Action4Canada - Dr. Blair Peters - Gender Affirming Surgeries = Mutilation Here's Proof, Jan. 5, 2022

00:00:00.000 All right. Well, again, thank you so much for taking the time to chat with me. I really,

00:00:06.680 really appreciate it. Let's start with introductions. Could you please tell us your

00:00:10.860 name and your pronouns? Yeah, perfect. My name is Blair Peters. I use he and they pronouns,

00:00:16.480 and I am a gender-affirming surgeon located in Portland, Oregon at OHSU or Oregon Health

00:00:22.260 Science University. Very cool. Could you tell us a little bit about if you have a subspecialty,

00:00:27.700 what it is, or maybe some examples of the most common procedures that you perform?

00:00:32.640 Yeah, definitely. So 80% or so of my practice is gender-affirming surgery. So I do facial,

00:00:38.620 chest surgery, and genital surgery. But the majority of my practice, instead of where my

00:00:44.340 passion lies, is really genital surgery cases. So I do a lot of vaginoplasty and a lot of phalloplasty.

00:00:51.360 That is amazing. When we spoke before, you mentioned these quote-unquote non-binary procedures 1.00

00:00:57.120 that you're seeing become a little more routine. Could you expand on how that might differ from what

00:01:02.640 folks who have a little bit of context about genital, gender-affirming surgery, how that might

00:01:07.080 be different? Yeah, definitely. I think, well, I hope the field is changing. In a lot of ways, I think

00:01:13.340 everyone grows up with, and especially in medical training, really internalizes this binary bias.

00:01:20.360 And that really paints a lot of what the traditional procedures offered to people are. It's like on one

00:01:26.220 end, you have a vaginoplasty, and on the other end, you have a phalloplasty. And every surgery has an

00:01:31.360 inherent level of risk to it. And everyone's dysphoria comes from completely different places,

00:01:36.540 especially in regards to their anatomy. So my whole approach to gender-affirming surgery

00:01:41.440 is not putting my own bias of what a binary genitalia should be onto someone. It's listening to them and

00:01:48.360 figuring out where is your dysphoria coming from? What can we fix with surgery? And what is the 0.89

00:01:52.880 appropriate level of risk for you? And there's some people that come in, and they embrace a

00:01:57.860 non-binary gender identity, and they envision more of a non-binary type of appearance to their

00:02:02.320 genitalia. Whereas other people just come in, maybe a transgender woman or a transgender man,

00:02:07.500 and they, you know, transgender man wants a phalloplasty, for example, but doesn't want a risk of 0.64

00:02:12.540 urethral complications, so decides to do everything except urethral lengthening. So there's a lot more 0.50

00:02:18.220 of like a spectrum of procedures now that are available, and a lot of them kind of falling

00:02:24.560 maybe between the two or outside of the two. So I think it's becoming more of a field where

00:02:31.340 it's less about reinforcing this binary view of genitalia and anatomy, and more so embracing

00:02:37.080 the person's own unique concept of themselves. And me as a surgeon, my whole goal is helping you

00:02:43.060 self-actualize how you see yourself internally. I really love that. I like the collaborative

00:02:49.480 decision-making as opposed to like, this is what we're doing, and that's all you have to choose from.

00:02:54.920 And I heard you mention a spectrum of operation procedures, but choices folks have. So for folks

00:03:02.120 who might be listening and don't really have some examples, so we know that there's like

00:03:07.160 phalloplasty and vaginoplasty, but could you give an example of some of the different ways someone might

00:03:12.160 have a non-binary GAS? Yeah, definitely. So the easiest example would be in terms of chest surgery, 0.89

00:03:22.860 so that the kind of classic more non-binary type of surgery would be a mastectomy without having 0.98

00:03:28.300 any nipple grafts, for example. And that's just one variation of different types of chest surgery.

00:03:34.100 Some people are going for procedures where it's a mastectomy, but you're not totally flat. So you're

00:03:39.740 somewhere between having a breast mound and not having a breast mound, and that's what sort of

00:03:45.160 works for individuals, because sometimes you're flat enough that you can bind and appear flat,

00:03:50.100 but then also if you're feeling more feminine one day and want to have the appearance of a breast,

00:03:53.340 then you'll have an appearance of a breast. As far as it relates to genital surgery, I'd say the 0.97

00:03:58.200 greatest variation is in terms of what we can do with phalloplasty. So some individuals will go for the

00:04:03.760 full kind of traditional phalloplasty, whereas others may choose a shaft-only phalloplasty. So

00:04:10.120 that basically means that we create a phallus, but we don't touch or lengthen the urethra. So you don't

00:04:15.480 have any risk of strictures or fistulas. But within a shaft-only phalloplasty, there's a lot of different

00:04:22.060 things you can do with the other genitalia. So some people will choose to leave everything else 0.90

00:04:26.580 otherwise unaltered. Some people will choose to still have a scrotoplasty and have the clitoral tissue

