Gender-affirming surgeries are on the rise, according to statistics from the American Society of Plastic Surgeons. More than 16,000 transgender patients received chest, genital or facial surgery in 2020, up 12 percent from 2019.
The demand is there, but learning how to perform breast augmentation and mastectomy (also known as top surgery), vaginoplasty and phalloplasty (also known as bottom surgery), glottoplasty (voice surgery) and craniofacial contouring for trans patients is not currently a required part of the plastic surgery residency curriculum.
Rishub Das, medical student with the Department of Plastic Surgery at Vanderbilt University, authored a paper together with Brian Drolet, associate professor of plastic surgery at Vanderbilt, advocating for implementation of gender-affirming surgery into the curriculum.
What do you hope is the outcome of the paper you co-wrote?
That's the main goal with writing this piece, was just that [gender-affirming surgery] isn't a central part of the curriculum, but more and more surgeons are seeking it to be a part of their experience when they go to residency programs, or medical students who are interested in a career in surgery. I think people are coming to understand that it's just a core type of surgery that deserves a little bit more attention in terms of education and training. And maybe if it is a part of the curriculum, there'll be more surgeons who are trained in those surgeries so people will have more access to it.
Is there adequate access to GAS in Nashville right now?
I would say from the payer standpoint, insurers are covering the surgeries for patients who meet the requirements — which means that they just start going through the health care system, they have a primary care provider, they've seen a mental health professional, their gender dysphoria is well documented. Then, we would go ahead and do surgery at Vanderbilt. In terms of other providers, it's very scarce in this area, and there are not many providers who are trained and who are offering the surgery.
If someone had not learned gender-affirming surgeries in school, could they go back and learn now?
I think that the current people who are performing gender-affirming surgery likely do not have any specific training in it; it's more something that they just picked up in their practice. And a lot of the surgeries are based on surgeries that we already do. Like for example, when we do a masculinizing chest surgery, we're basically just removing a transgender man's breasts and that's just a mastectomy. It's a little bit modified to make more of a cosmetic appearance in terms of the scarring and to maybe create some fullness to the chest to replicate [the] pec muscle. … That's one of the things that we addressed in the article is that it would be great if this was just standardized and everybody got the same training who undergoes surgical residency. That way there isn't a need to go back and do the training or to do a fellowship, because it would just be part of the program.
What are the risk factors and recovery times of these surgeries?
These surgeries are still new — the gender-affirming surgeries and the bottom surgery in particular. There are some complications that are pretty significant. They're not life threatening, but they definitely do alter somebody's quality of life. And so we obviously make that very clear to patients. But for some surgeons, that might be seen as unethical to them to undergo these procedures. They might not understand weighing the risks and benefits. For some of our patients, their gender dysphoria [is] so severe that their quality of life is just so bad anyways without these surgeries. Even if it does mean that they have a small complication or if they have an extended hospital stay, they're willing to take that risk. Because they just need it.
Beyond learning the surgeries, are there social aspects that surgeons should learn?
I think the medical community has a lot of work to do on this front in terms of educating providers, especially older providers who aren't really getting education now about LGBTQ+ identities in general. I think transgender folks and nonbinary folks are now increasingly entering the health care system because they are seeking hormone therapy, which has been shown to be very effective in treating dysphoria.
I think as providers interact with more people from LGBTQ+ identities, we'll start to realize that creating affirming environments is going to be essential to making sure that they have equivalent health outcomes as any other patients would.