Frontlines of the Culture War
A Candid Conversation About the Realities of Transgender Care in America
Instagram: @queersurgeon
YouTube: Meet OHSU's Dr. Blair Peters - YouTube
New York Times: Half the world has a clitoris. Why don't doctors study it?
In this thought-provoking episode of "Gay in America," host Robert delves into a profound conversation with Dr. Blair Peters, a Canadian surgeon practicing in Portland, Oregon, who specializes in gender affirming care. Dr. Peters shares his journey and insights into this rapidly evolving field of healthcare.
The episode begins with Robert's candid admission of how the ongoing conversation about transgender care in the United States has deeply affected him. He expresses his frustration at the level of hatred emanating from the radical right and how it has left him feeling angry. However, he acknowledges that his conversation with Dr. Peters helps rebalance his thoughts and feelings on the subject, setting the stage for a crucial dialogue.
Dr. Blair Peters, a plastic surgeon specializing in gender affirming surgery, discusses the evolution of this field. He emphasizes that gender affirming care is not just a queer issue but an everyone issue, highlighting its significance in the broader healthcare landscape.
One of the central themes of the episode is the accessibility of gender affirming care in the United States. Dr. Peters sheds light on the challenges and barriers that individuals face when seeking such care. He points out that despite more doctors providing these services, the demand still far exceeds the supply, leading to long wait times, especially for complex surgeries.
Moreover, Dr. Peters addresses misconceptions about gender affirming care, particularly regarding trans youth. He dismantles the false narrative that suggests children are undergoing gender reassignment surgeries, emphasizing that trans kids do not get surgery.
The episode also explores the impact of the current political climate on transgender healthcare and the threats faced by healthcare providers who support the trans community. Dr. Peters reflects on the divisive rhetoric and the dangers it poses to those who provide and receive gender affirming care.
Ultimately, this episode serves as a powerful reminder of the importance of empathy, understanding, and education when it comes to gender affirming care. It highlights the resilience of the LGBTQ+ community in the face of adversity and the need for acceptance and support from society at large.
What has it been like for you to access healthcare? Tell your story in the comments below…
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Host (00:05):
Gay in America is an oral history podcast sharing experiences of gay people from all orientations, backgrounds, and ages in America. Our goal is to inspire each other to live our best gay lives and help us all understand that our shared experiences unite us as a community.
(00:27):
Hi, this is Robert and I'm going to be honest and admit that the conversation in the United States about transgender care has radicalized me. This realization has been sobering because I'm usually very thoughtful about my opinions and I generally do try to research an important topic before I arrive at my beliefs on the subject. But the level of hatred I've seen emerge from the radical right has gotten to me and I'm really angry about it. So I'm grateful to my next guest who is a Canadian surgeon practicing in Portland, Oregon since 2019, who specializes in gender affirming care, despite being on the front lines of a very real culture war in America. He helped me rebalance my thoughts and feelings on the subject of transgender care. I hope you get something out of this fascinating conversation that helps you too. I do need to offer a trigger warning though this episode does discuss the existence of a film from the nineties titled not another teen movie. You've been warned.
Blair (01:38):
I didn't really have a calling to medicine in particular. I think I just found my calling within it. Hey everyone, I'm Dr. Blair Peters. I work and live in Portland, Oregon where I'm a plastic surgeon specializing in gender affirming surgery.
(02:05):
Queer health isn't just like a queer health issue or a queer issue. It's like an everyone issue per patients are like patients to everybody. So back when I started wanting to specialize in gender affirming surgery, there wasn't really a pathway to do that. Traditionally, people would go and watch some surgeons in Thailand or Europe for a little bit and kind of come back and have a pretty steep learning curve figuring out how to do those things on their own. I was fortunate to do one of the first fellowships really in North America to specialize in this specifically. It's definitely a very rapidly growing field. The reality is there's a huge need for gender affirming surgical care. It's always existed, it's always been there. We just have never really looked at it, and it's only with really recent healthcare insurance changes and some progress socially and academically and medically that this care is even really available to people.
(03:01):
So there's people, younger people to people that are in their seventies or eighties that are having access to care for the first time in their lives. So there is a small number of us that specialize in some of the more complex surgeries like genital surgery, but certainly something like top surgery or gender forming mastectomies that's now becoming part of every single general plastic surgeon's practice just because such a huge volume. I'd say it's probably not as common as a breast reduction yet, but it's certainly getting to that level of common in plastic surgery training in practices across the country. So there's many, many, many people that are definitely treating trans and gender diverse patients in medicine nowadays.
