Opinion | A Bright Future for Gender-Affirming Care

In this Instagram Live clip, Jeremy Faust, MD, editor-in-chief of MedPage Today, and Blair Peters, MD, of Oregon Health & Science University in Portland, discuss the need to include gender-affirming care in academic medicine and how the next generation of providers is holding the line.

Click here to watch Part 1 and Part 2 of this conversation.

The following is a transcript of their remarks:

Faust: You are a pioneer in a way that you are one of the first people who did a fellowship specifically in this area. Is that right?

Peters: Yeah. A few years back, I was one of maybe the first three people to do a formal surgical fellowship in advanced gender surgery.

Faust: How did that come about? For any field, how does a new fellowship like that where the cutting edge is literally wherever your scalpel is, how does that work?

Peters: It was just dire need. My pathway into gender-affirming surgery: I was a plastic surgery resident in Canada, and we had started doing some gender-affirming mastectomies or “top surgeries.”

And I’m someone that’s from the queer community who was also going through my own phase of growth of just starting to expand into hanging out with people of gender-diverse and trans identities and starting to understand, in a very developed country, why are people having to go to Thailand or Europe to access what’s supposed to be this medically necessary procedure? Why am I, as a plastic surgeon, not getting trained to do any of these things?

Then you start asking those questions, and people would have to go overseas and come back and have no follow-up care. It was just abysmal, the resources that people were provided, which was, in effect, none. Basically, it was community-supporting-community the best they could to get the care that they needed.

I decided that there’s got to be a better way, and we have to find a way to integrate this into academic medicine because we all train in academic medicine — that sets the curriculum of which we are all competent. If we don’t get this into academic medicine, then we’re never going to meet full demand and normalize it in the way that it needs to be normalized.

So I settled on this multi-year process trying to figure out where the heck can we even go to learn these things? I was very fortunate to end up at the institution I’m at now, as I was the first fellow here being trained by both plastic surgeons and neurologists, because a lot of these procedures intersect multiple fields of medical practice.

Then, it’s kind of grown from there. There’s seven or eight formal fellowships now. I train two fellows a year here now. I’m sort of stepping into that role, which has been fun. But all of those things are very, very new. You know, before a handful of years ago, people would maybe go watch a surgeon in Europe or Thailand for a little bit and come back and do the best that they could because that was all the resources that they had.

It’s pretty remarkable that it took as long as it did to even have safe surgical training programs for an entire group of people that is greater than 1% of the population. That’s a lot of people.

Faust: Yeah. I hadn’t realized that people were going overseas for that care, but it shouldn’t be surprising, because as an emergency doctor — I haven’t seen it with gender-affirming care, but I’ve seen it with a lot of plastic surgery — where people go to some other place because it’s less expensive. Unfortunately, we often see in this case, not the lack of follow-up being the problem, but the lack of, quite frankly, just technique and the side effects from having gone and gotten a botched liposuction or something south of the border or overseas, and we see these terrible outcomes.

It’s like, “Oh gosh, couldn’t we have just done that here and avoided complications?” Are we having that same problem where the outcomes aren’t as good when people go elsewhere?

Peters: I’m privileged where I am at, in one of the largest programs in the country. So I’m typically mostly seeing patients that I’m taking care of or that are coming to me for second opinions.

But there absolutely are people that are still going overseas because they maybe don’t have insurance in the U.S. and they’re going to have to pay out-of-pocket, so they’re going to go somewhere else. That’s absolutely still a thing that happens and can absolutely still compromise outcomes.

I think the barrier that people don’t realize is there’s still a very limited number of programs to train in a meaningful way. It took me 2 years to figure out how to train in this, and I had to self-fund my fellowship here. It wasn’t a secured funding stream. Do you know how difficult that is at the end of 13 or 14 years of medical education? So it’s taken a lot of people a lot of blood, sweat, and tears, and personal sacrifice to make this tangible.

What’s exciting is [that] institutions and organizations are stepping up. Even in the last 5 years, gender-affirming surgery is a recognized core area of training in plastic surgery now. It has sections at all of our meetings, it is in our plastic surgery journals, every year at least one new fellowship gets added.

So things are drastically changing, which also sort of contradicts what’s happening socially and politically where medicine-wise, care is getting better and education is rapidly getting better, and we’re seeing a lot of, I’d say, regression in the social landscape. There’s a bit of a disconnect happening.

Faust: You said the students are obviously integrated in this because it’s just part of the continuum of care now. It’s not really outside of that. Is plastic surgery becoming — and not that it already wasn’t a huge draw for students — but is there increased interest out of students who are interested in helping this underserved community?

Peters: Oh my gosh, yeah. I mean, to anyone that is worried that things aren’t going to get better, all you have to do is talk to the younger generation who are demanding LGBTQ+ education from day one of medical school. If the medical school is not doing a good enough job, they’re bringing it in themselves. They’re absolutely not going to let people be politicized or their care to be politicized.

So that is what inspires me more than anything and why I do a lot of this work, just to keep that door open and hold these spaces and show people that these careers are possible, because there is an absolute tidal wave of providers coming behind me that are going to have very similar career trajectories. That change is absolutely coming, because I think the students are just tired of it.

People are just people, we all deserve to make decisions for ourselves and live the lives that we want. They’re, I think, the first generation really holding that line, and institutions are shaped by the people inside of them, and medical students are collectively a very powerful group of people. They’re the future of healthcare and they’re shaping it.

Faust: That’s great. Anything you want to add? A parting message here during Pride Month and raising awareness for gender-affirming care? What’s your message to people who maybe don’t get it or who are curious? I’ll just give you the floor.

Peters: Yeah. I think you don’t need to understand someone to respect their choice to be who they are. I think more than anything, that’s what this is all about.

I think it’s very easy, particularly in this present time, to feel like things aren’t going to get better and they’re awful, but I do promise you that they will. We all just need to keep doing the work, but also keep holding each other accountable.

So to anyone that is a healthcare provider or at an institution or an organization or in medicine, this is actually your job too. You should be carrying that burden. You should be looking at, what is my organization doing? Do you have a statement? Start asking those questions, because that’s really what we need.

It’s not about trans people advocating harder for themselves. It’s not about the gender-affirming providers continually fighting these battles. It’s about people taking that tax off of us and making it clear that we as a field are supportive of people accessing the healthcare they need. End of story.