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

Dr. Cecile Ferrando, a urogynecologist specializing in gender affirming surgery, discusses her journey into medicine and her focus on gender affirming surgeries. She explains the difference between vaginoplasty and vulvoplasty, the various procedures she performs, and the importance of revisions in achieving the desired outcome. Dr. Ferrando also highlights the poetic aspect of gender affirming surgery, where male structures that would have been female are repurposed to create female structures. In this conversation, Dr. Ferrando and Vanessa Joy discuss various aspects of gender-affirming surgeries. They address misconceptions about self-lubricating vaginas and the importance of managing expectations. They also talk about the significance of hair removal and the need for a supportive surgical team. Dr. Ferrando shares funny experiences with patients leaving post-it notes and giving gifts. The key takeaway is to choose a surgeon who is experienced, communicative, and supportive.

To learn more about Dr Ferrando's new practice at UCSD:

https://providers.ucsd.edu/details/1255592325/obstetrics-&-gynecology

Takeaways

Dr. Cecile Ferrando is a urogynecologist specializing in gender affirming surgery.

• Vaginoplasty and vulvoplasty are the main procedures performed for trans feminine patients.
• Revisions are common in gender affirming surgery, and it is important to ask surgeons about their revision rates and the types of revisions they perform.
• The surgery involves repurposing male structures that would have been female to create female structures.
• The poetic aspect of the surgery lies in the fact that the body's development is determined by chromosomes, and the surgery aligns the genitals with the individual's gender identity. Misconceptions about gender-affirming surgeries include the idea of having a self-lubricating vagina, which is not a reality.
• Hair removal is still necessary for certain areas, even in procedures like peritoneal vaginoplasty.
• Choosing a surgeon with experience, good communication skills, and a supportive team is crucial for a successful outcome.
• Patients should manage their expectations and understand that surgeries may have speed bumps and imperfections.
• Building a strong surgical team that works well together and prioritizes patient care is essential.
• Patients should ask questions, be choosy about their surgeon, and not settle for less than the results they desire.

Transcript

Vanessa: 0:00

Okay, here we go. Hello. Welcome back to transcending humanity. This is episode 42. And just as a reminder, the views and opinions of the hosts and guests on the show are those of their own and not those of their respective organizations, employers and what have you. I have a super exciting episode for you today. I guess that I've been looking forward to having known for a long time, the amazing Dr. Cecile Fernando, the person who gave me my wonderful equipment downstairs. Dr. Fernando, can you give us a little two minute Hello, a little background on you?

Dr Ferrando: 0:41

Sure. It's such a pleasure to be here. Thanks for asking me to join. I am a Euro gynecologist. So I actually specialized in OB GYN first and then did some extra urologic training. And so I mostly see patients men and women who need some sort of pelvic reconstructive procedure. So both sis and trans. I got into gender affirming surgery about 12 years ago and started my practice 10 years ago, started at Cleveland Clinic in Cleveland, Ohio, and I just recently left Cleveland Clinic and now I'm in San Diego working at UC San Diego health.

Vanessa: 1:21

San Diego is quite the upgrade from Cleveland when it comes to your surroundings. So we miss you up here. But girl, I don't blame you. I, too. So should I

Dr Ferrando: 1:35

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

Vanessa: 1:40

It does have its own vibe. You said it does. Are you from Cleveland originally?

Dr Ferrando: 1:47

No. So I actually I was born in France and my my father's French and my mother's American. So I spent a little bit of time in my early childhood in France. But then I moved to New York as a young a young kid, and then just sort of moved around after that. So I lived in New York City for a while and then I lived in Boston, and then I made my way out to Cleveland.

Vanessa: 2:11

That's a lot of jumping around. But pretty exotic was to grow up really. So that's cool. super catchy and the medicine in the first place.

Dr Ferrando: 2:21

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 was trying to find my artistic ways when I was really young, I think like a lot of people and then you sort of think about how you maybe want to make a living. And it sounded pretty good to be able to make a good living taking care of others, right, that sort of feels like a really noble profession to go into. And I sort of felt like, Oh, I could use some of the creative ways that I have in my profession by doing something maybe surgical and something where I'm restoring anatomy or creating anatomy. So it's sort of the way that it got me here, but I was wanting to take care of people.

Vanessa: 3:00

That's a good reason to get into medicine. I wish every one that got into medicine had a reason like that.

Dr Ferrando: 3:07

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

Vanessa: 3:15

which is understandable to the amount of stress. And just the stuff that you have to see every day has to. I can't even imagine I couldn't do it. I can't even handle a little cut. So yeah, I don't know how people in the medical industry do it. And I have a lot of props for people that do so what led you to get into gender affirming surgeries.

