AOSA Part 4

Hello, everyone. Welcome back to Behind the Knife. This is Dan Schiess. I'm one of the surgical education fellows with BTK, and I'm very excited to welcome back our friends from the Association of Outsurgeons and Allies for the fourth episode of this wonderful collaboration. This episode will be focusing on gender affirming care.

We're joined again by Dr. Andrew Schlussel, who will introduce our guests for today. Well, thank you, Dan. And again, on behalf of the Association of Outsurgeons and Allies, Really, thank you again for co hosting this episode with us tonight. I'm really excited. We have a very diverse group of guests to provide a multidisciplinary discussion about gender affirming care and gender affirming surgery.

So, without further ado, our guests are first Dr Megan Lane. She is a plastic surgery resident at the University of Michigan. Who is planning on going into gender affirming surgery and general reconstruction. She completed a research fellowship in the National Clinician Scholars Program and focused on.

primarily on patient reported

outcomes in gender affirming surgery. Next, we have Dr. Scott Chiat. Dr. Chiat is a double board certified by the American Board of Otolaryngology and the American Board of Facial Plastic and Reconstructive Surgery, and he is currently at University of Wisconsin. His areas of expertise include rhinoplasty and facial gender surgery.

He also practices reconstructive surgery, including facial paralysis and reanimation. His gender affirming practice includes all areas of the face and Adam's apple. Next, we have Dr. Amy Sawanable. Very excited to have her, another co fellow from UMass for colorectal. She is currently a colorectal surgeon at the University of Michigan.

She assists the gender affirming surgeons at the University of Michigan in performing robotic assisted vaginoplasty. Her research focuses on optimizing quality of life among surgical patients and their families, surgeon well being, and cancer survivorship. Next we have

Dr. Monica Yaddo Ferrula. Dr. Yaddo Ferrula was born and raised in Puerto Rico.

She completed a residency in general surgery and then plastic surgery at Tulane and Penn, respectively. She pursued a year of training in advanced gender surgery and is now currently at OHSU. Her practice largely focuses on facial feminization. Chest Affirmative Surgery, Thaloplasty, Otologist Breast Reconstruction, and Limb Salvage.

And then, last but not least, we have Dr. Mike Fischelli. Dr. Fischelli is a practicing reconstructive urologist at Cleveland Clinic. He completed his urology training at the Cleveland Clinic in Ohio, and then fellowship in Urogenital Gender Affirmative Surgery with the urology team at OHSU with Dr. Yaddo Farula.

So, he is now the Director of Durogenital Reconstruction and Co Director of the Gender Affirming Surgery Program at the Cleveland Clinic. He is very committed to LGBTQIA urologic access, and actively works to protect and expand care to the rainbow

community, and well as to our trans and gender diverse patients.

His practice currently is focused on queer urologic health concerns and genital gender surgeries such as vaginoplasty, mitoidoplasty, and phalloplasty. For more information, visit www. FEMA. gov So really wonderful, amazing, diverse group of folks here, and I just wanted to get the first question started to give you all a chance to really tell some folks about yourself.

But what motivated you to specialize in gender affirming care? So I can go first. My name is Megan Lane. I'm one of the fourth year plastic surgery residents at the University of Michigan. I use she, her pronouns. I don't have a really great pod word. Podcasts where these story for me, I think it was really a collection of experiences that started when I was in college.

I was a woman in general studies major. And when I went to medical school, I really wanted to do something that would allow me to incorporate that into my future practice. You know, I think one big thing is that I really did not think I was going to like surgery early on in medical school. And when I rotated on

both general surgery, I really loved it.

And then particularly plastic surgery. And through that experience, I was able to see some gender affirming surgical procedures. And throughout that, as well as residency, it's really become clear to me, at least, that gender affirming surgery is kind of the pinnacle of plastic surgery. It combines everything that I love about it.

It's head to toe. You get to collaborate with so many other specialties. You get to engage in really great shared decision making and patients overall are very happy after this and it's very rewarding in that aspect. I can go next. My name is Amy Swanable. I'm a colorectal surgeon at Michigan.

I became interested in this space because I actually have always been interested in this space. This is actually what I thought I was going to do when I went into surgery. And it just so happened that I'm not You know, I ended up loving abdominal surgery, but always had had a clinical interest in doing general gender affirming care, partly because I'd been exposed to it for my entire life.

