We have talked in a previous episode about the different types of transitions. But since we had a chance, today, to talk to the expert. I wanted us to really narrow in and focus specifically on medical transition. We want to know what it looks like and what the risks are. And what the risk of not accessing this medical care might be. And we want to be aware enough to notice misinformation when it’s being shared. Today we’re going to break down the different types of things that might be happening with any individual in a medical transition. And we have Dr. Rixt Luikenaar in our midst to guide us through it. They literally wrote the book, the textbook, on managing health care for transgender patients.

Dr. Rixt A. Luikenaar is a board-certified OB/GYN at Rebirth Health Center in Salt Lake City. They have a special interest in transgender hormone therapy and LGBTQ health care, including pregnancy and preventative care. Dr. Luikenaar received their medical degree from the University of Groningen Medical Sciences in Groningen, The Netherlands, graduating cum laude. They have a diverse background and have completed medical missions to Tanzania and Colombia and worked as a senior medical officer in OB/GYN in Cairns, Australia, during a sabbatical, taking care of indigenous Australians. Some fun facts about Dr. Luikenaar, they are from the Netherlands. They are married. They have 3 children, and they Love sphynx cats and electronic dance music and raves. Welcome, welcome, welcome to Dr. Rixt Luikenaar.

I want to make sure we dig deep into the many different parts of medical transition. So I’m going to move pretty slowly, like baby-stepping through the questions if that’s ok. Let’s start with just talking about hormone blockers or puberty blockers. Talk to me about the treatment, who gets it, what are the risks, what are the benefits, all of that sort of thing.

DR. RIXT A. LUIKENAAR: Puberty blockers and GnRH analogs are medications that very conveniently, and temporarily, can stop somebody’s hormone production from the brain level, from the pituitary gland in the brain.. So, these are medications that can be injected. They can be swallowed. They can be inserted in a little rod in the arm and then it releases a blockage action on the pituitary gland so that there is no production of estrogen or testosterone from a person’s own body. So these benefits, in the world of Gynecology, benefit women with endometriosis, women with fibroids. And in the world of urology, people with prostate cancer. But, then, also benefits children or teenagers who go through puberty too early or those who do not like the puberty that they’re going through. So it’s used as a means to stretch time. To buy time and to allow people to think about what they want to have, what their gender identity for gender [INDISCERNIBLE].

JEN: When we’re talking about gender affirmation treatment in this medical world, what sort of ages are we talking about that can benefit from puberty blockers?

DR. RIXT A. LUIKENAAR: So when you talk about any kind of medical transition, you’re talking about people or adolescence that have started puberty. So, by no means, are these people under the age of 10 because in general — unless you go through puberty too early – puberty hasn’t started. So it makes no sense to block something that isn’t there. So you wait until somebody shows signs of puberty or feels that there are things happening to their body that are changing and they’re becoming dysphoric about it. For example, breast development, voice drop, facial hair, those kind of symptoms. And there, of course, are different stages of puberty. But that is a time where you start thinking, “OK. Maybe we should block this for this person.” And that is generally around the age of 12, for cis boys generally a bit later on, so maybe around 13, 14.

JEN: And how long do people stay on puberty blockers?

DR. RIXT A. LUIKENAAR: Jen, it varies. I honestly have nonbinary adults who are on puberty blockers because, for them, it’s an ideal way for them to block the production of their own internal hormones and maybe they chose to have a little bit of male or female hormone added to that. In general, if you look at the protocol through the World Professional Association for Transgender Health (WPATH) puts on gender health or the protocol that the Center for Gender Expertise in Amsterdam has come out with, you use puberty blockers for people between the ages of 12 and 16. And then, like I said, it can be extrapolated to people over 18 as well.

JEN: What if somebody is working with you and they’re experiencing gender dysphoria and they start hormone suppression and they’re hanging out with all of their peers and they don’t like it? They don’t like the hormone suppression. Is it too late? What damage has been caused?

DR. RIXT A. LUIKENAAR: At that point you just stop the hormone blockers. You let the shot wear off. You stop taking the pills. You take a rod out of somebody’s arm. And the body immediately recognize, “Hey, there’s no longer something blocking me.” So the hypothalamus and the pituitary glands start producing percursores and then send the sign to testicles or ovaries to produce hormones again. And the body continues going through puberty and they catch up. So, they’re, by no means much later going through puberty at that point.

JEN: So we, sometimes, as moms say to each other, “There’s not really long term consequences for puberty blockers. Is that kind of what you’re saying also?

