Interviewer: All right, well again, thank you so much for taking the time to chat with me, uh I really really appreciate it. Let’s start um with introductions, could you please tell us your name and your pronouns?
BP: Yeah, perfect. My name is Blair Peters um I use he and they pronouns and I am a gender affirming surgeon located in Portland Oregon at OHSU or Oregon Health Science University.
Interviewer: Very cool. Could you tell us a little bit about if you have a subspecialty what it is or maybe some examples of the most common procedures that you perform?
BP: Yeah definitely. So 80 percent or so of my practice is gender affirming surgery, um, so I do facial chest surgery and genital surgery, um but the majority of my practice instead of where my passion lies is really genital surgery cases so I do a lot of vaginoplasty and a lot of phalloplasty.
Interviewer: That is amazing. When we spoke before you mentioned these quote unquote ‘non-binary procedures’ that you're seeing become a little more routine could you expand on on how that might differ from what folks who have a little bit of context about genital gender forming surgery how that might be different
BP: Yeah definitely. I think - well I hope - the field is changing in a lot of ways. I think everyone grows up with and especially in medical training really internalizes this binary bias, um and that really paints a lot of what the traditional procedures offered to people are. It's like on one end you have vaginoplasty, and on the other end you have a phalloplasty, and every surgery has an inherent level of risk to it and everyone's dysphoria comes from completely different places - especially in regards to their anatomy.
So my whole approach to gender affirming surgery is not putting my own bias of what a binary genitalia should be onto someone. It's listening to them and figuring out where is your dysphoria coming from, what can we fix with surgery, and what is the appropriate level of risk for you. Um, and there's some people that come in and they embrace a non-binary gender identity and they envision more of a non-binary type of appearance to their genitalia, whereas other people just come in, maybe transgender woman or a transgender man, and they you know - transgender man wants a phalloplasty, for example, but doesn't want a risk of urethral complications, so decides to do everything except urethral lengthening.
So there's a lot more of like a spectrum of procedures now that are availablem and a lot of them kind of falling maybe between the two or outside of the two. Um, so I think it's becoming more of a field where it's less about reinforcing this binary view of genitalia and anatomy and more so embracing the person's own unique concept of themselves, and me as a surgeon my whole goal is helping you self-actualize how you see yourself internally.
Interviewer: I really love that I like the collaborative decision making as opposed to like this is what we're doing and that's all you have to choose from and I heard you mention a spectrum of um operation procedures that choices folks have so for folks who might be listening and don't really have some examples so we know that there's like phalloplasty and vaginoplasty but could you give an example of some of the different ways someone might have a non-binary um GIS?
BP: Yeahn definitely. So, um, the the easiest example would be in terms of chest surgery. Um, so that the kind of classic more non-binary type of surgery would be a mastectomy without having any nipple grafts for example, um, and that's just one variation of different types of chest surgery. Some people are going for procedures where it's a mastectomy but you're not totally flat so you're somewhere between having a breast mound and not having a breast mound, and that's what sort of works for individuals because sometimes you're flat enough that you can bind and appear flat but then also if you're feeling more feminine one day and want to have the appearence of a breast, you have an appearance of a breast.
As far as it relates to genital surgery u I’d say the greatest variation is in terms of what we can do with phalloplasty, so some individuals will go for the full kind of traditional phalloplasty um, whereas others may choose a shaft-only phalloplasty. So that basically means that we create a phallus but we don't touch or lengthen the urethra, so you don't have any risk of strictures or fistulas. Um, but within a shaft only phalloplasty there's a lot of different things you can do with the other genitalia, so some people will choose to leave everything else otherwise unaltered some people will choose to still have a scrotoplasty and have the clitoral tissue buried, but leave their vaginal canal, and talking to some of those individuals it's sometimes a desire for future child bearing or enjoying penetrative intercourse with vaginal canal, or just not having dysphoria from the vaginal canal and not wanting the risk of a vaginectomy. Um, and then others will sometimes do what we call perineal masculinization, where they'll do everything except for urethral lengthening, so then basically we'll do a phallus, a scrotum, um, a vaginectomy, bury the clitoral tissue, and then ultimately the individual will sit to urinate through [eurostomy?]
