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Gender-Affirming Phalloplasty: A First for Cedars-Sinai

The urology and plastic surgery team that performed the first gender-affirming phalloplasty at Cedars-Sinai: (from left) urology resident Christopher Dru, MD; Maurice Garcia, MD, director of the Transgender Surgery and Health Program; Edward Ray, MD; and USC plastic surgery resident Erin Weber, MD.

By Edward Ray, MD

Significant challenges still face many transgender patients. Aside from discriminatory practices and a lack of constitutional protections, this circumstance has come to the forefront of societal awareness in recent years. A large number of transgender and gender-nonconforming patients suffer from a clinical diagnosis of gender dysphoria. This is a condition whose prevalence is not well known, but is now the most common diagnosis in the Diagnostic and Statistical Manual of Mental Disorders that prompts referral of transgender patients for gender-affirming surgery. This condition, previously labeled "gender identity disorder," is defined as a state of emotional and psychological distress experienced by an individual whose gender assigned at birth differs from their gender identity. Gender-noncomformity, including transgenderism, has a prevalence that may be as high as 0.6 percent, based on global population surveys.

In recent years, a certain degree of societal destigmatization has encouraged some of those who suffer from gender dysphoria to seek treatment including counseling, hormonal therapy and sometimes surgery. This has also brought to light the scale of this previously under-reported problem. In 2005, California passed the Insurance Gender Nondiscrimination Act, which prohibits medical insurance plans from discriminating against transgender people or denying access to "medically necessary procedures." According to recent legal interpretations, "medically necessary procedures" includes gender-affirming surgery for patients with gender dysphoria.

In 2016, Cedars-Sinai recruited Maurice Garcia, MD, a urologist specializing in gender-affirming surgery, to found and direct Cedars-Sinai's Transgender Surgery and Health Program. When asked about the challenges of starting the transgender program, Garcia replied that the most difficult part "was making a persuasive argument that the program was viable from a financial standpoint." Because there are so few centers offering gender-affirming surgery in the United States, Garcia said that it is not clear how effectively the Centers for Medicare & Medicaid Services (CMS) or private payers will be reimbursed for these services. In helping Cedars-Sinai understand how the medical center would recoup its costs, Garcia spent a great deal of time and energy formulating a business model to balance charges and predicted insurance payments. As the first, and still one of the only, MediCal physicians in the state to offer gender-affirming surgery, Garcia has mandated that the program continue to accept CMS insurance in the program.

In addition, Garcia is also a world-renowned researcher and prominent member of the World Professional Association for Transgender Health (WPATH), an organization of healthcare professionals that promotes an evidence-based and ethical approach to the treatment of gender-nonconforming patients. The Standards of Care, or simply "SOC," is a document written by and periodically updated by WPATH that synthesizes current evidence and professional consensus on a diverse range of health issues and medical controversies affecting this unique group. In light of the fact that many physicians and other health professionals know very little about gender-nonconformity, the SOC, which is available online in 16 languages, is a useful introduction and guide for all medical specialties.

Edward Ray, MD, a reconstructive plastic surgeon in the Department of Surgery who is fellowship-trained in microvascular surgery, and also a member of WPATH, has partnered with Garcia to perform phalloplasties for female-to-male transgender patients. In this procedure, skin and fat tissue flaps are harvested from other areas of the body (such as the forearm or thigh), fashioned into a neo-phallus, including a urethra. When a flap is harvested from a distant location, such as the forearm, it is then reattached to the body using microsurgical techniques. Nerves from the flap are coapted to nerves in the inguinal and genital area to provide sensation to the flap.

On June 26, 2017, Garcia and Ray performed Cedars-Sinai's first free radial forearm phalloplasty for a transgender patient. The team has had great success with this first patient, who recently underwent a second stage scrotoplasty as well as reattachment of the urethra to make the phallus functional for urination. A second patient who already had a neo-phallus made elsewhere underwent creation of a neo-urethra. In all, five phalloplasties have been performed so far, the goal is to do several per month.

Ray also performs chest surgery (subcutaneous mastectomy, breast reduction and breast reconstruction) for transgender patients. Garcia offers urogenital reconstruction options to both male-to-female and female-to-male transgender patients. Until this program was started, there was no well-established center in Southern California, and gender dysphoria patients referred for surgical treatments had to travel to San Francisco or out of state. Patients are traveling from all over California and abroad to seek the program's expertise.

"Feedback from all transgender and gender non-binary patients has been exceptional," said Garcia. "Patients consistently say to me and others on evaluations how well they were treated. I will say that patients often report that they were ‘surprised' to learn that we have this program, which tells me that we have to do a better job of messaging.

"[This] program reflects a long history of values that speak to a commitment to diversity and service to the underserved—including to historically socially marginalized populations," he added.

While the recent gender-affirming phalloplasty is a surgical first for Cedars-Sinai, it is also a first step and represents a commitment on the part of the medical center to bring life-changing gender-affirming surgery within reach of patients from Southern California and across the country.