DR. RIXT A. LUIKENAAR Yeah. If you look at these blockers used by the Center for Gender Expertise in Amsterdam, they’ve been used since the 1980s. So we have 40 years of data that does not reveal any kind of side effect or long term effect for people that have been on these blockers. So I believe they’re absolutely reversible, not damaging, and that they’re very useful for people who question their gender identity, especially teenagers.

JEN: Perfect. Is there any controversy or misinformation that you see in the news or even in state legislatures floating around about puberty blockers that we could clear up for our listeners.

DR. RIXT A. LUIKENAAR Yeah. I think there is this fear that they do something permanent or long term or can affect somebody’s sexuality or things long time. And that’s not what they’re meant to do or meant to be. And I think that, again, that’s being targeted just because of what it is. But not so much of what these medications do. So they’re good to use, temporary, for somebody that’s questioning their gender identity. And, if somebody chooses to no longer go through with a medical transition, then they can stop taking hormone blockers and they will wear out of the body. And there is no change, no permanent harm done to a person at that point.

JEN: Awesome. Thanks for being clear about that. After a certain age, some people might need or want hormones. They might want puberty to begin. So let’s start with estrogen. Who might need estrogen supplements and what are the risks and benefits and all of those things again.

DR. RIXT A. LUIKENAAR So, again, in the world of gynecology we use estrogen for many indications including menopausal, cisgender women. So we also use estrogen in contraception like birth control pills. And then we also use estrogen when it comes to a person born male who chooses to feminize their body as well as sometimes cis women who don’t produce hormones, we give estrogen hormones too, for example, certain intersex conditions. But we give it, if you’re looking at a medical transition for transgender people, we would give it to a person born male who identifies as female or more feminine and wants to change their bodies to fit their inner ways of thinking of their gender identity.

JEN: What kind of things happen to somebody’s body, let’s say a transgender woman for example. What sorts of things does estrogen cause to happen in the body?

DR. RIXT A. LUIKENAAR So the good thing is that these changes take some time, right? So you want to talk to somebody about what they can anticipate and it depends a bit upon their age sometimes. But you want to make sure, and that’s why we work with an informed consent model. That you talk details about all the pros and cons of what can happen in the beginning and long term, and make sure that somebody knows very well what those changes are and what can be expected.

So it generally goes by time. So the first three months, somebody will start notice a little bit of breast budding, a little bit of nipple tenderness. They may have a little bit of nipple discharge. But they’re definitely going to get some breast development which is the permanent change on estrogen therapy. And that’s also something that we mention to people and especially if somebody comes and requests a medical transition. We always ask, hey, are you ok with breast development because that is, essentially, permanent. And if breasts are growing, the only way to – if you’re not too long into transition there is some reversibility there. But if somebody’s been on hormones, especially estrogen, longer then you’re looking at removal of breast buds like cis boys would have gynecomastia surgery as they sometimes from the hormonal changes also produce a little bit of breast tissue. So breast tissue is an important one.

And then, of course, assuming that we have discussed the fertility aspect and the aspect on the fact that hormones can decrease someone’s fertility. And that we’ve had a discussion about sperm banking our future biological children. While somebody takes estrogen, it will decrease the sperm count. And other things that will happen is the skin gets softer.

And over a longer time, you’ll see feminine features occur in the body. So you see, kind of, a decrease in muscle mass and widening hips and facial features that are fully as your subcutaneous fat changes over time. And, hair, upper head hair becomes very lucious and thick. And then there is usually the emotional aspect where they feel more in tune with themselves and more feminine. And that’s kind of a goal when you talk to people about taking these hormones, like how affirming is it for them, and what have they noticed so far. And that’s something you continue to ask during every visit with these patients.

JEN: So you kind of touched on this already. Most of these things are reversible if somebody changes their mind, except breast development might be more permanent and need surgery to change that. How does the process work? How far into the process do people decide this isn’t working, this isn’t what I wanted, it’s not going well?

DR. RIXT A. LUIKENAAR I bring up, during every first visit with every patient, and if you look at the data and studies, the risk is less than 5%, generally less than 3%. I have not had a patient ever go to a surgeon and have their breast tissue removed that we grew with hormone therapy during a medical transition. I’ve not ever seen that.

