Selected Podcast
Transgender Medicine: Gender Affirmation and Facial Feminization Surgery
Dr. Jerry Chao sheds light gender affirmation and facial feminization surgery for transgender patients.
Featuring:
Learn more about Jerry Chao, MD
Jerry Chao, MD
Dr. Jerry Chao is Assistant Professor of Surgery at The George Washington University, and is board-certified in plastic surgery. Dr. Chao graduated from the Massachusetts Institute of Technology, after which he obtained his medical degree at Weill Cornell Medical College in New York. He then completed a combined residency in general surgery and plastic surgery at New York Presbyterian Hospital, followed by a fellowship in Craniofacial and Pediatric Plastic Surgery. He currently performs surgery at The George Washington University Hospital, Sibley Memorial Hospital, and Inova Mount Vernon Hospital.Learn more about Jerry Chao, MD
Transcription:
Melanie Cole (Host): For transgender kids and their families, access to individualized treatment can be hard to find. Welcome to The GW HealthCast. I'm Melanie Cole, and today we're speaking with Dr. Jerry Chao. He's an Assistant Professor of Plastic Surgery at The George Washington University School of Medicine and Health Sciences and is affiliated with George Washington University Hospital. Dr. Chao, explain a little bit about transgender care in this country and how it's typically been treated. On average, how many kids struggle with their identities?
Dr. Jerry Chao (Guest): Sure. That's a challenging question because a lot of studies have conflicting numbers in terms of epidemiology. Studies range from an incidence of anywhere from 1 in 10,000 to 1 in 200,000 individuals who may experience gender dysphoria. Now, it's important to note that gender dysphoria itself is a very broad spectrum. It's a broad spectrum in ways in which individuals express their gender identity. In general, it refers to any sort of discomfort that an individual feels which is related to a discrepancy between their gender identity and that gender that was assigned at birth. A lot of the manifestations in that and treatment of that may be related to physical appearance.
The approach to treatment really starts with a multidisciplinary group, which includes a primary care physician, psychiatrist, mental health professionals. When the patient comes and sees me for surgery, that's usually at a later stage in the transition process when the patient has really made the commitment to living as that new gender.
Host: Tell us a little bit about the cultural shift, Dr. Chao, that's catapulted the need for these types of services that you're discussing today.
Dr. Chao: Well, I think a lot of it has to do with the changes in healthcare availability to transgender individuals, and a lot of that changed around 2010 with the Affordable Care Act. Before that, a lot of gender-affirming surgeries — which refer to any surgery that's performed to treat gender dysphoria — before that, a lot of these surgeries were paid out of pocket by the individual seeking these treatments. Many studies that have been performed do show significant improvement in the quality of life and ability to integrate socially after undergoing gender-affirming surgery.
With the Affordable Care Act, there's language that prohibits any discrimination in obtaining equivalent treatment by any healthcare entity that receives federal funding. The language is somewhat broad, so insurance companies have different ways that they offer these services to their members, but because the healthcare and insurance world has been changing so much over the past decade or so that's allowed boarder access to things such as gender-affirming surgery. That's why it's an exciting time in the field of plastic surgery, and knowledge of these services and research into ways to offer these services better to gender dysphoric individuals has been really skyrocketing over the last five to ten years.
Host: Is there an ideal age at which patients should be seen by a specialist, such as yourself, as being crucial to their emotional well-being? What are some of the challenges you see most often?
Dr. Chao: The question of age is a tricky one. I think that one of the considerations by WPATH or the World Professional Association for Transgender Health, their standard of care is that patients should as surgical criteria be of majority age in that particular country prior to — be able to consent. In terms of when that process is started there are individuals who may have feelings of gender dysphoria early on during adolescence or puberty, and often those patients do get to see mental health professionals and psychotherapists for help with that social transition aspect.
Host: Tell us a little bit about the assessment and treatments that are offered to patients and tell us a little bit about facial feminization surgery. What does it aim to do?
Dr. Chao: Facial feminization surgery is really not just one surgery, but it's a broad spectrum of surgeries that are aimed to change typically masculine facial characteristics to feminine characteristics. Now, the goal of all of these facial feminization surgeries is to number one, allow that individual to feel that their physical appearance more matches their gender identity as well as to allow them to integrate into society more seamlessly and to be able to pass. When we see people for the first time or meet anyone for the first time, there are hundreds of signals that our brains process that tells us whether an individual has a masculine or a feminine appearing face. We make that decision subconsciously whenever we meet an individual.
