BCBC - Podcast - S3EP009 - Dr, Raj Purohit - Gender Affirmation Surgery

Welcome to the first podcast of October 2018.  This is our month on topics around the theme of Gender Identity, the Gender Spectrum, and Gender Transitions.  We have a really packed month - with 5 amazing Monday Mumblings, 5 podcasts, 5 blogs, and 4 nuggets.  Make sure you stay tuned in to all of our episodes!   In This Episode:  Today Monkey and the Professor got to chat with Dr. Raj Purohit.  Dr. Raj was born in Rajasthan, India (https://en.wikipedia.org/wiki/Rajasthan) but grew up in the midwest - he is a Michigander at heart.  He left Michigan to study history and political theory in college - at Williams.  He believes that background certainly informs many of his decisions and things he is very passionate about - he grew up in a family of artists and doctors.  In medical school, he took a year off to apprentice with a painter in Rajasthan.  He attributes his apprenticeship and painting to have a significant impact on how he views surgery.  He came back to the US, finished his medical training at Columbia, went on to UCSF for his internship in surgery and residency in urology.  He did a Fellowship in pelvic reconstructive surgery - this is where he developed an interest in cis gendered patients originally - in reconstructing the urethra from trauma and complications, and ultimately shifted his focus to developing the Gender Affirmation Surgery program at Mount Sinai a year ago. Dr. Raj made the decision to go into medicine because of his strong family background in medicine, where many of his family members are also doctors.  His wife and sister-in-law are both doctors as well.  You could consider medicine to be a family business.  Even with that, something sparked within him when he entered the operating room for the first time - it was a sense of belonging and home and passion.  He sees the surgical suite as a controlled environment, whereas a surgeon, he is an artist - painting the body and bringing out the beauty from within the canvas.  Surgery is where he finds his balance in both art and medicine. We started off with a very high-level overview of what is involved in Gender Reassignment.  To begin with, the preferred term is Gender Affirmation - because what is really happening is helping the person become externally what they are already internally - it merely affirms their gender identity. At no point are they really assigning a gender to the patient - that patient is already the gender they are on the path to appearing as.  We really love that terminology and phrasing.  As Dr. Raj states - the doctors are not assigning or giving the patient a new gender - they are only uncovering what is already there, the gender the person already feels exists.  (https://amzn.to/2xOODmq)  So - Gender Affirmation Surgery typically involves some level of reconstruction on the body so that the body will fit the gender that the person already identifies as.  Patients have already gone through hormonal therapy and have had changes in their bodies to reflect the correct gender profile. These surgeries are broadly split into two groupings - Top Surgery and Bottom Surgery (https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries).  For transwomen (assigned male at birth, but identify as female) the surgery may entail: facial feminization to transform the masculine features of the face to a more feminine appearance (https://www.healthline.com/health/transgender/facial-feminization-surgery) vocal chord surgery (https://health.howstuffworks.com/medicine/surgeries-procedures/transgender-voice-surgery.htm) breast augmentation to enhance the size and shape of the breasts to create a more feminine appearance to the chest Creation of a vagina through a surgery called vaginoplasty https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/vaginoplasty This typically includes removal of the testes as well For transmen (assigned female at birth but identify as a male) the surgery may entail: (https://www.ftmsurgery.net/) Breast Reduction/Removal includes bilateral mastectomy (removal of the breasts) and male chest contouring Hysterectomy removes the uterus, and may also include the removal of the cervix as well as the ovaries and Fallopian Tubes Creation of a Phallus and/or Testicles Through the implantation of a penile and/or testicular prosthesis to provide the ability to have erections. Dr. Raj stressed that this is really a continuum of options - not every trans individual will have all of these surgeries or go through hormones or have implants - it is a very individual decision as to what a person wants to do and go through.  They may do one or two of these options, none of them or all of them.  As a surgeon, he believes his job is the help the patient achieve a body that they are comfortable with, and who they want to be.   Pre-Surgical Requirements: We spoke with Dr. Raj on counseling for gender affirmation procedures - what is involved, what is required.  