But I always bring up with every patient, “Please come talk to me when you feel like this is something that is disappointing. It’s not what you had anticipated, It doesn’t feel right to you.” And that can be at any stage of a transition. Is it in the first month, the first three months, the first six months, the first few years. That is as somebody goes through a gender journey that is possible. And, also, that people maybe don’t choose a sensation that is as binary, right, between male and female, but that people are more looking for their own gender number.

You know, a lot of people believe that if gender could be a number, then there are so many possible genders out there as there are numbers. And you pick your own numbers. And it’s different for each person, right? So that way you can also look at each transition becoming a more individual transition then a straightforward transition with hormones towards male or female may not fit everyone. So it doesn’t mean that they regret their transition or they want to detransition. I see more often that people feel like, “Well, I kind of like where I’m at now at this point in my gender journey and I’m going to hang out here for a while.” And that’s perfectly fine, OK with me.

And what do we do to, as far as hormones that we administer, how do we keep me there in this place? Or maybe people feel like, “Well, I’ve gone a bit far over to the feminine side and maybe now I want to throw out my testosterone blocker and allow a little bit more testosterone back in my body to see how I feel when I take that.” So there is a lot of communication between doctors and patients, and maybe therapists as well, when somebody’s on a gender journey just to make sure that throughout the transition that they are ok with what’s happening to their body and their brain and their spirituality and all the different things.

JEN: I love that concept of a gender number. And I’ve never heard it before, but I’m going to start using it a lot now. So, I hear so many lies and misconceptions about transgender women. I don’t feel like I’m hearing a lot of them about estrogen themselves. Is there any misunderstanding you hear about estrogen therapy that need to be cleared up.

DR. RIXT A. LUIKENAAR I think people understand that there are permanent changes happening. I think the general concept that a lot of trans-feminine people are actually OK with breast tissue and that there’s a lot of people walking around here that we have no idea because they were compression vests or they wear binders and they wears hoodies because they’re not ready to show themselves to the world. That is happening. So I’d say, I think that one thing I want to reiterate that, for a lot of transfeminine people, breast tissue is actually very much desired and celebrated and loved. That doesn’t get enough attention, maybe, that the positivity of that aspect is sometimes frowned upon because it’s not seen as a masculine thing. But, at that point, you’re no longer talking about masculinization. You’re talking about feminization.

JEN: So, in comparison, talk about testosterone, like who might be a good candidate for testosterone supplements and what are the risks and what parts are permanent with testosterone replacement therapy?

DR. RIXT A. LUIKENAAR Testosterone replacement has been used by cis men who have low testosterone that choose to be on testosterone therapy, especially at an older age or sometimes younger people that don’t produce as much testosterone and that the doctor feels they need to be on it for long term health. And then it’s also asked for by people born female who choose to have, or that desire to have a gender journey towards the masculine and sometimes towards male and desires to take some testosterone therapy. Although, I also prescribe testosterone for menopausal women with decreased sexual desire and fatigue who desire to have a little bit of testosterone there for general well being and sexuality and not so much for the physical changes that transgender men would like to see.

JEN: So is that just, like a different amount? Like, if I, as a menopausal woman, want testosterone to help with sex drive, there’s going to be that tipping point where all of the sudden I’m growing a beard and that might not be what I was hoping for? What kind of things do people see with testosterone when they are seeking a gender transition?

DR. RIXT A. LUIKENAAR Yeah. So I always think there is this, with testosterone, there’s this ongoing amount that we use for cis women that want a little bit. And then you go over into the nonbinary folks are using it for a little bit of masculinization. And then there you’re using more for somebody that wants to see more further masculinization. And then there is the standard dose determined by the World Professional Association for Transgender Health care that gets your testosterone levels into cis male reference range. And that’s a dose used for a more traditional binary transition towards male.

So going from that kind of dose, you are going to definitely hear a little bit of voice changes happening within the first three months that somebody starts taking testosterone therapy. And that would be one of the changes that the outside world can notice. The person themselves notices an increased sex drive. They notice a slightly increased clitoral size. They call it bottom growth. They also notice a bit more hunger. They’re eating more food. They feel more hungry. And then occasionally a little bit more irritable, although not an anger or any such thing. So that’s about the first three months.

And then, in the six months that come after that, you see more masculinization, especially in the sense of some facial features, more muscle mass, body hair starting to grow, and then also a little bit of facial hair which is very genetic determined. Some people don’t grow facial hair for years and others grow quite a bit of hair after about one year. So these are changes that are happening for somebody within the first year. And then, over time, you see that body fat and muscle redistribution and that kind of masculinization of like a square top and a narrower bottom. The Adonis Triangle that some people are going for. So that does take several years to achieve that if you choose to.