Dr Ferrando: 3:39

I actually was one of the like, I think I'm one of the few people who sort of knew that's what I wanted to do. When I went to medical school, I took a little bit of time off between medical school and college to figure out exactly what I was going to do and how I was gonna pay to go to medical school and try to figure all of that out. And I had some experiences as like a 2122 year old living in New York where I got to meet some youth in New York City, I was working with some disenfranchised homeless youth and learned a lot about why they were homeless, and a lot of them had been either chose or asked to leave their homes and were completely disowned by their families. And a lot of them were trans. At the time. We weren't really calling it that. You know, this was in the early 2000s. 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 like attracted to the sort of the concept of exploring sort of one's gender. I think we weren't talking about it mainstream and it the concept was so clear to me that that was possible that we didn't necessarily need to identify with who we actually are how we were actually born right Who We Are versus how and and what we were given biologically don't necessarily need to align. And so this was a time where we weren't, there was no discussion about it, we didn't read about it in books, nobody was teaching it. It wasn't on TV, right, except maybe portrayed right in a certain kind of way that was really probably very negative. And so I had all these experiences 20, almost 25 years ago. And so what I also was learning as I started learning about how people were getting their hormones, how people were getting surgery. And I found out that again, there was no mainstream medical way for people to get these things, people were buying hormones from each other, they were ordering them from certain places, they were sharing hormones, there was definitely a black market for it. And then for surgery, what really sort of made me start, it really sort of propelled me to go in one direction with my medical career was that I realized that only people who had money could actually get surgery, or it was people getting surgery from people who weren't qualified to do the surgeries. But people were just willing to take whatever they could get, and people were getting harmed from it. You know, this is back in the day where people were getting, you know, like silicone injected in very strange, you know, places and dying from sort of infections from the sort of underground injection clinics. And so I just sort of started thinking, you know, this could be mainstream, right. And so, and I kind of hit it at the right time, because as I was going through my training, a lot of stuff changed. Like in 2008 2010 2012, there was a lot more visibility. So I, I sort of I call it this wave that I was on right time, right place, seemed like a lot of people were starting to get it around the time that I was.

Vanessa: 6:40

God, I mean, I until like 2005 2006, I didn't even know that trans people really existed. Like I've known something was up with me since I was five easily. But growing in like a Christian conservative family that was like, this was something we talked about, you know, but I saw a documentary called Trans generation. And then I'm like, we, this is a thing, you can actually do that. And yeah, I kind of buried away for 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 researching surgeons, when going to 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's called now. And I saw like activism, I saw trans flags. And I'm like, okay, she gets it, she gets it. And for other surgeons, I didn't see that kind of thing. And for something this major, I mean of that, and a plasti is definitely not a light surgery in any way, shape, or form. And I wanted somebody that I could really, I knew I respected the community. And honestly, I wanted a woman to do it, because it's not a man's job, in my opinion, but that's just me. So, it's, it's wild.

Dr Ferrando: 8:16

Yeah, I mean, it was quite the process. I mean, and I understand that, I think that um, and I thank you for all those things, nice things that you just said, I think that you know, there are different types of surgeons who do the surgery, and we all sort of are cut from different cloth, some of us similar cloth, some of us not, I think do think that there are others like me, I I've run into them, I know them. But I think it's recognizing that first of all, the surgery is not about us. So you know, my work, you know, there's like an ego component, but it's really about the patients and trying to help you along sort of your journey, and everybody has a different story. Everybody has a different timeline. Everybody comes from a different experience, right? And that for me, right? I know how to do the surgery, I can do the surgery, and I'm happy to do it right. And so I'm just sort of a tiny little part of that storyline. But I'm not sort of the center of that story. And I think that that's important for surgeons to remember that we're technicians, right we have skills we they get better over time we learn new skills, we innovate our skills, but that it's actually a privilege to be asked to be part of your story. I think that that's like a really important thing and it's why I really enjoy the work.

Vanessa: 9:28

It's when I woke up from anesthesia. Like I think one of the first things I asked him like is this really just happened and the feeling of just relief from living for 42 years with my body not mentioning my brain and having that major step and then the care afterwards. There was the hotel stay for a little while and honestly the worst bed ever had an ankle and horrible, but I'd have to hold the hospital stay. But then after that you had me go to the hotel attached to the Cleveland Clinic. And you did essentially house calls at the hotel. And that really humanized the entire experience for me, even though there was like, the unpleasant thing where my catheter got clogged, and we had to take that out, put a new one in, let me tell you, I do not recommend that for anybody. But like, just the entire vibe. And you really, there was just a real human aspect to it, I didn't feel like a number, I actually felt like part of the community. And that really meant a lot to me. And you 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 this as well. That you've obviously been, you know, perfecting over the past decade plus, but it's funny the amount of sis women that asked me about the surgery, and the even asked to see pictures. Is is comical. And it's fun for me. Because when they see they're like, that is amazing. For anyone that doesn't know what they look like, it's a very accurate facsimile of a needle vagina. So it's the entire thing. It's just wild. What, what what procedures do you do now?

Dr Ferrando: 11:42

Yeah, so I in terms of human gender affirming surgery in general? Yeah. So I've stuck to doing mostly vaginal plasti and Volvo plasti. So I mostly take care of trans feminine patients. I did a lot of hysterectomy, is it so gender for me, hysterectomy is for men, and trans masculine individuals. And I still do those and I'm happy to see those patients I enjoy actually taking care of trans men a lot. And so, and so those are the main procedures. I did Matoi do plasti for a small amount of time. But I leave that to some of my other colleagues. It's I think, you know, I decided, while I was sort of building my practice to focus on a few surgeries, in addition, you know, I have another like a cisgender practice where I do reconstructive surgeries for those patients. But I decided when it came to gender affirming surgery to stick to sort of a small handful and to get those sort of very, very, you know, down in a way that I really sort of the patient experience was great. complication rates were low and that patients most importantly, were really happy with their outcome at the end.

Vanessa: 12:54

I mean, keeping a small menu is that's what Gordon Ramsay tells people to do. So stick to what you know. It's true. Can you explain to the listeners quick, renowned differences between vaginal plastic and a vulva plastic?

