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Marianne and Dr Helen are joined by two NHS surgeons specialising in top surgery. Mr Ioannis Ntanos and Miss Chloe Wright discuss the ethics and health policy around top surgery for trans and non-binary individuals. In this episode of the GenderGP podcast, the guests cover binding, the positive impact of top surgery on intimacy and their ambition to move top surgery from its current position as a fringe of breast surgery, into its own specialty.

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The GenderGP Podcast

Top surgery for trans guys

 

Hello, this is Dr Helen Webberley. Welcome to our GenderGP Podcast, where we will be discussing some of the issues affecting the trans and non-binary community in the world today, together with my co-host Marianne Oakes, a trans woman herself, and our head of therapy.

 

Dr Helen Webberley:
We have two surgeons with us today, two UK-based surgeons who are both very experienced and talented in top surgery. So I’m really, really delighted to welcome both of you. We have Mr Ioannis Ntanos and Ms Chloe Wright, two surgeons. So I’m going to let you introduce yourselves, just to tell us who you are, why you ended up having a specialism in top surgery, which is what we’re talking about today. And any golden nuggets that you want to start with. So Ioannis, if you don’t mind, I’ll call you Ioannis, introduce yourself and tell us who you are. And welcome to GenderGP.

Mr Ioannis Ntanos:
That’s absolutely fine. Thank you very much. Hello everyone. So yes, my name is Ioannis Ntanos. I’m a breast surgeon, but focusing on top surgery for the last three and a half years since I joined the team in North Manchester General Hospital. My exposure to top surgery started with me moving to Manchester, but from the first moment, I was extremely interested in it, not only from a surgical point of view but from an ethics and health policy point of view, too. And this is solely within the last three and a half years. And I was trained under the lead at the time here, (unclear 1:44) who was here in Manchester. And I’ve recently taken over from leading the services at this point. Thank you.

Dr Helen Webberley:
Welcome. And Ms Chloe Wright. Nice to have you. Introduce yourself.

Ms Chloe Wright:
So thank you for having me with you. So I’m Chloe Wright. In my current position, I’m a consultant oncoplastic breast surgeon, but I’m delighted that in the new year, I’m going to be joining Manchester General Hospital. And that will be in the delivery of care for people who are seeking their gender-confirming top surgery. I had the benefit of really early exposure to this surgery in my training and so 2009. And so then, through the course of my ongoing surgical training of breast surgery training as an interest, I further pursued in my fellowship, my sort of breast surgery and plastic fellowship, I spent time then working with surgeons in different units to develop these skills. And it’s been a research interest of mine, particularly the impact of chest, gender-confirming surgery on health-related quality of life. So I’m really interested in the new year to be sort of putting this together, and together we’re like, yeah, this has goals, but to really work, to develop pathways, frameworks of care, quality assurance, to really see that we can deliver excellent care for people.

Dr Helen Webberley:
Well, when we introduced ourselves to each other about the need for research and the, you know, the pathways, the frameworks, the quality assurance, these are so important because they’re missing at the moment, aren’t they?

New Speaker:
For sure. I mean, what I recognized completely when, you know, and this was a game at North Manchester general hospital, and it was (unclear 3:44) kind of pioneered delivery of this surgery at the hospital there, but it was considered as fringe stuff. You know, it wasn’t considered to be a sort of mainstream, and it is. It is mainstream. And what we do more and more of is to recognize that, you know, to see that this needs to be a part of the education that comes through medical school education, that’s part of the FRCS syllabus, you know, so the syllabus for general surgical trainees. And so, you know, really to make sure that it’s something of which everyone is aware, but to make sure that we really work out that people who deliver their surgery are appropriately trained and that they have a supportive network of people around them,

Mr Ioannis Ntanos:
Top surgery, when it comes to transgender, health care is different. Skills that are acquired from other specialities can be transduced, but you, we need to follow a holistic approach. It is a multidisciplinary team approach when it comes to transgender individuals. So there are different things that we take into consideration. If you compare that to any other aesthetic surgery, it’s different because top surgery for transgender individuals is lifesaving. It’s more than just life-improving, but surgery. If you compare it to oncological surgery is more, it’s different because it has a lot of filaments to aesthetics. So there are different ways in which we can choose the appropriate surgical technique. Some of them are out of very distinct. So they have to do with the body type, with the chest size, with a quote of the scheme, but others to do with the individual’s preference. And we always need to try and match expectations as much as we can.