Interviewer: That's really fascinating. I have to be honest I didn't even conceptualize that there would be options for surgeries like that or different variations until I had a patient of mine tell me that they were considering getting genital, um, gender affirming surgery but they didn't want um all of the the high maintenance aftercare of a traditional vaginoplasty, um, and having maybe some penile preservation, and it honestly just blew my mind when I when I knew that was a thing and so it's really it's really interesting to get your perspective of someone who actually provides that care um so thank you for sharing that with us as it relates to pelvic floor PT. Um, how do you find yourself embracing embracing the roles or the skill set of public floor pt for your patients?
BP: I would say increasingly um so I think initially my introduction to pelvic floor physiotherapy was really in the vaginoplasty patient population and I think they've become a lot more worked into sort of the care map and the multidisciplinary care team surrounding genital gender affirming surgery. Um, but at least at OHSU we were noticing you know a lot of the time when we were asking for help was when patients weren't doing well after vaginoplasty which didn't really make a lot of sense, and you started kind of paying attention to a whole host of reasons why an individual pre-operatively may have a whole bunch of issues with pelvic floor dysfunction, and then we're doing this huge reconstructive surgery rearranging anatomy and then putting you through a really um demanding post-operative care process and just expecting things to go well it didn't make sense. So we've really moved to from day one pre-operative pelvic floor physiotherapy even before we operate, that continues through the post-operative period and that's been drastically successful in terms of success with dilation, sexual satisfaction, decreasing urinary issues, um pretty much any functional metric of vaginoplasty um so much so that we're starting to do a little bit more of the same pretty much for any of our genital surgery patients especially the phalloplasty patients that'll undergo a vaginectomy or urethral lengthening, because again that's a lot of change in pelvic floor anatomy. Um, so we're increasingly utilizing therapy both postoperatively um and then a little bit preoperatively. The new thing that I’m working on is optimizing sensory or erogenous outcomes following genital gender firming surgery, so I’m working with our pelvic floor physiotherapists at OHSU right now developing a protocol to optimize sensory recovery after phalloplasty and they have so much experience with a lot of those extra modalities and sort of my expert as a nerve surgeon that we're starting to find that to be a really successful adjunct for people as well.
Interviewer: Hearing that just makes me want to jump up and down, because the folks that I see who are fortunate enough to have had no pelvic floor issues prior to surgery or after the biggest thing I see is they're not able to have an orgasm when they want to or it's not as strong as they would like they're able to use their anatomy for pleasure and um I’m sure that you have opinions on um the emphasis in medical care on all functions except for anything pleasure related and it's how mind-boggling it can be um and also some of the stuff you said I feel like it um it also speaks to a pattern that I see in general in medicine where finally orthopaedic surgeons maybe were starting to use prehab before to improve their surgical outcomes and how we're maybe starting to see that trend um translate to other areas of surgery as well and then just you know after an acl or something like that.
BP: Um so that's that's really awesome, and I’ve heard some larger health institutions where they have a full care team it's definitely more standard but uh the few pelvic floor PTs I know who have a good chunk of experience treating folks after vaginoplasty or phalloplasty it was definitely not like standard of care so it's really it's really heartwarming to see their [inaudible] be evolving and improving.
Interviewer: Um,when I spoke to you previously you mentioned, um, and this had not occurred to me until I spoke with you, that there's you know demographic change in our patients, and how our TGNC patients are younger and they may have undergone pubertal suppression and how that affects the skin available for a more traditional penile and version of vaginoplasty. Could you share a little bit about how that has shifted your practice?
BP: Yeah, definitely. Um you made a comment about sort of the demographic shifting, I would just say they're expanding in either direction. Um, so yeah, a lot of adolescents, um, presenting for surgical intervention, but also a lot of people that are like in their 70s sometimes coming in for general surgery, and then everything in between.
