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In this episode, VP of the APTA Connecticut Chapter, Dr Stephanie Weyrauch, CEO of Inclusive Care, Dr Krystyna Holland, and Obstetrics and Gynecology faculty member at Denver Health, Dr Jennifer Hyer, talk about bottom surgery and gender-affirming care.
Today, we talk about vaginoplasty complications, pelvic floor goals post-vaginoplasty surgeries, and setting post-operative expectations. What are the barriers that trans people face when trying to access gender-affirming healthcare?
Hear about pre-operative education, hysterectomy versus vaginoplasty outcomes, trauma-informed care, and hear their advice to healthcare providers, all on today’s episode of The Healthy, Wealthy & Smart Podcast.
Key Takeaways
- “You only have one time in your life to be post-op.”
- “The only way out of this is through.”
- “Give yourself grace, because you need to heal.”
- “Trauma-informed care is a commitment to continuing to try to reduce our own propensity for perpetuating harm.”
- “Once you start, you’re going to see a lot of folks that need this care.”
- “Be honest about who you can help and what feels good for you.”
- “Not everyone currently is a safe person for trans and non-binary people, and that’s okay. We are not all for everybody.”
- “We are seeing patients who are gender-diverse, and we need to be able to provide good care to people.”
- “If you don’t change your environment, it’ll change you.”
- “The hard work is always worth it.”
More about Dr Stephanie Weyrauch
Dr. Stephanie Weyrauch is employed as a physical therapist at Physical Therapy and Sports Medicine Centers in Orange, Connecticut. She received her Doctorate in Physical Therapy and Master of Science in Clinical Investigation from Washington University in St. Louis.
Dr. Weyrauch has served as a consultant for a multi-billion dollar company to develop a workplace injury prevention program, which resulted in improved health outcomes, OSHA recordables, and decreased healthcare costs for the company’s workforce. She has served on multiple national task forces for the American Physical Therapy Association (APTA)—most recently, she was elected to the APTA Nominating Committee—and actively lobbies for healthcare policy issues at the local, state, and national levels of government.
She currently serves as Vice President of the American Physical Therapy Association Connecticut Chapter and is a member of the American Congress for Rehabilitation Medicine. Dr. Weyrauch has performed scientific research through grants from the National Institutes of Health and National Science Foundation at institutions including Stanford University and Washington University in St. Louis.
Her research examining movement patterns and outcomes in people with and without low back pain has led to numerous local, regional, and national presentations and a peer-reviewed publication in Archives of Physical Medicine and Rehabilitation, a top journal in rehabilitation.
More about Dr Krystyna Holland
Krystyna Holland, DPT (she/her) is the founder and CEO of Inclusive Care, a physical therapy office in Denver, Colorado specializing in the provision of trauma informed pelvic floor care to individuals across the gender identity spectrum. Krystyna’s journey as a provider started as a patient. Traumatic experiences in her own medical treatment inspired her to open Inclusive Care.
In addition to helping folks feel confident in their ability to live without leaking and have intimacy without fear, Krystyna aims to change the fundamental patient-provider relationship from one that centers the provider as a problem solver to one that focuses on collaboration between the patient and the provider.
She is a well-known Instagram educator (@Krystyna.Holland), an instructor of trauma-informed care trainings, and a healthcare consultant.
More about Dr Jennifer Hyer
Jennifer Hyer, MD joined the Obstetrics and Gynecology faculty at Denver Health in 2007. She is an Associate Professor of Clinical Practice in Obstetrics and Gynecology at the University of Colorado School of Medicine. She completed medical school at the University of Tennessee Health Sciences Center and completed her Obstetrics and Gynecology residency at the University of Colorado. She is a Fellow of the American College of Obstetrics and Gynecology and a Diplomate of the American Board of Obstetrics and Gynecology. She is a member of the 2017 class of the Association of Professors in Gynecology and Obstetrics (APGO) Academic Scholars and Leaders Program. In 2022, she joined the Denver Health Medical Staff Executive Committee.
In 2021, she was honored by her peers with the Denver Health Outstanding Clinician Award. Her clinical activities include full scope practice of Obstetrics and Gynecology at Denver Health Medical Center as an attending physician. She has been providing surgical management for transmasculine patients since 2016. In 2018, she expanded her surgical skill set under the direction of Dr. Marci Bowers and Dr. Chris Carey to include vaginoplasty for transfeminine patients. She continues to provide these surgical services and is the only transfem bottom surgeon at Denver Health. She has presented Denver Health gender affirming surgical data at both national and international conferences. She hopes to expand the Denver Health Gender Affirming Surgical Program and participate in research opportunities to improve care of all LGBTQ+ patients.
