Introduction: Transgender people face many obstacles to accessing healthcare but cultural changes are likely to increase provision of sex reassignment surgery in countries with sufficient resources. Haemophilia services traditionally focus on providing factor replacement therapy for males and should therefore understand how the care they provide can be adapted to meet the needs of transgender people. Haemophilia is an X-linked congenital bleeding disorder, caused by deficiency of coagulation factor VIII (haemophilia A) or factor IX (haemophilia B). The condition is passed on through carrier females, the majority of whom have a factor level high enough to allow for normal blood clotting. However, around 10% of carrier females are symptomatic and at risk of abnormal bleeding. Case presentation: This case report describes a person with mild haemophilia A who, on first presentation to the haemophilia service, stated he was a transgender person in transition to becoming a male. Haemophilia was diagnosed when heavy bleeding occurred following bilateral mastectomy approximately 25 years previously. He now requested phalloplasty. Management and outcome: Phalloplasty was performed at a hospital geographically separate from the haemophilia centre, requiring careful coordination between the two services. A haemophilia specialist nurse provided education and training about haemophilia and its management to the surgical nurses. Twenty-four-hour support was available from the nurse and a specialist doctor. Preparation and administration of clotting factor was the responsibility of the haemophilia nurse until the surgical team was confident in its use. Clotting factor replacement was managed using standard procedures, successfully maintaining factor VIII above a target level of 100% with a twice daily dose. Surgery went well, but wound healing was delayed, in part, due to persistent bleeding. Discussion: Close collaboration between the haemophilia and surgical teams provided effective prophylaxis of bleeding during a complex
procedure that presented new challenges. Both services now have better understanding of the needs of transgender people.
1. Thomas R, Pega F, Khosla R, et al. Ensuring an inclusive global health agenda for transgender people. Bull World Health Organ 2017;95:154-6.
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017;102:3869-903.
3. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th version. 2011. Available from www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf (accessed 19 November 2018).
4. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016;388:390-400.
5. Lyons K. Gender identity clinic services under strain as referral rates soar. The Guardian. 10 July 2016. Available from www.theguardian.com/society/2016/jul/10/transgender-clinicwaiting-times-patient-numbers-soar-gender-identity-services (accessed 19 November 2018).
6. Joseph A, Cliffe C, Hillyard M, et al. Gender identity and the management of the transgender patient: a guide for nonspecialists. J R Soc Med 2017;110:144-52.
7. World Federation of Hemophilia. Carriers and women with hemophilia. 2012. Available from http://www1.wfh.org/publication/files/pdf-1471.pdf (accessed 21 November 2018).
8. Schechter LS, Safa B. Introduction to phalloplasty. Clin Plast Surg 2018;45:387-9.