JEN: Can you talk to us, we’ve mentioned this before, it seems like really important information, especially for parents to have, and then as teens get older for them to have for themselves. How does testosterone and estrogen work as far as birth control? If somebody’s on testosteronel and they believe they can no longer get pregnant, what do you say to your patients about those sorts of things?

DR. RIXT A. LUIKENAAR I’ve seen those patients come to my clinic pregnant. So there is not a good option. So, yeah, the first thing that you mention when you talk about hormones is that these hormones are never birth control. Because I also have patients who are trans female and trans female dating each other so that they’re both on hormones. But you can be on feminizing hormones and the other person being on masculinization hormones and in no way do these prevent a pregnancy, if people what we call vagina sex or kind of traditional intercourse, right? So it’s something to discuss. And especially with people on testosterone therapy, it wants to make you a bit more interested in sex for most people.

I have some patients who are ace or asexual but others – yeah. It does a lot when it comes to your sexual desires. So people want to be more sexually active and then it’s important that they also have the means of birth control. And then we go over the several types of birth control that would be more so recommended or desired with a person on testosterone and depending on the age and what’s feasible. And if they forget things because they may have ADHD. You run into the different birth control options for a person. For a transfeminine person assigned male at birth, these hormones block or drop, they drop somebody’s fertility, but you know, it takes one sperm to make a baby. So it’s just important that people are advised to use protection. That is important.

JEN: That’s going to be the slogan. It only takes one sperm to make a baby. Have you seen a lot of information regarding testosterone treatments that people might not be aware of what’s accurate?

DR. RIXT A. LUIKENAAR I think that, one thing I always discuss is the gynecological aspect. So, I mean, the one thing we don’t see is – and I want to clarify this – is we do not think testosterone causes infertility if a person has started having periods and then started testosterone therapy after that. So this means a body that is 14, 15, or 16, and wants to start a medical transition, and has not been on puberty blockers, but then decides to go on testosterone and has consent from the whole family, it does take your periods away because it’s in the uterus lining. So periods don’t happen anymore. But actions in the body’s ovaries are mature. And if the person chooses, they can get pregnant and have a biological child.

And there’s limited studies that reveal that this is a possibility. But we see enough cases also, from all the people that work in all the different transgender clinic where it seems that, where it seems to be no issue to say per se with the ability to get pregnant. But, you know, a significant amount of transmasculine people that choose to transition and start testosterone therapy are also diagnosed with polycystic ovarian syndrome. And polycystic ovarian syndrome is a condition that occurs in 10% of cis females and definitely more higher percentage in transmasculine people where the ovaries already produce a little bit of extra testosterone. These people are also often a little insulin resistant and they have irregular periods.

And that’s where the aspect of decreased fertility comes in because it’s more difficult for a person with polycystic ovarian syndrome to get pregnant because they’re periods are irregular. So giving them fertility drugs and sometimes medications to make their insulin work better, will actually increase their chances for pregnancy. And that is not always clear out in the community, that these are aspects of testosterone and pcos.

JEN: Before we move on to more surgical stuff, is there anything we need to make sure we cover when it comes to the ideas of these hormonal medications in the realm of gender therapy, particularly with it comes to children or minors because that’s what the government’s talking about and the media is talking about? And then, also, when people maybe are 50 and they start – anything in that realm that we need to cover before we move on?

DR. RIXT A. LUIKENAAR There is some talk about when you block somebody’s puberty and then they start cross hormones like estrogen and progesterone that there may not be a lot of development of secondary sex characteristics and therefore penial growth, and some people believe that maybe a decrease in the ability to enjoy sex later on in life or that there is maybe even a decrease in sexual desire. That hasn’t been studied intensively and I do try to make it a point to talk to my even young teenagers and people that we start hormones and blockers on on how they perceive their sexuality and if they’re masturbating, which is always something I recommend because it’s healthy for organs, it’s health for the person, and you may add edit this out of this story.

But it’s something that needs to be discussed when it comes to later in life when somebody’s 18 and has been on puberty blockers and then on estrogen therapy and if they’re going to choose to maybe not have gender affirming surgery and then what to do with your parts when this happens. And if people choose to have gender affirming surgery, is there enough tissue available for surgeons to create a new vagina. And those are topics I would say that are a bit controversial, have not been significantly been studied. And I do think it’s something to keep focusing on.