She also has a research interest focused on maternal mental health, and she has presented on this topic at both the national and international level. She has received grant funding from the Denver Health Foundation and Zoma Foundation to support integration of behavioral health into obstetrics clinics. Additionally, she has partnered with colleagues at academic institutions within Denver to collaborate on projects to improve maternal mental health and access to support services.
Suggested Keywords
Healthy, Wealthy, Smart, Gender, Transgender, Surgery, Gender-affirming care, Education, Advocacy,
To learn more, follow Drs. Weyrauch, Holland, and Hyer at:
Website: www.inclusivecarellc.com.
LinkedIn: Krystyna Holland PT, DPT.
Twitter: @TheSteph21.
Instagram: @thesteph21.
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Read the Full Transcript Here:
00:02
Hello, Dr. Y rock back for another great interview, always happy to have you and welcoming for the first time on to the podcast, Dr. Christina Holland, who I was with when I bought my first hat. I know it was a big deal. But I was with her in Denver bought this great hat. And also joining us today is Dr. Jenn hire. So thank you both for joining us for our conversation today on bottom surgery and gender affirming care. And to start things off, I’m going to throw it over to Stephanie, as this was the hurt this podcast is her brainchild. So Stephanie, I will throw it over to you to start.
00:44
Yeah, well, thanks, guys for joining us today. So kind of what I was thinking with this podcast and why it was something that I wanted to talk to Karen about was I’m getting more and more patients in my practice, that are looking for pelvic floor physical therapy and are undergoing gender affirming surgeries. And it’s not really a topic that I feel a lot of healthcare professionals know about, especially with some of these stories that I’ve heard from my patients telling me that they’ve had health care providers that they’ve told that they were going to be receiving gender affirming care, and the health care provider didn’t want to treat them because they didn’t feel comfortable treating them. And if we’re going to continue to improve our health care system, we need to make sure that we can provide the proper care to this population. And so I’m really happy and excited that you guys are able to join us today. And I’d like to just start off by asking you how you got into treating this population. And some of the collaborations that you two have worked on together in making sure that these, this population gets the health care that they need.
01:53
Jen, why don’t you start? I think your story is really interesting. Okay,
01:57
so I’m an OBGYN by training. And I started with gender affirming care, initially taking care of trans masculine patients or patients assigned female at birth. And to me, it was really a no brainer, we, you know, I do hysterectomy ease anyway. And I was like, how great and this is a surgery that can lower someone’s risk of suicide and depression and like, gosh, yes, please, how can I help this? You know what, Yes, I’ll do this. And then shortly after that, the hospital where I was working, was interested in bringing in vaginal plasti, for gender affirming bottom surgery for folks assigned male at birth. And through, you know, the stars aligned, and we were able to collaborate with Dr. Marci Bowers, who is really a pioneer in this field, and has done so much to help so many people, including educating, you know, other surgeons. So we partnered with her, and that was four and a half years ago. So we’ve been I’ve been doing this surgery since May of 2018. And it’s been really great. You know, I’ve met so many amazing people. And we have a ton of folks that need care. And at the genesis of our program, we actually started physical therapy, physical therapists were involved with us in designing our program, designing our post op care, because at the time, we were already co located with physical therapists in our office. And it was just a really logical thing for us. And it’s we’ve never looked back, every patient sees a physical therapist.
03:47
Yeah, which was really cool. As a physical therapist, as a physical therapist. I had randomly connected with the physical therapists who was part of this program, I had just moved to Denver. I got involved in April, my first day was April 120 19. So I guess, not too terribly long after the program started. And I had known that I wanted to work with trans folks more generally, as kind of a way to improve health equity. I knew that that care for trans folks was not good. I didn’t know the extent to which it was not good, but I knew that there were limited options. And so that was kind of part of my my broader career plan. And so it was, I didn’t actually know how I was going to do that. So it was very lucky for me that I ended up at coffee with this person who’s a dear colleague and also a dear friend, and she ultimately got me involved in the program at at the hospital with Dr. Hire.
04:51
Great stories. So Dr. Hyer tell us a little bit about the surgery, the vaginal plasti how’s the surgery performed? What are Um, some common complications that can happen, what are some expectations post post surgery that you typically tell your patients about.
