The Skinny Confidential Him & Her Podcast - Dr. Michael Safir On Understanding The Transgender Experience, Empathy, Compassion, & The Ability To Look At Life From Different Perspectives

Episode Date: December 2, 2021

#414: On today's show we are joined by Dr. Michael Safir. Dr. Safir is a board-certified urologist in San Francisco who specializes exclusively in gender-affirming bottom surgery procedures. With sub-specialty certification in Female Pelvic Medicine and Reconstructive Surgery.  To connect with Lauryn Evarts click HERE To connect with Michael Bosstick click HERE Read More on The Skinny Confidential HERE For Detailed Show Notes visit TSCPODCAST.COM To Call the Him & Her Hotline call: 1-833-SKINNYS (754-6697) Check Out Lauryn's NEW BOOK, Get The Fuck Out Of The Sun HERE This episode is brought to you by The Skinny Confidential  The Hot Mess Ice Roller is here to help you contour, tighten, and de-puff your facial skin and It's paired alongside the Ice Queen Facial Oil which is packed with anti-oxidants that penetrates quickly to help hydrate, firm, and reduce the appearance of fine lines and wrinkles, leaving skin soft and supple. To check them out visit www.shopskinnyconfidential.com now.  This episode is brought to you by Oshēn Salmon Oshēn Salmon was created for those who longed for their perfect protein match. One that was easy to prepare, packed with protein, and made us glow from within. Hello omega-3s! Ocean raised salmon has more than 1,500 mg of Omega-3 content which is double the Omega-3 contentus versus most wild salmon. To get your box of Oshen visit www.oshensalmon.com and use code SKINNY for 15% off plus free shipping.  This episode is brought to you by Reliefband  Reliefband is the #1 FDA-Cleared anti-nausea wristband that has been CLINICALLY PROVEN to quickly relieve and effectively prevent nausea and vomiting associated with motion sickness, anxiety, migraines, hangovers, morning sickness, chemotherapy and so much more. Visit www.reliefband.com and use promo code SKINNY for 20% off plush free shipping and a no questions asked 30-day money back guarantee.  This episode is brought to you by Manscaped This holiday season I’m giving thanks to my friends at MANSCAPED™. Do I tell my extended family that I bought my man the Performance Package 4.0. from the global leaders in below-the-waist grooming? I am in love with their products and his confidence has shot up since he started using them for all of his grooming needs. Gift your man MANSCAPED™ this holiday season so his tree stands taller if you know what I mean. Help him join the 2 million men worldwide who trust MANSCAPED™ with 20% off + free shipping with the code SKINNY by going to www.manscaped.com This episode is brought to you by Brooklinen Give the gift of comfort this holiday season and save while you do it! Go to www.brooklinen.com and use promo code SKINNY for $20 off with a minimum purchase of $100 Produced by Dear Media 

The following podcast is a Dear Media production. She's a lifestyle blogger extraordinaire. Fantastic. And he's a serial entrepreneur. A very smart cookie. And now Lauren Everts and Michael Bostic are bringing you along for the ride. Get ready for some major realness. Welcome to The Skinny Confidential, him and her.

Well, initially, there's sort of a flood of emotions. Like, you would assume every one of them would be positive, but sometimes not. Like I said, some patients are grappling with other mental illness that isn't immediately solved or cured when they have the operation. So there's a powerful emotional period right after surgery, during the hospitalization, the patients recognize, wow, I'm excited I had this operation, but oh God, I have to recover from this operation now, and I'm worried about wound healing

and all these sort of things. And as the patients start to heal and feel really complete, they share that with us. And frankly, as you might imagine, that's emotionally the most powerful time for me. Hello, welcome back to the Skinny Confidential Him and Her Show. Today, we have a very different episode for you, but I feel like that's what's fun about this podcast is it's like a bag of Chex Mix. You never know what you're going to get. And today's episode definitely does not disappoint. This is a subject that I personally did not know a lot about. I am a curious person by nature. I was talking to my friend Libby about

this subject and she brought up her friend who would be an incredible podcast guest, Dr. Michael Safer, and we decided to have him on. So Dr. Michael Safer is a board certified urologist in San Francisco and he specializes exclusively in gender affirming bottom surgery. And this is a subject that I think is a sensitive subject. And we wanted to really showcase our curiosity on the podcast in front of all of you guys. So you kind of get a very him and her perspective. Michael has his questions. I have mine.

Well, I think because we can't be the only ones that are curious about this subject, how to address this subject, how to be sensitive around it. And we're never going to be perfect in these things. But I think these type of conversations are ones that open up understanding and compassion and conversations for others to have and make people comfortable to actually have these conversations and ask the questions that they want to ask. Yeah. And we've had Gigi Gorgeous on.

She's trans. And then we also've had Gigi Gorgeous on. She's trans. And then we also have had Caitlyn Jenner on and she is also trans. And to hear their stories, I personally wanted to understand more about the process and what that looks like. And this podcast is not a stance on any which way. It's just a conversation. And for me, me, I personally want to be able to have more conversations that are not so black and white. I think that it's important to just be able to talk about things without having all this contention all the time. And so that's what this episode is. It's a genuine conversation. Well, I think we live in a time where people are expecting other people to just know everything,

know how to think, know how to behave, know how to act, know what kind of questions. And that's just not how life works, right? The way you get to understanding and the way you start to actually be able to have conversations and questions answered and open up room for compassion and understanding is by having hard conversations, right? And it's not to say this is a hard conversation, but it's not a conversation that's had so frequently, especially from both of us. So hopefully this opens some eyes, hopefully this opens some ears and creates a space where people can start to have a little bit more understanding around this subject. Yeah. So we talk all things. We talk about surgery. We talk about turning a

penis into a vagina, a vagina into a penis. We talk about transgender experiences, what it looks like for someone to even come to Dr. Michael Safer. And I think this is a really interesting episode. If you want something more beauty and wellness, I just put up an episode on Get the Fuck Out of the Sun. It's my last and final episode. It's a solo episode and I really dive into skincare. So that's what you can expect with the Skinny Confidential. You never know what you're going to get. One second we're talking about transgender surgeries and the next second we're talking about skincare. With that, let's welcome Dr. Michael Safer to the Skinny Confidential Him and Her podcast. This is the Skinny Confidential Him and Her. I need to know how you got into this unique line of work.

