Transgender and Nonbinary Affirming Surgery ft. Kayla McLaughlin, PA-C

Transgender and Nonbinary Affirming Surgery ft. Kayla McLaughlin, PA-C

***DISCLAIMER: KB ONLY***

This podcast is a series of interviews with medical providers, mental health professionals, community members and advocates. Each interview represents the opinions of the individual. Individuals may use different terminology than what you’re used to. The intention is to educate not discriminate, and we welcome positive and constructive feedback. Please keep in mind; this is not a replacement for medical care or advice. I am simply presenting my views along with educational information that will be both evidence based research and external networks that have an impact on LGBTQI and nonbinary health care. Consult your provider for any medical or mental health concerns. My name is Kerin “KB” Berger and welcome to Queer MEDucation!

***INTRO MUSIC*** 

***INTRO TO EPISODE: KB ONLY***

Welcome back to Queer MEDucation.

Special thanks to our friends Jessie and Cal from Salon Benders for joining us on last week’s episode. Salon Benders’ is more than just a salon. They believe transformation is an inclusive process affecting all gender identities. They draw inspiration from gender minority narratives and resilience. And guess what: they’re hiring full and part time stylists, cosmetologists, and barbers to lovingly serve our impeccable community. For more information, visit www.salonbenders.com/jobs

Transgender and nonbinary affirming care is a hot topic these days. There are many steps to transition, every individuals transition process looks different, and generally speaking, transition is time consuming and costly. So what are the procedures available for surgical transition? In today’s episode we talk to a physician assistant working in gender affirming surgery. Some of the information is, some might say…medical. No problem! Please visit queermeducation.com for show notes, which includes references for medical terminology, anatomy 101, and visual animations of each procedure,. For those completely new to surgical transition related topics, you may want to take a peak at the references first, so you can enjoy the interview even more. Please enjoy!

***INTERVIEW: KB AND KAYLA MCLAUGHLIN***

KB:                 Hey, what's up? It's KB. I have a very special guest today. I'm just going to let her introduce herself.

Kayla:             Hi, my name is Kayla McLaughlin and I am a physician assistant in southern California at Kaiser Permanente and I do gender affirming surgery, including complex bottom surgeries and facial feminization.

KB:                 How did you get into that work?

Kayla:             Actually, I kind of sort of fell into it, so whenever I was in my clinical year of PA school I did a focus on cultural medicine, so I modeled my clinical year to kind of go to a bunch of different minority groups across the United States and kind of study how marginalized populations sort of fit into the western medicine model. Uh, so I did pediatrics in Yuma, Arizona with kids who were children of undocumented folks or children that are undocumented. So a lot of, you know, meeting a five year old that's never had a vaccine or never been to the doctor than I did psychiatry and a Mormon camp in Utah. So how, like hyper-religious people sort of accepts psychiatric care whenever there's actual disease and pathology present. And Dermatology with migrant field workers and etc., things like that. So when I graduated, my mentor in PA school actually was already working at the LGBT Center, which is where I got my first job, uh, the Los Angeles LGBT Center. So my first job as a pa was in HIV research, which I didn't really know anything about, but it was a very nice introduction to medicine because it was sort of like a slow warm up to seeing patients; you know, you're seeing healthy patients and following a very strict protocols and not prescribing any medicine other than your study meds. So that was great. But I just really liked that work and I found it really interesting; and it had, it had never really dawned on me before that LGBT people were a group that were marginalized medically, that there was anything like special or unique about them in terms of medicine. So I did that for a while and then able was able to move up to the transgender healthcare program at the LGBT center. So basically doing primary care and like endocrine services and gynecology and things like that for transgender folks, which I loved that. And that was a great position to have and then a position came open at the place where I work now, which is Kaiser. Their gender affirming surgery team, so I didn't really have any surgery experience prior to applying and I almost didn't apply because I thought like, I don't have the basic qualifications for this job. Um, but I was the only candidate they interviewed the head trans experience. So I started there in February and basically started what would sort of be like a crash course in surgery since then. So it's a combination of basically cranial facial plastic surgery and urology.

KB:                 Interesting. Did your background in trans health have an impact on the, um, like the learning and teaching of the surgeons or did most of the surgeons have direct experience?

Kayla:             Yeah. So once they started the program, I think a lot of the surgeons definitely sort of went all in with learning all about the ins and outs of the surgery. Like they went all over the world and trained basically with anyone you can think of that was having good results, which was amazing. But in terms of having like being able to have a PA, who basically, they can have a shorthand with immediately in terms of the cultural competency, um, even in the interview that surgeon, uh, that I work with, she was like, you know, the surgery is the easy part that we can teach you. The experience of these patients is something that, you know, I can't, I can't say to you, I can't really, um, teach that to you. You need to just like having that experience. So I would say that yeah, there's, there's times where I'm learning from them and they're learning from me for sure.

KB:                 Yeah. I think that's amazing. I think as PAs we go through our clinical rotations, um, and really any medical professional or clinical training, we go through all the rotations. So we really have a wide range of medical experience, but nobody can teach you how to be culturally competent or compassionate at the bedside. And with our trans folks, it's just crucial because there's been so many negative experiences and that have directly affected their health care. So I'm sure they're grateful to have that program at Kaiser now. Do you miss doing general trans care or are you really enjoyed it?

