Gender Affirmation Surgeries and Care with Dr. Cecile Ferrando

Podcast Transcript

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Kate Kaput:
Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput and I'll be your host today. We're talking about transgender health care, including gender affirmation surgery and other topics with Dr. Cecile Ferrando, Cleveland Clinic's, Director of Transgender Surgical Services. It's great to have you here, Dr. Ferrando.

Dr. Cecile Ferrando:
Thank you for having me, it's a pleasure to be here.

Kate Kaput:
So I'd like to start... I know that you've been a long-time advocate for transgender patients' health and wellbeing. I'd like to begin by asking you to tell us a little bit about your practice at Cleveland Clinic and the types of patients that you typically see. Who comes to you?

Dr. Cecile Ferrando:
So my main specialty is female pelvic medicine and reconstructive surgery. It's also known as uro-gynecology. So I have an obstetrics and gynecology background, and then have a reconstructive surgery fellowship subspecialty training. So the types of patients I see, I see mostly patients seeking reconstructive surgery or what we call gender affirmation surgery specific to genital reconstruction.

So in my practice I've mixed in seeing patients who are specifically looking for gender affirmation care, as well as all types of patients looking for reconstructive surgery specific to vaginal reconstruction and pelvic reconstruction.

Kate Kaput:
Got it. Thank you for that background. So let's start by talking about terminology and concepts. For listeners who are not transgender and who are just trying to better understand this topic, can you talk about gender identity and what it means to be transgender?

Dr. Cecile Ferrando:
Gender identity can be a really complex, complicated issue, or it could actually be really simple. It depends upon how you wish to look at it. I mean, gender identity is really who you are, how you feel, whether you feel like you are on the feminine side, whether you're on the masculine side. It's an internal feeling. How you manifest that identity is actually called gender expression, meaning how you express things on the outside.

So while it can be confusing, if you keep it simple, there are plenty of individuals who identify as female or feminine, but may choose to have a more male or masculine expression, they may have an expression that's more in line with their actual identity and may dress and express in a feminine way.

And that way of expressing yourself as based upon the clothes you wear, the way you wear your hair, the way you wear your jewelry or makeup, but that expression is different from someone's true identity. Somebody who's trans, if you think about the origin of the word trans, means traversing or opposite. So somebody who's transgender identifies with a gender that is opposite of their what we call natal sex or their biologic sex, the sex that they were assigned at birth, which is usually based on one's genitalia at birth.

An important term when you're talking about gender identity and transgender is to understand the opposite with which is cisgender. Cisgender refers to individuals who identify with the body or the natal sex that they were born in. So somebody who is born female, has female external genitalia, and they self-identify as female is considered cisgender, whereas somebody who was born with female genitalia, but identifies as male would be somebody who is transgender. And then again, that self-expression can be very different from their own identity.

And I think the added point to make, to add a layer to make it more complex, is to really understand the difference between identity and sexual preference or what we often refer to as sexual orientation, which is individuals whom you are attracted to. So one of my mentors, the easiest way to really think about it is identity is who you go to sleep as at night, and sexual preference or orientation is with whom you go to sleep with at night, or who you would choose to go to sleep with.

Kate Kaput:
A term that we hear about a lot when we're talking about transgender health care is gender dysphoria. What is gender dysphoria and how can it manifest in transgender people in particular?

Dr. Cecile Ferrando:
So gender dysphoria is a symptom. It's what we commonly use now to help with diagnoses. Being transgender is not an ailment or an actual disorder. That's an antiquated view of what it means to be transgender. Transgender is just a way that some individuals self-identify. But when we're treating symptoms, we have to have a diagnosis. So some transgender individuals experience something called gender dysphoria, and I'm really careful in saying... You don't want to say all individuals, it's really some.

Some individual self-identify as the opposites gender compared to their natal sex and feel comfortable in their bodies without seeking any care. But those individuals who are uncomfortable experience something called gender dysphoria, which is this disconnect between one's gender identity and their biologic or natal sex that creates symptoms of dysphoria, meaning that distress that comes with living life within that context. So that's what gender dysphoria is.

