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Carly just got back to Louisiana to watch a movie with her girlfriend and sit back. It was in the spring of 2017, and about two weeks earlier, Carly, a 34-year-old trans woman, had undergone a vaginoplasty: a procedure sometimes done after injury or cancer, but most often for transformation-related care. Carly chose a surgeon, Dr. Kathy Rumer, who specializes in gender confirmation procedures in the Philadelphia area.
They Skyped in the months leading up to the surgery, but never met in person before the surgery. Carly said she briefly visited the doctor before being pushed into the operating room, but she did not see Dr. Rumer again during her three days of recovery in the hospital. A week after the operation, the nurse booked her in for a follow-up appointment.
After returning home from the movie “Louisiana”, Carly took a closer look at her new vulva. While most two-week-old postoperative vulvas look unsightly, Carly was shocked when she found “a large piece of dead skin the size of a thumb,” she said. The next morning, she called the emergency number provided and sent an email to Dr. Rumer’s office. On Monday, the office advised Carly to email pictures of problem areas for surgeons to review. A few days later, Carly and her mother said they heard from a doctor who was on vacation and told Carly that she had nothing to worry about. Dr. Rumer said her mother, a retired surgeon, could cut open the overhanging skin if it continued to be painful.
The proposal shocked Carly and her mother. She said her genitals smelled “bad” and her labia sagged with a thin layer of skin. A week after speaking with Dr. Rumer, Carly said she went to the local gynecologist, who panicked and took Carly to Oshner Baptist Hospital in New Orleans for emergency surgery. Part of Carly’s vagina was affected by necrotizing fasciitis, an infection that is dangerous in any operation. This often causes tissue loss in the infected area.
Carly was operated on by a team of doctors, none of whom had experience with a post-op vulva or vagina—post-op genitals are a bit different from cisgender ones. She spent two days in the intensive care unit and a total of five days in the hospital. Both she and her mother said that many calls from Carly’s mother and her OB/GYN to Dr. Rumer’s office went unanswered during this time.
When they got a response from Dr. Rumer’s office – an administrative mess with Carly’s records – the surgeon was upset that Carly hadn’t scheduled a flight to Philadelphia for the doctors to fix the problem. According to Carly and her mother, Dr. Rumer snapped at them on the phone with Carly’s mother: “I distinctly remember hearing it that day,” said Carly, who could have overheard the conversation. “Dr. Rumer said, “I followed the WPATH guidelines for treating my patient. If you think you can do better, why not give her a vagina?”
Dr. Rumer was referring to the World Professional Association for Transgender Health (WPATH), which develops guidelines and best practices for transgender health around the world. An organization that acts as an active gatekeeper has strict rules allowing patients to undergo transition-related surgery, but it does not explicitly control the practice of performing these procedures. Potential patients like Carly are basically on their own when it comes to finding a doctor for surgery.
Dr. Rumer is an experienced surgeon: he has run his own practice since 2007, has been treating transgender patients since 2016, and performs up to 400 gender-affirming procedures annually, including facial feminization, breast augmentation and GRS. In 2018, Dr. Rumer appeared in an NBC documentary about the transformation of a college student. According to her website, she is one of the few board-certified female plastic surgeons in Philadelphia’s tri-state area, a member of the American Academy of Orthopedic Surgery, and the director of plastic surgery at the Philadelphia College of Osteopathic Medicine (PCOM). and Fellowship in Reconstructive Surgery. She has been a member of WPATH since 2010. (Full disclosure: I had a surgical consultation with Dr. Rumer via Skype at the end of September 2017, but ultimately decided to see a different surgeon.)
Many patients who come to Dr. Rumer for hip surgery are satisfied with the results. But for those who are dissatisfied with their procedures at the hands of Dr. Rumer or others, it is difficult to meaningfully respond to their complaints. In the highly politicized world of gender-affirming surgery, it can be difficult to find answers to questions about standard care. Advocates describe various surgical practices and “transgender centers of excellence” overseen by local hospitals and government medical boards. Offices can vary greatly when it comes to patient-to-physician ratios and what specific training a surgeon has.
