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10. Gender Affirming Surgery with Dr. Shubham Gupta
95 Plays1 year ago
June is Pride Month! And in honor of this, we want to highlight the various kinds of Gender Affirming Surgery and medical care.
So what is Gender Affirming Surgery? Gender Affirming Surgery (GAS), also known as gender confirmation surgery or sex reassignment surgery, encompasses a variety of surgical procedures that some transgender and non-binary individuals may choose to undergo to align their physical appearance with their gender identity. These procedures can be broadly categorized into chest surgeries, genital surgeries, facial surgeries, and other body contouring procedures. Here's a more detailed breakdown:
The primary aim of gender affirming surgery is to alleviate gender dysphoria, a condition where there is a significant incongruence between one's gender identity and their physical sex characteristics. These surgeries can have profound psychological and social benefits, improving quality of life and mental health for many individuals.
Let’s find out more from Dr. Shubham Gupta, Chief of Reconstructive Urology at University Hospitals, Cleveland Medical Center.
Dr. Shubham Gupta focuses his clinical practice on genitourinary reconstruction and cancer survivorship. His expertise includes the diagnosis and treatment of urethral stricture disease, Peyronie's disease, erectile dysfunction, and male urinary incontinence. He has a special interest and extensive experience in managing complex intra-abdominal strictures, fistulas, and radiation sequelae. Additionally, utilizing multi-disciplinary collaborative models, he provides advanced care to transgender patients, including gender-affirming surgery.
Featured in this episode:
- Types of gender affirming surgery
- Sexuality and GAS
- The difference between transfeminine and transmasculine procedures
- The difference between sexual orientation and gender identity
- Not all transgender or non-binary individuals pursue surgery as part of their transition
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Transcript
Gender Affirming Surgery Overview
00:00:01
Speaker
We are coming out of the operating room for one of the first gender affirming surgeries that I participated in. I'm a gynecologist, so I do the vulvar part, the external portion, and I help with the vaginal canal as well to make sure that it's going to be functional after surgery. But I'm basically am in charge of doing all the external vulva vaginal aspects of the procedure. As we were rolling from the operating room to the recovery area, our patient was starting to come out of her anesthesia. And the first thing that she said was, freedom. She said, I'm finally free. And it struck me that it had been years that she felt that she was trapped in the wrong body and that her identity did not align with the way she looked.
00:00:43
Speaker
I was so happy to be part of the procedure that helped her get to that place. And she thanked all of us for doing that
Post-Surgery Experiences: Freedom and Unwanted Attention
00:00:51
Speaker
for her. A year went by and she really had come into her own and she was blending in to her surroundings. And she asked me, she said, you know, I used to notice that people kind of would look at me and I wondered if it was because they suspected that I was trans, but I'm pretty sure I'm passing now. And when I'm on public transportation, I see these men leering at me. And it's so creepy. And I just want to punch them in their face. And I looked at her and I said, welcome to being a woman.
00:01:26
Speaker
She was passing and they weren't looking at her because they thought that she was somebody different or maybe they were wondering or curious if she was transgender, but honestly they were looking at her as a woman and they were lusting after her or they were just feeling completely free to stare at her and that made her feel uncomfortable. We talked about this world that we live in where men feel totally fine with doing that and how uncomfortable it makes women and yet men still do that. We talked about her taking a self-defense class and just making sure that she felt like she had ways to stay safe. And again, it kind of made me sad. Wow. She had reached her free point where she had found alignment with her identity.
00:02:13
Speaker
but now she was going to have to deal with the discrimination that the average woman experiences in the US every day.
Role of Reconstructive Urology in Gender-Affirming Care
00:02:21
Speaker
All right, welcome back everybody to Arwell Manatee. I am pleased to be here with my friend and colleague, Dr. Shubham Gupta. Dr. Gupta is a reconstructive urologist. He's the director of the Gender Care Program at University Hospital's Cleveland Medical Center. Of course, his views do not necessarily reflect those of his employer, just as a disclaimer, but he is a leader in our institution and he is the one not only leading the programs, but also doing the surgery for gender-affirming care and and surgery.
