Transgender & Sex-Change Surgeons, Marci Bowers, M.D. & Miroslav Djordjevic, M.D.

Hi, it's Doctor Robert Seikert. Welcome to a new episode of The Doctor Podcast Show. This is episode #18. Today we're going to be discussing a very important topic that's been in the news a lot in the last few years. It's transgender medicine and transgender surgery, and I'm pleased to have three of the world's leading experts today to discuss this topic. We have Doctor Marcy Bowers, who's appearing via Zoom all the way from California, where she is practices medicine and surgery there. Doctor Bowers was trained as a gynecologist but is now one of the world's leading transgender surgeons.

And Doctor Bowers has a unique perspective of this because she herself transitioned from male to female several decades ago, so she's one of the few transgender females who actually does the surgery. Also with us today in in alphabetical orders, Doctor Miroslav George Evic, who practices here in New York City at the Mount Sinai Medical Center and also practices at the University of Belgrade in Serbia in Europe. And Doctor George Evic has also done thousands of transgender surgeries and is one of the world's leading experts on this.

We also have with us Doctor John Stever, who's trained as a pediatrician and an adolescent medicine specialist, and his practice is focusing on treating adolescents who are interested in transitioning. He treats with various hormones and puberty blockers, and he will also be giving us lots of information about that. Thank you, everybody, for coming today. I'm going to start with Doctor Bauer and Doctor George Evic. Dr. Bauer, if you could just introduce yourself and give us some background about why you decided to specialize in transgender surgery.

Thank you, Robert for having me.

My name is Martha and introduced. I also have a faculty appointment at Nonstop Not in New York, where we began the nation's first comprehensive transgender surgical program. So I that's a very important program that was developed in 2016.

Jess Ting was Co founder and we're very proud of that program. I entered the field because at the in the early 2000s there were very few other surgeons working in this area of medicine. I recognized that the the group of need from the community, and I also realized that this is a phenomenon that has been here since the and since the ancient days of antiquity, and that this was a a medical need whose time had finally come all. Right. How about you, Doctor Dorjevic? How did you get interested in transgender surgery and what's your background in that?

Thank you again for your invitation. I started the almost 30 years ago with this program. It was a luck that I started to work with my mentor Professor Perovich at the early 90s and he was a pioneer of this type of surgery in Europe. So we developed our center in the Belgrade and started to develop new surgical techniques and to introduce new possibilities for our transgender population. And I'm continued to do on the same day until now. All right. And Doctor Seaver, could you explain to us what gender dysphoria is?

We hear that a lot about that. Can you define that and explain it? Well, gender dysphoria is basically the state where a person is upset or anxious or feeling bad about themselves, but a state of anxiety and and dislike of themselves due to the disconnect between how they perceive their gender and how society views their gender. So in sort of simplistic terms, when a boy feels trapped in a woman's body or vice versa. I see. All right. And why do you think that happens? What causes Gender dysphoria?

Well, I don't think we really know exactly why some people do not identify in their head with the gender that they are assigned to at birth. Spheres of possibility, gender expression, gender orientation, sexual orientation, sexual behavior, those are all independent variables that come together and make up who we are as sort of sexual beings in the very broad sense of the term. And so we really don't understand why some people identify as male, some people identify as female. Usually, statistically speaking, a baby that's born with, say, a penis is assigned male, identifies as male and usually grows up to be heterosexual, attracted to women.

But because all those variables are independent, you can have a lot of different variety of that, and that's just normal diversity within the natural world. I see. All right, Doctor Bowers, can you tell us what type of transgender surgeries you do? Do you operate on both males and females and and what do you do? And we operate on both trans feminine and trans masculine individuals doing performing genital confirmation. So in the in the, in the, in the female or trans feminine person, we perform aginoplasty, which is creation of a of a neo vagina from the existing male anatomy.

And conversely for the trans masculine individual, we perform genital confirmation surgery that would consist of what's called a metoidioplasty which is a which is basically literally the Latin derivative is becoming male and and in fact we take we take testosterone enlarged all of our tissues and we can create a quite realistic and functional neo phallus. It is smaller than the adult male in most cases but but there is some overlap within the lower limits of what what could be expected. By the way, this is meant for mature audiences.

If you're sensitive about this topic, please, you know, be careful about that. We're going to discuss some very explicit surgical sexual techniques. So please be advised, can you explain how you convert male genitalia into a female genitalia? Yes, this is a very well known technique that introduced in our practice more than 50 years. So we usually use tissue from the male genitalia and create all attributes of female genitalia like labias, clitoris. It's very sensitive than your vagina. There are many techniques how to do this and we have now three groups of these techniques.

One is to use just genital skin to create a neo vagina. In the last couple of years we started to do something that is very well known in that she's females who born without vagina and we started to use peritoneal segments, this is a part of the abdominal wall to create a new neo vagina. And finally, in the case that we don't have enough material, not not enough skin after radical circumcision or in a case is after failed primary surgery, we use some segments with the bowels. So different techniques with just one goal to give similar genitalias, like, you know, see women.