Host (03:42):
There may be more doctors providing services, but that doesn't mean this type of care is easy to come by. I asked how a surgeon becomes a specialist in this type of care.
Blair (03:52):
It took me a couple of years to figure out how does one train to do these things? Well, previously, someone that was interested would go maybe shadow a surgeon for sometimes just a few days in Europe or Thailand and then come back to North America and have a pretty steep learning curve, like learning how to do these procedures, which can be quite complicated. I was fortunate to be one of the first surgeons to do a formal academic fellowship in gender affirming surgery, but there's now seven fellowships in the United States that focus specifically on training surgeons in gender affirming surgery techniques. But we're nowhere near meeting the actual demand for patients or training in these procedures because there is so few of us, and it does take a lot of guided mentorship to do these things successfully well. So we're definitely a good period of time away from having this care being accessible at most major hospital systems across the US anyway, so it's going to take some time.
Host (04:54):
So what is the truth? How long does it take to get gender affirming care in the United States right now?
Blair (05:01):
I think it depends what you're trying to get and by who. Certainly if you are a surgeon that the community has deemed as having good outcomes, then your wait list explode. So it's not uncommon for some of us to have multi-year wait list just for a consultation. I think some of the more accessible procedures like top surgery is getting better, and there's certainly a lot of surgeons in private practice that would have much shorter wait lists, but certainly for some of the procedures like genital surgery, it can often be years to make it onto an operating table. People are really manufacturing this narrative that you can just walk in and get care easily, and it's not like that at all. Most people that need care still can't access it or there are many, many, many, many barriers in front of them to do so. The people that can access gender affirming care easily are cisgender because they can walk into a physician's office or a plastic surgeon's office and get liposuction and a Brazilian butt lift and a breast dog or male breast reduction or whatever the hell they want without any mental health assessments, anything.
(06:11):
So that's just the irony in all of this is transcare and gender affirming care for trans people is behind so many different checkpoints and understanding that gender affirming care is something that exists all throughout medicine for cisgender people, breast cancer reconstructions, gender affirming care, hormone replacement therapies, gender affirming care, so is hair transplant. So many different things that everyone will embrace as long as you're a cisgender person and fit their idea of what you're supposed to be. So I just wish people would take the time more than anything to talk to trans people and just hear them out because I think most people that have those opinions have never sat down and actually heard someone's story and humanized it because you'll realize these are people that are just genuinely doing what they need to do to live a productive life in society and find peace within themselves. And if you're standing in the way of that, then who's the bad guy here?
Host (07:12):
The radical right wing party in the United States wants us to believe that children are lining up by the thousands to have gender reassignment surgeries, but that's just not true. Dr. Peters has a message for those who want to believe it is true.
Blair (07:28):
Trans kids do not get surgery, period. So that is the big narrative that is often being used in a lot of these hearings or to really cause this public outcry and try to ban care. And the result is the carrier banning is mental health support for trans youth, pubertal suppression for trans youth, which is just a pause button, giving people time to figure things out before they make any permanent changes of which natal puberty is also a permanent change that your body's going to take on fun fact. So don't believe what you're reading on social media, actually talk to a healthcare professional and actually get the real information before you're going to attack a group of people. That I think is the biggest thing is just that people need to realize trans kids and prepubescent trans people don't get surgery. Full
Host (08:23):
Transgender people are absolutely in the cross hairs of a political agenda. I wondered how this agenda impacts him professionally and personally.
Blair (08:33):
What a sad state for a country to be in where people's existence is being politicized and publicly debated. It just makes me sad for an entire group of people. But I think the most reflective thing is I started doing a lot of beyond the clinical work in the operating room and research all those other things, like really doing social media based work and advocacy based work and really just speaking publicly, not just advocating for access to care, but even putting information out about surgery for people because it's really been so inaccessible for so long. And I feel like the first year I was doing that, it was all positive. It was just information for the community. People were supportive about it and it was mostly a happy place and it kind of started very slowly with just harassment from a lot of more extremist groups.
(09:29):
But that has definitely just continued to escalate over the last couple of years where those of us that are in this work that are visible doing this work absolutely get physical threats. We get death threats. We have people calling our clinics. It's like I can't really open a public facing email inbox or social media without just being total onslaught by people that are caught up in these extremist propaganda. Just conspiracy theories as to what gender affirming care even is. And that's beyond the sort of states that have locked access to care for some of the groups within the trans community. It's just the vitriol towards trans people and the targeting of hospitals that provide that care has also resulted in programs being shut down, websites being taken down, physicians narrowing the scope of their practice because they're just afraid for their own physical safety. So it's causing huge, huge effects.