Yeah. Yeah. It's really sort of an interesting story. I went to medical school, did a residency in urology. And at that point, I was trying to decide what I wanted to do. I was lucky. I was younger than a lot of the people who were finishing training, and I had a couple of years to play with. And I was lucky. I was interested in reconstructive surgery. And when I was training, there really wasn't a terribly large field of reconstructive surgery for people that wanted to do genital surgery. So I was lucky I was able to coordinate something where I would train at UCLA and UCSF over the course of a couple of years and really get into some of the more unusual reconstructive

urology procedures that very few people were performing. And ultimately, I was in reconstructive urology for the cisgender community for about 15 years or so or more in LA. So I was not taking care of trans patients, but had a really powerful interest in it. And I went to Serbia, of all places in Eastern Europe, to visit with a surgeon who was doing transgender surgery and see what he was doing and came back really fascinated and energized. And I remember saying to my wife, you know, if I could find a system that was put together where they were doing a lot of transgender surgery, I think I'd be a great person to do this because of my weird, unique training. And so I was recruited a little less than five years ago by a group, the Crane Center in San Francisco, to start doing this surgery. And I had a really pretty comfortable

life here with my kids and my wife and our dog. And I remember talking with Rob and my wife, and I was like, you know, this is a great opportunity for me and it's wonderful surgery. And it's really taking advantage of some of the surgical skills that I have. And she knew that I had gone out and visit with a transgender surgeon in Serbia. And so we talked about it and sort of figured out a way to make it work for us. And so I've been doing exclusively transgender surgery for about four and a half years in San Francisco. And like before that, I was just doing reconstructive genital surgery, patients who had incurred some sort of injury or they had cancer surgery or, you know, because for me, it was always my inclination and my training to try to take care of the most underserved people, the people that were really having the hardest time.

There are sexy areas of surgery. And at the time, they weren't reconstructive surgery because we dealt with uncomfortable topics like incontinence and embarrassing things. And that was my forte. That's what I wanted to do. And that's sort of what I also saw in transgender surgery. How has the landscape changed from today from 10 years ago? I mean, it seems to me that it's completely changed. But to you, how has it changed? Yeah. Well, I think we can see it in a lot of different ways. We can see it that academic hospitals are embracing this and hiring surgeons to do this kind of surgery,

that it is a diagnosis code now so that it's deemed a medical disorder. And that's something that didn't exist maybe 10 years ago. Doctors have begun to understand and embrace this, which you would think they initially would get on board pretty quickly. But like any institution, there's an inertia that has to change to make people interested in something that they don't feel comfortable with and certainly they don't understand a lot about. So I think that people are really starting to come around. It's mainstream medicine. Patients are coming out of the woodwork to have surgery done. They feel comfortable. Adolescents are beginning to talk with people about what's going on in their lives and seeing that there's surgery out there

that works, that is up to date and modern and state of the art. And so I think, and it's been a gradual progression, I think. We were talking off air a little bit before this, kind of about the progression of, you know, how a patient would come to see you. And I always try to, you know, like we want to present all different aspects on this show, but also in a responsible way. And I thought what you said was insightful that, you know, people are kind of coming to you once they've done a lot of work on themselves, you know, with their families, with their counselors, with their partners, with, you know, individually. And you're kind of like the last stop. Can you talk about that a little bit on air? Yeah. Well, I think it all starts with someone who's young and find

someone who will listen to them. And hopefully it's a parent. And if not, it's a teacher. And there are a million really important steps that occur before a patient ever comes to see me. And I just want to point out how respectful and appreciative I am of all of the leaders, healthcare leaders that are not surgeons, who are primary care doctors and therapists and gynecologists and urologists who are sort of on the front line dealing with patients. So typically what'll happen is, you know, a child will express some discomfort that they're having about their gender. That'll start to be unraveled with the help of parents, pediatricians, primary care doctors, endocrinologists who talk with young people about hormones and hormone blocking agents. And then they'll make a decision about where things are going. And typically,

surgery doesn't occur until patients are sort of pubertal and beginning, for instance, to develop breasts or something that would be embarrassing if they weren't presenting as that gender. And they would see someone we would call a top surgeon. And we have top surgeons in our practice. I'm a bottom surgeon. So top surgeons who would deal with male to female transgender patients, female to male transgender patients, non-binary patients, and try to sort out how an individual wants to present. And those operations are done typically before patients become 18 years old. And it's really only after they're 18 that they're enabled to undergo bottom surgery. These are big operations. They're irreversible. They are defining moments for patients' lives.

That's kind of what I wanted to ask you because I was just thinking like as a parent, obviously you're always looking out for the well-being of your child and some of these procedures or the procedure is irreversible not to tell anybody how to live their way or not. But I think when I was a kid, you get wishy-washy on things or you make decisions like how much work is done in order to actually make sure that before you do a procedure, this is not only the decision of, I guess, now the adult, but also walking the parents through that. Because like you said, it's irreversible. Right. Patients are always under the care of therapists and hormone providers. And before any surgery is done, we have opinions drafted. We have letters written by usually two therapists, one of which is a PhD or an MD, the other

which can be a social worker or another therapist, as well as a medical doctor who is their hormone provider. And typically, they have been living and presenting as another gender than they were assigned at birth. And this is something that has occurred from a very early age. So this has been an ongoing process for most of these patients for five, 10 years before they're seeking out surgery. And if there are any concerns about the letters that are drafted by the therapist or hormone providers, we look into that obviously a lot more deeply. And it's never like, I want to have surgery.

