Providing Gender-Affirming Care with Facial Feminization Surgery

[Dr. Gopi Shah]
I think it's important to go ahead and get into some of the terms. Also just because as a healthcare provider, it is important for us to understand how to take care of our transgender patients for whatever it is that they come in for. For me, with peds, if I have a transgender pediatric patient who's coming in for sinus infections, I just want to make sure I understand the terminology. Can we go into, you use the words cisgender, we say transgender, can we just go into some of what we should know?

[Dr. Sarah Saxon]
Yes, it can be very confusing. I have to look things up to make sure I have things right all the time as well. I do this every day. Just don't put any pressure on yourself to feel like you have to get things perfect all the time. Transgender means that a person identifies as the opposite gender of what they were assigned at birth. If their birth certificate said that they are male, they identify as female now. Cisgender means they identify as the same gender assigned at birth. You go back to chemistry, the cis conformation of a molecule is the same side.

Then now you have a few other terms that are becoming more common, really in the last 5 to 10 years. There's gender fluidity, meaning someone doesn't really-- they can go one day as identifying as female, and the next day, they may identify as male. They go back and forth. A lot of times in surgery, they want to be able to have some feminine features but be able to if they want one day to live as male, then they can. Then gender, a non-binary person means that they don't identify as either, they're somewhere in between. Typically their pronouns would be more like they/them, instead of he or she.

[Dr. Gopi Shah]
That's very helpful. A lot of times, and I feel like with research, with demographics, I always think of, should I be using sex or gender? Even when you're thinking about looking at a chart review, prospective study, and demographics, I wonder, because gender and sex, which you're assigned to at birth is-- I feel like--

[Dr. Sarah Saxon]
It can be confusing with surgery because if someone's of childbearing age and they identify as male, but they still have a uterus, they could still be pregnant. They'd still need a pregnancy test before surgery. They still need pap smears. They still need all the regular medical care, which in primary care, it can be limiting too because there are very few primary care providers that feel comfortable. Even insurance providers say if they identify as male, then they're not going to cover a pap smear.

Everything's still changing, and we have a long way to go.

[Dr. Ashley Agan]
Everyone's trying to figure out how to change things and make it work. Can you talk to us about the process of transitioning, what does that mean, and what steps are involved?

[Dr. Sarah Saxon]
The process of transitioning is different for everybody. Typically, a transgender person feels this way from birth, so even when they were two, they felt like they were the opposite gender. Obviously, they don't have surgery when they're two. Now, and actually, Children's has a transgender clinic where they'll start seeing kids who start to tell their parents they feel this way, and they'll have group therapy sessions or individual therapy sessions at a certain point in time, they start to take hormones. This can be either as a child or in adolescence or as an adult.

Everyone starts at different points in time, depending on their background and support structure. Some people wait until they're retired from their profession to start transitioning, I have a 71-year-old that just retired, and now is ready to live their best life. Usually, when they come to me, they've at least done some therapy and hormone therapy. Then typically next steps is facial feminization because they just want to blend in in public, and then they may or may not choose to do top or bottom surgery, meaning breast augmentation or genitalia reconstruction.

Oftentimes, I'll have patients that just do facial surgery, and that's it.

[Dr. Gopi Shah]
Well, as a provider treating any transgender patient in our ENT clinic for any otolaryngology problem, what do you think is the most important thing that we can incorporate or think about as providers and in our practice of how to really be a good provider for these patients?

[Dr. Sarah Saxon]
I think just being aware of and being open to using the right pronouns. If you feel nervous that you're not doing the right thing, you can just ask because they don't mind, you can say, "What pronouns do you prefer to use?" They'll say he/she or they/them. Not to put so much pressure on yourself about it, but to have the right intentions. It can be on a subconscious level, you might mess up sometimes [chuckles] and that's okay. As long as you're well-intentioned, I think EMRs have a long way to go in having the infrastructure to put what their legal name is versus what they go by.

What gender they go by versus their medical history. Knowing if someone is on hormones, and this is something I didn't touch on before, I do have everyone, especially for longer cases go off of hormones two weeks before surgery. There's no data to say that there's increased DVT risk, but no one's ever going to do that study because it's too risky. Some people can be on pretty high levels of hormones. As these patients get older, they may need cancer surgeries, things that are hours long, and their DVT risk, theoretically, is pretty high.

They have all the same medical issues that everyone else could have too. Getting pre-op clearance and whatever you need, but just being aware of the specific issues they may have with hormone therapy or the past surgeries they've had. If they've had bottom surgery, getting a foley in may be a problem if they have strictures. A lot of things can come up even for me that I don't think about. [laughs] It's a learning process through our whole lifetime. I'm sure other things will come up as more and more people get all these surgeries more commonly.