Queer Doc (they/them): Welcome back to the QueerCME podcast. I'm very excited to have Dr. Wagner on with me today and so I will go ahead and let Dr. Wagner introduce themselves.
Elena Wagner WA-Seattle: Hey, I'm Elena Wagner.
Queer Doc (they/them): oh, and if you feel comfortable, we love to ask folks how they like their gender identity or like any of that, kind of stuff if you want to share.
Elena Wagner WA-Seattle: Yeah, I'm a cisgender woman and I identify as a straight.
Queer Doc (they/them): Ask them. Thanks for sharing and then how does your work that you do with minimally invasive? Gynecology overlap with trans health care?
Elena Wagner WA-Seattle: Absolutely. So in the kind of in surgical realm, a lot of folks are potentially interested in gender affirming, surgical management, and that may be a hysterectomy. That may be an oophorectomy removal of the ovaries. Hysterectomy removal of the uterus. And then, or potentially surgical sterilization removal of the fallopian tubes, which is called a self-injectomy In addition, I have a lot of patients that may have kind of standard gynecologic problems and that need management, endometriosis, fibroids, abnormal bleeding and then that may be a little bit more complicated if somebody is on testosterone or other hormonal. Medications that can. affect those, pathologies
Queer Doc (they/them): Yeah, so and our target. I should have maybe told you this beforehand, but our target audience is like community clinicians. So providers…
Elena Wagner WA-Seattle: Perfect.
Queer Doc (they/them): who manage typically primary care or hormone prescribing for a transgender diverse patients. And so, and, you know, when it's like a good time to them for them to think about referring people to, someone you if they're in your community or someone like you in their own community,
Elena Wagner WA-Seattle: Yeah, so I I certainly somebody's interested in surgery. You know, they're generally speaking for folks that are coming and looking for a gender affirming surgery. A lot of times they are gonna be offered a minimally invasive approach just because tend to be in the younger end of the spectrum, but there are a lot of folks that may be offered an open procedure and open hysterectomy and jet for benign. Not cancerous reasons if somebody's being offered that they probably should seek a second opinion with somebody…
Queer Doc (they/them): If?
Elena Wagner WA-Seattle: who has additional expertise. So certainly if they're interested in surgery or interested in learning about surgery, I think that's another confusion that patients have more so than providers is that if they come to speak to the surgeon, that means they're committed to having a surgery done. Where is it? Can also just be an opportunity to learn like what that looks like and what recovery would be like you know what to think about going into that sort of thing. So anybody that's interested in talking about surgery, it's
Elena Wagner WA-Seattle: appropriate referral, you know, I think that in general referral For kind of more complex than an ecology end of things. Certainly.
Elena Wagner WA-Seattle: I'm happy to have I think probably where it gets tricky from a primary care. Provider, referring provider standpoint is one kind of the first line normal stuff that people have tried doesn't work. Would be one scenario. Um, so you know, a lot of patients with Volvitis,…
Queer Doc (they/them): If?
Elena Wagner WA-Seattle: you know, rolled out infection. There's a lot of other things that can cause aching, so that's kind of a good place to refer. People that may have a lot of challenges with pelvic exams. Is another place. Not every primary care. Provider is going to have a pediatric speculum available to them or other kind of tools that we can. Sometimes do a more comfortable exam and folks that aren't regularly engaging and vaginal penetration. And then in kind of the more, you know, of course, you can also offer exam under anesthesia in the scenario, where patient, just really can't tolerate anything in the office as well. And then
Queer Doc (they/them): I have like 72 fall of questions already so I'm totally gonna be the doctor that interrupts the other doctor but um, first. Okay. I want to come back to like trauma-informed pelvic exams because I definitely want us to like focus on tips and…
Elena Wagner WA-Seattle: Good.
00:05:00
Queer Doc (they/them): tricks for providers. But before we do…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): I want to go back to one of my other questions which was like what's kind of the like risk benefit pros cons of minimally invasive versus open hysterectomy and…
Elena Wagner WA-Seattle: Sure.
