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Leading-Edge Surgeries for Trans Men

Gender affirmation surgery. Gender confirmation surgery. Gender alignment surgery. Surgeries to treat gender dysphoria go by a few different names, but the patients would all call them life-changing.

Here, Dr. Dave Gurajal discusses the latest female-to-male procedures, including new techniques for creating a functional phallus. He also covers the necessary preparation for gender affirmation surgery, involving a support and care team that can include a variety of specialists.
Leading-Edge Surgeries for Trans Men
Anandev Gurajal, MD, MS
Anandev Gurajal, MD, MS is among the most accomplished, compassionate, and dedicated gender confirmation surgeons practicing in the San Francisco Bay Area. He is dedicated to guiding his patients through the life-affirming journey to a happier, more fulfilling future. 

Learn more about Anandev Gurajal, MD, MS

Bill Klaproth (Host):  So what is female to male or masculinizing surgery? Why is it done and what do you need to know? Well let’s find out with Dr. Dave Gurajal from Align Surgical Associates.

This is the Healing Podcast from MarinHealth. I’m Bill Klaproth. Dr. Gurajal, thank you so much for your time. First off, what is gender confirmation surgery and why is it done?

Anandev Gurajal, MD, MS (Guest):  Well there is a condition called gender dysphoria and this is the distress that some people feel when their internal sense of gender is not aligned with their external or physical body. It’s kind of the feeling of being a male but having female body and vice versa. Or it could even be feeling of being a gender that’s not either male or female. So, having a sense that you are trapped in the wrong body is seriously and profoundly difficult and it leads to some heartbreaking facts. For example there is about a 62% depression rate among the transgender community, 45% attempt some form of suicide. There’s a 47% sexual assault rate. So, these are things that no one would experience by choice. There’s an estimated 1.4 million adults in the US alone who identify as transgender. This is not a small number of people.

So, gender surgery which goes by many different names. People call it gender confirmation surgery or gender affirmation surgery or sex reassignment surgery. This is all surgery which is intended to help with the distress of gender dysphoria. This is done by changing a patient’s body to be more in line with the gender that that patient feels.

Host:  Right. You phrased it in a way that makes it easy to understand. As you said, people feel like they are trapped in the wrong body.

Dr. Gurajal:  That’s right.

Host:  And that this adds up to emotional and physical distress. So, the question is this aesthetic or reconstructive surgery? People aren’t doing this just for the looks of it, right?

Dr. Gurajal:  That’s right.

Host:  This would be more reconstructive surgery? Is that correct?

Dr. Gurajal:  Well you know there have been different feelings about this historically. If you look at the definition of reconstructive surgery, it is surgery which is done to correct structures to improve their function or to create a normal appearance. So, in light of being transgender, which is you know, literally a brain with one gender being paired with the wrongly functioning or wrongly appearing structures. The surgery that we do is to help create functioning and appearing structures to match that brain. So, I think when you look at it this way, ah, you would conclude that it is reconstructive surgery.

Host:  Okay so let’s talk about this. What types of procedures are done for female to male or masculinizing surgery?

Dr. Gurajal:  Yeah, that’s a good question. So, you know, I think it’s important to say that – that if a patient wishes to be on hormones, and in the case of female to male or masculinizing patients, this would be testosterone. That testosterone can create a lot of the desired changes, you know, things such as deepening of the voice, or facial hair, increases in muscle mass and changes in fat distribution. And surgery is sort of the last step in this whole process. And it’s only done if a patient feels it’s necessary.

So, the surgeries that are done can be to the chest, to the genital area or to the shape of the body as a whole. And these are commonly referred to as top surgery and this is done to create a more masculine appearing chest. There’s also metoidioplasty or phalloplasty and these are procedures done to create more male appearing genitalia. And then there’s body contouring which is done to create a more masculine shape to the body.

Host:  Hmm, okay. So, then does this procedure or set of procedures include both functional such as sexual and physical transformation such as appearance?

Dr. Gurajal:  Yeah, exactly. Anytime that gender confirming surgery is done, it’s absolutely critical to pay attention to both the form and the function of the results. And I feel that this is especially true with phalloplasty which again is the creation of male genitalia. Phalloplasty is probably one of the most difficult surgeries that’s done in medicine and it’s because there are so many structures which have to not only be created but also function together well and have a natural appearance. So, the surgery involves shaping tissue to create a phallus, making a tube within the phallus for patients to void urine through, creating a scrotum, placing implants to allow for erection and connecting nerves to try and establish sensation.

So, this is a lot of different things and achieving this is very, very difficult.

Host:  Well it’s easy to understand how difficult this is once you described all of the complexities involved. So, let me ask you this, we hear of this. What is nonbinary gender confirmation surgery?