Keep in mind that different locations (states, countries) have different requirements on counseling and other things that must be completed prior to gender affirmation surgery can occur.  All patients do require a psychiatric evaluation before being approved to move forward with surgery - this is very much the case when it comes to some of the more involved surgeries like phalloplasty and vaginoplasty.  Most centers require that patients live in that gender identity for at least a year and that they are additionally on hormone therapy for at least one year prior to surgery. The delays before surgery are not really about ensuring people do not change their minds.  Really, by living in the gender identity they relate to, it provides them with experience with the varied receptions within society, their jobs, etc.  That may impact the medical care that is then available to them post-surgery.  It is important that access to proper medical attention post surgery is readily available for the patient’s well being in the long term.  Unfortunately many during this year of living in their gender find themselves ostracized, or being terminated for their place of employment - both scenarios having significant impacts on their lives overall.   Hormone Therapy: The therapy treatments with transmen and transwomen are obviously different.  The aim of hormone therapy is to make transgender people feel more at ease within their bodies, both physically and psychologically.  Hormone therapy is usually the first treatment that trans people want to have and, for some, it may be the only treatment they need. Some people find that they get sufficient relief from taking hormones so that they do not need to change their gender role or have surgery.   Transmen (FTM) For trans men (FTM) who have been born into "typically female bodies" (i.e., bodies that have functional ovaries), as well as trans men who were born into intersex bodies, the goal of testosterone therapy is to induce and maintain the presence of masculine secondary sex characteristics.  Addition of testosterone is the therapy - this is a very dominant hormone making it an easier treatment for transmen.  There are many changes that occur almost immediately with the administration of testosterone. In FTM testosterone therapy, testosterone (often called "T" for short) can be administered into the body in a number of ways. The most common method is intramuscular injection with a syringe. Other delivery methods include transdermal application through gel, cream, or patch applied to the skin; orally by swallowing tablets (this method is uncommon as it has been shown to have negative effects on the liver); sublingually/buccally by dissolving a tablet under the tongue or against the gums; or by a pellet inserted under the skin. The T-delivery method used will depend on the type of medication available in the country of treatment, the health risks/benefits for the patient, personal preference, and cost. Testosterone is not stored by the body for future use, so in order to maintain healthy levels, it must be administered in timed intervals and in appropriate dosages. Injectable and subcutaneous T pellets remain active in the body the longest. Injectable T is typically administered between once a week to once every three weeks, and subcutaneous T pellets are replaced every 3-4 months. Transdermal T (patch, gel, or cream) is typically applied to the skin in smaller daily doses; oral and sublingual/buccal T are also typically taken daily.   Transwomen (MTF):  Transwomen have a more complicated approach to hormone therapy.  It tends to be a combination of adding feminine hormones while simultaneously blocking male hormones.  The goal of feminizing hormone therapy is the development of female secondary sex characteristics and suppression/minimization of male secondary sex characteristics.  Estrogen is not a very dominant hormone - treatment with estrogen is combined with a testosterone blocker like spironolactone (this blocks the production of testosterone at a cellular level).  There are many formulations of both estrogen and the testosterone blockers that can be provided to the person going through therapy - pills, injections, etc. With the combination treatment, increased fat levels in the body can be seen, reduced testes sizes and the growth of breasts, among many other physical changes.   The transformation of the physical bodies with hormone therapy can start within a few weeks to months but will continue over time.  The effects in a couple months may not give a complete indication of where things will continue to progress.   The Challenges of Surgery for Transmen: Transmen do not typically go forward with the bottom surgeries - phalloplasty - at the time of this recording - the general opinion is that those surgeries are not very optimal.  Constructing a new penis is a very difficult challenge - and functional penis creation is difficult and dangerous.  