Queer Doc (they/them): who like follow up to that is like as referring clinicians. Like who should we think about? Like maybe siloing more towards open versus more turds, mentally and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): base of
Elena Wagner WA-Seattle: So, for benign surgery and that of course, cancer surgery is a whole different ball game. Um but really most people should be able to be have access to a laparoscopic or a vaginal procedure event. Um and you know one thing that I've been really excited about is a vaginal laparoscopic surgery and so it's called a V notes hysterectomy and and so there's no abdominal incisions which I really think is gonna increase the availability of a vaginal hysterectomy for folks that may not have been a good candidate for a traditional vaginal approach so that's one area. I'm kind of excited about folks that may need an open. Procedure are going to be people that have a complicated surgical history and then probably the biggest one would be a big giant uterus like a big fibroid uterus, and then, or people that have
Elena Wagner WA-Seattle: Maybe really complicated endometriosis. A lot of times those the benefits of seeing somebody like a minimally invasive gynecologist is that we've done additional surgical training. Most of the hysterectomy is done in the US are done by people that do less than 10 hysterectomies a year. And we all know that the more often you do something,…
Queer Doc (they/them): Oh wow.
Elena Wagner WA-Seattle: the Better. And so, the mainly basic surgeons are tend to be more high volume. And so somebody who doesn't do as many hysterectomies, may not be as comfortable. Tackling a 500 gram uterus, for example, with a laparoscopic approach, whereas somebody with my training feels very comfortable doing that.
Queer Doc (they/them): All right, and and so when we just to clarify for our listeners, when we say complicated surgical history, we're specifically thinking abdominal pelvic surgery. Yes, so,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): just for anyone listening, I know most of us are clinicians, but we're not talking about, like, you know, they've had rotator cuffs like multiple times or…
Elena Wagner WA-Seattle: Exactly.
Queer Doc (they/them): knee replacements multiple times. We're talking specifically abdominal pelvic because of the scar tissue adhesions, and all of that kind of stuff that can make it more complicated.
Elena Wagner WA-Seattle: Exactly.
Queer Doc (they/them): And then for, and for
Queer Doc (they/them): I didn't know that most hysterectomies are done by people who did less than 10 a year is there. I'm wondering how much of like one, what kind of outcome differences there are from an open versus minimally invasive approach and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): then how much of those differences do we think are related to it being less invasive and how much of it is just you do so much more. So like
Elena Wagner WA-Seattle: Oh, probably both, but general, the open procedures, you know, an open procedures can be something. I always, you know, a lot of my patients have had something like a C-section to reference that too. But it's a much longer recovery, there's significantly, more pain. There's more risk of things like bleeding and infection as well. And blood clots, dbts are all more present in open procedures.
Queer Doc (they/them): Okay. Nice. And for us to know about and then, Um, General what I feel like One of the other questions that I always get asked, you know, by my patients is kind of, I'm off time. Amount of time to prepare off after surgery,…
Elena Wagner WA-Seattle: What?
Queer Doc (they/them): you know? And with instructing me, I usually say, like, two to eight weeks and it depends on, you know, what kind of work, you're, you're trying to take off of,
Elena Wagner WA-Seattle: Absolutely. So I usually tell my patients, if they're gonna have a minimum basic either Blockarscopic or vaginal surgery, I, I also tailor it to and what they do for work. So, I usually tell people, if they are somebody who's work or have the option to do work, that mostly evils sitting at a computer Nothing that's involves healthy lifting or physical, or being on your feet all day. I tell them three to four weeks before to plan on three to four weeks before they're feeling up to going back to work completely.
Queer Doc (they/them): You.
Elena Wagner WA-Seattle: There's certainly a subset of folks that I think especially with
Elena Wagner WA-Seattle: More flexibility with working from home that are getting back to work week too. From like answering emails. Maybe working a couple hours a day standpoint and usually by two weeks they're physically feeling pretty well if you're not having a lot of pain they're up and moving around. Okay? But they probably just get tired really easily and kind of a long day of work. Well tucker you out more than it would have before surgery. And so usually three to four weeks for planning purposes, when you're going to feeling back to kind of less fatigue, able to go whole day of work, that sort of thing. And then I tell people six to eight weeks if they have a significant physical component of their job. So as the top of the vagina heels, we want to let that rest before we put a lot of pressure on it. Okay.