Okay, let's do the surgery next month and get your teed up. This plays out over a long period of time, multiple therapists, multiple doctors, surgeons, and an opportunity to put the brakes on if there's something that is a red flag or concerning. What's a red flag? What's worse? You guys stop and you say, this is looking fishy. This is feeling weird. Right. It's pretty unusual, but it would be someone perhaps who doesn't understand the scope of the surgery, understand the full extent of the changes that are going to occur in their body. We have a really cool process called confirmed consent,

during which a patient watches a video about the procedure and then has to answer questions, not only questions that are germane to the actual operation, like, hey, you know, these changes are going to occur, true or false, but also questions that probe their cognitive function. Does this patient really understand enough to be able to offer informed consent about having the procedure done. And so it's only after they pass that whole process that we start to move things forward. And so there are a lot of steps that we take. Most of the red flags, as you're asking, have to do with just, you know, just patients think it's just going to be a simple procedure, no possible complications. Patients who are unaware of the reversibility, you know,

believe that it is reversible. Or there are issues where, you know, we're talking with the patient and we just don't establish a rapport. Like we think that there's something that concerns us about the patient going into the surgery and we'll put the brakes on and not say, oh, you can't have the surgery done, but hey, let's sit down and talk about this a little bit more broadly. Let's get in touch with your therapist. Let's address these issues because we know how important it is to the patients.

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That's O-S-H-E-N-S-A-L-M-O-N.com. Ocean raised, ocean loved, salmon as it should be. I imagine in this line of work, you see a lot of depression, anxiety, even suicide. Yeah. How has that changed? Maybe it's gotten better now. And how do you guys sort of help people navigate through that? Yeah, it's really hard for the patients, and I'm really deeply respectful of their whole process. And self-harm is really, really common, really, really common to the point where for some of our reconstructive surgery, we use one of the forearms, and people that practice self-harm have cutting scars across their whole forearm. These are things that we look for when we're examining patients and talking with them about the surgery. So depression, anxiety are really, really, really common.

And thankfully, in addition to the work that the therapists do to help sort out gender issues, they're also addressing depression, anxiety. Many of our patients are on medication. Many, many patients, you know, attempt suicide at some point during their transition, during dark moments and deeply dark moments for them. And it's elucidated in letters that are drafted about patients. And the situations are heartbreaking. And all you can be is a cheerleader for the patient to say, look, I'm going to do this. It should help you. This is the scope of what I'm doing. This is the way it's going to help. Depression, anxiety aren't going to go away because you've had a cool operation that changes you in important ways. So those are going to be ongoing things that need to be dealt with. Suicidal ideations don't necessarily go away because of surgery, but I can tell you from personal experience, having done hundreds of these operations,

just the sense of well-being is really powerful in the patient and helps them to focus on the other mental health issues that need to be addressed. Before there was doctors like you, and I don't know if it's 20 years ago or 40 years ago or 80 years ago, whatever, what were people doing? Were they doing procedures illegally and going down to Tijuana? Were they self-mutilating? What were these people who were struggling so bad with their gender doing? Yeah. The answer is yes. They were doing everything. They were foregoing surgery. They were living in the shadows. They were not presenting as they wanted to. The ones who did have surgery, some of them went to Thailand to have surgery. And so, you know, patients had opportunities to seek out care,

but the opportunities were kind of sparse. And frankly, the surgery was not quite as advanced. So a lot of patients were, they were a little bit reluctant to have surgery done when they knew the results weren't going to be so promising. And so, I mean, when I was growing up, there was Renee Richards, who was a great tennis player who I watched play at the U.S. Open. And Renee Richards was Richard Raskin, who was a prominent male ophthalmologist who went through this process. So for me, and I used to love to go to the US Open when I was growing up in New York, I saw Renee Richards play and it was really a powerful thing for me to, you can understand this is sort of like late seventies, you know, where you have someone who is transitioned and they really playing out on the world stage and on a tennis court in front

of thousands of people. So there were some people who were seeking out care, but it sort of exploded now that the surgery is better, now that patients are finding resources to help them earlier in life. I think that no American is unaware of the transgender issue now, which is very different than probably it was 20 years ago. How do you walk people that are in these people's lives through this process? Because I think that's where you start to lose people, right? It's like they just cannot contextualize or even begin to grasp and understand how somebody could be feeling. That's right. And that's a great point because the diagnosis of gender dysphoria, which is what our patients are experiencing, is something that I don't experience.

And I can't tell you what it is like to experience that, what it's like for that to get worse or better. I can only learn secondhand from having seen hundreds of patients and trying to understand what their struggle is and the things that I can do that make them feel better, the things that I can do or others can do that make them feel worse. And so the short answer is we can all just do our best to understand what they're experiencing. And, you know, and I think part of it is people are uncomfortable asking questions because curiosity about it can cross a line to where that's why we wanted to do this podcast we wanted to do it because i feel like when you talk about it then

you take the unknown out of it which is where the fear comes from right here's i think this what happens in the world is like i think probably at a high level but i think it's a lack of understanding and a lack of empathy right because you can only see the world from your worldview right you it's it's impossible for some of us to adopt and say okay maybe you can only see the world from your worldview, right? It's impossible for some of us to adopt and say, okay, maybe I can look at the world from somebody else's different point of view. And it's hard to put yourself in those shoes. And then the other part of this, I think, you know, you watch the news cycle and there's different types of groups that maybe hijack a movement and take it too far. Like, for example, if I come out and start identifying

as a squirrel, right, is that okay or is that too far? And I think you start to kind of like, you make the focus so broad that people are like, okay, I'm going to disregard a majority of a population because this another area I don't understand. Does that make sense? Am I stumbling there? Yeah. No, I think your point is good. I think it all begins like everything else in our lives with education. And what's interesting about this is we never got this education. When I grew up, there was an individual in our community and people were like, oh, stay away from that person. Somehow what they're doing by dressing as another gender is going to make them want to molest a child. And so we're not supposed to.