05:10
Um, so the surgery I do is called penile inversion vaginal plasti. So essentially what and there are other forms of vaginal plasti where the vagina can be made with peritoneum that’s called peritoneal pull through or there. Some places will use bowel for the vaginal tissue, but I’m only going to speak to what the surgery I do so for penile inversion, vaginal plasti, we essentially the Neo vagina is made from Skrtel skin that is like cleaned off and deep fat it and we sew it on a dilator and then sew that to in the penile skin, which is how it gets the name penile inversion, vaginal plasti. And then the labia are made with the inverted penile skin as well. And clitoris is made with the glans of the penis. And then we do a large dissection between the prostate and the rectum to create that space for the Neo vagina. In terms of complications, there’s the complications that are, you know, unique that apply to all surgeries, pain, bleeding, infection, damage to internal organs, but specific to vaginal plasti. It’s really important that folks dilate, post op. And the it’s been I’ve had some pretty, you know, tragic cases where folks didn’t dilate and that space closes quickly. And I don’t I don’t know when I don’t understand because you know, I only see people at points in time. And I don’t always know what they’ve been doing in terms of dilation. But I’ll have people say like, oh, I dilated, I, I’ve missed maybe one time, which post op, they’re supposed to be dilating three times a day for 12 weeks, but they come in, and there’s just no vagina. And, you know, I believe them that they have been dilated, but I don’t know what’s been going on. So that’s a complication. That is pretty tragic and heartbreaking. They can also get stenosis around the shortest, depending on their comfort level with the dilator. And moving up with the dilators. Because, you know, they’re they’re fighting their body which is trying to heal. The grafts typically take very well because it’s a full thickness skin graft. So that’s one of the I feel like major successes of this surgery is that we have this beautiful graft of tissue to use. And so I don’t see a lot of problems with prolapse or or that folks can also get infections, especially I see that with people that don’t do hair removal. So hair removal is pretty costly. And some people just, they can’t afford it. And so that can happen with infection and any sort of setback you have will delay the progress of the healing and the surgery and getting you to the space that you want to be.
08:16
So Christina as a pelvic floor, physical therapist, is this something that you help patients? Do you help them reach these goals? Or what’s some of the goals that you help patients postoperatively reach when they have this surgery?
08:30
Yeah, so from the very beginning, it’s a lot of patient education about wound care what I what I one of the things I really love about vaginal plastic patients and working with vaginal patients after vaginal passing in general, is that it’s like such a full scope of physical therapy because you have the wound care element you have the musculoskeletal contributions to whatever their body was doing before there’s likely to Doctor hires point about you know, fighting the healing process of there is this like new open wound that you are now inserting a plastic acrylic dilator into three times a day for 12 weeks, immediately post op is just wild, right? So there can often be some sort of like vaginal Miss involuntary contraction type of component. There can also be like any other number of things that we that we see in people in general, you could have low back pain if the person has a mobility concern on the front end. Like it really is just so much physical therapy. So yeah, the way that I typically describe it to patients is that my job is to help you reach the goals that you set for yourself. So if your goal is to have penetrative receptive, penetrative vaginal intercourse, I’m here to help you do that. If your goal is to maintain your vaginal depth for appearance and for the potential but actually you don’t like participating in receptor penetrative vaginal intercourse, intercourse, that’s okay. We’re not going to make that a goal for you. So I help people be able to do all of those things as well as be able to, you know, maintain continents as well as be able to empty completely, we see a lot of folks who might have some urinary hesitancy, with tension in their pelvic floor muscles, just like we anticipate with cisgender women and or physician or men for that matter. So yeah, so a whole bunch of things is the kind of short answer.
10:23
And what is typically the amount of time that you typically will see patients for. Yeah, so
10:29
it was really lucky in the hospital that I could see them for really, as long as I needed to. I was seeing folks. So at 77 days post op when they had their packing removed, and then helping them dilate. For the first time I was then seeing them typically, it kind of depends, because people will often travel from really far away. So they might not always have access to come back and see me in my in my ideal situation, I would see them again, ideal but conservative in a public hospital, let me clarify all of this, the systemic things happening there, one week, after their package has been removed, to make sure that things are going well, because oftentimes, they’re still quite numb, after when the packing is removed. And then again, at four weeks, six weeks, 12 weeks, assuming that like nothing else, is is going poorly or is unexpected. And so it’s interesting, though, I’m no longer in that in that same hospital system. So I still see trans folks and I still see folks after vaginal plasti I am now however, typically seeing them I feel very grateful for this, that because they can be seen at the hospital where Dr. Hire works, they’re typically seeing me either from a different surgeon or a different place or years after the fact. And that duration of time that they’re being seen also very much depends on insurance. So Colorado has really, really great Medicaid and has really good, actually like legislation around what insurances have to cover for gender affirming surgeries. And so that’s something that’s also very special about Colorado, they care in Colorado, more specifically.
12:05
Well, yes, let’s talk about the barriers that this population faces. I know that with some of the stories that I’ve heard with my patients, they just absolutely break my heart. What are some barriers that trans folks face when trying to access health care, gender affirming health care?