I see Doctor Bowers in the media. There's always discussion about top surgery. Can you explain what top surgery means to the audience? Well, there's trans masculine top surgery, which would be the removal of breast tissue with usually with nipple preservation, so that nipple is replaced as a free graft. But it depends on the type of technique that's used. Sometimes there's a minimal scar technique, almost like like liposuction for much of the breast tissue can be removed that way. But a lot of these depend on what type of breasts a person has for.

For trans feminine top surgery, that would consist of usually of breast augmentation and in a standard in standard fashion. Right now these patients are are treated with hormones right and and you treat with various hormones and and puberty blockers as well. Can you explain what you do well? Most of what I do is, is medical transitioning. And so depending upon the age of the patient and their involvement of their family and what the patient is interested in, that determines what combination of hormones one can use to induce a puberty that the patient desires.

So for somebody who's transitioning towards a feminine body, we use estrogen to build breast tissue to change body shape to a more hourglass shape. For those who are on the trans masculine spectrum, we use testosterone to create some facial and body hair, to create

a dropped voice, dropped vocal pitch, and to also stop the menstrual period. For people who are much younger, we often use puberty blockers to stop the current puberty progression, and that often gives people time and their families time to sort out how they want to proceed over the next few years. So it really is important to remember that there's no one way that this is done. This is always done, at least in adolescence, in context of what the patient is seeking and often involves. Especially if they're minors, it has to involve their parents as well.

Right. So here's a question for all three of you. What's the youngest age where you'll give patients either puberty blockers or a variety of hormones that that you mentioned? Well, I would say the youngest age is in, you know, in concordance with the guidelines which would say once somebody has started their pubertal sequence and so that will depend upon the age. So that could be 10, that could be 10, maybe 8 even. Maybe even 8, but that's not very common. But once they've started their pubertal sequence, that's when you block puberty with a medication that basically stops the signal from the brain down to the gonads and you basically use that medicine to stop puberty.

And that medicine has been around for a very long time. It's been used for other conditions like precocious puberty very successfully, is very powerful but has actually very minimal side effects and is really sort of a pause button on the puberty. You stop those medicines and those effects go go away and puberty progresses. What your next question is, is when do you start cross gender hormones? And that is a definite conversation with the patient, the family, maybe your mental health colleagues and the doctor.

And so there's no absolute recommendation. W Path, which Doctor Bowers is the head of, currently has guidelines on the use of cross gender hormones and so people will do crossgender hormones as young as 14, sometimes even younger depending upon the individual scenario. All. Right. What's the youngest patient that you'll operate on? Doctor George the. Youngest patient is a patient 18 year old. You know, we had a couple of candidates who who were very agreed to to start with a surgical transition and we waited until 18th birthday and then continued as a gift to these patients without surgical transition.

But in all of these cases, we had good letters of recommendation from our colleagues, psychiatrist, psychologist, social workers and endocrinologist who confirmed that we can do this without any possibility for maybe some mistake. Because don't forget we have a as our colleague told we have reversible transition that is using of hormones or pre puberto blockers. But if you're going to do a surgery, it is a final option and later is really very, very difficult to change something and to correct some mistakes.

Right, Doctor Barris, How about you? What's the youngest age that you operate on? Well, it's a shame that we're identifying age as a criteria because really what it should be is a combination of physical and social maturity. Dr. Bowers is is absolutely right. Yeah. In the perfect world, we would use a combination of emotional maturity, physical maturity and things like that. The difficulty is that that's. But it's not done commonly, it's not done. There's there's been a lot of blowback about about any sort of treatment and a lot of misconception and misinformation that surgeries are being performed in adolescence, which is simply not the standards of care, and it's not the truth.

So we. So was 18 year year cut off? And so, so that's really what we're looking for because undergoing surgery, obviously there's a lot at stake in a young person. We want to get it right. We don't let people regretting their decision, which is not common anyway and and not common in this population, but nonetheless we want to be perfect. No surgery is ever perfect, but we try to come as close as possible and so that's why we like to see both physical and mental maturity. Do you ever operate on someone under 18 without parental consent?

No, we always involve parents, we always do and we don't, we don't operate under under 18 anymore. We have done a handful of those cases in the past. They've been well received and and very appreciated by patients but but, but the standard is still age 18. It's just you know most would say that's a fairly arbitrary number because there certainly are people who are quite mature by the age of 17 even that would be capable of making that decision. But unfortunately, with the with the inflammatory backlash from some who would like to get rid of transgender persons altogether, the the the the idea of of proposing this at any other age besides 18 is just unthinkable at this time.