JEN: I appreciate that. I actually want to dive into the surgical realm a little bit. I think we covered hormonal medications pretty well. So I’d like to talk about surgery which is a different type of medical transition. We won’t dive quite as deep simply because it doesn’t apply to quite as many people and it doesn’t seem to affect minors as much, so they’re not targeted by law makers.

I do want to kind of skim the surface for basic understanding of these types of surgeries. So, in my mind when I think about gender affirming surgeries, there’s a lot of surgeries and sometimes I think people fall into the trap of believing that there is a transition surgery. There’s that horrible question, right, have you had “The Surgery”. But when we think of all the physical characteristics that society sometimes associates with femininity or sometimes associates with masculinity, we can kind of start to understand the variety of choices people make for their own bodies when it comes to surgical choices. So let’s start. When people think about femininity, one of the first things they think of is the chest area. So for both trans masculine and transfeminine women, what options are there when it comes to their chest and their upper body, like the shoulder to the belly?

DR. RIXT A. LUIKENAAR If you talk about breast surgery or chest surgery, it’s mostly mastectomy versus breast augmentation, right? So those are like the two major surgeries when it comes to the upper body surgery. Also, for transgender women, a breast augmentation is the most performed surgery that they choose to have. And it’s about a 25% rate of transfeminine people that go that route. It’s often covered by insurance as well. So that does help a lot. So that hasn’t really been an issue anywhere out there in the media. I would say I have not ever seen a person under 18 requesting a breast augmentation that was a transgender female.As we do allow the body to be on hormones for a while before I would recommend a breast augmentation. Although there isn’t a particular law on how long you should wait, but you should likely be a few years on hormones before you talk to a plastic surgeon about having a breast augmentation.

So that’s for transfeminine people. For transmasculine people, having breasts is super dysphoric. That is probably one of the main things that people struggle mentally. And that’s why there’s such a market for binders, for trans tape, even though trans tape causes incredible wounds and sores because it just sticks to the skin and you rip the skin off with it if you remove the tape. Hoodies. People like leaning forward and getting a hump on their neck because they never walk straight because they’re so worried about their chest. Also, teenagers gaining weight, more or less, so that that covers their chest if there is some bulk around it. So it has a huge repercussion for transmasculine people if there’s not the ability for a mastectomy. And that is a point of controversy right now because we had a bill passed in January that doesn’t allow surgeries for people under 18 for transition related reasons. So, meanwhile, I did send a patient to a plastic surgeon yesterday that was a cisgender female with a size G bra who decided to have a breast reduction and that is still legal in the state, right?

JEN: I get really all sorts of prickly about how all of the laws target individuals and not actual procedures or side effects. And that’s a great example of how some kids, if you’re 16 or 17 and you’re having issues, that’s fine. But if you’re a different kid, “Not for you”, you just have to suffer for five years, and too bad for you. Another body part particularly for people who have experienced testosterone, testosterone changes faces, right? So we get more square jaw. We get some facial hair. We get Adam’s apple. We get that brow bone, right, those testosterone effects. Testosterone is a powerful thing. What sort of surgical options are available for people who want them if they’ve gone through this testosterone version of puberty and they want to feminize their face?

DR. RIXT A. LUIKENAAR Ok. So, and again, these are also not done for people under 18. I have not ever seen a trans teen have facial surgery under the age of 18. Although, you can be 15, 16 and go to a plastic surgeon for a nose job if you’re a cisgender person. So I would say, facial feminization surgery is a skill where people undo these changes that were done by testosterone. And I think, therefore, you need to be trained in that because it takes a skill, right? Where you go in and look at somebody’s bone structure and say, “Well, this, this, and especially the middle part of the face, right? This needs to kind of be feminized.” So it’s typically the nose, the ratio of the upper lip toward the nose, the chin and then some of the buffing above the eyes.

So that can be shaved down, and hairline can be removed. Rhinoplasty, the nose surgery, is often part of that. And that lip distance from the lip to the nose is part of that. And some people divide it between upper face and lower face surgery and some surgeons do it all at the same time. And then, if need be, they can shave an Adam’s apple off as well while they’re at it. So these surgeries can be done individually, but they can also be done just at once. At some of the centers, some of the centers in Argentina, Spain, South Korea, California. And there’s some surgeons in Utah that perform it, but not all at the same time.