12:24
I think, for us in terms of getting surgery barriers include hair removal, being able to pay for the hair removal, being able to afford to take time off from work, also social support. So I really do talk to people about who is your tribe, you know, who’s going to help you, no one else needs to be wiping your bottom, no one else needs to be dilating your vagina, but who’s going to come by and check on you, who’s going to make sure there’s food warm food for you who’s going to walk the dog who’s gonna do the house, you know, the the life around you. And some people have nobody, like who’s gonna pick you up from the hospital, I don’t know anyone, I’m going to take a lift, I’m like, that’s not an option. You have six months till surgery, talk to your family, find someone. And you know, sometimes people do and sometimes they don’t. And I think that’s the hard thing is like this, those that are socially isolated, those that have financial constraints. We don’t offer this service to folks that are unhoused because of the logistics around all the care that you need. And, you know, you need to be close to a bathroom and a toilet and clean water. And so I think, off the top of my head, those are the biggest barriers.
13:51
I mean, in addition to there aren’t that many people who are qualified and doing the surgery providing the care. I mean, I’ve been really surprised at how few pelvic floor physical therapists alike are doing this type of care. i It’s a new, it’s also a newer science and a newer medicine. And so, you know, accept true access, not only like from our perspective of being able to afford it, but also being able to find it anywhere near you, I think is also a really big barrier. And that’s not even that’s, I think, a little bit more specific to vaginoplasty. But then if you add in, you know, the amount of trauma that trans individuals experience in the world at large, let alone in the medical system specifically. So like that becomes then a barrier to them being able to get more care, just like you were saying Stephanie around like, it’s so vulnerable to have to call providers and say hey, will you help me and for them to say No, I won’t like because of something about your identity. I just can’t like it makes me really upset to be so honest with you. So the high levels of trauma could definitely impact care as well as as like, the willingness and resiliency both physically and emotionally to be being able to navigate systems that are very complicated.
15:09
And how to this is a question for both of you. How do you, Dr. Higher in your case, maybe preoperatively? How are you setting expectations for recovery? And Christina, the same when someone’s coming to you in that first week post op? What are you saying to them to set those expectations because I know every time I’ve had a surgery, if I had a doctor who set very clear expectations of this may happen on you know, a week from now, or two weeks from now, if this happens, call me if this doesn’t happen. Do you know what I mean? So how are you kind of setting those expectations with your patients, because I have to imagine that may help this very vulnerable population feel a little more confident in their, in their surgery and post operative care?
15:59
Well, for me, when I’m meeting people at the pre op, I describe the surgery, I talk about the immediate post op care in the hospital, talk about when you go home, I really I always talk to people about what’s your job, who’s your support, can you take 12 weeks off, and I really harp on it and say, Listen, you only have one time in your life to be postdoc. This is the time when you really need to be dilating three times a day. And sometimes it’s not just a five minutes, some people spend an hour every day, hour, three times a day. And I’ll say to them, like, you know, at work, you’re not going to be able to do this. And so I just flat out, tell them what I think they should do. And then they have to tell me what they’re able to do. Because some people are like, I can’t, I can’t miss that much work. I’m gonna go back. This is my plan. And I say okay, but you need to know, you might lose vaginal depth. And if you do, I can’t help you to get it back. Because my practice has been because I use the scrotal skin for the Neo vagina that’s gone. And so I and we also give folks handouts about dilating, you know, tips, and we’re constantly going over things. And then also maintaining a really open communication, we have my chart, we have a phone number they can call, you know, just say please call me before it gets. If you’re having a problem. If you’re noticing you’re losing valuable depth, please come in, don’t say at home and wait for your appointment in two weeks. So I think that’s the biggest thing is like open communication, giving them a printed out set multiple ways of getting information across.
17:51
Yeah, and postoperatively. Even if you just think about tissue healing, anywhere, most of the layperson doesn’t know about the stages of tissue healing, right? And people are always like, for any surgery ever. It’s like Is this normal? How would they know they’ve never had the surgery before, they’re not a professional who knows what the tissue is supposed to be doing. And in addition to that, the a lot of the incisions for vaginal plasti. And a lot of the like, new tissue is on the inside of their body where they can’t easily see it either. So and there’s a smell, there’s like a, there’s a smell to healing tissue. And then there’s especially a smell to healing tissue tissue that is tucked up on the inside of your abdominal cavity, right, so like, your pelvic cavity. So we have a lot of those conversations around like the very first thing I always say is, when I was seeing folks immediately did use them to dilate is, have you looked at your new vagina. And because that’s also a place that we want to start from a trauma informed place, because I need to know what their relationship with that part of their body is in general. I also if there’s someone who’s like, Oh, I’m really squeamish. We got to set good expectations literally from moment one, because it is a wound. And so we have to talk about like, alright, I would, here are the things that we need to go through in this visit. And let’s come up with a plan for how we can get you there. So I want you to know what it feels like to dilate fully. I would also like for you to know that you can confidently dilate fully yourself, and how can we best make that happen? The very first thing of expectation set of expectations also includes like, what your vagina looks like now is not what it’s going to look like four weeks from now is not what it’s going to look like six weeks, eight weeks, 12 weeks, six months, one year from now. And so reminding people of that and reminding people that like you, the only way out of this is through and to trust the process is a really big part of the expectation setting as well.