Dr Helen Webberley:
Marianne, Ioannis was talking then about this, not just being life-improving surgery, but sometimes lifesaving surgery. Is that what you’ve experienced in your therapy with, with patients?

Marianne Oakes:
Yeah, without question. And another term I use is life-making because a lot of the people that I see that are preparing for this have got no life. They ha they don’t have access to the gym. They can’t go swimming. They can’t book holidays with their families. They can’t go out in the sun. You know, all these simple things that we take for granted are denied them. And the lengths that they’re going to, to hide that part of the body, you know, the extreme binding, the clothes you have to wear. It’s so limiting on the life that they have. So yeah, if we’re not saving the life at the very least we’re doing is, is giving them a life. So yeah, I think what you said there, Ioannis, towards the end, you know, managing the expectations as well. And you know, when I ask people what’s their goal for surgery, you know, they would say, well, what, a flat masculine chest? And they’re worried that that’s not enough. And I, you know, I said, no, you don’t need to tell me anymore. Why would you not want that? So yeah, managing the expectation. If that’s what they can achieve or anything close to it, I think that that’s brilliant.

Dr Helen Webberley:
Surgeons, how can we achieve that for these patients? I don’t know because I’ve never been to this operating theatre. I’ve never seen anything done. How do we, how do we manage them and create that expectation for patients?

Mr Ioannis Ntanos:
First of all, you have to be focused on the individual’s expectations. So, so in order to match it, you have to have the expectations at the top of your list when discussing surgery with them. This is where we should start with, and this is why transgender healthcare as Chloe said earlier, should move out from the fringe of breast surgery and focus on becoming an individual surgical speciality, which is not right now. Surgeons who are trained in transgender top surgery have done that individually, but not through a structured curriculum. So first of all, focusing on the expectations, being honest, without individuals know what to offer them and to try to offer them in a way that is suitable for them. It’s not just about surgical technique. Marianne is absolutely right. These tiny things, being able to go to the gym, okay, enjoying life are very important. So we might choose a technique over another, the next one, for example, for reasons of minimizing the risk of requiring a revision, okay? Even if different surgical techniques are available for the same person.

New Speaker:
I think, exactly following on from what Ioannis says, it already is a very specific type of surgery. It follows the same principles of discussing any surgery with an individual. You know, it’s understanding what they hope to achieve from it. And marrying that up with actually what you feel that you can reasonably deliver, recognizing what those expectations are and seeing how they can be met. And each individual their desires, their hopes, their aspirations for surgery. They differ, there are some who are just like, you know, I will be content to be able to wear a t-shirt and, you know, I’ll be delighted with that. And then you’ve got other individuals who are. Actually, I want to be able to strut my stuff with my top off. See, it’s really, you know, it’s working that out. And then it’s saying like. Actually, I’m really sorry, but where we are today, you are not, you’re not, you’re never going to look like you should be on the cover of men’s health. And it’s working these things together so that a person’s expectations, realistic that you can really, that you’re not going to disappoint them. And that, you know, you’re working to the point of really delivering the best that you can for a person. And that’s where, you know, there are different surgical techniques that suit different term breast volumes, skin quantity that needs to be sized nipple position. And that then has its trade-off with scarring. That may be their potential complications need for revision. And it’s all that sort of extended, true, informed consent.

Dr Helen Webberley:
So, Chloe, you were talking at the beginning about health-related quality of life and the research and what have you. And I’m guessing that if we’re going to be able to move this from a fringe of breast surgery into its own speciality of its own, right, then this outcome is really, really important to know. Can you tell me about some of the research you’re working on?

Dr Helen Webberley:
So what we recognize clearly in healthcare is we want to see outcome metrics. And the way that we measure them typically is with years survival. It is with serum concentrations. You know, we look at these things. But in something like the gender-confirming surgery, you can’t measure it in those ways. So the only tool which can use us then to look at health-related quality of life. When we, it was some time ago, now that we looked at did a systematic review to look at what health-related quality of life tools, there are specific to this population. And there aren’t any that exist that specifically look at top surgery. And if we are in the (unclear 11:40) it, where, you know, health care resources are few, that they’ve looked to being trimmed down. We need to see that we’re getting our money’s worth out, you know, our healthcare system. We need to prove that this surgery, you know, we see it common sense says that the surgery works for people, but we need to demonstrate it and evidence that. And so that’s looking at health-related quality of life outcomes. There’ve been some studies looking at quite specific, (unclear 12:13) related quality of life, sexual functioning. The group working from Amsterdam looked specifically at this for chest contouring surgery and showed really positive outcomes. The data that we collected from North Manchester was using the short form 36 tool. It’s a generic tool of health-related quality of life. It’s been around since the eighties. It’s been used for nearly 20,000 research studies. The data where we looked at the baseline health-related quality of life for individuals preoperatively versus how their health-related quality of life was the, it was a to a median of, I think it was about nine months post-op, and that showed statistically significant improvements in the emotional domains of health-related quality of life, as you would expect that to be. And so in the future, you know, that she’s in the short term, we want to know if that continues. So the next thing that Ioannis and I are going to be looking at is revisiting that patient population. So we will now have four years of follow-up data to show if it’s sustained. And so then, you know, what we’re looking to do is to really evidence it. That evidence, what we see and recognize already, is that this surgery works and that, you know, it helps people to be able to live their life as they wish to.