We had, my cousin is transgender and we knew

that she was transgender ever since she was a toddler. She's only a couple of years younger than me. And we always had family friends who were transgender and had undergone a gender affirming surgery. So it wasn't it wasn't something that I thought that I'd be interested in until.

I realized that it wasn't widely available to everyone. And my research is in studying how to optimize quality of life amongst patients. And to me identity is such an important part of people feeling Or optimize or feeling like they might be their best self. So that identity piece and quality of life is so important to me.

And so when the opportunity to came to me to become involved in this with my expertise and being able to use the robot, I jumped at it just because one, I felt like it was an important mission to me to be able to serve patients in a different way. And also because I had always had an interest in this.

So I think that I kind of stumbled upon my career path because life happens when you're busy making plans and while initially I thought I was going to do critical care and general surgery, I became enamored by the

creativity of plastic surgery. And so I followed that pursuit, which took me from New Orleans to Pennsylvania.

And subsequent to that, within the first six months of being there and working with Dr. Joe Sirletti, it really kind of took off. You know, struck a chord that I was in a very unique position with a skillset that, you know, largely wasn't. That a lot of other individuals didn't have and how could I not use that for the greater good and to serve my own community being a queer surgeon myself.

And so it seemed that it would marry both my aspirations in a way that would be positive for the community, which had been so ill served from, you know, Historically in medicine, so it was basically just a follow through and then I was privileged to be at OHSU where I met Dr. Fischelli and it's been a dream come true ever since.

I feel like I have to follow Monica now, but Mike Fischelli, he, him. So. I, as a urologist, had always

thought about wanting to do reconstructive surgery but not in the queer space. That wasn't something that I had any exposure to and I sought that out during one of my research periods that also happened to be during COVID, so that was a bit of a struggle, but I ultimately ended up at OHSU and shadowed for a little while and got to see sort of the gender expansive care that was happening and realized that that was really what I wanted to pursue and kind of add to my my niche of interest and just continuing to advocate and mirror the type of queer care I was hoping to like one day receive myself.

So I think that that was just part of the, the motivation. And then getting to be Monica's co fellow, I learned a lot more about plastic surgery and sort of what opportunities are there for patients, and it just became a much more inclusive experience. And so, I think early exposure, kinda, and then just sort of getting to mirror sort of who I

wanted to be as a provider.

My name is Scott. I use he him pronouns. So when I finished my training in residency 12 years ago, there really weren't any programs. Well, there was one a program in Boston by esteemed Jeff Spiegel in the facial plastics world. That was really the only place that was. training or educating on facial gender surgery.

So I had no training. I pursued a wonderful fellowship and came to find myself as a busy surgeon and a busy advocate. I was involved in the American Medical Association really from day one of medical school through my entire career, and we were advocating for things like access and coverage and fighting insurance policies and all the things that a big medical organization seeks to do.

And one of the facts that we kept throwing out was 21 percent of patients who found themselves with insurance coverage. You know, after all the people who didn't have insurance coverage, 21 percent of surgical

patients didn't have a provider network. As an LTA surgeon, I found it really wonderful to be participating in the care of LGBTQ patients.

And it just became a really big part of my practice. I'm still involved in advocacy less so, in big organizations and more, just in my subspecialty organization, seeking care changes on the facial gender surgery level, which is kind of the last frontier for insurance coverage and the hurdles that we need to jump across.

And, you know, I get to work with really cool people, like all the people on this podcast. So that's a really wonderful part of you know, jumping into this part of your practice even kind of mid career. Well, thank you. I think this is really again, wonderful. And it's also great to have folks from urology and head and neck on here too.

I think it's so rare that we can find all the. Some specialties put together in one conversation. So Megan, I had a question for you since you're still in training, but I know you definitely sought out a lot of

exposure to gender affirming surgery, but what do you recommend to the younger listeners out there, if they're interested in how to get started and what the exposure is like, or trainees today?

Yeah, that's a great question. So when I was looking through some of the literature for this podcast, there's a paper back in 2016 that said about 30 percent of plastic surgery and urology residencies don't have any clinical exposure to gender affirming care. And so, I would hope that's getting a little bit better but I will say generally for me, I was super lucky to be at a place with a comprehensive gender services program.