19:47
That’s a great point too. And because sometimes I have to be like alright, cool your jets like we are not really operate on this. This is fresh tissue. It’s like you said it’s a wound. If you go back in there and try Gotta tweak this or make your labia you know this, you’re going to just kill that tissue it’s going to fall off. So creating expectations of how things. Look. You know, one thing we always say in gynecology is the labia are sisters, not twins. So this applies here as well, you know, and don’t don’t overly critique yourself. And I always say, give yourself grace, because you need to heal.
20:30
Christina, have you noticed? Patients that maybe come in Korea before the surgery, that there that you have to work on pelvic floor muscle tension in order to have the surgery be more successful? Is there any correlation that you’ve seen clinically, or that is supported by the literature on getting physical therapy prior to having the surgery?
20:53
Why Stephanie, I’m so glad you’ve asked. This is the thing, I care a lot about it. And it’s complicated. So oftentimes, people who are getting the surgery actually don’t have very much access to pelvic floor physical therapy, preoperatively. That could be because of system things, right? They’re traveling and all of that could also be because of dysphoria, like it can be very, very uncomfortable for people to interact. Like it doesn’t feel safe for those folks to be in their bodies, with the genitals that they that they were born with. And so not to say that all trans folks experience dysphoria, because they do not. But that can be another big barrier to accessing especially preoperative pelvic floor physical therapy. So I did not play this question. But I would have because I’m, I’m currently working on a project to try and figure out if we can do like, some of the more general pelvic floor education and kind of like a preoperative, psycho educational program to see if that could have been, like beneficial impacts on from the post operative side. The very limited literature that currently exists about pre operative pre vaginal plasti, pelvic floor physical therapy is that yes, we see improved outcomes. And we also know that some people do drop out of those programs because of they will tell you that they experienced dysphoria, and it was uncomfortable for them. So it’s very nuanced, I think that there would be so much potential for improved outcomes. And the barriers are, can be very significant.
22:18
I love that so much too, especially around trying to treat some of the genital, like dysphoria that folks have that sometimes I’m not aware of, until it’s too late until they’re like, I couldn’t do it. I couldn’t dilate. I couldn’t I hate this part of my, you know, it’s springing up too much for me. And I would love to have folks do physical therapy preop the issue for us is resources. You know, the physical therapist time is so valuable, and they’re already so busy and so overbooked and overworked. And but I would love that, I would love that.
22:57
So how do you help patients overcome or deal with some of this dysphoria Christina in the preoperative operative phase, because I feel like that would be so especially after what Dr. Hyer said, that would be extremely important in having a successful surgery in order to start feeling safe in this body that you identify with.
23:19
Yeah, so in private practice, I am seeing more people who are interested and able to both from like an accessibility standpoint in terms of like Time, time, resources, financial resources, those sorts of resources, as well as from emotional resources to be able to plan like, Okay, this is a surgery, I’m interested in having, I really want to set myself up for success, what can I do, and in those cases, it’s actually really not very dissimilar to the things that I teach my pregnant patients or my patients who are trying to conceive in terms of what is your current pelvic floor mobility, like so I don’t care very much about strength, but I do want them to have good mobility and control, good ability to open up like do hip openers and have good flexibility and control mobility through their hips, as well as their lower abdomens. So and then I give all of that coaching based on what the patient in front of me is able to do. So I will ask questions like, you know, what is your relationship with that part of your body? Are you able to look at so if are you able to feel your rectum does that how does that feel if you check in with yourself can you feel when you take a deep breath in that your rectum drops down gently into the seat below you so I will then I will try and use non gendered anatomical terms so I will stay away from talking about the penis. I typically stay away from talking about the perineum as well because sometimes people don’t know what it is. Although I have counseled many a patient about where their tent is, and that is a gender neutral term, my friends, so So using as much anatomical but like anatomic anatomy that every single person regardless of their genitals has been really Oh But an honest with patients around like, what is this experience? Like for you? Are there words you would prefer me use? Or before it’s up for me not use? I have an external ultrasound like live action ultrasound unit that I will use. And that does it doesn’t matter what your genitals you have, and I can’t see your genitals via that. So that’s been really helpful. So yeah, I think those are, those are the things that are coming to mind.
25:24
Do you ever use bio external biofeedback?
25:28
I haven’t. You could especially like external, like, extra Annelie. But I have not.
25:38
And what something that has come up for me, and we talked a little bit about this before we went on, is the two of you know each other, you’ve worked together. Dr. Higher, you talked about the importance of, of your team, and that care for this population is really a team sport. How many people? Would you say you don’t have to be specific, but let’s say we’re talking about here in the United States have access to the team? You know, like, or if you if you are a person who is interested in this surgery, where do you have to look for this team?