So, like, we've been miseducated on this. And some of it is just to go back to the basics and say, wait a second. There's gender and there is sexuality. I really want you to explain the difference. Right. And I think this is a really important conversation. Right. Well, I think sometimes the easy way is to say it like if you have a nurse who sees you in the pre-op area before your gender surgery and you think your nurse is hot, male or female, you're going to wake up thinking your nurse is hot when you wake up. Huge distinction between sexuality, who you're

attracted to, and gender, right? So no one changes because they had an operation on their skin and soft tissue of their body. Your attraction is who you're attracted to. Now, you know, sexuality can be fluid and change, but it doesn't change because you've had some operation on your skin, an operation to change how you look and how you feel, right? And so sometimes simple things are helpful, like just that image of, you know, if someone is attractive to you, that doesn't change, you know? And it's sort of like when we were growing up and it would say sex, male or female, and we all would like giggle, like sex, like what are they

talking? That's gender, right? And so it's just a matter of starting to have a dialogue that introduces us to the vocabulary, introduces us to, you know, just some themes that run through sexuality and gender, and sometimes some really simple, ridiculous, you know, examples to help you understand maybe and crystallize what may be a difficult thing to understand otherwise. Let's talk about the vocabulary. Let's pretend we're talking to a kindergarten class. No one knows anything about all the different kinds of gender and pronouns. How can you explain, you mentioned earlier cis, like explain it all to us in a very easy way. Right. Well, there are many, many genders and that is something that is fluid and changing. And it's changing because people are defining themselves in certain ways and we are learning of new genders.

I think it's sort of... But let me, so let me, let me ask you this, because I think this is where people start to get confused and overwhelmed. I can understand if you identify as male, female, like, you know, that's as humans, like at birth, biologically, we're assigned one there. I think where people start to get confused is when you, there's thousands and thousands of things and you can just identify as anything. And then the world's kind of supposed to just get behind. When you ask a large group or an established society to just start kind of going along with everything, I think that's where people start to have a rough time. Yeah. Well, I think the easiest way to understand this is to say, I can't understand right now or appreciate all of the possibilities of gender,

but who is this person that is in front of me? And so that's something as humans we can deal with. And the most rudimentary way that we deal with this is to understand what an individual's pronouns are. And that's why you're hearing so much about pronouns. And it seems like on the one hand, such a mundane topic, like why is, why is it, but it's really important because it's, it's intrinsic to who you are. It's, it's, it's like someone coming up to you and misgendering you, and you've worked your whole life to present a certain way, and you've gone through painful operations, and you've gone through mustering the courage to walk out of your front door as a different gender or presenting as a different gender than you did before and suffering glances of people, right? And so the pronoun thing is really important. And so

I think being respectful of someone's pronouns, I think, is a good start. I think if there is a question that you have and you're uncomfortable about something, just say, I'm uncomfortable asking this question and I want to be respectful, but can you tell me something because I'm not understanding this? And I think gradually everyone will be more comfortable. This situation is itself in transition. Sure. Right. And we're all learning the vocabulary, the nomenclature. And I think that the key is, is just be respectful. Ask someone what their pronouns are, respect their pronouns. If you have a friend who's being misgendered and they're talking about your friend, clarifying that conversation is, I know that Steve likes to be

referred to as he or him, and the words that you use weren't really descriptive of how Steve is presenting, and just a heads up that if you're addressing him, it's appropriate to use the pronoun him. And we all grow up with certain biases in conservative households. I grew up in a very conservative household where, you know, this wasn't necessarily a direction that you might've imagined my life to go. I think the important thing is, is it's not about me and it's not about you. It's about the other person. That's how I feel. I just think everyone should be able to live life how they want to live it. I mean, and I hope I instill in my own daughter like she should be living life on her own terms, whatever that looks like for her. I don't want to push my ideals and my opinions onto her

when it comes to how she feels. I would like to know, though, just going back to this, about the vocabulary. Because I think that everyone wants to be very respectful, especially right now, I think because people are learning more. What is the proper vocabulary? Okay. So ever since we moved to Texas, Michael insisted on getting this completely unnecessary, huge ass bumpy car. And what it's given me is one thing and that's car sickness. So thank you, Michael.

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Why I like this is it's 100% drug-free. It's non-drowsy and it provides an all-natural relief with zero side effects. Really though, it's for anyone that gets nauseous, right? So if you have any kind of nausea from any kind of symptoms, this is what you would do. You wear this band. It's completely easy. Like Lauren said, it's all natural. It's safe. You put it on, you get rid of nausea right away. And it's one of the least intrusive ways to battle nausea. And here's how it works because I'm always interested in the research of it. It stimulates a nerve in the wrist that travels to the part of the brain that controls nausea. So then it blocks the signal to your brain

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So head to ReliefBand. That's R-E-L-I-E-F-B-A-N-D.com and use our promo code SKINNY for 20% off plus free shipping. Again, there are a lot of pronouns that are out there, a lot of genders, and you can't possibly at this moment memorize all of them. An easy starting point would be to understand what transgender is, what non-binary is. And that's a good starting point. People who are non-binary are people who say, I don't define myself as one or the other gender. So binary meaning one of two things, that's not me. And so what I want to do, so referring to someone as non-binary means that that person is not defining themselves as male or female or even trans male or trans female.