(10:26):
And the sad reality is with the amount that people are talking about it, you would think this care was really accessible and it's not people we just talked about waiting years to even have a consultation and we were just on the precipice of even trying to increase access. And we're seeing that in some ways fall back again. So yeah, the short-term future I definitely have a lot of concerns about, but things have just changed very rapidly and it's a weird situation to be in now where anytime I speak publicly or anything I write or publish is just taken and one line will be taken by these extremist groups and assigned whatever narrative they want it to mean. So it's a strange thing to just have your job and the care you're providing for people be just scrutinized so heavily. So I think we're all still kind of trying to adjust to whatever this current new normal is.
Host (11:25):
So I asked him how he understands this wave of Christian nationalist hatred and the impacts it's having on those who receive and provide this care.
Blair (11:34):
The loudest voices are not the majority. The loudest voices are really these extreme people that are spouting things that aren't even within the realm of truth, people that are just completely not living in the real world and heavily influenced by I think a lot of the social media algorithms and Fox News and don't really realize they're being manipulated into someone else's political agenda, which is sad itself. So I think that helps me understand in some ways that people genuinely are just uneducated and just ignorant to what trans existence is and the work that we're doing. But I think to be honest, I feel like my resilience level for it is a lot higher than most because I have been really publicly visible in this work for the last three or four years, and I've had a lot of experience navigating what that means. But I have friends and colleagues that are in this work that aren't comfortable dealing with that or just don't want the negative attention that goes with it.
(12:32):
And sometimes we're being asked to testify at hearings, which puts you out there. Oftentimes we're being asked to comment in the media, which then again puts you out there. And it is really important to counter the narratives that are just completely unfounded and wrong. That visibility does come with some degree of personal danger. And I think that's the sad reality of it is I know surgeons that are doing less of this care or are not caring for certain groups under the trans community because they just, they're not comfortable with what that means for them personally,
Host (13:09):
But it's still transgender people who are suffering the most right now.
Blair (13:13):
So when you think about people that are undergoing major surgery, there's no such thing as minor surgery that is such a silly term. And you really need to be, again, healthy physically, emotionally, mentally to really optimize the outcomes that you're going to have. And we now have people from across the country sometimes trying to access surgeons that are located in a few pretty specific locations, mostly concentrated on the coast and are already dealing with really long wait times and dysphoria and what that means from a mental health perspective. But then you add people coming from states trying to access care where they could lose insurance coverage at any second, and some people are just really not doing well and are very dysregulated and really struggling. It's not their fault that the wait times are so long, but it's not the healthcare providers either. And that can be really difficult to maintain a healthy relationship when we're both being assaulted from either side and try to understand we're on the same team dealing with in effect the same kind of issues that are being generated.
(14:20):
But it's just hard, I think for a lot of people. And the reality is it's still the most privileged people within a marginalized group that are still have the resources to even navigate those complexities in the first place. So it is affecting people and I think people are scared and they want to get access to care before they feel that they might lose it, which is just ironically the exact opposite of what critics of gender affirming care should want is people having all the time in the world to just make decisions when it's the best time for them and not be influenced by external factors. So if the whole world just let people be who they are and just let people make decisions for themselves, you probably see a lot less people feeling they needed to get surgery to fit into societal norms so they could just be safe moving through their day to day. This whole extremism and criticism is becoming a self-fulfilling prophecy of pushing people down a direction. So if you want to see less gender affirming care, then accept trans people for who they are. How about that?
Host (15:34):
Dr. Peters has a few thoughts on why some people are so against gender affirming care.
Blair (15:40):
The vast majority of Americans are supportive of trans people. So let's just put that out there because again, I think with what gets attention in the media really can cloud people's picture of the fact that the vast majority of people in medicine, every major medical organization, any educated person supports gender affirming care. And a lot of this vitriol is really coming from these extremist sort of sides of the political spectrum. The reality is trans people have just always existed. They've been here much longer than gender affirming care ever has. And a lot of this had really just kind of been happening behind closed doors. And I think in some ways where we are now is we have this group of people that I think historically have had a lot of privilege and on the tail end of Black Lives Matter and Covid and so many different things, I think they're starting to feel disenfranchised where they're losing a certain degree of their privilege and they're misinterpreting that is somehow like they're being oppressed now, which is obviously not the case.