00:04:32.460 buried, but leave their vaginal canal. And talking to some of those individuals, it's sometimes a

00:04:38.020 desire for future childbearing or enjoying penetrative intercourse with vaginal canal or just not having 0.92

00:04:43.840 dysphoria from the vaginal canal and not wanting the risk of a vaginectomy. And then others will

00:04:50.580 sometimes do what we call perineal masculinization, where they'll do everything except for urethral

00:04:57.260 lengthening. So then basically we'll do a phallus, a scrotum, a vaginectomy, bury the clitoral tissue, 0.76

00:05:03.940 and then ultimately the individual will sit to urinate through ure ostomy. 0.92

00:05:09.460 That's really fascinating. I have to be honest, I didn't even conceptualize that there would be

00:05:14.660 options for surgeries like that or different variations until I had a patient of mine tell me

00:05:19.880 that they were considering getting genital gender affirming surgery, but they didn't want

00:05:24.500 all of the high maintenance aftercare of a traditional vaginoplasty and having maybe some 0.96

00:05:31.360 penile preservation. And it honestly just blew my mind when I, when I knew that was a thing. And so 0.72

00:05:36.280 it's really, it's really interesting to get your perspective of someone who actually provides that

00:05:39.640 care. So thank you for sharing that with us. As it relates to pelvic floor PT, how do you find

00:05:46.620 yourself embracing, embracing the roles or the skillset of pelvic floor PT for your patients?

00:05:52.460 I would say increasingly. So I think initially my introduction to pelvic floor physiotherapy was

00:06:02.000 really in the vaginoplasty patient population. And I think they've become a lot more worked into sort

00:06:07.800 of the care map and the multidisciplinary care team surrounding genital gender affirming surgery.

00:06:12.520 Um, but at least at OHSU, we were noticing, you know, a lot of the time when we were asking for

00:06:19.380 help was when patients weren't doing well after a vaginoplasty, which didn't really make a lot of

00:06:24.340 sense. And you started kind of paying attention to a whole host of reasons why an individual

00:06:29.040 preoperatively may have a whole bunch of issues with pelvic floor dysfunction. And then we're doing

00:06:34.280 this huge reconstructive surgery, rearranging anatomy, and then putting you through a really, um,

00:06:39.740 demanding postoperative care process and just expecting things to go well, it didn't make

00:06:43.940 sense. So we've really moved to from day one, um, preoperative pelvic floor physiotherapy,

00:06:50.340 even before we operate that continues through the postoperative period. Um, and that's been

00:06:55.560 drastically successful in terms of, um, success with dilation, sexual satisfaction, decreasing

00:07:01.020 urinary issues, um, pretty much any functional metric of vaginoplasty. Um, so much so that we're

00:07:08.600 starting to do a little bit more of the same, um, pretty much for any of our genital surgery

00:07:13.420 patients, especially the phalloplasty patients that will undergo a vaginectomy or urethral

00:07:17.740 lengthening. Cause again, that's a lot of change in pelvic floor anatomy. Um, so we're increasingly

00:07:23.240 utilizing, um, therapy both postoperatively, um, and then a little bit preoperatively. The new thing

00:07:30.600 that I'm working on is optimizing sensory or erogenous outcomes following genital gender affirming

00:07:35.580 surgery. So I'm working with our pelvic floor physiotherapists, um, at OHSU right now developing

00:07:41.660 a protocol to optimize sensory recovery after phalloplasty. And they have so much experience

00:07:47.080 with a lot of those extra modalities and sort of my expert as a nerve surgeon that we're starting

00:07:51.940 to find that to be a really successful adjunct for people as well. Hearing that just makes me want to

00:07:57.440 jump up and down because the folks that I see who are fortunate enough to have had no pelvic 0.56

00:08:02.620 floor issues prior to surgery or after the biggest thing I see is they're not able to, um, have an

00:08:09.020 orgasm when they want to, or it's not as strong as they would like. They're not able to use their

00:08:12.620 anatomy for pleasure. And, um, I'm sure that you have opinions on, um, the emphasis in medical care

00:08:18.920 on all functions, except for anything, pleasure related. And it's how mind boggling it can be. Um,

00:08:24.460 and also some of the stuff you said, I feel like it, um, it also speaks to a pattern that I see in

00:08:30.860 general in medicine where finally orthopedic surgeons, maybe we're starting to use prehab

00:08:35.700 before to improve their surgical outcomes and how we're maybe starting to see that trend, um,

00:08:42.040 translate to other areas of surgery as well. And then just, you know, after an ACL or something like

00:08:47.200 that. Um, so that's, that's really awesome. And I I've heard some larger health institutions where

00:08:52.420 they have a full care team. It's definitely more standard, but, uh, the few pelvic floor PTs I know

00:08:58.840 who have a good chunk of experience treating folks after vaginoplasty or phalloplasty, it was