When this happens, it can be difficult to talk about such a private issue – Carly asked for a pseudonym for fear of retaliation and publicly pointed out such a personal issue to the media. Speaking at a time when few people have access to medical care after a traumatic experience could be used by anti-transgender activists or interpreted by advocates as a step backwards.
Carly’s words were posted on anti-transgender forums when she posted about her experience with Dr. Rumer on a message board to warn other potential patients. Her complaint to the Pennsylvania Department of Professional and Vocational Affairs did not result in any official action. Jezebel interviewed four other people who said they had problems with the procedures Dr. Rumer performed, from allegations of poor aftercare to vaginal structures that caused them severe pain, or vulvas that didn’t look anatomically correct. Problem. In addition, since 2016, there have been four malpractice suits against physicians on similar issues, all of which ended in out-of-court arbitration. In 2018, the Medical Board of Pennsylvania contacted the surgeon after another group of transgender people who had seen her speak at a conference on transgender medicine filed a complaint alleging that the doctor falsified success rates, but no disciplinary action was taken.
As Dr. Rumer wrote on her website and argued in court, it seems likely that these complications were the result of non-compliance with her office’s postoperative instructions, or part of the reasonable risks of any such procedure. But when Jezebel went to Dr. Rumer with a detailed list of questions and patient statements, we got a response from the lawyer. In April, Dr. Rumer’s lawyers tried to subpoena me in an unrelated libel case, demanding that I hand over “all notes, emails, documents, and research” related to the story. Shortly before publication, Dr. Rumer again declined to comment and, through her lawyers, threatened to add Jezebel to her pending defamation suit.
These patients’ experiences and difficulties in finding help were not associated with a single physician. As demand for GRS grows, there could be an even greater concern: Without a dedicated reporting mechanism for affected patients or an agency tasked with regulating the details of transaffirmative care, patients seeking these procedures will be blocked. there is no guarantee of quality of service at check-in, and it is not clear how to move forward if they are unhappy with the results.
While any surgery, especially on the most sensitive parts of the body, comes with risks, GRS does not pose a risk to transgender women. According to a 2018 study, the percentage of transgender people who end up regretting vaginoplasty is about 1 percent, well below the average for knee surgeries. In fact, the most common reason for regretting surgery is a poor outcome.
The modern technique of vaginoplasty was developed in Europe over 100 years ago and has been practiced in the USA for at least the last 50 years. In 1979, Johns Hopkins University stopped offering GRS for political reasons, even though it was one of the leading hospitals in the United States to develop the practice. Many other hospitals followed suit, and the Department of Health and Human Services banned Medicare from covering the procedure in 1981, prompting most insurance companies to expressly exclude transgender-related coverage from private insurance plans shortly thereafter.
As a result, few specialists in the US offer lower body surgery at all, serving the small group of patients who can actually afford surgery. Most transgender people were forced to pay for out-of-pocket surgeries until 2014, when the Obama administration reinstated Medicare coverage for gender confirmation surgeries and banned insurance exclusions for transgender surgeries in 2016. Once Obama-era policies are passed, more transgender people will be able to pay for these procedures through insurance or Medicaid, and some hospitals are rushing to meet the pent-up demand.
However, such procedures are expensive: vaginoplasty costs about $25,000. A 2018 study by researchers at Harvard University and Johns Hopkins University found that between 2000 and 2014, the number of transgender verification surgeries increased significantly, with an increasing number of them being privately insured or paid for by Medicaid. “As the coverage of these procedures increases, so will the need for skilled surgeons,” the researchers concluded. But there are few standardized rules about what “qualified” means, and other areas of the medical profession influence gender change. on the problem. Surgeons report to various institutions and GRS training can range from a week’s observation with a renowned surgeon to a multi-year apprenticeship program. There are no independent resources available for patients to obtain data on surgical complication rates. Often, patients rely solely on data provided by the surgeons themselves.
While countless people have benefited from GRS coverage, one unintended side effect has been what San Francisco-based gender surgeon Dr. Marcy Bowers calls a “goodbye” culture. hospital within the allotted time, and not die from some terrible complication, or be re-hospitalized multiple times,” she said, “that’s how they measure success.” become “preferred providers” by effectively attracting new patients to their practice based on these metrics.