Do all your I want to ask all of you, do all your patients get a psychiatry consultation before they take the medications and or have the surgery? No, I would say that all of my patients have involvement with mental health specialists. So if somebody is a psychologist or even an experienced LCSW who's got the experience to make these evaluations around gender, gender dysphoria and things like that, that's sufficient. There certainly are psychiatrists who are not trained in this area, and I would not take their recommendations over someone who's got a lot of experience.

So it does not have to be a psychiatrist per SE, right? But I think all of us involve our mental health colleagues in the decision process, again with the patient, with their families, before any action is taken for minors. Right. So, Doctor George Evans, Yeah. The important corollary, if I can add, sure, sorry about that jump in. But the important corollary to that is that this is not to suggest that this is a psychological issue. Most people now really feel that this is some sort of you know, it's probably a biological hard wiring of the individual and but what we need the male health support for is to is to sort through confounding issues.

You know performance in school, psychosocial adjustment and many of the other stressors that affect people at any age but especially in the the teenage population where it can be really difficult even growing out without any diagnosis let alone gender dysphoria. So we want to make sure that everything else is is treated or under treatment or and and stable before or or at least in conjunction with ongoing treatment for the gender issues themselves. What about you, Doctor George? Epic. Do you get a psychiatric?

Yes, I agree with my colleagues completely and it is very important to have a professional who works with the transgender population. This professional can be psychologist, psychiatrist, mental health professional or something, but he has to be professional. He has to guarantee that this person is ready to go through the surgical transition. That is not easy, especially if you're going to create mail genitalias sometimes in a couple of surgical procedures and steps. So very, very important is to have a good created letters of recommendation and opinions what we can expect after surgery and also one.

Very important thing is to continue to work either mental health professional or. Just psychologists or social workers to continue to work with our candidates after surgery to explain what's happened and then to prevent some unsatisfactory outcomes from our candidates. Right. So Doctor Bowers, what percentage of patients that you operate on later ask for reversal of the surgery? It's mentioned that it's very difficult to do that complicated surgery, but what percentage want to change their mind later?

I mean, almost zero. I mean, I can think of three patients in the thousands. I've operated on my predecessor, Stanley Viber, who was in the Goodness Book of World Records for having done the most surgeries ever and I went past that in April. So we've seen a lot of patients and neither Doctor Byber's patients nor my own aside from just a handful of people. Statistically it might be as high as 1%, but it's really not much above that. And generally the reasons for someone stopping their treatment or you know, it isn't Even so much as as as wanting surgical reversal.

But even just stopping hormones is a is a is something that is considered and even that is remarkably rare. So this idea that people are, some like somehow going to miss their old gender, you know, they've grown up that way, you know, once they make that change and they're socially living as who they feel more comfortable being, it's rare that they can go back. What about you, Doctor George, Evic, what percentage of your patients want a reversal at some point? This is very interesting question, but I don't know which percent of my candidates why?

Because I don't know what's happened in the future with my candidates who had a surgery with me. But I will tell you something about our personal experience and our team Belgrade team in Serbia. We published the first article almost 7-8 years ago with the first seven K days who showed interest for reversal surgery, who came from abroad, from elsewhere and we finished these surgeries. Now we have a collection of more than 50 cases. It is very rare. I agree with Marcy that is very rare and then but we have to open our eyes to prevent this because one mistake for this person is 100% unsatisfactory result.

And this is like like a drama, you know, so you can follow also in the last couple years you can follow so huge discussion in United Kingdom about this about pre puberto block cares about wishes of the young population, 8 years, 10 year old teenagers who showed interest to be transgender because it is a popular maybe today. So we have to be very careful on this and there is a solution, thanks to God, thanks to our experience that we can reverse and do something similar. But my recommendation is to be very careful for all of the surgeons who are working today to be very careful when we accept the candidate for this type of surgery.

So Doctor Bowers mentioned it's it's less than 1% but you've been doing this for many years or decades. Is there any data on on the reversal if if you're doing all these cases? Thanks to God, we we were the central former Yugoslavia that was that was a country with more than 25 million people and we still cover all of the transgender population in in this area. And we performed the 1000, I think 200 cases in the last 30 years. Nobody showed a regret, but I'm not sure that some of them maybe leave and then.

Obviously, the ones you know about, you don't know if they go back to another country, they may not follow up with you. But of the ones that you followed either in New York or in Serbia, what's the percentage of reversal? No, according to my work it is very. Very bad. I told you we have now 52 cases that we did the reversal in the last 10 years, you know, So it is almost, almost not to be compared this with the number of procedures that we did. Right. Doctor Seaver, you mentioned earlier that these medications, the blockers, the puberty blockers and the hormones don't seem to have side effects.

There's some literature that indicates they may have side effects such as osteoporosis and and other no. No, I I no. All medicines as you know have side effects, right? Right. They for the power of the puberty blockers, they have very few side effects, but there are limits to them. You cannot use a puberty blocker for more than two, maybe three years because there is concern about bone health and the acquisition of calcium into bones. And that if somebody is on a puberty blocker for too long without adding in hormones that they are set up for later in life of having osteoporosis and things like that.