I think more and more for younger trainees, I think that it's very much worth asking the questions of, you know, do you have a gender services program or do you in your practice see trans patients participate and do gender affirming surgery as part of your residency training program. And I've even had medical students ask about the clinical

experience they can have as medical students.

And I think that's also something, even when you're looking at medical schools, you can definitely ask about. So, you know, I was super lucky to be at a place that did a good amount of gender affirming surgery. In addition similar to Dr. Vascelli, I did a rotation as a med student called trans health, which was actually not only with the surgeons, but also the mental health and hormone providers, which was very informative.

And then I did a month actually recently on urology, which I think is Dr. Fuseli is saying, being able to see different surgical subspecialties that you don't necessarily interact with a ton as a plastic surgeon, I think is super helpful in deciding if this is right for you. And then in addition to that.

Reading about gender affirming surgery, reading the literature, and then, I think, really importantly, reading some of the social sciences literature, particularly from trans scholars, I think is very informative, especially as a cis physician, so. That's wonderful. Is the trans health program, is that through your school, or is that a national

program?

That went through my school. So it was a newer rotation when I was a medical student at this point was like, I would say, eight years ago, so it's a super popular rotation at the University of Michigan. I'm not sure if other people and other universities have had similar rotations for medical students or residents that have developed.

Yeah, I mean, I was just gonna kind of echo sort of what you started to talk about, just that. As a urologist, what I saw in training was mostly complications of gender surgery and Not really understanding that primary surgery process. I think getting a chance to shadow and go to another program was awesome.

And I encourage folks to ask program directors about being supportive in getting that exposure. I mean, my program director knew that we weren't exposed to this and knew that I was interested and fully supported me spending some time and even tried to help me get funding to make sure that I could go to Oregon and get out there and see sort of what was happening.

And then, yeah, I think a lot of programs are starting gender inclusive, gender expansive rotations for medical students and residents. I don't know necessarily at some of the other programs, but we have a trans medicine and surgery rotation where. Med students can rotate through all of the different interdisciplinary kind of groups and sort of be part of our interdisciplinary discussions and participate and I think it kind of mirrors the experience that Monica and I had at OHSU, where we saw med students, fellows, and different people from all walks of the medical careers.

And I will say rotating urology. You know, as a plastic surgery resident, I don't always see the long-term issues that come up with vaginoplasty and VOP plasty. So it was very informative and it was great to see. So yeah, just to that multidisciplinary multi, I would say the multidisciplinary exposure I think was super helpful.

Can I ask a question? Do you guys have opportunities for students who are not from your own programs

to be able to come do visiting rotations? I think COVID squashed a lot of that, but we have a lot of med schools in the area that do send rotating med students. So it's not uncommon to see folks in the area get, you know, a rotation that if they're really looking for it.

Because the infrastructure is there. It's just a matter of having someone come in. So I have seen a couple but I think COVID really kind of impaired our ability to like entertain med students from, you know, neighboring states, for example. In the otolaryngology head and neck literature, there was a similar study.

I think that the co authors replicated it for plastics, urology, et cetera. And it was exposure to our education on the treatment of transgender and gender expansive patients. And so, while I don't think Amy, I don't think people are necessarily, to my knowledge, seeking out rotations at the University of Wisconsin to come and spend time with us, I know that Are visiting students make a point to

come to my or and just, you know, some of the things that their training programs might not have, you know, you know, outside of what I do as well.

And it's a really important talking point during that that applicants will bring up during the resident interview season of just like, this program has something that, we really want to be seeing it's even someone who may not have no interest in pursuing. This is a primary you know, career passion, but the exposure to is something I think we really all of us know that it's important and hopefully the listeners also have opportunities to seek those out if they don't have their own training program.

We don't have a dedicated rotation at OHSU for outside medical students seeking to do, we do have a transgender health program rotation, but we find that largely because of OHSU's program and involvement early on in transgender health. A lot of

the sub i's that we get from a plastic surgery perspective are seeking those opportunities to come and visit us because of the transgender and gender affirming surgeries that we do.