And then there's transgender, the implication that someone was assigned a gender at birth and doesn't want to present as that gender. It doesn't mean that they've had surgery. It doesn't mean that they want surgery. It doesn't mean that they'll ever have surgery. But they're presenting a way that is different than the gender they were assigned at birth. And so in general, globally, this has been referred to as a transgender movement. And a lot of the subcategories sort of branch from there. And then there are pronouns, which, again, so many of them, but they're unique to that individual, while at the same time potentially are not necessarily static and fixed and may change irrespective of whether someone has surgery or not. The one thing that you don't want to do is to express curiosity about whether the patient, whether or not the individual you're meeting has had surgery yet. That is an incredibly personal question. What do you mean?

So if you meet someone who is transmasculine, it's not really okay to say, oh, have you had a phalloplasty? Even as the doctor. As a doctor, if it is essential to the care of that patient at that moment. I mean, if you're fixing someone, a laceration on someone's forehead, it's probably not important for you to dig deep. And I have to tell you, as a doctor, I have curiosity about a lot of things. But if my curiosity is leading me in a direction that isn't important for the care of the patient, forget if we're talking about transgender issues or other issues that may be not germane to that patient's care on that day to that problem, it's really not okay to go down that road of asking patients if they've had

operations, either top surgery or bottom surgery. They may disclose that to you as they become more comfortable with who you are, but asking the question and satisfying your own curiosity is really not doing anything for that person. The person is saying to you, it's important that I am he, him, and that you refer to me that way, right now, those are the ground rules. And by using those pronouns, you know, let's hang out, let's talk, and let's see what develops. I am going to ask a question that I think is very important to ask because I think a lot of people are embarrassed to ask the question I'm about to ask. If a woman comes to you and she identifies as a man and she has a vagina, just like from a creative perspective, how do you turn a vagina into a penis? Okay. Yeah, that's a great topic because that's essentially what I do during the week is I take traditional biologic genitalia, like a vagina, and create a penis for this person. And so the person, going back to the scenario that you created, that patient would come into my office and most of them would identify as a male, right? They

wouldn't be identifying as a woman. They'd be identifying as a man or a boy or whatever. And they would say, I'm interested in having some surgery that affirms my gender because I am male and I was born with anatomy that didn't match and I want to have an operation. And so many of those patients have already had their top surgery because some of that is done before they turn 18. But after 18, we talk about the options that are out there for creating a penis. And really there are two options that are out there for creating a penis. And really, there are two options that are out there. One is called a phalloplasty, and the other is called a metoidioplasty or a meta. And there are different procedures. The goals of each is to create something that is congruent with an individual's gender.

And so typically, the way we would do the operation if we were doing a phalloplasty is to use a portion of their body, their forearm or their thigh, and create a phallus to roll it into a tube with an internal tube to pee out of with a urethra and then transfer that area of the body after closing down their old anatomy to do a vaginectomy and create a scrotum. And I mean, there are images on the internet that you can see. I mean, curiosity leads you to Google something. That's wonderful. That's an impersonal thing that you're not intruding on someone's space. But if you're curious about the surgery, there are a million photos of phalloplasties or penises that are created by us in the operating

room. When you have sex after that first, my first question is how long can you have sex? Like, do you have to wait six months? Do you have to wait a year? And then are you feeling the same feeling that a man would have if you had a penis? Yeah. The goal of the surgery is to create a penis that you can have intercourse with. And we put an implant in like nine to 12 months after the original surgery. And the question about sensation is we find with optical magnification, the nerve on the clitoris that is going to convey erogenous sensation. We take one of those nerves and we hook it up to the nerve of the forearm. And then through a process of nerve regeneration that occurs over a year, patients develop sensation of fine touch and ideally erogenous sensation in the phallus. That is so gnarly that you do this for a living.

That is so crazy. That is, it sounds like really high level work. Yeah. I mean, it's a great operation. It's sort of the super bowl of reconstructive urology that we get to do all of the time for our patients. And again, with tremendous respect, it's an amazing operation. Three surgeons, six and a half, seven hours. Wow. A five-day hospitalization, long recovery. Can you pick the size of your penis? I was going to say with respect, but I have to ask, can you?

Because if I was going to do that, I'm going to get a big 10-incher. Well, you think you are. You think you're going to get a hammer, but I don't know. Can you pick your size? Within reason, we have a discussion about size. There are issues, some limitations based upon the size of the forearm. I have a small wrist. There are things that, yeah, there are a lot of physical reasons why we can't sort of max

out the size of things. We want the patient's partner to be comfortable during sex. We don't want to create something that's going to visually be impressive but not function as a sexual organ, right? So we try to create something. We listen to the patients. We discuss things. We see what's surgically possible.

And there's balls too. Right. We create. So you can create all of that. Does it usually 100% go as planned? Or sometimes afterwards, is it not the result that you hoped for? Yeah. So, I mean, all surgery can have complications and we're operating on multiple areas of the body. And there's a lot of revision surgery that goes along with this. And so,

through the healing process, it can heal in ways that are like not symmetrical. The wounds can not all come together. One of the issues that we deal with is urination issues, like the tube that we reconstruct to urinate out of the tip of the penis. There can be a narrowing or an opening in an area that doesn't heal. And so that's sort of, it's sort of the yin and the yang of surgery, the good aspects of surgery and the yang, the parts of the operation that need revision, don't go as hoped, need another round of surgery. Let me ask you this. And again, like kind of going when things don't go as you hoped.