Kate Kaput:
Got it. Thank you. So we want to be really clear that many transgender individuals choose not to have any surgeries done whatsoever, and that it is never appropriate to ask a person whether they've had these surgeries unless they offer up that information. But with that said, Dr. Ferrando, what can you tell us about the term gender affirmation surgery and what does that term refer to in a broad sense?

Dr. Cecile Ferrando:
Sure. So gender affirmation, and this term has changed over the decades, and this ease to be gender confirmation, now it's gender affirmation, because what we're trying to describe is us as society also as medical providers, if we're providing those services for patients, affirming individuals for who they are. So we're providing a service that doesn't necessarily change them or confirm them, but it affirms them so that they can self-identify and live a comfortable life in the bodies that they deserved and should have been born in. So essentially what we're doing is physically aligning people with the identity with which they identify. So affirmation surgery can refer to any type of surgery that does just that.

And you make an excellent point about... It isn't really appropriate to ask people what surgeries they've had, and there's this real misconception about gender transition, so when somebody identifies as transgender and decides to go on their own personal journey of transition, that there's such a thing as a complete transition, meaning that somebody is not fully female or fully male if they haven't had every possible affirmation treatment that exists like medical treatment, hormones, all the surgeries that are possible.

Every individual lives their own journey and chooses what they need in order to affirm themselves in the way that makes them feel comfortable and gives them that sense of self-efficacy and place in the world. So I teach our students and our trainees to not ask people about... Unless it's medically related to the reason that they're there, but there's no need to ever ask somebody whether they've had surgery or what kind of surgery they've had, and the steps to take after that is to also understand that it doesn't make them less female or less male if they've had one surgery over another or no surgeries at all.

Kate Kaput:
Thank you. I think that's extremely important for folks to understand just in general about transgender individuals, whether you're a medical professional or not. With that said, though, can you tell us a little bit about the specific procedures that fall within the spectrum of gender affirmation surgeries? We hear sometimes about top surgery, bottom surgery, facial feminization surgery. Can you explain some of those procedures to us and what they might entail?

Dr. Cecile Ferrando:
Sure. I like to describe the surgeries in tiers, like the top tier and middle tier and bottom tier. The top tier starting with the face and neck. So facial feminization surgery or feminizing procedures to minimize masculine facial features that some transgender women, so those are individuals assigned male at birth, identifying as female, so presenting often with a female self-expression. So those women often try to undergo feminizing procedures that may include changing some of the facial bones, the chin, rhinoplasty, which is changing the structure of the nose to make things appear more female. There are very subtle things in the male and female. What we call facies, or the faces that make us appear, from a societal standpoint, as male or female in their anatomic, and those things can be changed.

And then there's neck surgery, so what we call tracheal reductions. So that's removing what we commonly refer to as the Adam's apple in individuals identifying as female. And then in the middle tier is what we call top surgery, but it's really breast or chest surgery. So for transgender women, that's breast augmentation, so enhancing the breast tissue to give a more female appearance to the chest. In men, there are lots of terms for it. It could be as simple as terming it mastectomy. It can also be referred to as masculinizing chest surgery, and that's essentially removing the breast tissue and creating a more male appearance of the chest, a masculine appearance of the chest.

And then there's what I refer to the bottom tier, which is removal of some of the pelvic organs. So in trans men, that's a hysterectomy and sometimes removing the ovaries and the fallopian tubes, and in trans women, that would be a orchiectomy, which is removal of the testes. And then there are the reconstructive procedures, which is creating the external genitalia from what is currently there and doing reconstructive surgeries. And there are lots of different types, but it's essentially recreating the genitalia that would have been, so that patients feel more aligned with themselves.

Kate Kaput:
Great. Thank you. So it sounds like there's a whole range of these surgeries, and I'm sure that the answer isn't the same for each of them, but when it comes to undergoing gender affirmation, surgeries, how does the process start? What doctors are involved in the whole process, figuring out what surgeries someone is going to have, how to go about them? What does that process look like?

Dr. Cecile Ferrando:
There is an organized process for this. There's a professional society. It's called the World Professional Association for Transgender Health. It's a multidisciplinary society, meaning many types of physicians and stakeholders are involved in the society and in the creation of guidelines that a lot of medical providers and surgical providers use to be able to help guide patients through the process. A lot of the guidelines are recommended and there to be used as a framework for providers. And one of the requirements are that...