Dr Helen Webberley:
That’s so important. You know, it’s really frustrating, isn’t it? Because you’re quite right. We have a duty to spend the public purse wisely, and there will be people saying this is not essential surgery. However, this surgery is available on the NHS. So that decision has already been made. So now we have to decide, well, we have to back up, we know that it works because we’ve had the pleasure. And the honour of speaking to people, Marianne speaks to people all the time about this. So we have the pleasure of knowing that it works and now we have to back it up. And it is a bit frustrating, isn’t it? I wish we had had 28 years. So okay, at the moment, we’ve got nine months of data, and soon we’ll have four years of data. And then, and then we’ll have 12 years to data, which is going to be amazing, but we’ve started. We started. And that’s the really, really important thing to show people that this isn’t esthetic surgery. This is lifesaving, life-improving, life-making surgery, and really important. Marianne, what about Chloe was talking about things, things like sexual function and as well as how you can be confident in the world or the gym or at home. Is that something that, that you see in post-op patients?

Marianne Oakes:
I was going to say intimacy is something that trans people frightened to articulate. You know, the idea that they want this, and it will allow them to, you know, have a full, active sex life, be close to another person. But I don’t, you know, as humans, that’s the really important part of our existence and why would a trans person not want the same conditions to be able to help them to form deeper, meaningful relationships, and actually top surgery. That is something that comes up all the time when I’m speaking to people about it. I wanted to just make another point about something you said earlier as well if you don’t mind. You know, when we’re talking about somebody coming for surgery, we did a podcast with somebody who’d been through a vaginoplasty. And she said that the surgeons were more concerned with how well it looked not how it functioned. And actually, she was saying that this is our body. And sometimes the surgeons aren’t listening to us. They’re telling us what’s best for us. And actually, everything you’ve said to me, it gives me masses of hope that actually you’re coming from this from a person-centred point of view and holistic. What is this person actually asking for? What do they want it to achieve for them? Because if we don’t ask them questions, which is going to give them what we want to give them. And so I thought it was really, really good for me to hear as a trans person, that there are surgeons and then there are doctors and medical people that are more concerned with the patient than own ego, I suppose, for want of a better description.

Dr Helen Webberley:
Let’s face it. It’s interesting Marianne, isn’t it? Because again, what Chloe was saying about, you know, we can’t do a blood test to see how successful this surgery was. We can’t do a scan to show how successful it was. I’m hoping we don’t have to measure years of life because that would imply harm and premature end of life. So we’re looking, so we actually have to look at you know, how much that life improves, which makes it patient-centred, doesn’t it? Ioannis, I can see you nodding, does this happen to you?

Mr Ioannis Ntanos:
My money is on it’s right. Okay. First of all, we include discussing intimacy issues in our first consultation with our individuals. We are not afraid to discuss on whether top surgery will improve or not, will change or not their sexual pleasure, their intimacy with partners, their future aspirations in search of health. It is part of what we discussed, trying to discover the individual’s expectations. So that’s one thing. And frankly, no physician should be afraid to discuss intimacy in whatever setting that is. It is important, as Marianne said, it’s an important part of our lives. So that’s one thing. Secondly, we are discussing top surgery right now, but we are offering top surgery in North Manchester, at least, mainly to trans men. So we are mainly performing mastectomies and chest wall reconstruction because top surgery in trans women is not regularly offered in the NHS. And I think, I think we should just make a small note of that in our discussion here. I think it’s not right. I think it’s a discrimination against trans women. I know why NHS is thinking this way, because if they were, I think that thinking that if they offered it regularly to trans women, they should be offering to cis women, too. And that could create a backlog of a huge cohort of patients who would like to have, cis women that would like to have a breast augmentation, but I think it’s wrong. I think the NHS should consider offering top surgery to trans women, too.