Um, but 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 affirming 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, 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.
Interviewer: Yeah, I had no idea it was a two surgeon um two surgeon so that's definitely an interesting thing to consider and as you mentioned the robotic um niche expertise and and meeting more folks who have that skill set could you speak a little bit to how that might, um how that might impact their after care or even getting ready for surgery things like um is electrolysis still a requirement or is the need for dilation still as important etc.?
BP: Yeah, definitely. Um regardless of technique whether it's standard penile inversion, intestinal vaginoplasty or robotic, lifelong dilation is pretty much the rule. We've seen patients coming back even 20 plus years out from a vaginoplasty that have something happen in their life that they just don't dilate and are having sex for a year and they will lose a lot of a lot of depth it doesn't tend to be a width issue so much but definitely will lose a lot of depth. So we do kind of say you know, lifelong dilation if you want to maintain as much depth as possible. Um, the differences in the earlier care, because with the robotic vaginoplasty we're using peritoneal flaps that are still connected to their own blood supply as compared to the penile inversion where most of most of the canal is lined with scrotal skin, um the canal is a little bit stronger and a little bit more robust we think in those first couple of weeks so we start dilation a little bit earlier in our robotic vaginoplasty patients than we do in the traditional penile inversion patients.
The other differences we're noticing because we're dissecting the canal in the robotic cases from within the abdomen and we go from inside to outside versus in the traditional vaginoplasty everything's done from outside in, um we do think we're getting a few extra centimetres of vaginal canal depth um in the robotic vaginal plastic cases as well so um we don't have the full data ready but just anecdotally with the measurements bouncing between those two techniques the robotic consistently seems to be measuring a couple centimetres deeper and that could be significant I’d imagine because um at least from what I’ve seen is that the uh standard of depth that at least is trying to be attained from a surgical procedure is um greater than um than someone born with a vagina.
Interviewer: But would you say that's because the likelihood that there will be depth loss you want to maximize that as much as possible surgically? Does that sound, sorry, I think there's multiple factors …
BP: Yeah, that's part of it is what you get in the operating room is never going to 100 be maintained so you will always lose a certain percentage um but there are some differences too because a natal vagina has a lot of elasticity to it and there's actual smooth muscle in the wall, versus we're lining canal with a skin graft or a perch nail flap which it's not as distensible, um. So you need to rely on just having greater depth to begin with in order to have the depth of penetration that a lot of people will want.
Interviewer: Perhaps we could, um, shift here for a second and talk a little bit about the psychosocial implications. So, and I, I wrote this question specifically about younger trans and gender non-conforming patients, but as you said expanding in either direction, so if you have insight about older patients who are coming in for surgeries please do share with us. Um but you had mentioned previously about 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?
BP: 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 erogenous experience in their life is incredibly difficult because they don't really have a baseline to compare it to.
Um, and then you know post-operative care anyone knows that's seen post-operative vaginal plastic patient is really intense and we're kind of asking someone that is younger and hasn't really engaged or done much with their genitalia to all of a sudden do this like really aggressive relaxation for dilation and it's just a huge ask. So, we're finding that to be a barrier almost more so than - yes the surgery is technically challenging and demanding, but I think we're developing pretty good strategies to deal with that, um, but what we really need is like a robust support system and I think there's gonna be a huge role for therapy perioperatively in terms of giving pre-operative genital engagement, trying to have those conversations preparedness, readiness, support through that post-operative, um, protocol because some of the early challenges are getting someone to successfully dilate, um, that's never had to engage with your pelvic floor musculature [laughs] and is maybe 17,18 years old. It’s hard.
Interviewer: Absolutely. I was talking to a colleague the other day about that and because she had a patient who was an adolescent and underwent pubertal suppression and had vaginoplasty and I - it just had me thinking you know when we undergo pelvic floor training, and I’m not a paediatric pelvic floor specialist by any means, but 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.