JEN: I think I’d like to focus, for just one second, on the surgeries you’ve talked about. I’ve had a few friends go through them and they’re not minor. They’re pretty intensive surgeries. There’s a lot of pain and recovery. And these are one of the side effects of forcing people to experience a testosterone puberty that don’t want it. This idea, “Well, you can just wait until we’re 18. You can just wait until you’re 26.” But at that point, they’ve experienced all of this testosterone that’s changed their bodies in dramatic ways and then they have to pile on extensive and expensive surgeries if they’re hoping to present themselves in a specific way in society.

DR. RIXT A. LUIKENAAR Yeah. And facial feminization surgeries is rarely ever covered by insurance. So it is the one surgery that more people wish they can have, but can’t afford.

JEN: Some gender identified characteristics our medications and surgeries don’t really address. Unless I’m unaware. Is there, like, a surgery available for like, hand size, or shoulder width, some of those kinds of things? Are there options to change those sorts of things?

DR. RIXT A. LUIKENAAR There are surgeons. I mean, if there’s a market, there will eventually be a surgery, right? That’s usually, kind of, how it goes. So, even with voice face femininity surgery which has become a lot more mainstream than it used to be, there are surgeons that are offering that in the United States. I’ve heard of people having part of their clavicle removed that will actually drop their shoulders in a little bit. And there are also surgeons that will remove a rib and therefore make a waist narrower. So the fat transplants can be done everywhere. One of, I would say, the more favored surgery for several of my transfeminine patients is a Brazilian butt lift or fat transplantations to the buttocks. So, I think that there, like I said, if there’s a market for it and people want it, there will be a surgeon that will learn how to do it.

JEN: Clavicle surgery, I’ve never heard of. Voice feminization surgery I was aware of, but you’re right. Things will develop as need and demand arise. And I kind of think that’s a beautiful thing for adults to be able to do what they want to live the life that they want.

DR. RIXT A. LUIKENAAR But you’re right. For example, for trans teens who didn’t start early on, you know, I always ask about shoe size because I know how hard it can be for trans girls to have a large foot or to be extremely tall. So, again, the benefit of puberty blockers, there for people to prevent that so they can live the rest of their lives as female with other females and not needing to buy special size of shoes or clothing due to their height, that’s an important aspect there as well.

JEN: Yes. Thank you. OK. So what most people are really asking, even though it’s none of their business when they ask, have you had “The Surgery”, right, is they’re talking about genital surgery? And right now it seems to make society at large confused and scared and we’re having crazy conversations about it all the time. So what are the general categories and stuff that we’re talking about when it comes to genital surgeries? What sort of hoops do people have to jump through in order to access these surgeries? For all of us non-doctors out there, what do we need to understand?

DR. RIXT A. LUIKENAAR So, again, that’s do first in transfeminine surgeries. So, for transfeminine downstairs surgery or genital reassignment surgery, it used to be called sex reassignment surgery. There’s other terms for it as well. It just essentially means, for some, that you just remove the testicles so that there is no longer a chance that the body can detransition. And I would say that is the main reason for my patients to request having just their testicles removed because they’re afraid, especially now-a-days, because we’re not sure what’s going to happen in society. That if they wouldn’t have access to hormones that their body would detransition them back to male. So having your testicles removed can be an important decision in that to where the body is just going to stay feminine forever if they’ve already been on feminizing hormones for that long.

And these are often, of course, who choose not to ever have a biological child. They’ve been offered the option for semen preservation or sperm banking so that’s a normal discussion to have with all these different types of surgeries, right? So, if someone doesn’t just want their testicles removed but have a female appearing genitalia, so a neovulva, or the neovagina, then they can request that being done by, now even surgeons here in Utah. There’s over a hundred surgeons now, in the United States, that offer that surgery. And it’s a very well done surgery. It’s been done for many years. It was done in Thailand for many years before it really became a more fashionable surgery here, a requested surgery here in the United States. And because there is, in general, enough tissue to line a vagina and to build a vulva and the glands being changed into the clitoris or built into the clitoris and there’s great function. And can be done so that there’s great sexual satisfaction as well, that that surgery is more and more feasible now. For example, it’s covered by medicaid even in our state. And we have surgeons locally available that can do it. Or there are surgeons in other states as well that can do it. So people have a bit of an option on which surgeon they would like to go for it.

And then for those who do not desire to have a vagina canal for whatever reason, you can make the female-appearing vulva with a working clitoris and not make the canal. So that’s a bit of an option for people who are older or who are not interested in ever receiving penetrative sex. So, as far as cost, I mean, these surgeries are expensive. But, like I said, they’re covered by many, many insurances. And I still have patients go to Thailand because there are some well-known surgeons who do the surgery out there and the surgery is a lot cheaper out there. It’s about 10 to 12 thousand dollars to have a vaginoplasty in Thailand.

