Opinion | The Realities of Providing Gender-Affirming Surgery

In this Instagram Live clip, Jeremy Faust, MD, editor-in-chief of MedPage Today, and Blair Peters, MD, assistant professor of surgery at Oregon Health & Science University in Portland, discuss the realities of providing gender-affirming care in 2023 in the face of sweeping legislation across U.S. states limiting gender-affirming medical care.

The following is a transcript of their remarks:

Faust: This topic, I think, has obviously come onto people’s radars. In a lot of ways, in the past couple of years, there’s been some great things, like awareness and acceptance. Then with that, the other side of the coin, comes harassment and hatred. There’s this tension as the field becomes more in the public eye. How are you doing?

Peters: It’s a really hard thing to have medically-necessary care and your job politicized, to a point where a lot of us receive threats of violence and have genuine concerns of our physical safety. It’s sort of scary how much someone’s healthcare has been politicized, to the point that it’s becoming this issue that is radicalizing people to incite violence.

I think the saddest thing is so much of this is based off of misinformation and inaccurate representations in the media and a lot of social media. You see in a lot of these anti-trans legislative hearings, a lot of things are being pulled from social media or media articles. It’s the rare experience to actually have trans patients and gender-affirming experts speaking to the reality of care.

So it’s just gotten so bad really quickly, and it’s just hard, I think, for everyone in these spaces, especially for patients.

Faust: Well, I think you show a lot of bravery. Even as I — the smallest little thing — was just writing my audience a notification about this event. I was like, “Am I going to get hatred that I am not accustomed to?” Oh my God, this is 30 minutes of my life, it’s nothing compared to what you have to go through. So hats off to you for being on the front line.

Let’s get away from the politics for a second just to know what you do, because when I was a medical student, I scrubbed in to a lot of cases of appendectomy and I scrubbed into liver transplant. You’re a surgeon. Tell us, are these surgeries difficult or complicated? Tell us about just the technical aspect of it.

Peters: I mean they certainly can be.

Gender-affirming surgery, in particular, is such a huge umbrella. So many things fall under that category. Some of the simpler procedures might be something like a breast augmentation or maybe a mastectomy. But sometimes [gender-affirming surgery] can include pretty technical reconstructive facial surgery, like facial feminization surgery, or more complex genital procedures. It can be even something as simple as an orchiectomy, or simpler procedures like laser hair removal are all types of gender-affirming.

It’s all about treating the areas that are causing people either dysphoria or stopping them from having euphoria and feeling positive about themselves and right in their body so that they can function better and feel better and be happier, better versions of themselves for the world.

I kind of describe gender-affirming surgery as, it’s not any one thing. I think it is using surgery as a tool to help someone physically actualize their internal sense of self. That sounds a little potentially vague because it’s different for everybody. Everybody’s experience of gender is different, as is their experience of dysphoria. It would be kind of silly to think that the exact same procedure is how you’re going to treat every single patient that experiences gender dysphoria.

That’s what I think is challenging about it, but also unique about it in some ways, because you’re pulling a lot of humanity into medicine, which wants to be very algorithmic all the time. I think that’s something that is the best part of my job is understanding my patients and getting to know what they need from me and really balancing, minimizing risk and maximizing benefit for them.

Faust: That’s a great answer. The operating room is a place where technical expertise plays out, and I think people forget that some of these things are really straightforward and some — just like in all of medicine — other things are not. Just to remind people that you’re a surgeon.

Peters: I am!

Faust: You know what you’re doing, you know what you’re doing in there — and all the training that comes with that. So, thanks for going there.

Let’s talk a little bit about the hospitals and the work environment, because you get threats — hospitals and physicians get threats. Just from the perspective of someone doing this, you sort of answered this up front, but do those threats and those difficulties make the actual job harder? Or is it more like after you’re done with the job, you have to think about that?

Peters: I mean it absolutely does, because it reflects what a lot of the trans and gender-diverse community is dealing with as well.

As someone that has patients from across the country, people are scared that they’re going to lose access to care at any point, and waitlists for some of these procedures are really, really long. I have people waiting years sometimes to see me, and when you’re taking on a major life-changing decision like surgery and there’s a million other things to think about and plan [for], the last thing you want is this threat that you could lose access to care at any moment.

It’s very destabilizing, especially in a world where you’re being persecuted for who you are.

So people are coming to the clinic really stressed and sometimes panicked. When we’re both getting it from both ends where the provider is also dealing with concerns of physical safety and everything that goes into that, I think it takes a lot of strength on both sides to hold that space and still make sure that good medicine is happening while doing your best to really address what’s going on socially and politically.

I think we as providers are responsible for our patient’s health, and that health is affected by things far outside of the walls of a hospital. So I think it really is our job to be engaging socially and politically to protect the people that we say we’re here to protect and take care of.

Faust: How are the organizations doing, the larger organizations? A lot of times experts [and] advocates are pushing for something that is outside of the normal way of doing things in the past or pushing for progress, and a lot of these institutions are very conservative and old and don’t want to change things.

But I haven’t gotten the sense, as a relative outsider to this conversation, that people are coming after the hospital to say, “Oh, you’re not doing enough to make this available.” I don’t sense that the bad guys, so to speak, are necessarily the hospitals, which is kind of a little surprising in a way. Is that right? Am I reading the room right?

Peters: I’d say yes and no.

I think the absolute false picture that’s really been portrayed in the media with the amount of coverage — I think everyone’s gotten this understanding that gender-affirming care is super easy to access. It’s actually incredibly difficult to access. It’s only with recent insurance changes from about 2014 that people could even access insurance-covered care, and there are a lot of states that may have one gender-affirming clinic. There may be one surgeon providing care to huge populations of people. Which is why this legislation is so scary, because if you lose a single provider or a single center, that may be an entire state that no longer has access to care.

So, that’s what’s hard to sit back and watch. People have this idea that it’s so incredibly easy to access care when the vast majority of the community has never had access to care in the first place.

I actually spend a lot more of my time helping hospitals and training other surgeons and helping people build gender-affirming surgical programs, because there’s still nowhere near the number of programs, surgeons, and centers to even come close to meeting demand.

You kind of brought up the point about things being new. The reality is gender-affirming care — or the need for gender-affirming surgery and care — is not new. It’s just that we’ve chosen to look at it for the first time. We’ve completely oppressed the needs of trans and gender-diverse people for decades. It seems new to you because we’re giving it space to even talk about it in the first place.

That’s why some of these waitlists run so long. There are people that are for the first time in their life, at 70 or 80 years old, transitioning because they actually have insurance coverage to do so for the first time ever.

What’s sad is that we finally are starting to get somewhere, but it does feel like that is being threatened.

But I think a lot of the media attention too has created this public perception that there’s this debate about gender-affirming care and medicine. There isn’t a debate. Every major medical organization overwhelmingly supports gender-affirming care as medically necessary care, as do the vast majority of physicians.

I think the fear, though, of public backlash and heat is where a lot of institutions can sometimes fall short at really standing strong in those statements and supporting and protecting the providers that are providing that care. That’s been a mixed bag, seeing how people have handled that across the country.