00:10:00
Queer Doc (they/them): Okay. And then, as far as, um, I had another question. Could be one, second. My brain will catch up. and,
Queer Doc (they/them): oh, Sex after Histo. Blso, I think one of the things that like Most physicians are bad at talking about is sex. That's just a truly. I don't just think it like the research shows. We actually suck at it…
Elena Wagner WA-Seattle: Oh, really
Queer Doc (they/them): but I'm definitely as referring clinicians. I think like one of the jobs I try to do is like, talk about the things that maybe your surgeon will forget to tell you about. And so like Ask them about these things and these are the things that you know, about them. So like What does your counseling kind of look about look like for patients? Like this is like kind of things to expect after.
Elena Wagner WA-Seattle: Sure. And so yeah, totally. I try to be proactive and bring up the sex component because a sometimes people feel awkward asking about it, but it's definitely something everybody wonders about. So, one question people always have is kind of once. Everything is said and done and healed, what is sexual function? Like, what is, how is sexual function going? And so generally speaking, the best predictor of having a satisfactory sex life after hysterectomy is having a good satisfactory sex life before hysterectomy. Um, you know, I tell them we don't touch any of the external genitalia so it wouldn't expect any changes from an orgasmic standpoint there.
Queer Doc (they/them): If?
Elena Wagner WA-Seattle: Depending on why they're having a hysterectomy if they're having pain, if they're having bleeding, all of those reasons, all those symptoms tend to be a negative effect on sexual satisfaction and comfort during intercourse. And so,
Elena Wagner WA-Seattle: If we remove those negative aspects to sex and a lot of times sex gets better after hysterectomy for those folks. For people that are you know looking or more maybe don't have pain or bleeding and are looking more for a gender affirmation. Sometimes I think we're moving the risk of like an unplanned pregnancy. Actually can be really freeing and make people remove one more kind of break when they're engaging in sexual activity if that's a concern at all.
Elena Wagner WA-Seattle: Um for after sex I usually see people back at six to eight weeks and do an internal exam to kind of look at how the top of the vaginal canal has healed and give them the clear for penetrative in our course. I'll have a conversation with folks that maybe aren't engaging and penetrating AmeriCorps, or don't want to engage in penetrative in our course in the future about kind of pros and cons of doing that part of the exam. And, you know, Sometimes we'll skip it if it makes sense. For that particular patient. A common question. I'll get is, Well, I don't do any penetration. When can I do external stimulation or other sorts of sexual activity? And so, you know, I usually tell folks me the main reason we and I also try to help people. Why I don't want them to put things in their vagina because that helps them understand. Sometimes I've had patients get into it, you know, just the tip scenario that then went a little sideways. And so, you know, we're we want to allow that in.
Elena Wagner WA-Seattle: The heel before putting pressure, if it splits open, that's not fun for anybody. And then for infection purposes. So I usually tell people to try not to do anything for like, two weeks or so, you're gonna be sore. You're gonna be tired, you're gonna be recovery. I usually see hysterectomy patients at the two week mark.
Queer Doc (they/them): It.
Elena Wagner WA-Seattle: And so, usually, this is when this question comes up, if they had didn't ask ahead of time or sometimes I'll get a patient message. And at that point I say, You know, if you're interested in doing external stimulation, go for it. You know, if what I would recommend is, you know, again nothing in the vagina and we review why. Um and then I just say Take it slow and easy you know some patients when they orgasm, that's still involves some core work and and some muscular excerpt, You know, exertion um, and to stop if anything hurts and otherwise, you know,
Queer Doc (they/them): Yeah. And for um, you know, testosterone tends to decrease the elasticity of all of the vaginal mucosa and all of that kind of stuff. And so we definitely see some Particularly patients who maybe were like as a call in the community size queens or interested in like larger penetrative receptacle. Receptacle receptive sex.
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): We see some loss and like volume, right? Because it lost an elasticity. Do we have any effects like that after like hysterectomy procedures?
