The “How Does a Gender-Reassignment Surgeon Work?” Transcript

Read what Dr. Jess Ting had to say about his job at Mount Sinai Hospital’s Center for Transgender Medicine and Surgery.

Dr. Jess Ting.
Dr. Jess Ting
Photo illustration by Slate. Images by Thinkstock and Mount Sinai Health System.

This is a transcript of the Dec. 10 edition of Working. These transcripts are lightly edited and may contain errors. For the definitive record, consult the podcast.

The following podcast contains explicit language.

Jacob Brogan: Youre listening to Working, the podcast of what people do all day. Im Jacob Brogan. This season on Working, were talking to individuals whose jobs touch on aspects of LGBTQ life. Not everyone whos trans chooses to have gender-reassignment surgery, but many of those who do want that surgery are unable to have the procedures they desire. Sometimes thats for insurance reasons, and sometimes its because there just arent enough surgeons to go around. For this weeks episode, we talk to someone whos trying to change some of that.

Dr. Jess Ting is a gender-reassignment surgeon at Mount Sinai Hospitals Center for Transgender Medicine and Surgery. Hes also working to train a new generation of surgeons through the hospitals fellowship program. Among other things, in this episode he tells a little about how he ended up working in this area and talks about the procedures that hes helped pioneer. By way of warning, I should also say that there are some pretty graphic descriptions of surgery in this episode, so if youre squeamish, this may not be the one for you, but we think its super interesting and important.

What is your name and what do you do?

Dr. Jess Ting: My name is Jess Ting, and I am a plastic surgeon that specializes in transgender surgery.

Brogan: What does that entail, exactly? What kind of surgeries do you conduct? What kind of surgeries do you specialize in?

Ting: Today, for example, I did a gender-reassignment surgery. All of the surgeries that I do right now consist of gender-affirming surgeries where we take someone from one physical state, a gender which they were assigned at birth, and convert their physical state to a gender which is more in line with their internal gender identity. Say you were assigned male at birth, but you are female internally. We can take your physical body and make you a female.

Brogan: Well get into the details of your day in a minute, I think, but can you say a little now about what these surgeries actually involve? Practically speaking, what are you doing with the bodies or the patients that you work with?

Ting: We work in either direction. Say if youre a trans woman, you were assigned male at birth and you have male genitalia, you have a penis and scrotum, and we can take those male parts and make them into female parts. We take the penis and scrotum and make that into a vagina and clitoris.

Brogan: How many of these surgeries do you conduct a year?

Ting: We just had a meeting this morning. We have these monthly meetings and they told me that we have done 350 surgeries since March of 2016.

Brogan: Thats at Mount Sinai, where you work?

Ting: That is at Mount Sinai Hospital, where I work.

Brogan: How did you end up at a point in your career where you were working on transgender health issues specifically? Im guessing that thats not what you were originally trained primarily to do, right?

Ting: No. To be perfectly honest, when we started this program at the end of 2015, I had never really even met a transgender person. I didnt even know what that meant. I was a plastic surgeon, I had a busy practice consisting of mostly breast reconstruction after mastectomy for breast cancer. Mount Sinai, for a variety of reasons that we can talk about later, decided to start the first transgender surgery program in New York City. If you can believe it, in a city this large with this many people, there was no place where you could have gender-affirming bottom surgery.

Brogan: Did you have to retrain yourself? Did you have to rethink the background that you had in order to start conducting these surgeries?

Ting: Yeah. It was pretty daunting, because these surgeries are unlike any others. The surgery I did today, its a vaginoplasty. Its a combination of OB-GYN, urology, plastic surgery. Its really a unique meshing of techniques from different specialties that just doesnt exist in any other field of surgery. When we decided to do this, I had to go back and relearn. That involved traveling around the world to learn from the handful of people who do these operations.

Brogan: How many folks are there doing these sorts of surgeries around the world today? Do you have a sense of those kind of figures?

Ting: The bottom surgery, the genital-reassignment surgery, I would say there may be 20 to 30.

Brogan: Around the world?

Ting: Around the world. Now that number is exploding, because as you know, theres a tremendous increase in the interest, tremendous increase in the number of programs and the number of people who are seeking surgery, and in a number of medical centers around the world that are trying to do these operations.