And just because I want to present, I just want to ask all these questions while we're here. Say somebody has one of these surgeries and after, like they think this is a surgery they want and then they go through the whole process, which is obviously a very heavy process. What do you do if you encounter somebody that has the surgery and then it's like, Hey, this is not what I expected or not what I wanted. Yeah. This is a process that goes on for years. By the time they come, they're ready. By the time they come to see us,

and it's been affirmed by two mental health professionals and their hormone provider. Well, I guess that's what I'm getting to because I think obviously with what you are doing, and we talked about in the beginning of the show, there is a lot of pre-work that is done before someone comes and sees you. But I guess maybe what I'm more alluding to is somebody hasn't done that work and then

they're jumping into something like this. Yeah. Well, I mean, there are well-established guidelines that all surgeons who do this operation follow WPATH, which is an organization that oversees surgeons that do these operations and take care of transgender patients, surgeons and non-surgeons alike, there are guidelines that we use. And we recognize that this is serious. We recognize that we don't want to do an irreversible procedure on someone. Like I said, we do this confirmed consent thing with assessing cognitive skill and is this person ready to have the operation and putting the brakes on. I mean,

there's so many steps along the way during which someone could say, not, I don't want to have this surgery, but maybe it's not the right time for me. Or if there are options with some of the surgery, I do another operation that's an alternative to phalloplasty where someone, we use their current anatomy and sort of lengthen things to create something that's a smaller penis and a smaller scrotum. And it doesn't involve a lot of the complexities of the phalloplasty.

So there may be other operations that patients are interested in, but Byers or Morrison doing an operation to reverse it isn't something I've ever had to do. Ho, ho, ho. You know what I do not want for Christmas, Michael Bostic? Let me guess. Dirty balls. I don't want cheesy, stinky, disgusting, sweaty balls. And you know who's helping me achieve that? Manscaped. I am stuffing your stocking full of Manscaped. Things like their two-in-one shampoo conditioner. It just launched. You can use it everywhere. They also have a cologne-infused body wash. Everyone can use this one, I feel like. And crop mops. Crop mops are it. I feel like the ball wipes, this is

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I'm not going to lie. Yeah, what is going on? We know it. The ball deodorant. You guys even need ball deodorant. I mean, there's obviously a huge need for this. They have ball deodorant, ball toner to keep you smelling nice down there. We want things looking like Disney on ice.

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at manscaped.com with code skinny. Cheers to rocking the best gifts of all this season. A gift for him, but really a gift for you. XOXO Manscaped. That's amazing. It's really, really great that you haven't had to reverse. What about turning a penis into a vagina and is one harder than the other? Well, I mean, they're both very complicated operations. Making a penis usually involves three surgeons. Making a vagina is something that typically one surgeon can do on their own because it doesn't involve microvascular surgery. Microvascular surgery is reestablishing a blood and nerve supply to a part of the body that was taken from another area.

So when we're making a vagina, we have to sort of take the penis, turn it inside out, and use the skin as an internal tube in order to provide depth for vaginal penetration. So they're both complicated operations, multi-hour operations, long recovery, hospitalization. They're complex in very different ways. I don't like to say that one's more complicated than the other, but they have their own complexities. Let's talk about some of the, there's a ton you've done, but positive outcomes, right? Somebody goes through the process and they transition and they have a surgery. How are they feeling after? What are you hearing from them?

What's the sentiment? Yeah. Well, initially, there's sort of a flood of emotions. And you would assume every one of them would be positive, but sometimes not. Like I said, some patients are grappling with other mental illness that isn't immediately solved or cured when they have the operation. So there's a powerful emotional period right after surgery, during the hospitalization. The patients recognize, wow, I'm excited I had this operation, but oh, God, I have to recover from this operation now.

And I'm worried about wound healing and all these sort of things. And I'm nauseated from the pain medication or this recovery is taking longer than I would have liked. And so then there's that sort of phase. And then ultimately, as the patients start to heal and feel really complete, they share that with us. And frankly, as you might imagine, that's emotionally the most powerful time for me where patients are like, thank you so much. I look down and it represents who I am or I feel more complete or more confident. You know, obviously, you can imagine how patients feel. Yeah, that must be incredible.

Very rewarding. Can you still have children either way? I think the shortest answer to that, that in general, it requires harvesting of eggs. It requires putting sperm in a sperm bank. It requires what we collectively refer to as assisted reproductive techniques. And you had Dr. Gadir on your- Yes. And he says every single guy should beat their meat in a cup and save their sperm. And he said every girl should freeze her eggs over 25. So plug for Dr. Gadir. But the reproductive endocrinologists play a really important role.

And this all transpires before surgery and may delay them having their bottom surgery. So is that part of the process saying like, hey, as you're going through, if you are thinking about having children, there's a suggestion to say, hey, do these things or think about doing these things before. Well, typically they explore these issues because they get on hormones

that may work against the viability of their sperm or of their eggs. And so they begin to explore this with their hormone provider at the outset of typically when they start getting hormones. And so this has been something, and we talk about it during the consultation. And if the patients are thinking of having kids, we sort of explore that and talk about what's going on with their partner and what have they done so far, and then come about with a resolution as to whether it would be more prudent

just to wait on things and let's talk in six months or a year. Yeah, those conversations happen a lot. I think that this is an important thing to discuss what I'm about to say. I think it's important to talk about people who don't have the access or the money to do this and are maybe living in poverty. Is there any kind of grant that they can get? Is there financial aid? What are some resources for someone who just can't afford to do this, but they know that they want to do it. Right. I think most people are surprised to understand that more than 90% of these operations are performed for patients who have health insurance and that their health insurance covers the procedures. These would ordinarily be really expensive procedures. And I hate to imagine anyone paying out of pocket. Some have.