00:02:49
Speaker
So welcome, Dr. Gupta. Thank you so much for your time today. Thanks so much for having me. I've been wanting to come on the podcast for a very long time. I've been lobbying ah various interest groups and finally I made it. I made the cut. So thanks for having me. Well, I only recently opened up my guests to men. I've only even been interviewing women and I thought, okay, I need to also interview some men. whatever Whatever works. Even if I'm the diversity candidate, I'm perfectly fine with it. Oh, well, certainly you're here for your expertise and I'm so happy to have you here. and
00:03:23
Speaker
I just thought you know with Pride Month being here, we really want to know more about transgender issues,
Navigating Patient-Centric Care Amid Social Noise
00:03:31
Speaker
transgender medicine. I think a lot of people who work in medicine and people who do not work in medicine are interested in this topic. you know I get a lot of questions. I'm sure you get even more questions when you're at dinner parties or wherever you are because people are just curious. And so I wanted to kind of just pick your brain. Can you tell our audience for trans women who are coming to see you? What are they coming to see you for? Yeah, I mean, just to kind of zoom out for a little bit, you're absolutely right. I mean, these issues concerning transgender people are front and center, but they're front and center for a variety of reasons. And a lot of them have to
00:04:06
Speaker
Do with you know the political wins of the day ah you know the social consciousness and some of those things are positive some of those things are negative but at the end of the day like when when someone comes to see us or say gender affirming surgery or gender affirming care. You know, it's it's important from a healthcare professional standpoint to cast all of those noises to the side and just focus on the patient and the community. So, you know, as you referenced, you know, we have ah we have a comprehensive gender care program at university hospitals and it is supported by some pretty fabulous nonclinical staff who make sure that the patient flow and the patient navigation piece is as close to seamless and flawless as
Understanding Gender-Affirming Surgery Options
00:04:49
Speaker
possible.
00:04:49
Speaker
people who come to me come to me for the so for surgical reasons, some instances where people will come to me seeking just general advice and general guidelines on gender care and we are happy to provide that. but Confining the discussion to gender-affirming surgery, if a transfeminine patient were to come to us seeking care, most of her questions would be centered around what are the options for gender-affirming surgery. And the discussion we might have is sometimes we have to kind of discuss what gender-affirming surgery itself means. And really what it means is a surgical intervention that affirms the patient's gender identity. And that could be as simple.
00:05:32
Speaker
as, you know, a small area of liposuction in the arms or in the abdomen or something like that. It could be facial related things like rhinoplasty or no surgery or jaw surgery or tracheal shave, or it could be breast augmentation, or it could be bottom surgery, also called genital surgery. So for the purposes of simplicity, I like to think that any surgeries that are below the waistline are bottom surgeries. And that's where people like me kind of come into play. And then any surgeries that are above the waistline or stop surgeries. And that's typically the area that we involve plastic surgeons and ENT surgeons and other surgeons for that. So trans women comes to me seeking advice about bottom surgery.
Patient Goals: Aesthetic and Functional Objectives
00:06:15
Speaker
What we would typically do is explain to them what bottom surgery and means.
00:06:20
Speaker
And there's not really really a set template, at least in my clinic. My first objective is to try and understand what the patient's own goals are, what the patient understands when they say, hey, I have distress or dysphoria. What the patient means when they say, I want to have genitals that look like my appropriate gender. If they have any specific aesthetic, if they have any specific functional other goals and objectives that
Gender Incongruence and Dysphoria
00:06:46
Speaker
they want to meet. so I mean, you do provide surgery that's transmasculinizing and transfeminizing. And I realize even as I'm asking the question that probably a lot of listeners won't even know what that means. So do you mind explaining what that means? Because like you said, you we do you know try to offer full spectrum ah options.
00:07:06
Speaker
So when a person is born with a specific set of genitals, they would be assigned a certain sex when they're born, right? So a child is born with a penis and testicles, they'd be called a male. The vast majority of the time, as a child grows up, this inner sense of identity, who they are, is congruent with or aligns with their genitals and the sex they were assigned at birth. And in a small minority of patients, and you know that's up to 0.6% to 1% of the US population, for instance, in a small minority of patients, there's a mismatch. So they may have genitalia that are male genitalia, having a penis and testicles.
00:07:49
Speaker
but they identify as a woman and vice versa. So that is called gender incongruence. So there's an incongruity between the genitalia and the person's gender identity.
Misconceptions About Gender Dysphoria and Sexual Orientation
00:07:59
Speaker
now That does not mean that they're going to do something about it. you know sometimes Sometimes it is a minor incongruence and there's not something that rises to a level of consciousness. ah That person would want to do something about it. However, a lot of the times there's distress associated with that incongruence. So you look down and there should not belong on your body.