Marianne Oakes:
Sorry, I’m just going to dive in there. I’m glad you mentioned trans women as well. For one, I think, for many people, not everyone, but many people, the breasts, the chest area is the biggest single signifier of femininity or masculinity. And I don’t think we can underestimate the value of that for somebody that is transitioning. And equally, it is, it says for women and men alike, you know, you know, we shouldn’t–but equally, most people are comfortable with what they’ve got. But for some, you know, it is a really important potent aspect of their very being. So, yeah, the main signifier for men and women is the chest area. So I’m glad we’re talking about that as well.

Dr Helen Webberley:
One of the things that we often talk about here on the GenderGP podcast is the fact that if we were ever able to have a future where medical, the medical intervention that precedes any surgery was given at the right time and the puberty that a person was able to go through what was in line with their gender identity at the time when people normally go through puberty, then we wouldn’t need to have male top surgery, and we wouldn’t need to have female top surgery. And so that’s something that I always aspire for the future, which would put you two out of a job, but in a very welcome way. What about nonbinary people? Let’s not leave out, you know, a very, very large portion of the transgender community and a growing number of people coming forward saying this, that, or the other. Do you have any experienced with patients in the middle of the gender spectrum as it were?

Ms Chloe Wright:
Well, I think if I put this conversation in my sort of preparations coming to North Manchester, an area that has come about much more in the last couple of years as the referrals come through to our clinics, as part of it, that Ioannis has much more experience than me. So I think I’ll put over to him on it.

Mr Ioannis Ntanos:
So, yeah, thank you, Chloe. I mean, nonbinary individuals are an interesting cohort of who we see in this clinic. And we started collecting data prospectively in the last two years. So right now, our data includes 35 individuals so far. Dealing with nonbinary individuals is not different than dealing with binary, trans men or trans women. And WPath does not differentiate on our approach when it comes to top surgery. So the same guidelines apply. What we need to do is go back to what we said earlier about expectations and trying to meet them and have an open mind when it comes to discussing outside the binary context. That what I think that it should be an appropriate choice is not the same expectation that an individual might have. So personally, I’m very happy to discuss anything outside what someone else would consider, and I hate that word, normal. Larger areolae, different positions of nipples, different types of flatness or masculine appearance. It can all be discussed trying to provide the best outcome we can for our individuals. So I don’t think, I mean, right now, some surgeons consider two letters of referral when it comes to nonbinary as opposed to one letter of referral when it comes to the binary persons. I don’t think that should be the case we’re dealing with. We are trying to deal with gender dysphoria; everything else is irrelevant. So I’m happy to discuss any individual requests with everyone.

Dr Helen Webberley:
I think some people, Ioannis, some that I see on social media are finding it difficult to get that referral to you. And particularly if it’s nonbinary people are worried that their GP won’t refer them to the gender clinic and that they won’t even be allowed to start gender-affirming medication, nevermind actually then being referred on for gender confirmation surgery. Do you find that in your experience, or do you not get to see that?

Mr Ioannis Ntanos:
Well, we get referrals from the GICs? And from my experience, that is not discrimination. I have seen referrals from individuals that were not on hormonal treatment, that they had specific requests when it comes to surgery, and there was no issue in referring them to us. I don’t know if that is the specific benefit with having Manchester because this is this, this is how we approach our clients. But I presume it’s the same for any other unit in the country. Nonbinary persons can be referred to GIC and the GIC to the respective unit for surgery.

Ms Chloe Wright:
I suppose the problem is this isn’t, it is we only see the ones who have breached that barrier and made it through to us. You know, we’ve got no idea if the ones who don’t, who (unclear 24:52) get past that barrier.

Mr Ioannis Ntanos:
That’s absolutely true. You’re right, Chloe. But I think the barrier comes–if someone is referred to the GIC because we are in regular contact with the gender identity clinics, they will eventually be the referred to us, and then we can explore the options based on the individual expectations or preferences.

Dr Helen Webberley:
I think that your very confident statements, Ioannis, a couple of minutes ago, and they’re just so important. You know, nonbinary people are allowed to be referred to the GIC, and the GIC is allowed to refer them to surgeons, even if they’re not on medication. And I think, you know, these kinds of things are going to be really powerful for people who go to their GP and say, actually, I am allowed to be referred. Please do so. This is where it says I am allowed to be referred. And at the clinic, again, having that confidence to say, I am allowed this, please do it for me kind of thing. And this again, totally goes on to what you were talking about, Chloe, with pathways and frameworks and having those set in stone, which is a work in progress, I’m sure. There’s a lot of work to do, but it’s happening, which is really, really exciting I think for the future. Marianne, do you see any people that have struggled to get through or is it?