Kayla:             I do! I feel like so by the time that someone gets to a surgical consult, they have had a many evaluations with their primary care and mental health and they're, you know, generally a very healthy person that's ready for surgery. So it's like a very neat and tidy kind of situation. Whereas, um, and it's something that they've, they've been looking forward to for a long time, but I feel like when I would meet a trans person, a trans patient for the first time and like, I'm the first person clinically that were ever like, really telling their story to. And I'm the first person who prescribed them hormones. I mean, I feel like that experience was so much more emotional for people and so much more. I mean this is still very emotional, but it's like they've been in this process and their transition for a long time at this point. Whereas whenever someone is like, you know, 70 years old and has never told someone any of these things and then, you know, they're saying that to me. So I do miss that. Yeah.

KB:                 So, um, tell us a little bit about the surgeries that you all perform.

Kayla:             So the surgeries that, uh, I am a directly a part of, so there is our complex bottom surgery programs, so that includes vaginoplasty and there is a full depth vaginoplasty and also a zero depth vaginoplasty. And then we do phalloplasty, which is a stage procedure. So that's where of an umbrella term that includes all the way up to the, uh, you know, graft of getting the phallus put on, um, and then the steps prior to that, which is a metoidioplasty, the clitoral release. Um, folks can also have a combination hysterectomies and oophorectomy, uh, during that procedure. And then I also help out with the facial feminization surgery.

KB:                 So what is your role as a PA, on, in the surgical team?

Kayla:             So for our surgical team, the reason that they needed a PA or, or saw a PA out was that the surgeons have their other specialties essentially. So, um, our surgical team consists of craniofacial surgeons, plastic surgeons and urologists that have their other practices. So when we would have, there was no like consistent medical person, like they're waiting for in case there was questions or complications or anything like that. So I'm sort of like the steady state that's there, you know, 8-5 throughout the week. So we have clinic two days a week that I, I support that clinic with the surgeons were patients come in for their surgical consults, pre-ops and postops. Um, I assist in the OR two days a week, um, and then help with like admitting the patient, doing the pre op orders. For the patient while they're inpatient, I manage their care also. So any, um, and, and you know, some of our patients stay for two days and some stay for like, seven days. Um, so managing them and then also on Fridays I have my own clinic where it can kind of be just like anything and everything. So checking both hair status below before they can get a vaginoplasty, counseling patients, just any kind of difficulties they might be having post-op. We do a lot of sexual health and sex education, so that kind of stuff. Yeah.

KB:                 Cool. So it sounds like you kind of have your hand in so many different pots and

Kayla:             Yeah. Everyday it's kinda different.

KB:                 Yeah. That's fun. Do you like surgery?

Kayla:             I do. It can be intense. It's uh, it's, it's hard because it's like it's intense and also not, you know, it becomes very routine. The surgeons you work with also set the tone of the room and everyone that I work with is very chill. We're able to like, it's always a teaching moment or you know, there's never like a. I know like I just remember in rotations like hearing horror stories from some of my peers were like just get screamed at by surgeons and stuff and this certainly isn't the vibe here. So yeah. Yeah, I like it.

KB:                 I did one rotation, I trained on the east coast and my surgery rotation the first time was like: I walked into the ER or in the OR, and the nurse just basically yelled at me for no reason. <LAUGHS> And then I did a rotation in, um, in Houston, Texas and everybody clapped when I walked in the first time. So I think there is a sense of like chill vibe on the west coast,

Kayla:             Yeah, definitely.

KB:                 So, tell the listeners a little bit about what makes somebody a candidate for surgical transition.

Kayla:             So for someone to be a candidate for surgical transition, we basically follow the guidelines set forth by WPATH. So someone who is in the process of transitioning is in care with a primary care physician, has been evaluated by mental health and gotten mental health clearance. And depending on the surgery, sometimes you need one letter, sometimes you need two letters. So one letter surgeries. and this is a letter of support from a mental health professional, so facial feminization surgery and top surgery required one letter whereas a hysterectomy or the. I'm sorry, the phalloplasty and the vaginoplasty required to

KB:                 And when you say separate, do you mean two separate, um, clinicians?

Kayla:             Yes, two separate, separate clinicians. Um, but they can get the letter after one session so it's not someone that they have to like have been in care with for a long, long tIme.

KB:                 Okay. When you say mental health professional, just so the listeners are clear, is that a psychologist, a social worker or a psychiatrist?

Kayla:             So it'd be any, any and all of those. So we have LCSW and there are psychiatrists and psychologists, so anyone. So if the patient has a prior relationship with a mental health provider, that person can certainly write their letter. And basically, all they're evaluating for any preoperative depression; um, if someone is in a situation financially to be able to take the time off of work; if the home they're going to post operatively is safe and clean for them to recover and things like that. Um, so it's not really like assessing their "transness" and making sure that like surgery is the best goal for this patient at this time. And not even saying that it's not. If it's not now that as, it won't be later, but yeah.

KB:                 Yeah, no, but I think it's really important to kind of bring that point up that the letters to me, sound like they are only to benefit the person's success post up. And sometimes, yeah, if you don't have good care post-op, um, if you're not financially stable to not be in work, I mean surgery is a big deal for anybody regardless of what the procedure they're going through. So I think that's a really good point. Does WPATH require that, like, in their protocols?