Dr Ferrando: 13:09

Yeah, sure. So not everybody you know, we vaginal plastic is kind of what we call like a misnomer, right? It's not really what the procedure is. The vaginal plasti is just one one part of the whole list of procedures in it that's really just making the vagina So in essence, most women who are undergoing the surgery are getting a vulva plasti The question is whether or not they're getting a vet vagina, so the vaginal plasti part, so we tend to call it vaginal plasti. And that sort of includes everything right, doing the outer genitalia plus the vaginal canal. But some women, or some individuals don't want a vaginal canal for many reasons, regardless of their age, or sort of intimacy goals. And so they choose to not have the vaginal part. And so we just do our external genitalia. I tried to create sort of the illusion of a smile of an opening because that looks more anatomically correct. But then there you really there's, there's no ability to have penetration or anything like that. And there's a whole list of reasons why some patients choose to do that over over having a what we call a full depth procedure.

Vanessa: 14:15

Oh, yeah, I mean, that was something that was conversation I had with myself whether I was gonna go full depth or just a standard bobble plasti visible depth does require a lot more work. The part of the patient with dilate Yes. And just upkeep in general, like shortly after, for the first three months after surgery, you dilate three times a day, and then you build up twice a day. And currently I am almost a year out now 10 months out. And I'm once a day. But you know, it takes a certain amount of dedication for that. And yeah, so there's definitely multiple ways of doing it. And it's whatever is most comfortable for the patient.

Dr Ferrando: 14:58

Yeah, I think there's So the work you need to do after and then it's the highest risk part of the procedure, it's the part that if something goes wrong, you know, everything else you can usually usually resolve, there's a few other parts of the procedure that if something goes wrong, that may not be reversible. But for that part, if you create an injury or have a problem, the patient has a really long road ahead, and they may not even be able to have a vaginal canal, you know, if there's an injury, you get something called a fistula, and then you may not be able 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 a surgeon, whether the risk of having that happen is really low. It's still possible, right? So you have to sort of choose the right surgeon, but also know that you're willing to take on that risk. And note the consequences if it does happen. So pay some patients shy away from 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 do all that dilation. The alternative is to do just this vulva plasti, which we also call zero depth and no depth, those are the other like terms for it for sure.

Vanessa: 16:10

And there are multiple kinds of full differential plasti as well. There's penile inversion, which is what I had. And then the other one, it's a colon thing.

Dr Ferrando: 16:19

So there's three total. So the penile inversion is where we use all the skin in the genital. So the scrotum skin, penile skin, everything is used to line the new the new vagina. And then the other option is the peritoneal vaginal plasti. Where in, you sort of do the same procedure, but then you have to through the, through the belly through the abdomen, I'm usually using robotic assistance. So you have these little incisions on your abdomen, and we put little camera in, we harvest something called the peritoneum, which is sort of this filmy layer that covers some of the organs, and you don't need it, and it grows back. So we can take some of it, and we use it to attach it to the the little skin we do use in the canal. So it creates a vaginal canal using a different a different part of the body. And that's really good for patients. Well, there's sort of different perspective, some surgeons only do that procedure. And it's because they feel safer doing the vaginal canal that way, they feel like they can avoid getting an injury or having a problem like I just described. So they'll do it that way. And then they'll just tell you some of the peritoneum and other surgeons like me, I'll do that procedure once in a while for patients where I don't think that they have enough skin. And I'm worried that I'm not going to give them a good enough vaginal canal. And I think that that's a really good option. I worry about having that as the first surgery you have. Because if you need a revision surgery for your vagina, that would be the option. And if you've already had it, you it's no longer an option. So for me, it's my backup surgery in case somebody goes through life events and can't dilate, and they lose the vaginal canal or some other problems, you really can use that as a secondary surgery. If you do it first, you'll never be able to regain that depth if you need to do it. And then you mentioned the colon surgery. So that's a sort of a really old surgery, but it still exists. We take a piece of the colon and we actually recreate the vagina using colon. It's got some benefits, but it has some downsides. So in my for me that that's like the last resort, something that I would only do in very, very rare circumstances.

Vanessa: 18:32

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

Dr Ferrando: 18:46

yeah. So it's your story to tell in terms of what I did for you. It's your, if you feel like sharing that. So but about I would say it depends upon the surgeon. Right. And this is actually a really good question to ask surgeons, when you go and see them is what's your revision rate? Right? How often? Do you take patients back to the operating room to do a revision? And then I think the more sophisticated question is asking them what kind of revision so for me, I always tell patients now because this has evolved over time when I was first starting, I did a lot more revisions because I was on my own learning curve. And, you know, you sort of tend to get things right and perfect the first time better, but I will say revisions often happen cosmetic revisions, because the body is going to heal the way that the body heals. So sometimes things get fused together. So for instance, the clitoris gets buried, so it's there but you can't see it because the labia got stuck together. Sometimes there's some asymmetry of the labia. Sometimes there's some wound problems during the healing phase and so it doesn't heal like as like cosmetically symmetric or as right so you can do little things. Those are really common I would say about for me about one in 10 of my patients needed revision. So for every 10 patients, I do a vaginal plus your Volvo class Dionne, I take one of them back to the operating room about six months after surgery to do a very small procedure right? Now what you want to know from your surgeon and I think that's very acceptable, because again, the body is going to heal the way the body heals. And it doesn't mean you can't get perfect results with a second really tiny procedure. And you don't need letters for that procedure. You don't it's it's no different than a cisgender, labia plasti. So it just gets submitted to the insurance company like a regular female procedure. And it's usually not a big deal. You don't have to take a lot of time off, you can usually go back to work very soon. It's just a couple of stitches. It's not a big deal. What you want to know about from your surgeon is how often are you are they doing major revisions, meaning redo vaginal canals? How often are they taking the patient back to the operating room weeks after their surgery to redo something right? That means that they haven't sort of refined their their skill set. And they're probably not getting it right the first time around small cosmetic things six months later, no big deal. That's, that should almost be expected. And if it doesn't, you don't need it great. But ask the surgeon about what kind of revisions they're doing and how often because there's a difference in surgical, you know, the the caliber of the surgeon depending upon what that answer is. That's