There's some question about mental health development, but it's very subtle and I've not seen any of that. Many of our kids often struggle because of societal pressures from depression and anxiety. But I've not seen any study that said that puberty blockers add to that. And in fact there are studies looking at quality of life that when you talk about puberty blockers and then moving on to if that's appropriate for that individual moving on to cross gender hormones that most of those people feel like their quality of life has just improved incredibly.

And so even the people who in my area, so that's more medical, even those people who have said I don't want to do this anymore, usually it is not because they feel like they are trans that they are not transgender. It does not they do not reverse how they see themselves but usually it's from other reasons. I've I'm tired of taking needles. I'm living in a place that is just so hard to do this. I don't want to do this right now. None of them have ever said I no longer feel transgender. So that reversal is very, very rare.

Some of the original data was very flawed around that, and I think the more modern studies clearly demonstrate that. You know, especially as you get older, 16 and above, the percentage of people who reverse are extremely less than 1%. There's also seems to be some debate about the incidence of depression in people who go on to, you know, convert or become transgender as compared to if they didn't. There's also some literature recently about increased suicide rate in in patients who've had transgender medications and and transgender surgery.

What? What's the data on that? Well, I think, you know, you have to remember that many of these individuals are under a tremendous amount of stress from society. And in some sense it's that. It's that, you know, Chinese water torture, a single drop on the head every 10 seconds when somebody misgenders you, every single time you go into a store or on a bus and they say the wrong gender, the wrong pronouns, that has a little bit of effect on your mental health. And so we do see with these kids, especially in families where the parents are rejecting of this, we do see higher rates of anxiety, depression, self harm, suicide attempts, suicide completions.

So we know that there's a lot of things going on. But when you subtract out those confounding variables, the mental health stuff of our kids is really quite remarkable. And especially if you start them on the hormones that they are seeking, many of their mental health issues improve. Now these are not psychiatrically active medicines. And so I always tell my patients, do not stop therapy. If you are on an antidepressant, stay on that. You should only stop that when you and your psychiatrist feel that you've gotten better or you're no longer needing it.

But just because you started one of one of my medicines does not mean you should stop your antidepressants or things like that. So it's really important to to make a distinction. We are very clear. The data is very clear that gender dysphoria per southeast is not the problem. It's the society at which our kids live in and the constant pressure that they are under that causes the anxiety, the depression and all that stuff. All right, Doctor Barris, are you aware of any of your patients becoming suicidal or committing suicide?

And doctor. I mean, you seem to be passing along a false narrative. And well, I'm I'm just asking because you have the experience. Suicide is a is a obviously a great concern mental health among particularly among adolescents and there's no question that that as mentioned being transgender and dealing with a society that has a an inclination and in many cases an acceleration of anti transgender attitudes that that puts pressure on an on an individual. But if you again if you if you take out the confounding you take out all of that you just you simply don't see people you see you see people psychosocial lives improve and this has been looked at over 50 years so this isn't something that's new.

This is known as Swedish study of 50 years of evidence has shown that not only are people's legs improved and that regret has declined, but that it's done, it's gone down over the decades. So, So that's just simply a false narrative that's put up by gender skeptics and I'd really like to stamp that out once and for all. There's no question that gender affirming treatment is beneficial and but it's a it's a it is a vulnerable population. And if it's if, if, if people are are treated poorly, you know it, it puts pressure on that individual and their support, right?

And don't forget that when you look at rates of regret of common surgical procedures, transgender or gender affirming procedures are much lower than similar procedures done in cisgendered individuals. So we don't always we almost never talk about the cisgendered woman who has an augmentation and then regrets it later. We seem to focus a lot on the transgender woman who has something and then regrets it. But in fact, if you look at those studies and one came out, oh, six months ago or so, I'd have to go find it.

The regret rate for these gender affirming surgeries is remarkably low compared to similar surgeries done on cisgendered individuals. Incredibly low. Yeah, Google, just Google famous actresses who have regret about breast augmentation. It's a rate far higher than we ever see for our trans populations. And just start there. Look at regret after knee replacement and you'll find regret rates far higher than what we see. And yet people focus on trans surgeries and and try to try to inflate that as a narrative.

It's just simply simply not right. Thank you for having me. I must excuse myself. I'm. So sorry, no problem. Thanks very much for coming today. We really appreciate your taking your time. Thank you, Doctor George. Evik, what's your feeling about this issue? About the. No, I don't have exact date about suicides in a group of transgenders who had any contact with me, not just surgical but any contact and then but this is a very good issue that we discussed already that nobody is not sure is this regret comes from bad surgical outcome or it is a some psychological psychiatric problem or some comorbidity.