Elena Wagner WA-Seattle: Um, so I think in studies, there's maybe a tiny amount of shortening in the length of the vaginal canal after hysterectomy and depending on the closure it may lose like a centimeter or so. I I'm not actually aware of any specific studies about like, you know, folks that are engaging in larger penetration having changes in elasticity. It's more a change in length, that is going to change after hysterectomy and then, you know, depending the cervix may or may not. It's a most of the time, we remove this erics and a lot of folks are interested in that because then they don't necessarily need cervical cancer. Screening going forward. Um and so that's really where the change in length comes from. But there shouldn't really be any change in elasticity. You.
00:15:00
Queer Doc (they/them): Yeah, do you? Do you before people like decide what to do with their cervix? Do you talk about? Like what they're interested in cervical stimulation during sexual activity?
Elena Wagner WA-Seattle: I'll bring it up. I'll usually talk about pros and cons, and I think one thing that patients and probably providers to get confused about all the time, is it, when, when I talk about a total hysterectomy, I mean uterus and cervix. And a lot of times patients will come in and think everything and they'll come in and say, they had a partial hysterectomy and I'm like, but your cervix has gone, you know, so I always try to be careful about making sure. We're talking about the same thing. And then I usually talk about total versus subtotal hysterectomy and, and kind of what the person constantly get the service in our, I think a minority of patients will elect to hang on to their cervix, but it's an option.
Queer Doc (they/them): Yeah, and I think this is one of those. languages like one of my big things and are being like part of the trans community,…
Elena Wagner WA-Seattle: Wow.
Queer Doc (they/them): then being a clinician and then And kind of like the colloquial way we use the vagina to mean vulva, like drives me up a wall.
Elena Wagner WA-Seattle: Okay, I catch myself say vagina in the clinic when I mean folder and I'm like I should know better and
Queer Doc (they/them): Like and I think so in our field, right? People say vaginal classy all the time and I'm like, Do you want to evolve a vaginal plasty or…
Elena Wagner WA-Seattle: Yeah. Or Imagineectomy or yeah.
Queer Doc (they/them): do you want to vaginoplasty rate because they're actually two things? Or just evolve of nasty, right? And like so um yeah we my patients, I often talk about the difference between like a blso and hysterectomy and whether or not you like keep your cervix or not. And so um as referring clinicians I do think like helping our patients, understand the language that they might find in their surgeons office is one of the like roles, we can help like support our patients with because some surgeons are really great at breaking it down in some surgeons are less It.
Elena Wagner WA-Seattle: and,
Elena Wagner WA-Seattle: Absolutely. So appreciate it because that all so you know, it's nice because of course, when we're going through the thing, I have kind of my checklist of things that I try to go through, but, you know, if I kind of get off track or whatnot, then it's nice when the patient is like, okay, I actually did want to ask about if it's possible to keep my cervix or what to think of what are the, what are the considerations there? And so that's super helpful.
Queer Doc (they/them): Yeah. Yeah I usually give my patients like a pre-surgical like Oscar served in these questions list but you know I haven't it's kind of a general like thing it's not tailored to each surgery and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): that's like something I could think about like dialing and over time for different surgeries.
Queer Doc (they/them): Just one more thing on my to-do list though. But I'm gonna write that down because I think it's a great idea. And then, okay, I have more questions and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): One of the things we come up, see come up all of the time in our field around surgery is BMI restrictions that we don't see come up in patients accessing surgery for other health conditions in the same way,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): right? Like there is a lot of kind of
Queer Doc (they/them): Steaming. thought that like, These gender firming surgeries are in a way more elective than surgeries we do for other things like for cancer and and so you know that there's a lot of tension in our community around that and I think I'm curious like for a minimally invasive approach.
Elena Wagner WA-Seattle: Sure.
Queer Doc (they/them): Do you have any kind of thought about patient size body size?