Jen: And you mentioned depth, I think that’s an interesting thing for people to consider. There’s not even one type of vaginal surgery. There’s multiple types and options and people really do get to create the situation that they want. And I looked up, you tell me if I found good statistics, but about 5 to 10% of trans women choose this surgery. More might if it weren’t for the financial aspects. But about 5 to 10% of trans women are having this bottom genital surgery. Does that sound about right?

DR. RIXT A. LUIKENAAR Yeah. And I would say that is a real number. About 90% has no interest. It is cost-based and barrier-based. And there are also people who may decide later on, but they don’t immediately need to have that. So the idea that every trans woman wants a vagina is not right. There are plenty of trans women out there who are happy with a functioning penis and they want to keep it functioning. So then we discuss that with them and how to do Viagra and Cialis and make sure that everything functions OK. So, yeah, that is about 10%.

JEN: Ok. I just wanted to make sure I wasn’t giving out bad information. Talk about the opposite version. If we’re talking about, not vaginal surgery, but penial surgery, what’s the situation looking like there?

DR. RIXT A. LUIKENAAR Yeh. I would say it’s easier to work with extra tissue than to work with tissue that you don’t have that you need to go find somewhere in the body. So this surgery is more complicated and more involved and also more expensive and goes in a lot of different phases and also has a lot of complications. So I would say, I’ve done this work for 13 years, seeing thousands and thousands of trans patients that probably have had, as far as I know, less than 10 to 20 patients have this surgery. So it is expensive. It requires multiple surgeries done in sequences with repair of fistulas and strictures so these are the typical complications that occur. And a lot of transmasculine people have no desire to have a penis for many reasons.

There’s also the idea that sensation may not be the same because the clitoris is buried into the shaft and may not always give sexual satisfaction. Although, we also don’t have enough studies to see the long term benefits of a phalloplasty or metoidioplasty. So the two kinds, right? You can bring up the clitoris and line the urethra through it, so somebody could technically stand up. You don’t have to, but you can line the urethra through it. And then you close the vaginal canal. But then you have to take out the uterus. And you close the vagina canal, build a scrotum and then insert artificial testicles. That’s a metoidioplasty.

With phalloplasty, you, same thing, you close the vagina, you build the scrotum out of the outside labia and then insert artificial testicles. But you build a shaft for the penis from part of the forearm. It’s called a radial arm flap. Or you can use part of the leg muscle, thigh flap. Or you can use now-a-days even part of somebody’s back muscle or you know they are also doing abdominal wall flaps. So, again, this tissue has to be found somewhere else in the body and then has to be transferred down below to be a functional penis which is really difficult to do. So the sensation, the ability to be erect, the ability to urinate through it, those are all really difficult things to create. And it cannot be done everywhere. There are fewer clinics in the United States that do this type of surgery compared to a vaginoplasty. And, also, there’s seriously not a person under the age of 18 that has ever done this or wanted to do this or was allowed to have this done.

JEN: I, in my same numbers, when I was finding numbers, between 3 and 5% across a lifetime of trans men opt for this surgery. I want to toss in really fast and ask you another question that neither of us – I think people know this. I just want to be super clear – that neither of us are saying that any transition is required for any transgender patient or person. That, as we’re talking about these options, people really do pick and choose different things and different options based on their own needs. And by no way are we saying any certain thing is required for any label. So I want to talk to you about that a little bit because I hear, on legislative floors across the nation for several months, really discouraging conversations about forcing or overly encouraging people to transition.

I first experienced Dr. Luikenaar years and years ago with a patient and our experience started with a giant pile of paperwork that included every effect of possible medication side effects, and we had to sign multiple times. It was very information-based, like, this is what happens and you decide if these are the things that you want or that you don’t want. And there was no pressure. And I want to talk about that. How much time do you spend encouraging patients like, “You probably would be happier if you tried this.” Like, what does that look like in practice?

DR. RIXT A. LUIKENAAR I don’t encourage at all. People have to want it. I mean, people have to take the step to call the office, to make the appointment, to be in a waitlist, to fill out a bunch of paperwork, to actually show up for the appointment. And there is a certain no-show rate of people that are scared. The neurodivergecy, is a lot of people in our community that are neurodivergent. So to make that step, to actually show up, come to the office, have that conversation and then go over all the pros and cons that these are people that have not just made this up a few days ago. Most of the patients I talk to, it doesn’t matter what age, they’ve thought about this for years and sometimes decades. But they finally had the courage to come.