Dr. Gurajal:  Yeah, well you know nonbinary patients feel that their genderal does not conform to the traditional male or female architypes. So, they are kind of somewhere in between. And this points to a very important idea that gender identity actually exists along a spectrum. It’s not strictly one thing or another. So, just as important as it is to serve our transmale and transfemale patients, it’s also important to serve our nonbinary patients as well. And all the operations that we do can be tailored to each patient, capture where they lie along that spectrum.

Host:  So, that may be a person who doesn’t really identify as a female or a male particularly strongly? Is that what that is?

Dr. Gurajal:  That’s right.

Host:  Hmm.

Dr. Gurajal:  Yeah exactly.

Host:  Wow. Okay. So, then what’s sort of preparation do patients have to do before making this huge decision?

Dr. Gurajal:  Yeah, like I said, care for our transgender patients is very multidisciplinary and the best form of care is to have a team who is guiding you. You can start often with your primary care physician or even your pediatrician if at that age. You knows trans can bring their kids to their pediatrician and sort of broach the topic and go from there. You PCP can then make the appropriate referrals to the needed specialists to start building your team. You know essential components of this team can be mental health providers, social workers, endocrinologists, ah OB-GYNs and then of course surgeons. The most important thing in the whole process is to get the support you need and the information you need so that you can be making good decisions along the way as you transition.

Host:  And then I would imagine part of that decision is financial as well. Does insurance cover gender confirmation surgery?

Dr. Gurajal:  Fortunately, insurance companies are starting to cover more and more of these procedures. And in fact, in our practice at Align Surgical, a majority of cases we do are covered by insurance.

Host:  Well that’s really good to hear. I mean this is a really unique specialization. Is there special training you have to go through for this?

Dr. Gurajal:  Yeah, I’d say it’s quite unique. For example in the case of phalloplasty, there are only maybe 30 or so surgeons in the world who are actively doing phalloplasty. Following medical school and residency training which itself can take more that ten years; there’s further training in gender confirming surgery that’s required. And there are very few places to get this ah, training because there at not very many formal programs and again, there are very few people doing it. So, it’s quite difficult to get that training. You really want to make sure that whichever surgeon you go with, that that person is board-certified first of all and that they have indeed received this very specialized training. You know it’s totally okay to ask your surgeon who taught you and you know they’ll actually be probably very proud to say who their mentors were if they indeed have received that training. With gender surgery being such a small field, we are very grateful to the people who taught us. So, we are only too happy to tell you.

Host:  So, what are the other ways they should assess the team and the overall program?

Dr. Gurajal:  I think you want to find first of all, a multidisciplinary team like I mentioned and when it comes to the time of choosing your surgeon, you really want to make sure that that it’s somebody who has had experience in the field. With gender surgery increasing in popularity, there are more and more surgeons doing some of the procedures. But maybe not with the training that we talk about. So, I think experience is very important and the number of cases that your surgeon has done for the procedure you are interested in in particular. And then you know I would say that the second basic thing is that you really, really want to be comfortable with whomever you’re going with. You know make sure that you feel a sense of connection with your surgeon and that they understand you and they see you for who you are and that it just feels right. That’s very, very important that you feel comfortable with your surgeon.

Host:  This is such a unique specialization Dr. Gurajal. What made you want to go into gender confirmation surgery?

Dr. Gurajal:  When you learn plastic surgery, you see that it can do all these amazing things. You know we can reconstruct body parts for cancer. We can close wounds. We can fix things in these incredible ways. You know but getting to that point is not easy. To get there, it will have taken lots of people working on tough problems who are kind of building on each other’s ideas over decades of time. You know that’s how this progress has been made in – in all these areas of surgery. This has happened with things like face transplants and like I said, reconstruction after cancer or trauma. But my feeling is that transgender surgery in particular has not yet had the same kind of benefit you know again, of people innovating and building on their ideas over time.

So, my belief is that there’s now a huge opportunity to help the transgender community. We have the chance to use the best thinking we have, the best tools and techniques to really innovate and advance a field for people who are really in need. So, that’s kind of what drives me and my mission in particular, is leading the phalloplasty program at MarinHealth. So, I’m very honored to be working with them to build the phalloplasty program and our transgender more broadly. They are just a tremendous resource and a great facility to be ah working with. And I’m very grateful for that.

Host:  Well Dr. Gurajal, what you do is truly unique and we’re very happy that you are offering this right here in our community. Thank you again. This has really been informative.

Dr. Gurajal:  Thank you so much Bill.

Host:  That’s Dr. Dave Gurajal and for more information, please visit and if you found this podcast helpful, please share it on your social channels. And check out the full podcast library for topics of interest to you. This is the Healing Podcast brought to you by MarinHealth. I’m Bill Klaproth. Thanks for listening.