So for patients that are seeking surgery, they should be engaged in some sort of mental health, so some sort of counseling with mental health specialists who are well-versed in transgender care, in gender nonconforming care, who understand what it means to be transgender and to know what kind of care those patients need.

Often those providers will provide referrals, and specifically they'll write letters that use the terminology that's needed to really help patients obtain the next steps of care if they choose to pursue those steps, and those include medical care, so hormone therapy to affirm themselves, those hormones are called gender affirming hormones, and then also surgical care as well. And most providers who offer surgical services to patients will ask their patients to have been on gender affirming hormones for at least a year.

A really good part of the process too is to have patients self-expressed as their self-identified gender for a year as well, to make sure that they're comfortable in those circumstances that they want to continue pursuing some more of the irreversible changes that we have to offer them.

And once a patient has done that and has had good mental health care and has good control of any comorbid medical conditions or mental health conditions, then they're essentially ready for the different procedures that we have to offer them. So it's a process. I always tell patients, when patients seek care and they're right at the beginning and they haven't done anything, I say it's usually minimum a year, but for most patients it's a couple of years until they're ready to really undergo some of the more irreversible parts of transition.

Kate Kaput:
Got it. So it sounds like it's really a team effort between a lot of medical professionals and the patient themselves. Something that you mentioned just now is the importance of transgender patients speaking with doctors who are culturally competent in trans care. Studies continue to show that many transgender individuals are wary of the healthcare system, specifically because many healthcare providers are not yet trained in providing culturally competent Trans care.

What should a transgender person look for in a surgeon or other team of doctors to ensure that they are speaking with medical professionals who truly understand them and the sort of needs that they may have?

Dr. Cecile Ferrando:
That's a great question. So presumably when patients are seeking care from surgeons who are specifically performing gender affirmation surgery, usually that's a very safe environment. It's usually somebody who has cared for that group of patients for a while, or at least really understands that group of patients. That's been my personal experience and understanding. Same thing when they're looking for specific gender affirmation care. So when patients are looking for hormones, usually the providers who are offering hormone therapy to patients also know trans care and understand the verbiage and have already established that environment that makes patients feel safe.

The real nuance and the challenge that patients have is when they're looking for routine care, or somebody has already transitioned and they've moved, and now they're looking for a primary care provider or a family medicine provider or a gynecologist, or even a subspecialist. Someone needs to get their knee replaced. And part of the individual's medical history is their trans status, and the fact that they have had certain organs removed or still have certain organs. And in some cases it's important to disclose who you are and where you've been and that being transgender is part of your medical history because of the treatments you've undergone. Some of the hormones patients are on are dangerous at the time of surgery and they shouldn't still be on those hormones leading up to surgery. So they need to tell their doctors that.

So it's when patients are seeking quote-unquote regular care that they really need to seek people who are what we call either gender affirming friendly, transgender friendly, trans friendly, LGBT friendly. Often, as we've evolved in healthcare, that allyship or LGBT friendly care is now demonstrated either on people's websites. It's made very clear, but it becomes hard.

So I encourage patients, when they leave our practice and they're done with their transition journey with us, I tell patients when you call an office, you should just feel comfortable and easily ask, seeking the service, I'm curious as to whether or not your office is LGBT friendly or transgender friendly, and you see transgender patients. It's really okay to ask that over the phone. And I think more and more the response is, "Of course, and yes we do." If a practice says, "Oh no, we don't," or, "That's not something that we do," I always urge patients to seek care elsewhere because it's very clear that that practice will likely not be as culturally competent as the patient desires and deserves them to be.

Kate Kaput:
Got it. So in a similar vein, let's talk a little bit about what to stay away from when it comes to seeking an office or a doctor for surgeries in particular. Sometimes transgender patients turn to so-called practices or offices that aren't actually qualified to provide the care that they claim. Why is it so important for trans patients to see reputable healthcare professionals for their gender affirmation surgeries and other health care concerns, and what are some of the risks associated with going elsewhere?

Dr. Cecile Ferrando:
So in general, I think medical care is pretty universal, and you want to be cared for by physicians and providers who practice evidence-based medicine, who understand the latest recommendations, who dose hormones at certain doses that have been shown to be both efficacious and safe. So it's really important to go to a practice that either has already a reputation amongst the trans community of being a really good practice, or that just has providers who are well-versed in that type of care.