In May 2018, 192 postoperative transgender patients wrote an open letter to WPATH expressing some concerns about the current system in which surgeons offer resource-limited patients “free or low-cost surgery to get a complication rate with preoperative counseling”. academic publications and public speaking about surgical experience, experimental surgery without informed consent, inaccurate medical information provided to patients, and inadequate aftercare for patients.
“There is still an imbalance between demand and the number of people trained in these procedures,” said Dr. Lauren Schechter, president-elect of the American Society of Gender Surgeons. “Of course our goal is to educate more people so that people don’t have to travel, at least in key areas… So there is also a delay between properly educating people and launching institutional centers [and] hospitals. ”
Reducing delays to meet the growing demand for gender-affirming procedures often means reducing valuable training opportunities for hospitals and surgeons. “Basically, two steps forward and one step back,” said Jamison Green, former president of WPATH and current director of communications, of the surge in surgery. Taking a step back, he said, some surgeons may choose to train under the toughest conditions: “They don’t join WPATH. They do not allow themselves to be taught. then They say, “Oh yes, now I know what to do.” As one anonymous surgeon quoted in a 2017 survey: “Someone goes to people with prestigious names; they study for a week and then start doing it. totally unethical!”
Changing insurance plans and laws governing U.S. insurance companies mean that transgender people often seek out such procedures for fear that insurers may change their coverage rules when screening potential surgeons. Insurance coverage often dictates where patients get care, like Danielle, a 42-year-old trans woman who lives in Portland, Oregon and relies on Medicaid. In her state, some gender-affirmation surgeries are covered by the state’s Medicaid program, but in 2015, Danielle felt the need to do so as soon as possible as medical care for transgender people became a Republican political goal.
“I thought before we have a Republican president, I need to have a vagina,” she told Jezebel in a spring 2018 interview. When Medicaid sent her to Portland to see Dr. Daniel Dougie, she told her she was his 12th transvaginoplasty patient. When she woke up from the anesthesia, she was told that the operation would take twice as long because her genitals were difficult to open.
Although she said that her visual and sensory results were good, Danielle’s experience in the hospital left a lot to be desired. “No one in this ward knew how to deal with people’s injuries,” she said. She said she felt abandoned and rushed to help after a lengthy and invasive procedure. Jezebel spoke to several of Dr. Dougie’s other patients, and together they eventually filed a formal complaint with the hospital. While Daniella’s complaints were about her experience of post-op care in the hospital, others struggled with serious complications, including fistulas and urinary incontinence after surgery. According to a source familiar with the group’s discussions with the hospital, the group believes the hospital has a much higher complication rate than other hospitals offering similar procedures.
In response to several Jezebel questions, Dr. Dougie said the hospital does not engage in specific interactions with patients due to privacy laws, but acknowledged that the staff spoke extensively with transgender patients. “We participated in several face-to-face meetings with individuals and groups over time. These meetings continued until consensus was reached on current patient concerns, goals of the discussions were reached, and a relapse prevention plan was developed,” Dr. Dugi wrote in an email.
Specifically, the hospital has established a Community Advisory Committee of local transgender and gender non-conforming individuals who consult with staff and management of the OHSU Transgender Health Program, Patient Affairs, and other stakeholders.
Dr. Dougie informed Jesabel that surgical complications at the hospital were monitored and used to improve outcomes, with complication rates matching or exceeding published results from other specialist surgeons. “Our surgeons strive for excellence, but sometimes there are complications,” he said. “All OHSU clinicians conduct regular internal reviews of their medical and surgical outcomes through morbidity and mortality meetings coordinated by each department’s director of quality.”
Dr Dugi noted that staff concerns about the quality of care and outcomes have been raised to a peer review process that can then be passed on to institutional review boards. “All medical centers follow this standard and are determined by national accreditation bodies,” he said.
While OSHU patients discussed possible reforms with hospital management, some of Dr. Rumer’s former patients went to more extreme lengths. During 2018, four former patients of the surgeon filed separate malpractice suits in court for the Eastern District of Pennsylvania. They were each represented by the same law firm and claimed that Dr. Rumer’s work was so badly done in their cases that the plaintiffs (all New Yorkers) needed revision surgery at Mount Sinai.