Vanessa: 21:26

that's definitely amazing advice. And if you do need a revision, there's nothing wrong here. There's nothing wrong with the procedure that you 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. And my clitoral hood was a little bit where she said the the very clitoris. And it was in and out, like in an hour outpatient. And I was back on my feet really quickly. So. And yeah, insurance didn't even bat an eye at it. So getting insurance for the main procedure that requires a lot of research. But in the end, it costs me excluding all the hair removal in the hotel stay and cost me $19.67. Whoa, which Yeah, yeah, it's pretty bad as

Dr Ferrando: 22:19

well, we've cut we've come a long way, that's for sure. I think it's amazing what happened 10 years ago, with insurance starting to cover I mean, that's when we started getting busy as surgeons, right, we got to sort of take care of everyone, because most health care 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 this, even by a lot of Medicaid programs is much, much better

Vanessa: 22:47

at and vary state by state for the listeners. So be sure to do your research. Before Your Next year of insurance. Just make sure everything's covered. All the i's are dotted and T's are crossed. It's particularly hard in Ohio. To get it done. I will say I had asked her insurance, which was Cleveland clinic's insurance. And Dr. Brenda was with Cleveland Clinic. So that all worked out. Can you settle a little argument for me during the penile inversion, is there ever a time that the penis is completely detached from the body.

Dr Ferrando: 23:19

So most of it is, but there's a small portion of it that isn't and it's the portion that has all the nerves in the blood vessel that feed the like glands or the head of the penis. And that's what we convert into the clitoris, we just remove a lot of it, but we keep the top part. Because if you were to look at like get a picture anatomically everything's at the very top part and it runs on like the top portion of the penis. And so, it is you have to be careful doing this part of the surgery but so a very small part of it, maybe I would say, you know anywhere from 15 to you know, 10 to 15% is kept but everything else is is removed. But no, there is never a complete detachment and like sewing of the blood vessels and the nerves everything stays it's almost like a very skinny stock that you you keep and the job of the surgeon is to make sure that stays well and healthy during the whole surgery so that you have a functioning clitoris at the end.

Vanessa: 24:17

And we myself and my girlfriend's appreciate you. Keeping all that is I still swear it's like dark arts or something, how you get the clitoris to work in the place where it's supposed to be. And the entire thing is just mind boggling and how it works. Is there any like? Go ahead?

Dr Ferrando: 24:43

No go You go ahead. Maybe the question you're gonna ask.

Vanessa: 24:47

I was just gonna say is there like, what's the quick and dirty of what happens during a full capacity?

Dr Ferrando: 24:54

Yeah, so why there's a reason I love this surgery so much. So there's something very in my Canyon, very poetic about the surgery, I think, you know, some people would hear me say then like, kind of roll their eyes. But it's the reason I love it so much is, if you actually and then I'll explain to you like what goes on during the surgery. But if you look at what happens to us when we are in utero, so when we're developing and we're destined to be a little boy fetus or a little girl, fetus, right. And then we develop right, and then we become a baby and we're born. That's decision tree of, excuse me, that decision tree of the genitals developing is dependent upon your chromosomes. So if there's a Y chromosome, there, it develops in the male, if there's no Y chromosome, the default is like the it'll develop into the female. So it's at the very beginning that these things are decided, right, which just feels so frustrating, because obviously, that's totally beyond any of our control. It's just genetics, and chromosomes. But every part that becomes male, like that exact part, those cells that then get bigger and develop, if there was no Y chromosome, they would have developed female. So like, the glans of the penis is the clitoris in the female. The urethra where we urinate out of is actually like off in the mail that long urethra is the inner lining of the labia, that pink moist area. They're called homologous structures. So like, essentially, what we do during the surgery is we take the male structures that would have been female if there wasn't a Y chromosome, and we repurpose and use them to create the female structures. So there's nothing in the in the, in the trans female, like in the Jenner and the genitalia, that like the all of those things originated from the male parts that should have been female. And so I think that that's the beauty in the surgery. It's not like we're taking like an eyeball and like making that the clitoris right, that doesn't make any sense. It was never destined to be the clitoris. But the glans of the penis? Sure is, you know, what should have been the clitoris had things just spin, right? Right. That's the way that I see it. So that's why I think there's like some poetry to the surgery. So what we're essentially doing is that we are, we deconstruct the penile anatomy, so we remove a lot of it, but keep the very skinny top part. And we fold it on itself. So by folding it on itself, it's almost like if this were like this is the the skinny piece that's left in my fingernail is the is the clitoris right? It used to be a big glands, we fold it on itself like this. And what that does, right is it creates the little clitoral button. Okay. And then this bent part is something called the clitoral column, which all women have, regardless trans sis, right, that's an most if any woman who'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 knows that, oftentimes, you don't necessarily need to stimulate this part, right? This is the part that has the most stimulation, and any woman trans sis, in between, sort of has stimulation from that area. So it's important to maintain that. But essentially, we fold it on itself. And then the important thing is just making sure as the surgeon that you're putting it at the level that the clitoris should go, should be placed so that everything looks female, you don't want it too high. You don't want a button sitting on top of your pubic bone and looking like you have two belly buttons. That is really weird. And I've seen that happen. And you don't want it to too low because then you got to go looking for.