That professional society I mentioned earlier, the World Professional Association of Transgender Health offers, several times a year, this course called the global foundations. It's a foundation course, their global education initiative, which teaches providers, all sorts of providers, mental health providers, medical providers, surgical providers, the basics and foundations of transgender care.

I think we're getting to a place where eventually individuals will need to be at least credentialed by the society, and patients will be able to ask, "Have you taken this course and are you certified to actually take care of transgender patients?" We're not there yet, but I imagine we will be. But patients should ask providers how many patients do you see a year? Is this something that you do routinely in your practice? Do you practice evidence-based medicine? And have you taken care of somebody like me before? I think those very simple questions are very, very important.

When it comes to surgeons, it's a little bit more difficult. There are not as many surgeons as mental health and medical providers. That is changing. The training opportunities are increasing and people are able to learn how to do these surgeries. So I think it's becoming better and better. But for a while you had to find somebody who is reputable and who had done several surgeries and was competent in that kind of care.

So I think patients should be comfortable asking their surgeons how many of this particular type of surgery have you done before? For those surgeries that are reconstructive and have a cosmetic component, they should be able to ask surgeons to produce pictures of the patients they've operated on before. That's a very common thing that we do in reconstructive surgery.

And patients should be wary of surgeons who say that they don't have any pictures or that that's not part of their practice and surgeons who refuse to tell them how many patients they've operated on when it comes to certain procedures. I think that those are the red flags, and patients should be well aware of the ability to ask those questions.

I think as a whole, this is a pretty vulnerable patient population. Again, I don't want to make any generalizations. And I think that with vulnerable populations, those individuals sometimes do not speak up and always ask the questions that they should ask in order to ensure that their care is going to be good. So if there's anything I can do it would be to empower this patient group to ask those questions, to be direct, and to make sure that they feel comfortable, especially when it comes to surgical care.

Kate Kaput:
All of that. Yes, that's really important, and I think some helpful guidance in terms of that specific questions to ask other healthcare providers. Is there anything that you can tell us... Moving away from surgery, is there anything that you can tell us more broadly about healthcare for trans patients? For example, is there anything special that trans folks need to know when it comes to more routine procedures like mammograms, Pap tests, prostate screenings, and other routine healthcare needs?

Dr. Cecile Ferrando:
Yes. I mean, I think that when you... Specifically for care providers, but patients should know this too. First of all, we all need routine healthcare and we all need to be routinely screened. The less we go to the doctor, the less we're likely to be able to catch things early. This is also a patient population that historically has had very poor access to healthcare for many reasons.

First, the major reason, and we just discussed it, is people being competent in taking care of this patient population and making them feel comfortable in the office.

But second, there are misconceptions about what kind of care patients need. So I think that sometimes when patients think they've had this removed, they may not need this kind of screening, and there's a lot of confusion about what they need to do. If you look at… There's no formal guidelines for transgender care, but it can be extrapolated from what we do for the cisgender population.

So we have to take into account a patient's age, their biologic sex, what organs they still have, and what hormones they've been on. And we put all of those pieces together to decide who needs what kind of screening. So for instance, a transgender woman who has had a vaginoplasty procedure, which is a genital reconstructive procedure to create female external genitalia still needs a prostate exam after the age of 50. And some of the blood tests that we do for our cisgender men, so those who are biologically male, don't apply to the trans female population because the hormones that they take can result in falsely reassuring results. So they need an examination. But in these patients, their anatomy is different, and commonly for prostate cancer, men are screened with regular rectal exams or digital rectal exams.

You can't do that in trans women, and you won't feel the prostate that way because they now have a reconstructed vagina and the space between the prostate and the rectum. So you have to do a vaginal exam on a transgender woman to feel her prostate.

So I think that there's this misconception in the trans population that now that they're completely feminized from their perspective, they no longer need a male specific screening examination. And from the care provider's perspective, they may not know, or they may feel intimidated, or there are certainly many physicians who don't routinely do vaginal examinations and rely on gynecologists to examine women from that aspect of their anatomy. But there certainly are many gynecologists, if not most gynecologists, who are not familiar with the prostate because those individuals specialize in feminized care. So this is where it can get really complicated.