And what led to that can just be a supportive family member. It can just be the fact that they turned a certain age. It can be the fact that they divorced a partner. It can be that a parent died. I mean, there’s so many reasons why a person decides to, now, come and transition but it has been on their minds for a long time. So I don’t typically see the people that are like, “Well, there’s somebody in my class that wanted to do this. I thought I’m going to do it too.” And that doesn’t happen.

And if I ever see people who haven’t already read up this information online, who haven’t already known what their body should look like, what they want their body to look like, what they’re thinking. I mean, you know, if people still need to sort some of this out and they’re really not sure, then it’s a good time to maybe give them information to a gender therapist and say, “Hey, Go on a journey with this therapist and figure out what you’re looking for. And when you have more of an idea, come back.” So we can always have people come back one, two, three, four, five, six, seven times until they’re ready. There’s no one way to do this.

JEN: OK. So this is going to be a kind of a personal-ish question, not based on statistics or anything like that. But as you’re working with this specific gender population, what sort of things do you notice about their mood and their other medical histories and stuff as they start to go through this process and make choices and changes? Do you see changes in them as people or is that something mostly reserved for the therapist’s office?

DR. RIXT A. LUIKENAAR I think, by the time they come to us, they are already somewhat relieved because they’ve already figured this out, right? So a lot of people go through this questioning and journey by themselves and then, a lot of them by the time they come and see us even though they made have had a history of depression, anxiety other mental health challenges, it’s already better, typically, by the time they come see us because they’re relieved because they’re like, “Yeah. this is what I’m going to do. This is what I want to do. This is going to help me.” So I do see that. And then, over time, yeah, it sort of depends. I mean, there is a high rate of depression, anxiety, PTSD, eating disorders, neurodiversity in this community and that’s a given. And that’s people of all ages.

JEN: No. That’s perfect. I was just curious. I know that with my own experience there’s teams of people and your department kind of handles medication and the therapists are handling different things. And I just didn’t know if you had, over time, noticed.

DR. RIXT A. LUIKENAAR I work with a lot of therapists. I mean, I worked with, especially with teenagers, you deal with parents and school counselors and pediatricians and family doctors and therapists. So, you know, you kind of do that a bit more in a team approach than with adults. With adults it’s mostly, it’s not required to see a therapist if you know what you want, and then we can talk about that. And you can start hormones and it’s not mandatory to see a therapist. So it varies. I think it varies.

Although, I think the community in general, right now, feels very targeted. People are very scared about what’s happening in this country. I have patients moving out of state at least every day, somebody is moving or planning to move because of the fear of what could happen in Utah and that maybe they no longer have access to the [INDISCERNIBLE] that they’re looking for. So there, collectively, is a lot of fear going on in the community. Parents are very worried too.

JEN: Yeah. We’ve been referring to that as the transgender diaspora here because we are losing so many of our friends and stuff also. So, before I let you go, is there any other wisdom or insight that you feel like people often overlook or maybe need to hear when it comes to this topic when they’re new to it.

DR. RIXT A. LUIKENAAR I think it’s just back to, like, I want to reiterate, that this is not a phase, this is not something that comes and goes. The rapid-onset gender dysphoria, I believe, does not exist. And I don’t see that in my practice either and I’ve practiced since 2011. So, I think that we should let people be themselves and maybe let doctors figure this stuff out with patients, with parents, with therapists, with a team. But I just don’t think legislators understand what they are doing right now to this community. I mean, they’re causing a lot of pain and grief.

JEN: Indeed they are. I know how busy you are. I know how much your time is worth. I want to really, really express to you our gratitude for being willing to spend an hour helping to educate our listeners a little bit on a topic that is deeply personal. Medical issues are generally private, but for some reason, these have hit the public stage and public discourse in some really unfortunate ways. So thank you so much for helping us all to understand a little bit better.

DR. RIXT A. LUIKENAAR Yeah. Absolutely. You’re welcome. Any time. And people can always reach out, email us or I’m always happy to give information.

JEN: We will include links to your website and links to the WPATH guidelines and other links for anyone who wants to check the show notes, we’ll put those in there. Thank you again for coming.

DR. RIXT A. LUIKENAAR Yeah. You’re welcome.