Vanessa: 28:36

So if you want it sort of anyways. Exactly.

Dr Ferrando: 28:40

So, you know, help some help them help them. So it's about sort of understanding and like the anatomy where something goes, right, like if you look at the groin of the patient, you can tell at what level the clitoris should be at than the urethra, we basically open up the urethra so that it's short, and it goes right but below the clitoris a few centimeters below. But then I use I don't get rid of the urethra, I keep it on its blood supply. And I flip it over and I use it to create that pink moist area between the clitoris and the urethra because if you look at most women, they don't just have skin between their the clitoris and the rethrow. So I think part of the artistry of doing the surgery is making it so that it looks really female, and it should look pink and it should look moist. Right? And all the holes should be in the right locations and aligned in the same way. So yeah, I mean, there is some artistry to doing it. But there's technicality in that. If you do most things the same way over and over again. You'll also get it right. But that's how most that's how the procedures performed. But it's using the stuff that should have been which I think is great. You know, that's

Vanessa: 29:51

that's so cool. It's like hitting the rewind button on gestation kind of. That's exactly right. Yeah,

Dr Ferrando: 29:58

it's exactly I mean, I've had some pay She's caught a rebirth, right? They feel like they're burnt. You know, I've had some patients choose 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 birth date of birth, but you can in you know, from a spiritual perspective, 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 from that surgery, and you realize that, that as I said earlier that it's done. It's, it's a whole it's a whole thing and only the people that have had the procedure understand that the whole thing so I

Dr Ferrando: 30:36

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

Vanessa: 30:54

Definitely transcending humanity has joined the feminist podcast collective in we will be exchanging ads on each other shows in order to grow our mutual following. Here's one for this week.

Transcending Humanity: 31:05

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Vanessa: 31:57

What are some common misconceptions that you would like to dispel while you have your time?

Dr Ferrando: 32:04

I think that common things that I did, one of them is like vaginal lubrication. So like so a self lubricating vagina in reconstructive surgery is virtually non existent. So even with peritoneal vaginal plasti, that's the one that got very popular, I have colleagues who started doing the procedure, this procedure a lot in New York City, and all of a sudden it caught on like wildfire, because they published some really great papers on it. And while the surgery, like I mentioned earlier is a great procedure, it the selling point is not that you end up with a self lubricating vagina, the the peritoneum that gets used for that vagina ends up looking very similar to the skin you use when you're doing penile inversion after some time. So there's no real procedure that really has like figured that out, though, there is lubrication for some patients, from actually the urethra area, because those glands that are there are still there. And so if some patients have very healthy, intact glands, they'll get lubrication at the opening of the vagina. And I would tell patients like that just means you're one of the lucky ones. And there's no way of predicting so using self like lubrication and vaginal moisturizers, you can use things like coconut oil, actually, in that area to keep things sort of moister are is a good thing. But there's no such thing as a reconstructed self lubricating vagina. I'm trying to think of like other myths that I've heard, or that I can think of that's the that's the biggest one.

Vanessa: 33:43

That's a big one. I see a pop up all the time. Yeah,

Dr Ferrando: 33:46

I think too. I've had this experience and I try to set patients upfront with their expectations. But again, I don't know what it's like to walk in a patient's shoes and have sort of this thought of what a vulva is supposed to look like. I think we get a lot of sort of those cues from from looking at like pornography and things online, certainly. And then if you know a lot of people you know, maybe individuals share and show each other their Volvo's, which sounds funny, but I actually think is a very normal thing, especially if you're looking to have one created for you. But I think we get a lot of our online cues from, you know, our cues from online, which can really even in the CIS population, create expectations that don't, sort of really, you know, were made a certain way. And so one of the things that's very hard to do with this procedure is create like large labia. Some women want very large labia, and most of the time with this type of procedure, you should expect to have small labile columns. You can have a revision sometimes to make them a little larger, but you can only work with what you have. And so and that and these reconstructive procedures rely on good blood supply to heal properly. And so it's very hard to get Create like big labia menorah, which some women will ask for. So that's like a myth that's like that it's possible to do that, for sure. I think those are the two 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 is different to we're all built different. And they're all beautiful. You know, there's, there's even coffee table books just full of them. Just there are Yeah, yeah,

Dr Ferrando: 35:33

I love those I love like I have the sun. There was one that was created a long time ago. It's called the wall evolvus. It's like these casts of 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 I took that idea and said, like, for rondos, wall evolvus from like, so when I give presentations, right? I have with permission from the patients who allowed me to take pictures and use them obviously, it's just, you know, a picture of the vulva. But um, I have like, I don't know, maybe like 40 You know, small pictures lined up real close together. And it's clear every single person looks completely different, but they look no different than Asus, vulva. They just look completely different bigger lips, smaller lips, labia majora, labia menorah, you know, skin pigmentation, sometimes you can see the scars on the labia and some patients you can't. So that's what I show patients in the office not to digress. But that's another thing, if the surgeon you're seeing cannot show you pictures and what to expect, and shows you a wide range, not just sort of their best picture, I tried to show pictures of patients whose scarring is a little bit more prominent patients who are whose weight is more similar to the patient, right? You don't want to 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, I think that you want to show realize, so make sure your surgeon shows you pictures, if they can't show you pictures. That's kind of a strange thing. So I just wanted to throw them in there. Two other myths I was thinking about is that with peritoneal vaginal plasti, you don't have to dilate after surgery. And that's one of the benefits. Not true, you have to dilate just like a penile inversion. So it's not a reason to. And then the other reason people really are jazzed up about doing a peritoneal vaginal plasti is because a lot of surgeons don't require hair removal for that procedure. So you can skip that skip step. The only thing I will say is it's true, but we still tend to use some of the genital skin at the opening of the vagina. And so you might not end up with hair growth deep deep down inside if we use the peritoneum, but you still have hair growth in places that most women don't want hair. And so I always say that some hair removal, especially around the scroll area is still helpful. And so I don't choose to have a personal version of plus you just because you don't need to you do hair removal and skip that step. I do understand that hair removal can be financially like a financial strain for some people. So I don't want to be exclusive when I say that, but just one of the myths is that no hair removal leads to similar outcomes. You'll still have hair in weird places if you don't do some hair removal. That