26:18
I think in the current state, most folks are getting taken care of by a team of people, the old way. So before we had more insurance coverage of the surgery, I was generally like a solo center, or there was way less access to surgeons because fewer people were doing this. But I do think that now you are seeing folks going to like a major, like most major cities now have someone doing gender, at least one group doing gender affirming, care, and, and gender affirming bottom surgery. So I think what ends up happening is you go to the big city where you live, that you can get to and you’ll you’ll find people and also with organizations like W path, the World Professional Association for trans health as well as us path. You know, they’re really toting that like, this is the best care, you know, having this team, having behavioral health, having physical therapy, having your surgeon, you know, that is wraparound care for folks, and people do better. And so the word is out, you know that this is really to be expected.
27:40
I do think that there continue at least from a pelvic floor standpoint to be so I do, I think I’ve heard of a lot of patients being able to access, maybe one off pelvic floor physical therapy services in the best case scenario, especially when people are traveling. And a lot of behavioral health, which is part of the W path guidelines, which is why I think that’s, there’s something in that, but I still am seeing a lot of people, a lot of surgeons are not necessarily there is no it’s not guaranteed that they even receive a pelvic floor physical therapy referral after after vaginal plasti. Even if those services are maybe available, I think probably for a lot of the reasons you already mentioned, Dr. Hire in terms of like those physical therapists are seeing a lot of different types of patients on a lot of different teams, and they don’t have a lot of access in their schedules.
28:27
So Stephanie, when you have patients that are calling your clinic for physical therapy, are they referred by a local physician? Or is this someone who’s had surgery and was not referred to physical therapy and is looking because they feel like they need this care?
28:48
Typically, they are referred by a physician. Very rarely do I have people in this population who will self refer?
28:59
And how about you, Christina or Dr. Hire? Have you had people who are sort of self referring or lighting for you outside of you know, from a physician?
29:13
I have a couple, like very few and that’s primarily from Instagram of all places. I’m trying to think of who else Dr. Higher and I will like we communicate even though I’m outside the system now and we’ll still have some shared patients. Yeah,
29:31
yeah, I don’t have people that self refer, but I will have people that find me. You know, like they went somewhere else and had surgery in another state. And I’m always just so like, oh my gosh, I could not work this way. But they they have like no intentions of following up where they have the surgery, no plan. I mean, and so then I will send them to physical therapy, you know, I mean, you can feel it that pelvic floor, I’m like you’re fighting this, you got to learn how to relax us, let’s get you in with a physical therapist. So but nobody is like, so they self refer by finding me, I guess. And then I get them to the physical therapist sometimes. But I, the only surgeon that lets me know that she’s sending me a patient is Dr. Bowers. And that’s because like, you know, it’s like, Oh, hey, this patient is going to come to you for post op care. Okay, great. But otherwise, people just kind of show up. I find it fascinating.
30:40
What about the patients who are getting hysterectomy to have you noticed? Or what are their typical, typically their outcomes? And how do they differ from these patients getting vaginal class stays as far as outcomes go and post operative treatment? I think the hysterectomy
30:55
folks are similar to the vaginal plasti. Folks, you know, everyone has a different goal, like post op what they’re going to do. I mean, some vaginal, vaginal plasti or hysterectomy, folks are having penetrative penile intercourse, some of them are not and never would and never will and, you know, are planning to go on and get a phalloplasty or Matoi. Do plasti. Some folks, my gender diverse folks that are non binary, some of them aren’t on hormones and and they want to keep their ovaries but they want the uterus in the service and the tubes out. So it’s, I think everything you just have to find out from the patients, I do have. Also these patients have had serious trauma as well. And I think it’s validating to them to be like, hey, you know, you need to go see physical therapy. And typically, in gyn surgery, one of the things that we say is like, you don’t do a hysterectomy on somebody to treat pain, right? Because that’s going to rev up all your pain fibers, it’s going to make your pain worse, it’s going to make it more difficult post op. But sometimes I do do a gender affirming hysterectomy and somebody that also has pelvic pain. And it’s just a great resource to have them in with physical therapy. Because again, like I can’t sing the praises enough, I think it’s so important to know your body to feel your body to touch your body. And for somebody to teach you how to do that is amazing.
32:38
Yeah, I agree with all that. And I appreciate so much that you Dr. Hire will very strongly distinguish between what surgery can do and what surgery cannot do and what surgery is likely to do and what surgery is not likely to do. So yes, for sure. Some of the time having hysterectomy can improve someone who also has pelvic pain can improve their pelvic pain. And also if the main reason people want to hysterectomies, it’s because of pelvic pain, it’s not the best treatment right for that. And so, and I also agree that there are so many different goals of people who are getting hysterectomy is and my like personal my personal professional opinion is that we don’t refer for pelvic physical therapy after hysterectomy is enough just more generally, regardless of someone’s gender identity. So I would love to see more recommendations after his dose because more referrals after his does, because I do think that we’re missing people who could have a better quality of life. And and again, not everyone’s going to choose to opt into that for a million reasons. But I would like to see broader referrals more generally.