Elena Wagner WA-Seattle: We actually, and I will say in gynecology land, we I have seen this even in kind of the cisgendered population for folks that are looking for surgery for kind of bleeding pain, that sort of thing. And, you know, again this kind of is where folks at maybe do less surgery, or less comfortable with people with bigger bodies. And so, you know, there was a person, a surgeon that I knew in training that if somebody had a BMI over 40, they would essentially kind of
Elena Wagner WA-Seattle: Really try to stonewall on care or surgical management of like hysterectomy for any reason whatsoever. And and you kind of went into the same thing where you know a lot of gynecologic pathology isn't especially benign gynecologic pathology is not necessarily going to shorten your life. And a lot of it is a huge quality of life burden and and, you know, which is unfortunate because people with abnormal bleeding have a worse quality of life than people with breast cancer, when they look at the data on that. And so I have lots of opinions about that in general, but it's not something that's necessarily limited to gender affirming here, but certainly runs into some of those. Same barriers I, you know, I think it's a
00:20:00
Elena Wagner WA-Seattle: Myself and my partners. It's a case-by-case basis and it really comes down to a discussion with the patient specifically for gynecologic surgery because we operate in the pelvis. We have to put patients in Trendelenburg in order to access the pelvic organs and get the intestines. Outlay. And so for folks with a bigger body mass, some of those patients with the we took them up backwards in the way to the abdomen rest on the diaphragm and…
Queer Doc (they/them): Diagram.
Elena Wagner WA-Seattle: the chest, that can be more difficult to ventilate, those folks. And so, it really ends up being an anesthesia issue. um, and you know, there's a lot of tip like tricks that we have to try to work around that and I you know, and then I was to talk to the patients that, you know, you might have higher risk of wound complications, you might
Elena Wagner WA-Seattle: Have higher risk of like DBT or things like that after surgery compared to somebody or in risk of infection compared to somebody with the smaller bat body mass, but it doesn't necessarily mean that they absolutely cannot have surgery. I generally don't think that, you know, a blanket statement of never is a good idea. But, you know, I I've seen some patients that came in looking for a gender farming surgery and they you know, because of their other medical conditions. It couldn't lay flat in the office. And so, for example, that's not somebody that's gonna be able to tolerate a surgical procedure and Trendel umber versus somebody who might walk in with the exact same BMI maybe distributed, it differently has a different kind of other comorbidities and whatnot and might be able to tolerate surgery, okay? To get that done.
Queer Doc (they/them): And do you work? Because you're here in Seattle? No bigger bigger. Urban area, more access to more clinicians. What like I know, like I'm gonna show some of my ignorance of our like larger field but anesthesiologist,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): like, right who have training to work with, like people with larger bodies, um, like how, how many of them are there? Where do we find them? Like,
Elena Wagner WA-Seattle: Oh, I would say kind of an it probably the easiest way of you're just gonna looking is anywhere that has a bariatric surgery program or that you can general surgeons are going to be doing a lot of bariatric procedures. That's probably the easiest way to, to find that anesthesia population and then aside from that I don't I think it's hard to I guess I actually don't really know how you would go about screening the anesthesia department in another institution aside from you know, phoning a friend.
Queer Doc (they/them): Yeah. Yeah. And definitely, I find as a referring provider, one of the things that like
Queer Doc (they/them): We have all had happen in one of the things. Like I actively worked to try to avoid is to refer someone who then to a surgeon who then says, like I'm not gonna operate on you because of your size and…
Elena Wagner WA-Seattle: Yeah, that sucks.
Queer Doc (they/them): that's like super traumatic, right? And so you know I have like a list of my surgeons. I have like their like um you know, a lot of my preferred referrals have a similar statement as you do that. It's a case by case basis. Um, versus like I have other surgeons who just have a hard BMI cut off and but I think I definitely run into the like where the surgeon was like this would probably work. And then the anesthesiologist was like I'm not doing this case, right? And so like even was even worse for much like patient traumas standpoint…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): because we had like some hope from the surgeon, right? And then it was just kind of like now and so does your I'm wondering like this is where I'm like getting in the weeds and I will eventually move up topic. and I'm curious like, How many times do you see? Like, Surgeons like yourself or or just other like surgeons in general who do gender affirming procedures partner with anesthesiologists that they don't regularly work with who work in like a bariatric center. Like I'm sure there's like, so moving pieces of like pulling people out of different systems to make that happen.