Vanessa: 38:22

actually answers a question that I had, because some transplants that I've talked to that are getting the procedure or have had the procedure said that they didn't have to do any hair removal. And now that explains why. But as the doctor said, there's some ways that you might not want here to be growing. So yeah,

Dr Ferrando: 38:44

I mean, I want to commend I think I want to sort of I want to say to the the it is commendable. In one aspect. I've been a long term, longtime, longtime advocate of trans individuals. And so I want to reduce barriers as much as possible for patients. I don't want it to be hard to come and get surgery, I believe in setting up like a process so that your outcome is good, so that you're thankful for the process and you feel happy and you can go live your best life, right. But barriers are tough. And I think some of the surgeons who are trying to get patients to come and see you don't need to have hair removal done. And you can do it this way, are trying to reduce barriers for patients, which I do think is commendable. In my experience, I've just seen that if you skip the hair removal process, even if you do these other ways, you still end up with some hair regrowth at some point. And it's you don't know how upset it will make you until you're in that situation. And I know a lot of patients want to get there because you've been living your whole life as somebody different or it's it's just been a struggle. Again, I don't know that struggle so I can understand wanting to get to this endpoint that you've been picturing in your mind. But that endpoint isn't as If you don't end up with the results that you really wanted, so I always, I think those conversations are really important. It's why I spend a while talking to my patients at the beginning, before we even decide to do surgery.

Vanessa: 40:12

And for some personal advice from a trans woman to other trans friends, if hair removal is something that you're going to do, check your insurance policies very closely in contact, see if your insurance company has people that specialize in trans health care most companies do. Because a lot of them will actually cover hair removal if you get it done at certain places. I found out about that, right after my final session. And but also this crowd funding can also help. That's how I that's how we pay for most of it. Here removal is not pleasant, but new, the after effects are, you know, it's it's definitely worth it. So, but as Dr. Fernando said, you know, there's definitely there's definitely a barrier to entry there, too, that's understandable. And

Dr Ferrando: 41:01

find find out from your surgeon's office, what what's the minimum hair removal I need to do. I think there's this misconception that it's everything or it's all sometimes like, I will like we some surgeons will show pictures or draw you a picture or even show it on yourself and say like bring this and you only need to do this there is bare minimum hair removal, some choose to just get rid of it all because that's the aesthetic you prefer anyway, I always say, make your life easy, do the bare minimum. And then if you want to do hair removal on your vulva a year after surgery, just to get the look that you want, go ahead and do that then. But you really don't need to remove all the hair, you just need to remove it in certain areas that we need to have, you know, to not have hair regrow in the future, and it's not, you know, the entire scrotum, the entire penile shaft of the groin, that's a lot. So if you are sort of on a budget or a timeline, specifically ask what you need to have removed. And again, good doctors offices will tell you exactly what you need.

Vanessa: 42:03

That is amazing advice too, especially like with the drawing or showing people on their own body, what needs to be done. Because there's, there's a lot of hair down there and a lot more than you think. And you really realize it when especially for getting electrolysis and you really realize how much there is a quick shift gear because I don't want to take up too much more your time. But a lot of people don't consider that an entire team is involved in these surgeries. How do you find teammates that you can trust?

Dr Ferrando: 42:39

I'm so glad you brought that up. Because that is so important. I have been nothing without my team. I just was I moved right. So I don't have my same team anymore. In fact, I'm building my team. And I'm pretty much a you know, working solo, I'm sort of going back to how it was when I was first in Cleveland looking for a team. So I was talking to my teammate, Natalie, if there any individuals who listen to this who have been in my practice, you'll know you'll obviously recognize her name. But you need a team right being I think the best surgeons also have people who health care, do all the care because a lot of us are really busy. There's a lot of patients to take care of. And so if you come up with a team, and everybody has a job, and we all work together, and we're all sort of like it feels like the patient, patients get a lot of attention, but then they feel like they're being well cared for and that there's like one still one person responsible for their care. But yet there's all these touch points. So So for me, what was always important was that I had a good person who was the frontline person who got you into the practice. And who made sure that you had everything administratively that you needed your insurance preauth your plan for traveling, you're the entire post, post operative stay all of that stuff. And then somebody clinical who really sort of can help you with the phone calls. helped me see patients after surgery. As you know, Rach, my right hand, you know, Assistant, Natalie does all of the post operative care. She spent a lot of time working with me to learn all of that. So, you know, you basically you post physicians, you interview your heart on people and so you get the people that you want you look for somebody with a good heart open minded. I will tell you, you know, again, I keep referring to Natalie, she's a nurse practitioner. When I hired her in 2018. She had zero experience taking care of any surgical patients, zero experience being around gender diverse people. But she had a good heart and said to herself, I'd like to do something different and understand gender identity a little bit different and just immerse myself into it. So it's asking the right questions and then also spending the time with them training right? Being really hands on So you don't need to be anymore. So I truly believe that surgical practices, especially for gender affirming care are not, you know, as good as they possibly could be unless they have a full team that gets it. And then, regularly asking patients for feedback. So at the beginning, I used to ask them, was your experience good? Did you feel safe? Did you feel like you could bring up complaints, right? The system's not always perfect. We don't always completely understand if a patient you know, has has a, you know, a complaint or a problem. There's obviously Miss miscommunication sometimes. But I think in general, we do a really good job. And it's about, you know, me steering the ship, but making sure that everybody who's on it is on board with me, and that we're all, you know, paddling in the in the same direction, right? I guess that wouldn't be a ship, it would be more like a kayak. But making sure that we're all on the kayak, that we have our life vests on that we make sure the patient puts, you know, her life vests on, and that we all paddle in the same direction. We don't make the patient paddle though.

