Diversity, Equity & Inclusion: Finding Inner Peace

Gender identity is your internal sense of self, how you relate to your place in the world. For transgender individuals, their gender identity doesn’t align with the sex they were assigned at birth, and some choose to undergo gender affirming surgery to feel like their authentic selves.

Gender affirming surgery is one of the focuses of my plastic surgery practice. I’m passionate about performing female-to-male (FTM) top surgery, but that’s not the direction I thought my career would take. I grew up in the Midwest in a relatively conservative household and didn’t know about transgender issues. When I came to Seattle for my fellowship in plastic surgery, I learned how to perform gender affirming procedures and liked doing them. After opening my own practice, new patients continued to seek out my care as word about my services and skills spread around the local trans community. Today, I’m humbled patients from around the country travel to Seattle so I can perform their surgeries.

Since 2015, gender affirming surgeries — including FTM top surgery, facial feminization and male-to-female (MTF) breast augmentation — have increased by over 40%. I’m seeing the same trend; the number of procedures I’ve performed has increased significantly in recent years because changing social and cultural trends are allowing patients to be more comfortable with embracing their gender identity and being their true selves. Additionally, legislative mandates — including the Affordable Care Act — require insurers to cover gender affirming procedures. With increased demand for these procedures, there is more of a need for surgical professionals and facilities to optimize the care of transgender patients. Accomplishing this goal requires creating safe and comfortable surgical environments for these individuals.

• Correct pronouns. Ask patients to note the sex they were assigned at birth and their identifying pronoun on intake forms. Confirm the pronoun with which patients identify — this could be based on their new post-procedure identity — in pre-op before surgery. Discuss the pronoun during the safety time out and write it on the OR’s whiteboard, so every member of the surgical team is on the same page and knows how to properly address the patient when they emerge from anesthesia.

Also remove gender markers from individual bathrooms in common areas so anyone can use them, regardless of their gender identity.

• Comprehensive care. Surgeons who view gender affirming surgery as a singular event likely achieve suboptimal results. These patients have often waited several years to undergo this life-changing procedure — and have put an incredible amount of thought and research into the decision. Surgery is the result of an extremely emotional journey for patients, and they deserve our upmost respect during each interaction. Every provider who touches the patient — pre-op nurses, surgical assistants, recovery room nurses, anesthesia providers — needs to understand the steps that lead to optimal care and must never become complacent about making patients feel welcome or ensuring they don’t feel like a number in a long day of surgery. 

• Continuing to learn. Ask transgender patients for feedback about their surgical experience. They will often share valuable insights, both positive and negative, that can help guide your efforts to provide inclusive, welcoming care. For example, our patients once shared that some anesthesia providers who were programmed to make assumptions based on physical appearance addressed them with the wrong pronouns. This presented us with a teachable moment, and we took the opportunity to reeducate our staff about the importance of addressing patients in a proper and respectful way.

It’s OK to admit you don’t know everything about optimizing the care of transgender patients and accept that mistakes will happen. Learn from them and focus on getting better. Kindly and respectfully point out where staff didn’t do the right thing so you can keep striving to create a culture that’s accepting, inviting and understanding.

Before leaving, the patient looked me in the eyes and said, 'Thank you for giving me a new life.'

I learned more about the importance of continually working to improve the care of trans individuals from Gabriel Neuman, a former patient of mine who underwent FTM top surgery. Gabriel was a recent guest on my podcast to discuss his journey from foster care to gender affirming surgery. During the pod, Gabriel shared that during a consult with another top-rated plastic surgeon, he was misgendered and told his breasts were a “weird shape,” so the surgeon couldn’t guarantee how the incisions would appear after surgery. On the other hand, Gabriel said the care he received at my practice was professional, informational and seamless. He should expect nothing less, and it was good for me to hear. He also pointed out that the trans community is connected nationally through social media and online chat rooms. The reputations of surgeons, surgical providers and facilities matter and are shared with individuals who are considering gender affirming surgery.