Getting Real About Gender Affirming Surgeries With Dr. Cecile Ferrando - Episode 42 - Vanesstradiol

Episode Transcript
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Vanessa (00:00):
Okay, here we go.

(00:00):
Hello. Welcome back totranscending humanity. This is

(00:02):
episode 42. And just as areminder, the views and opinions
of the hosts and guests on theshow are those of their own and
not those of their respectiveorganizations, employers and
what have you. I have a superexciting episode for you today.
I guess that I've been lookingforward to having known for a

(00:23):
long time, the amazing Dr.
Cecile Fernando, the person whogave me my wonderful equipment
downstairs. Dr. Fernando, canyou give us a little two minute
Hello, a little background onyou?

Dr Ferrando (00:41):
Sure. It's such a pleasure to be here. Thanks for
asking me to join. I am a Eurogynecologist. So I actually
specialized in OB GYN first andthen did some extra urologic
training. And so I mostly seepatients men and women who need
some sort of pelvicreconstructive procedure. So

(01:02):
both sis and trans. I got intogender affirming surgery about
12 years ago and started mypractice 10 years ago, started
at Cleveland Clinic inCleveland, Ohio, and I just
recently left Cleveland Clinicand now I'm in San Diego working
at UC San Diego health.

Vanessa (01:21):
San Diego is quite the upgrade from Cleveland when it
comes to your surroundings. Sowe miss you up here. But girl, I
don't blame you. I, too. Soshould I

do miss Cleveland, I will say there's something
there is something special aboutthe town of Cleveland.

Vanessa (01:40):
It does have its own vibe. You said it does. Are you
from Cleveland originally?

No. So I actually I was born in France and my my
father's French and my mother'sAmerican. So I spent a little
bit of time in my earlychildhood in France. But then I
moved to New York as a young ayoung kid, and then just sort of
moved around after that. So Ilived in New York City for a
while and then I lived inBoston, and then I made my way

(02:09):
out to Cleveland.

Vanessa (02:11):
That's a lot of jumping around. But pretty exotic was to
grow up really. So that's cool.
super catchy and the medicine inthe first place.

I think I was always inclined to be a doctor,
I sort of steered away from it.
I was sort of in and out. I wastrying to find my artistic ways
when I was really young, I thinklike a lot of people and then
you sort of think about how youmaybe want to make a living. And
it sounded pretty good to beable to make a good living
taking care of others, right,that sort of feels like a really

(02:41):
noble profession to go into. AndI sort of felt like, Oh, I could
use some of the creative waysthat I have in my profession by
doing something maybe surgicaland something where I'm
restoring anatomy or creatinganatomy. So it's sort of the way
that it got me here, but I waswanting to take care of people.

Vanessa (03:00):
That's a good reason to get into medicine. I wish every
one that got into medicine had areason like that.

Well, I think I think that everybody, I think a
lot of people start that way.
But I think some people losetheir way. So yeah,

Vanessa (03:15):
which is understandable to the amount of stress. And
just the stuff that you have tosee every day has to. I can't
even imagine I couldn't do it. Ican't even handle a little cut.
So yeah, I don't know how peoplein the medical industry do it.
And I have a lot of props forpeople that do so what led you

(03:35):
to get into gender affirmingsurgeries.

I actually was one of the like, I think I'm one of
the few people who sort of knewthat's what I wanted to do. When
I went to medical school, I tooka little bit of time off between
medical school and college tofigure out exactly what I was
going to do and how I was gonnapay to go to medical school and
try to figure all of that out.
And I had some experiences aslike a 2122 year old living in

(04:02):
New York where I got to meetsome youth in New York City, I
was working with somedisenfranchised homeless youth
and learned a lot about why theywere homeless, and a lot of them
had been either chose or askedto leave their homes and were
completely disowned by theirfamilies. And a lot of them were

(04:24):
trans. At the time. We weren'treally calling it that. You
know, this was in the early2000s. So it was almost 25 years
ago. But I sort of became very,Yeah, very. I don't know, I
don't want to say the word likeattracted to the sort of the
concept of exploring sort ofone's gender. I think we weren't

(04:46):
talking about it mainstream andit the concept was so clear to
me that that was possible thatwe didn't necessarily need to
identify with who we actuallyare how we were actually born
right Who We Are versus how andand what we were given
biologically don't necessarilyneed to align. And so this was a
time where we weren't, there wasno discussion about it, we

(05:08):
didn't read about it in books,nobody was teaching it. It
wasn't on TV, right, exceptmaybe portrayed right in a
certain kind of way that wasreally probably very negative.
And so I had all theseexperiences 20, almost 25 years
ago. And so what I also waslearning as I started learning
about how people were gettingtheir hormones, how people were
getting surgery. And I found outthat again, there was no

(05:29):
mainstream medical way forpeople to get these things,
people were buying hormones fromeach other, they were ordering
them from certain places, theywere sharing hormones, there was
definitely a black market forit. And then for surgery, what
really sort of made me start, itreally sort of propelled me to
go in one direction with mymedical career was that I
realized that only people whohad money could actually get

(05:51):
surgery, or it was peoplegetting surgery from people who
weren't qualified to do thesurgeries. But people were just
willing to take whatever theycould get, and people were
getting harmed from it. Youknow, this is back in the day
where people were getting, youknow, like silicone injected in
very strange, you know, placesand dying from sort of
infections from the sort ofunderground injection clinics.
And so I just sort of startedthinking, you know, this could

(06:15):
be mainstream, right. And so,and I kind of hit it at the
right time, because as I wasgoing through my training, a lot
of stuff changed. Like in2008 2010 2012, there was a lot
more visibility. So I, I sort ofI call it this wave that I was
on right time, right place,seemed like a lot of people were
starting to get it around thetime that I was.