00:09:03.640 definitely not like standard of care. So it's really, it's really heartwarming to see the thighs 0.97

00:09:08.320 be evolving and improving. Um, when I spoke to you previously, you mentioned, um, and this had not

00:09:15.500 occurred to me until I spoke with you that there's, you know, demographic change in our patients and how

00:09:21.920 our TGNC patients are, uh, uh, younger and they may have undergone pubertal suppression and how that

00:09:28.980 affects the skin available for a more traditional, um, canile inversion of vaginoplasty. Could you share

00:09:35.740 a little bit about how that has shifted your practice? Yeah, definitely. Um, you made a comment

00:09:42.340 about sort of the demographic shifting. I would just say they're expanding in either direction. Um,

00:09:48.980 so yeah, a lot of adolescents, um, presenting for surgical intervention, but also a lot of people

00:09:55.760 that are like in their seventies, sometimes coming in for genital surgery and then everything in

00:10:00.660 between. Um, but the, the adolescents for sure present some unique challenges. Um, obviously there's

00:10:08.940 great evidence supporting pubertal suppression for a whole variety of benefits. Um, but the one thing

00:10:14.180 that is very new is genital surgery in someone that has underwent pubertal suppression. Um,

00:10:21.360 not so much an issue in, um, someone with assigned female at birth anatomy that undergoes a phalloplasty

00:10:28.100 because we're creating something with a, you know, a free tissue transfer or a flap anyway,

00:10:32.580 but a much bigger issue for an individual that's undergoing a penile inversion vaginalplasty.

00:10:38.460 Um, because we use all of that tissue to basically create the vulva as well as line the internal 0.52

00:10:43.800 vaginal canal. And as a specialty, um, those of us that do a fairly high volume of genital

00:10:50.480 gender affirming surgery, you know, we've maybe done a couple, a handful of pubertally suppressed

00:10:55.700 adolescents as a field and no one's published on it yet. Um, OHSU is we're just putting our first

00:11:01.880 series together as we're kind of learning and figuring out what works. Um, but it's really

00:11:07.460 changing things, um, because you don't have enough tissue to line the vaginal canal. So you either

00:11:14.620 have to take a skin graft or take skin from elsewhere or use some artificial products. Um,

00:11:20.580 the way that we're dealing with it is by using a robot and we're basically performing intra-abdominal,

00:11:26.140 um, components of the surgery. So we're using peritoneum, which is the inner lining of the abdomen

00:11:31.360 to line most of the vaginal canal. And by doing that, that allows us to use all of the remaining

00:11:37.600 tissue externally to create a vulva, um, and try to make also an aesthetic results. Um, but robotic

00:11:44.360 surgery is, you know, its own sub niche of training. Um, that's a two surgeon case. So I do that with a

00:11:51.340 reconstructive urologist where I'm the plastic surgeon on the vulva doing everything externally. And then my

00:11:56.680 partner, Dr. Gialani D she's doing everything robotically and internally. Um, and we've had 0.97

00:12:01.920 really good success with that so far. So that seems to kind of be where our field is heading in

00:12:07.720 terms of dealing with those challenging cases where there is a paucity of tissue to use is robotic

00:12:13.740 vaginoplasty. Um, and it's also something that within the community as well as being more and more

00:12:19.660 requested and sought after for a host of reasons. Yeah, I had no idea it was a two surgeon, um, two

00:12:26.460 surgeon case. So that's definitely an interesting thing to consider. And as you mentioned that

00:12:30.460 robotic, um, niche expertise and meeting more folks who have that skillset, could you speak a little

00:12:37.480 bit to how that might, um, how that might impact their aftercare or even, um, getting ready for

00:12:43.220 surgery, things like, um, is electrolysis still a requirement or is the need for dilation still as

00:12:50.700 important, et cetera. Yeah, definitely. Um, regardless of technique, whether it's standard

00:12:57.580 penile inversion, intestinal vaginoplasty, um, or robotic lifelong dilation is pretty much the rule.

00:13:04.780 Um, we've seen patients coming back even 20 plus years out from a vaginoplasty that have something

00:13:10.640 happen in their life that they just don't dilate and are having sex for a year and they will lose a

00:13:15.860 lot of, um, a lot of depth. It doesn't tend to be a width issue so much, but definitely will lose a lot

00:13:20.880 of depth. So we do kind of say, you know, lifelong dilation, if you want to maintain as much depth as

00:13:26.920 possible. Um, the differences in the earlier care, because with the robotic vaginoplasty, we're using

00:13:32.720 peritoneal flaps that are still connected to their own blood supply as compared to the penile inversion

00:13:38.300 where most of the canal is lined with scrotal skin. Um, the canal is a little bit stronger and a little

00:13:43.860 bit more robust, we think in those first couple of weeks. So we start dilation a little bit earlier

00:13:48.900 in our robotic vaginoplasty patients than we do in the, um, traditional penile inversion, um,

