Gender reconstructive surgery makes many demands on practitioners who choose this field. According to Gladys Ng, MD, associate clinical professor of urology and surgical director of the UCLA Gender Health Program, it requires the deft hands of a surgeon, the aesthetic bent of an artist and the compassionate heart of a social worker.
The number of programs that offer training for doctors who want to be trained in this field can be counted on one hand, said Andrew Zilavy, MD, the first recruit of UCLA’s Genital Gender-Affirming Surgery fellowship.
The fellowship is a one-year training program after residency. It focuses on all aspects of the diagnostic and therapeutic management of patients with gender dysphoria seeking gender-affirming genital surgery. The fellowship has a rolling admissions process.
Fellows will practice faculty primarily at UCLA Urology’s Burbank and Westwood clinics and operate at UCLA’s Westwood primary medical center and UCLA Santa Monica Medical Center, said Dr. Ng, who also serves as director of the fellowship program. In addition to clinical responsibilities, he said, the fellow will participate in the activities of the multi-disciplinary team of specialists.
The partnership was born out of the UCLA Gender Health Program with the goal of training more healthcare providers, physicians and surgeons to provide care to transgender patients, he said.
“There is a high demand in relation to the number of providers,” said Dr. Of. “There is a need to train more surgeons to provide gender-specific care including genital gender-affirming surgery to help people align their bodies with their gender identities.”
Complexities and challenges
Gender reconstructive surgery is unique not only because of the complexities of performing these procedures. There are many other unique challenges that transgender patients face, he said.
Dr. Zilavy said there is “a general lack of access to care that doesn’t exist in other fields.”
“There is also a need for coordination between providers. So, it’s a team effort more than any other field of medicine,” he said.
Described by Dr. That gender-affirming surgeries “are the pinnacle of reconstruction.”
“These are life-changing changes in the body in one part of the genitals,” he explained. “They are complex in terms of aesthetics and functionality. The recovery from these operations can be a lot, including maintenance, which can also be a lot.”
Among the procedures performed by surgeons is the complex phalloplasty, which includes the creation of the penis, a multi-stage operation performed by a urologist and a plastic surgeon.
“Making a phallus is no small task,” said Dr. Of. “It takes 18 to 24 months of operations, in stages, to get where the patient wants to go. It’s like a marathon. It requires people to take time away from other things in their lives, including work. But it’s also happy and wonderful. Many people tell me that their lives have changed a lot.”
Dr. Zilavy, who was a former resident in the Urology Department at the University of New Mexico, said he was looking for exactly the type of fellowship offered at UCLA.
“This fellowship is the highest level for urologists who want to be trained in this field,” he said.
More resources and services are needed
Says Dr. There is a continuing need for services and resources for transgender people. He himself taught the nursing staff. She attends conferences with other providers, mental and behavioral health specialists and social providers.
“Having all these other resources available and in place is important,” said Dr. Of. “Building the program is an ongoing process.”
He said the clinic sees five patients a week on average. The team performs about five to six vaginoplasties a month and has done three phalloplasties in the past six months, he said. Phalloplasty uses a flap of skin and tissue from another part of the body to create a penis, and vaginoplasty creates a vagina and usually involves removing the penis, testicles and scrotum.
In addition, the team has also performed two metoidioplasties in the past two months. This is a procedure that the phallus-size of an enlarged clitoral structure from exposure to testosterone to create a more phallic-looking structure, which can allow an individual to urinate while standing. .
Some of the many qualities that Dr. What he is looking for in a partner are observational skills and a willingness to learn because the job requires it.
“A lot of what we do is urethral reconstruction as part of masculinization surgery,” he said. “This means creating a urethra (the duct through which urine is discharged from the bladder) to the tip of the phallus. It’s a lot of rebuilding. Therefore, the qualities I look for in a partner are observation skills, patience and willingness to learn.
The mental health of patients is also a major concern in this area of medicine, said Dr. Of.
“If I’m concerned about a patient’s mental health when I see them, I refer them to the appropriate resources here at UCLA,” he said. “For example, if the patients are in a social situation where they are not recovering well, I ask the Gender Health Program team to check it and provide resources or help. Sometimes, people go for surgery in revision when things don’t go well the first time. There can be a lot of trauma associated with that.”
In such situations past traumas can be triggered in patients when they visit the clinic.
“We’re doing our best to make sure we don’t make it worse for them,” he said.
Rewarding and fun work
As the first partner in the program, Dr. Zilavy said she was amazed by UCLA’s “excellent gender health program.”
“That shows a lot of people’s hard work,” he said. “for this program to run like this – getting people the care they need socially, medically, surgically – I don’t expect it to work well. It comes down to a lot of people who care.”
Both Dr. Ng and Zilavy say while the challenges are many in this job, the rewards are also many.
“Many patients thank me for changing their lives,” said Dr. Of. “Patients tell me that they are very happy after the operation. For me, it is gratifying to see that these people are able to continue the lives they want to live.”
Remembered by Dr. Zilavy is a patient on whom he underwent masculinization surgery.
“They tell me they haven’t been naked from the waist down with their partner for five years because they feel so dysphoric and disconnected from their bodies and their lives,” she said. “For me, this job is about helping someone reconnect with what is probably the most important part of their life.”