Vanessa (06:40):
God, I mean, I until like 2005 2006, I didn't even
know that trans people reallyexisted. Like I've known
something was up with me since Iwas five easily. But growing in
like a Christian conservativefamily that was like, this was
something we talked about, youknow, but I saw a documentary

(07:00):
called Trans generation. Andthen I'm like, we, this is a
thing, you can actually do that.
And yeah, I kind of buried awayfor a while after that. But what
you're just talking about, like,helping people and like learning
about the community and stuff,that's how they found you,
actually, when I was researchingsurgeons, when going to

(07:21):
Cleveland is convenient,because, you know, I live in
Northeast Ohio. But at the time,you had a Twitter profile, I
refuse to call it what it'scalled now. And I saw like
activism, I saw trans flags. AndI'm like, okay, she gets it, she

(07:41):
gets it. And for other surgeons,I didn't see that kind of thing.
And for something this major, Imean of that, and a plasti is
definitely not a light surgeryin any way, shape, or form. And
I wanted somebody that I couldreally, I knew I respected the
community. And honestly, Iwanted a woman to do it, because

(08:05):
it's not a man's job, in myopinion, but that's just me. So,
it's, it's wild.

Yeah, I mean, it was quite the process. I mean,
and I understand that, I thinkthat um, and I thank you for all
those things, nice things thatyou just said, I think that you
know, there are different typesof surgeons who do the surgery,
and we all sort of are cut fromdifferent cloth, some of us
similar cloth, some of us not, Ithink do think that there are
others like me, I I've run intothem, I know them. But I think

(08:38):
it's recognizing that first ofall, the surgery is not about
us. So you know, my work, youknow, there's like an ego
component, but it's really aboutthe patients and trying to help
you along sort of your journey,and everybody has a different
story. Everybody has a differenttimeline. Everybody comes from a
different experience, right? Andthat for me, right? I know how
to do the surgery, I can do thesurgery, and I'm happy to do it

(09:01):
right. And so I'm just sort of atiny little part of that
storyline. But I'm not sort ofthe center of that story. And I
think that that's important forsurgeons to remember that we're
technicians, right we haveskills we they get better over
time we learn new skills, weinnovate our skills, but that
it's actually a privilege to beasked to be part of your story.

(09:23):
I think that that's like areally important thing and it's
why I really enjoy the work.

Vanessa (09:28):
It's when I woke up from anesthesia. Like I think
one of the first things I askedhim like is this really just
happened and the feeling of justrelief from living for 42 years
with my body not mentioning mybrain and having that major step

(09:53):
and then the care afterwards.
There was the hotel stay for alittle while and honestly the
worst bed ever had an ankle andhorrible, but I'd have to hold
the hospital stay. But thenafter that you had me go to the
hotel attached to the ClevelandClinic. And you did essentially
house calls at the hotel. Andthat really humanized the entire

(10:15):
experience for me, even thoughthere was like, the unpleasant
thing where my catheter gotclogged, and we had to take that
out, put a new one in, let metell you, I do not recommend
that for anybody. But like, justthe entire vibe. And you really,
there was just a real humanaspect to it, I didn't feel like

(10:38):
a number, I actually felt likepart of the community. And that
really meant a lot to me. Andyou you wish to use the word
technician. I would also argue,I don't know if you agree or
not, that there's an art to thisas well. That you've obviously
been, you know, perfecting overthe past decade plus, but it's

(10:59):
funny the amount of sis womenthat asked me about the surgery,
and the even asked to seepictures. Is is comical. And
it's fun for me. Because whenthey see they're like, that is
amazing. For anyone that doesn'tknow what they look like, it's a

(11:24):
very accurate facsimile of aneedle vagina. So it's the
entire thing. It's just wild.
What, what what procedures doyou do now?

Yeah, so I in terms of human gender affirming
surgery in general? Yeah. SoI've stuck to doing mostly
vaginal plasti and Volvo plasti.
So I mostly take care of transfeminine patients. I did a lot
of hysterectomy, is it so genderfor me, hysterectomy is for men,
and trans masculine individuals.
And I still do those and I'mhappy to see those patients I

(12:06):
enjoy actually taking care oftrans men a lot. And so, and so
those are the main procedures. Idid Matoi do plasti for a small
amount of time. But I leave thatto some of my other colleagues.
It's I think, you know, Idecided, while I was sort of

(12:26):
building my practice to focus ona few surgeries, in addition,
you know, I have another like acisgender practice where I do
reconstructive surgeries forthose patients. But I decided
when it came to gender affirmingsurgery to stick to sort of a
small handful and to get thosesort of very, very, you know,
down in a way that I really sortof the patient experience was

(12:47):
great. complication rates werelow and that patients most
importantly, were really happywith their outcome at the end.

Vanessa (12:54):
I mean, keeping a small menu is that's what Gordon
Ramsay tells people to do. Sostick to what you know. It's
true. Can you explain to thelisteners quick, renowned
differences between vaginalplastic and a vulva plastic?

Yeah, sure. So not everybody you know, we vaginal
plastic is kind of what we calllike a misnomer, right? It's not
really what the procedure is.
The vaginal plasti is just oneone part of the whole list of
procedures in it that's reallyjust making the vagina So in
essence, most women who areundergoing the surgery are
getting a vulva plasti Thequestion is whether or not
they're getting a vet vagina, sothe vaginal plasti part, so we

(13:30):
tend to call it vaginal plasti.
And that sort of includeseverything right, doing the
outer genitalia plus the vaginalcanal. But some women, or some
individuals don't want a vaginalcanal for many reasons,
regardless of their age, or sortof intimacy goals. And so they

(13:51):
choose to not have the vaginalpart. And so we just do our
external genitalia. I tried tocreate sort of the illusion of a
smile of an opening because thatlooks more anatomically correct.
But then there you reallythere's, there's no ability to
have penetration or anythinglike that. And there's a whole
list of reasons why somepatients choose to do that over
over having a what we call afull depth procedure.

Vanessa (14:15):
Oh, yeah, I mean, that was something that was
conversation I had with myselfwhether I was gonna go full
depth or just a standard bobbleplasti visible depth does
require a lot more work. Thepart of the patient with dilate
Yes. And just upkeep in general,like shortly after, for the
first three months aftersurgery, you dilate three times
a day, and then you build uptwice a day. And currently I am

(14:38):
almost a year out now 10 monthsout. And I'm once a day. But you
know, it takes a certain amountof dedication for that. And
yeah, so there's definitelymultiple ways of doing it. And
it's whatever is mostcomfortable for the patient.

Yeah, I think there's So the work you need to
do after and then it's thehighest risk part of the
procedure, it's the part that ifsomething goes wrong, you know,
everything else you can usuallyusually resolve, there's a few
other parts of the procedurethat if something goes wrong,
that may not be reversible. Butfor that part, if you create an
injury or have a problem, thepatient has a really long road

(15:19):
ahead, and they may not even beable to have a vaginal canal,
you know, if there's an injury,you get something called a
fistula, and then you may not beable to dilate. So then you lose
the canal anyway. And it's very,very upsetting to patients. And
so I think that if you go to asurgeon, whether the risk of
having that happen is reallylow. It's still possible, right?