33:42
Well, and we’ve said a couple of times, we’ve used the term trauma, trauma informed care. So Christina, can you just give the listeners a little bit more information on what we’re what we’re talking about when we’re saying trauma informed care? What does that mean?
34:01
Yeah, the the easiest definition I typically use is, trauma informed care is a commitment to continuing to try to reduce our own propensity for perpetuating harm. And what that means is just recognizing that we are we have the capability of harming people and doing harm to people, regardless of our good intentions. And so continuing to make conscious decisions over and over again to try and reduce that potential. So when we’re talking about working with trans women who are coming in for vaginal plasti, for example, it’s knowing some of the things that could that are more likely to contribute to trauma in that population. So things like being misgendered or miss named or miss pronoun. Things like knowing that some people may experience dysphoria or discomfort with certain parts of their body. And so, being conscientious about how we’re communicating about those body parts, checking in with patients or on what? What words feel affirming and good to them as opposed to feeling misgendering? Or, or othering? In some way? Those are things that I typically think of Dr. Higher, are there other things that immediately come to mind for you?
35:14
I think one of the things for me around trauma informed care is really trying to be the best advocate for the patients as well. And like, one experience that happens is people will be with their family member who’s misgendering them a spouse, an aunt, a mother, and I usually say, Oh, I’m sorry, am I using incorrect pronouns? Like, can we talk about this, because this is really awful what you’re doing to this human who is here, to have surgery, and they’ve been taking hormones, and they’ve done a legal name change and gender change, and you are here, calling that I mean, it’s it to me, it’s almost like they’re calling them a profanity, it’s so incredibly disrespectful, and I get really fired up. And I’m like, I just want you to know that, I hear what you’re saying. And if this in some people are like, No, it’s okay. And, you know, we have certainly have a representation of gender diverse folks in, in the celebrity population. And so some of them, you know, they choose the name and, you know, how they interact with their family that I, I think that’s my piece two is introducing myself and trying to be an advocate for them. And, and I say to them, like, I want you to feel safe. And if I say anything that makes you uncomfortable, I want you to tell me, because I won’t know if you don’t tell me. So I think that’s the other piece for me is like just really kind of like advocating for them and letting them know that I’m their advocate.
36:52
Well, I think one of the things that’s hard about trauma informed care is you can do things, the most trauma informed way and people and it can still be not the right thing for the person in front of you. And so there’s you I mean, I think it’s very obvious to this entire conversation, both view Doctor hire, and I like to continue to talk about like Lenny’s instances. And in these instances, because everyone’s different. Everyone’s relationship with their bodies, different with their gender identities different with their sex life is different. And so you, the thing that I think is so important about trauma informed care, and knowing and especially as we continue to push our professions forward and really hold ourselves and our colleagues to higher standards in regards to this is that you can do everything exactly right in by like trauma informed the trauma informed handbook, if that were a thing that existed, and it can still be the wrong thing for your patient, you can still perpetuate harm. And so keeping lines of communication open around, please tell me if I get this wrong, please tell me how is that landing for you please tell me if something I say doesn’t land. Or if I’m in the wrong, am I being very honest, and you know, coming to the patient experience with some amount of like, humility and recognition that the person in front of you your patient knows themselves better than you possibly could? And, and really remembering that I think is an is another big important part from informed care.
38:12
And I think our patients to so often will not correct and not, you know, do they just sit there and let the language go or let the wrong name or, and, and I want, I want to continue to try to be the advocate for them and make sure they know that they can correct it. And you know,
38:39
I know that’s something I appreciate so much about you.
38:43
So what advice do you have to health care providers who are getting into this space? Or who are having more patients come to them with these issues? What are some of your advice to help these health care providers provide the most sensitive, best care that they can to this population?
39:04
You need to really join to be a path. The you know, it’s a team of professionals that are doing this work. It’s very interdepartmental, from behavioral health, to education to physical therapy, I mean, it there’s so many resources there. So you need to find your tribe. Find your W path and continue to to learn and your program will grow because word of mouth is huge. And that’s how, you know patients find us. The I mean, the hospital doesn’t really advertise per se like hey, come get your vagina over here. But people talk and you know, once you start, you’re gonna see a lot, a lot of folks that need this care.
