Non binary gender affirming surgery and the problem of treating patients who were 'pubertally suppressed'

[ArabeIIaScott]

As far as I can tell, this is basically the pick 'n' mix approach to genitals:

https://www.youtube.com/watch?app=desktop&v=FhIycMvV8vk

There's discussion, too, of the increasing number of patients who have had pubertal suppression, and how the medics apparently just don't really know how to deal with the issues this has created.

''‘…folks who maybe have had minimal engagement with their own genitals, either due to dysphoria or just due to the young age at which they're having surgery after pubertal
suppression or minimal to no sexual experiences prior and how after vaginoplasty we're asking them to do all these high maintenance things and be really involved, um, with this anatomy.

And just, yeah, the psycho social implications of that -yeah um it's something we've been talking a lot about in our team at ohsu and we're kind of writing up our early experience with peds endocrinology and pelvic floor physio and us as surgeons and kind of really collaborating to put out you know this is our early experience with this group of patients and this is what's working and what isn't.

Um, because there's just so little that's really been talked about or described, and as you know more and more vaginoplasties and gender surgeries being done and has more suppressions coming through like it's it's coming right at us so as a field like we all kind of need to be aware and start thinking about how we can optimize these outcomes and it's challenging because there's this question of how does that factor into consent when you're consenting someone for pubertal suppression, and there likely is some effect on downstage genital surgery but you don't know if an individual is going to desire genital surgery in the future or not and then it's also hard to have that conversation with someone that maybe hasn't went through puberty or ever engaged in sexual activity.

It's a really tricky thing – um - and when it comes time to actually do surgery if an individual does go through suppression and ultimately in their later teenage years and wants a vaginoplasty not only are you facing the struggle of not having a lot of tissue to work with, um, but that tissue hasn't been under the influence of testosterone which definitely affects some things and then a lot of patients just from psychosocial issues and the dysphoria that they're experiencing or just blatant transphobia in society may have not had the opportunity to have a sexual partner, um, and more often than not there's been almost no genital engagement in terms of self-stimulation or masturbation so then trying to assess things like erogenous outcomes after a surgery when someone's never had a neurogenous experience in their life is incredibly difficult because they don't really have a baseline to compare it to.’

I will do a full transcript later. Lots in here that is horrifying.

Shocking - how did these practitioners not think this stuff through in advance?

I think the problem may be that they are working, as suggested by a review in the BMJ '...suggesting CPGs for gender minority/trans people have been driven by provider-interests rather than healthcare needs'

https://bmjopen.bmj.com/content/11/4/e048943

Who... designed... that... logo?

It's bloody awful, isn't it?

Appears to be from here:

https://twitter.com/queersurgeon/status/1427732141690003462

The more sunlight that's shown on this area, the more abysmal it's shown to be. He's saying the quiet bit out loud - that they have been experimenting on mentally unwell children with no clue as to the outcomes

Medical practitioners suddenly realising that, having told children they CAN change sex and doling out puberty blockers and crude surgery, these children / young adults are unaware of their bodies, have not experienced the normal teenage self exploration of sexual sensations, have bodies that have failed to mature physically and are living with the outcomes of barbaric medical practices. In addition to facing a lifetime of infertility and lack of sexual feelings.

Why every parent is not raging from the fucking rooftops I cannot imagine. 😡

I'm slowly neatening up the transcript, just posting another excerpt as I go:

'... the the adolescents for sure present some unique challenges um obviously there's great evidence supporting pubertal suppression for a whole variety of benefits um but the one thing that is very new is genital surgery and someone that has underwent pubertal suppression um not so much an issue in um someone with assigned female at birth anatomy that undergoes a phalloplasty because we're creating something with a you know free tissue transfer or a flap anyway but a much bigger issue for an individual that's undergoing a penile inversion vaginoplasty um because we use all of that tissue to basically create the vulva as well as line the internal vaginal canal and as a specialty um those of us that do a fairly high volume of genital gender firming surgery you know we've maybe done a couple a handful of puberty suppressed adolescents as a field and no one's published on it yet um ohsu is we're just putting our first series together as we're kind of learning and figuring out what works um but it's really changing things because you don't have enough tissue to line the vaginal canal so you either have to take a skin graft or take skin from elsewhere or use an artificial product the way that we're dealing with it is by using a robot and we're basically performing intra-abdominal components of the surgery so we're using peritoneum which is the inner lining of the abdomen to line most of the vaginal canal and by doing that that allows us to use all of the remaining tissue externally to create a vulva and try to make also an aesthetic result um but robotic surgery is you know its own sub niche of training um that's a two surgeon case so i do that with a reconstructive urologist where i'm the plastic surgeon on the vulva doing everything externally and then my partner dr giolani d she's doing everything robotically and internally um and we've had really good success with that so far so that seems to kind of be where our field is heading in terms of dealing with those challenging cases where there is a paucity of tissue to use is robotic vaginoplasty um and it's also something that within the community as well as being more and more requested and sought after for a host of reasons'

My bold.

The word "heartwarming" was used at one point.

Are they for real? If I was a rightwing homophobe all I'd need to do is show that logo with the slogan "coming for your kids". Just as well I'm not, eh?

That makes me feel sick.

Also apologies, I'm cleaning up gradually and haven't got to punctuation and capitalisation yet.

The doctor in the interview says elsewhere:

https://twitter.com/queersurgeon/status/1401661086160457730

'Professionalism is a TROJAN HORSE. it is a vehicle used to deliver homophobia/transphobia/sexism/racism/misogyny/xenophobia.'

https://www.professorwatchlist.org/professor/blairpeters

"Helping you self actualise how you see yourself internally"

This is so deeply damaging and destructive.