(16:40):
And I think what is happening is a lot of the politicians that are failing that are the real reason for why they can't afford healthcare or can't get a good paying job or can't afford a house or all of these other things that they're really unhappy about, they're finding the most marginalized group who happen to be having a moment of visibility, which is trans people and they're taking them and they're framing them as the issue. So they're giving people a rallying point to smoke and mirrors scapegoat away from the real people that are harming them, which is the people that're voting for. I think that's to boil it down generally what is happening. And I think we're at an interesting time where social media is very uncontrolled and people can say whatever they want. People will write these just completely falsified propaganda pieces about me or other people doing our work.
(17:39):
And there's very little you can do about it. And people interpret something in a tabloid magazine or news as truth, which it's very many times not, and they're getting their news from TikTok and Twitter X feeds now, which is literally just people spouting off lies and conspiracy theories, and then that's being reinforced on Fox News. And if all you're doing is living in that microcosm, then why would you believe anything else? So it is just really interesting. If you look back at, I remember when Laverne Cox was on the cover of time with the title like the Transgender Tipping point, it wasn't the same degree of vitriol, it was just sort of this big visibility moment for trans people, and it was kind of the first sign of America B, embracing more open trans existence. How quickly did that get weaponized?
(18:30):
This isn't a transgender issue, not just anymore. It never was, right? It's like you see what has been done to the trans community and now it's the gay community. It was a reproductive rights. People never thought Roe v Wade would ever fall unless you are a straight cis male that probably votes Republican and has some extremist views, you are not safe. So if you're just waiting for them to come for you, it's already too late. Trans people are out there and they're not just advocating for themselves, they're also protecting you and your rights. So if you're not backing the trans community, then you are a part of the problem. That's just the hard facts about the situation.
Host (19:16):
While he's worked with many people in our community, it's important to remember that Dr. Peters is also a member of the community.
Blair (19:25):
I'd say my language for myself has evolved a lot over the years. The labels I clinging to now would be queer and gender diverse is where I'd placed myself under that umbrella, but very much for most of my life identified as gay because that was, that's all we had. I came out when I was either 19 or 20, right on the precipice of my 20th birthday, so 14 years ago, I guess I'm 34 now. But definitely interestingly enough, did not have a period of consciously being like, oh, I'm gay. I need to come out. Before that, I just kind of, not even stumbled, just fell aggressively out of the closet. But then looking back, it's like I always knew it just was so apparent, but I was in a situation where just gayness was very clearly framed as a bad thing. And I think I had a lot of cognitive bandwidth and did a lot of mental gymnastics to just protect myself from acknowledging what everyone around me saw. So the first time that I remember feeling, I guess gay sexuality being like, oh, I'm attracted to this. It was a scene in, I don't know how, if this is a cult classic or if people would know this movie, but it was some terrible comedy called not another teen movie. I dunno if that rings the bell for anyone, but that Chris Evans scene with the Yeah, that did things to me at the time. I was like, okay. So I still viscerally remember that
Not Another Teen Movie (21:17):
Tip. You can keep it, Melanie. Hey Jake, hey Arthur.
Blair (21:23):
And then basically my coming out story is very unglamorous, but basically I had kind of just started talking to this guy online and just told myself, oh, we're just hanging out. Didn't really think much of it. And then just kind of started hooking up, I guess, and started dating. And then just one night I snuck 'em into my parents' basement when I was 19 and they saw some size 12 skater shoes at the back door and we're like, the hell is this? That was that.
(22:11):
Growing up, it was very clear that we would drive past a pride and it was, oh, that's weird. You don't want to be there. It was very clearly negative. That was definitely what I got from growing up. And I think my parents always tried to lead with love. I think they were just afraid for me or they just wanted their kid to succeed. And I think they don't want you to have a hard life, and I think that's a lot of where negative reactions to someone coming out come from is they just don't want the world to treat you differently or for life to be any harder than it is. And I think unfortunately, that stops a lot of parents from responding in the right way when someone comes out and it's framed as hide, suppress, protect yourself. And that was definitely a lot of the early messaging I got. I was kind of told to stay in the closet. I'd never get into medical school. My sister at a conservative college in the United States couldn't know I grew up in Canada. Fun fact,
Host (23:13):
I asked him, what is best gay experience has been so far?
Blair (23:17):
Oh, I feel like I'm kind of living it now. Honestly, I think so much of my first 10 years of being a gay or queer person was just trying to figure out for myself what that meant and just really unlearning everything I had been taught and really internalized about gay existence. And I think that's what so much of traveling and dating or hooking up or partying or whatever, that's like I just needed all of those experiences to just figure out who am I in all of this? What is my sexuality in all of this? There's so much shame that's instilled in you growing up as a gay person. It's really hard to then go forward and have healthy sexual or healthy relationships. It took me a long time to figure out how to almost put myself back together again without realizing I was broken down in the first place.