Brogan: You said that when you first got into this that you had little sense of what trans life, trans experience entailed. Has that changed? Did you have to delve into that world, that discourse, as you started training yourself toward being able to work on these issues?

Ting: Yeah, absolutely. Besides learning the techniques, the technology, the medicine, and the surgery, I had to become educated in the culture and the cultural sensitivity. Learning to ask someone, what is your preferred gender, what is your preferred name? Its been life-changing.

Brogan: Yeah. One thing that I think is probably critically important is that different individuals have, different trans individuals, of course have different relationships to the process of transitioning. Surgery is not the singular end point for everyone who identifies as trans. As you are working with patients, and in fact probably as you were learning about this whole discourse, do you find yourself having conversations with people about their different experiences of the process of transitioning?

Ting: Yeah, as you say, and thats a very good observation: not every transgender patient wants to transition surgically. Theres great diversity in what patients want. Ive learned to just listen, follow the lead of the patient, and ask them what do they want? What is their transition?

Brogan: What are some of the options that Mount Sinai can provide to those folks who are finding other ways to embrace their gender identity?

Ting: We have a multispecialty center. For some patients, transitioning is just taking hormones. We have endocrinologists, primary care doctors, who can support a patient through that sort of transition. For other patients, a transition is just a name change, or a gender-marker change on their driver’s license. We have social workers who can help patients navigate the labyrinthine things that they have to go through to get that accomplished.

Brogan: Thats great. The procedures that you conduct when you do conduct these surgeries, are they things that are clearly established in medical literature, or have you had to work things out on your own as youve delved into this line of practice?

Ting: One of the incredible things about this specialty is that its a very young specialty. The operations that we do are new, and theyre unrefined, theyre undeveloped. One of the remarkable things is, only a year and a half into this whole new specialty, weve already … No. 1, Ive invented a whole new way of doing a female to male phalloplasty. Ive developed new techniques for doing vaginoplasties. Its a unique opportunity to be doing a specialty, which is so undeveloped, to be entering the field really in its infancy, the opportunities for innovation and pushing the envelope in terms of what we can do with the technology that we have.

Brogan: Can you say more about techniques that youve developed? What have you done on that front?

Ting: Say, for example, in a vaginoplasty, were creating a vagina. If you think about a biological vagina, its smooth, its moist, its secretory. Whereas, the most common operation that we do today for creating a vagina is, we create a vagina, which is lined with skin. Its dry, it can grow hair, its really not very close to a biological vagina. About a year ago, a patient came to me and said, Well, Dr. Ting, theres this paper in India where they have this technique where they take peritoneum, which is a lining from the inside of the abdomen, and its unique tissue because its smooth, its hairless, its secretory. In many ways, its very similar to a vagina.

The patient was like, Well, can you make a vagina out of this? I read the paper, I brought it home, and the exact technique that they had used would not apply in our patients. I kept thinking about it for the next several weeks, and I came up with this adaptation of that technique, where we could take the peritoneum, harvest it laproscopically, remove it from the body, and then reinsert it through the vagina to create a vagina which is much more similar to a biological females vagina, by using this tissue, this peritoneum. Now we can create a vagina, which is smooth, its secretory, self-lubricating.
Just much more similar to a biological vagina.

Brogan: That must be really exciting to be able to shake up or push forward this surgical field that is so important to so many people.

Ting: Well, its really cool. Yeah, its terrifying on the one hand, because were pushing the envelope. The existing operations, theyre not there yet. The need is there to create better operations.

Brogan: Youve only been doing this for a few years, but do you find that the medical discourse is changing? Is there communication between surgeons, between people who are trying to move these techniques forward, or is it everyone for themselves at this point?

Ting: Absolutely. Transgender surgery used to be a specialty that lived on the margins of the medical world. There were no large medical centers that would allow transgender surgery to happen within their hospitals. You would find a surgeon here or there, usually operating in a small community hospital. One of the pioneers operated in a tiny town in Colorado, and 10, 15 years ago people operated in these little silos. They were isolated, operating by themselves, and people were very proprietary and protective of their techniques. No one shared, there was no open discourse.