Kayla:             So it's um, it's different for... So for facial feminization surgery there's actually no guidelines. They leave that very open ended I think intentionally because that is a very sort of vague and subjective sort of, um, surgery, surgical approach, transition. Whereas for bottom surgery, I believe that two letters of recommendation along with one year of living in that gender, those are, those are pretty much requirements. Hormones are also a requirement. But if you read the fine print WPATH they say that if the patient is unable or unwilling to take hormones, then that can be a requirement that is not fulfilled and they can still proceed with surgery. So someone who has a history of blood clots that is not going to take estrogen, that doesn't mean that they can never have a vaginoplasty.

KB:                 Interesting. I think with top surgery, like why path kind of change things the last tIme they revised to say that you didn't necessarily have to be on hormone replacement to get top surgery.

Kayla:             Yes, which is a great point because what happens is if somebody, for example, has a very large chest and then they start taking testosterone, we know that the effects of testosterone are pretty immediate and apparent. So their social transition becomes very difficult if they're growing a beard and a very deep voice and they still have very large breasts. So in order to make it easier for this person, we can do the top surgery first and then they can start the hormones if they, if they choose to.

KB:                 Okay. So that's kind of an option and part of the evaluation?

Kayla:             Yeah.

KB:                 Oh, that's great. Yeah. And plus it probably decreases the time period that they're binding and hunching...

Kayla:             And in addition there are, you know, that also helps with nonbinary folks who might not ever want to take testosterone that definitely want to have top surgery and should have top surgery. So I think eliminating that requirement. Um, it was very insightful.

KB:                 What does pre-op involve besides the letters? Any other medical workup?

Kayla:             -Yeah, so pre-op, whenever the patients come for the consult, pretty much all of their labs and everything are already taken care of. So they have to have been seen by their PCP within the last year, had a physical exam, labs, if they are on hormones, those hormones have to be within a therapeutic range. Um, so for estrogen less than 200 and for testosterone; I forget what number is it? I think it's 500? Something I should know. <LAUGHS>

KB:                 We'll put it in the show notes.

Kayla:             Yeah, yeah, yeah. Um, and uh, so, but in any other medical conditions that they have, um, medical or behavioral health issues have to be, um, well controlled. So if someone also is diabetic or hypertensive, those things have to be under control or at least, um, you know, they're working on it with their PCP. And then, so, because what's interesting is, from the time of consult to the time of surgery, it's sometimes like a year later, um, because when we see patients for vaginoplasty specifically, they have to start electrolysis essentially after that. So one thing is that you get the referral for electrolysis or electrolysis is covered for vaginoplasty because we can't have any hair growing inside of the vagina; and that process takes about nine months to a year. So we used to tell patients about six months to have all the hair cleared, but we've found that it's taking more like a year for that to happen.

KB:                 How often do you do the electrolysis? Every four to six weeks?

Kayla:             So we, the hair cycle is about every six weeks. Um, but people can go once, you know, people go once a week for like four hours or once a week for one hour every two weeks. Yeah. So it's kind of up to the person and their schedule and the electrolysis is not, it's, it's quite painful. So kind of how much someone can tolerate in one sitting. Um, because they can use like a lidocaine topical but if they want to buy injections from the electrolysis place that they go to, it's like, I think it's $100 a session. So yeah. So it's really, it really depends on the person's time and availability and tolerance.

KB:                 Right. That's a great point. Is there a particular age recommendation or requirement for any sort of gender affirming surgery? Do you know?

Kayla:             No, I think that, well I believe it has to be over 18 for the vaginoplasty and phalloplasty. That could change. Yeah. I know for top surgery we've, we've done some and there have been some done for teenagers.

KB:                 Yeah. I think it's going to be really interesting to see the evolution of pre-pubertal transition and how that's going to affect the need for surgery and the overall success of the surgeries in the future. I think it's going to be...

Kayla:             Well, one interesting thing is that um, so someone who starts a transition pre-pubertal, pre-puberty, so we do have penile inversion vaginoplasty and that's, like, the most common technique in United States, where you basically use the tissue from the scrotum and penis and invert that to make a vagina. If someone has been on blockers from before puberty, that skin kind of doesn't exist. So I mean if it exists, but it's not in, it's not enough. So we'll be using a lot more, like, graphs. There's also the colovaginoplasty, which is whenever they take a piece of colon that has sort of, you know, people don't really do that anymore because then you get into like an abdominal surgery that's just whole other can of worms. But that might be like the most viable option for someone who doesn't have a, the penile skin change. It might change those things

KB:                 For sure. Yeah I think it's just so fascinating, like, where medicine's going to go in this particular field. So since you kind of started talking a little bit about gender affirming surgery, I'd love to hear more about a little more in depth about vaginoplasty and maybe just kind of the steps during the surgery...