00:08:22
Speaker
and When there's distress associated with the incongruence, that's when we say the person has gender dysphoria. For people like you and I, it's a relatively simple concept to understand, but honestly, personally, I myself had a lot of trouble, you know, when I was very early in the medical, in my medical career, quite understanding the difference between sexual orientation and gender dysphoria. Oh, if someone is gender dysphoria, are they gay? Is that what it means? You know, and and you know, these are not necessarily ignorant or stupid questions. Some people just don't know. And I was one of those people. And the best way I think of framing this is
00:08:59
Speaker
gender identity is who you go to bed as. So if you go to bed as thinking you're a man or woman, you know, that's the gender identity. And sexual orientation is who do you want to go to bed with. So that allows us to really parse the difference between ah gender dysphoria and sexual ah orientation. And it also allows us to understand that someone may have gender dysphoria and they may be gay or someone may have gender dysphoria and they may be straight. And the combination and and permutations are several. So that's what gender dysphoria means. So a trans feminine person or a trans woman is someone who had male genitalia at birth and was assigned the male sex at birth. And they grew up in and realized that no,
00:09:46
Speaker
My gender identity is a female identity, so I'm going to start taking steps to transition to a female. so Hence, trans and feminine. Conversely, a trans masculine person would be someone who is born with female genitalia, external genitalia. And as they grew up, they realized their internal gender identity was masculine, and they would want to take steps to transition into that appropriate gender, and that's transmasculine. You know, the terminology around this has changed. It continues to evolve. you know We used to say transsexual, we don't say transsexual anymore. Some people don't like to say trans women or trans men and like to say trans feminine and trans masculine for a variety of reasons. But the bottom line is that if you understand the basic basic principles and if you have little slip ups here or there, no one really worries about that that much.
00:10:39
Speaker
Yeah. No, that makes sense. And so you do provide surgeries for, I guess, transfeminization and transmasculinization. Can you tell us a little bit about what the different procedures are that you offer?
Vaginoplasty Components and Techniques
00:10:52
Speaker
Yeah. So restricting ourselves to bottom s surgery, so operations and surgeries below the waistline. For transfeminine patient, we would do feminizing genital surgery. So we'll make their genitals look more feminine. catch-all term for this is called vaginoplasty but it it really involves a lot of different surgeries combined into one. So it's a surgery that may take anywhere from four to six hours and there's an overarching premises that we convert the male anatomy into a female anatomy.
00:11:20
Speaker
that is functional as well as aesthetic. And within that, what we do is we have an extirpative part that is removal of the male anatomy part, and then a reconstructive part, creation of the female anatomy part, which includes things like clitoroplasties, making the clitoris and positioning it where it belongs to a woman, urethraplasty, making a urethra and positioning it appropriately, labiaplasty, which is creation of the labia minora and majora. and then as well as creation of the vaginal canal which is the vaginal capacity itself. There are some people who choose not to have a vaginal canal because they are not necessarily interested in or are good candidates for receptive vaginal intercourse and we can do all the external work for them and that's called vulvoplasty or some people call it zero-depth vaginal plastic. So that's that. Now there are some people who also don't want the whole shebang. They have specific parts of their genitalia that cause them distress
00:12:13
Speaker
Some people have specific distress related to their testicles, and we can just do an archeectomy as a standalone procedure, which is removal of the testicles. And sometimes that's good enough for people, you know. Again, it all goes back to understanding what the patient's goals and priorities are, and just have engaging in a true shared decision-making process
Challenges in Creating Phallus Structures for Transmasculine Patients
00:12:32
Speaker
throughout the entire thing. On the other side for transmasculine patients, when we do bottom surgery, the principles are the same. You know, there's a removal of the female anatomy and creation of the male anatomy portions of it. So removal of the female anatomy will include things like hysterectomy.
00:12:46
Speaker
which is removal of the uterus, oophorectomy, which is removal of the ovaries and fallopian tubes, plus or minus. But that's something that you would do yeah that's in your wheelhouse, vaginectomy, enclosure of the vaginal canal. For transmasculine patients, you know the creation of phallus-like structure is one of the big challenges in reconstructive surgery, you know whether it's reconstructive urology or reconstructive plastic surgery. That is the reason why there is not a clear-cut winner as to how to create a phallus-like structure. Once these patients are on testosterone and all of them would be on testosterone before coming to see us,
00:13:23
Speaker
they would have some hypertrophy or growth of the clitoris. And what we can sometimes do is we can mobilize flaps around that hypertrophy clitoris to make them a small neopiness or a mini penis. And that procedure is called metodioplasty. On the other hand, some people want a full size penis, in which case we have to bring tissue from other parts of the body. Whatever part of the body we bring tissue from, we call it such and such phalloplasty. So if we take tissue from the forearm and make a penis out of it, it's called a radial forearm phalloplasty. If we take tissue from the thigh, then it's called anterolateral thigh phalloplasty. If we take tissue from the abdomen, it's called abdominal phalloplasty. If we take tissue from the back, there's a muscle here, latissimus starcisis, that's called an MLD phalloplasty. There are so many different variations and flavors you know here in the US. in In a lot of countries in East Asia, there are ah you know many other flaps that are done.