As this has moved into the mainstream, that has changed. There are more conferences. There are societies. Theres much more open exchange of ideas. One of the things that weve done at Mount Sinai is weve created the first fellowship in transgender surgery. Something like that, they didnt even exist. Up until July of 2017, there was no place in the United States where a doctor could go and formally learn how to do these operations.

Brogan: That means, in effect, that youre training the next generation of surgeons who will work on these issues?

Ting: Absolutely. Its ironic, right? Because Im a beginner myself, Ive only started doing this a year ago. Yet, here we are training the next generation. Theres just such—

Brogan: Learn by doing.

Ting: Youve got to learn by … theres an expression in medicine: See one, do one, teach one. What we found very shortly after opening our program is that there is a tremendous unmet need for surgeons, for doctors to take care of transgender patients. A year and a half in, we have a waiting list. That numbers in the hundreds.

Brogan: How did this project at Mount Sinai begin in the first place? What was its genesis?

Ting: It was really a coincidence of sorts. There was a transgender medical program at St. Vincents Hospital. There was one at Beth Israel Hospital. Those used to be separate stand-alone hospitals. At one point, Beth Israel acquired St. Vincents, and then Mount Sinai acquired Beth Israel. Here we are, we have inherited this large primary-care practice of transgender patients. Theres a woman named Barbara Warren whos director of diversity and inclusion at Mount Sinai. She was very involved in the program, and she came to the board of directors, the board of trustees at Mount Sinai, and gave a presentation on the transgender practice.
Our CEO, Ken Davis, decided there on the spot that Mount Sinai would take a leadership position and start the first transgender surgery program in New York City.

Brogan: How did you become involved?

Ting: Ken Davis asked our hospital president, Dave Rich, to get this program rolling. I had worked with Dave Rich on a number of other programs in the past. He came to me and said, Listen, youre a plastic surgeon, and we need a plastic surgeon to start this program.

Brogan: At that point, no background, no experience with this specific surgical field? Youre just ready to go? Was it close enough to what youd been doing before that you felt comfortable? Was that scary at that point?

Ting: It was scary. I had a little bit of exposure to this in residency, but not very much.
I was at a point in my career where I was looking for the next challenge. To be able to start on the ground floor and start the first program in a city like New York, and to serve an unmet need for so many people, that was just an opportunity I couldnt pass up.

Brogan: Absolutely. Is there such a thing as a typical day for you these days, since youve started this program, this project?

Ting: Todays a pretty typical day.

Brogan: OK, how did it go?

Ting: Today was an awesome day. I got up at 6 o’clock. At 7:30, I was in the operating room. We were doing a male-to-female gender-reassignment surgery on a 30-year-old transgender female.

Brogan: Is that typical, that youre there at 7:30 in the morning, getting going?

Ting: It is. I now do four days of surgery: Monday, Tuesday, Wednesday, Thursday. We start at 7:30 on each of those days.

Brogan: Is there a reason that surgeries are scheduled for those hours in the morning?

Ting: There are only so many hours in the day, and we want to help as many patients as we can, so we start at 7:30 and we try to do two surgeries a day, or one surgery and seeing patients in the afternoon.

Brogan: Today you did that one surgery in the morning, and then what came after that?

Ting: Today I did that surgery; we started at 7:30. I was done by 12:30, and then at 1 I started seeing patients in the office. That means seeing patients who are coming to us before surgery and patients who are coming to us after surgery. Its a mix.

Brogan: Generally, is there a balance of the time that you spend consulting with patients and the time you spend in surgeries? Is it 50/50, or somewhere in that range?

Ting: Yeah, probably I spend about 70 percent of my time in the operating room. Thats something that no one else can do right now, aside from me, so I try and maximize the number of patients that we operate on. We have help in the office. I have a physician assistant; we have residents who can help me see more patients. The idea is to get through our waiting list. We have a waiting list of 300 or 400 patients. The faster we can get those patients ready for surgery, and the more time that were operating, the more we can take care of patients who have been waiting, for decades sometimes, for surgery.

Brogan: I assume that, especially with a relatively small staff with you as the only operating physician, if Im understanding right, that there are just limits to how much you can actually do in a given day at this point.

Ting: There are absolutely limits that I am finding.