Marianne Oakes:
Well, I struggled to get through, didn’t I?

Dr Helen Webberley:
Well, that’s true.

Marianne Oakes:
But you know, the reality is that I think that the gender clinics–it can sometimes be a lottery which clinicians you see or what their attitude towards nonbinary might be, or to even being trans might be, and the tick boxes that you’re fulfilling. So I do think there probably is an issue before people get referred you, and I think you were right there, Chloe, that you do get to see the ones that have navigated it. That’s not having to go at the gender clinics. They’re trying to interpret protocols. And the trouble with that is that people trying to break protocol, what me and Helen talk about this all the time. Sometimes, you know, somebody comes to me for an information gathering session. And I just think, why do they have to talk to me? It’s so clear that this is right for them. And that we’ve got the strength to do a report. You know, we’ll fulfil the requirement. This is right for them without question. I don’t think that when you turn or put the gender clinics in the NHS, the protocol allows for that. It still says no (unclear 27:32). So I was working as a professional, a qualified counsellor working in this area, and they didn’t see me fit for hormone therapy. I can’t–to this day, I don’t know what I did wrong. I did get it eventually, but so, you know, even the most well-rounded person–I just didn’t meet their protocols. So I think that’s something that, you know, obviously you can’t influence, but I think the message would, it should be going out to the gender clinics, you know, to trust you to make the final decision on who should get surgery and whether it’s right for them as well. Do you know? You’re the ones that are going to be performing that surgery.

Dr Helen Webberley:
I’m going to move the conversation on, because one thing I talk about this week is I’ve seen again, lots of chat about, and Ioannis, I think it was you who mentioned it, quality of the skin. And there are always lots of questions from worried parents about binding and what’s the best or the worst way of binding. Because obviously, that’s what many transmasculine people do before they have the ability to have access to surgery. Have you got any advice to give people who are looking at binding or ways of binding, or parents who are worried about their young people who were binding? Do you have any advice for them?

Mr Ioannis Ntanos:
Binding it is a huge issue. And I understand the reason why a person should choose to bind, as Marianne said, our chest is the most prominent indicator of our gender, but it can cause some challenges. The binder affects more things that just the quality of the skin; it affects breathing capacity, affects posture. And in some cases, it might alter the surgical plan. So prolonged binding in someone in the chest which is borderline for a keyhole operation, for example, for a periareolar mastectomy, because of a long binding and the stretching of the skin that follows may make that operation impossible. So because of the use of the binder, we might switch to a different type of procedure that might involve more scarring, that could have been different if someone wasn’t binding their chest. So my suggestion is to keep binding to a minimum as I started by saying that I know the limitations and I know that it’s happening, but we should be looking after trying to protect ourselves in the long run. There are alternatives to binding. Some of them have their issues, as well as like using tapes, like using taping of the chest. There are other issues there. Everyone is individual. So, the quality of the skin, for example, the presence of acne should be taken into consideration. Postures should be taken into consideration. What is the expectation in surgery, in the long run, should be taken into consideration. Generally speaking, please try and keep the binding to a minimum.

Ms Chloe Wright:
And isn’t it, when you say about sort of binding to a minimum, Ioannis, it is about a minimum of hours in the day that it’s worn rather than like degree of binding. You know, so I absolutely recognize it that you know, it seemed to sort of, for it to be in the time, you know, when you’re in the home is as much as you can feel comfortable to remove the binding at that times, but yet you need to be limiting the hours in the day rather than the compression of the binding.

Marianne Oakes:
Can I just ask a question, would that support the case for speedier intervention as well? So if somebody is on a waiting list for two years, without the advice about binding, without that knowledge, that actually that’s causing the more damage and that, you know, there is a case for earlier intervention, just purely from the long-term ramifications.

Ms Chloe Wright:
I mean, I think so, you know, certainly, gosh, I mean, there are very many reasons why it’s not correct that the person waits two years, but we’re not talking about that. But, you know, certainly, it will have a deleterious effect on tissue quality. You have less skin elasticity, there will be a greater excess of skin and the more skin that needs–to be in general terms, the more skin that needs to be removed, the bigger the scarring needs to be, you know, is a pretty simple concept of it. Do you have increased skin stretching? You’re going to need to have bigger scars to remove that skin and say. Therefore, your esthetic outcomes will perhaps not be as great as they would be if you were doing it was no binding at all.

