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Bill Klaproth (Host):  So, what is gender confirmation surgery? Why is it done? And what do you need to know? So, let’s find out with Dr. Thomas Satterwhite, a Plastic Surgeon.

This is the Healing Podcast from MarinHealth. I’m Bill Klaproth. Dr. Satterwhite, thank you so much for your time. So, first off, what is gender confirmation surgery and why is it done?

Thomas Satterwhite, MD (Guest):  So, gender confirmation surgery is a series of procedures that’s done in order to align one’s body to their gender identity. And so, it’s important to think of gender as not something that’s defined by your overall outside appearance but by how you feel inside; your internal, mental perception of yourself. So, there are you know a small percentage of people in this world anywhere from one to 30,000 to one to 100,000 who suffer from a condition – I refer to it as gender dysphoria where once again, the mind isn’t aligned with the body and this leads to a huge degree of psychosocial distress.

So, gender confirmation surgery is done once again, to align the body to one’s internal gender to bring about resolution of gender dysphoria.

Host:  And so how should we think of this? Is this considered aesthetic or reconstructive surgery?

Dr. Satterwhite:  And this is actually viewed as reconstructive surgery. Once again, it is medically necessary. These are procedures that help with individual’s psychosocial wellbeing. It helps with the treatment of gender dysphoria with resolution and most cases depression, anxiety. It allows patients to better take care of themselves and so truly this is a reconstructive series of procedures and not cosmetic.

Host:  So, there’s real medical and mental positive value to this. So, it’s easy to understand why this is considered reconstructive surgery. So, what types of procedures are done for male to female or feminizing surgery?

Dr. Satterwhite:  And there are a whole host of operations that can be done for feminizing. And starting from the top, facial feminization surgery which is to eradicate all masculine features of the face and to create a more feminine face. Breast augmentation or chest feminization typically involves the placement of implants. Vaginoplasty which is basically removing the male genitalia and then creating a vagina. And there’s also body contouring. So, body contouring is done to create a more feminine appearance so typically adding more fat to the butt and to the hips to create more of an hourglass feminine figure.

Host:  It sounds like this procedure or set of procedures include both functional such as sexual and physical transformation such as appearance.

Dr. Satterwhite:  It’s true. So, there are functional and there are appearance or aesthetic aspects to these operations and that’s the need for plastic surgery in general. But everything we do does encompass with the functional and the aesthetic aspects of it. And you can particularly see it certainly in vaginoplasty which is not just the appearance of creating a vagina but also having the functional aspects of a vagina in terms of engaging in comfortable sexual intercourse if the patients chooses to do so. So, yes, it’s both aspects.

Host:  I’m going to ask you about what is nonbinary gender confirmation surgery?

Dr. Satterwhite:  Yes, so nonbinary surgery is something that’s been developing over the past few years or so. What’s really important to understand and once again this also can be difficult for a lot of patients to wrap their heads around is that gender in and of itself, should not be viewed in a binary fashion meaning either male or female. Because there are patients out there who identify as both male or female or neither male or female or one day might identify as male and the next day as female. So, there are patients who identify once again, and this is a very nonbinary or gender fluid or sometimes even agender spectrum.

So, in those cases, patients may pursue operations that may not be seen as standard. So, there are patients who request having vaginoplasty for example but rather than having a full depth vagina will have what’s called a minimal depth vaginoplasty where they have the outside appearance but don’t want a vaginal canal. Or there are some patients who want to have mastectomies so trans-male patients who want to have the breast tissue removed but they don’t want their nipples placed back on, they just want to have the mastectomy itself. And once again, going back to vaginoplasties, there are some patients who say you know, I’m not unhappy with having my current genitalia, but I’d feel more complete is I did have a vagina as well so there are some patients who have what’s referred to as a phallus preserving vaginoplasty where they maintain their current genitalia but have a vagina created along with it.

And so these are definitely changing – the procedures that have been going on. And a lot of it is dictated by the changing aspects of the community.

Host:  Well it’s good to hear that it seems like there’s an evolution in these procedures and practices so that’s good news. So, then what sort of preparation do patients have to do before making the decision to undergo gender confirmation surgery?

Dr. Satterwhite:  Yeah, so preparation is an important part of the operation. I tell all of my patients this that the hardest part is getting yourself ready and the second hardest part is the recovery. So, in terms of moving forward, patients do need to follow the guidelines that are set forth by the World Professional Association of Transgender Health which is WPATH, it’s a consortium of medical and mental health professionals and researchers that have created guidelines that patients must follow before moving forward with operations or any type of gender affirming care. So, patients typically need to be on – they need to be living in their desired gender for at least a year in most cases.