Brogan: Yeah, would it be possible to do three, four surgeries in a day, or would that just be beyond the limits of the human body?

Ting: There might be someone who could do three or four surgeries in a day, but not me. These operations, theyre really huge operations. Theyre daunting, theyre scary, youre operating in very critical structures. The margin for error is very small, you have to focus, you have to be on your game. Youre changing peoples lives, so it has to be perfect every time.

Brogan: What are the initial consultations like? When you first sit down with a new patient, someone who might be considering surgery, what conversation are you having from the get-go?

Ting: The first priority, if we want to do, say, surgery, we want to make sure our patients are ready for surgery emotionally, mentally. We want to make sure theyre physically prepared for surgery. We want to make sure that socially theyre well prepared to cope with the postoperative course. That theyre living in someplace thats safe, that they have people who can help them after surgery, that they have a plan for recovery. Before we do surgery, we need to make sure that the patients are adequately prepared, that they know what theyre getting themselves into. This is a big commitment, its a big step. Yeah, we follow the WPATH guidelines.

Brogan: What are those?

Ting: Right, the WPATH is the World Professional Association for Transgender Health professionals. Essentially, anyone who wants gender-reassignment surgery has to be living in the desired gender for a year, they have to be on hormones for a year, and they need letters from two mental health professionals stating that they are ready for surgery.

Brogan: Do you communicate with other professionals, with doctors whove seen them in the past, or do you just rely on those letters, that kind of information that theyre bringing to you?

Ting: Right. Yeah, one of the advantages of working at Mount Sinai is that we have a multispecialty center. Its the CTMS, the Center for Transgender Medicine and Surgery, and at our center we have psychiatrists, psychologists, primary care doctors, endocrinologists, mental health professionals, and every patient that has bottom surgery at our program is screened by this multidisciplinary panel. Every week, we sit down in a conference room with about 10 other doctors, social workers, psychiatrists, and we talk about every patient. We make sure that every patient is fully prepared for surgery. Once theyve passed that screening process, then and only then do they get an appointment to see me for surgery.

Brogan: Theyve been through a lot, this really holistic program, before they come to you?

Ting: Exactly—theyve been through a lot.

Brogan: Are there ever folks who are coming from outside the Mount Sinai system, or is your work entirely focused on internal treatment through that program?

Ting: We operate primarily on patients in the New York City area. Not just within Mount Sinai, but anywhere within 100 miles of New York City. As our reputation has grown, we are getting referrals and inquiries from all over the world. Just last week, we had emails from Australia, Japan, Europe, South America.

Brogan: After a patient, a potential patient, has been through this whole process with other physicians, other medical care professionals, when you first sit down with them, what are you trying to learn or discover? What do you need to know from them in order to do the best possible work?

Ting: When I meet a patient for the first time, I generally meet them just once before surgery. I just want to try and get a sense for who they are and what they want from surgery. I want to make sure that their expectations are reasonable, and that their expectations are in line with what I can provide them. The goal is to have happy patients.

Brogan: Of course, yeah. If you ever do get an inkling that the patients expectations are not in line with what you can provide, is that something that you communicate there? Do you have some other way of trying to take a step back?

Ting: Absolutely. This has happened, I have come across patients who I felt were not realistic in what they wanted, what they thought they could have from surgery. Ill just turn around and refer those patients back to the center, and have them reevaluated. Ill spend time talking to them. The last thing we want to do is operate on someone who we cant give them what they expect.

Brogan: What other kinds of information do you convey in those meetings with patients?

Ting: Its important to talk about the risks of surgery, and all the things that can go wrong. We try to do safe surgery, but sometimes there are complications there, things that we just cant control for. Its important that patients go into these operations knowing what the possible risks are.

Brogan: Sure. Thats true for any surgery, I assume, that you would ever conduct or have conducted, to some extent.

Ting: Absolutely. Informed consent is part of every presurgical consultation.

Brogan: Is there anything else thats important in those conversations?

Ting: I want to make sure that the patient is emotionally and psychologically in a place where theyre ready for surgery, and where I think that they will have a good outcome where they will be able to take care of themselves after surgery.