The idea would be a penis that can experience erections, that can be urinated through (so peeing standing up is possible), and that can provide pleasurable sensations through touch.  Broadly speaking there are two ways that a penis can be constructed.  The first is clitoral enlargement (3 to 8 times) that occurs from the taking of testosterone.  A new penis can be created from the enlarged clitoris.  Additional skin flaps can be used to create a new urinary tube.  This provides sensation and urination.  The downside is that erections are not possible because the anatomy involved in erections cannot be created within this structure.  Obviously, there is a small amount of fullness through stimulation but it is not really an erection.  The second downside is that the clitoris can only enlarge so much - a couple inches at most, so you are left with a fairly small penis - and many are not satisfied with that size.  The significant benefit is that the surgery is easy and has a high rate of success with low risk of complications. The second methodology for bottom surgery is the phalloplasty. This is where some tissues from another part of the body is used to create a brand new penis.  You can create a tube within a tube - the first time is a penis, the second is the urethra.  You can implant as well a penile prosthesis to enable an erection.  You can have a penis with quite a good size.  The downside is that sensation is very limited and not the same as the clitoris.  The additional downside is a very high complication rate - scar tissue, infection, etc.  At this point, the best way to avoid these is not figured out.  Much debate and research is still ongoing. Dr. Raj believes a future possibility might be penile transplants.  A number of transwomen are removing their penis - that might be one source for the transmen.  That may provide a penis with all three criteria.  There is, however, a very long way to go to get the immunology, sensation, and functions correctly.  There is precedent in penile transplants - a Massachusetts General trauma patient had their pelvis blown off.  The surgery was successful there so that leads to possibilities in the future for transmen.   Surgery for Transwomen: Vaginoplasty is a far more common procedure than phalloplasty.  The complication rates are significantly lower than other surgeries - it is truly a technique that appears to have been optimized for success.  These surgeries come in a few different flavors - the most common is the penile inversion surgery.  The penis is inverted back into the cavity and the outer skin becomes the vagina inner walls.  Sometimes skin grafts are added from the scrotum to deepen the cavity.  The benefit here is that you have sensation.  The former head of the penis becomes tailored into the clitoris.  It is a functional and sensational surgery - providing transwomen with the benefits they would seek from a bottom surgery.  The vagina must then be dilated for the rest of their life to avoid a long-term complication of scarring down but essentially this is a fairly optimal procedure.  Additionally cosmetically this surgery looks amazing.  What Dr. Raj finds most fascinating is that each center who performed these bottom surgeries historically had developed their own techniques but it is only in the last few years that there has been a sharing of the information so that the group knowledge can work together for better ways to treat patients, with fewer complications and more successes.  It is also moving the industry towards a standardization in procedures that include what works.  There is a fairly good overview with FAQs on this subject that you can download http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF   The Cost of Transition: This is a question that comes up all the time.  Unfortunately, there is no simple answer and it will often depend on insurance coverage and such.  Many insurances will not cover all or any of the procedures, hormones, etc.  Many will. In general terms, Dr. Raj suggested most insurances will cover hormones.  Blue states tend to cover some or all of the surgeries - whereas many red states do not cover these at all.  For patients that do not have insurance, cannot get Medicaid, or some from states where the insurance will not cover the procedures the surgical costs can range anywhere from $20,000 - $50,000 dollars.  The cumulative costs of hormones can be expensive over the course of a lifetime but are not crazy on a monthly basis. The great thing about today’s world versus a few years ago is there is more and more of a push to include and cover these surgeries than ever before.  Dr. Raj does not believe gender affirmation surgery as a choice - he believes it is a necessity to someone’s health and well being.  This follows the way the medical and insurance industries are moving - these surgeries are no longer considered simply to be a vanity.  Being in the wrong body has significant physical effects on health and well being.  