor of urine, and more.¹ She was also taking spironolactone, which is a testosterone blocker.

I explained the impact that hormone modification might have on host resistance, especially as it pertained to inflammation in the periodontium. This coupled with the stress of transitioning are certainly risk factors for periodontal disease. Now is the time for her to be ever vigilant in terms of good self-care practices so that she is less vulnerable to inflammation. For the first time in the years I'd been treating her, I felt like a light bulb went off, as Jessica seemed to be more motivated about improving her interproximal care. (Mind you, this conversation was taking place before I'd had the chance to examine her intraorally.) Nonetheless, it served as solid clinical evidence when I probed her gingival tissues and took note of the evident generalized bleeding. She listened closely and appeared very attentive to my clinical advice.

As the visit continued, she wanted to open up about her lifelong struggle with the realization that she was in a body that was not meant for her. I asked her where she was on her timeline. I had read some articles and was slightly familiar with the protocols. She said that she had been taking hormones for 15 months, which meant that when I saw her last, she had not been forthcoming about her medications. (I understand her reluctance to divulge that to me.)

She said that she hoped to be considered as a candidate for surgery but that it would require another six months of living as a woman, with two psychiatric "sign offs" before she could proceed. Since the surgical change is permanent, the risks, time off from work, and rehabilitation are all factors she must consider. Further, the costs are significant and insurance companies are not likely to cover them. For this reason, her surgical transformation might be delayed. She said that she had found peace of mind by simply making the changes that she had so far.

She was candid with me about her family situation, which was going to remain intact. She and her current legal wife will both parent as mothers to their two elementary school-aged children.

I found the experience awkward only at the beginning of the appointment. Once we got going, Jessica was as warm and nice a person as Ken had always been. Frankly, it broke my heart when she thanked me for being willing to treat her. She later expressed the same gratitude to our dentist.

Perhaps today's column will serve to help you with patient management should you encounter this scenario in your practices. Our world is ever changing. We are professionals treating patients regardless of their gender-changing status. Onward we go; it is in our hearts' core.

Reference

1. Hembree WC, et al. (September 2009). Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline (PDF). Journal of Clinical Endocrinology & Metabolism.

EILEEN MORRISSEY, RDH, MS, is a practicing clinician, speaker, and writer. She is an adjunct dental hygiene faculty member at Burlington County College. Eileen offers CE forums to doctors, hygienists, and their teams. Reach her at [email protected] or 609-259-8008. Visit her website at www.eileenmorrissey.com.