But it would be great, right, if we could establish, you know, rotations across the country, just in academic centers that would expose you for the Interdisciplinary multidisciplinary systems that we have in place. So speaking of visiting your O. R. and exposure. Why don't we go through some of the operations you perform and you can give us some of the specific details and nuances and things that you are very passionate and I know enjoy doing.

So, I think that one of the overlooked surgeries that not even I kind of fully appreciated prior to Doing my year of fellowship here was the difference, the nuanced differences between a gender affirming breast augmentation and a cisgender breast augmentation. You know, there are some key differences in the way that testosterone shapes

the chest for an individual who has gone through puberty exposed to endogenous testosterone.

And that. Mostly focuses on the skin elasticity and certainly the higher displacement of the inframammary fold as a result of that because the base with required to get these individuals a certain projection and fullness of their chest requires a much larger implant is. Superbly important to drop the IMF, which is essentially when you're learning how to do cisgender breast augmentations is the first rule that they tell you not to do is to blow through the IMF.

And this is quite the opposite, right? And so we've found that, you know, in revision surgeries and individuals that have had surgeries before sometimes you can find that the implants are really high riding or that they've had to basically downgrade the size of the implant in order to accommodate for a smaller pocket.

And so it's really interesting, right? Kind of seeing the differences of when

you drop that IMF to really kind of displace the nipple slightly higher up and give them a much better projection and chest fullness that would also contribute to their cleavage. And I think that that should never be underestimated.

So essentially what we typically do at OHSU is we measure the base with for the chest. And then we add that to the, and we basically take that divided by half and add one or 1. 5 centimeters. And that gives us our new nipple to IMF distance. And that's how much we drop that in order to calculate the type of implants.

And I think that the other golden pearl that I've learned is that. Better to order every single implant under the sun. So that way it gives you a real good opportunity of seeing what best fits that patient, despite, you know, the changes that happen with estrogen supplementation. Certainly there.

Sometimes you just can't predict what skin is going to stretch out and how much of it you're going to actually get from a projection

standpoint. And so I always encourage that anyone who's doing any kind of GABA or gender affirming breast augmentation order more implants that they can ever suspect they'll need because it's better to have it and test them out.

I've been surprised More numbers than I can count with my fingers to get patients results that I never anticipated with implant sizes or profiles that I didn't expect. I have a quick question, follow up question. Do you feel like you have to use higher profile implants for patients or is it kind of just variable depending on the skin quality?

I actually find that over 90 percent of the patients that I treat are better suited with a low profile. The skin of the nipple areolar complex is so much more pliable than the remaining skin that naturally as pressure builds behind that mound, it'll tend to create a more herniated effect and look.

And so in addition to that, you know, because the skin It does improve significantly with

estrogen, but certainly there is still some restriction there. I find that the patients look more natural with a wider base that gives them cleavage while still centering the implant. But at the same time, avoiding that sort of her needed look of the central mound.

So I can jump in with an area that maybe some of the listeners may or may not have as much familiarity. So the head and neck, you know, there's rhinoplasty, there's going to angle reduction, the mandible angles, there's cranioplasty really common procedure to remove some of the large frontal bossing, that big bar kind of, bony protuberance that comes out from the frontal bone.

Making the eyes look kind of caved in. But while that might not be entertained by all of the listeners, there's certainly a lot of overlap with The neck Adam's apple reduction in feminizing surgery. The really beautiful thing I think that

many of us enjoy at our multidisciplinary institutions is the ease at which that we can call a friend in and do surgeries together.

The world of. Adam's apple reduction can be a little divisive. There are those that seek to find the vocal cord attachments, the vocal folds, to make sure that you preserve that vocal ligament, that attachment, it's called Broyle's ligament. And that can be done through an LMA, you put any kind of a scope through it and then you place a needle through the thyroid cartilage and basically you're just trying to be really darn sure you know exactly where the Adam's apple anatomy is on the inside on the inner lamina from the outside before you take out some cartilage.

So I know that there's many people around the world that don't do this, and they take out Carlos, and they have successful outcomes but you know, in my team at the University of Wisconsin we just share a lot of our cases. We're fortunate to have great payers in our local area, and we have a plethora of clients.

patients and great patients to care for. So we we're booked out and we that, that promotes a lot of Hey, can you help out mentality between providers really seeking to get the best outcomes for patients. So if you find yourself at an institution and the patient asks you to do Adam's alpha reduction you don't know how to scope.