Each of the plaintiffs described narrowing and damage to their urethra, vaginal canal, and labia, as well as bulging or deformed clitoral hoods, issues known as “permanent damage” such that the plaintiffs “can never have sexual function again.”
The lawsuits, which describe the “humiliation” and “severe psychological trauma” caused by Dr. Rumer’s work, originally called for a jury trial, but were eventually referred to voluntary private arbitration. In one case, lawyers intend to sue Dr. Jess Ting, a surgeon and professor of medicine who specializes in GRS at Mount Sinai, according to a pretrial memo. He is expected to testify that even after three surgeries, Dr. Rumer’s work did not allow the plaintiffs to “achieve orgasm or sexual satisfaction without pain”, as well as solve other important problems, including “oversized clitoris without a clitoral shield” and hair no clitoris. removed correctly.
“As a surgeon, I can tell you that every surgeon has bad results,” said Dr. Ding Jezebel. “We all have complications and things don’t always go the way we want them to. When you see a pattern of outcomes that suggests a surgeon may not be up to standard of care, you feel the need to speak up.”
In a pre-trial brief filed in late February, before the case went to arbitration, Dr. Rumer’s lawyers argued that the surgeon was not negligent, did not deviate from the standard of care, and that the patient’s problem was a “recognized complication.” “[c] Vaginoplasty. The complaint also states that the patient “did not work while treated by Dr. Rumer” and that the 47-year-old did not report major problems until more than a year after the operation. Details of the arbitration process and its results were released not made public, v. Rumer None of the plaintiffs in the doctoral case responded to numerous requests for an interview.
“As a doctor, no one likes malpractice suits,” said Dr. Dean. “This is a very uncomfortable topic for me as a defendant of malpractice. Having said that, I feel that as practitioners in this very small new area, we need to look after ourselves and maintain standards.”
Jezabel contacted several well-known gender surgeons to ask how many of Rumer’s former patients underwent reoperation to correct her findings. Most understandably declined to comment, but the three people, who asked not to be identified, followed more than 50 patients who had initially contacted Dr. Rumer for GRS since 2016.
“We all want transgender people to have more options for surgery, and we’re doing everything we can to educate and promote better outcomes,” said Dr. Bowers, a San Francisco-based gender surgeon. surgical complications, anger and hostility towards complainers, lack of availability or accountability. She added that Dr. Rumer “also understands the vulnerability of patients desperate for surgery with relatively few surgeons.” ”
Hannah Simpson, a 34-year-old transgender woman from New York, said that two weeks after undergoing GRS with Dr. Rumer in the summer of 2014, she noticed that her vulva began to look asymmetrical and parts of it very red. and swollen. Despite Dr. Rumer’s assurances that everything was fine, Simpson developed necrosis of the vulva.
Simpson, who was studying medicine at the time, described her new vulva: a deformed clitoris that was “one-sided” and a labia that “looked more like a bump than two flaps.” Simpson also had other complications, including vaginal hair that surgeons promised to remove and the odd placement of her urethra. In addition, Dr. Rumer left extra tissue around the entrance to the vagina, which made the dilation very uncomfortable, Simpson said. On a subsequent date, and then in a subsequent email that Simpson shared with Jezebel, Dr. Rumer blamed the dead skin on a Depends Simpson pair that Simpson had worn too tight in the hospital, which Simpson considered an evasion problem. Dr. Rumer refused to answer Jezebel’s questions about how she treated this patient or any other patient.
Necrosis like Simpson’s necrosis is a risk with any vaginoplasty and can be caused by wearing too tight underwear in the early stages of postoperative recovery, although it can be difficult to pinpoint the exact cause in this particular situation, Schechter said. infections in the patient. “Infection, tissue necrosis, suture dehiscence – all this happens with any operation,” he said. Schecter noted that postoperative travel and a dirty or unsafe home environment can also lead to complications, but ultimately the surgeon must advise the patient and ensure that these risk factors are minimized.
A second operation with a different surgeon was unsuccessful in restoring Dr. Rumer’s original work and even led to other problems, and Simpson did not have a clitoris. By her own count, she has now consulted 36 surgeons to reconstruct her genitals. This experience disillusioned her in the medical profession and she stopped pursuing her medical degree. She did not use any formal means of filing complaints, fearing that this would lessen the likelihood that another surgeon would take over her case.