But I think the take home message is that breast cancer remains real in this patient population, so both trans men who used to have a female breast tissue. Some of them have never had chest surgery. So certainly they have regular breasts that need to be screened. Trans women who are on estrogen to be able to be feminized are more at risk for breast cancer and need screening. Trans women need prostate cancer screening. All patients need colon cancer screening.

So I think it's important to educate both caregivers and patients, but it starts with how old are you and what screening would you need based on your age? What's your biologic sex? So who were you born as, to start with. I guess who is identity, but what was your biology when you were born? And now who are you and what hormones have you taken and what surgeries have you had. And you have to put all of that information together. So as you can imagine, it's a little bit more complicated than taking care of a cisgender individual, but it certainly is important.

Kate Kaput:
That makes a lot of sense, and then I think going back to the importance of culturally competent trans care, it makes it all the more important because it's not just a one and done, a surgery and then never approached again. It's really a whole person, whole body approach for the entirety of a trans patient's life. Let's talk a little bit about support for transgender patients.

Specifically I know that transgender people often have to deal with other people's curiosity and opinions about their choices, surgical and otherwise, in terms of how they present. How can trans patients deal with questions or accusations or judgment from people in their lives, especially, and including loved ones who might try to sway their decision one way or the other about having a particular kind of surgery?

Dr. Cecile Ferrando:
Oh, I mean, it's such a difficult question to answer because everybody's experience is different. I've cared for patients who have very supportive families and friends, so their transition is a lot easier in some respects.

I've had others who have felt pretty marginalized in their lives and are alone with that transition.

And then I have this third category, it's one that you allude to, where there's some support, but those support individuals are questioning a lot and adding a lot of stressors to the patient's decision. So the answer really is that this is about one's personal journey and, like all of us, regardless of whether we're cis or trans, we have to look in the mirror and we all are responsible for deciding who we are, whether that's about our identity or what our mission is in life and what kind of sibling we are, what kind of parent we are, and we have to choose to be on our own path with regard to that.

On top of it, we all get the choice of how we look and how we're going to express ourselves. With transgender individuals, it's trickier. Somebody who identifies as female and feels like they look masculine, through their eyes and through their lens needs to make a decision about whether they want to alter those features to be able to... The term we use is pass in society.

Our society has evolved, but it hasn't evolved to a point where people don't sometimes feel uncomfortable in certain public situations, unfortunately, and it is a reality than anybody who has any kind of disability has to confront our society with things that may be challenging based upon either physical features or the way we present ourselves.

So the advice that I usually give is that, again, it needs to be, these are personal decisions and nobody is in charge of anybody when it comes to what treatment we decide to pursue. We luckily live in a world right now, certainly in the United States, where many of the services are now covered by healthcare and by healthcare and insurance. So patients don't have to work as hard to be able to obtain some of these procedures, which is a really good thing because they're very expensive. So if you're talking about a very marginalized group to begin with, usually expense is a very big part of someone's decision.

Now that we've removed that obstacle, and the last obstacle remains what people are going to think and whether they're going to make them feel lesser of a person for choosing this path is a personal challenge that individuals have to overcome.

What's interesting is the reverse, is people feeling pressured to do something just because they feel like if they don't do it, they won't be all masculine or all female. There's a reverse situation that also happens that I've encountered. So there's not just the pressures of, "Oh, my spouse or my mother doesn't feel comfortable with me completely feminizing myself," it's the reverse. Sometimes it's intimate partners. Sometimes it's individuals within that person's community saying that you're not female enough, or you're not masculine enough unless you've had those procedures. And again, it comes down to asking patients, when you look in the mirror, what do you see? What do you want to see? And then my response is how can I help you align those two things?

Kate Kaput:
I think that transitions nicely into the next question, to talk about support and how we can provide support to transgender patients. For those of us who love someone who is considering a gender affirmation surgery, whether they're our partner, our child, our friend, what are some of the ways that we can be most supportive? What kinds of relationship support do individuals undergoing trans related surgeries typically need from their loved ones?