So we have to be very, very focused on the main problem and then to try to help to to society, to help to transgender population who really needs some additional support after after surgery and then and I would like. To to to. Make a short discussion that I'm not agree completely with Marcy. Marcy is not here, but she knows my my discussions also. And with the colleague, Why? Because if you're going to discuss about regret after breast augmentation, we cannot compare this with the removal of the uterus, with the removal of the testicles, the removal of the penis.

It is not comparable, that's correct. So I agree that is very rare thanks to good thanks to good treatment. And then, but what is the problem? Problem is that if you compare the situation 10 years ago here in United States, we had just five centers who performed transgender surgery. Now we have more than 200. So with the growth of the number of the candidates, with the growth of the number of the transgender service, then possibility to make some bad result and then is higher. This is statistic.

So now you can compare what's happened for example in India, in China, 1.4 zillion people, billion people and nobody knows what's happened because they're coming for something and then disappear because country is too huge and that. So this is one of the of the main issues that we have to take in our mind, not just to treat our patient who is with us now in this room not to open. Our eyes and to try to help to society. It is international thing and we have to work together to improve our life over the world because.

Nobody knows how many. How much is a real incidence of transgender persons who were born today, you know? Right. I'm glad you brought up that having a breast surgery change or reversal is, is relatively minor comparing to having genital surgery which is major, major surgery. So I would agree with you and and disagree with Doctor Bowers on that you know. No Marcy. Marcy means Marcy is on the same side like me. But maybe she didn't have enough time to explain this. But it is a really very rare. Her conclusion was that it is a very rare.

But I would like to repeat, if you have one unsatisfied who is regret, it is a huge problem for him and we as a part of society have to work together to help him or her, right? So for this reason is much. Better to prevent this mistake. If it is possible of course, right? I also don't think the knee surgery and allergy is a great one because most people have knee surgery because they're in severe pain or or disabled. But moving on, what's the recovery like from these surgeries, both males and females?

I would assume it's it's complicated and a long. Yes, now, now, now the the the techniques that we developed in last 1520 years are now very safe and thanks to good technology and improvements we have today a very safe surgeries. Now for example male to female is around 4 hours. We are going to use our robots to create something from abdomen to make a better near vagina or in opposite if you're going to create a male genitalias. This technique that Marci told about metoidioplasty is a very nice technique.

Today we finished this technique in less than two hours and create completely new male genitalias from female genitalias, thanks to our knowledge in Embryology. Because we're starting together in the first couple weeks of our, you know, of our Embryology with the same genitalias you know. And then in one moment someone is going to be male, another one to be female. So base is the same and we are going to use this and to create and to correct these genitalias according to the patient which with a very nice techniques.

Right. I'm an ophthalmologist, so I do different types of surgeries. I can understand how you convert a male into a female, but how do you create a penis surgically from female genitalia? Today we have a techniques that we group in a phalloplasty surgery. This is a surgery that we are going to use extra genital tissue to create neophilus. The gold standard is to use part of the skin with the subcutaneous tissue for arm. There are another techniques, for example anterior tight phalloplasty or abdominal parts, abdominal skin with the fatty tissue.

So you take tissues from other parts of the body, yes, and then create the real rejection issues or problems with that. No rejection. Because if you use the tissue from our candidate, you know and you use a very popular and very good microvascular techniques to give almost similar genitalis. But it is not never like in a in a tease males in a male to female, it's much better. I can tell you something, one of one of the candidates who passed the surgery and who got the female genitalia visiting gynecologist who never discovered after many visits, never discovered that this person was a was a male before transition, you know.

So this is today the really very very nice with the perfect function of the aesthetical result. But in opposite, we have to work more to give a better similarity between genitalia and better function. Avoiding an erection. Right. So you mentioned the surgery is very safe. What is the complication rate, serious complication rate? And do you get sued a lot for malpractice? Yes, of course we can discuss about complication rate just according to our evidence based medicine. So we can compare results just in the published papers in the published results.

But today we have a plenty of centers who never publish their results. So I can discuss about results with my team. We we have a really very low complication rate between 5 and 10% that is a perfect today. It was 3035 percent 20 years ago. So I cannot I cannot discuss about another rate. But good developed centers who works more than 10 years and who perform minimum two to three transgender surgeries per week are a good centers with a low rate of complication. What about malpractice issue? Do you get sued a lot for malpractice from people who are dissatisfied with the results?

Absolutely, absolutely. But we have to be very careful and then to give our comments about bad result, about malpractice. Don't forget good result is not the result. If me as a surgeon conclude, oh, I did this perfect good result is if I hear from my candidate that he or she is satisfied with the new genitals, this would result for me. But everybody the service are a little bit different, you know and we would like to put our US to be in the first position always and then but we have to be more realistic and to accept satisfaction from our patients, from our candidates and then to discuss our surgical results and our success rate.