(15:40):
So you have to sort of choosethe right surgeon, but also know
that you're willing to take onthat risk. And note the
consequences if it does happen.
So pay some patients shy awayfrom that. And then just like
you said, the other reason is,if you know yourself that you
don't have the time, dedication,or desire and your ultimate goal
is to not use a vaginal canal,then maybe the other the end,
you don't have the time to doall that dilation. The

(16:00):
alternative is to do just thisvulva plasti, which we also call
zero depth and no depth, thoseare the other like terms for it
for sure.

Vanessa (16:10):
And there are multiple kinds of full differential
plasti as well. There's penileinversion, which is what I had.
And then the other one, it's acolon thing.

So there's three total. So the penile inversion
is where we use all the skin inthe genital. So the scrotum
skin, penile skin, everything isused to line the new the new
vagina. And then the otheroption is the peritoneal vaginal
plasti. Where in, you sort of dothe same procedure, but then you

(16:40):
have to through the, through thebelly through the abdomen, I'm
usually using roboticassistance. So you have these
little incisions on yourabdomen, and we put little
camera in, we harvest somethingcalled the peritoneum, which is
sort of this filmy layer thatcovers some of the organs, and
you don't need it, and it growsback. So we can take some of it,

(17:00):
and we use it to attach it tothe the little skin we do use in
the canal. So it creates avaginal canal using a different
a different part of the body.
And that's really good forpatients. Well, there's sort of
different perspective, somesurgeons only do that procedure.
And it's because they feel saferdoing the vaginal canal that
way, they feel like they canavoid getting an injury or

(17:22):
having a problem like I justdescribed. So they'll do it that
way. And then they'll just tellyou some of the peritoneum and
other surgeons like me, I'll dothat procedure once in a while
for patients where I don't thinkthat they have enough skin. And
I'm worried that I'm not goingto give them a good enough
vaginal canal. And I think thatthat's a really good option. I
worry about having that as thefirst surgery you have. Because

(17:45):
if you need a revision surgeryfor your vagina, that would be
the option. And if you'vealready had it, you it's no
longer an option. So for me,it's my backup surgery in case
somebody goes through lifeevents and can't dilate, and
they lose the vaginal canal orsome other problems, you really
can use that as a secondarysurgery. If you do it first,

(18:05):
you'll never be able to regainthat depth if you need to do it.
And then you mentioned the colonsurgery. So that's a sort of a
really old surgery, but it stillexists. We take a piece of the
colon and we actually recreatethe vagina using colon. It's got
some benefits, but it has somedownsides. So in my for me that
that's like the last resort,something that I would only do

(18:28):
in very, very rarecircumstances.

Vanessa (18:32):
I'm glad you didn't do that when I may. I've heard some
horror stories about it. And youalso did a revision on me. That
would be a labia plasti,essentially. Yeah. So

yeah. So it's your story to tell in terms of what I
did for you. It's your, if youfeel like sharing that. So but
about I would say it dependsupon the surgeon. Right. And
this is actually a really goodquestion to ask surgeons, when
you go and see them is what'syour revision rate? Right? How
often? Do you take patients backto the operating room to do a

(19:07):
revision? And then I think themore sophisticated question is
asking them what kind ofrevision so for me, I always
tell patients now because thishas evolved over time when I was
first starting, I did a lot morerevisions because I was on my
own learning curve. And, youknow, you sort of tend to get
things right and perfect thefirst time better, but I will

(19:28):
say revisions often happencosmetic revisions, because the
body is going to heal the waythat the body heals. So
sometimes things get fusedtogether. So for instance, the
clitoris gets buried, so it'sthere but you can't see it
because the labia got stucktogether. Sometimes there's some
asymmetry of the labia.
Sometimes there's some woundproblems during the healing
phase and so it doesn't heallike as like cosmetically

(19:51):
symmetric or as right so you cando little things. Those are
really common I would say aboutfor me about one in 10 of my
patients needed revision. So forevery 10 patients, I do a
vaginal plus your Volvo classDionne, I take one of them back
to the operating room about sixmonths after surgery to do a
very small procedure right? Nowwhat you want to know from your

(20:12):
surgeon and I think that's veryacceptable, because again, the
body is going to heal the waythe body heals. And it doesn't
mean you can't get perfectresults with a second really
tiny procedure. And you don'tneed letters for that procedure.
You don't it's it's no differentthan a cisgender, labia plasti.
So it just gets submitted to theinsurance company like a regular

(20:32):
female procedure. And it'susually not a big deal. You
don't have to take a lot of timeoff, you can usually go back to
work very soon. It's just acouple of stitches. It's not a
big deal. What you want to knowabout from your surgeon is how
often are you are they doingmajor revisions, meaning redo
vaginal canals? How often arethey taking the patient back to

(20:52):
the operating room weeks aftertheir surgery to redo something
right? That means that theyhaven't sort of refined their
their skill set. And they'reprobably not getting it right
the first time around smallcosmetic things six months
later, no big deal. That's, thatshould almost be expected. And
if it doesn't, you don't need itgreat. But ask the surgeon about

(21:14):
what kind of revisions they'redoing and how often because
there's a difference insurgical, you know, the the
caliber of the surgeon dependingupon what that answer is. That's

Vanessa (21:26):
that's definitely amazing advice. And if you do
need a revision, there's nothingwrong here. There's nothing
wrong with the procedure thatyou had. As Dr. Fernando said,
we all feel differently. For me,I had my labia were a little bit
flabby, I guess you can say. Andmy clitoral hood was a little
bit where she said the the veryclitoris. And it was in and out,

(21:50):
like in an hour outpatient. AndI was back on my feet really
quickly. So. And yeah, insurancedidn't even bat an eye at it. So
getting insurance for the mainprocedure that requires a lot of
research. But in the end, itcosts me excluding all the hair
removal in the hotel stay andcost me $19.67. Whoa, which

(22:16):
Yeah, yeah, it's pretty bad as

well, we've cut we've come a long way, that's
for sure. I think it's amazingwhat happened 10 years ago, with
insurance starting to cover Imean, that's when we started
getting busy as surgeons, right,we got to sort of take care of
everyone, because most healthcare plans paid for this, there
are very few that don't anymore.
Some come with bigger, you know,some have deductibles, co pays,
etc, you're very lucky. But um,in general, the coverage for

(22:41):
this, even by a lot of Medicaidprograms is much, much better

Vanessa (22:47):
at and vary state by state for the listeners. So be
sure to do your research. BeforeYour Next year of insurance.
Just make sure everything'scovered. All the i's are dotted
and T's are crossed. It'sparticularly hard in Ohio. To
get it done. I will say I hadasked her insurance, which was
Cleveland clinic's insurance.
And Dr. Brenda was withCleveland Clinic. So that all
worked out. Can you settle alittle argument for me during

(23:11):
the penile inversion, is thereever a time that the penis is
completely detached from thebody.