BP: 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 and I think that applies for all of y'all doing the pelvic floor physio too [laughs] so I’m sure we'll be in close communication.
Interviewer: Yeah 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. Um, you mentioned you know how intense post-op care is after vaginoplasty and and that kind of is a nice segue into my next question about how it's becoming increasingly common for folks to opt for a vulvoplasty, I believe is how you refer to it, um otherwise known as a minimal or no depth vaginoplasty. Uh what trends do you notice um in terms of how this impacts the outcomes of your patients?
BP: Yeah, so I think everyone you know runs their practices a little bit differently and I think it kind of comes down to again like what I was saying with the binary bias of things um but I see a lot of patients that come in from all walks of life all different backgrounds all different ages with varying degrees of social supports um and you know on the other end of the spectrum we were just talking about adolescents there's a lot of people that come in like their 60s or 70s with other health issues and conditions who don't have a partner to help them through surgery, maybe don't have stable housing or all these other barriers and sometimes you just start talking to someone and they're just so dysphoric from their genitals they just don't want to be dysphoric, and they want to have you know comforting clothing and being
able to change in a public bathroom, or restroom, or locker room, and just feel like they don't have male genitalia um. And for those people Vulvoplasty is great um, and a lot of them don't even know that it's an option, because a lot of people I don't think take the time to really have that conversation, and it makes a huge difference in terms of what someone's preparation looks like with a Vulvoplasty you don't need any electrolysis because there's no internal
tissue you don't need to dilate it all postoperatively so it's a much swifter and quicker recovery and for many patients that don't desire sexual penetration those are kind of the two questions it's like do you desire sexual penetration if it's no and are you dysphoric from not
having a vaginal canal or will you be dysphoric from having a vaginal canal?
If the answer is no then it, the next question is, well then why are we doing a canal, because that's where the like the big injury of you know rectal injury and urinary incompetence and all of those things start to come into play. So I think part of it is a lot of patients realizing and understanding that that is an option and then you know, knowledge is power and I think we have a lot of people just coming in requesting gladoplasty[?] straight up um for a lot of our patients um some of our adolescents for example who are not sure if they want a canal um we've done a couple of vulvoplasties 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 and they're at a better place in their life, so we're kind of starting to stage a little bit in certain cases too or maybe someone's not fully ready for a vaginal canal or they're not sure that they want one, um, or some people that embrace more of a trans feminine non-binary identity, and they feel a Vulvoplasty is better in line with how they view themselves internally.
So there's really a lot of different reasons why someone wants a Vulvoplasty - sometimes it's just they don't want the risk of a canal or they have barriers to electrolysis and dilation and don't want to deal with that, or it's just how they view themselves and their gender identity, um but I would say over the last year like 30 plus percent of patients have come in actually requesting globalplasty um. I do say 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, but I think part of it is that's our whole style as you kind of tell us and we figure out what's best for you verse you can come in for one of these two things.
Interviewer: Yeah I really love that it's becoming less of like a choice a in choice b and there's there's more options. How - I’m curious - how technically, surgically difficult is it to create a canal after doing a globalplasty. I really like the idea of them having the opportunity to be able to live in that body and see if that meets their needs sufficiently or yeah, but how how difficult is that?
BP: Yeah, so disclaimer with that: I’m definitely not saying that that is the right thing to do for everyone because it is more complicated, um, and it is a whole second surgery um so if you know you want a vaginal canal you just used to do a vaginoplasty. But that's where being able to offer robotic vaginoplasty is a game changer because we can line almost all the canal with peritoneum because traditionally all of the skin you're lining the canal with is all that scrotal skin that if you're doing a vulvoplasty you're discarding.