You don't know how to visualize the vocal folds. I think it's a wonderful way to collaborate with your or the laryngologist or really anyone who can perform laryngoscopy to be able to call on a partner. It's also fun operating with other surgeons and seeing other people, you know, do their approach.

So I think that's a really good thing. Great way to forge together these relationships. I won't, I really love the anatomy of the frontal sinus. I think it's so cool the way that the skull develops and some people have foramen for V1 and some people have notches and some people have well aerated sinuses.

But you know, that's the love of an otolaryngologist getting into the sinus world. So, I guess we each have that individual

passion, but it, you know, once we start getting to the neck and really a lot of probably what many of us do together is multidisciplinary. And that's kind of the cool overlaps that we share today.

And I'll add to what Scott's saying. I absolutely love the multidisciplinary aspect of this. I think operating with other surgeons is probably one of the most fun things to do. I mean, we always operate with our residents and the medical students, but when you have another person across the table who is an expert in their field and being able to do it together is just a ton of fun.

The, my, my part of the operation is probably the least extensive just because I'm only there for the robotic portion of it. So what I do is I assist with the robotic David off. The procedure was actually developed for those with vaginal agenesis and was adapted for those with vaginal stenosis.

And has now been used for primary PIV. So what I've been doing with some of the plastic surgeons here at the University of Michigan is working on some folks with who've already undergone primary PIV and have developed vaginal stenosis. And so my approach

to this is to really help do secondary surgery and allow for some vaginal depth.

Some of the benefits that people reported. And I know Monica, you do robotic vaginoplasty as well as that. My understanding, so you can probably speak to this better than I can about how you guys approach this, but my understanding of it was that the benefits of doing this was there might be potential increase in vaginal depth and again, for redo surgery.

And so I think for me as a colorectal surgeon being able to help utilize the robot in a minimally invasive approach that you don't have to have a big open abdominal incision is helpful. And if you know, if there's any question about. Potential rectal injury where those of us who do, you know, rectal surgery and don't want to see rectal injury or have to repair it.

It's helpful to be able to see it from the abdominal side of things. One thing that I think is super helpful about me being able to help do these operations that it's actually made me a better colorectal surgeon in general, because when I do the rectal cancer cases just being able to see it from the anterior portion.

So

those of us who do rectal cancer surgery, we typically go posterior before we anterior. And so this is just a, You know, when doing a robotic PIV surgery, you go anterior as opposed to posterior. And so it's just allowed me to be much more comfortable in both spaces and get into denambias and be more comfortable using the robot.

So it's been, it's one, it's been really fun working with other surgeons, but two, it's also helped me be, I think, a better surgeon. And Monica, I don't know if you have anything to add about doing the robotic approach for PIV. So, Monica and I when we did our fellowship we tended to split the case where the plastics team did the vulvar construction and the urology team did the intra abdominal portion of robotic vaginoplasty.

So, that dissection, you know, your anterior is my posterior. So, very classically. Akin to a robotic prostatectomy and then the perineal dissection is very close to a lot of what we do for urethral reconstruction and recto urethral fistula cases. So I think one of the nuances

with vaginoplasty is really skin management.

And there's this huge increase in folks who are coming in to talk about vaginoplasty saying that they want initial primary robotic vaginoplasty and kind of bypassing a lot of Using their own skin. So I think you meet different philosophies of surgeons and you really have to, you know, describe shared decision making and go through all the risks of all the operations.

But offering a robotic vaginoplasty as a primary surgery often means that you can't redo that to gain depth. And I think the literature has shown that. Despite initial depth of anywhere from 14 to 16 centimeters. Most folks lose some of that initial one to two centimeters because the parents name is actually rather sticky.

So despite adequate dilation the depth kind of all averages out. So I do try to encourage folks to kind of consider that if they undergo robotic vaginoplasty, they're burning a salvage method, especially in our younger gender folks who. I'm pursuing bottom surgery earlier, but in general, I think skin management is one of the really nuanced parts of vaginoplasty where, you know, you have to consider whether or

not they have enough existing genital skin, where could you get additional genital skin or even additional you know, abdominal or thigh skin or something else, or do you just jump to, you know, dermal substitutes which everyone has their own opinions of.