So most of it is, but there's a small portion of
it that isn't and it's theportion that has all the nerves
in the blood vessel that feedthe like glands or the head of
the penis. And that's what weconvert into the clitoris, we
just remove a lot of it, but wekeep the top part. Because if
you were to look at like get apicture anatomically
everything's at the very toppart and it runs on like the top

(23:41):
portion of the penis. And so, itis you have to be careful doing
this part of the surgery but soa very small part of it, maybe I
would say, you know anywherefrom 15 to you know, 10 to 15%
is kept but everything else isis removed. But no, there is
never a complete detachment andlike sewing of the blood vessels

(24:03):
and the nerves everything staysit's almost like a very skinny
stock that you you keep and thejob of the surgeon is to make
sure that stays well and healthyduring the whole surgery so that
you have a functioning clitorisat the end.

Vanessa (24:17):
And we myself and my girlfriend's appreciate you.
Keeping all that is I stillswear it's like dark arts or
something, how you get theclitoris to work in the place
where it's supposed to be. Andthe entire thing is just mind

(24:37):
boggling and how it works. Isthere any like? Go ahead?

No go You go ahead.
Maybe the question you're gonnaask.

Vanessa (24:47):
I was just gonna say is there like, what's the quick and
dirty of what happens during afull capacity?

Yeah, so why there's a reason I love this
surgery so much. So there'ssomething very in my Canyon,
very poetic about the surgery, Ithink, you know, some people
would hear me say then like,kind of roll their eyes. But
it's the reason I love it somuch is, if you actually and
then I'll explain to you likewhat goes on during the surgery.
But if you look at what happensto us when we are in utero, so

(25:16):
when we're developing and we'redestined to be a little boy
fetus or a little girl, fetus,right. And then we develop
right, and then we become a babyand we're born. That's decision
tree of, excuse me, thatdecision tree of the genitals
developing is dependent uponyour chromosomes. So if there's

(25:37):
a Y chromosome, there, itdevelops in the male, if there's
no Y chromosome, the default islike the it'll develop into the
female. So it's at the verybeginning that these things are
decided, right, which just feelsso frustrating, because
obviously, that's totally beyondany of our control. It's just
genetics, and chromosomes. Butevery part that becomes male,

(26:00):
like that exact part, thosecells that then get bigger and
develop, if there was no Ychromosome, they would have
developed female. So like, theglans of the penis is the
clitoris in the female. Theurethra where we urinate out of
is actually like off in the mailthat long urethra is the inner

(26:21):
lining of the labia, that pinkmoist area. They're called
homologous structures. So like,essentially, what we do during
the surgery is we take the malestructures that would have been
female if there wasn't a Ychromosome, and we repurpose and
use them to create the femalestructures. So there's nothing
in the in the, in the transfemale, like in the Jenner and

(26:45):
the genitalia, that like the allof those things originated from
the male parts that should havebeen female. And so I think that
that's the beauty in thesurgery. It's not like we're
taking like an eyeball and likemaking that the clitoris right,
that doesn't make any sense. Itwas never destined to be the
clitoris. But the glans of thepenis? Sure is, you know, what
should have been the clitorishad things just spin, right?

(27:07):
Right. That's the way that I seeit. So that's why I think
there's like some poetry to thesurgery. So what we're
essentially doing is that weare, we deconstruct the penile
anatomy, so we remove a lot ofit, but keep the very skinny top
part. And we fold it on itself.
So by folding it on itself, it'salmost like if this were like

(27:28):
this is the the skinny piecethat's left in my fingernail is
the is the clitoris right? Itused to be a big glands, we fold
it on itself like this. And whatthat does, right is it creates
the little clitoral button.
Okay. And then this bent part issomething called the clitoral
column, which all women have,regardless trans sis, right,

(27:50):
that's an most if any womanwho's you know, and I use the
term woman like on a spectrum,right? So not to refer to the
binary. But like any woman knowsthat, oftentimes, you don't
necessarily need to stimulatethis part, right? This is the
part that has the moststimulation, and any woman trans
sis, in between, sort of hasstimulation from that area. So

(28:13):
it's important to maintain that.
But essentially, we fold it onitself. And then the important
thing is just making sure as thesurgeon that you're putting it
at the level that the clitorisshould go, should be placed so
that everything looks female,you don't want it too high. You
don't want a button sitting ontop of your pubic bone and
looking like you have two bellybuttons. That is really weird.
And I've seen that happen. Andyou don't want it to too low
because then you got to golooking for.

Vanessa (28:36):
So if you want it sort of anyways. Exactly.