So if someone's going to get a secondary canal after a vulvoplasty and you can't do robotic surgery you're going to need to take skin graft from somewhere else, but we usually don't have to do that if we're doing it with the robot, so we reserve that for patients that are like 90 sure they want a vulvoplasty, but they're just like not totally sure whether or not they'll like want sexual penetration in the future, but they have no plans they don't have a partner, and maybe like they're at a place in their life where it's also going to be really difficult for them to do that care. It just keeps the door open um, or you know like I said for the odd adolescent that is really dysphoric and needs that part of it address but isn't at a place where they're ready for a vaginal canal. We do find that to be a useful thing and it's anecdotally, it's too early to say like what the conversion rate is in terms of people coming back for canals but you know in the last year having done quite a few of vulvoplasties in that type of scenario, the vast majority of people are ecstatically happy and I don't think are going to pursue a canal any further.
But it is doable but it has to be done typically robotically, um it could be done sort of from the traditional or perennial dissection but it would be pretty definitely higher risk um, but as far as for robotic surgeons it's a very doable thing.
Interviewer: That makes a ton of sense and I I don't know maybe you do um to my knowledge there isn't any any evidence on this yet but at least clinically anecdotally and talking to other um pelvic floor pts who who specialize in post-op gender affirming care uh almost none of the vaginoplasty patients that I see have any desire to utilize the canal for um penetrative intercourse either because they're just more comfortable um you know going rectally or they I have a lot of patients both vaginally vaginal plastic who only have partners with vulvas, and it's just penetrative intercourse has just never been really on the table, and now whether that's due to the difficulty of what you mentioned with erogenous simulation post-op, or if maybe the traditional vaginoplasty with the canal was offered because of that reinforcement of the binary that you were talking about, it's really interesting to consider. Do you know of any research examining that?
BP: The only paper that I - there's a paper that um one of the vaginal plastic surgeons OHSU put out about just the percentage of patients seeking vulvo plastinous practice and then exploring why they had chosen vulvoplasty for themselves and then also exploring how they viewed vulvoplasty - like did they view their vulva as like any less female than you know a traditional vaginoplasty with or without a canal and the answer was overwhelmingly no they viewed their genitalia just as fully feminine um at least in their sort of own internal sense of self and the choices were all over the map, but it is like you say like it's the minority of people that are actually using their vaginal canals um.
I think a lot of people do need to have a vaginal canal to feel complete for themselves and
to you know have their dysphoria adequately relieved but I think there are a lot of people over the years that have just gotten a vaginoplasty because that was what was available to them and there was never really that conversation otherwise, um so I think again it's that whole concept of a binary bias and sort of you know realizing that we can be a little bit more fluid surgically, and we typically start our consultations with patient goals and priorities for a genital case, and we basically list things like you know: comfortable in a locker room; aesthetics; erogenous sensation; desire for penetration - all of these things and people will sort of rank them in terms of their priorities and you can be like a five out of five on every single one, but some people are all over the map, and if people are coming in and their main concern is just like you know, I don't want to have this there, and I want to feel comfortable but I have no desire for penetration, it's kind of screaming vulvoplasty um. But I don't think a lot of people are even kind of starting with that of like - what do you actually want like what do you care about, um, so, I think we're just trying to change that landscape a little bit, so...
Because the thing with vaginal plastis too is, 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 and I would feel much better about a conversion canal than trying to take away a canal which is very hard to do um yeah. So, that's kind of my personal opinion, I guess.
Interviewer: Yeah, I think that's an excellent point, and, and speaking to the - I love the idea of ranking the priorities and the outcome and, and, um, I also love hearing you reiterate how um, having someone's dysphoria be, be relieved is usually the most important thing, and I’m I’m pretty sure that in all of medicine we could all do a lot better about leading with that and having that open discussion as opposed to just laying out options for folks and not really letting them be part of that collaborative decision making. Um, yeah, you're definitely doing all the advocacy, I see you out there trying to change the world, you're doing it! Um, I just wanted to shift gears a tiny bit because I think that you have a lot of insight to offer on this – uh, previously when we spoke you used the phrase ‘trans broken arm syndrome’ and I thought it was just such an excellent consideration for all of us as providers to keep in mind. Would you mind sharing what that is, and how you maybe see it impacting medical care for our trans patients?