But I think that's one of the neat aspects of vaginoplasty when you really start getting into some of the technicalities of it. Amy, a question for you. With colonic vaginoplasty you know, there is a lot of discussion about what the surveillance is going to be, whether there's any inherent changes in the actual mucosa because of, you know, the lack of transit.

Do you We don't have any sort of protocol for these individuals we don't offer OHSU, but I know that, you know, I've discussed with several other colorectal surgeons and there's a lot of questions. Well, how do we monitor this? Yeah, so I would say it is, we don't offer colonic vaginoplasties at the University of Michigan either.

But I will say in thinking about the, and Andrew, please pipe in if you have any

thoughts about this as well, but I would say just because it's moved to a different place doesn't mean that we shouldn't continue the surveillance. If you are so right, average risk people now, the guidelines for colorectal cancer surveillance are 45.

And we know that. younger and younger people are getting colorectal cancer. And so if there's any kind of, and it's going to be different, right? Because if you're using this as a neo vagina, as opposed to your rectum, if there's like abdominal pain, weight loss neo vaginal bleeding, I think that should be.

red flag signs that should be evaluated. I, I don't, you know, those are for average risk individuals. So people without family history without red flag signs, they should, the screening shouldn't be starting at 45. And I think that's such an important thing, Monica, that you bring up is that we have to make sure that patients who are undergoing these operations are still getting the appropriate surveillance for for their cancers, their potential cancers, right?

Whether it be Colorectal cancer or anal cancer. I think those are still things that we need to be making sure that they are also at risk of developing these as well. And Andrew, I don't

know if you have any thoughts from a colorectal standpoint about people getting surveillance. I'm not familiar with anything about like the changes in mucosa as a result of it turning, you know, as a result of it being used not for colonic purposes or defecation purposes.

But Andrew, I don't know if you have any thoughts about that. I would agree with standard. screening. I'm not sure if anyone's looked at the risk of anal cancer from that. I mean, you are in theory kind of creating a neo squamous columnar junction when you're making that analysis. I would presume down to the skin.

I don't know if they've had any reports of transformation, especially since it's used for intercourse. So, I would be interested to see if they had anything there, but I think from a, I don't know, carcinoma standpoint, definitely. It would maintain the same surveillance, which I also think is really interesting just when seeing transgender patients, not from a gender affirming care standpoint, just ensuring that everyone is getting the appropriate cancer screening,

whether it be a breast, cervical, colorectal, I think, taking an organ history is really important for patients because eventually they're going to leave your care and other physicians and servers need to be treated.

Educated on how to take care of them as well. Yeah. And then to highlight the fact that, you know, the prostate still exists for people who undergo PIV surgery. So if you guys want to, I mean, I think that's a really important thing that we talk about as well as this cancer surveillance for prostate cancer, who in those who have undergone vaginoplasty.

So I don't know if you guys have thoughts about that, that we should be discussing. Yeah, I mean, there's some good literature that's come out that the risk isn't as low as we thought it was. Albeit, you know, timing of hormone therapy certainly does kind of change some of that risk. And so I think longer term data needs to come out on that.

And we know that, you know, the PSA cut off tends to be lower, which we'd prompt further evaluation. I think UCSF had a huge data series that showed that 14 out of Yeah. 10, 000 is

the number needed to identify or number of number of new cases that come up per year in trans patients. So often presenting with delayed diagnoses relatedly, I think, a couple of the things we were just talking about with.

You know, cancer prevention, cancer screening you know, WPATH Standards of Care 8 still recommends that vaginoplasty patients get vaginal exams, set of routine surveillance, and I don't know how many OBGYNs have felt a prostate before and so I, as a urologist, certainly always am welcome and happy to, like, see folks for their speculum exams, continue to monitor their prostate, I think just having someone who's familiar with their anatomy that's also going to be affirming is important, and so.

Making those long term relationships and training more people and providers to continue to offer that type of care is certainly, certainly crucial. And there are some case series that I've seen of HPV causing significant cases of squamous issues in vaginoplasty, but I haven't seen anything in the colonic setting.