Doing the surgery results in a reduction of mental health issues that can also then lead to less physical health issues. “This is something as doctors we can fix, so why should we not fix it?”   The Impact of Age on Transition: Currently, in society, there are seeing more children (pre-pubescent) and young teens moving towards gender transition.  This is often done through postponing puberty through the use of drugs to suppress hormones.  This is a very controversial topic - both in society and within the medical community.  There is not great data on this topic and on the long-term effects of postponing puberty.  What is known - many children under the age of 12 (puberty) may identify as a gender that they were not assigned to at birth.  The majority of those kids will identify as the gender they were born with later in life.  There is no real debate for these kids and doing hormone therapy - they are unlikely to continue on with the transition as they get older.  The real debate is what to do about those kids who are 12 years and entering adolescence and entering puberty.  There are studies that have shown that once puberty is hit and after, the gender is fairly fixed and is unlikely to change as they get older.  That means that they are not likely to change their gender identity back to what it was assigned at birth - it is established in their identity.  This is where the question comes into play - should puberty be stopped and/or should hormone therapy be initiated so that those secondary sex characteristics of the assigned birth gender do not develop.  Questions around early surgery are also being debated.  A lack of data makes outcomes uncertain - would they provide better outcomes with earlier surgeries or would there be additional challenges because of coming growth. For risks and things to be aware of for children, Dr. Raj suggested that parents should speak to an endocrinologist.  This is their area of expertise and they can advise if there are and are not things to keep in mind.   Resources for Parents: There are a lot of websites - but the best in Dr. Raj’s mind is the World Professional Association for Transgender Health (https://www.wpath.org/).  This site is used by medical professions as well and contains accurate well-vetted information.  Many other sites out there may be full of misinformation.  It includes standards of care, risks, questions, and so much more. Other resources include Lambda Legal (https://www.lambdalegal.org/).  This organization is geared toward LGBT issues and has a lot of amazing references present for parents.   Transitions in Older Generations:  The older generations - considered geriatric, are making a lot more of a splash in transitions.  There are more articles out in the world about people in their 70’s, 80’s and 90’s going through gender affirmations and transitions.  Dr. Raj notes he is seeing an uptake of people across all age ranges, but he is highly impressed by the older people who come in.  They have lived with the social ostracization through their years.  Now as the world is becoming more supportive, they seem to be able to feel safe in moving forward.  The courage the older generations have lived with their entire lives, to now come forward with the transition is a true inspiration to Dr. Raj. Later transitions have different risks than those done at a younger age.  One the one hand there are social risks for gender transitions - groups of friends and peers may not support the transition and it may result in a loss of companions and loved ones in their social network.  This can result in feelings of loneliness and feelings of isolation.  There are also risks of hormonal therapy in older transmen versus younger men.  Testosterone can increase blood count and the risk of high blood pressure and sleep apnea and cholesterol.  This means these are things that need to be monitored more deeply.  There are also concerns of prostate cancer for transwomen who are then put onto hormones.   It is unknown if there need to be more screening, testing, and treatment around the prostate.  Surgeries for gender affirmation are all serious lengthy surgeries with risks.  Older patients may not be great candidates depending on their health - but as always, Dr. Raj does what he can to help his patients, young and old, do as much as they can to become the physical body they identify with.  The patients often have to assess the risks for themselves as well.   Long-Term Health Risks that May Result from Gender Affirmation Surgery: Unfortunately, there is not a lot of really good data on the long-term risks associated with gender transitions.  A few things that are known however are the risks associated with the hormone therapy.  Patients taking testosterone to run higher risks of increased blood count, high blood pressure, sleep apnea, and high cholesterol.  They also tend to gain weight and may develop acne.  