Simpson’s complaints about Dr. Rumer’s work are similar to those of other former patients who spoke to Jezebel. “I have always warned people to stay away from Rumer,” said Amber Rose, a 28-year-old non-binary from Boston. In 2014, they went to Dr. Rumer for hip surgery because of all the options offered by their parents’ insurance plan, the surgeon had the shortest waiting time.
Rose’s operation didn’t go as planned. “Rumer left a lot of erectile tissue under my labia minora, which could be a problem,” Ross said. “It didn’t look like a vulva.” Even other doctors, they said, “at least once tried to insert a finger into my urethra because it wasn’t obvious.”
Ross said that Dr. Rumer did not build a clitoral hood, leaving their clitoris completely open for stimulation. Also, Rumer’s hair removal method failed and left some hair inside the labia but not in the vaginal canal itself. “He kept accumulating secretions and urine, and he got so smelly that I was afraid of it for the first year,” they said, “until I realized there wasn’t supposed to be hair in there.”
According to Ross, six years later, they are still unhappy with their operation and are concerned that Dr. Rumer operates on transgender people. But they say their frustration also stems from systemic problems with the procedures: a shortage of GRS doctors and long waiting lists, meaning people like them have few options to choose from and not enough information for the surgeon.
Buttock surgery for transgender and transgender people is multidisciplinary and requires expertise in plastic surgery, urology and gynecology. Each of these disciplines has an independent committee responsible for accreditation. Recent attempts to quantify the vaginoplasty learning curve suggest that 40 procedures are required to fully learn the technique. Without approved fellowship or apprenticeship guidelines from WPATH or any other professional body, patients will have to undergo a wide range of surgical standards for the rest of their lives.
Individual hospitals are ultimately responsible for determining who is authorized to perform certain procedures in their facilities. Dr. Schechter told Jezabel that hospital boards typically require surgeons to be certified by at least one of more than 30 medical boards across the country, and may have different minimum training standards for potential surgeons. But according to WPATH’s Greene, there is no medical board that specifically certifies individual surgeons to perform gender-specific surgery: “I’ve been pestering surgeons to get societies like the Society of Plastic Surgery to try to figure out how to do this kind of training. as part of the board exam so you can get certified,” he said. “Because now, so to speak, they are not certified for specific diseases.”
Currently, the American Society of Plastic Surgeons holds a general board certification but does not specifically deal in sex-related procedures, meaning that affiliated surgeons do not have to meet certain training standards to perform genital surgery on transgender patients. Green said that this is an institutional structure that is not suitable for the current tasks. “Now we have urologists, gynecologists and various microsurgeons involved in genital reconstruction. So it’s a lot harder than before,” he said. “But no board is ready to accept that.”
To fill the void, physicians such as Dr. Schechter and others who specialize in gender-affirming care have banded together to fight for a more standardized education system for hospitals looking to enter the field. In 2017, Dr. Schechter co-authored an article in the Journal of Sexual Medicine outlining some of the minimum training requirements for future surgeons.
According to the report, surgeons who perform sex-confirmation surgeries must undergo extensive training, including seminars, in-office sessions, hands-on and post-operative care sessions, as well as ongoing professional development. While these recommendations will improve the quality of education across the country, they remain voluntary for individual hospitals and surgeons. Non-profit organizations such as WPATH have traditionally attempted to meet training needs but have not been able to make system changes on their own. The organization conducts its own surgical training, which began during Green’s presidency from 2014 to 2016. But for an organization like WPATH, the cost of training can be prohibitive, and it remains optional and free for surgeons who really want to do their job.
Some, such as counselors working in LGBT primary care centers, assist patients with gender-affirming surgeries, and in 2018 organized a WPATH open letter recommending a “center of excellence” model in which insurers and professional organizations work together, to guarantee only paid insurance. surgeons trained in specialized programs. (The model, he says, tackled similar problems in bariatric surgery in the early 2000s, providing specific outcome data and tightening restrictions on surgery when faced with similar problems.) Blasdel notes that while some medical institutions have recently began to call themselves a “transgender center of excellence”, “Currently there are no criteria that a surgeon or institution must meet in order to receive this title.