In this interview,
Caroline Cox, MD, discusses gender confirmation surgery, as well as the health disparities faced by the transgender community, and how doctors can begin a treatment program for patients before surgical intervention.
Related Links: Dr. Cox' physician profile
Welcome to the podcast, Siri's from the specialists. A pen medicine. I'm Melanie Coal, and I invite you to listen as we discuss gender confirmation surgery. A pen medicine Joining me is Dr Caroline Cox. She's an assistant professor of clinical obstetrics and gynecology at Penn Medicine. Dr Cox, it's a pleasure to have you join us today as we get into gender confirmation surgery before we do that, tell us some of the medical ills and health care disparities that transgender people face. Sure, I think this is a really important issue to highlight. Aziz, transgender and gender nonconforming patients have faced a lot of discrimination not only in their general lives but especially in the medical field. So we have a chance to really step up as providers and and combat these disparities here. But traditionally, studies have shown that transgender and gender nonconforming patients have faced discrimination and health care. They have faced really sometimes completely unprofessional behavior from providers who, you know, maybe just don't understand, um, what they're facing as transgender patients or don't know really the right words to say so. All these interactions can lead to these patients, then avoiding healthcare and potentially not getting even the basic screening tests that they need are the really basic medical care that they need. Thank you for that. And Dr Cox, you specialize in Euro Gynecology, which includes gender confirmation. Surgeries tell us a little bit about the training necessary to perform gender confirmation surgery. What's involved. So right now, thes surgeries are really not done by, ah, very large number of providers. And I will say, to be honest, most Euro gynecologists are not trained in general confirmation surgeries. I happen to go to a fellowship training program at University of Michigan, where there was, ah, large, well coordinated center for transgender care. And so we have a lot of transgender patients, and I commonly performed thes surgeries in my fellowship. And that's how I learned on. I think that's how most surgeons are learning these days are from kind of more like mentorship apprenticeship type training programs, But the training is really, very depending on what type of surgery it is So focusing on the type of surgery I do as a Euro gynecologist, Um, it really coincides well with the typical Euro gynecology surgery I do, which is vaginal surgery, because the type of gender confirmation surgery I do is called vaginal ectomy, where we d epithelial eyes the vagina and then close it off. So, Dr Cox, in addition to comprehensive understanding of the procedures hormones, other risks involved in gender affirming surgery tell us some of the other steps that you feel are important to note for providers that must be accomplished before these surgeries can take place. There is an organization called the World Professional Association for Transgender Health, or W Path, that sets out the minimum requirements for surgical intervention on individuals who want to have gender affirmation surgery. It is quite a long list of requirements and most well trained surgeons that you know I'm familiar with. Follow these recommendations and I do as well. But it involves the age requirement being the legal age of majority, having a persistent, well documented gender dysphoria. And it goes on from there. And some of the requirements include letters from mental health providers as well. So thes these air very, very specific prerequisites for this type of surgery that we essentially as the providers just follow what the W path tells us. So then tell us how complicated the surgeries are and what's involved. Give us a brief overview off the LGBT Q program at Pan Medicine and really tell us what you're doing with patients. Sure, so the LGBT Q program at Penn Medicine is really evolving and the group that is working on it, we actually just met a couple of weeks ago virtually and have been talking about how we want to go forward. And we really do want to grow the surgical options here a pen and make it a Mork coordinated effort. Easier for patients to navigate. So that's where we are in the process of at Penn. And it's a lot of different specialties working together, which is always exciting to see and no matter what area it is, but personally the type of surgeries I do, as I mentioned before this pageant ectomy and I also do as as many other gynecologist will dio his direct me and a sofa wrecked me for people assigned female at birth who are transitioning to mail and for this type of surgery, The hysterectomy in the old for ectomy is is pretty bread and butter for for O B G. Y N s, um, typically for us. A pretty simple surgery, removing the uterus, tubes and ovaries. And then the Vagit act to me is the more specialized part that I am trying to dio. And it does sound simple when you just think about it, of just removing all the epithelium from the vagina and closing it to remove the dead space. But technically it is challenging, typically because thes are individuals with very