Gender Confirmation Surgery at Penn Medicine | An Interview with Caroline Cox, MD Melanie Cole: Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole Cole and I invite you to listen as we discuss gender confirmation surgery at Penn Medicine. Joining me is Dr. Caroline Cox. She's an Assistant Professor of Clinical Obstetrics and Gynecology at Penn Medicine. Melanie: Dr. Cox, it's a pleasure to have you join us today. As we get into gender confirmation surgery, before we that, tell us some of the medical ills and healthcare disparities that transgender people face. Dr Caroline Cox: Sure. I think this is a really important issue to highlight, as transgender and gender nonconforming patients have faced a lot of discrimination, not only in their general lives, but especially in the medical field. So we have a chance to really step up as providers and combat these disparities here. But traditionally studies have shown that transgender and gender nonconforming patients have faced discrimination in healthcare. They have faced really sometimes completely, unprofessional behavior from providers who maybe just don't understand what they're facing as transgender patients or don't know really the right words to say. So all of these interactions can lead to these patients then avoiding healthcare and potentially not getting even the basic screening tests that they need or the really basic medical care that they need. Melanie: Thank you for that. And Dr. Cox, you specialize in urogynecology, which includes gender confirmation surgeries. Tell us a little bit about the training necessary to perform gender confirmation surgery. What's involved? Dr Cox: So right now, these surgeries are really not done by a very large number of providers. And I will say to be honest, most urogynecologists are not trained in gender confirmation surgeries. I happened to go to a fellowship training program at University of Michigan, where there was a large well-coordinated center for transgender care. And so we had a lot of transgender patients and I commonly performed these surgeries in my fellowship, and that's how I learned. And I think that's how most surgeons are learning these days are from kind of more like mentorship, apprenticeship type training programs. But the training really vary depending on what type of surgery it is. So focusing on the type of surgery I do as a urogynecologist, it really coincides well with the typical urogynecology surgery I do, which is vaginal surgery, because the type of gender confirmation surgery I do is called vaginectomy, where we deepithelialize the vagina and then close it off. Melanie: So Dr. Cox, in addition to comprehensive understanding of the procedures, hormones, other risks involved in gender affirming surgery, tell us some of the other steps that you feel are important to note for providers that must be accomplished before these surgeries can take place. Dr Cox: There is an organization called the World Professional Association for Transgender Health or WPATH that sets out the minimum requirements for surgical intervention on individuals who want to have gender affirmation surgery. It is quite a long list of requirements and most well-trained surgeons that, you know, I'm familiar with follow these recommendations and I do as well, but it involves the age requirement being the legal age of majority, having a persistent well-documented gender dysphoria, and it goes on from there. And some of the requirements include letters from mental health providers as well. So these are very, very specific prerequisites for this type of surgery that we essentially as the providers just follow what the WPATH tells us. Melanie: So then tell us how complicated the surgeries are and what's involved. Give us a brief overview of the LGBTQ program at Penn Medicine, and really tell us what you're doing with patients. Dr Cox: Sure. So the LGBTQ program at Penn Medicine is really evolving. And the group that is working on it, we actually just met a couple of weeks ago virtually and have been talking about how we want to go forward and we really do want to grow the surgical options here at Penn and make it a more coordinated effort, easier for patients to navigate. So that's where we are in the process at Penn. And it's a lot of different specialties working together, which is always exciting to see, no matter what area it is. But personally, the type of surgeries I do, as I mentioned before is vaginectomy, and I also do, as many other gynecologists will do, hysterectomy and oophorectomy for people assigned female at birth who are transitioning to male. And for this type of surgery, the hysterectomy and oophorectomy is pretty bread and butter for OB-GYNs. Typically for us, a pretty simple surgery removing the uterus tubes and ovaries. And then the vaginectomy is the more specialized part that I am trained to do. And it does sound simple when you just think about it, of just removing all of the epithelium from the vagina and closing it to remove the dead space. But technically it is challenging typically because these are individuals with very narrow, vaginas, very long vaginas, which just technically makes the surgery more difficult. And often the effect of testosterone on the vaginal epithelium is that it becomes very fragile, it tears very easily. So it's a bit tedious to remove off the epithelium in this case and traditionally the surgeries have been rather bloody as well. So over time, we've worked on strategies to reduce the blood loss associated with these surgeries and had really, really great success with some of these techniques. Melanie: Doctor, and this is such a really fascinating topic, tell us a little bit about the follow-up for the patient since surgery isn't the only aspect and we mentioned a little bit of this in steps involved in pre-surgical workup. What are some important things to note for the patient? What kind of support do they need as they transition and after surgery? Dr Cox: The patients really do need support and I really believe that all transgender care needs to be interdisciplinary for it to function well. As a surgeon. I'm not involved in prescribing hormones for transitioning, but I have to work with providers who do prescribe those hormones to give that aspect of care, of course, the mental health aspect of care. And then some of the surgeries are done by really, really disparate types of surgeons as well. So patients will often get chest surgery in addition to genital surgery. They may get facial surgery to change the look of their face. They might get voice surgery to change the tone of the voice. So it really involves a lot of providers working together. And that's exactly what we're working on here at Penn, is trying to create the optimal way for that to happen, for us all to talk, to share our patients, to make sure they're navigating through the system with some type of assistance and trying to make that easier for all of them, to make the experience better for the patients. Melanie: Well, it certainly is a multidisciplinary and interdisciplinary approach. So tell us about an experience you had with a patient and their choice to undergo gender confirmation surgery. Dr Cox: So there is one patient that really stands out to me as having a big impact on me. And this was a patient from when I was at University of Michigan. And this patient had traveled from out of state to have his gender affirmation surgery. So he was born female at birth, but living as a transgender man. And he had already had his hysterectomy, but came to us for his oophorectomy and vaginectomy. So we were planning to start the surgery with the laparoscopic oophorectomy and then planning to do the vaginal portion of the surgery with the vaginectomy. And to us, this was a pretty standard surgery. We really didn't have any concerns, but essentially as soon as we had started the laparoscopic surgery and we had insufflated the abdomen, we put the laparoscope into the abdomen, he went into cardiac arrest. And I had never had this happen personally as a surgeon before, but myself and the resident that I was operating with immediately had to start doing chest compressions on him. And the anesthesiologist had to call a code and the anesthesiology team was able to resuscitate him in the operating room, and then brought him to the ICU to recover. And to me, this was as big of a complication as I could possibly imagine during a surgery. But when I went to talk to him, when he was extubated later in the day to talk about what had happened, really all he wanted to know can we do my surgery tomorrow?" And so that really hit me in just that to him this is not an elective surgery, this is not a cosmetic surgery. This is an absolutely essential surgery to his identity, so much that he wanted to go back to surgery the next day after his heart had completely stopped. So it had a huge impact, just solidifying the fact in my mind that these are really essential surgeries for these patients. Melanie: Well Well, that certainly does. And Dr. Cox, as we wrap up, please tell other physicians what you'd like them to know about when you feel it's important that they refer to the specialists at Penn Medicine, and please reiterate the importance of this continuum of care for gender affirmation surgery.