Dr Helen Webberley:
I mean, I think the take-home message that I’ve learned from, from your valued advice is that we completely understand the importance of something like binding because going out outside Marianne talked about that gender signifier. So we understand that the need, and we understand that it is, is this a thing we will feel a little bit, we all feel like we wish it wasn’t necessary. But we understand that it is, but really the message is to try and limit it as much as possible while still keeping your own mental health as tip-top as it can be. So thank you. Thank you very much for that advice. I’m thinking about the future where we have robust training in medical school. Where we have inclusion and post-grad training and the FRCS, which is the exams that surgeons do to qualify to be a consultant surgeon at the end of the day. And then ongoing training. Again, it feels like a long road ahead to have gender-affirming medical care and gender-affirming surgical care in the medical education arena. How are we going to achieve it?

Ms Chloe Wright:
I think small end roads are already being made at one of our colleagues at North Manchester, Kate Williams, she’s been invited to be involved in writing a section for one of the breast surgery textbooks books, which is part of the sort of core bible of textbooks in terms of surgery. So the smaller roads are happening. I think from my sort of goals and aspirations of working through this in the first instance. We are based in Manchester. Manchester medical school is enormous. You know, it would be making those one-to-one contacts within the medical school, finding out what part it plays in the existing syllabus and teaching of our students. Because, you know, you need to be bringing in that education, all levels of individual working through the healthcare system, but particularly it’s those people who are coming in at the beginning, you know. For it to be that, you know, this is a part of your, your baseline. This is your basic medical training so that all people working in health care have that. I can only hope that then there is a trickle effect that goes further outwards. And then you get something that, you know, others as individuals who work in this area and can hopefully trust to inform those wider changes that go further.

Dr Helen Webberley:
So it sounds, I mean, Ioannis, do you have anything to say on that?

Mr Ioannis Ntanos:
I just wanted to say Chloe is right. We should start with medical school, and we should start with education. And being in the centre of this procedure, we should be in the centre of driving the education at all levels as possible. But we also need to come together all the surgeons who are actually offering these procedures. We should come up with some kind of guidelines on who is offering the procedure and on what terms. I know that our bottom surgeons in London are a bit ahead of us. So there is a process right now to include gender affirmation surgery in the plastic and urology curriculums. And the Royal College of Surgeons is involved in that process, but they have left out top surgery, and we are trying to see how this can be included as well. And so things are moving forward. It’s important for all of us to be as vocal as we can and drive this change forward.

Dr Helen Webberley:
I mean, I think it, you know, the big organizations have to have to listen to the small individuals that are currently driving this forward. And, you know, it makes us very vulnerable that there are no guidelines for us to follow in the UK. It makes doctors quite feel quite scared because there’s nothing better than having a NICE guideline, you know, the National Institute of Clinical Excellence to follow or a UK published NHS guidance. This is how you treat this condition or the Royal College of General Practitioners, the Royal College of Surgeons in their curriculum. This is included in the curriculum, and every single surgeon, GP, or doctor needs to learn this. Otherwise, you’re not qualified to do the job. And so it feels like a long way to go, but it’s being driven by the individuals. And, and I think you’re right. What we need to do is, is get the big organizations behind us to understand the importance. And you know, the General Medical Council itself, who are the standard setters of education. They are supposed to set standards for education. And we need to look to them to say; please set some standards by which the Royal Colleges and the medical schools and the postgraduate deaneries are able to set standards that then us as doctors can feel comfortable to follow. So it feels like a big job, but it’s happening, isn’t it Marianne? I mean, we’ve seen a big change in the voice of the transgender person over the last, say, five years, and then other doctors like our guests today coming forward and making changes for the future. We’ve seen a big, big change in the last five years, haven’t we?

Marianne Oakes:
I mean, I can’t tell you just how excited down by what I’ve heard today, because it has been on the fringe, Transgender healthcare, just as a user, a service user, does feel like it’s an inconvenience. And, you know, I hear stories about this tool to get clinicians to want to work in that area. And then you see what happens to some of the people that do. And so that actually it’s starting to be recognized even in a small way, feels to me a really hopeful. And maybe it is that there is a wind of change. There is not a coincidence that we are able to do this podcast today. So I’m just really excited by what I’ve heard, without question.

 

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