narrow vaginas. Very long vaginas, which just technically makes the surgery more difficulty. And often the effective testosterone on the vaginal epithelium is that it becomes very fragile terrors very easily, so it's a bit tedious to remove all the epithelium in this case, and traditionally the surgeries have been rather bloody as well. So over time we've worked on strategies to reduce the blood loss associated with these surgeries and had really, really great success with some of these techniques. Doctor, and this is such a really fascinating topic. Tell us a little bit about the follow up for the patients, since surgery isn't the only aspect, and we mentioned a little bit of this in steps involved in pre surgical work up. What are some important things to note for the patient. What kind of support do they need as they transition? And after surgery, the patients really do needs important, and I really believe that all transgender care needs to be interdisciplinary for it to function well as a surgeon, I'm not involved in prescribing hormones for transitioning, but I have to work with providers who do prescribe those hormones to give that aspect of care. Of course, the mental health aspect of care. Um, and then some of the surgeries are done by really, really desperate types of surgeons as well, so patients will often get chest surgery. In addition, Thio genital surgery they may get facial surgery. Thio change the look of their face. They might get voice surgery to change the tone of the voice. So it really involves a lot of providers working together, and that's exactly what we're working on here. A pen is trying to create the optimal way for that to happen, for us all, to talk, to share our patients, to make sure they're navigating through the system with some type of assistance and trying to make that easier for all of them to make the experience better for the patients. Well, it certainly is a multi disciplinary and interdisciplinary approach. So tell us about an experience you had with the patient and their choice to undergo gender confirmation surgery. So there is one patient that really stands out to me is having a big impact on me. And this was a patient from when I was at University of Michigan, and this patient had traveled from out of state toe, have his gender affirmation surgery. So he was born female at birth, but living as a transgender man. And he had already had his hysterectomy but came to us for his oh fer ectomy and vaginal ectomy. So we were planning to start the surgery with the laparoscopic Ofer ectomy and then planning Thio do the vaginal portion of the surgery with vaginal ectomy. And to us, this is a pretty standard surgery. We really didn't have any concerns, but essentially, as soon as we had started the laparoscopic surgery and we had insulated the abdomen, we put the laparoscope into the abdomen. He went into cardiac arrest, and I had never had this happened personally as a surgeon before, but myself and the resident that I was operating with immediately had toe start doing chest compressions on him, and the anesthesiologist had to call code. And the anesthesiology team was able to resuscitate him, uh, in the operating room and then brought him to the I c u to recover. And to me, this was this was a big of a complication, as I could possibly imagine during a surgery. But when I went to talk to him when he was excavated later in the day to talk about what had happened, really, all he wanted to know was, what can we do? My surgery tomorrow? And so that really hit me and just that To him, This is not an elective surgery. This is not a cosmetic surgery. This is an absolutely central surgery to his identity so much that he wanted to go back to surgery the next day after his heart had completely stopped. So it had a huge impact. Just solidifying the fact in my mind that these air really central surgeries for these patients. Well, that certainly does. And Dr Cox is we wrap up. Please tell other physicians which would like them to know about when you feel it's important that they refer to the specialists at Penn Medicine. And please reiterate the importance off this continuum of care for gender affirmation surgery. So I think that patients can be referred for really a whole host of reasons generally in patients who are already undergoing hormonal transitional care who are potentially interested in some type of, UM, genital surgery or perhaps a hysterectomy Oro for ectomy as someone who's born female. That would be a good person to refer, even someone who's just kind of thinking about the options and would like to know more about those options for gender confirmation surgery. I would be happy to talk to them. And if I'm not the right person, I can also help get them to the right person within this network that we have at the medicine. Such a fascinating topic. Thank you so much, Dr Cox, for joining us today and sharing your incredible expertise that concludes this episode from the specialists at Penn Medicine. To refer your patient to a specialist, please visit our website at penn medicine dot org's slash refer or you can call 877937 pen for more information and to get connected with one of our providers. Please also remember to subscribe, rate and review this podcast and all the other pen medicine podcasts. I'm Melanie Call.