BP: Yeah, definitely. Um, so ‘trans broken arm syndrome’ is this sort of concept - it's not even – sorry, not a concept, it's a very real world thing! But it basically is when a healthcare professional will sometimes consciously or subconsciously attribute every single medical issue or problem someone has to their transgender identity. Um, so I think it's something that we all have to keep in mind where – yes, gender affirming surgery has complications and considerations, yes, hormone replacement therapy can also have other things and occasionally complications, but there are millions of medical issues that are completely mutually exclusive, or not mutually exclusive, for someone's transgender identity. So we just kind of have to keep that in mind, and you know we have patients coming in for vaginal plastic consultation, for example, that have like iatrogenic urethral structures, and if we weren't thinking or looking for those things, all of a sudden they have this post-operative urinary dysfunction, and we're like oh pelvic floor blah blah blah blah - but no, like, we've done that person a disservice because we're not looking outside of their status as a transgender individual, and I think it's just a trap that you know, I think even I’ve caught myself almost falling for a few times and being like, okay, wait, like, I can't [inaudible] this person's voiding dysfunction because they maybe have some hormonal atrophy on their penile tissues from estrogen, like I actually have to make sure they don't have like some sort of anatomical issue or problem, um, and I think we all just need to keep that in mind, that yes these things are related but sometimes anything else can be going on, and we're doing that person a disservice if we're just kind of attributing it to part of their gender affirming treatment, and not sort of doing the due diligence to treat everything separately and independently as well
Interviewer: Definitely, and reinforcing that the history of pathologizing the LGBTQ plus community in general and and contributing to that kind of collective trauma. Um, also I just I can't help it when I hear you talk about that notice the parallels between that and fat phobia and medicine and the over attribution of so many things to someone's weight um et cetera.
Yeah I’m sure that you could speak about that as well! Um, well, I don't want to take up too much of your time, I really really appreciate it my last question is a little more personal ,because on your social media you speak openly about your identity as a queer person and your struggles with how this intersects with your role in the medical field. I saw a post you had about mentorship recently I thought that was phenomenal, um, would you mind sharing some examples of how being part of this community influences your surgical practice?
BP: Yeah, um. I don't even know how I would do this if I wasn't queer like no shade to none like no shade to non-queer surgeons, like, we need all of you! But, um it's such an amazing thing I think for me to just feel like I’m at work treating my community and like looking after people that I would otherwise like hang out with at pride, or at a queer bar, or a safe space and you know being able to show up to clinic with like pink hair and jeans and a t-shirt and like no one's questioning my professionalism or like competency to do surgery, and I think also understanding the language and the culture and being able to just go into a room and have patients, you know, have these very comfortable conversations with me about sexual
practices, or preferences, or polyamorous relationships, or how all of these things are going to interplay into what they ultimately want for themselves, um.
So I think it's a huge asset in terms of almost instantly walking into a room just creating an environment where we have rapport just courtesy of representation and connection to community ties, um, and I do speak a lot about that sort of the concept of in professional or these traditional spaces like why visibility is so important, because visibility allows for you to meaningfully represent a community of people which not only leads to better care for them but it leads to a better sense of satisfaction for you coming to work as your authentic self. Um, so I couldn't imagine a better position for me to be in um I think there's nothing more powerful or more professional than someone really loving themselves enough to show up to work authentically and just take pride in what they do, um, and whether someone agrees or disagrees with you on that I think they're gonna respect you regardless because everyone else around you will.
Interviewer: So beautifully said yeah it's deeply fulfilling I I have to agree it it is something that yeah I similarly I don't think I could be doing this, like, if I wasn't a part of this community. There's just something unspoken about it, and and it is so fulfilling to see that and and I really love that you speak so much about representation and you're always talking about how there's people med students in your DMs talking about how much you're inspiring them so um thank you for all the work that you do thank you again for your time um therwise if you don't have anything else that's all I have for you today.