Brogan: Yeah. All right, so youve met with someone, sounds like, as you say, youre generally only going to meet with them once before surgery. How long is it between that initial meeting and the actual procedure, typically?

Ting: We have a pretty long waitlist for surgery. The patients, for example, that I saw today are getting booked for surgery in June of 2018.

Brogan: Wow, thats a long time out.

Ting: Its a long time out. Thats with me operating at full capacity, every day that I can possibly operate.

Brogan: Do you ever have to grapple with the frustrations of patients about that kind of timetable?

Ting: Yeah. Patients, people, want to be who they want to be. For our patients, for some of our patients, having the surgery is the most important thing that they can do for themselves. Yeah, if you have to wait a long time for surgery, its tough. Its frustrating, and some of our patients have waited 30, 40 years for surgery.

Brogan: Right, this isnt the first time theyve been delayed.

Ting: This isnt the first time. One of the cool things about what were doing is we are allowing patients to have these surgeries who otherwise just would not be able to, who wouldnt have the resources to do so. Up until we started this program, there were no places in New York City where someone, say, who had Medicaid, could have transition surgery.

Brogan: That must be very gratifying to be contributing to that.

Ting: Yeah, its really cool.

Brogan: What prep do you do in advance of surgery in the days or even hours before? What do you have to do to get ready to conduct one of these procedures?

Ting: Its like playing a football game, you have to get yourself mentally in the right place, make sure I have a good night sleep. The operations are tough, theyre not easy. Before I start every surgery, Im always thinking about, “OK, what are the 50 things that can go wrong in this operation? How do I make sure that none of those happen?” I have to do every step perfectly. Im visualizing different steps, and what can go wrong, and how do I do this? How do I make that better? How do I throw that stitch just the right way? A lot of it is mental preparation for me, visualization.

Brogan: You do it all in your head before you do it—

Ting: I do it all in my head.

Brogan: —On the body.

Ting: Yeah. Say a little prayer before every surgery.

Brogan: Then at 7:30 in the morning, you head into the surgical theater, is that the right word? Into the surgery room, whats the best word?

Ting: The operating room.

Brogan: Into the operating room, thats it. Can you lead us through that experience? The patient, when they show up, are they already anesthetized or are they already under, usually?

Ting: No, the patients come in and they walk into the holding area. Were there, and we talk to them, we go over what theyre going to have done. We double-check that nothings changed, that theyre still ready to proceed with surgery, that theyre mentally and emotionally in the right place for surgery. We go over the consent again. We talk about the exact surgical plan, what can go wrong, what were going to do that day in surgery, then we have them sign all the proper consents. Then the nurses come by, the anesthesiologist comes by, everyone has their role to play. We bring the patient to the operating room. Start an intravenous line, and slowly just put them to sleep.

Brogan: I imagine that there must often be some heightened emotions in that time just before surgery begins, when youre having those conversations. Do you have to be attentive to your bedside manner in advance of the surgery?

Ting: Yeah. For patients, its a very emotional time. Many of them have waited a long time and theyre nervous, theyre terrified, but at the same time, really excited to start this new phase in their lives.

Brogan: Once theyve gone under, whats next? Whos in the operating room with you, first of all?

Ting: Theres an anesthesiologist. Theres a scrub nurse, thats someone who hands me all my instruments and all the equipment that I need. Theres another nurse, a circulating nurse who will travel around the room and gather up anything that we need. Then Ill have someone helping me, either a resident or a fellow, thats a surgeon in training, or sometimes a physician assistant or a medical student.

Brogan: What does the process involve, for example, for one of these vaginoplasties that you described earlier, that you helped create, this process? What are you doing there when youre actually in the operating room?

Ting: The first thing we do, after we get the patient positioned on the operating table is we take these Magic Markers and we sketch out exactly what were going to do on the patient, on their skin. Theres such a wide variety of anatomy from patient to patient, everyone is different. We really have to customize the surgical plan to each patient.

Brogan: Youve done some of that work I assume in advance of the actual surgery, based on their chart, or is it all happening there in those hours?

Ting: When I see them in the office, Ill examine them, and Ill already have an idea of what were going to do, but its not until were in the actual operating room that we draw on the patient and we sketch out the actual place where the incisions will be, where were going to place the clitoris, where well place the vagina, where were going to be taking the skin graft from. All of that is done in real time in the operating room.