So, you know, help some help them help them. So
it's about sort of understandingand like the anatomy where
something goes, right, like ifyou look at the groin of the
patient, you can tell at whatlevel the clitoris should be at
than the urethra, we basicallyopen up the urethra so that it's
short, and it goes right butbelow the clitoris a few

(29:02):
centimeters below. But then Iuse I don't get rid of the
urethra, I keep it on its bloodsupply. And I flip it over and I
use it to create that pink moistarea between the clitoris and
the urethra because if you lookat most women, they don't just
have skin between their theclitoris and the rethrow. So I
think part of the artistry ofdoing the surgery is making it

(29:22):
so that it looks really female,and it should look pink and it
should look moist. Right? Andall the holes should be in the
right locations and aligned inthe same way. So yeah, I mean,
there is some artistry to doingit. But there's technicality in
that. If you do most things thesame way over and over again.
You'll also get it right. Butthat's how most that's how the

(29:45):
procedures performed. But it'susing the stuff that should have
been which I think is great. Youknow, that's

Vanessa (29:51):
that's so cool. It's like hitting the rewind button
on gestation kind of. That'sexactly right. Yeah,

it's exactly I mean, I've had some pay She's
caught a rebirth, right? Theyfeel like they're burnt. You
know, I've had some patientschoose their surgery date as
their new birthday, you know,sort of have that, you know,
whether it's you know,conceptually or official, right?
Like you can't change your birthdate of birth, but you can in
you know, from a spiritualperspective, you know, certainly
change your your birthdate. So,

Vanessa (30:20):
that's, I mean, that's really good way of putting it
because when you wake up fromthat surgery, and you realize
that, that as I said earlierthat it's done. It's, it's a
whole it's a whole thing andonly the people that have had
the procedure understand thatthe whole thing so I

mean, what you say is correct, that's something
that I will never understand,right? I've certainly witnessed
it and watch the experience butonly people like yourself and
Assa and other individuals thatI've you know, taken care of and
people that you know, can speakto how it actually feels to wake
up from that procedure.

Vanessa (30:54):
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Vanessa (31:57):
What are some common misconceptions that you would
like to dispel while you haveyour time?

I think that common things that I did, one of them
is like vaginal lubrication. Solike so a self lubricating
vagina in reconstructive surgeryis virtually non existent. So
even with peritoneal vaginalplasti, that's the one that got

(32:25):
very popular, I have colleagueswho started doing the procedure,
this procedure a lot in New YorkCity, and all of a sudden it
caught on like wildfire, becausethey published some really great
papers on it. And while thesurgery, like I mentioned
earlier is a great procedure, itthe selling point is not that
you end up with a selflubricating vagina, the the

(32:46):
peritoneum that gets used forthat vagina ends up looking very
similar to the skin you use whenyou're doing penile inversion
after some time. So there's noreal procedure that really has
like figured that out, though,there is lubrication for some
patients, from actually theurethra area, because those
glands that are there are stillthere. And so if some patients

(33:09):
have very healthy, intactglands, they'll get lubrication
at the opening of the vagina.
And I would tell patients likethat just means you're one of
the lucky ones. And there's noway of predicting so using self
like lubrication and vaginalmoisturizers, you can use things
like coconut oil, actually, inthat area to keep things sort of
moister are is a good thing. Butthere's no such thing as a

(33:32):
reconstructed self lubricatingvagina. I'm trying to think of
like other myths that I'veheard, or that I can think of
that's the that's the biggestone.

Vanessa (33:43):
That's a big one. I see a pop up all the time. Yeah,

I think too. I've had this experience and I try to
set patients upfront with theirexpectations. But again, I don't
know what it's like to walk in apatient's shoes and have sort of
this thought of what a vulva issupposed to look like. I think
we get a lot of sort of thosecues from from looking at like
pornography and things online,certainly. And then if you know

(34:07):
a lot of people you know, maybeindividuals share and show each
other their Volvo's, whichsounds funny, but I actually
think is a very normal thing,especially if you're looking to
have one created for you. But Ithink we get a lot of our online
cues from, you know, our cuesfrom online, which can really
even in the CIS population,create expectations that don't,

(34:28):
sort of really, you know, weremade a certain way. And so one
of the things that's very hardto do with this procedure is
create like large labia. Somewomen want very large labia, and
most of the time with this typeof procedure, you should expect
to have small labile columns.
You can have a revisionsometimes to make them a little
larger, but you can only workwith what you have. And so and

(34:49):
that and these reconstructiveprocedures rely on good blood
supply to heal properly. And soit's very hard to get Create
like big labia menorah, whichsome women will ask for. So
that's like a myth that's likethat it's possible to do that,
for sure. I think those are thetwo biggest things that I've
really run into. I

Vanessa (35:11):
mean, those are two really good ones to stuff that
you hear a lot. And I mean,people with needle Volvos
they're every single person's isdifferent to we're all built
different. And they're allbeautiful. You know, there's,
there's even coffee table booksjust full of them. Just there
are Yeah, yeah,

I love those I love like I have the sun. There was
one that was created a long timeago. It's called the wall
evolvus. It's like these castsof different Volvo's. I don't
know if you've ever seen them.
But you can if you Google it,it's like, a picture of small
like sculptures of Volvo's that,you know, women had cast got
cast and they did this. And so Itook that idea and said, like,
for rondos, wall evolvus fromlike, so when I give

(35:56):
presentations, right? I havewith permission from the
patients who allowed me to takepictures and use them obviously,
it's just, you know, a pictureof the vulva. But um, I have
like, I don't know, maybe like40 You know, small pictures
lined up real close together.
And it's clear every singleperson looks completely
different, but they look nodifferent than Asus, vulva. They

(36:17):
just look completely differentbigger lips, smaller lips, labia
majora, labia menorah, you know,skin pigmentation, sometimes you
can see the scars on the labiaand some patients you can't. So
that's what I show patients inthe office not to digress. But
that's another thing, if thesurgeon you're seeing cannot
show you pictures and what toexpect, and shows you a wide

(36:37):
range, not just sort of theirbest picture, I tried to show
pictures of patients whosescarring is a little bit more
prominent patients who are whoseweight is more similar to the
patient, right? You don't wantto show somebody who has a BMI
of like 33, and is 52 years old,a picture of somebody who is 19
and has a BMI of 20. Right, Ithink that you want to show

(37:00):
realize, so make sure yoursurgeon shows you pictures, if
they can't show you pictures.
That's kind of a strange thing.
So I just wanted to throw themin there. Two other myths I was
thinking about is that withperitoneal vaginal plasti, you
don't have to dilate aftersurgery. And that's one of the
benefits. Not true, you have todilate just like a penile
inversion. So it's not a reasonto. And then the other reason

(37:20):
people really are jazzed upabout doing a peritoneal vaginal
plasti is because a lot ofsurgeons don't require hair
removal for that procedure. Soyou can skip that skip step. The
only thing I will say is it'strue, but we still tend to use
some of the genital skin at theopening of the vagina. And so
you might not end up with hairgrowth deep deep down inside if

