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When Nikki Burish, MD, moved from Wisconsin to New York City for her plastic surgery residency at Mount Sinai Hospital, she didn't know anything about gender-affirming surgery. Toward the end of her residency, she was assigned to a rotation at a Mount Sinai facility in downtown Manhattan where plastic and reconstructive surgeon Jess Ting, MD, often performed gender-affirming surgeries for trans patients.

"There wasn't much in our literature at that time [about gender-affirming care], and certainly not much online about fellowships. There were no fellowships I'd even heard of," Burish told 番茄社区.

"At the time I was like, 'No, I'm going to do aesthetic surgery. I'm not interested in this,'" she said. But when Ting's then-surgical fellow went into labor, Burish took on the fellow's responsibilities. She soon became fascinated by the field's creativity and innovation. When the time came to apply to fellowships, Burish decided to apply for Ting's program in gender-affirming surgery. Now, with a year of training under her belt, she's about to complete her fellowship.

Physicians who perform gender-affirming surgeries don't have to complete a fellowship; in fact, most don't. Surgical fellowships for trans surgeries have only been around for 5 or 6 years. But for Burish, the fellowship has been essential to her training.

"Just to serve the patient population, I think they deserve the very best," Burish said. "And so I thought I could be my very best if I got to do the same surgeries over and over and over again to become an expert at them."

For years, plastic surgeons and reconstructive urologists from the U.S. who wanted to enhance their abilities in performing gender-affirming surgeries had to travel to European countries -- or even further abroad -- in order to shadow practicing surgeons who specialized in the highly complex operations. Within the last 5 years, many of those same surgeons have started their own fellowship programs to train the next generation of early-career surgeons in gender-affirming surgical care.

The first of these fellowship programs was established in 2017 by Ting at Mount Sinai. Like many surgeons before him, Ting, after experiencing difficulty learning the intricacies of gender-affirming surgeries, spent months traveling to Belgium and London to learn from other surgeons. When he returned, he started getting emails from other surgeons in the U.S. who wanted to observe his operations.

"That's when I thought, since it was so hard for me, and clearly there's an unmet need for training in gender-affirmation surgery, why don't we start a fellowship?" Ting told 番茄社区. During his research process, he couldn't find another fellowship program that focused specifically on surgeries for trans patients.

Soon after Mount Sinai established its Center for Transgender Medicine and Surgery, it quickly developed a waiting list of over 400 patients, Ting recalled; even now, it still might take a patient well over a year to get into the operating room. All the more reason, he said, to train more surgeons.

The demand for gender-affirming surgeries has in the last decade, and the creation of these fellowship programs has followed suit. In 2008, provisions laid out in the Affordable Care Act supplied some coverage for gender-affirmation surgeries. But it wasn't until 2014 -- when on offering coverage for gender-affirming surgery -- that things really started to change. Now, state by state, Medicaid has to open up its coverage options for medically necessary transition-related care. And many states have in place that prohibit anti-transgender discrimination, including the exclusion of transition-related care.

Since 2017, the number of programs has grown from one to eight, with new fellowships still in the process of being created. Organizing a formal training program for gender-affirming care is no easy task, as the field spans multiple specialties, such as plastic surgery, urology, gynecology, and otorhinolaryngology.

Surgeons not only have to work together across specialties, but also develop new skills that they likely weren't taught in residency in order to properly perform the wide array of surgeries that fall under the umbrella of gender-affirming care.

For plastic surgeons, such operations might include facial feminization, masculinizing chest surgery (or "top" surgery), vaginoplasty, phalloplasty, and thyroid chondroplasty (shaving of the tracheal cartilage). Reconstructive urologists work closely with the plastic surgery department, taking care of the changes or modifications that are made to a patient's urinary tract.

But surgery is only one of the major components of providing high-quality care to trans patients.

"I view gender-affirming surgery really as a multidisciplinary field," said reconstructive urologist Lee Zhao, MD, the co-director of the Transgender Reconstructive Surgery Program at NYU Langone. "We have social workers, which the fellow works closely with. We have endocrinologists, psychologists -- it's a whole team."

Zhao told 番茄社区 that, at first, he was thrust into the world of gender-affirming surgery after operating on patients who had suffered secondary complications from other surgeons.

"It's despicable," Zhao said, referring to the surgeons who were unwilling to take care of their patients' complications. "Taking care of complications is something that you have to do, you shouldn't offer operations if you can't take care of it."

Daniel Dugi, MD, a urologist and co-founder of the Transgender Health Program at Oregon Health & Science University (OHSU) in Portland, also started practicing gender-affirming care after patients would come in seeking help for surgical complications. And like other surgeons in the field, Dugi spent nearly a year traveling abroad to observe gender-affirming surgeries and preparing to perform them himself.

"At the time, there wasn't a big national conversation about trans care in the same way that there is now," Dugi said. "'Orange is the New Black' wasn't the big deal, Caitlyn Jenner hadn't come out."

So Dugi -- who went through his medical training in Texas, during which there was never a mention of gender-affirming surgery -- focused his efforts on creating a thoughtful program for trans healthcare at OHSU. Now, the program's first fellow is about to complete her training after starting in August 2020.

Gender-affirming surgery has always been controversial. But, in tandem with the increasing demand for this surgery seen in the last decade, there has been a continuing national debate over whether or not trans people grow to regret their decision to medically transition.

At one point, Dugi himself was at the of this debate, after nine former patients sent an to OHSU's administration. The unnamed patients described feeling coerced into having surgery, dissatisfaction with their results, and feelings of regret. Yet, has shown that the prevalence of patients regretting their gender-affirmation surgeries is extremely low.

"What we don't talk about is the rate of regret of having a major surgery for cisgender people, in all the different surgeries that are offered," Dugi said. "We should treat people as adults and allow people to make adult decisions about their bodies, and inform people about all the risks and benefits."

Zhao told 番茄社区 that, among roughly 600 cases a year, he has never had a patient regret their surgery. But the possibility, he said, makes the case for having more fellowship programs.

"It's really, really important to train fellows not only on the surgical techniques but also in the care of patients of transgender experience," Zhao said. "So you can choose the right patients to do surgery on and ensure that the [World Professional Association for Transgender Health] guidelines are followed. That's a critical part of the training."

After she finishes her fellowship at Mount Sinai, Burish plans to move to South Carolina to work at Prisma Health in Columbia. There, she hopes to organize a center for transgender care much like the one at Mount Sinai, where she can work with other physicians and nurses to provide gender-affirming surgeries.

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