00:13:55.820 patients. The other differences we're noticing because we're dissecting the canal and the robotic

00:14:00.580 cases from within the abdomen, and we go from inside to outside versus in the traditional vaginoplasty,

00:14:06.500 everything's done from outside in. Um, we do think we're getting a few extra centimeters of vaginal 1.00

00:14:12.180 canal depth, um, in the robotic vaginoplasty cases as well. So, um, we don't have the full data ready,

00:14:19.500 but just anecdotally with the measurements bouncing between those two techniques, the robotic consistently

00:14:24.660 seems to be measuring a couple of centimeters deeper. And that could be significant. I'd imagine

00:14:30.740 because, um, at least from what I've seen is that the, uh, standard of depth that at least is trying 0.97

00:14:37.620 to be attained from a surgical procedure is, um, greater than, um, than someone born with a vagina. 0.77

00:14:45.580 But would you say that's because the likelihood that there will be depth loss, you want to maximize

00:14:50.400 that as much as possible surgically? Does that sound about right? I think there's multiple factors.

00:14:55.220 Yeah. That's part of it is what you get in the operating room is never going to 100% be, um,

00:15:02.100 maintained. So you will always lose a certain percentage. Um, but there are some differences

00:15:07.460 too, because a natal vagina has a lot of elasticity to it. Um, and there's actual smooth muscle in the 1.00

00:15:13.540 wall versus we're lining canal with a skin graft or a peritoneal flap, which it's not as distensible.

00:15:19.460 Um, so you need to rely on just having greater depth to begin with in order to have the depth of

00:15:24.820 penetration that a lot of people will want. Perhaps we could, um, shift here for a second

00:15:32.980 and talk a little bit about the psychosocial implications. So, and I, I wrote this question

00:15:38.260 specifically about younger trans and gender non-conforming patients, but as you said,

00:15:42.180 expanding in either direction. So if you have insight about, um, older patients who are coming

00:15:46.500 in for surgeries, please do share with us. Um, but you had mentioned previously about folks who maybe

00:15:51.780 have had minimal engagement with their own genitals, um, either due to dysphoria or just due to the young

00:15:57.460 age at which they're, um, having surgery after puberal suppression or minimal to no sexual experiences

00:16:04.100 prior and how, um, after vaginoplasty, we're asking them to do all these high maintenance things and be

00:16:10.420 really involved, um, with this anatomy and just, yeah, the psychosocial implications of that.

00:16:15.700 Yeah. Um, it's something we've been talking a lot about in our team at OHSU and we're kind of writing

00:16:23.460 up our early experience with peds endocrinology and pelvic floor physio and us as surgeons and kind

00:16:28.420 of really collaborating to put out, you know, this is our early experience with this group of patients

00:16:33.220 and this is what's working and what isn't. Um, because there's just so little that's really been

00:16:38.580 talked about or described. And as you know, more and more vaginoplasties and gender surgery is being

00:16:43.220 done. And as more suppression is coming through, like it's, it's coming right at us. So as a field,

00:16:48.020 like we all kind of need to be aware and start thinking about how we can optimize these outcomes.

00:16:52.660 And it's challenging because there's this question of how does that factor into consent when you're

00:16:59.780 consenting someone for pubertal suppression and there likely is some effect on downstage genital surgery,

00:17:06.260 but you don't know if an individual is going to desire genital surgery in the future or not.

00:17:10.580 And then it's also hard to have that conversation with someone that maybe hasn't went through puberty

00:17:15.380 or ever engaged in sexual activity. It's a really tricky thing. Um, and when it comes time to actually

00:17:23.300 do surgery, if an individual does go through suppression and ultimately is in their latter

00:17:27.700 teenage years and wants a vaginoplasty, um, not only are you facing the struggle of not having a lot of

00:17:33.540 tissue to work with, um, but that tissue hasn't been under the influence of testosterone,

00:17:38.180 um, which definitely affects some things. And then a lot of patients just from psychosocial

00:17:44.980 issues and the dysphoria that they're experiencing or just blatant transphobia in society may have not

00:17:50.580 had the opportunity to have a sexual partner. Um, and more often than not, there's been almost no

00:17:56.660 genital engagement in terms of self-stimulation or masturbation. So then trying to assess things like 0.85

00:18:02.900 erogenous outcomes after a surgery, when someone's never had an erogenous experience in their life

00:18:07.940 is incredibly difficult because they don't really have a baseline to compare it to. Um,

00:18:14.020 and then, you know, post-operative care, anyone knows that seen a post-operative vaginoplasty

00:18:19.620 patient is really intense. And we're kind of asking someone that is younger and hasn't really

00:18:25.940 engaged or done much with their genitalia to all of a sudden do this like really aggressive, um,

00:18:30.980 relaxation for dilation. And it's just a huge ask. So we're finding that to be a barrier almost more 0.59

00:18:40.820 so than yes, the surgery is technically challenging and demanding, but I think we're developing pretty

00:18:45.940 good strategies to deal with that. Um, but what we really need is like a robust support system.