But for the most part, programs like Medi-Cal typically offer this kind of surgery to their patients. And so it's not only sort of the Cadillac or Rolls-Royce insurance programs that allow patients to have this operation. It is Medi-Cal, low-income options for patients. And so those options are out there for patients. Patients gradually discover how to get insurance that allows them to have transgender benefits and not all states, thankfully, California,

allow patients to have sort of unfettered access or the potential for unfettered access to transgender services. And so it's not only an operation for people who can afford it, it's typically an operation that one way or another patients can get access to. I would like to talk a little bit about children.

How young are you seeing children uncomfortable in their gender? Is this like at two? Are you seeing this in kindergarten? Is it across the board the same? What is it like with children? Right. So most of my patients tell me retrospectively with their life what things are like because they're typically 17 or 18 by the time they see me and tell me about of kindergarten or four, five, six years old, where they thought that something was different. They wanted to be referred to as a different name. They wanted to wear different clothing. And it created a problem. It created an issue for them where either their parent didn't understand or their parents didn't yet have the tools to help them understand. It's really unusual for my patients that they live an entire adult life and then say, hey, I want to transition. Typically, the patients have had these feelings forever and only in their 50s, say, because of a change of a social situation, they get out of a bad marriage or they enter into a relationship

with someone who's understanding that they're like, you know what? I think I do want this surgery to happen. I do need to have the surgery to affirm who I am. I've been going too long without having my parts match what I've been feeling all this time. Do a lot of partners stay together or is their divorce rate higher? How does the partner usually understand? How does that work for the partner? Well, I'm fascinated with the partners and their feelings. Obviously, someone has to be very understanding. And in my experience, and I've been doing the surgery about four and a half years, it's pretty unusual that someone leaves a relationship because of the surgical changes that occur. I'll typically meet the patient and their significant other in the exam room,

either a week or a few days before surgery. I've talked to them multiple times. They've fallen in love with someone who has a certain anatomy. They love that person. They understand the journey that the person's going on. And then it's like I was saying before, if you think your nurse is attractive or your doctor is attractive, that doesn't change. Obviously, that person has to be on board for the genital transformation that's occurring. And there are people that are not up to that. There are people who are like, that isn't okay with me and relationships potentially fall apart.

You guys know I have been showing my home on Instagram stories and I've been showing the sheets a lot. And those sheets are Brooklinen. You've seen this everywhere. They have the best sheets and they're so affordable. They have like a baby pink that's so cute, especially if you have a dorm room or you live alone. And then they also have white linen sheets. And those are the ones that I like. They're super effortless and elegant. But most importantly, and this is a problem that I was having, they don't get messed up in the wash. You know how when you wash sheets and they get all fucked up and wrinkly? I don't love that. So these ones that I have, the linen ones, I wash them on cold and then I line dry them. And this really preserves

the fiber and elasticity and they look good as new every single time. If you can't lay them out to dry, that's totally fine. You can also do them tumble dry on low heat. I feel like sheets are such a luxurious upgrade to the house. So if you're shopping for the holidays and you want to get someone something that they love, I think they will love Brooklinen's sheets. They have linen, they have cotton, they have all different kinds. It's such a great gift to give someone to for the last minute because they ship very quickly. They have so many five stars. It's wild. They have like thousands and thousands of five stars. They have all different kinds of collections, but you also have to check out all the other cozy sheets that they have. You can also grab some of their candles. They're the perfect little bedroom candles. They have eye masks and accessories. The holidays are coming up

and I'm telling you, I feel like this should be on your wishlist. Give the gift of comfort this holiday season and save while you do it. You're going to go to brooklinen.com and use promo code skinny for $20 off with a minimum purchase of $100. That's B-R-O-O-K-L-I-N-E-N.com. Use promo code skinny for $20 off with a minimum purchase of $100. brooklinen.com. Use promo code skinny. Well, this is why I think that there's nuance to all of this because again, going like there's gray area in all this and where what we try to do on the show, and I know like it's not always perfect, but we try to have all of these different conversations to open up conversation and thought, and have people challenge their ideas and their beliefs, right? Like that's what we try to do here. But, you know, I know I fell in love with Lauren and honestly, then, you know,

this is now a really, you know, and her vagina. And if she turned around tomorrow and said, hey, I want to change and I want to have a penis, like I can candidly and honestly say that I would not be into that. That's because like I'm wired to like that vagina. And I think this is where people get in trouble. How far do

people need to go to one, be accepting, but also say like, hey, there's certain things that... But that's also you. Sure. You might be like that. He just said there's different sides. I am using the example of me. But so I know in this world that there is a high

likelihood and a chance that I could be attacked for that statement. And if she went through something like that, that I could also potentially be attacked for not being accepting of that. But I fell in love with my wife the way she is and I like her the way she is. And so I don't know if it's always fair to just have people say, you have to accept just because somebody else decides to change. I think they're saying that you have to accept the person, but maybe you don't have to accept the relationship if that doesn't work for you. Sure. Like I said, there's nuance in gray areas. Yeah. And I can't control how anyone behaves or pass judgment on rocky times in a relationship. People want out of

relationships for a lot of different ways. I think it's a very special relationship that is able to endure genital reconstructive surgery. It is a very, very special, wonderful, loving situation that like fills me with joy when I see couples come in and I just know. So it's not sickness and in health with Michael. No, probably not. Motherfucker. I'm going to play this clip. It's not sickness and in health. I'll let you guys talk about that later.

You guys can work on that again like in all of these conversations the challenges always arise when somebody wants to make an individual choice and then they want others in their life or around them to alter or change their beliefs and behaviors because they've decided to make that choice and it's not to say one side is right or wrong and i think like if you start with the base level of trying to accept and trying to understand and trying to be empathetic, but we also all have to respect other people's beliefs, thoughts, perspectives. Well, I think the one interesting thing that I would maybe help you understand things a little bit more is it's not like Lauren tonight is going to make a change in her life. No, no, no.

