Advancing Gender-Affirming Care: Collaboration, Cultural Competency, and Pelvic Health Integration

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More about my guest:
Megan Brennick (she/her) is an occupational therapist specializing in pelvic health and lymphedema therapies within the Hartford Healthcare Rehabilitation Network in Connecticut.
In addition to her role as clinic director of a multidisciplinary outpatient site, Megan is a member of her organization’s pelvic clinical council where she is responsible for clinical excellence initiatives within the hospital’s Center for Gender Health to optimize equitable access for patients of all genders. She has presented nationally at the USPATH (Professional Association for Transgender Health) conference and at state symposiums on integrated and comprehensive care alongside her physician and speech therapy colleagues.

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Transcript

Lindsey Vestal:

New and seasoned OTs are finding their calling in pelvic health. After all, what's more a DL than sex peeing and poop. But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions, and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are Pelvic Health OTs. I'm your host, Lindsay Vestal, and welcome to the OTs and Pelvic Health Podcast.

Lindsey Vestal:

Megan, thank you so much for being a guest on the OTs for Pelvic Health podcast. This is going to be such an important conversation today. So thanks for making the time to join me.

Meghan Brennick:

I'm thrilled to be here. Thanks for the invitation.

Lindsey Vestal:

Yeah, so a little bit of background. You work for Hartford Healthcare Rehab Network in Connecticut, and you guys are doing some really amazing things over there. So I'm just going to kick off with a pretty basic question, which is do you mind sharing the story of how Gender Affirming Care Center was conceptualized and brought to life where you are?

Meghan Brennick:

Yeah, I would be honored to share this. So for background, I work for Hartford Healthcare, which is an institute of 41,000 colleagues. We have seven acute care hospitals and in our outpatient centers we have 51 of them, in which over the last year we had 1.1 million visits. So that is quite an impact on our state and our region. And with that, we have a growing network of pelvic health clinicians, 23 of us right now and growing. So to give you some background on how this led to gender affirming care integration back in 2018, our organization added equity as one of our five core values. So when we're caring for our patients and each other, that was highlighted alongside safety. It was highlighted alongside our commitment to excellence, integrity, caring, all these things that are really key when we're caring for our patients. So equity was brought to the forefront.

We added four colleague resource groups in 2021, and last year we added the Veterans Colleague Resource group. So now we have this neighborhood mobile health program, we have these colleague resource groups, we have our equity value. The last two years we've organized this medical mission event, which brings together 4,000 of our colleagues to volunteer to bring health screenings, pallets of coats, boots, and gloves into the community. And this became a hotbed for us to expand our programming. So our director of psychology, she recognized this need and understood we're a safe haven state, so folks need affirming healthcare and they can't get it in other parts of the country. So she networked with folks through wpath, which is the World Professional Association for Transgender Health and other institutions that marketed their programs to understand what kind of key components were vital to start to get buy-in from a larger healthcare system for gender affirming care.

Lindsey Vestal:

I am still reeling in all of those statistics that you shared with us for a hospital-based system. As large as that is, you guys have demonstrated such nimbleness and just incredible. I mean, I'm sure there was lot of work there and a lot of things that we don't quite realize when we hear it, but that took so much passion to be able to create exactly what has happened. So I mean, I'm just absolutely amazed. I am curious of the 20, I think you said 23 pelvic health professionals. How many of them are OTs? About a third of our team right now. Awesome. Just incredible. My jaw is going to continue to drop I think throughout this conversation. Megan, I'm curious if you could share any challenges that you might've encountered while integrating pelvic health with some of the other disciplines and perhaps have, you can share how you overcame them.

Meghan Brennick:

Absolutely. So let's delve into a little bit of what is the Center for Gender Health in our system because how do we get care out to folks in our communities? It's not necessarily one stop shopping brick and mortar. We're somewhat scattered throughout the state, but the disciplines that are involved include primary care, endocrinology group and individual therapy. We have providers that do bio-psychosocial assessments. There's surgeons that do breast augmentation and chest reconstruction, facial feminization surgeries, genital affirming surgeries, psychiatry, voice therapy. And then you have us in pelvic floor and we closely partner with the gender gynecology clinic for AFAB folks. So folks who are assigned female at birth, which I'll get into soon. So it's a multidisciplinary system of providers and we've gone through different challenges in the last two years. We obviously notice by being scattered across the state, there might be better opportunities to help patients access our care more equitably.

So right now I'm looking at getting myself onto the hospital campus so folks who have transportation issues might be able to see us instead of just having pelvic health located out in the suburbs. Other challenges, wanting to get our competencies standardized for therapists. So training our breast surgery team, the folks who are OTs and PTs that work with folks after their oncology procedures. Let's help them practice at the top of their scope and help them also understand the differences in the approaches from oncological mastectomy care to top surgery care. We're also partnering with outside institutions because up until very recently, bottom surgery or genital affirming surgery is considered destination medicine. So in Connecticut, we're hugging New York, we're hugging Boston, and our patients who are living in Connecticut are getting those procedures done at those outside institutions in order to optimize outcomes and reduce the need for revisions, and also to be the accountability partners that we love to be.