(37:43):
we use the peritoneum, but youstill have hair growth in places
that most women don't want hair.
And so I always say that somehair removal, especially around
the scroll area is stillhelpful. And so I don't choose
to have a personal version ofplus you just because you don't
need to you do hair removal andskip that step. I do understand

(38:04):
that hair removal can befinancially like a financial
strain for some people. So Idon't want to be exclusive when
I say that, but just one of themyths is that no hair removal
leads to similar outcomes.
You'll still have hair in weirdplaces if you don't do some hair
removal. That

Vanessa (38:22):
actually answers a question that I had, because
some transplants that I'vetalked to that are getting the
procedure or have had theprocedure said that they didn't
have to do any hair removal. Andnow that explains why. But as
the doctor said, there's someways that you might not want
here to be growing. So yeah,

I mean, I want to commend I think I want to sort
of I want to say to the the itis commendable. In one aspect.
I've been a long term, longtime,longtime advocate of trans
individuals. And so I want toreduce barriers as much as
possible for patients. I don'twant it to be hard to come and

(39:06):
get surgery, I believe insetting up like a process so
that your outcome is good, sothat you're thankful for the
process and you feel happy andyou can go live your best life,
right. But barriers are tough.
And I think some of the surgeonswho are trying to get patients
to come and see you don't needto have hair removal done. And
you can do it this way, aretrying to reduce barriers for
patients, which I do think iscommendable. In my experience,

(39:26):
I've just seen that if you skipthe hair removal process, even
if you do these other ways, youstill end up with some hair
regrowth at some point. And it'syou don't know how upset it will
make you until you're in thatsituation. And I know a lot of
patients want to get therebecause you've been living your
whole life as somebody differentor it's it's just been a

(39:48):
struggle. Again, I don't knowthat struggle so I can
understand wanting to get tothis endpoint that you've been
picturing in your mind. But thatendpoint isn't as If you don't
end up with the results that youreally wanted, so I always, I
think those conversations arereally important. It's why I
spend a while talking to mypatients at the beginning,
before we even decide to dosurgery.

Vanessa (40:12):
And for some personal advice from a trans woman to
other trans friends, if hairremoval is something that you're
going to do, check yourinsurance policies very closely
in contact, see if yourinsurance company has people
that specialize in trans healthcare most companies do. Because
a lot of them will actuallycover hair removal if you get it

(40:34):
done at certain places. I foundout about that, right after my
final session. And but also thiscrowd funding can also help.
That's how I that's how we payfor most of it. Here removal is
not pleasant, but new, the aftereffects are, you know, it's it's
definitely worth it. So, but asDr. Fernando said, you know,

(40:55):
there's definitely there'sdefinitely a barrier to entry
there, too, that'sunderstandable. And

find find out from your surgeon's office, what
what's the minimum hair removalI need to do. I think there's
this misconception that it'severything or it's all sometimes
like, I will like we somesurgeons will show pictures or
draw you a picture or even showit on yourself and say like
bring this and you only need todo this there is bare minimum
hair removal, some choose tojust get rid of it all because

(41:24):
that's the aesthetic you preferanyway, I always say, make your
life easy, do the bare minimum.
And then if you want to do hairremoval on your vulva a year
after surgery, just to get thelook that you want, go ahead and
do that then. But you reallydon't need to remove all the
hair, you just need to remove itin certain areas that we need to
have, you know, to not have hairregrow in the future, and it's

(41:45):
not, you know, the entirescrotum, the entire penile shaft
of the groin, that's a lot. Soif you are sort of on a budget
or a timeline, specifically askwhat you need to have removed.
And again, good doctors officeswill tell you exactly what you
need.

Vanessa (42:03):
That is amazing advice too, especially like with the
drawing or showing people ontheir own body, what needs to be
done. Because there's, there's alot of hair down there and a lot
more than you think. And youreally realize it when
especially for gettingelectrolysis and you really
realize how much there is aquick shift gear because I don't

(42:24):
want to take up too much moreyour time. But a lot of people
don't consider that an entireteam is involved in these
surgeries. How do you findteammates that you can trust?

I'm so glad you brought that up. Because that is
so important. I have beennothing without my team. I just
was I moved right. So I don'thave my same team anymore. In
fact, I'm building my team. AndI'm pretty much a you know,
working solo, I'm sort of goingback to how it was when I was
first in Cleveland looking for ateam. So I was talking to my

(43:00):
teammate, Natalie, if there anyindividuals who listen to this
who have been in my practice,you'll know you'll obviously
recognize her name. But you needa team right being I think the
best surgeons also have peoplewho health care, do all the care
because a lot of us are reallybusy. There's a lot of patients

(43:21):
to take care of. And so if youcome up with a team, and
everybody has a job, and we allwork together, and we're all
sort of like it feels like thepatient, patients get a lot of
attention, but then they feellike they're being well cared
for and that there's like onestill one person responsible for
their care. But yet there's allthese touch points. So So for

(43:41):
me, what was always importantwas that I had a good person who
was the frontline person who gotyou into the practice. And who
made sure that you hadeverything administratively that
you needed your insurancepreauth your plan for traveling,
you're the entire post, postoperative stay all of that
stuff. And then somebodyclinical who really sort of can
help you with the phone calls.
helped me see patients aftersurgery. As you know, Rach, my

(44:03):
right hand, you know, Assistant,Natalie does all of the post
operative care. She spent a lotof time working with me to learn
all of that. So, you know, youbasically you post physicians,
you interview your heart onpeople and so you get the people
that you want you look forsomebody with a good heart open

(44:24):
minded. I will tell you, youknow, again, I keep referring to
Natalie, she's a nursepractitioner. When I hired her
in 2018. She had zero experiencetaking care of any surgical
patients, zero experience beingaround gender diverse people.
But she had a good heart andsaid to herself, I'd like to do

(44:46):
something different andunderstand gender identity a
little bit different and justimmerse myself into it. So it's
asking the right questions andthen also spending the time with
them training right? Beingreally hands on So you don't
need to be anymore. So I trulybelieve that surgical practices,
especially for gender affirmingcare are not, you know, as good

(45:06):
as they possibly could be unlessthey have a full team that gets
it. And then, regularly askingpatients for feedback. So at the
beginning, I used to ask them,was your experience good? Did
you feel safe? Did you feel likeyou could bring up complaints,
right? The system's not alwaysperfect. We don't always

(45:27):
completely understand if apatient you know, has has a, you
know, a complaint or a problem.
There's obviously Missmiscommunication sometimes. But
I think in general, we do areally good job. And it's about,
you know, me steering the ship,but making sure that everybody

(45:47):
who's on it is on board with me,and that we're all, you know,
paddling in the in the samedirection, right? I guess that
wouldn't be a ship, it would bemore like a kayak. But making
sure that we're all on thekayak, that we have our life
vests on that we make sure thepatient puts, you know, her life
vests on, and that we all paddlein the same direction. We don't
make the patient paddle though.