I'm using a very like- You fell in love with someone. Yes. And you went through dating. I'm using an extreme example. And you talked and- I'm using an extreme example. Maybe sometimes people already know that the person already was-

No, no, no. And that is the way that it is. It's not like she just turns around one day and says, I'm changing. I get it. And that's what I try to do when I talk to people is to dispel this notion that someone had an epiphany last night that they want to be the other gender. And I didn't understand this whole situation before I started taking care of an entirely transgender community. But this is something that happens over a gradual period of time. People probably are

in and out of multiple relationships before they find someone who understands who they want to become from a genital perspective. The person that they are is the person that they are. Yes. And so, you know, you decide you want to change your hair color or you're going to get a buzz cut or something like that. Those are superficial changes that, you know, you work out and you're like, I don't like your hair. I don't like that. But this is someone's identity is apparent ordinarily through the entirety of the relationship. And if someone is not on board with that, they're usually out of the relationship pretty early. Yeah, it's not the right relationship. To round it out, and obviously, like I told you, I was going to be playing devil's advocate here,

but I think the point that, you know, if we're leading a horse to water here, was that these people that are choosing to identify have been, they've been identifying like this pretty much for life. And that if you can't recognize that over that period of time, then maybe that's something you should step back

and say, hey, there's something here. And if you can't recognize that over that period of time, then maybe that's something you should step back and say, hey, there's something here. And if you can't recognize the struggle that you must feel to wake up every single morning and not feel comfortable in your body, for me, like that is practicing empathy. Like I can't imagine waking up every morning and being like, I feel like a guy. That's what I'm saying is it goes, it's a very long process.

It's not like somebody just has a spur of the moment. I'm saying is it goes, it's a very long process. It's not like somebody just has a spur of the moment. I'm changing my identity overnight. Right. Well, here's an example. Let's say tomorrow you were to wake up and you didn't have a penis. How quickly would you be on the phone with someone about that? Well, probably pretty quickly. I'd say, what the hell happened here? All right. So- Would you get a 12 inch? His arm's pretty big. motivator in someone's life that is driven by this crazy situation that you just were not born

with the right parts. And you got to do whatever you have to do to make that right. It may not happen today or tomorrow or a year from now. It's going to be in a process. You may be in and out of relationships, in and out of therapists, in and out of different types of clothes that you wear and how you present until you finally understand the complexities of who you are and whoever has come along that ride with you. I would challenge everyone in the audience right now to imagine waking up. I think that's really powerful what you just said. Waking up tomorrow and having a penis if you have a vagina or having a vagina if you have a penis and what you would do.

Because if I woke up tomorrow with a penis, I'm doing everything I can do to cut the penis off. The depth of what I was trying to kind of, and maybe this was a long drawn out way to do it, paint. We had Caitlyn Jenner on this show and we talked about her process, her entire life of going through this transition, right? And this was obviously somebody that was dealing with wanting to transition for a very long period of time. And was like this Olympian that was supposed to represent masculinity. The ultimate, you know, masculine imagery there, but that, you know, and so I think

in a long drawn out way trying to point out like this is not something that's just a spur of the moment quick decision. This is who these people are and they've identified this way for a very long time.

Gigi Gorgeous also came on and it was the same sort of story. Yeah. And these stories are unique and powerful. They share a lot of things. They're different in how they play out over time

and who's along on the ride with them for this. But ultimately, it drives people to undergo procedures and undergo life changes that are dramatic, not only recovering from an operation, but like now you're going to wear a dress or you're going to do something. And how do you muster the strength to do that the first day when you walk out and you show up at work or you see a friend or someone that hasn't seen you in a long time? Imagine how courageous you'd have to be to deal with that. It's it's It's incredible. If you could leave our audience with a statement

that you wish the world would know about what you do and what you've seen, what would it be? I'd say it's not about you. It's about the other person. And that's sort of like a decent life lesson that people live their lives in different ways. People are suffering from diseases that you'll never known anything about. People you've talked to today have had struggles that you'll never understand, that they haven't disclosed to you. So it isn't about you necessarily and your values. It's not really hard to be accepting of another individual. It's pretty easy. And you don't really give up a lot of who you are to be accepting. And so... And how boring would the world be if we were all the same? I mean, really, how boring would that be? Right.

You are amazing. Is there a resource that you can leave us with for anyone who is curious about this or wants to know more? Sure. They can visit my Instagram page, which is M-S-A-F-I-R-M-D, or visit our website, which is crane, C-R-A-N-E-C-T-S.com and learn a lot. There's a lot of information available on the website. You know, prospective patients can call and just figure out what the process is. And you know, it's a very nonjudgmental situation. You know, obviously we're incredibly sensitive to things and whatever patients call and need or want is what's given to them. And let's see if we can help. I have to acknowledge you because I think what you do is so incredible and I have a lot of respect for it. And I think that even you like are breaking so many barriers against these taboos.

Yeah. I mean, thank you so much for coming on the show. I think the first part of understanding starts with conversation. I fear that we're getting to a period where people are scared to have conversations, you know, scared to say the wrong thing, scared to ask the wrong question. But without that,

you can't get to a place of empathy and understanding. Yeah. Agreed completely. Thank you so much, Dr. Safer. That was absolutely incredible. One more time,

where can everyone find you on Instagram? They can reach me at M-S-A-F-I-R-M-D. Perfect. Or they can visit website www.cranects.com. Thank you, Libby, for setting this up. Thank you. Be sure to listen to my last and final episode of Get the Fuck Out of the Sun on my limited series with Dear Media. It's so fun. You guys asked me all these questions.

I answered everything in depth. And of course, a little giveaway to win a signed copy of my book. All you have to do is tell us who you want to hear next on the podcast on my latest Instagram at Lauren Boston.