For several of the operations, particularly for vaginoplasty, they do need to be on hormones, so feminizing hormones, so estrogen and progesterone for at least a year. They need to have two letters from mental health therapists before moving forward. And patients need to prove that they do have true understanding of what the operation is, what the limitations are, what the postoperative complications can be and what the wound care is involved, and they also need to have good support. They need to prove that they have a good social support system before moving forward which is essential for good postoperative care.

Host:  Right and then let’s talk about the financial aspect of it. Does insurance cover gender confirmation surgery?

Dr. Satterwhite:  We are fortunate in California that gender confirmation surgery is covered by most insurance plans. And this includes all aspects of gender affirming surgery. And there had been a long time when insurance coverage was not provided because it was deemed cosmetic but now that we view these operations as reconstructive, more and more insurance companies are indeed covering them.

Host:  This is a very unique specialization. Is there special training that you had to go through?

Dr. Satterwhite:  It is a very specialized area. It’s a niche within a niche within a niche. So, my background is in plastic surgery, so a surgical specialty and I actually spent another year doing a craniofacial fellowship and this helped with my background in facial feminization surgery. I joined another surgeon in 2014. It was in Marin and from him I learned how to perform vaginoplasties because during my training, I wasn’t exposed to gender confirmation surgery. From there, I had visited other surgeons as well and I had learned from them and then since then, from 2014 onwards, the training process now is different. There are fellowship programs that are available in the United States and throughout the world. So, rather than having to do the whole apprenticeship model which I went through, most other surgeons in the past have gone through, patients can actually get more formalized training in these fellowship programs.

Host:  This is a really, really interesting. So, how should someone go about finding experts like you and your team?

Dr. Satterwhite:  In terms of finding appropriate medical professionals and surgeons; it is important to do your homework. The WPATH website once again, the World Professional Association of Transgender Health, WPATH.org, you can go there and there’s a way of finding a provider and so you can find providers based on a geographical location. I think that’s the best source to go to. There’s a multitude of conferences that are available that people can attend both patients and healthcare providers. There’s one conference called Gender Odyssey, another one called Gender Spectrum which are both here in California. And these are wonderful opportunities to learn more about the operations. Those are definitely the best ways to find the appropriate healthcare providers.

Host:  And what should they look for to assess the team and the program?

Dr. Satterwhite:  Starting with patients, so patients, they really should be looking for someone who has had a lot of experience, who has a good team around them to provide a lot of their care. And then I think that’s also the same thing for referral services as well to really have a surgeon who does have a good team, has a lot of experience and has the compassion and has good results.

Host:  And last question Dr. Satterwhite, as you said, this is a niche of a niche of a niche. What made you want to go into gender confirmation surgery?

Dr. Satterwhite:  That’s a very good question. So, gender confirmation surgery once again, is a very sub, sub specialized area and I think what had motivated me to follow this journey is a lot of events that have happened in my own life both personally and professionally. I think myself, as a gay, black man, I’ve had my own personal struggles, struggles with my family, struggle with society and I think in many respects, that has made me prime to want to work with the disadvantaged community. I have always wanted to do that so I can find that connection. And I think at this point, the transgender community is the most marginalized and disadvantaged community as it stands right now in the United States and hopefully that will change. So, from a personal front, that was my motivation. From a professional front, I always knew that I wanted to go into surgery.

I was originally going to go into transplant surgery and then became very fascinated by gender confirmation surgery. So, several of my mentors from Stanford had been pioneers in gender affirming surgery. And they were retired when I was a medical student and a resident at that point but they still had taken me under their wing and I learned a lot from them and that I think generated that spark and that I just carried that along and as I met more and more doctors who were doing this work, and it resonated with me. And I knew that this was a path that I wanted to take.

Host:  Well you’re performing a valuable service to what you call a marginalized community. So, I know a lot of people are very appreciative of your efforts. Dr. Satterwhite, thank you so much for your time. This has really been interesting and informative. Thanks again.

Dr. Satterwhite:  It’s my pleasure. Take care.

Host:  That’s Dr. Thomas Satterwhite and for more information, please visit www.mymarinhealth.org and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is the Healing Podcast brought to you by MarinHealth. I’m Bill Klaproth. Thanks for listening.