39:53
I think it’s really important to be very honest with yourself about what you’re own biases are and what your own competencies are. So I think it can be tempting to kind of lump affirming care into this like politically correct space, and people want to provide it because it’s the right thing to do, without taking the time to examine their own biases that are going to show up regardless of whether or not they intend for them to, and that can have such a huge impact. So trans patients in general, no, even if they have themselves not experienced medical trauma, know that medical trauma happens at a much higher incidence in the transgender population. And so it’s, they’re already very guarded, and rightfully so. And so it is way more harmful for a person to go to be hesitant about going to care and like doing it anyway. But knowing that it could go poorly, and having signs that it might go poorly, than if they go to a place that they assume to be safe, that they have like, let themselves trust that these people in this situation can be safe for them. And then to have it be harmful and damaging. So with that, being really honest about who you can help. And you know what feels good for you. I mean, we’re still having the conversation and pelvic floor physical therapy about whether or not we’re all seeing cisgender men. And so like being really honest about what about that is about anatomy, and like competency and dealing with specific types of anatomy. What of that is about dealing with our own, you know, trauma or bias or experiences and like, doing the work to know that about ourselves before we start to advertise for these types of programs, because there is such a huge need for it. And I do trauma informed care trainings, and I talked to lots of pelvic floor physical therapists, and like, not everyone currently is a safe person for trans and non binary people. And that that’s okay, we can’t, we are not all for everybody, we talk all the time about how, especially when in the private practice conversation around like finding patients, obviously, it’s different. If you’re in a public health care system, like, you got to make sure you have the competencies to see the patients that are coming, that are directed your way in the system. But in private practice, we’re already often talking about like, who are the right patients for us, can we find referrals for people that aren’t a good fit? And this I think I, I wish it weren’t this way, because I want there to be so much more care for so many of these folks. And I worry about the long term lasting damage of people, to people who, like trusted that they were going to get their needs met, and then were traumatized in the system. So that’s not like my favorite answer. But I think that that is that’s my advice for both providers who are interested in doing this work, as well as for patients who are looking for providers to do this work.
42:47
I think that is extremely wise advice. And I really appreciate you both coming on this podcast. And talking about this, I hope that our listeners have learned a lot about this population feel a little bit more comfortable talking about these issues, because we are going to be seeing patients, even if it’s not for pelvic floor physical therapy, we are seeing patients who are gender diverse, and are all types of genders. And we need to be able to provide good care to people. Or else if we feel like we can’t make sure that we have referrals that we can do that for. So I just want to thank you for both of you coming on tonight. So
43:29
it was a pleasure. I enjoy all the work that you all do. And I appreciate you. Well, we’re
43:35
thrilled that you’re such a big proponent of physical therapy. And before we close thing things out, I always ask everyone this last question for the podcast. And that’s knowing where you are now in your life and in your career. What advice would you give to your younger self, so it could be right out of medical school or
43:55
right out of PT school? So Christina, we’ll start with you. What advice would you give to your younger self,
44:05
if you don’t change your environment, it’ll change you. And so even if the job that you think you want isn’t immediately the job that is accessible to you, finding an environment that does foster the things that you’re interested in your own personal and professional growth, I think is hugely important.
44:24
Great and extra hire.
44:28
I would say the hard work is always worth it. You know, it definitely pays off a lot of times the easy road. Gosh, that looks really nice. But you know, if you pull it if you invest in yourself, there’s going to be amazing things that come so yeah, just keep going.
44:49
Yeah, that extra mile is rarely crowded, right? So true. Well, before we wrap things up, where can people find
44:57
you guys if I’m If they have questions, if you know they want to seek out your advice, Christina, you had mentioned Instagram. Go ahead, shoot. Yeah, shout out your business. Shout out your Instagram.
45:11
Yeah, Instagram is a great place to find me. It’s my first dot last name on Instagram. And yeah, if you reach out my DMs I read, I read all those things. Sometimes it takes me a little while, but I will get to it.
45:23
Cool. And Dr. Higher where can people find you?
45:27
I mean, just, I don’t know. I don’t have Instagram. I don’t have Twitter. I am like, just old and I need someone to educate me on this stuff. But you can email me I guess, or you’ll you’ll give my bio. So yeah. Or you know what, tell Christina. And she.
45:49
I was just gonna say, Jen, we’ll have we’ll have wine. And I’ll teach you about
45:54
Chris. Oh, my God, you need to do that. Yeah. Christina. Send it to Christina.
45:59
Yeah. And we’ll know where you work. Right. So so don’t worry about it. People know where you work and and we’ll have some links and things like that at the podcast website at podcast at healthy, wealthy smart.com. So if you didn’t get all of this information, you can go there. And you can read the full transcript of today’s conversation and get some helpful links. We’ll link to W path in US path as well. And any other pertinent links you guys think that we should have on there? We should have on there. We will have on there. So yeah, like Stephanie said, thank you both. Thank you to Christina. Dr. Hire Stephanie, thank you so much for bringing this topic up on the podcast. This was great. So thank you all so much.
46:46
Thank you. That was a pleasure.
46:48
Yeah, and thank you everyone for listening. Have a great couple of days and stay healthy, wealthy and smart.