There has been much written recently about the increasing demand for gender-affirming services; specifically, surgical procedures. However, transgender and gender diverse people have always existed. So to then have the need for gender-affirming care. For a long time, this need refused to be seen or acknowledged. Medicine as a field and society as a whole are finally starting to open their eyes.
It is not that “there is growing interest in gender-affirming surgery and LGBTQ+ care in medicine,” as is commonly quoted. The truth is that the medical field is just beginning to dismantle and emerge from the active oppression and negligence of care that was long practiced against our marginalized queer community. By integrating gender-affirming principles into the foundational practices of medicine, we are doing the bare minimum. We are providing care that has always been medically necessary, but only recently acknowledged as such.
Historically, a majority of gender-affirming surgeries had been performed, in a sense, behind closed doors — barely visible and hidden away from mainstream academic medicine. It is only recently with insurance changes and enlightened perspectives at the level of academic and institutional leadership, that gender-affirming surgery is being accepted and integrated into academic medicine. This is a critical step forward, as academic medicine represents the arena where physicians and surgeons train and therefore effectively sets the curriculum in which they are educated and acquire competency. Academic institutions possess resources that allow for innovation, research, visibility, and advancement of medical specialties. Queer people exist everywhere, accounting for 5% to 10% of the population. It is medicine’s responsibility then to ensure that gender-affirming care exists everywhere too.
Taking into consideration the lack of institutional resources, visibility, and research support traditionally accessible in the field of gender-affirming surgery, there has been little published, documented, or standardized in our field. Despite the fact that for decades many of these surgeries have been performed in different iterations, our literature is still in its infancy. Our formal educational training in gender-affirming surgery is still in many ways incubating. As a whole, medicine remains woefully unprepared to meet the needs of the entire queer community.
Despite a growing number of centers offering gender-affirming surgical services, there are still far too many barriers to access. It is still mainly the most privileged members of the marginalized transgender and gender diverse community that are most able to access care. We should not be celebrating how far we have come when there is still so far to go. The truth is that the people who most need gender-affirming healthcare services are the most unable to access them. These services are life-saving, not just life-changing. A lack of access is to many people life-threatening — to others it is far worse.
Considering this, fellowship training in gender-affirming surgery is crucial and past due. In addition to the barriers seen with accessing care for patients, there are also many barriers to accessing training as a provider. Gender-affirming surgery involves facial, chest, genital, and body surgery. In order to offer these procedures, highly specialized training is required across numerous surgical specialties, including plastic surgery, craniofacial surgery, microvascular surgery, and urology, just to name a few. The combination of exposure and training does not happen by chance, and it’s often challenging to gain experience outside of one’s delegated specialty in surgery. It requires organized, targeted, and collaborative education and training at an institutional level.
I had the honor to be the first advanced gender surgery fellow at Oregon Health & Science University (OHSU) in Portland, Oregon. Along with my co-fellow in Urology, Christi Butler, MD, we represent some of the first surgeons in the world to ever complete formal academic fellowship training in gender-affirming surgery. To my knowledge, we are the first graduating class, training across both the specialties of plastic surgery and urology in addition to acting as members of a comprehensive multi-disciplinary transgender health program. It is the dawn of a new era in gender-affirming surgical training, with institutions like OHSU leading the way.
Blair Peters, MD, and Christi Butler, MD, are among the first surgeons in the world to complete formal academic fellowship training in gender-affirming surgery.
Although this was an amazing privilege, my journey to access this training was complex, navigating a path not yet travelled. It inspires me to see a growing number of gender-affirming surgery fellowship programs emerging in academic medicine. Presently, most patients are unable to access surgical services locally. Many have to travel nationally or internationally to receive surgery, often resulting in minimal follow-up or supportive care. Despite the many barriers, these individuals continue to self-advocate, persevere, and stand up to the many oppressions of our healthcare systems. They fight for their right to care and for their right to live.
Many of the rights and privileges I enjoy as a white queer person were in no small part fought for by transgender women and queer people of color. Despite this reality, these groups represent some of the most oppressed members of our society. As the “gay liberation” movement marched forward, transgender people were in many ways left behind. No longer. Working in this field as a queer person has allowed me to see the need, the role, and the impact that someone from the queer community can have in academic medicine. The time for academic institutions to see us, hear us, and make change is now. It was not social obligation that led me here. It was a passion to connect, support, and to serve the community I fiercely love and belong to.
I want to take on and refute a common criticism and misconception I frequently encounter regarding care for the transgender and gender diverse community. Many people in medicine informed me that this “patient population is difficult” and that I was “brave for taking that on.” I stand in stark contrast. You will not meet a more generous, and appreciative group of patients to care for. I am not brave. They are brave for trusting me with some of the most intimate aspects of themselves. I am not sure I can ever affirm my patients as much as they affirm me as a person and as a surgeon.
Not one single person in need of gender-affirming care and surgery should have to struggle to access it. It is a basic right. Medicine’s historical oppression of queer people has resulted in a paucity of knowledge, expertise, and representation. We must continue to expand formal education and training in this field to one day be able to meet the needs of the entire community. If you are thinking about getting involved in LGBTQ+ care I promise you will not regret it. To my queer siblings: we need you in medicine. We need you in surgery. More than ever. I promise there is a place for you here.
To anyone in medicine living in a state of neutrality: the status quo is oppressive. Please step aside or get engaged and actively support gender-affirming practices and care at your institution. Being queer in medicine and surgery is truly an act of resistance — and we are just getting started.
Blair Peters, MD, is a plastic and reconstructive surgeon specializing in gender-affirming surgery. He is an incoming assistant professor in the Division of Plastic Surgery and Department of Urology at OHSU.