Right. One of the criticisms, criticisms that are around from people who are against transgender surgery and and medicine is that both hospitals and doctors are making a huge amount of money from this. What? What's your comments on that? Well, I can't really speak about the surgical programs and the finances of the surgical programs. The medical programs simply do not. They're not money makers for any hospital that I know of. Like most programs in medicine, it's just they don't. They do not make a lot of money.

These medicines, for the most part, with the exception of the puberty blockers, are not that expensive. So the drug companies are not making killing on providing testosterone or estrogen. There are some minor exceptions to that depending upon the formulation that you use. But overall those are medicines that are very, quite cheap. The puberty blockers are very expensive and you know, we could get into a discussion about why that is and and the cost of medicines in the United States. But I don't believe that anyone is making a ton of money off of of these medicines, and I know of no no medical program that is making money off of this.

I see. What about the surgical component? The the same criticism exists that surgeons charge huge amounts of money for this. The insurance companies are paying it. The hospitals are making a lot of money. Is that a true criticism or not it? Depends. It depends on countries. If you compare countries over the world, If you compare for example good developed countries, there is a difference. For example, I think the the most expensive is to have this type of surgery in the United States. Now thanks to God and thanks to our thanks to situation, our clients are covered by insurance.

For example, I had the plenty of the patients from United States to came to Belgrade to Serbia to have a surgery. And then when we saw that it's possible to do in United States and to be covered by insurance, I joined Mount Sinai immediately and started to work here to help to these people here not to travel. And then because surgery in my country is not expensive. It's not expensive comparing with good developed countries, but it is expensive, not expensive if we discuss about the level of the money that.

What does it cost in Serbia? In Serbia is Serbia is between 10 and 20 thousand U.S. dollars for everything depends on type of procedure and then. You know what about here? I don't exactly you have you have to track maybe in hospitals and then but I don't know exactly but according to reports of my clients it is 5-6 times more than than than. For example in my country the same is for example. Like a hundred $120,000. I think so and. Do most insurance companies now cover the surgery? I think so. I think so.

And do they? Cover the the medical treatment for these patients. With some work, most commercial insurances and many of the Medicaid and I assume Medicare programs will cover the medicines. It's often a process where you have to write letters and say why this medicine is needed. But again, it's many of these medicines. If you go on to some of these programs like good RX or things like that, you can get really quite excellent deals on the medications per Southeast. That's the estrogens and testosterone which have been around a long time.

But what about the puberty blockers? Those are still very expensive. What's very expensive? I have seen insurance companies say that they cost about $1500 a pop. I've seen people, that's per dose. And how often do they get those that I've? Also seen where people have pharmacies have sold them retail for close to $5000, so the price to the consumer can vary a lot.

Those medicines, depending upon the formulation, can either be once a month or up to every six months. And there is an implant that can last up to 2-3 years. But the implant is expensive because you need to have a surgeon place it and then remove it, and so there's some additional cost there. I see now you operate both in in Serbia and here. How's it different? What's what's the difference between doing your surgeries in Serbia and doing them in the United States? It is the. Same for me it's the same.

I have fantastic conditions here. I developed my center in the Belgrade and we covered also all aspects in the Belgrade. It's very safe with the modern technology. And then so for example, we have every year more than 30 persons, 30 doctors who are coming to learn to solve to. Observe our surgeries. To work with us and to develop, to develop experience. Also I started to work in United Kingdom because it was for me unbelievable data that today under the NHS in United Kingdom we have today more than 8000 candidates who are waiting for surgery And the waiting, the waiting time is between 5 and 10 years.

So it was a reason that that I that I accepted invitation to join the center in trails at Westminster Hospital in London and to develop a new team and teams who will started to work and then to help with this very huge population. Of course I asked my my partners here at Mount Sinai for license and then due to some you know, conflict of interest and then and they agreed with me and gave me support to join London hospital and to try to help on this part also. Wouldn't it be less expensive for somebody from USA to to go to Serbia?

Cuz the airfare would wouldn't be that expensive And it sounds like it's it's much less expensive to do the surgery there and you're the same surgeon regardless of where you are with the same good facilities. So why don't people do that? Absolutely. But the Venice started to work here in United States. But I would like to tell you I I did the first trans render surgery with my credentials in 2009 in Detroit receiving hospital that was a a a beginning. You know the truth of the of of this hospital is now one of the leading trans render surgeons in in Texas.

You know his name is Richardson Pucci very well known reconstructive urologies. So between 2009 and 2016, I had the plenty of the candidates from United States who didn't have possibility to do this surgery here and to pay at the same level than in my country. Another issue is that I try to do surgery in one stage. So I never split the surgery in 345 stages because it is cheaper for my clients. There is only one recovery period and then so I think this is one of the reasons that our techniques and our procedures that we promoted through the world in the last 30 years are the reason that we have a plenty of candidates from all parts of the world and also almost all transgender solutions who are going to visit us and to change experience with us all.