How many people regret tattoos they got in their 20s? Play with make up and dresses but to have this off the peg avatar building approach to your body, as if you're operating in second life, is chilling.

This is trans humanism, where the body can be modded and skins bought.

'we've done a couple of volvoplasties just to sort of relieve dysphoria have them live in that body for a couple of years and then make that decision for themselves when they're maybe ready for sexual penetration or dilation'

live in that body

sorry for 'volvoplasty', that's youtube's auto captions.

'I think we're a little bit different geographically in Portland and on the west coast where I feel like we just have a lot more sort of non-binary queerness fluid identities versus like places like New York seem to be very binary, um, so I think part of it's geographical.'

'I would much rather do a vulvoplasty and have a small chance someone will want a vaginal canal in the future and do a slightly more complicated surgery,
than having the more common thing of a person that isn't really wanting the canal and doesn't use it and isn't doing a good job dilating and then all of a sudden is having these pelvic floor issues and chronic discharge and infections and it just becomes a like a huge mess so I think it's better to just avoid those things unless they truly need them.'

What's the definition of 'truly need', here?

This is truly awful. I'd not thought about the aspect of this that these surgeries force those suffering from gender dysphoria/body dysmorphia to have to focus on and engage with their genitalia and sex characteristics, whereas they could largely have ignored them if they had done nothing.

In the interview, the doctor is specifically talking about children, too. As far as I can gather, dysphoric children who've had puberty suppressed.

'...there's still this ongoing conversations regarding the ethics of doing an internal assessment on an adolescent who's never had any sexual activity or even self-stimulation and do like their first experience with their anatomy being from this provider, or from you know dilation, which the symptoms associated with that.

So it's just, yeah, there's a lot of layers to consider no there is for sure and it's i think we're all having very open conversations and with patients and families too, trying to figure out what is the best thing, because you know long term we want people not only to have relief of dysphoria, but have like a functional and satisfactory great sex life too, and um, you know we're trying to think like what can we do ahead of time - like, are things like encouraging genital engagement properly is that a bad thing or a good thing?

I don't think we really know yet in terms of what's the trade-off with physical anatomy versus, you know, exacerbating dysphoria. It's a very complicated issue, and I'm not sure there's like one answer for everybody, um, but I think definitely something that we're gonna learn a lot more about in the next five to ten years, as we're doing just increasing numbers of these cases.'

Interviewer:

'... it will be fascinating to see how it unfolds. I hope that there we see more research rolling out regarding assessing the efficacy of different interventions.'

😶

Research into efficacy - would be you know, nice.

but I think definitely something that we're gonna learn a lot more about in the next five to ten years, as we're doing just increasing numbers of these cases.'

To think they are so confident that numbers will increase over the next five to ten years. Rather they should be seeing the bottom dropping out of this niche surgery.

Thank you ArabellaScott for all this work transcribing these words.

In one sense I am impressed that they are thinking enough to see the dilemmas and problems, but how is it they can’t take the next step and say this it s must stop? It is like a juggernaut.

A passing derail: apropos some PSHE and the WHO’s insistence on how sexual prepubertal children are, it is interesting to see this doctor recognise that they clearly are not.

I am guessing that there may be various reasons some of these children are not comfortable with their bodies. If what we've read is correct, there are often comorbidities such as trauma from abuse.

I have the full transcript which I can post if it's of use - probably the excerpts above are the most relevant parts. Just needs a bit more tidying up and punctuating.

Tragic and horrifying.

‘I would much rather do a vulvoplasty and have a small chance someone will want a vaginal canal in the future’

i have pondered on this. Dworkin wrote that mainstream art and culture represent penis in vagina as the most genuine or only true sex. (e.g. Clinton’s “honest” statement of “I did not have sex with that woman.)

Vaginal canals are for passing menstrual blood and birthing babies. They are muscular structures which are not the most optimal for holding organs in place. Women can have sexual pleasure with no vaginal penetration.

So what’s the purpose of creating a vaginal canal for trans women? It’s not female aesthetics, you can’t see it without a mirror and some careful angling. It can only be for penetration presumably fed from the idea that “vaginal” penetration is the ultimate womanly affirmation by having “proper real heterosexual” sex.

Can you post it once it's done. This pillocks words need to be somewhere safe for when the video inevitably disappears at some point in the future.it

They are so wrapped up in themselves and what they can do to their patients that they are forgetting "Do no harm".

They are monsters, the way he blithly discussed the issues with young patients and at no point has the idea of maybe not operating on young people who have been on puberty blockers and have no sexual experience crossed his mind.

Thank you @ArabeIIaScott I'm not sure how you can bear it! It would be great if you could post the full transcript. I do want to know what these people think and I have watched some of the video but it's causing me distress so I wont watch more. Reading the words on a page is easier.

As for "do no harm" they are confirming every stereotype about surgeons being naturally sociopathic. It's funny to see them trying to be good but just not quite getting it. They live to do amazing things with human bodies and empathy with human minds is not their thing. Or as Ritchie Herron said "the surgeon was more autistic than I was".

I've been joking about it but I'm joking the way my ancestors made jokes about pogroms. It's how we cope.

Some more thoughts on this here, mainly the clip. A full transcript would be great! It’s shocking how they acknowledge they are traumatising people just by being the first people to touch their genitals.

https://www.mumsnet.com/talk/womens_rights/4814716-american-genital-surgeon-admits-theyre-learning-as-they-go?page=2&reply=126500122