Vanessa: 46:09

I was glad that I didn't have

Dr Ferrando: 46:12

I think I've exhausted that metaphor, but I hope that sort of gets like the answers like the question, right? Like, we have to remember that 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 process was amazing. Natalie, I've seen her dozens of times since the procedure. She's very calm, very patient with questions. And, you know, like a typical patient, I'll have freakouts here and there and she's scheduled me into make sure everything's okay. And but just like the entire staff also, like being brought into the operating room, like everybody introduced themselves. Most of them, I admit, already, they had taken the time during the pre appointments to come and meet me. And then you get put up onto the surgical Gurney or whatever the surgical table. So you can tell I'm I'm a layperson. And just you could see the camaraderie there. People don't trust each other. And when they, when they're injecting the, to put you to sleep, it's nice to know that the people that are working on You don't hate each other. So yeah,

Dr Ferrando: 47:27

you're making me miss my team a lot. You know, I've only been on San Diego for a little bit. So now I'm feeling a little nostalgia, because it's a team that I worked with for almost 10 years. And so, but everybody believed in my mission. And I think that that was really important and took a lot of education. And you know, when I first started doing surgery, I had to explain to them and talk to them and normalize it right. So it wasn't smooth sailing at the very beginning. But I have always been surrounded by really, really kind people. And so as long as people are kind hearted, you can teach them anything. And that's the important thing to so having, you know, I have a radar, right, I like sort of like look for it. And I want my patients to feel safe. Nobody wants to go to sleep, unsure of the people around them, right? Like, like I said at the beginning, it's a massive privilege to be chosen to do the surgery. And you don't want anybody going to sleep under your care, feeling unsure of like, what's going to happen to them while they're while they're in that very vulnerable position. Right? You're naked, right? You're having a very intimate procedure done. You are told who's going to be in the surgery room right in the operating room. But how do you know for sure you're going to be asleep. So it's, it's, it's pretty delicate. So I'm really proud of everything that we set up 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,

Dr Ferrando: 48:59

I'm joining a good team that's already there. I'm just going to enhance an enhancement. But yes, it's going to be fun setting up my practice here and seeing patients and then it'll be interesting to see who shows up.

Vanessa: 49:10

Are you already practicing or?

Dr Ferrando: 49:12

Yeah, so I've started my practice. I've been doing mostly care for sis women right now. But um, I'd be happy to see patients and bring them in for gender affirming care. So you know, it's easy to find me i You just you know, put in my name and you'll find me under the UCSD health I have my own bio and my office number is there so it's not difficult to find me I'm still on the Twitter. Although I don't post as much anymore. I used to disseminate a lot of patient information there but it feels a little it's different now.

Vanessa: 49:44

So threads is a really good place threads is the queer paradise anymore. If you're if you're not familiar with it, that's it's a good place to for that but yeah, it's I'll have a link to for people to find you out. Um, in the description this as well. I'll close out with one question, what's the funniest experience you've had as a surgeon

Dr Ferrando: 50:15

some of the funniest experiences I've ever had are like patients leaving me post it notes on their like lower abdomen when I like take their gown off and to get them ready for the surgery, you know, there'll be asleep and we position a patient and then I'll like take you know, because I tried to keep patients covered until the very very end I mean, you obviously we need to uncover you to do the surgery but I don't do it until it's appropriate and then when I do some patients so you know they just leave me I had one patient leave me a funny posted about her warranty right like on there any like a little post it right on the lower abdomen. And so that's probably like, the funniest thing. You know, that has, like ever I've had it happened a handful of times. And each time I laugh pretty hard, because it's always like a complete surprise. I think that's the funniest thing. Those are the funny moments that I've had for sure.

Vanessa: 51:08

Damn, I missed the opportunity. So and then some people like stuffed like ketosis and stuff to having the

Dr Ferrando: 51:15

I have gotten some stuffed uterus. Oh, I actually I think one of them were things that made me I had one patient who does a lot of like really pretty crochet work, but like, I'm stuffed crochet. So she made me a uterus. And then the funniest one she made me was the clitoris. But it looks like the real anatomy of a clitoris. Like, it's like because of the if you look at the anatomy of a clitoris, it's pretty impressive. It looks like the penis actually, like, if you like take off all the skin and just look at the anatomy and the blood supply. It's just smaller. And it's like anatomically correct, which is bizarre, like people look at it sometimes. I have it actually. Oh, here, it's right here. Would you like to see it? Yes. Okay, so now you're really going to laugh. I can show you because I'm in my new home office. And I haven't unpacked yet. But this is the uterus. She made me. Super cute. Super cute, right? I hope this goes to show anybody that if you ever make me anything, I will keep it forever. But this Are you ready for this? Okay. So this is the clitoris and it has a little hood. Adorable that you can like take in and out. So I think that's so funny. And in the same bag, I have an entire bag of hundreds of cards that I've received over the time. And anytime I get a card from anybody, I always keep it so I've kept every card a patient has ever given me and I keep it in a folder and then I just have it there because sometimes I read them and I remember my patients but I have my little baggie of like patient things and I've gotten I have like a stuffed unicorn. I have a stuffed rainbow.