For estrogen, there is a higher risk of gallstones, clots, cholesterol issues, cardiac disease, and high blood pressure.  The things that are debated but there is no immediate proof is the increase in breast cancer for those on estrogen and progesterone.  There is no data, yet, that testosterone can increase the risks of uterine and breast and ovarian cancer in transmen.   Ultimately all these questions require more research and research dollars to look into.   Pregnancy and Hormone Therapy: Following some of the conversations we had this month, we were curious as to known complications from stopping hormone therapy as a transman to get pregnant.  Dr. Raj suggested a few things to consider - normalizing hormones to that of a gender female before getting pregnant and possible concerns for the baby from the additional testosterone in the system.  These are also situations that do not have a lot of real research to understand what the possibilities are.   Resources at Mount Sinai: Mount Sinai has one of the best online resources available to people.  They have spent time and commitment in developing one of the best transition centers in the world.  They have created a multidisciplinary team to ensure that they can work strongly in a coordinated care method on the patients’ behalf.  They have also developed two Fellowship programs within the gender affirmation field.  In Dr. Raj’s opinion, Mount Sinai is moving the field forward through training and procedure development.  The research there is also pulling data together for long-term understanding and improvement.   Parting Words: Dr. Raj likes to think about what appeals to him about the transgender community and the work he does.  Some of the patients he has come from very supportive environments and can make the transitions easily.  However too many others face ostracization, employment loss and os much more  He inquires of each of our listeners - what are you willing to give up absolutely everything so that you can be true to yourself?  Dr. Raj joins our barnyard today - he identifies as a pig in our barnyard.  He does not mind to get dirty and to spent time flopping around in the mud.  Pigs are also very intelligent animals and he believes that also indicates a part of his personality.   About Our Guest: Dr. Rajveer Purohit is the Director of Voiding Dysfunction and Reconstructive Urology and Associate Professor of Urology at The Mount Sinai Hospital.  He has performed over 400 complex reconstructive surgical procedures including urethroplasty for urethral strictures with grafts and flaps, surgery for complications of radiation therapy, treatment of mesh complications and complications of pelvic surgery such as incontinence and maintains a particular interest in transgender surgery.  In addition, Dr. Purohit has continued to maintain an interest in general urology including surveillance for cancer, vasectomy, urinary problems, sexual dysfunction, and work-up for hematuria and elevated PSA. Dr. Purohit graduated Magna Cum Laude from Williams College and earned his medical degree (MD) and Masters in Public Health (MPH) from Columbia University before completing his surgical internship and urology residency at the University of California in San Francisco. While there he trained with one of the pioneers of male urethral reconstruction and then completed a fellowship with Dr. Jerry Blaivas in pelvic reconstruction and voiding dysfunction and was on the clinical faculty at New York Presbyterian for over 10 years before joining Mount Sinai. He has been listed in New York Magazine’s Best Doctors in New York City. He has been awarded the Pfizer Scholars in Urology,  AUA/Praecis Gerald P. Murphy Scholar, Society of Medicine and Reproductive Urology Travel Scholar award, a California Urology Foundation Grant and an Arnold P. Gold Fellowship and multiple Patient Choice and Compassionate Doctor awards. Finding Dr. Raj! Mount Sinai Department of Urology:  https://www.mountsinai.org/profiles/rajveer-s-purohit Twitter:  @DrUroRecon   Additional Resources and Links: www.wpath.com www.Lambdaleagle.com https://www.pinknews.co.uk/2018/06/26/starbucks-to-pay-for-all-transgender-staffs-surgeries/ https://nypost.com/2017/03/29/transgender-wwii-veteran-comes-out-as-a-woman-at-90/ https://health.usnews.com/health-care/patient-advice/articles/2018-05-25/what-is-gender-affirming-surgery https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries https://www.youtube.com/watch?v=EWdtByPm9a4 https://www.youtube.com/watch?v=zGkiC3Y8kk0 https://health.howstuffworks.com/medicine/surgeries-procedures/transgender-voice-surgery.htm https://www.webmd.com/women/guide/vaginoplasty-and-labiaplasty-procedures#1 https://www.ftmsurgery.net/ http://www.teni.ie/attachments/9ea50d6e-1148-4c26-be0d-9def980047db.PDF http://transhealth.ucsf.edu/trans?page=guidelines-feminizing-therapy https://www.cosmopolitan.com/sex-love/news/a52196/what-its-like-to-transition-transgender-man/ https://www.healthline.com/health/transgender/bottom-surgery