00:18:53.940 And I think there's going to be a huge role for therapy perioperatively in terms of

00:19:00.340 eating preoperative genital engagement, trying to have those conversations, preparedness, readiness,

00:19:05.700 support through that post-operative, um, protocol. Cause some of the early challenges are getting

00:19:11.140 someone to successfully dilate, um, that's never had to engage with their pelvic floor musculature

00:19:15.460 and is maybe 17, 18 years old. It's hard. Absolutely. I was talking to a colleague the other

00:19:22.100 day about that because she had a patient who was, um, an adolescent and, and underwent

00:19:26.820 pubertal suppression and had vaginoplasty. And I, it just had me thinking, you know,

00:19:31.540 when we undergo pelvic floor training and I'm, I'm not a pediatric pelvic floor specialist by any means,

00:19:36.580 but there's still this ongoing conversations regarding the ethics of doing an internal assessment

00:19:41.860 on an adolescent who's never had any sexual activity or even self-stimulation and,

00:19:47.300 and do like their first experience with their anatomy being from this provider or from, you know,

00:19:53.860 dilation, which the symptoms associated with that. So it's just, yeah, there's a lot of layers to

00:19:59.540 consider. No, there is for sure. And it's, I think we're all having very open conversations and with

00:20:05.700 patients and families too, trying to figure out what is the best thing. Cause you know, long-term we

00:20:10.020 want people not only to have relief of dysphoria, but have like a functional and satisfactory,

00:20:15.380 great sex life too. And, um, you know, we're trying to think like, what can we do ahead of time?

00:20:22.420 Like are things like encouraging genital engagement preoperatively, is that a bad thing or a good

00:20:28.180 thing? I don't think we really know yet in terms of what's the trade-off with physical anatomy versus,

00:20:34.100 you know, exacerbating dysphoria. It's a very complicated issue and I'm not sure there's like one

00:20:38.740 answer for everybody. Um, but I think definitely something that we're going to learn a lot

00:20:43.860 more about in the next five to 10 years as we're doing just increasing numbers of these cases. And

00:20:48.740 I think that applies for all of y'all doing pelvic floor physio too. So I'm sure we'll be in close

00:20:54.980 communication. Yeah, it will be fascinating to see how it unfolds. I hope that there, um, we see more

00:21:00.740 research rolling out regarding, um, assessing the efficacy of different interventions. Um, you mentioned,

00:21:06.420 you know, how intense post-op care is after vaginoplasty and, and that kind of is a nice segue into my

00:21:11.380 next question about how it's becoming increasingly common for folks to opt for a vulvoplasty, I believe

00:21:17.380 is how you referred to it. Um, otherwise known as a minimal or no depth vaginoplasty. Uh, what trends

00:21:23.140 do you notice, um, in terms of how this impacts the outcomes of your patients?

00:21:27.540 Yeah. So I think everyone, you know, runs their practices a little bit differently. And I think it

00:21:33.860 kind of comes down to, again, like what I was saying with the binary bias of things. Um, but I see a lot of

00:21:39.860 patients that come in from all walks of life, all different backgrounds, all different ages with

00:21:46.340 varying degrees of social supports. Um, and you know, on the other end of the spectrum,

00:21:51.540 we were just talking about adolescents. There's a lot of people that come in like their sixties

00:21:54.500 or seventies with other health issues and conditions who don't have a partner to help

00:21:58.900 them through surgery, maybe don't have stable housing or all these other barriers. And sometimes

00:22:04.340 you just start talking to someone and they're just so dysphoric from their genitals. They just don't 0.98

00:22:08.260 want to be dysphoric and they want to have, you know, comfort in clothing and being able to change

00:22:13.140 in a public bathroom or restroom or locker room and just feel like they don't have male genitalia. Um,

00:22:21.620 and for those people, vovoplasty is great. Um, and a lot of them don't even know that it's an option

00:22:30.500 because a lot of people, I don't think take the time to really have that conversation. And it makes a

00:22:36.740 huge difference in terms of what someone's preparation looks like with a vovoplasty. You

00:22:42.420 don't need any electrolysis because there's no internal tissue. You don't need to dilate it all

00:22:48.100 postoperatively. So it's a much swifter and quicker recovery. And for many patients that don't desire

00:22:54.980 sexual penetration, um, those are kind of the two questions. It's like, do you desire sexual 0.60

00:22:59.220 penetration? If it's no, and are you dysphoric from not having a vaginal canal or will you be dysphoric 0.99

00:23:04.660 from not having a vaginal canal? If the answer is no, then the next question is, well, then why

00:23:09.140 are we doing a canal? Because that's where the, like the big injury of, you know, rectal injury