As OTs and PTs and Pelvic health, we wanted to partner with these other institutions and collaborate care a little bit better. So that's been an opportunity for us and a challenge that we're starting to tick away at of accomplishing that goal. We also kind of in general from the rehab perspective, want to be proactive and preventative with our use of pelvic health. So not only reserving access to us when someone's having a major surgical complication, but thinking about prehab and education as an opportunity to get plugged in. So by having a presence in different multidisciplinary settings like grand rounds or community network, DEIB, lecture series or nursing trainings, this gets the word out and awareness of our presence and our scope of practice.

Lindsey Vestal:

Absolutely incredible. And just hearing you mention the breadth and width of all of the different team members, even things like voice therapy, which honestly is something I had never considered, but just makes so much sense. Would you mind Megan sharing an example of perhaps how collaboration with another discipline or even several disciplines really led to improve outcomes for your clients?

Meghan Brennick:

Absolutely. So I actually think our voice therapists have been incredible team members to get the pelvic health specialty out there because they were well established when folks are going through affirming voice therapy and other surgeries perhaps, and they've invited us to the table so to speak. We've had a really rich relationship with specialty providers in the pelvic health world. So working closely with colorectal, these providers will attend and educate folks in our special interest groups. We have urogynecology that involves pelvic in their oasis pathway for folks who have had significant tearing after delivery. We have endometriosis specialists, we have EDS specialists in our neighborhoods. So we've already had this culture of knowing our resources and collaborating, but even so, we've been able to bring feedback and examples of good catches, so safety moments where pelvic has really proven to be a valuable resource in that same proactive way.

I have particular case example of a patient who I was seeing for pelvic health, specifically pelvic pain, and this patient identified as a trans male. And during the time that I was caring for them, they had shared with me that they were going to be having a revision for their top surgery. And so we paused on our therapy, they had their top surgery and came back and a few weeks later we realized they were having significant restrictions in their chest from the scar tissue from restrictions in the shoulder and just an insurmountable amount of pain that really interrupted their sleep and quality of life. So I recognize this as an opportunity to collaborate closely with our breast OT team and say, Hey, you're already doing all this wonderful work in the lymphedema realm in the post oncology surgery realm. Why not work with these patients? Why not help them in the same way? And we did that and this became a learning moment and an opportunity to share with the plastic surgery team. This was an example of someone who might just benefit to see us sooner, why wait? So that was definitely a key moment in how we could collaborate better and improve those outcomes.

Lindsey Vestal:

Absolutely incredible. When I'm thinking about cultural competency, and again just bringing everyone onto the same page, and again, such a unique situation given the size of your facility, are there any key principles or strategies that you think were really important in that cultural competency training?

Meghan Brennick:

Absolutely. So when we talk about not reinventing the wheel, there are some superb institutes out there that already have so much wonderful educational resources. One of them that comes to mind is the Fenway Health Institute. So they're an organization based out of Boston that I reference often, and it's been a starting off point for our institute to figure out what we need to offer for anyone who is patient facing, so clinicians, administrative staff. So we've pulled some of those materials as starting off points. We've also used Med Bridge and created learning tracks. So there are different modules that folks can take in their own time at their own pace to get a deeper understanding of basics terminology relevant to working with lgbtqia plus folks, the history and the current state of cultural oppression and intersectionality, context of cultural assumptions, values, orientations with tools also for bridging cross-cultural differences and implicit, excuse me, implicit bias training.

We've paired that also with some in-person didactic training. So going back to the top surgery example, we have folks actually on our colleague team who identify as transgender, and that is just an absolute vital component to all of this is that we have folks who are in the lived experience have a seat at the table both on the colleague side and patient care side. So actually next month we're going to have an in-person didactic training, educating our colleagues on the nuances between how you would care for someone post mastectomy for oncology versus someone who's having gender affirming top surgery.

Lindsey Vestal:

As I said, my jaw is going to continue to drop in this conversation. Megan, and I'm not joking. This is just, I've never heard of anything so comprehensive and so thoughtful. My mind goes next to the impacts that you're having on the clients. Do you mind sharing any feedback you've received about the care provided at the gender affirming center?

Meghan Brennick:

Absolutely. So one of my favorite examples of how we've received feedback is that word is getting out about some unique offerings in our institute. So the gender gynecology clinic is absolutely exploding. It started just last year on an every other week basis or sometimes just twice a month, and they're now offering weekly clinic days with an md. They're also adding a new A PRN provider because there's such a high volume of patient need and demand. So it's actually pulling one of the physicians out of retirement because there is such a demand for this service. So again, it's an environment that's meant to offer folks a safe space, both a psychologically safe space and a physically appropriate space to offer gynecological care for folks who were assigned female at birth. And we know that from certain places that you and I have might gone to ourselves, a room that's covered in pink and floral is just not welcoming or inclusive to everybody.

So this has been a game changer for both our patients in the community and colleagues that we care for within our own hospital system because we have colleagues at our patients. So it's been an amazing institute offering and the collaboration too, that we've received feedback on outside institutions that might be doing something a little bit different but can also offer more opportunities for access. I think patients are recognizing that our focus is on quality of life and not isolating them from other institutions that may have something really valuable to offer that we can't quite accommodate for yet.