00:14:20
Speaker
that we don't routinely do here. yeah And the bottom line of that is that we don't really have a clear cut winner as to what kind of masculinizing surgeries would have the best outcomes. Yeah. And speaking of outcomes and also cause our podcast is about sexuality and when you're doing genital surgery, I'm sure the topic of sexuality comes up before and even after
Post-Surgery Sexual Function and Psychological Impact
00:14:40
Speaker
surgery. So can you talk a little bit about, you know, what do patients ask you about? What are the things that you Maybe you want to make sure that they know or, you know, how you approach the topic of sexuality around surgery. That is something that I'm continuing to learn as time goes on. I've learned how to be humble with managing expectations with it. So just because we can create an anatomy that looks like female anatomy, doesn't mean that's going to translate into perfect sexual function that could be expected for a woman.
00:15:13
Speaker
There are a lot of variables that go into it things like sensation around the clitoris, things like latency of the vaginal canal. things like pelvic muscles. There are a lot of psychological things that go into it. And as we've done more and more of this and you know it, there are patients of ours who would have really good aesthetic outcomes that you and I would see and say, hey, this looks great. And they say, hey, I cannot orgasm or I have trouble getting intimate with my partner. You know, this would be the time for me to give a shout out to you because this is something that you realize early on when we started working together.
00:15:47
Speaker
And we're like, hey, let's try and investigate it further. One of the funded studies that you're leading, the status function study, is looking at a lot of sexual and aesthetic and other outcomes after a vaginal plastic. I generally think of hierarchy of surgical techniques or surgical advances. And the first one would be how, let's figure out how to do a specific procedure. The second one would be, let's try and minimize post-operative complications. And the third one would be, let's try and get good, successful technical outcomes. And the last one, the holy grail tippity top would be, let's try and get the functional outcomes that the patients actually want. You know, as well as anyone else, I mean, we've gone through those little phases and pretty much any surgery.
00:16:31
Speaker
whether it's prolapse surgery, whether it's prostate removal surgery, and and so on and so forth. And now I think a lot of physicians in the US, led by folks like you, frankly, who are saying, listen, just having a good aesthetic outcome is not enough. We want to make sure the patients are able to use it for the specific reasons that they are seeking the surgery. So, yeah. Well, thanks for the plug. That's not why I was asking you the question. but But you know, I think like what's so interesting when I talk to some of our patients post-operatively is that I have patients who tell me their orgasms are incredible and that they can have extended orgasms or multiple orgasms and they are way happier than they ever were before because that dysphoria is gone, but then also they're having really good
00:17:16
Speaker
outcomes I guess are sensation really and then I have some patients who really are struggling with it and like you said sometimes there's a psychological component and I tell my patients like it's almost like you're going through puberty again trying to get to know yourself trying to figure out how things work and then eventually they can get there and then there's that minority of patients who They just don't feel that much or there's really a bigger issue. They might need another surgery or they might need some other medical intervention. I know it's it's a frustrating thing because
Pre-Surgery Orgasm Experience and Post-Surgery Satisfaction
00:17:45
Speaker
I haven't figured it out. I don't know if you if you have any comments on it, like how to predict that, right? I think counseling and preoperative assessment are crucial for it. There are some people who believe that one of the big predictors is if a person has never had an orgasm before for whatever reason, they may have trouble having an orgasm after, even after having the correct anatomy and stuff. but
00:18:05
Speaker
I'm not entirely sure whether that's been validated or not. Let me ask you a question. We find in our trans feminine patients is after vaginoplasty, the majority of them when they have an orgasm, it's from clitoral stimulation. And it is true in the cisgender population too, right? Right, 80%. I think that's about the same in our patients as well, right? So I mean, that's an important thing for people to understand that it's not just the vaginal canal itself, it's just clitoris sensation around there that's important. It's almost like welcome to the world of being a woman, right? I've had some really interesting conversations with my patients like even about you know the way that they're walking through life as women once they really have achieved their goals of their physical expression of like a feminine expression and sometimes they encounter things that are not necessarily pleasant
00:18:53
Speaker
like difficulty with orgasm or sexual harassment it's kind of amazing to see that play out in front of us oh absolutely and things like urination when they have like a faux penis and a long urethra they're used to even if they sit and pee it's easy to direct the stream when we shorten the urethra it's like spraying everywhere it could be a hot mess it's true i have visual operations all the time don't worry most of my patients have the same issue Then some of those patients may be predisposed to infections because of shorter urethra or vaginal microbiome and things like that.