Right. Do you think the increased volume of surgery and interest in this has always been around, but it's been suppressed somehow and people didn't talk about it because seems to be much more popular in the last few years. Previously you'd hear occasional cases of it. Why is that? I think a lot of it has to do with awareness and knowledge. Until people started to really talk about gender as distinct from a person's body, you know gender identity as being different than their body and being different than sexual orientation being different than behavior.

Until you have that language and that ability to think about it, you don't really. You'd have to be pretty savvy to understand that there's a difference. And I think now that we do talk about the differences between gender identity and bodies and sexual orientation, you have people who understand that, oh, the reason I like boys is not because I'm a gay man. It's because I'm a woman and I'm a heterosexual woman. I like men. And so people can really start to think about this. And that has then also led to people being aware that it's not all about the binary, that, you know, just like hair color is on a continuum, height is on a continuum.

All these sorts of things, gender identity, sexual orientation can be on a continuum And so we're starting to see people who do not identify as male or female but something in between or something not on that spectrum, a non binary person. And that's sort of some of the cutting edge stuff that we're talking about right now. Right now, again, we're often dealing, I'm often dealing with teenagers and their thoughts are evolving and growing. And so somebody who may identify as non binary now may continue that non binary identity into adulthood or they may with further growth and development of their brain may settle into a more binary role.

But I think what we're seeing to answer your question is that there's just more discussion about it and more exploration and so people can understand that. That might be why I feel this way. What about the critics of this who claim that the reason teenagers are becoming more interested in this is that it's it's kind of a fad through TikTok and other social media that they're being influenced by this and and later they'll kind of change their mind or be sorry. What what do you think about this this fad explanation?

I don't think this is a fad. People may desire to play with gender expression, and that's been around forever. We've all known this since we were all in high school. There were people who just like to play with gender expression. Some people may be taking that a little bit farther and saying it's not just expression, it's gender identity. But then This is why we have processes in place so that 15 year old can't just walk into a clinic and say I want hormones and walk out with it. We involve their parents, we involve them, we involve the doctors, we involve the mental health experts.

So it's it's a process. And the goal of that is not to limit people, but to really make sure that they're thinking is clear and that it is not a fad or something they're doing just to piss their parents off or they're doing it because their friend is this way. That's that's the the importance of the evaluation process. So. What's the quickest you've ever recommended a patient for surgery from the time they first appear to your office and and desire having a sex change operation? You said it's a process.

How? How long is that? Process well. I never recommend anyone for surgery. That is a decision that they can make on their own, that they will decide if that is for them, I will help them explore that someone may say, I want to have a penis and I will say, well this is what I know about it. This is the the surgeons, this is the recovery, these are the potential complications. So I never push someone to have a surgery. They're coming to me and saying help me make this decision. The so in that sense there is no minimal time cuz many of them have made that decision way before they've met me.

I see now how fast one can get a surgery depends upon their circumstances. I think the best programs have waiting lists up to a year. There are private surgeons who will do it much faster than that, but that's not available to everybody. And again, you want to go to a center that has a lot of experience. And so when people say, well, I could go to this private Doctor Who will do it in two months versus Mount Sinai or one of the major centers in New York. But there's a waiting list. I usually point them to the center with the most experience.

I see Doctor Georgievic, I know you're involved in some research of doing surgery simultaneously on on male and female at the same time. So you're you're taking the genitalia from male, putting in a female, and then doing the opposite, female genitalia in a male. So this is this is this is my main research now it was on my vision and my dream 1015 years ago because I calculated that with the too many male and female organs that they are going to remove and put in the garbage. I I concluded that it will be may be useful to use this very healthy organs because today transgender population average is approximately 20 to 23 year.

So we have a completely healthy genital organs and who is going to give us a license to cut this and to put to be not to use for someone who really needs for this. So it was a basic for my research and now we are in a final step. We are working in my forensic institute, my University of Belgrade, and we now try to develop techniques how to use genitalias from the person who is going to 1 gender and then to to to transplant to another. Person who are looking. For this and as as a result of this, I will tell you something that is very well known now in the in the literature in the world.

We did the we did the three genital organ transplantations. First one was a uterus transplant in that is female. In the monozygotic twins it was 11th. In the in the world at this moment it was a 2017. Then in 2019 we did the 2nd testicular transplant. First one was in Texas the late 70s and last year we did the ovarian transplant. And from all of these three transplantations we had a delivery that is very good result. So right final approach will be to transfer the penis. This is my main goal goal of my career and I hope that this future started yesterday.

Right now you're a urologist by training. Do you work with other surgeons like vascular surgeons to connect the blood vessels and neurosurgeons to connect the nerve supply from the donor to the host? How do you do that? So today we have today we have a possibility to create a teams and then to involve different specialties. But I started, I told you 30 years ago and I started to work this and I was alone and I developed my skills to do microvascular, to do nerve junction and then, so today I have all of these skills to do myself.