Vanessa (46:09):
I was glad that I didn't have

I think I've exhausted that metaphor, but I
hope that sort of gets like theanswers like the question,
right? Like, we have to rememberthat we're all on the same team.
And we all just want to help,you know, the people that were
taken care of.

Vanessa (46:24):
Yeah, I mean, for my experience, the communication
throughout the entire processwas amazing. Natalie, I've seen
her dozens of times since theprocedure. She's very calm, very
patient with questions. And, youknow, like a typical patient,
I'll have freakouts here andthere and she's scheduled me
into make sure everything'sokay. And but just like the

(46:47):
entire staff also, like beingbrought into the operating room,
like everybody introducedthemselves. Most of them, I
admit, already, they had takenthe time during the pre
appointments to come and meetme. And then you get put up onto
the surgical Gurney or whateverthe surgical table. So you can

(47:07):
tell I'm I'm a layperson. Andjust you could see the
camaraderie there. People don'ttrust each other. And when they,
when they're injecting the, toput you to sleep, it's nice to
know that the people that areworking on You don't hate each
other. So yeah,

you're making me miss my team a lot. You know,
I've only been on San Diego fora little bit. So now I'm feeling
a little nostalgia, because it'sa team that I worked with for
almost 10 years. And so, buteverybody believed in my
mission. And I think that thatwas really important and took a
lot of education. And you know,when I first started doing
surgery, I had to explain tothem and talk to them and

(47:48):
normalize it right. So it wasn'tsmooth sailing at the very
beginning. But I have alwaysbeen surrounded by really,
really kind people. And so aslong as people are kind hearted,
you can teach them anything. Andthat's the important thing to so
having, you know, I have aradar, right, I like sort of
like look for it. And I want mypatients to feel safe. Nobody

(48:11):
wants to go to sleep, unsure ofthe people around them, right?
Like, like I said at thebeginning, it's a massive
privilege to be chosen to do thesurgery. And you don't want
anybody going to sleep underyour care, feeling unsure of
like, what's going to happen tothem while they're while they're
in that very vulnerableposition. Right? You're naked,

(48:32):
right? You're having a veryintimate procedure done. You are
told who's going to be in thesurgery room right in the
operating room. But how do youknow for sure you're going to be
asleep. So it's, it's, it'spretty delicate. So I'm really
proud of everything that we setup and got done at a Cleveland
Clinic.

Vanessa (48:53):
I'm sure you're going to be building an amazing team
in San Diego as well. So I'm,yeah,

I'm joining a good team that's already there. I'm
just going to enhance anenhancement. But yes, it's going
to be fun setting up my practicehere and seeing patients and
then it'll be interesting to seewho shows up.

Vanessa (49:10):
Are you already practicing or?

Yeah, so I've started my practice. I've been
doing mostly care for sis womenright now. But um, I'd be happy
to see patients and bring themin for gender affirming care. So
you know, it's easy to find me iYou just you know, put in my
name and you'll find me underthe UCSD health I have my own
bio and my office number isthere so it's not difficult to
find me I'm still on theTwitter. Although I don't post

(49:36):
as much anymore. I used todisseminate a lot of patient
information there but it feels alittle it's different now.

Vanessa (49:44):
So threads is a really good place threads is the queer
paradise anymore. If you're ifyou're not familiar with it,
that's it's a good place to forthat but yeah, it's I'll have a
link to for people to find youout. Um, in the description this
as well. I'll close out with onequestion, what's the funniest

(50:08):
experience you've had as asurgeon

some of the funniest experiences I've ever
had are like patients leaving mepost it notes on their like
lower abdomen when I like taketheir gown off and to get them
ready for the surgery, you know,there'll be asleep and we
position a patient and then I'lllike take you know, because I
tried to keep patients covereduntil the very very end I mean,
you obviously we need to uncoveryou to do the surgery but I

(50:35):
don't do it until it'sappropriate and then when I do
some patients so you know theyjust leave me I had one patient
leave me a funny posted abouther warranty right like on there
any like a little post it righton the lower abdomen. And so
that's probably like, thefunniest thing. You know, that

(50:56):
has, like ever I've had ithappened a handful of times. And
each time I laugh pretty hard,because it's always like a
complete surprise. I thinkthat's the funniest thing. Those
are the funny moments that I'vehad for sure.

Vanessa (51:08):
Damn, I missed the opportunity. So and then some
people like stuffed like ketosisand stuff to having the

I have gotten some stuffed uterus. Oh, I actually I
think one of them were thingsthat made me I had one patient
who does a lot of like reallypretty crochet work, but like,
I'm stuffed crochet. So she mademe a uterus. And then the
funniest one she made me was theclitoris. But it looks like the
real anatomy of a clitoris.
Like, it's like because of theif you look at the anatomy of a

(51:35):
clitoris, it's prettyimpressive. It looks like the
penis actually, like, if youlike take off all the skin and
just look at the anatomy and theblood supply. It's just smaller.
And it's like anatomicallycorrect, which is bizarre, like
people look at it sometimes. Ihave it actually. Oh, here, it's
right here. Would you like tosee it? Yes. Okay, so now you're
really going to laugh. I canshow you because I'm in my new

(52:00):
home office. And I haven'tunpacked yet. But this is the
uterus. She made me. Super cute.
Super cute, right? I hope thisgoes to show anybody that if you
ever make me anything, I willkeep it forever. But this Are
you ready for this? Okay. Sothis is the clitoris and it has

(52:20):
a little hood. Adorable that youcan like take in and out. So I
think that's so funny. And inthe same bag, I have an entire
bag of hundreds of cards thatI've received over the time. And
anytime I get a card fromanybody, I always keep it so

(52:42):
I've kept every card a patienthas ever given me and I keep it
in a folder and then I just haveit there because sometimes I
read them and I remember mypatients but I have my little
baggie of like patient thingsand I've gotten I have like a
stuffed unicorn. I have astuffed rainbow.