Brogan: How long does that part of the process take?

Ting: The sketching, the drawing, takes about 15 minutes.

Brogan: Where do you go from there? Whats next?

Ting: From there at that point we inject a local anesthetic, a lidocaine Marcaine mixture all over the place where we operate. I do that to minimize postoperative pain. The long-acting anesthetic that I inject will last for a couple of days, and that really helps minimize the pain in the first 24 hours after surgery. Once that is done, we make our first incision, which is usually harvesting the skin. We take the skin from the scrotum, cut it out in a butterfly incision shape, and that skin is used to make the deepest part of the vagina. Well take that skin and prepare it by thinning it out, then we save it on the back table, and well use it again at the end of the operation.

Brogan: What comes after that?

Ting: Then, in the next step, we do the orchiectomy, which is removal of the testes. Through that same incision, weve now removed the skin of the scrotum, so the two testes are there. We take them, we isolate them on their stalks, and we put these threads around the base of the stalk so they dont bleed. We cut them and we remove each of the balls, and those get sent to a laboratory to be tested for any abnormalities.

Brogan: OK.

Ting: Then at that point, in this operation we take the skin of the penis and essentially we turn it inside out and turn that into a vagina. Its like taking a sock and flipping it inside out. Before we can do that, we only want the skin, so we have to remove all the internal parts of the penis: the erectile part, the urethra. Those are all removed meticulously, leaving just the skin. As part of that process, we save a little bit of the glans, the tip of the penis, to make a new clitoris from. We want to save the nerve and blood supply to that little bit of tissue. Thats critically important, that becomes the new source of erogenous sensation in the female genitalia.

Then we take that clitoris and we suture it to the pubic bone, where a normal female clitoris would be. Then in the most dangerous part of the operation, we create the actual vaginal cavity. You need to create a space where there is none and theres not a lot of room in the male pelvis to make that space. Theres really only one place. Theres a narrow space between the rectum and the urethra, its maybe a centimeter wide, and we have to open up that space with a scalpel and an electrocautery, about eight inches deep, without injuring either the rectum or the urethra to create the new vagina. Once weve created that space, then we take that skin that sock, and we turn it inside out and place it into that space. That becomes the new vagina.

Brogan: How long does that part of the process take? That seems like it must be super-involved, but I also assume you must have to work relatively quickly since youre dealing with issues of blood flow and things like this, right?

Ting: Right. The making of the vaginal pocket takes about 25 minutes, 30 minutes. Then the whole operation takes about four hours.

Brogan: Are there more steps to that, that you want to describe?

Ting: Well, then we shorten the urethra so that the patient can urinate while sitting down.
Aesthetically we create the clitoral hood, we make the labia minora, make the labia majora. At that point, its a lot of aesthetics and artistry to just create the external genitalia.

Brogan: Do you find yourself proud of the work that you do there? You describe it as artistry and aesthetic.

Ting: Yes, absolutely. We can make the most beautiful female genitalia.

Brogan: Sure, thats great. The other major surgery that you perform, is “phalloplasty” the correct term?

Ting: Thats exactly it, yeah.

Brogan: You do these vaginoplasties and phalloplasty, and presumably very different. Is it easier, harder, just different?

Ting: Phalloplasty is a much harder operation. To be honest, the results are not nearly as good as the other way around. We can make a very realistic, beautiful, and functional female vagina, but its really hard in 2017 to make a phallus that is functional, that becomes erect, that has sensation. We cant really do all of those things today.

Brogan: Because therere so many factors in play there, from distribution of nerve tissue, I assume, to the functioning in essence itself—

Ting: Exactly. The erectile apparatus of the penis is unique in the human body. Theres nothing else like it. The closest we can come, we can create the skin of a phallus, and we can create a reasonable facsimile, and maybe it will have some sensation. Then a year down the line, we can take an erectile apparatus, its filled with water, and you can blow it up and that can create an erection.

Brogan: Thats a subsequent surgery thats—

Ting: Thats a subsequent surgery and it has its own set of complications. Its not 100 percent successful. Clearly, the phalloplasty is an operation thats in need of improvement.