Vanessa: 52:57

I think a unicorn. Yeah, I

Dr Ferrando: 53:00

think you gave me the unicorn. It's a white unicorn. It has like a little pride. I think it's the tail. I wonder if it's in here somewhere. Somewhere in here. It's probably at the bottom somewhere here. I have a unicorn. And then I have this little rainbow one that I love also it was like a pretty pride rainbow. So but the clitoris was incredible. Just because it was like really talented. And then it was just the little hood. I mean, that just put me over the edge. Oh no, I've also gotten a sweatshirt. I have it up in my closet somewhere. I can't remember what it says. I think it's like, I don't know if I'm allowed to say this on here. But it's like there's, I mean, it's not even that bad. But it's like Team policy or something like that. And it has like a kitty cat on it. But one of my patients like did a screen. She makes sweatshirts that are really nice. And she did that. And I used to wear that around for a long time. So those things make me laugh and they also warm my heart and they're personalized. But yeah, messages underneath the gown funniest part of everything because it always I'm very focused when I do surgery. Like I get pretty serious like one just like, yeah, obviously, but like I agree, but once like, I have sort of like this quietness about me when it's time for surgery. So I'm like getting focused. So whenever I've always found that it's always been in the midst of me getting my brain ready for surgery. So then it always makes me laugh out loud. So

Vanessa: 54:27

that's the funniest thing. Well, that's another question for patients asked their surgeons. Have the surgeons, other patients gotten them gifts and stuff? If not, why? So?

Dr Ferrando: 54:39

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 an ad. And I wanted to get one for you and one for Natalie. And but then that disappeared. And I couldn't. It was it was like perfect. I don't remember what it said. But it was just like yeah, whatever. What do you have any closing thoughts that you'd like to share? You're,

Dr Ferrando: 55:02

I'm just so happy to be able to chat with you, I think one of my things is that I've had really nice relationships with I don't, I've made a habit, a professional habit of not really sort of having a relationship outside of like the care until the patient is happy with their care and done right, like, you don't need anything else and you feel satisfied. And then I'm always happy to sort of communicate, you know, through social media or through this like platform. So it's, um, I think that this it feels special to be able to talk to you just, you know, as a person, as you know, a woman, a woman on this podcast, and I think back to when we met each other, and you came in for your consults, and you were a little nervous. I remember to now just being able to chat, but um, I think my messaging to there's enough surgeons doing surgery now compared to what it was that you have the choice and you should be choosy about your surgeon, there's no such thing as like, you know, as long as it's gone, I'll be happy. That's not true. That used to be sort of the old mentality, you need a beautiful vulva. And you need somebody who takes it seriously. And so I encourage patients who are having any surgery, I'm speaking to the men also, or trans male individuals looking for Matoi, do plasti phalloplasty anything in between? Know your surgeons experience, make sure they were trained, like get somebody who practice before they actually started a practice. Does that make sense? Not somebody who's practiced when they started their practice, that used to be the old way of doing it, when I wanted to do this surgery, there was no such thing as a training program. You had to watch people do it. And then you had to be a good enough surgeon to try it. But now there are training programs, I've trained lots of fellows other surgeons have. So make sure that they're trained, like they learned how to do the surgery, they got to practice with somebody supervising them. And then don't settle like you need, you know, the results that you've always wanted. But then also understand that the surgery, there are speed bumps that sometimes happen with these surgeries and they're not always perfect, even in the best of certain best surgeons hands. So just choose a surgeon who's going to be there for you for like 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 surgeon and be choosy. That's

Vanessa: 57:29

amazing advice. Like, if your surgeon doesn't want to answer questions, that's a big red flag. Ask questions because this is a major major surgery and there's a lot that happens with it. So communication is key. I can't thank you enough for being on the pod with me. This is This is amazing. And I really hope a lot of people find this informative. You're this kind of like condenses a whole bunch of questions that people have on Reddit. I don't know if you've been on Reddit and looked up stuff for gender affirming surgeries but I

Dr Ferrando: 58:04

go to Reddit I will say I don't know how to find anything on Reddit so I I've had so many patients say to me I oh I'm here because I like read all this stuff on Reddit about your practice etc. And then I like I can't find anything so I don't know if I'm doing it right or if I 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

Dr Ferrando: 58:27

I have to say like I'm like a borderline Yeah, Gen X or some is zeneo is like our or is that what it's called? A neck? Yeah. xennials Somebody who's like borderline Gen X millennial? Yeah, that's like that'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 listening watching please hit that subscribe button rate us five stars on Spotify, Apple, whatever. And don't forget our Patreon I really want to grow the show. I'm working on making it a weekly show against I've every two weeks so I want to grow, grow, grow, grow, grow, but we definitely need your support to do that. Thank you again, doctor friend for joining us. This was a wonderful experience. And we will see you all next week or next time or whatever. I'm transcending humanity. Bye bye