Gender reconstructive surgery makes many demands of 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 looking to get trained in this field can probably 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 with faculty primarily at UCLA Urology’s Burbank and Westwood clinics and operate in UCLA’s main Westwood medical center and UCLA Santa Monica Medical Center, said Dr. Ng, who also serves as the fellowship program director. In addition to clinical responsibilities, she said, the fellow will participate in the activities of the multidisciplinary team of specialists.
The fellowship was born out of the UCLA Gender Health Program with the goal of training more health care providers, physicians and surgeons to provide care to transgender patients, she said.
“There is a high demand relative to the number of providers,” Dr. Ng said. “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 just because of the complexities in performing these procedures. There are many other unique challenges faced by transgender patients, she said.
Dr. Zilavy said there is “a general lack of access to care that is not present in other fields.”
“There is also a need to coordinate between providers. So, it’s a team effort more so than any other field of medicine,” he said.
Dr. Ng describes gender-affirming surgeries “as the pinnacle of reconstruction.”
“These are life-altering changes to one’s body in the genital area,” she explained. “They are complex with regard to aesthetics and functionality. To recover from these surgeries can be a lot, including the maintenance, which can also be a lot.”
Among the procedures these surgeons perform is the complex phalloplasty, which involves the creation of the penis, a multi-stage surgery that is done by a urologist and a plastic surgeon.
“To create a phallus is not a small task,” Dr. Ng said. “It takes 18 to 24 months of surgeries, in stages, to get to 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 is also joyous and wonderful. A lot of people tell me that their life has changed significantly.”
Dr. Zilavy, who was previously a resident at the University of New Mexico’s Urology Department, said he was looking for exactly the type of fellowship UCLA offers.
“This fellowship is the highest tier for urologists looking to get trained in this field,” he said.
Need for more resources and services
Dr. Ng says there is a continuing need for services and resources for transgender people. She herself teaches nursing staff. She attends conferences along with other providers, mental and behavioral health specialists and social providers.
“To have all these other resources available and in place is crucial,” Dr. Ng said. “The program building is a continuous process.”
She 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 last six months, she 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 typically involves removing the penis, testicles and scrotum.
In addition, the team has also performed two metoidioplasties in the last two months. This is a procedure that phallus-sizes an enlarged clitoral structure from testosterone exposure to create a more phallic-looking structure, which can allow an individual to urinate while standing up.
Some of the many qualities Dr. Ng says she looks for in a fellow are keen observation skills and willingness to learn because the job requires them.
“A lot of what we do is urethral reconstruction as part of the masculinization surgery,” she said. “This means building a urethra (the duct through which urine is expelled from the bladder) all the way to the tip of the phallus. It’s a lot of reconstruction. So, the qualities I look for in a fellow are keen observation skills, patience and a willingness to learn.”
Patients’ mental health is also a major concern in this area of medicine, Dr. Ng said.
“When I’m concerned about a patient’s mental health when I see them, I refer them to the appropriate resources here in UCLA,” she said. “For example, when patients are in a social situation where they are not recovering well, I ask the Gender Health Program team to look into it and provide resources or help. Sometimes, people come for revision surgery when things did not go well the first time. There could be a lot of trauma associated with that.”
In such situations past traumas could be triggered for patients when they visit the clinic.
“We do our best to make sure we’re not going to make it worse for them,” she said.
Rewarding and joyful work
As the program’s first fellow, Dr. Zilavy said he has been pleasantly surprised by how “well-oiled the gender health program is in UCLA.”
“That is the manifestation of a lot of people’s very hard work,” he said. “To have this program running like this – getting people the care they need socially, medically, surgically – I had not expected it to work this well. It comes down to a lot of people who care.”
Both Drs. Ng and Zilavy say while the challenges are many in this work, the rewards are also rich.
“I’ve had many patients thank me for changing their lives,” Dr. Ng said. “Patients tell me they are very happy after surgery. For me, it is gratifying to see that these people are able to get on with the lives they want to live.”
Dr. Zilavy recalled one patient on whom he performed masculinization surgery.
“They told me they had not been able to be naked from the waist down with their partner of five years because they were feeling so dysphoric and so disconnected from their body and their life,” he said. “To me, this work is about helping someone reconnect to what is probably the most important part of their life.”