Intersection of Race and Gender Transition
00:19:24
Speaker
So one interesting anecdote that I heard from, didn't happen to my patient, one of my colleagues' patients was she had a trans masculine patient, so female to male, and it was a black patient. He was like, you know, I had experienced discrimination and dysphoria and everything else when I was a woman, but then when I became a man, I experienced real racism, you know? So ah going back to when you go that specific
00:19:48
Speaker
phenotype and the gender expression, all the goods and the bads come with it. Oh my goodness. Yeah. That's, that is striking. Wow. You know, you want to help support your patients to to meet their goals of their identity. That's not something I had you know previously really thought about even mentioning when talking about your hormones start to change the way you look and start dressing to that match your identity and and the way the world perceives you. And then it's going to possibly treat you differently. Yeah. So also just kind of going back to orgasm, I know the way that we create the clitoris, would you speak a little bit about it's not exactly the same as a native clitoris? And so can you speak a little bit about where those nerves are and where the sensation might be and and what you found for your patients?
Ensuring Sensation in Clitoroplasty
00:20:33
Speaker
Yeah, for sure. So when we look at a female clitoris, and then we look at the male glance penis that is the head of the penis, head of the penis with the underlying erectile bodies, I mean, they're homologous structures. And just over a period of development and hormones and stuff, they're developed into two distinct looking appendages. so When we try and understand that anatomy and respect it, that's how we are able to deconstruct a penis and do a reduction clitoroplasty so that the glands' penis becomes the clitoris. So we make it smaller. But at the same time, we preserve the entire neurovascular bundle that includes the nerves that provide sensation to as well as the blood vessels that ah carry blood to and from the clitoris.
00:21:17
Speaker
Right. Because honestly, I've watched a lot of surgeons operate. And when I watch you dissect for the, you know, to keep the neurovascular bundle intact, I think that you honestly are one of the most meticulous surgeons in this aspect. And it is probably the most important part of the procedure, especially when we're talking about sexual function. So there probably is some difference there and technique. For sure. And yeah, will your case of wine is going to be coming to your house anytime? saying that ah No, but totally seriously, totally. Ah, no, I appreciate it. So the bottom line is when we dissect it out, we have almost this strip of tissue near a vascular bundle. At the end of it is a clitoris. And what we do is we kind of fold it over and lay it over the ah lower pubic bone and secure the clitoris where it should belong on a woman. So very wide erogenous zone, much more so than cisgender women. They'll have sensation in the clitoris, but superior to the clitoris.
00:22:11
Speaker
um going as high as five centimeters and as wide as three centimeters, they're almost going to have that like this landing strip internally that if they stimulate that they're going to have good sensation or pleasurable sensation. And this is great news for all the men who end up dating trans women because they will not have problems finding the clitoris which is the main of existence for most men so yeah it's so easy to find it's so easy to stimulate yeah that's and you know a lot of our subjects when we are discussing it and they're helping us in the OR they're like oh my god i wish there was something wrong for this for cisgender women you know exactly i know right a super clitoris
00:22:53
Speaker
The other thing I've always wondered about and I've been trying to figure out from our research but really haven't figured this out yet and I wonder if you have any idea.
Sexual Sensation in Trans Women Post-Surgery
00:23:00
Speaker
The prostate is kept intact in these procedures and actually you can even kind of get to the prostate through the vaginal canal. And we know for a lot of men that you know prostate stimulation is pleasurable and there's part of sexual function involved there too. I've asked a lot of our patients, our trans women patients after vaginoplasty, if they're feeling positive sensations from this prostate area.
00:23:25
Speaker
And I haven't found that many who really have, have you found anything different or is there anything you feel like there could be an explanation? Yeah. So when we started doing this, I was also under the impression that they're going to have a pleasurable sensation from the prostate, but I haven't really found it. It's over reported. Maybe a few anecdotal things are there. And I don't think that's a huge locus of sexual function in trans women, perhaps because their prostate is so small because. There are androgen deprivation hormones and stuff like that. It is true that it is it is responsible for some sexual function in men. One of the areas of research that's kind of thriving is talking about sexual dysfunction in gay men after prostatectomy.
00:24:06
Speaker
That has to do not with just loss of erections, but loss of sensation from the prostate itself. That's by the by. Bottom line is that I haven't seen it being translated into a transmitter. Yeah. So interesting. Okay. Well, I could ask you questions all day and we could talk about this forever, but this has been a really good introduction. I really appreciate your time. Thanks so much for all the amazing work that you're doing. And I know you're engaging lives every day and we're so grateful to have you here in Cleveland. Thanks so much for your time. Thank you so much.