Kayla:             Sure. So, uh, like I said Before, we do a penile version vaginoplasty. And what that means is that we basically deconstruct the tissue that already exists and reconstruct it, eliminating some of the parts that we're not going to use. So one of the first steps is essentially degloving the penis, so taking the skin off and then we have the components of the phallus which are the erectile tissue, the urethra, the neurovascular bundle, which is on the dorsal side; so if you were standing up and looking down at the penis and scrotum and testicles. So the first thing is that we're going to take what's called a scrotal cap, so we take like a diamond shaped piece of skin off of the scrotum and set that aside because we're going to use that later and I'll get to that in a minute. Um, and then we basically do the orchiectomy, which is whenever we remove the testicles. So that is a permanent part of the procedure. Once someone's testicles are, like, in the dish, then they are no longer able to have biological children. So patients are council about making sperm and stuff like that beforehand. So then once we have done that, we're going to deconstruct the components of the penis. So we're going to take the erectile tissue. Um, so the bulbospongiosus muscle that we don't need to, that won't be needed anymore postoperatively and that's really kind of the only tissue that's like straight up discarded. So we take that and then we shorten the urethra. So the urethra has to be put into a position where when someone sits down, the urinary stream is going to go straight down into the toilet as opposed to like forward or backwards or to the left or to the right. Um, so we shortened the urethra and then we have the long skinny strands of nerves that are basically what's the neurovascular bundle. And this is hard to like describe with only audio. I'm like using my hands, but I know no one can see me. <LAUGHS>. So you have the long skinny strands of nerves and blood vessels that are attached to the body and we'd never disconnect us from the body because then they would not, you know, be of any use. So. and they, so it's sort of like you have like all these like, um, nerves that go to the end and the glans. So we have the head of the penis and sort of remains as it is. The head of the penis at that point is then cut down and folded in a way to look like a clitoris, and then we sort of just bundle those nerves up and put them in place where they should be. So the clitoris is a pinpoint area of erogenous sensation that when you're standing up and with your legs together, it can't be seen from the front and if you're sitting down, you're not sitting on top of it to cross your legs. It's not something that she'd be like bulging or too sensitive. So we put that in the correct position and then the skin that is basically under the corona of the, of the glans becomes labia minora. And then the remaining tissue from the scrotum becomes the labia majora. So to create the actual vaginal space, we go anterior to the rectum and posterior to the bladder. So we're in this very tiny space that really kind of doesn't exist, but we make this space and the depth of this space is very much dependent on that person's anatomy. And so within the pelvis you have the organs that I was just talking about and then superior to that is the, um, the peritoneum, so you have like the peritoneal reflection and inside of that cavity is, like, the guts, so we can't break into that space essentially. So the length of someone's vagina is dependent on how long their pelvis is, essentially. So someone who's like 6'2" will have a longer vagina than someone who like 5'3", but they... That's my baby crying. <LAUGHS> But what they, um, they all are relative to that person's body size, if that makes sense. So that part of the surgery is pretty much like the major part of the surgery because that's where like some major complications can take place. So what you don't want to do is go into the rectum, obviously. You would make a rectovaginal fistula. If that happens in intraoperative, that can be corrected In the moment where they will just use some tissue to kind of cover that hole that they've made. And then on the anterior side going into the bladder. Both of those things are very, very rare complications and happen less than one percent of time in surgeons that do this all the time. So once we create that space, we then take the skin that is still attached to the mons, where the skin that came from the penis and we, so that scrotal cap to the end of it because you basically have like a straw, but we needed to have a cap at the end of it so you don't have like an open ended vagina. So we, sew the half to the end and then we kind of like flip it inside out like a sock and then pull it down, put it into that space. We then pack it. So we put gauze that's impregnated with a lubricant and bacitracin into that space to get the skin to attach to the walls, the raw skin that's inside that we made the space. Um, and then we put a catheter in the patient. They have two JP drains in the mons that go down into the labia to drain any blood that could still be coming out post up. And then we sew the labia shut. So it's a pressure dressing, so everything, any bleeding is coming up and out as opposed to like in the labia. They keep their prostate, which is important to note. So, um, if you, so the bladder, the ureter or the urethra goes through the prostate. So if you take someone's prostate, especially a young person or anybody, they're going to have incontinence issues which can very much affect a person's life. So it is better to leave the prostate in place. Um, so we remind people all the time that, you know, many, many years from now, whenever you are no longer our patient or maybe like, you know, you don't, we don't have the electronic medical record, it's important to remind your providers that you do have a prostate and the prostate exams can be done through the vagina. So the prostate will be anterior to the vaginal wall, to the anterior vaginal wall.

KB:                 And, generally the prostate, if, if their own hormone replacement it will get smaller over time, but it doesn't mean they don't need a prostate exam to assess for any cancers or growths or irregularities.

Kayla:             Yeah. So prostate exams are important. And also PSA, so I, I believe that like the last time I looked, there aren't many cases of trans females that are on hormones that get prostate cancer and if they did get prostate cancer it would be a particularly bad one because that means it would have broken through all of that estrogen.

KB:                 Right.

Kayla:             So we're interested to see down the road how, how surgeons will approach prostate removal and stuff like that with someone that's post op.

KB:                 So then they're hospitalized for a couple of days?

Kayla:             They stayed for seven days. So for a lot of folks, this can be for different medical centers, um just want them to be nearby because if there is a complication, especially if you know California, I mean people drive very far to get to their medical centers if you know, if you're in like Philadelphia or something where, you know, people live in the city. But we have folks that are like two or three hours away. So we just have them stay to keep them comfortable, um, to just kind of monitor them. But I will say for the most part people are pretty bored because they're not in pain, they can't really see anything that happened in the surgery because they have like all this bandaging and stuff on and they've been off of their hormones for about five weeks at this point. They're like coming down off the anesthesia so it can really be a tough time for people while they're in the hospital. That's why we recommend the people that come in to support you, make sure that they're people who are actually supportive and don't stress you out. And uh, we have uh, a social worker on our team who sees the patient every single day and just as a support system for them. But yeah, so they go home on the seventh day, Day 6 is where whenever we take out all of that stuff. Um, so the catheter and the packing and the drains and all that stuff.