Vanessa (52:57):
I think a unicorn.
Yeah, I

think you gave me the unicorn. It's a white
unicorn. It has like a littlepride. I think it's the tail. I
wonder if it's in heresomewhere. Somewhere in here.
It's probably at the bottomsomewhere here. I have a
unicorn. And then I have thislittle rainbow one that I love
also it was like a pretty priderainbow. So but the clitoris was

(53:23):
incredible. Just because it waslike really talented. And then
it was just the little hood. Imean, that just put me over the
edge. Oh no, I've also gotten asweatshirt. I have it up in my
closet somewhere. I can'tremember what it says. I think
it's like, I don't know if I'mallowed to say this on here. But
it's like there's, I mean, it'snot even that bad. But it's like

(53:45):
Team policy or something likethat. And it has like a kitty
cat on it. But one of mypatients like did a screen. She
makes sweatshirts that arereally nice. And she did that.
And I used to wear that aroundfor a long time. So those things
make me laugh and they also warmmy heart and they're
personalized. But yeah, messagesunderneath the gown funniest
part of everything because italways I'm very focused when I

(54:07):
do surgery. Like I get prettyserious like one just like,
yeah, obviously, but like Iagree, but once like, I have
sort of like this quietnessabout me when it's time for
surgery. So I'm like gettingfocused. So whenever I've always
found that it's always been inthe midst of me getting my brain
ready for surgery. So then italways makes me laugh out loud.
So

Vanessa (54:27):
that's the funniest thing. Well, that's another
question for patients askedtheir surgeons. Have the
surgeons, other patients gottenthem gifts and stuff? If not,
why? So?

Why is nobody giving you any gift? Yeah, sure.
So

Vanessa (54:42):
I remember I was scrolling on Facebook and I saw
these mugs that popped up as anad. And I wanted to get one for
you and one for Natalie. And butthen that disappeared. And I
couldn't. It was it was likeperfect. I don't remember what
it said. But it was just likeyeah, whatever. What do you have
any closing thoughts that you'dlike to share? You're,

I'm just so happy to be able to chat with you, I
think one of my things is thatI've had really nice
relationships with I don't, I'vemade a habit, a professional
habit of not really sort ofhaving a relationship outside of
like the care until the patientis happy with their care and
done right, like, you don't needanything else and you feel
satisfied. And then I'm alwayshappy to sort of communicate,

(55:23):
you know, through social mediaor through this like platform.
So it's, um, I think that thisit feels special to be able to
talk to you just, you know, as aperson, as you know, a woman, a
woman on this podcast, and Ithink back to when we met each
other, and you came in for yourconsults, and you were a little
nervous. I remember to now justbeing able to chat, but um, I

(55:49):
think my messaging to there'senough surgeons doing surgery
now compared to what it was thatyou have the choice and you
should be choosy about yoursurgeon, there's no such thing
as like, you know, as long asit's gone, I'll be happy. That's
not true. That used to be sortof the old mentality, you need a
beautiful vulva. And you needsomebody who takes it seriously.

(56:11):
And so I encourage patients whoare having any surgery, I'm
speaking to the men also, ortrans male individuals looking
for Matoi, do plastiphalloplasty anything in
between? Know your surgeonsexperience, make sure they were
trained, like get somebody whopractice before they actually

(56:32):
started a practice. Does thatmake sense? Not somebody who's
practiced when they startedtheir practice, that used to be
the old way of doing it, when Iwanted to do this surgery, there
was no such thing as a trainingprogram. You had to watch people
do it. And then you had to be agood enough surgeon to try it.
But now there are trainingprograms, I've trained lots of

(56:52):
fellows other surgeons have. Somake sure that they're trained,
like they learned how to do thesurgery, they got to practice
with somebody supervising them.
And then don't settle like youneed, you know, the results that
you've always wanted. But thenalso understand that the
surgery, there are speed bumpsthat sometimes happen with these
surgeries and they're not alwaysperfect, even in the best of
certain best surgeons hands. Sojust choose a surgeon who's

(57:15):
going to be there for you forlike that process and who you
know is going to support you,but be choosy. That's like I
guess my take home message.
Don't settle like your surgeonand be choosy. That's

Vanessa (57:29):
amazing advice. Like, if your surgeon doesn't want to
answer questions, that's a bigred flag. Ask questions because
this is a major major surgeryand there's a lot that happens
with it. So communication iskey. I can't thank you enough
for being on the pod with me.
This is This is amazing. And Ireally hope a lot of people find

(57:52):
this informative. You're thiskind of like condenses a whole
bunch of questions that peoplehave on Reddit. I don't know if
you've been on Reddit and lookedup stuff for gender affirming
surgeries but I

go to Reddit I will say I don't know how to find
anything on Reddit so I I've hadso many patients say to me I oh
I'm here because I like read allthis stuff on Reddit about your
practice etc. And then I like Ican't find anything so I don't
know if I'm doing it right or ifI knew how to find the threads
or figure it out so I'm

Vanessa (58:21):
not that great at it either. I think it's pretty
nice. We're Millennials like

I have to say like I'm like a borderline Yeah, Gen
X or some is zeneo is like ouror is that what it's called? A
neck? Yeah. xennials Somebodywho's like borderline Gen X
millennial? Yeah, that's likethat's exactly who I am. So we

Vanessa (58:40):
can we can blame it on Yeah, that's right. Well, thank
you again everyone for listeningwatching please hit that
subscribe button rate us fivestars on Spotify, Apple,
whatever. And don't forget ourPatreon I really want to grow
the show. I'm working on makingit a weekly show against I've
every two weeks so I want togrow, grow, grow, grow, grow,
but we definitely need yoursupport to do that. Thank you

(59:03):
again, doctor friend for joiningus. This was a wonderful
experience. And we will see youall next week or next time or
whatever. I'm transcendinghumanity. Bye bye

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Getting Real About Gender Affirming Surgeries With Dr. Cecile Ferrando - Episode 42

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.css-14f5ked{margin:0;word-break:break-word;display:-webkit-box;-webkit-box-orient:vertical;box-orient:vertical;-webkit-line-clamp:2;overflow:hidden;}Getting Real About Gender Affirming Surgeries With Dr. Cecile Ferrando - Episode 42