Plastic surgery and the ability to enact surgical justice

I felt out of place. It wasn’t the dull yellow flickering fluorescence of the hospital lights greeting me well before dawn. It wasn’t the photos of world-renowned surgeons lining the hallways as if monitoring my every step, or that some of those same surgeons were close by rounding on patients. It wasn’t the sea of dark suits swarming around me vying for a prestigious residency position. It was something far more profound — I had a secret.

I still can’t articulate my feelings: a mixture of shame, anger, and worry in addition to the anxiety of my approaching interview. I repeatedly crossed and uncrossed my legs, perspired to the extent that my new white dress shirt could never be worn again without a sport coat, and spun my pen around my thumb to alleviate my nervous energy. Though these interviews would determine my fate in the competitive and exciting field of plastic surgery, my uneasiness derived from wanting to say to the plastic surgeons interviewing me for residency, “I want to do gender affirming surgery.” I wanted this secret to come out, to slip from my lips during the barrage of questions about my qualifications.

Yet, I feared that talking about working with the transgender community would impact my candidacy. Even though I could quote various studies showing transgender individuals are some of the most marginalized people in our health care system, I couldn’t predict the response of the established surgeons who would be deciding my future within their field. A response my mentors had warned me they thought would be unfavorable.

I grew up in a neighborhood where my friends were mainly immigrants, and their families, unable to obtain health insurance, had never heard of a primary care provider. Seeing those same friends quit middle or high school and take sometimes legal, but mainly illegal, jobs to cover costs of ill family members, made me want to enter medicine to change health care delivery, to be an advocate for those marginalized. When I decided to pursue surgery, my goals within medicine were unaltered. Plastic surgery fit well with what I called “surgical justice,” or addressing social justice issues through technical surgical interventions. Working with children with cleft lips and palates or veterans who had lost limbs or transgender patients who needed gender affirming surgery were all in a days work for a “surgical justice” minded plastic surgeon, and I was excited about this field.

However, I was naïve about the stigma associated with gender related surgery. After hearing a Stanford University tenured professor tell his story of transition in a Queer Health and Medicine class and learning about care for transgender patients, I told my mentors in plastic surgery I wanted to do bottom surgery — create genitalia. It encompassed all aspects I sought in a career in medicine: technically difficult surgeries, outcomes that affected physical and mental well-being, numerous unanswered research questions, and the ability to enact “surgical justice.”

I vividly remember stating my interest in doing gender surgery during a case of breast reconstruction. There was a pause in the operation, and the eyes of the surgeons shifted from the pristinely carved abdomen to me. The normal cues of expression hidden behind their masks, I silently awaited a response. An eventual, if not entirely reassuring, “OK, interesting,” from the attending surgeon signaled the residents to continue their dissection. I had been fortunate enough to be at a medical school, which previously had a pioneering gender center with a very progressive community. My mentors and colleagues embraced my interest, but throughout training I was warned about being too forthright to others about pursuing a career focused on transgender care.

A former plastic surgery chief resident, who works in the field of gender affirming surgery, reiterated the prejudice he experienced when he told another surgeon of his own interest. They were just opening the skull of the patient in a neurosurgery case and the neurosurgeon asked, “What’re your interests in plastic surgery?” Once he stated he was going to do gender affirming surgery, the reply was swift and harsh: “Your parents must be ashamed.” I imagine the usual friendly banter was no longer possible during the case; there was nothing to distract from the quiet sound of scalpel opening skin. He rarely brought up his future plans in the operating room after this incident.

When I heard this story, I felt ashamed that this now pioneering surgeon in the field of transgender health had to hide his reasons for pursuing plastic and reconstructive surgery. I didn’t want to have to keep a secret as he had to, but when I energetically spoke of penile inversions, and taking skin and bone from the leg to create a phallus, I was told repeatedly to be circumspect about such topics. Was mentioning the complexities of transferring a piece of colon to create a vaginal canal and the psychological benefits of these procedures to transgender patients worth potentially not ever becoming a resident in plastic surgery? “Anything that makes you look ‘weird’ will be held against you in the pool of the most elite candidates in medical school,” one of my mentors told me.

When I sat down to write my personal statement for residency, I was unable to work with my stream of consciousness, my normal first draft. I used creative writing as an outlet during medical school, but here I had to be more than just creative. I had to conceal my main reason for wanting to become a plastic and reconstructive surgeon. I struggled to use words to cast a veil over what I truly wanted to say; still, a small paragraph touching on the complex care of transgender patients made it into my statement. I submitted my application feeling uneasy and doubtful of my pursuits. In fact, I also applied in internal medicine, as I knew colleagues in medicine who had made profound impacts on gender-related care and spoke freely on the topic.

During interviews, I kept my interest quiet, talking about gender affirming surgery only as an example of “surgical justice.” I didn’t feel genuine, I felt like an outcast. In our current era of healthcare innovation, it was amazing to me that I had to seemingly neglect the population I wanted to serve. I almost withdrew my application from plastic surgery residency. Luckily, an endocrinologist interviewing me for internal medicine residency said, after hearing the story of my plastic surgery background, “We need surgeons like you.”

Future medical providers should not have to hide their interests. Our patients want to be recognized for the person they are and aspire to be: they should demand and deserve respectful, genuine relationships.  Medicine should treat our students and colleagues with the same respect; we need providers willing to embrace diversity, to confirm our commitment to all people.

Shane D. Morrison is a plastic surgeon.

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