KB:                 And generally, how are people feeling?

Kayla:             They feel great. Yeah. So those are odd sensations, like to get a catheter removed and the vaginal packing out and all that stuff, especially on a site that was operated on. I think a lot of people, if you think about like when people wake up from plastic surgery like on tv shows and stuff where it's like, you know, they're in so much pain, it's not, it's not quite like that. So yeah, when we take out all that stuff people are very relieved because it's just a lot of stuff to have. Like we have the drains and the packing and the catheter and you know, a lot of times like they haven't had a bowel movement yet, so it's, it's very relieving to get all of those things take.

KB:                 Everybody on the surgical, the med-surg floor or the surgical ICU is trained in competent trans care and GNC care?

Kayla:             Our actual entire medical center was trained. If you work in the cafeteria, if you are, an environmental services, every single person was trained in a trans care. Yeah.

KB:                 Awesome. That's great. I mean the hospitals in general can be very triggering places for people, so it's great to hear.

Kayla:             Yeah. Yeah. Especially because there's difficulties, there's unforeseen things that come up, like how do you identify as transgender patient in the hospital without like putting a sign on the door, like there's a trans person in there, you know what I mean? Like you want everyone to know without being like ridiculous. Um, and then complications or difficulties with the electronic medical record, you know, it's like difficult to have someone's preferred name and in their chart or if they haven't been able to change their gender yet. Like if somebody even from even something that's like delivering a food tray doesn't know that people on the phone and things like that. So. So those are things that we are actively brainstorming kind of all the time.

KB:                 I mean, do you get feedback from patients post op?

Kayla:             Yeah. Um, so everyone has, I mean seems to have a very great experience. But there, there's just time sometimes when people are, are mis-gendered, not by someone on purpose. It's just those things that kind of happen. So for example, if someone from the cafeteria calls the patient and someone answers the phone, they and you know, people are trying to be very polite and you want to say like sir or madam and things like that. So, but yeah, so people give us good ideas of like, hey, maybe maybe like just don't say sir or don't say don't say those things whenever you're on the with a patient.

KB:                 Right, right. Yeah. After they leave the hospital, when you see them next?

Kayla:             So then they come in and about a week later for their first follow up where we were just kinda take a look and see how they're doing, see the, assess the swelling or how their urination and stuff like that is going. And then also dilation. Um, so they have to dilate the vagina postoperatively. And so we just ask to see or ask them how that's going. It's kind of, we don't do any kind of internal exam for a few weeks, so we let everything heel inside.

KB:                 Tell everyone out there about dilation and how important that is.

Kayla:             Yes. So dilation is essentially whenever...so someone who comes into the hospital and has a vaginoplasty surgery basically anywhere will be given a set of dilators and dilators essentially look like dildos, they are like along phallus-like structure or device that is used to keep the vaginal canal open to the depth that was achieved during surgery. And then to also help to widen it. So there are dots on the dilator. So that's also like a tool of measurement. So the very first time the dilator is inserted into the patient is by either one of the surgeons or myself and we put the dilator in and basically assess depth of someone's vagina. Um, and then that is the depth that they need to get to every time. So someone inserts the dilator, um, into the vaginal canal and they hold that there for 15 minutes to the back wall of the vagina. So basically like pressing, pressing that in. Because if the vagina is not dilated it will tend to close. And if a vaginal canal, if a neo vaginal canal closes and a neo vaginal means postoperative like uh, um, and that term is actually used for like cis females who were born without a vagina. If it closes, it's very, very difficult to open that space, if not impossible. So dilation is very important. There's a schedule so they kind of move up in the size of the dilators over time. So dilation in the beginning is with a smaller dilator, but it's less frequent. And then as time goes on they dilate less with a larger dilator. We do know that there are post op trans females out there that don't dilate, that were never told to really and their vaginas stay open, but sometimes they don't. And we also know that sometimes people can substitute where they do substitute sex for dilation. So if they have intercourse, typically intercourse is not like 15 minutes of sustained pressure to the back wall of the vagina. <LAUGHS> So it is a little bit different. and also like maybe the partners phallus isn't the same size as the dilator and things like that. So we don't really know if, you know, if people don't dilate, will their vagina 100% close? We don't know. But we just tell people that's, that's what we strongly strongly, strongly recommend

KB:                 Right because what we do know is dilation can have a better outcome essentially.

Kayla:             Yes, yes.

KB:                 For, and that's all because you know, the type of surgery, you're essentially, the inside of the vaginal canal is skin. So if you just think about how skin heals, there's a healing process and scar tissue is going to form and scar tissue tightens up. So it makes sense. Awesome.

Kayla:             We have the, uh, the pelvic floor muscles which are very strong. and cis-females we can have some times where people have painful intercourse or pain with going to the bathroom and things like that. So I actually recommend to our trans females, like things like kegels and stuff like that are actually not a great idea because the key to a healthy pelvic floor is learning how to relax the pelvic floor. So not squeezing around the dilator, not tensing whenever you're having intercourse and things like that because then they're, they're basically like occluding part of the vagina,

KB:                 Right, because they're increasing the capacity of the pelvic floor muscles essentially. Interesting.