00:23:14.580 and urinary incompetence and all of those things start to come into play. So I think part of it is

00:23:21.620 a lot of patients realizing and understanding that that is an option and then, you know, knowledge is

00:23:27.140 power. And I think we have a lot of people just coming in requesting vovoplasty straight up, um,

00:23:31.940 for a lot of our patients. Um, some of our adolescents, for example, who are not sure if

00:23:38.740 they want a canal, um, we've done a couple of volvoplasties just to sort of relieve dysphoria,

00:23:45.140 have them live in that body for a couple of years, and then make that decision for themselves

00:23:50.020 when they're maybe ready for sexual penetration or dilation and they're at a better place in their 0.98

00:23:55.060 life. So we're kind of starting to stage a little bit in certain cases too, where maybe someone's not

00:24:01.380 fully ready for a vaginal canal, or we're not sure that they want one. Um, or some people that embrace

00:24:06.980 more of a trans feminine, non-binary identity, and they feel a vovoplasty is better in line with how

00:24:11.540 they view themselves internally. So there's really a lot of different reasons why someone wants a

00:24:16.500 vovoplasty. Sometimes it's just, they don't want the risk of a canal, or they have barriers to

00:24:21.300 electrolysis and dilation and don't want to deal with that, or it's just how they view themselves

00:24:26.420 and their gender identity. Um, but I would say over the last year, like 30 plus percent of patients

00:24:33.140 have come and actually requesting vovoplasty. Um, I do say, I think we're a little bit different

00:24:38.980 geographically in Portland and on the West Coast, where I feel like we just have a lot more sort of

00:24:44.740 non-binary queerness fluid identities versus like places like New York seem to be very binary.

00:24:51.300 Um, so I think part of it's geographical, but I think part of it is that's our whole style is you

00:24:55.540 kind of tell us and we figure out what's best for you versus you can come in for one of these two

00:24:59.580 things. Yeah. I really love that. It's, it's becoming less of like a choice A and choice B and

00:25:05.240 there's, there's more options. How, um, I'm curious how technically surgically difficult is it to create

00:25:11.620 a canal after doing a vovoplasty? I really liked the idea of them having the opportunity to be able to

00:25:16.220 live in that body and see if that meets their needs efficiently or how, how difficult is that?

00:25:22.060 Yeah. So disclaimer with that, I'm definitely not saying that that is the right thing to do for

00:25:27.240 everyone because it is more complicated. Um, and it is a whole second surgery. Um, so if you know,

00:25:33.560 you want a vaginal canal, you just, you just do a vaginoplasty, but that's where being able to offer 0.99

00:25:39.000 robotic vaginoplasty is a game changer because we can line almost all the canal with peritoneum

00:25:44.820 because traditionally all of the skin you're lining the canal with is all of that scrotal skin

00:25:48.760 that if you're doing a vovoplasty, you're discarding. So if someone's going to get a secondary

00:25:52.900 canal after a vovoplasty and you can't do robotic surgery, you're going to need to take skin graft from

00:25:57.780 somewhere else. But we usually don't have to do that if we're doing it with the robot. So we reserve

00:26:03.700 that for patients that are like 90% sure they want a vovoplasty, but they're just like not totally

00:26:11.180 sure whether or not they'll like want sexual penetration in the future, but they have no

00:26:15.460 plans. They don't have a partner and maybe like they're at a place in their life where it's also

00:26:20.020 going to be really difficult for them to do that care. It just keeps the door open. Um, or, you know,

00:26:26.680 like I said, for the odd adolescent, that is really dysphoric and means that part of it addressed,

00:26:31.960 but isn't at a place where they're ready for a vaginal canal. We do find that to be a useful 1.00

00:26:36.540 thing. And it's anecdotally, it's too early to say like what the conversion rate is in terms of

00:26:43.400 people coming back for canals. But, you know, in the last year, having done quite a few of

00:26:48.100 vovoplasties in that type of scenario, the vast majority of people are ecstatically happy. And I

00:26:52.840 don't think we're going to pursue a canal any further, but, um, it is doable, but it has to be done

00:26:58.080 typically robotically. Um, it could be done sort of from the traditional or perineal dissection,

00:27:04.020 but it would be pretty definitely higher risk. Um, but as far as for robotic surgeons, it's a very

00:27:11.460 doable thing. That makes a ton of sense. And I, I don't know, maybe you do, um, to my knowledge,

00:27:17.100 there isn't any, any evidence on this yet, but at least clinically anecdotally and talking to other,

00:27:22.780 um, pelvic floor PTs who, who specialize in, um, post-op gender affirming care, uh, almost

00:27:29.460 none of the vaginoplasty patients that I see have any desire to utilize the canal for, um,

00:27:36.920 penetrative intercourse, either because they're just more comfortable, um, you know, going rectally

00:27:43.540 or they, um, I have a lot of patients with vaginoplasty who only have partners with vulvas and it's