One of the challenges for patients who have gender dysphoria is that unfortunately, in our culture if someone is identified as trans there can be a stigma associated with that, and that person may be subject to harassment. These surgeries can often have a very significant impact on that person's quality of life. Now, those surges themselves can range from soft tissue surgery such as skin to bony surgery — alteration of the underlying bony skeleton.
Research has shown that one of the most important areas to feminize the face is the brow region. That's because the feminine brow is softer, and flatter and men have more prominent of a frontal sinus in that area, which contributes to more prominence along that brow bone region. One of the most important surgeries to feminize the face is the reduction of that brow bone.
Other types of surgeries include making the nose more feminine via rhinoplasty, or alterations in the positions of the cheekbones, tapering and softening the chin or jawline, as well as more common types of procedures such as injecting fillers into the lips to give them a more feminine appearance. Like I said, facial feminization surgery is a very broad spectrum of procedures. It's a really individualized approach whenever a new patient comes to see me about that.
Host: Well, there are so many areas that we could discuss, Dr. Chao, but what is this like for the patient? As we're talking about facial feminization surgery, stick with that, but what is all of this like for the patient and their families to go through? What is recovery like? How are all of your multidisciplinary team involved in helping along the way?
Dr. Chao: Well, I work closely with multi-specialty clinics focused on helping the transgender population in the area, and that really helps me with facilitating and identifying the patients who are psychologically prepared and have really made that commitment to living in this gender identity. In terms of the whole process, I think it starts with managing expectations. The patients have usually been on hormonal therapy often for a period of about a year, which helps with certain aspects of feminizing the face and the head region, such as the hair distribution and the skin softness. However, there's a lot that hormonal therapy is limited in improving or feminizing.
Surgery also has its limitations, and there are certain expectations that really need to be laid out for patients in what is realistically achievable with surgery. I think once those are in place the patients do really well and have really good surgical outcomes in terms of when the surgical outcome matches a realistic expectation.
Host: As we wrap up, tell the listeners what you'd like them to take away from this segment on transgender medicine in general, and how do you offer support for the parents and the families? Wrap it up with what you would like them to know about this field of medicine and what you do.
Dr. Chao: Well, what I would like patients and families to know is that they don't need to feel alone. It can be very hard for some individuals to find physicians who they feel comfortable and who they feel equipped to take care of them. Patients may come to see me or other surgeons who perform gender-affirming surgery from far away. I think a lot of that has to do with lack of access to experienced surgeons or physicians. I would like them to know that there are physicians and surgeons who really have a strong interest and passion for helping this community and improving their quality of life.
Host: Good information. Thank you so much for coming on today and sharing your expertise and explaining this field of medicine and the various options and treatments for transgender individuals. Thank you again. You're listening to The GW HealthCast For more information, please visit GWDocs.com, that's GWDocs.com. I'm Melanie Cole. Thanks so much for tuning in today.
Melanie Cole (Host): For transgender kids and their families, access to individualized treatment can be hard to find. Welcome to The GW HealthCast. I'm Melanie Cole, and today we're speaking with Dr. Jerry Chao. He's an Assistant Professor of Plastic Surgery at The George Washington University School of Medicine and Health Sciences and is affiliated with George Washington University Hospital. Dr. Chao, explain a little bit about transgender care in this country and how it's typically been treated. On average, how many kids struggle with their identities?
Dr. Jerry Chao (Guest): Sure. That's a challenging question because a lot of studies have conflicting numbers in terms of epidemiology. Studies range from an incidence of anywhere from 1 in 10,000 to 1 in 200,000 individuals who may experience gender dysphoria. Now, it's important to note that gender dysphoria itself is a very broad spectrum. It's a broad spectrum in ways in which individuals express their gender identity. In general, it refers to any sort of discomfort that an individual feels which is related to a discrepancy between their gender identity and that gender that was assigned at birth. A lot of the manifestations in that and treatment of that may be related to physical appearance.
The approach to treatment really starts with a multidisciplinary group, which includes a primary care physician, psychiatrist, mental health professionals. When the patient comes and sees me for surgery, that's usually at a later stage in the transition process when the patient has really made the commitment to living as that new gender.
Host: Tell us a little bit about the cultural shift, Dr. Chao, that's catapulted the need for these types of services that you're discussing today.
Dr. Chao: Well, I think a lot of it has to do with the changes in healthcare availability to transgender individuals, and a lot of that changed around 2010 with the Affordable Care Act. Before that, a lot of gender-affirming surgeries — which refer to any surgery that's performed to treat gender dysphoria — before that, a lot of these surgeries were paid out of pocket by the individual seeking these treatments. Many studies that have been performed do show significant improvement in the quality of life and ability to integrate socially after undergoing gender-affirming surgery.