And I think you bring up a really important point too. I

was actually talking, having a conversation the other day with a trans female who. Went for routine monitoring of prostate and they went to do and I think it highlights, right, the need for more formalized education, even at the med student level for affirming care in all respects of medicine.

So they went to basically do prostate exam and as would be kind of. Typical, they did a digital rectal exam and she said, well, you know, I think that if you actually insert your fingers in my vagina, it'll be a lot easier because right now you're going through three walls in order to feel my prostate, right?

And so it just kind of shows how much how important it is to kind of really familiarize yourself with the anatomy. And like Mike was saying, you know, how many OB GYNs have really felt for a prostate, right? How do we make sure that these patients are appropriately being cared for, whether it's for STIs, right?

And, you know, mucosal absorption is increased in the

rectum and colon versus vagina. So how do we kind of screen for that? HPV risk and the squamous cell case series that Mike was also talking about. So all these things are super important. It ties in that the fact that, you know, affirming care spans so much further than just As it pertains to gender affirming surgery and those things, right?

And we have to be very cognizant of that. Yeah, and I totally agree. I think you're absolutely right. It's more than just the gender affirming surgery itself, but it's also creating these safe spaces where people feel like they can come to a person, right? We know that there's so much discrimination that happens in our health care settings and how to, how, and I think part of it is like what Scott alluded to is having people have exposure is the more exposure people have, the more that they can educate themselves about what, you know, culturally competent care is and how to provide good care to people who may feel that they don't,

they are not welcome in a certain healthcare setting or in any healthcare setting.

So let alone trying to get healthcare screenings, or like cancer screenings, and then folks don't feel comfortable even coming into our healthcare settings. I think that's like barrier number one personally is making sure people feel like they're in a safe space to come see us. So for our listeners out there that aren't specialized in this area, who are taking call and still seeing patients, I think, I was hoping you can educate us a little bit on some of the more common complications that we may see from some of these patients after they've had some surgeries, and how we can best approach those situations so we don't make anything more worse than, than what it is.

I don't know how often this comes up for other people, but I remember always, like, fearing this, this, like, if you send home a vaginoplasty patient and they presented an outside ER completely, like, with bruised

genitalia, complications from their wound healing, whether they've had some separation or start having a little bit of bleeding This concern that an outside ER is going to look at their perineum and be like, oh my gosh, this is infected.

This is clearly necrotizing fasciitis and the outside pelvic surgeon is just going to start debreeding all of your work. And I think that comes from horror stories from other surgeons, but I guess it's happened. And so I think one of the things that I always encourage our patients to know as well as, you know, other providers in the community is just to know that that there exists means to communicate with us and get ahold of us if they have questions.

And there's always an after hours or an on call like line to help facilitate specifically our gender program patients. And then the other thing I'll say is, if you're really lost like one of the common things I think we get, especially post vaginoplasty is like, where's the urethra and is it safe to catheterize if you're really lost?

Just remember, we're we're placing the urethra where, you know, we think it should be in anyone with a vagina or vulva and so it should be underneath the clitoris. And I think that, you know, in

general, most folks find it. And maybe that's me, the urologist trying to avoid that. All right. Really 2 a. m.

Midnight to fully consult situation, but I think those are just some like minor things I think the the long term complications don't present acutely in the ER And it's really those early post op things. I think we tend to be the most fearful of it's off topic from the initial question But Mike I just want to just comment Watching some of the nurses place foleys makes some of the most seasoned, experienced nurses that have been placing foleys for 30 years.

It, it, there's something, maybe there's a little bit of a fear of the unknown or just unfamiliar or not wanting to cause harm. That you know, I think there's a knee jerk reaction of like, Ah, call urology! Or, you know, Plastics is operating down the hall, call someone who's done vaginal plasticity. But, you know, we say this from an education standpoint, but I think it's, it's really real and people don't want to cause harm and they're unfamiliar.

So even the idea of, like, a patient's having an elective procedure years, months to years after their vaginoplasty and and the unfamiliarity of a fully placement down the road Yeah, like, how do you educate the entire workforce on, on fully placement after this procedure is daunting. Yeah, we don't always call you what we, I mean, I think it's okay to call, like, asking for help is never the wrong thing.