00:27:50.460 just penetrative intercourse has just never been really on the table. Um, and now whether that's

00:27:56.080 due to the difficulty of, um, what you mentioned with erogenous stimulation post-op, or if maybe

00:28:03.060 the traditional vaginoplasty with the canal was offered because of that reinforcement of the binary 1.00

00:28:08.860 that you were talking about is really interesting to consider. Do you know of any research examining

00:28:12.760 that? The only paper that I, there's a paper that, um, one of the vaginoplasty surgeons OHSU put out

00:28:22.240 about just the percentage of patients seeking vulvoplasty in his practice and then exploring

00:28:27.620 why they had chosen vulvoplasty for themselves. And then also exploring how they viewed vulvoplasty,

00:28:33.740 like did they view their vulva as like any less female than, you know, a traditional vaginoplasty

00:28:40.200 with or without a canal. And the answer was overwhelmingly no, they viewed their genitalia 0.74

00:28:44.800 just as fully feminine, um, at least in their sort of own internal sense of self. And the choices were

00:28:52.000 all over the map, but it is like you say, like it's the minority of people that are actually using

00:28:56.880 their vaginal canals. Um, I think a lot of people do need to have a vaginal canal to feel complete for 0.70

00:29:02.280 themselves and to, you know, have their dysphoria adequately relieved. But I think there are a lot of

00:29:08.400 people over the years that have just gotten a vaginoplasty because that was what was available

00:29:12.260 to them. And there was never really that conversation otherwise. Um, so I think again,

00:29:18.920 it's that whole concept of a binary bias and sort of, you know, realizing that we can be a little bit

00:29:25.200 more fluid surgically. And we typically start our consultations with patient goals and priorities for

00:29:31.640 a genital case. And you basically list things like, you know, comfortable in a locker room,

00:29:38.140 aesthetics, erogenous sensation, desire for penetration, all of these things. And people

00:29:43.680 will sort of rank them in terms of their priorities. And you can be like a five out of five on every

00:29:49.180 single one, but some people are all over the map. And if people are coming in and their main concern

00:29:53.780 is just like, you know, I don't want to have this there and I want to feel comfortable, but I have no

00:29:59.380 desire for penetration. It's kind of screaming volvoplasty. Um, but I don't think a lot of

00:30:05.900 people are even kind of starting with that of like, what do you actually want? Like, what do you care

00:30:10.360 about? Um, so I think we're just trying to change that landscape a little bit. So, because the thing

00:30:16.820 with vaginoplasties too, is I would much rather do a volvoplasty and have a small chance someone will

00:30:23.120 want a vaginal canal in the future and do a slightly more complicated surgery than having the more

00:30:28.560 common thing of a person that isn't really wanting the canal and doesn't use it and isn't doing a good

00:30:36.440 job dilating. And then all of a sudden is having these pelvic floor issues and chronic discharge and

00:30:40.040 infections. And it just becomes like a huge mess. So I think it's better to just avoid those things

00:30:47.680 unless they truly need them. And I would feel much better about a conversion canal than trying to 0.98

00:30:54.160 take away a canal, um, which is very hard to do. Um, yeah. So that's kind of my personal opinion,

00:31:00.860 I guess. Yeah. I think that's an excellent point. And, and speaking to the, I love the idea of ranking

00:31:06.580 the priorities and the outcome. And, and, um, I also love hearing you reiterate how, um, having someone's

00:31:13.480 dysphoria be, be relieved is usually the most important thing. Um, and I'm, I'm pretty sure that

00:31:19.760 in all of medicine, we could all do a lot better about leading with that and having that open

00:31:24.120 discussion as opposed to just laying out options for folks and not really letting them be a part of

00:31:30.180 that collaborative decision-making. Um, but yeah, you're definitely doing all the advocacy. I see

00:31:34.880 you out there trying to change the world. You're doing it. Um, I just wanted to shift gears a tiny

00:31:40.400 bit. Cause I think that you have a lot of insight to offer on this. Uh, previously when we spoke,

00:31:44.600 you use the phrase trans broken arm syndrome. Um, and I thought it was just such an excellent 1.00

00:31:49.560 consideration for all of us as providers to keep in mind. Uh, would you mind sharing what that is

00:31:54.600 and how you maybe see it impacting, um, medical care for our trans patients? Yeah, definitely. Um,

00:32:02.200 so trans broken arm syndrome is this sort of concept. It's not even, sorry, not a concept. It's a very

00:32:07.580 real world thing, but it basically is when a healthcare professional will sometimes consciously or

00:32:13.960 subconsciously attribute every single medical issue or problem someone has to their transgender

00:32:19.700 identity. Um, so I think it's something that we all have to keep in mind where yes, gender affirming

00:32:26.840 surgery has complications and considerations. Yes. Hormonal placement therapy can also have other

00:32:32.100 things and occasionally complications, but there are millions of medical issues that are completely