But for this? Project I have a very nice teams of transplant surgeons who are going to work with me and who will help to do this revolutionary. Project. Now you're transplanting tissue from one person to another, so there's going to be a rejection of that tissue by the host, the person who receives the organ. How do you deal with that? This is a bioethical issue. Why? Because we cannot recommend for example a genital organ transplantation in a person's and then to send this person under the very strong immunosuppressive therapy because this therapy has a side effects that will be very very problematic.

So we are here as a surgeons to develop a techniques. I did the three transplantations uterus, ovary and testicle in monozygotic twins. There was no necessary to be under immunosuppression. They have the same I was. Happy but now? But they have the same DNA, so there's no problem. Same rejection. Same genetic material but. How can you transplant a penis from one person to another and they don't reject? It I hope, I hope that I will find for example couple from the same family who are very, who are very compatible.

Or also we have a plenty of the persons who had some transplantation before like kidney transplantation or liver transportation or something like this and who are still on even suppressive therapy. If he finds someone who is a transgender, he will be a fantastic candidate to be a recipient. But for donors it is very simple because we have a plenty of possible donors for this. Very interesting. In the future, how do you, Doctor Siebert, how do you deal with parents who are against this completely?

Because that's obviously news a lot. Parents who are against their child transitioning, How? How do you deal with that? How do you deal with the patient and the parents? Well, I mean I think it's it's really important to remember that in this country, in our society, you know, the parents really do have the final say about the care that their children receive. So if I do meet a family that the child is very interested in transitioning or I meet a family where one parent would like to and is supportive and the other one would not like to and is not supportive, if there is a question about that, we cannot move forward.

I can talk to the patient. I can talk to their parents. I can erase any misconceptions. There may be things that they've heard that are not true, you know, trying to clear up any misconceptions. But fundamentally if a parent says I do not want this for my child, then my hands are tied and the most I can offer the child and the family is just ongoing support. So that and I will be very honest with some of these families, your child is 17 1/2. In six months they will be considered an adult and you will lose that control.

I always would like even an older teenager to be supported by their family. I would never want to start somebody on a transition and then have them be kicked out of their home. So we have to make sure our mental health colleagues are present and in place so that we have plans on what to do if somebody is kicked out of their home or rejected by their family. But it's it's a really tough thing when either one or both parents says no, I do not want any of this. I have to respect that. There's just simply no way under any existing laws right now that allows me to do something like that to a minor without parental permission.

Right. That's in New York State. I understand there's some states now that are trying to change the law so that minors can do this without parental consent. Maybe I don't know the specifics. Many states, most states have laws allowing minors to have access to certain medical conditions. So evaluation for pregnancy a pregnancy related care evaluation and treatment of STD's is a common thing that minors can self consent for. Many states allow for minors to self consent for evaluation and treatment of mental health issues as well.

So there are some things that minors can consent for, but gender care is not really one of them. And I don't know of a single state that has passed the law saying specifically with regard to gender care, gender affirming care, that so that a minor can self consent. Now this isn't to say that I don't support the kid, I don't support the child and say, you know, hey, you know, you're an adolescent, so you still need medical care. You need, you know, vaccines in your physicals and you need support by mental health professionals because your parents and you don't see eye to eye.

So there's going to be some conflict. And so let's get you involved in some counseling and explore some of these issues. So I am very supportive of them. I'm just not able to provide hormones and of course, I'm not a surgeon, so I don't do surgery. But yeah, those are tough scenarios. Right. Do you see conflicts like that? For example, a 19 year old who wants to have this done and the parents are totally against it? What do you do in that situation? It was a very often situation in the past, thanks to better education and also thanks to media that opened the society about the possible problems in transgender persons who are looking for help.

We have today much, much better situation. But I found a couple of cases

that developed the worst problems and in all of these cases parents were doctors, never accepted. You know daughter or son is going to be something different, you know. So I worked, I work like like a mental health professional and also tried to explain this and then so we finished this very successfully. But you can expect this, all this, you can expect all this. And also I would like to point out that in the last couple years we have a very low rate of the candidates who are coming without the parents, young candidates.

Before that this this population left the home, started to to live alone, try to organize money for surgery to do some crime or something like this without parents. But now it is almost normal and usual to have a parents to stay with you and you're going to discuss about your surgical transition. I'm very happy. Why do you think doctor parents are against this? I don't know. This is a personal feeling, you know, So I'm a doctor also does I train myself to accept my children to be the persons as they as they feel, you know.

So I'm here to support not possible to change a decision, you know, so just to be supportive. All right. Well, this has been a very fascinating, educational and informative discussion. We've discussed all all the aspects of this transgender medicine and surgery. I appreciate very much you both coming in today and Doctor Bowers, who had to leave early. Thank you very much. Thank you. Thank you. All right.

In this episode