With the Affordable Care Act, there's language that prohibits any discrimination in obtaining equivalent treatment by any healthcare entity that receives federal funding. The language is somewhat broad, so insurance companies have different ways that they offer these services to their members, but because the healthcare and insurance world has been changing so much over the past decade or so that's allowed boarder access to things such as gender-affirming surgery. That's why it's an exciting time in the field of plastic surgery, and knowledge of these services and research into ways to offer these services better to gender dysphoric individuals has been really skyrocketing over the last five to ten years.
Host: Is there an ideal age at which patients should be seen by a specialist, such as yourself, as being crucial to their emotional well-being? What are some of the challenges you see most often?
Dr. Chao: The question of age is a tricky one. I think that one of the considerations by WPATH or the World Professional Association for Transgender Health, their standard of care is that patients should as surgical criteria be of majority age in that particular country prior to — be able to consent. In terms of when that process is started there are individuals who may have feelings of gender dysphoria early on during adolescence or puberty, and often those patients do get to see mental health professionals and psychotherapists for help with that social transition aspect.
Host: Tell us a little bit about the assessment and treatments that are offered to patients and tell us a little bit about facial feminization surgery. What does it aim to do?
Dr. Chao: Facial feminization surgery is really not just one surgery, but it's a broad spectrum of surgeries that are aimed to change typically masculine facial characteristics to feminine characteristics. Now, the goal of all of these facial feminization surgeries is to number one, allow that individual to feel that their physical appearance more matches their gender identity as well as to allow them to integrate into society more seamlessly and to be able to pass. When we see people for the first time or meet anyone for the first time, there are hundreds of signals that our brains process that tells us whether an individual has a masculine or a feminine appearing face. We make that decision subconsciously whenever we meet an individual.
One of the challenges for patients who have gender dysphoria is that unfortunately, in our culture if someone is identified as trans there can be a stigma associated with that, and that person may be subject to harassment. These surgeries can often have a very significant impact on that person's quality of life. Now, those surges themselves can range from soft tissue surgery such as skin to bony surgery — alteration of the underlying bony skeleton.
Research has shown that one of the most important areas to feminize the face is the brow region. That's because the feminine brow is softer, and flatter and men have more prominent of a frontal sinus in that area, which contributes to more prominence along that brow bone region. One of the most important surgeries to feminize the face is the reduction of that brow bone.
Other types of surgeries include making the nose more feminine via rhinoplasty, or alterations in the positions of the cheekbones, tapering and softening the chin or jawline, as well as more common types of procedures such as injecting fillers into the lips to give them a more feminine appearance. Like I said, facial feminization surgery is a very broad spectrum of procedures. It's a really individualized approach whenever a new patient comes to see me about that.
Host: Well, there are so many areas that we could discuss, Dr. Chao, but what is this like for the patient? As we're talking about facial feminization surgery, stick with that, but what is all of this like for the patient and their families to go through? What is recovery like? How are all of your multidisciplinary team involved in helping along the way?
Dr. Chao: Well, I work closely with multi-specialty clinics focused on helping the transgender population in the area, and that really helps me with facilitating and identifying the patients who are psychologically prepared and have really made that commitment to living in this gender identity. In terms of the whole process, I think it starts with managing expectations. The patients have usually been on hormonal therapy often for a period of about a year, which helps with certain aspects of feminizing the face and the head region, such as the hair distribution and the skin softness. However, there's a lot that hormonal therapy is limited in improving or feminizing.
Surgery also has its limitations, and there are certain expectations that really need to be laid out for patients in what is realistically achievable with surgery. I think once those are in place the patients do really well and have really good surgical outcomes in terms of when the surgical outcome matches a realistic expectation.
Host: As we wrap up, tell the listeners what you'd like them to take away from this segment on transgender medicine in general, and how do you offer support for the parents and the families? Wrap it up with what you would like them to know about this field of medicine and what you do.
Dr. Chao: Well, what I would like patients and families to know is that they don't need to feel alone. It can be very hard for some individuals to find physicians who they feel comfortable and who they feel equipped to take care of them. Patients may come to see me or other surgeons who perform gender-affirming surgery from far away. I think a lot of that has to do with lack of access to experienced surgeons or physicians. I would like them to know that there are physicians and surgeons who really have a strong interest and passion for helping this community and improving their quality of life.
Host: Good information. Thank you so much for coming on today and sharing your expertise and explaining this field of medicine and the various options and treatments for transgender individuals. Thank you again. You're listening to The GW HealthCast For more information, please visit GWDocs.com, that's GWDocs.com. I'm Melanie Cole. Thanks so much for tuning in today.