00:32:39.200 mutually exclusive or not mutually exclusive from someone's transgender identity. So

00:32:43.940 we just kind of have to keep that in mind. And, you know, we have patients coming in for

00:32:49.320 vaginoplasty consultation, for example, to have like iatrogenic urethral structures. And if we weren't

00:32:54.640 thinking or looking for those things, all of a sudden they have this post-operative urinary dysfunction

00:32:59.460 and we're like, Oh, pelvic floor, blah, blah, blah, blah, blah, blah. But no, like we've done that

00:33:03.440 person a disservice because we're not looking outside of their status as a transgender individual. And

00:33:08.900 I think it's just a trap that, you know, I think even I've caught myself almost falling for a few

00:33:14.860 times and being like, okay, wait, like I can't just attribute this person's voiding dysfunction

00:33:18.340 because they maybe have some hormonal atrophy on their penile tissues from estrogen. Like I actually

00:33:23.720 have to make sure they don't have like some sort of anatomical issue or problem. Um, and I think we all

00:33:29.800 just need to keep that in mind that yes, these things are related, but sometimes anything else can be

00:33:36.040 going on. Um, and we're doing that person a disservice if we're just kind of attributing it

00:33:41.620 to part of their gender affirming treatment and not sort of doing the due diligence to treat

00:33:46.880 everything separately and independently as well. Definitely. And reinforcing that, that history of

00:33:53.720 pathologizing the LGBTQ plus community in general and contributing to that kind of collective trauma. Um, 0.82

00:34:00.820 also I just, I can't help it when I hear you talk about that, notice the parallels between that and

00:34:06.060 fat phobia and medicine and the over attribution of so many things to someone's weight, um, et cetera.

00:34:12.440 Yeah. I'm sure that you could speak about that as well. Um, well, I don't want to take up too much

00:34:17.460 of your time. I really, really appreciate it. My last question is a little more personal because on

00:34:22.140 your social media, you speak openly about your identity as a queer person and your struggles with how

00:34:27.980 this intersects with your role in the medical field. I saw a post you had about mentorship recently.

00:34:31.920 I thought that was phenomenal. Um, would you mind sharing some examples of how being part of this

00:34:37.400 community influences your surgical practice? Yeah. Um, I don't even know how I would do this if I

00:34:45.820 wasn't queer, like no shade to non, like no shade to non-queer surgeons. Like we need all of you,

00:34:51.120 but, um, it's such an amazing thing. I think for me to just feel like I'm at work treating my community

00:35:02.420 and like looking after people that I would otherwise like hang out with at pride or at a

00:35:07.220 queer bar or safe space and, you know, being able to show up to clinic with like pink hair and jeans

00:35:12.500 and a t-shirt and like, no one's questioning my professionalism or like competency to do surgery. Um, and I think

00:35:18.540 also understanding the language and the culture and being able to just go into a room and have

00:35:24.620 patients, you know, have these very comfortable conversations with me about sexual practices or

00:35:29.580 preferences or the polyamorous relationships or how all of these things are going to interplay into what

00:35:34.080 they ultimately want for themselves. Um, so I think it's a huge asset in terms of almost instantly walking

00:35:40.340 into a room, just creating an environment where we have rapport, just courtesy of representation and

00:35:45.840 connection to community ties. Um, and I do speak a lot about that sort of the concept of in professional

00:35:53.600 or these traditional spaces, like why visibility is so important. Um, because visibility allows for you

00:36:00.160 to meaningfully represent a community of people, which not only leads to better care for them, but it

00:36:05.760 leads to a better sense of satisfaction for you coming to work as your authentic self. Um, so I couldn't

00:36:14.000 imagine a better position for me to be in. Um, I think there's nothing more powerful or more

00:36:21.660 professional than someone really loving themselves enough to show up to work authentically and just

00:36:27.140 take pride in what they do. Um, and whether someone agrees or disagrees with you on that, I think they're

00:36:32.600 going to respect you regardless because everyone else around you will.

00:36:35.340 So beautifully said. Yeah. It's deeply fulfilling. I, I have to agree. It, it, it is something that,

00:36:43.620 yeah, I similarly, I don't think I could be doing this. Like if I wasn't a part of this community or

00:36:48.560 I did, there's just something unspoken about it. And, and it is so fulfilling to see that. And, um,

00:36:53.560 and I really love that you speak so much about representation and you're always talking about

00:36:58.660 how there's people, med students in your DMs talking about how much you're inspiring them. So, um,

00:37:04.420 thank you for all the work that you do. Thank you again for your time. Um, otherwise, if you don't

00:37:09.460 have anything else, that's all I have for you today. Um, no, I mean, that was great. I appreciate

00:37:15.160 the invitation. Thank you.

Action4Canada - November 18, 2023

Dr. Blair Peters - Gender Affirming Surgeries = Mutilation Here's Proof, Jan. 5, 2022

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