Kayla:             Exactly.

KB:                 And then um, how many other post op appointments do they have?

Kayla:             So they stay with us for about a year after surgery and that's just, it becomes pretty routine. So it's kind of come in and we do just a regular checkup and then I'm like a warm handoff to gynecology

KB:                 And gynecologists are also trained at where you're working. Can you tell us a little bit about some other procedures for male to female gender affirming surgery.

Kayla:             Um, so for male to female there is also a facial feminization surgery. And facial feminization is an umbrella term used to describe many or a group of surgeries. So typically what we're talking about was when you want to feminize someone's face, you can divide the face into thirds. So basically like the eyebrows up, nose, eyes and cheek, and then below the nose. So what tends to appear the most masculine in a trans female is the forehead, so the brow bone that is between the eyebrows and above the eyebrows and you know, of the eyebrows and can be sort of pronounced. Someone's nose is typically not gendered. Um, people who are female or male can have bIg small noses or like a bumpy nose and things like that. So that's usually not a part of feminizing someone's face. The jaw is something that can also be feminized. So the width and the length of someone's chin. And then also the pronounced angle, someone's jaw. So to do facial feminization surgery, the bulk of the work is in the forehead and the jaw. And basically to access the forehead we do what's called a coronal incision where we just go from ear to ear, like where a headband would be on someone's head. Um, and then, uh, to access the forehead to kind of take the skin down. And then that frontal sinus, we will either shave that down with like burring or you can do what's called frontal bar setback where you essentially like make the frontal bar a little bit smaller and then recess it back into the space. So essentially you just make beforehand smaller, less, less pronounced. So what some people have said post op is like, wow, I really have to wear sunglasses all the time now because I used to have like this covering over my eyes essentially. And so it really helps to feminize the face and the forehead. And then it opens up someone's eyes a lot too. Um, it really kind of opens up the face. And then with the chin, uh, it's, it's best to try to do like an intraoral approach, so through the couth, so there's no incision on the outside and basically either shaving or burring or like cutting the chin to make it less tall and less wide. And then we can also go to the back of the mouth and get to the angle of the mandible and then make that not quite as pronounced.

KB:                 From start to finish, of like pre-op to post up, how long does that whole process take? Several months.

Kayla:             Um, yeah. So not as long as there's no hair removal requirement or anything like that. It's basically just once the patient is definitely ready to go. And once their surgeon has availability.

KB:                 And you said that is covered by insurance?

Kayla:             Yeah.

KB:                 Awesome.

Kayla:             So that can be a little bit more difficult because, you know, with a vaginoplasty or phalloplasty, you're going from like, a to b. Whereas with a facial feminization surgery it's much more in the obscure sort of like what is a feminine face? Um, there are many beautiful women that have masculine phases. Uh, the purpose of the procedures not to be like a rejuvenating surgery, so we can't do and we know those facelift or anything like that involved. So it does, it does include some more like decision making in the abstract of what it means to have a feminine face or masculine face. So yes, but yes it is covered.

KB:                 That's interesting. And then what other procedures are involved that you all do? Do you do augmentation breast or chest augmentation?

Kayla:             I'm not involved with that. I know that the current guidelines are if after two years of hormones, if the patient basically doesn't have like a mammary fold where um, it's like they have less than A cup and that can be covered for breast augmentation to a certain size. Um, and that's why we always recommend that, I would say this to patients beforehand, like, wait, be on hormones for a little while before you go for we surgeries like that because you will face may change a little bit. Like obviously the bony structure of your face won't change, but your face may changed in a way that you aren't so bothered by certain parts of it or you know. Your breasts may grow and things like that.

KB:                 And do you do tracheal shaves over there?

Kayla:             Yes. Yeah. So that can be a separate procedure that someone can kind of do outpatient or can be a part of the facial feminization surgery.

KB:                 So really like this whole process can take anywhere from two to three to four years, depending on the insurance, the budget, um, having the right surgeon and access and what not.

Kayla:             Yeah. Yeah.

KB:                 But it's so great that you all have everything right there and that's what's great about, you know, going, knowing where you're going is really important for trans folks to know because there's only so many surgeons out there that have done many surgeries. So doing your research and talking to people in the community is super important when deciding where to get surgery, um done, location wise. Cool. Anything else about your experiences with gender affirming surgeries with, Um, trans females that we didn't talk about?

Kayla:             No, It's just such a, it's such a gift to be a part of the team that does this. And the reason is because one: the patients are so motivated and they're like the only walking into the hospital who who are about to have surgery that are like stoked, to be where it's like them and pregnant people are the only people that want to be in the hospital. So in that sense, it's like, it's great for me because I'm dealing with people that are like, they're very happy to see me, they're very happy to be here, you know, any boundaries or anything like that we had to serve in terms of like if they were a smoker, if their A1C was high, like they're on it and they participate in their care. And so I mean for me it makes my job pretty easy and uh, but yeah, that, that's just one part of it that's like, it's so, so great.