And you should always, you know, we always kind of. Bulk at it, but we in the end, you know, show up and try and do our best. I will say one of the times that kind of like really frustrates me is when someone's had a falloplasty with urethral lengthening and the urologist doesn't could call to place that catheter and someone's just jamming in a catheter blindly.

And, you know, those are the settings where you're pulling what hairs you have left on your head and just like, what is happening? But I don't think that that comes up that often. And those are always the stories that kind of stick with us. Back to, I think the question that was asked, that was like major, major problems that are of a concern.

I think most

surgeons who do these surgeries make themselves available to, to take that call in the middle of the night to always be available and to answer questions because we care about our patients. And this is a space that like we are trying to offer a service that that kind of makes up for the fact that these patients have been without support for so long.

So I don't think picking up the phone and trying to get ahold of the surgeon or even whoever their partner is on call that can help is ever the wrong answer. And I would just encourage Megan to speak up because Megan's so close to the ER calls, being the trainee. And, You know, sometimes us faculty members lose our sense of things, but you guys, you're seeing things, the phone calls, the immediate things, and you just have a closer sense of this, whereas sometimes we take for granted what happens.

Yeah. Or even in the operating room. So what are you thinking from a trainee perspective? So I think kind of similar to what Mike was saying you know, I think a lot of, I think all of us probably see patients that travel many hours and I

think not only for us, and I will say too, we also probably see patients that had been operated on by different surgeons.

I think, you know, especially being a center that does gender affirming surgery, being available to answer questions you know, seeing patients, I think, like, sometimes there is confusion, especially for vaginoplasty, particularly if patients have been seen by another surgeon who should get called.

And so just being available, being able to answer questions, trying to figure out things for patients. I would say importantly for general surgeons and people taking trauma call, I think one really important point is that you can't necessarily have this Premature diagnostic disc like closure, particularly if a patient has had a history of gender affirming surgery.

If they're coming in for abdominal pain, you can't necessarily assume that it's because of their gender affirming surgery that they had. So really being able to take a complete history and physical ruling out other acute issues can be going on, I think is super important.

I was going to say, I think that sometimes the biggest harm that's done is as a result of assumptions.

So individuals have, you know, just because they've had some form of affirming surgery does not mean that they've had every single affirming procedure that is congruent with whatever that binary or non binary, for that matter, identity may be. And so I think that we. We, we really kind of contribute to harm where patients lose trust, especially if they're going to a center where the affirming care isn't there, right?

If, if they're coming back to your hospital, then it's very low likelihood that they're not going to call urology or they're not going to call plastics. The problem is when they've driven for hours, now they're kind of post op enough where they might still be having an issue. And again, it may not be pert It may not be associated with their gender affirming procedure, but certainly they're going somewhere else, they're misgendered, they're ridiculed, they're humiliated in

front of everyone, and then they leave, right?

They don't trust the system, they don't think that they're going to care that they need, and I, and I think that we really fail to mitigate the harm that we cause by assuming that either they've had, you know, genital affirming surgery or they've had other interventions, I think that there's a huge gap to close there.

Well, I probably could talk to each one of you for hours about all the nuances of, of what you do. But just to wrap things up a little bit, I was just curious, where do you see the future of gender affirming surgery and what are we doing to make progress in this field? I think one of the big things that is continuing to present is, more community based and community led discussions and really getting at outcomes from the community's perspective. And a lot of that research is happening at places like OHSU where assessments and community needs are ascertained and then put forth

by members of the community and really letting their voice guide what we do as opposed to us imposing what we think we need.

So, And I think that's extremely important, and I hope that that type of patient reported outcome and quality research continues to blossom. I think another important thing is just the advancement of education in this field. The creation of formalized fellowships that I think will really standardize training particularly, you know, fellowships that allow people from urology, otolaryngology, plastic surgery to work together and learn from each other, I think will really help advance the field and hopefully provide better care to patients across the country.

Well, I just want to again thank you all so much for being on here tonight. It was such a pleasure to hear all of your different perspectives and I think all the listeners that in all levels of their career will, will get a lot out of this. And again, really appreciate your time and thank you again

to Behind the Knight.

This has been really, really fun and we really appreciate from all of us at AOSA. Thank you again.