Dr. Cecile Ferrando:
My best outcomes have been with patients who come for their surgeries with support people who are happy to be there with them and who show and express love and compassion and empathy for those individuals. The patients who've had the least amount of support are the ones who have the most challenges recovering from surgery. Even if the surgery went perfectly and well, there's a huge emotional component, and lack of support leads to poor outcomes, it leads to poor self-efficacy after surgery healing. There are things during some of the surgeries that patients have to do after surgery to maintain their surgery the first few months. And if they don't feel good about themselves or their decisions or they just feel completely unsupported or alone, they sometimes don't have that sense of willpower, ability to do the things they're supposed to do, which leads to poor outcomes unfortunately.

So part of what we do here at the Cleveland Clinic and something that we do really well is that we really do assess patients for their support on day one. So when somebody comes to see me for a consultation, I do the regular consultation, what's their history, their surgeries, their medical history. But one of my last questions is who is going to come with you during the surgical process? What is their name, what are their names? Who are they in your life? And then if they don't have anybody, we actually work to figure that out for them. So we have somebody, part of their job is dedicated to helping figure out what the support is going to be around the time of the surgery, because it is such an important part.

It's hard for some families to wrap their around what either their child is going through or their spouse's going through. These kinds of changes don't just affect the person. They affect their entire micro community or their family. So we also spend time referring families to various resources so that they have family support as well.

One of the things we also do here at Cleveland Clinic is we affirm families also. We validate them for feeling what they're feeling as they're helping their loved one go through this, but we also commend them for being at their side. So that support is key. And I think that as a society we're doing a better job making trans people more visible and representing trans people in positive ways.

I recently was watching a documentary that said this really well, but it's hard for trans people to even picture themselves in the world if they don't see themselves already being projected in the world. So I think as a society we're doing better creating that support. We just have to make sure we keep doing it responsibly.

Kate Kaput:
You talked a little bit about some of these resources just now, but I'd like to dig a little bit deeper. In a surgical sense and beyond what other kinds of resources are available to trans patients, especially to those who might not have those strong support systems in their personal lives, as they're going through some of these concerns, medical and otherwise?

Dr. Cecile Ferrando:
The trans community is a pretty strong community. There's a lot of conversations through social media and different virtual platforms. I know this, my patients share with me a lot of the information they share amongst each other. There's actually a lot of virtual discussions about surgeons and what surgeons have to offer their patients. So I know that's how referrals are often made. From a healthcare perspective, we as the Cleveland Clinic have done a really good job putting a lot of good healthcare information out on the internet and also through our own virtual platforms.

There are other big groups like the University of California San Francisco provides a lot of patient support and education through their online resources. There's a group called the Fenway Group out of Boston that also has a tremendous amount of resources. These are all academic centers that really have focused on transgender care. WPATH, the society also has information for patients. So I think there are more and more reputable sources for patients to really understand their options. But again, I think many patients connect with each other virtually to be able to support each other. And from what I understand from my patients, a lot of the support patients seek is from each other.

Kate Kaput:
Dr. Ferrando, as we start to wrap up today, is there anything that we haven't talked about that you think is important on this topic for our listeners to know, transgender patients or cisgender listeners?

Dr. Cecile Ferrando:
You know, I think that there's this misconception that we are now... That more and more people are transgender. What's really happening is that we're just seeing people who are transgender. Transgender people have never... They're not just coming out of the woodwork now because our society is evolving. If you actually look from an epidemiologic standpoint, it's not that we have in the last decade more transgender people, it's just that we're talking about it now. There are almost just as many individuals who identify as transgender as there are type 1 diabetics in the United States. That's a lot of people.

So I think that the important points for patients is that we continue to evolve. We have good health care resources. We're continuing to educate. We're continuing to make transgender care a priority amongst all specialties, not just individuals seeking to care for transgender patients specifically.

And then for the the rest of the community, there's a lot going on in this patient population, and they need a lot of love and support because their journeys are complicated and difficult, and they're made much easier when we just offer empathy and compassion. I'm proud to work at a place that has prioritized that and has made it a mission, and I hope to continue seeing that through other medical communities.

Kate Kaput:
Dr. Ferrando, thank you so much for being here today. If you would like to schedule an appointment with the Cleveland Clinic Center for Lesbian, Gay, Bisexual, and Transgender care, please visit clevelandclinic.org/lgbthealth, or call 216-445-6308. Thanks for joining us today.

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