(24:17):
Whereas now I just feel like extremely confident and nuanced in understanding who I am and what I'm doing in the world. And I think that's positioned me honestly really well to handle what I deal with on a day-to-day basis with what I do for work. But I have a super supportive partner. We just got engaged. I have a really robust friend group that are just a lot of queer, a lot not, but just very much in those communities and just everyone really living independently in a model that's very chosen family. I feel lucky, I feel happy and I'm surrounded by all these incredible people doing amazing things. So I just feel like my day-to-day is awesome.
Host (25:01):
Dr. Peters has an interesting take on queerness that I plan to share with all my straight friends and family. It flips the script for sure.
Blair (25:10):
I love being gay. Honestly. We grow up in a world that's like assumes a cisgender identity assumes heterosexuality, and that's just the script and the path that's laid in front of you. And there's so many things, everything from the second you come out the womb, even before that, honestly, you're forced down this trajectory. And I think it takes a lot of intrinsic self-generated force to step off of that pathway. It's really hard because there was a lot of people trying to push you back on, and if I didn't have explicit radical queerness, would I have gotten off of that pathway? And I think that's where so many people's misery comes from is they've never actually made decisions for themselves. And I don't think a lot of adult, straight heterosexual people truly understand who they are because they've never really faced questions or adversity. They've just followed the script.
(26:07):
And I think a lot of queer people, despite facing many levels of oppression and prejudice, are way happier than so many heterosexual counterparts. We understand who we are and I think we've been able to live authentic lives. So that's what I love about it is the authenticity of a queer existence because we chose more for ourselves. And I don't think a lot of other people outside of the community can truly say that. And certainly I look at a lot of people in my life and all my career friends are by far the ones that are out there just putting out goodness into the world and being vibrant, interesting people, really adding something to the mosaic of life.
Host (26:50):
There's been an explosion of queer positive media in the past decade that has made it easier for us to see ourselves in a positive light. Dr. Peter sees the impact this new queer openness is having on the medical community as well.
Blair (27:06):
I visited some med schools doing some sort of lectures and different things, and there's these lgbtq plus medical student groups with 30, 40 members and they have all these campaigns around campus, and a lot of the times they're the ones bringing me down to educate their leadership about career health issues and all these things. And it's just like I was at UPenn and was sitting in this room of 40 queer medical students. I couldn't even fathom that 10 years ago when I graduated. As much as it can sometimes feel like, especially with what's happening with Transcare right now, we're regressing. I mean, the progress really is happening and it's inevitable. You just have to look behind you at the younger generations and I mean, queerness is not going anywhere.
Host (27:54):
He was born and raised in Canada, so I wondered what it means for him to be gay in the United States.
Blair (28:01):
It took me a long time to embrace living in America. I think Canadians look at America like, what the fuck? Honestly, that's how we all kind of, I think, grow up that way. And it took me a lot to be like, why am I choosing to live in the United States? And then I think of course with what's happened over the last, I've been in the US since 2019, I'd say things have ramped up way more aggressively than they even were back then. So I think for me, being gay in America means equally rejecting what is supposed to be the American dream, but taking it and redefining what that means for a broader group of people because America does have a lot of opportunities and the reality is gay people are still way safer in America than they are in so many other places in the world. So we equally have a lot of privilege, but then deal with a lot of vitriol on the other side. So I think to me, it's being in the place where you feel like you can both grow into the best version of yourself, but help many, many others do the same. And that's the space I'm carving out, being gay in America.
Host (29:23):
Dr. Peters is pretty young and has already done some incredible things. I wondered what he plans to do in the future.
Blair (29:34):
I feel like more of the same. Really, my clinical practice is as busy as ever. I'm starting to do a lot of traveling to other institutions to try to help educate other centers and places to provide similar care. So really focusing on that, I'm training some fellows with how to do this work and trying to take a lot of the traditional care models of academia out of this ivory tower and just really into the streets and just normalizing the anatomy of trans bodies and people just need to get over it honestly. So I feel like that's what my main focus is, but really never trying to lose sight of not just the patient's humanity, but my own humanity in all this because it's just a lot sometimes. So I'm really rigid about making sure that I have time for my partner and I'm traveling and going to pride as just a queer person doing pride with their friends and not being the surgeon and everything. That means sometimes when I go out to Portland. So I think just kind of leaning into that and trying to just find happiness and fulfillment, which I think I have, but trying to hold onto it and not let external forces touch it.
Host (30:59):
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