KB:                 Kayla was just saying about an A1C and smoking a high a one c is indicative of pre-diabetes or diabetes and smoking can completely constrict the vessels in the skin and both things can have a negative effect on your healing. So in any particular surgical situation you want to not smoke and um, if you can control your diabetes as much as possible, it will be ideal for your overall prognosis because, um, you'll heal much slower otherwise. So. Cool. Let's transition to the transmale surgical procedures for our trans men.

Kayla:             The current clinical options, surgical options for trans men include and not just where I am, but just sort of in general is a metoidioplasty, which is essentially the clitoral release, which can include a urethral lengthening and a vaginectomy with a hysterectomy, and oophorectomy, so and we'll go back to that in a second. And then also phalloplasty, which refers to actually having a phallus or penis created from a skin graft taken from your body and then attached to your body with nerves and the urethra and all that stuff. So with this surgery there's a lot more, a sort of more options and like boxes to check and things like that. So someone who wants to proceed with complex bottom surgery as a trans male, the simplest thing that they could do if this was what they wanted to do is what's called a clitoral release. So essentially detaching the suspensory ligament from the clitoris, which allows it to drop and grow a little bit further. So the clitoris will grow with exposure to testosterone to basically become a phallus. So a clitoris is essentially a phallus, but you're sort of limited in how much it's going to grow because it's held by a ligament place. So once we cut that ligament, it can become a little bit longer and I'm sort of drops down a little bit. Typically that is not enough for someone to be able to stand to pee because it's not going to project pee off of the body enough to get it into a toilet. Um, sometimes people have a very large response to the testosterone so that procedure would be enough. But for most people, if their goal is to stand to urinate or to have penetrative intercourse, then moving forward with a full phalloplasty, with a skin graft and everything is probably their ideal choice. So the steps included in that would be, so people can do like a staged procedure where they do that setup part where we basically do the clitoral part hysterectomy and oophorectomy to taking out the uterus and ovaries. And actually a trans male can leave their ovaries if they want to. They don't ever have to take their ovaries out, but to do the phalloplasty who would take the uterus and the cervix and the vaginal canal just because we. It would be very difficult to access them later if there was ever, you couldn't even evaluate them, really for cancer postop. And so doing the hysterectomy and then also a vaginectomy, so that is essentially when we take out the vaginal canal by either like cauterizing and closing it in that way and then lengthening the urethra. So the urethra where it sits in a trans male is centered and goes down into the toilet, the urinary stream. We now need it to kind of come up closer to the pubic bone. So we lengthen that urethra up to the tip of the phallus that was released with tissue from the labia minora. Yeah. It gets really complicated to explain, but basIcally lengthening the urethra. So if you want to lengthen the urethra, it's pretty much a requirement to also have a vaginectomy because you don't want this space behind the urethra that was just made because if there's any back flow or urinary issues then you have like this vaginal canal that's not, like, providing support for that new urethra. So there are some people who have like, I've heard of that before where people want to have their clitoris lengthened and to be a phallus but then also to keep their vagina so, but it's just for the best urinary outcome it would be to close the vagina, lengthen the urethra and then to the tip of the phallus. So that essentially lays the groundwork for the phalloplasty, that would be the second stage.

KB:                 How long do you have to wait in between procedures?

Kayla:             So, between two anesthetic events, if you can, if you have a choice, it would be like three months. Typically they say probably about like six months just because of scheduling and things like that and just make sure that everything was well healed. So yes, usually around that amount. So important to know is after that first stage, what makes this surgery a little more complicated is that there is what's called an SP catheter in. So all that area down below that we operated on, we don't want someone to be urinating through that space yet because the urethra is healing. So there is a catheter directly in the bladder, like coming out of where your mons is essentially and they keep that for a few weeks and that's how they train their bladder. And then once we know that everything, well is well healed below, then we'll take the catheter out and then they can pee from below And what makes it easier, so after you have a metoidioplasty it's a lot easier to use a stand to pee device than previously. Yeah. So people are very excited about that because even if they can't pee with their own organs standing using a stand to pee device is much easier. So. So people have had success with that.

KB:                 I know there's a little bit of controversy about like if people should have phalloplast. Is it ready? Is the surgery optimal? I know you know, friends of mine have really toyed with that idea. Can you tell us maybe a little bit about like the complications you've seen, the successes you've seen?

Kayla:             So complications are usually going to come from something urological. So it's basically bladder mechanics. If you think about the bladder of a trans male, the urethra comes basically a very short distance and it goes straight down. So now what we've done is sort of make it go at a right angle. It has to go up and then around two bends and then down the length of the phallus. So sometimes the bladder has a difficult time with that. And then also the urethra, there can be what's called the stricture, which is a narrowing of the urethra. And that can happen at any point where there was a connection and if that happens and someone is not able to get pee out of their body, then that's obviously not great. So essentially those kinds of things. So urinary strictures, um, so someone who is a, who is going to consider phalloplasty, it is more of an intense process. They have to sort of be very aware of what's going on below and if there's urine leaking from somewhere and to be ready for those complications, that they do arise. So sometimes people have had to have an, you know, just sort of historically multiple procedures afterwards where you could have loss of the graft and things like that. And then the graft site itself, you know, that's also a surgical site that needs to be taken care of and can be infected and things like that. So really sort of like having a good support system and someone who is really there to help you and drive you to appointments. Things like that is really important.

KB:                 Do you know the percentage rate of complication?