Brogan: Once youve completed one of these surgical processes, are you immediately heading to another surgery typically, or do you have some downtime between them?

Ting: We immediately head into another operation. We need time to get the dressing on, to wake the patient up, and they clean the room. They turn over the room, it may be about an hour between surgeries.

Brogan: Youre sometimes looking at 10 hours of surgery in a given day, then?

Ting: Yeah, give or take.

Brogan: That must be pretty exhausting.

Ting: Its exhausting. Not even so much physically as it is just mentally exhausting.

Brogan: What follow-up do you do after a procedure? Do you see a patient later that evening, the next day? When do you check in with them?

Ting: We will check the patient usually the night of surgery, or one of our team members will go in and check on them, and then we see them the following day. Theyre in the hospital for three or four days, depending on what the operation is. Then they go home, and after that we see them back weekly for the first couple of months.

Brogan: Have you ever had patients reconnect with you down the line, talk to you about how theyve come away from it feeling? What their experience of life after surgery has been?

Ting: Yeah. Even after a six-month or a year period of convalescence, I still see the patients every year for a checkup. One of the cool things is, getting to see the patients after theyve transitioned, after theyve had these surgeries, to see how its affected their lives.

Brogan: What have you experienced with that? What have you seen from patients?

Ting: Honestly, its the most mind-blowing thing Ive ever seen. The oldest patient weve operated on was a 77-year-old trans woman. The first time I saw her, she was like, Well, Dr. Ting, Ive waited since I was 5 years old to have this surgery. When she first came in, she was really nervous and she told me she wasnt sure that we were going to do her surgery because she was so old. She thought maybe we were going to tell her, You know what? Youre too old to have surgery. I think she was terrified of that. When I told her, Absolutely, were going to book you for surgery, she started crying, she was so happy.

She had her surgery, and Ill never forget, the first time she came in for her checkup and we removed the bandages and she got to see herself, she just burst into tears. Shes like, Ive waited my whole life for this. Ive waited my whole life to be who I am. Yeah, so that was pretty cool. This is someone, shed been living as a woman for many, many decades. She was married, had a stable life, but this was just something that she wanted to do for herself.

Brogan: Yeah. Thats striking that on the one hand she was able to live as a woman, but this was a part of that that you were able to contribute to that she might not have been able to have at another moment in time.

Ting: Yeah, I think it was just one more step. It was just that one thing that always bothered her. Every day when she would look at her body, she would feel, “This is not me, this is not who Im meant to be.”

Brogan: Yeah. You were also helping to train as you said before, the next generation of gender-reassignment surgeons through the fellowship program at Mount Sinai. What does that part of your job entail? What kind of education or training are you doing there?

Ting: We started a fellowship in transgender surgery in July. Our first fellow, her name is Bella Avanessian. She finished plastic surgery training in June, and shes spending a year with us learning how to do these operations. Right now shes on maternity leave, she just had a baby, but after she comes back, and what she did for the first several months of fellowship is essentially just shadow me. She was with me every day in surgery, seeing patients by my side, learning how to do every step of the operation, learning how to take care of patients before surgery, how to manage them after surgery.

Brogan: Does that take any of the work off your hands, or are you still doing just as much as you wouldve been otherwise?

Ting: In the beginning, its probably more work because instead of just doing it, I also have to show it to someone else. Shes an incredible surgeon and shes learned very, very quickly.

Brogan: Thats great.

Ting: Yeah, shes taken on some of the tasks. Shes made it easier. The real payoff is next year, Im hoping that shell come back and join our faculty. Then well be able to operate on twice as many people.

Brogan: Thatd be great, and Im sure many people would appreciate it. Whats most rewarding about this work for you? You go to bed, I assume, exhausted every day. What are you feeling about your job as youre falling asleep, trying to get that good nights rest before the next mornings surgeries?

Ting: Thats a good question. Id have to say, there’re just not that many jobs where you can get up in the morning and say, Today Im going to change someones life. Thats the most rewarding part of what I get to do every day. Its really … its a privilege and a joy.

Brogan: Yeah, well thank you so much for joining us today to talk about your work. I learned so much from this.

Ting: Thank you for having me.