Lindsey Vestal:

Yeah, I would really be so interested in hearing a success story that demonstrates the impact of your work on your clients' lives, if you have one to share.

Meghan Brennick:

I do, and this circles us back to the voice therapy, the specialization within speech therapy. So I have a colleague who is a ologist and an exquisitely talented voice therapy provider. She happens to have a personal history as a professional singer, so she brings some lived experience to this too. She was seeing a patient that is now a patient I'm actively seeing in the voice therapy realm, and she knew of what pelvic therapy and occupational therapy scope of practice entailed and educated this patient that we offer social transitioning that's safe and affirming in terms of genital tucking practices per se. So we're looking at urethral safety. This patient is not going through any major hormones or surgical interventions. However, they have this aim to be able to dress a certain way and feel safe and affirmed in the public space. So they've been working with me for a little while.

We were building our rapport and expressed that they wanted to see a physical therapist to have assistant with feminizing gait. So we pulled in one of my clinicians, and they've been working on more orthopedic gait and balance oriented endeavors, like looking at this patient's pelvic obliquity, their thoracic mobility restrictions, and these three collaborations with the three disciplines has been really superb. I love this collaboration. So that's been really astounding, and we're looking at this Feminizing Gate program and looking at how we can appropriately bill for this and document this and hopefully scale it to other areas of the system where patients may have that particular interest in physical therapy. What a beautiful

Lindsey Vestal:

Story, what a beautiful story of really taking care off of the page. I mean, again, this idea of feminizing gait, it makes so much sense. We're not just performing the procedure and then saying, okay, you're off to the races. It sounds like you're supporting your clients in all aspects of gender affirmation.

Meghan Brennick:

Absolutely. That is our intentionality overall, and I had the pleasure of working with some colleagues and getting really honest about our opportunities for getting better at integrating care. So this is definitely a case example that we hope to build off of for sure. Yeah,

Lindsey Vestal:

A hundred percent. A hundred percent. Looking ahead, what are some of your goals for expanding or continually to involve the gender affirming care center in the future?

Meghan Brennick:

So acknowledging that we're part of a really large system and offer care at so many different levels and settings, it would be superb to be able to scale this education. We've offered to our pelvic team, our breast teams, and our more local administrative staff to more service lines throughout the system because the reality is folks receive in the home at our skilled nursing facilities, inpatient acute rehab. So I think we are definitely starting something really special here that we can offer into other realms, and this can be really taken and ran with. So we're partnering with something called the Center for Equity as well to revisit how we register patients. It doesn't feel super safe to identify yourself in front of a waiting room full of other patients, so that's an opportunity for how we can evolve our care from the administrative patient facing front desk level.

Lindsey Vestal:

What advice would you give to other pelvic health professionals interested in creating something similar?

Meghan Brennick:

Sure. I would say don't be shy to reach out folks doing the work. That was something I had to overcome. It's really wonderful whether you're encountering someone at a conference or you see them on Appell Facebook group, there are so many great triumphs that have played out before you that can be blueprints to how you move forward, and you definitely don't have to start from scratch.

Lindsey Vestal:

Yeah, and we had talked at the start of this conversation today that it took you a little bit of conscientiousness to reach out and mention that you were willing to come on the podcast. And so I bring that up to mention that even people like you who are doing this incredible work, boots on the ground, can feel a little bit of that hesitancy or that shyness. And so by you coming here and us having this conversation and showing what's possible, you're doing exactly that, and I can't wait to hear the stories that evolve from this because exactly. The more we can see what's possible, the more it's just going to get replicated.

Meghan Brennick:

I agree wholeheartedly on that one.

Lindsey Vestal:

Yeah. Yeah. I guess my last question for you, Megan, is how can the healthcare system better support gender affirming initiatives such as this one?

Meghan Brennick:

I think there's a lot of different ways to answer this question, and I'm going to speak from what came to mind initially, and that's a concept that was presented to one of my leadership meetings recently. Our organization last year hired a chief people officer for the first time, rose Shehan and Rose spoke to us at our meeting and explained that a lot of the things that we're endeavoring when we're looking out at our patient facing initiatives, it's not just for patients, it's for each other. This is caring for our colleagues. So if we can really embody that and acknowledge that this can take many forms that can inspire us to engage in a way that feels comfortable for us, whether it's reaching out to a local pride community group to explore sponsorship or delving into places where we're serving folks with less access to traditional healthcare. So you find you're in and you be a squeaky wheel, we don't give up and partner with other folks who are doing the work too. So whether it's the colleague resource groups or folks online, whatever venue, there are ways to get this into other places and spaces. We just have to remember it's for each other as well.

Lindsey Vestal:

I absolutely love that. Want to thank you so much, not only again for your initiative in wanting to speak with me today, but just also your thoughtfulness. It's very clear how much of a passion you have for this area, and I just can't thank you enough for your time and your wisdom in sharing it with us today.

Meghan Brennick:

Thank you. I hope this is the start of many more conversations on this topic.

Lindsey Vestal:

Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to ig, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health Podcast.