Kayla:             I believe that like for all phalloplasties that have ever happened, it's like 50% of the time there's at least one complication. And the good news is there's a lot of complications that are not a huge deal. Like you can have a small infection in like an incision site or where the SP tube is or you could have, you know, like a urinary structure that can just be dilated in an outpatient, in an exam room, things like that. Or you can have some major complications which would be, you know, a structure or a fistula, a urinary fistula and things like that.

KB:                 Yeah, any , um, positive stories like people who've been really happy with their procedures?

Kayla:             Everyone's very happy. Yeah. So even when people have complications, I mean it's something that they feel like they're very prepared for and that really shows how worth it it is for them. So people who are able to, one thing that we hear a lot is like I can go to the gym and I walk into the locker room and I don't have to feel odd about changing. I can just like use the bathroom and I don't have to be nervous that someone is like suspecting that I'm not supposed to be here or something like that. So being able to standing to pee is a big deal. Also just it helps people with. So in affirming their gender in terms of having their new anatomy, sex can be really awesome because they are not just worried about having a vagina and they can participate in sex in a way that is, you know, meaningful and you know, without dysphoria. Yeah.

KB:                 Yeah. I mean I think um, any surgery and even just medical intervention, really understanding, um, the, what you're doing. So when you, for example, start somebody on hormone replacement therapy, like really explaining the positives of it but also things that might happen along the way, things that we really don't know are going to happen along the way. And I think at the same goes for surgery and sometimes people are just so excited and you just want to give them everything they want. But the reality really, you know, 50% complication rate is fairly high. So I think just explaining that and as long as people are a 100% ready and onboard, you know that's super exciting that they're happy with the procedures regardless of all that stuff. Do you do top surgery?

Kayla:             I do not. So that is something that is not restricted to like a gender surgery team. So a lot of people throughout our medical center do that and just sort of plastic surgeons in general. I have heard and read a few things recently about how they will now or something to contemplate is facial masculinization, which when some one first said that to me I was like: no because I feel like, like what would that even be? And I feel like a lot of trans males like do appear very masculine. I don't know. So. But yeah, so I've heard a lot about the facial masculinization sort of being, coming down the pipeline is something that people will be requesting.

KB:                 For anybody who's out there who's interested in going into this particular field: Do you have any clinical pearls or suggestions on how to be a good first assist or how to find these opportunities?

Kayla:             I would say make the most of your rotations. If you're a student, so we all kind of rotate through surgery in different capacities. So I did general surgery and then I also did gyn-onc so I was able to do kind two surgical rotations and just retaining that staff because once you learn the basic fundamentals of like how do I scrub it and sterile technique and all that stuff. Like you will always know that and be a good first assist is just to, well I'm in a fortunate position where I work with her, a few surgeons, whereas other people in my medical center that are like the general surgery PA so like they could work with a different surgeon every single day of the week. So for that that will maybe be a little difficult because everyone has their own vibe and has their own way of doing things. But I would just, yeah, when you're at school, try to memorize all the instruments and get familiar with procedures. One thing that somebody told me that really did help me was the first time you watch a procedure or assistant procedure, watch it as if you have to do it yourself later. Like you have to do it by yourself later and really try to memorIze the steps because if you're, if you keep thinking about it in a way that's like, oh, I'm not going to do that step, ever. But like, I don't know, maybe someday you will or you know. So to be able to learn the steps of the procedure and also to always, um, just want to make the surgeon look good. Also. So like your anticipating what's next, knowing what they're going to need. Keeping our surgical area clear. You're always being at the surgical site and not being distracted by what's going on in the room. And... Wear compression socks. <LAUGHS>

KB:                 That's great advice. Do you have any advice for patients and how they can advocate for their trans surgery care?

Kayla:             Um, I would say that just want to research the physicians that you're going to see. So a lot of people, there's a lot of information out there. All doctors nowadays are like reviewed all the time. If you meet someone and you like them and you trust them and they feel like they are genuinely interested in care, then that's great. And if it doesn't then you know, maybe that's not a good fit for you. I would also say that there, I mean I'm not in this, not in this experience, I don't know what it feels like, but to have a sense of urgency, like people who they just want to get it done. So they will go like, you know, out of the country or they'll go for someone and maybe it's a little less expensive or something like that. Like you kind of, you only have one go kind of. So just make sure it's right and that it's the right time for you, that you have all those things like so you're not going to, you know, lose your apartment if you don't, if you take the time off work to do you need or if your work isn't supportive, you know, just try to get those things. I mean that's, that's really difficult to say. It's like easier said than done.

KB:                 But it's like anything else, if you're going to do it, do it right and this is your body and this is all you got so I think that's really great advice. Kayla, this was awesome. This information is super hard to find and you know, you can go to trans conferences and see the photos. Um, but to hear somebody who kind of does this work every single day kind of outside of a powerpoint presentation is really kick ass. So I really appreciate you taking the time to chat with us.

Kayla:             I'm glad to asked. And I'm always happy to share information. I'm totally accessible all the time. I get emails from students and stuff like that and patients through my or not my own patients, but like through linkedin and stuff. Yeah, because it is difficult to find. Even for me it's like whenever I'm trying to find like, oh, what should I do in this situation like there is no Uptodate, there is no, there is no information. So it's sort of just like, you know...

KB:                 Yeah so we all have to spread the info amongst ourselves so we can learn

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***CONCLUSION: KB ONLY***

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