Elena Wagner WA-Seattle: And I think it does come down to what how your system set up. So for example, after Mason where all employed by the hospital, there's like the anesthesia department and I kind of know all the people or at least have encountered them on the day-to-day basis and they might say You know what, hey this person is not a good person to do surgery at the ambulatory center for example they should be at the main hospital, I think where it gets tricky is. When you're you know, people are operating in a, you know, if they're in private practice and they operate at the hospital where they may have an anesthesia contract group. And I think that's where Those moving pieces, get more complicated compared to kind of a closed system, which also has its negatives on occasion. But at least, you know, we tend to have a better knowledge of working relationship with our groups and I think that's again going back to structure of our healthcare delivery system that can be frustrating for everybody.
00:25:00
Queer Doc (they/them): Yeah, so definitely kind of one of those things as a referring provider to keep in mind, like, when we're referring to clinicians with private practice to operate, an ambulatory day centers, like that might be less of a option for people with larger bodies. So like really to clarify, before we go there and…
Elena Wagner WA-Seattle: Yeah, and…
Queer Doc (they/them): academic institution,…
Elena Wagner WA-Seattle: a lot.
Queer Doc (they/them): or a large Employed system.
Elena Wagner WA-Seattle: Yeah, and I will say because like our ambulatory centers, they have a hard cutoff for BMI that where they you're not allowed to schedule patients there. And you know, again we can certainly debate back and forth whether that's appropriate or not. But I think part of the idea is to avoid somebody showing up in the anesthesia person. Being like this isn't the right place for to do this surgery.
Queer Doc (they/them): and then, as far as like, you know, part of what I'm trying to do in my work right now is like really think about incorporating like inclusivity like through everything I do as opposed to just kind of like as a end notes and so really like I'm curious Do because I obviously like we know and obstetrics, right? Like more black women die and childbirth than white women. Like, That's the undivatable fact that we have like, well documented, What do you see in like accessing surgery? Because like also one of the things right,…
Elena Wagner WA-Seattle: Sure.
Queer Doc (they/them): that happens to black people all the time is that they're pain is is not considered of value.
Elena Wagner WA-Seattle: Yep, wallet. Or Yeah.
Elena Wagner WA-Seattle: I think the biggest thing we see in my area is the so black folks tend to have vibrate disease, more popular, sorry more commonly. So in general population, 70% of people by 50 will have a fibroid on their uterus, but we know black folks tend to get fibroids more likely. So like more like 80, 90 percent by age, 50 and they're all so more likely to have a significantly higher burden of fibroid disease, and also a more they show up younger. And so that can cause a big burden on folks both from a pregnancy standpoint and from just, you know, general life standpoint and the problem, there is one, I think they for all of the reasons you noted tend to get put off or diagnosed later. And the other problem is they are tend to get open procedures more often than minimally invasive procedures. And some of that is
Elena Wagner WA-Seattle: Is because again, their fibroid burden is bigger and even if they're doing asking for something like a myomectomy. So we're moving. Just the fibroids of uterine sparing procedure. sometimes they are more likely to get an open procedure and some of that is just a pathology-based problem, but some of it is also an access to care problem and I saw a Abstract Recently, where even in patients that we're having surgery for adenomyosis, black women were more likely again open procedure an open hysterectomy compared to a minimally, a base of approach. Other thing there is for patients, that have a big fibroid, burden. They're often told they need. They, they're only option is a hysterectomy. And that Amira, uterine sparing procedures, not an option.
Elena Wagner WA-Seattle: And so one thing, you know, when they started coming out with you uterine transplants, I guess I shouldn't put that in quotes. But as a thing the kind of original target demographic for that was folks that had uterine a Genesis or Mr. Khyndrome. And when they started looking for people that were interested in and undergoing that procedure, a lot of the folks that were showing up were, were people that had their uteric like a hysterectomy for fibroid disease or something else and we're, you know, still wanting access to fertility.
Queer Doc (they/them): Yeah.
Elena Wagner WA-Seattle: And so, that's a big one where, unfortunately, those, those patients are getting a hysterectomy instead of a myomectomy or are not engaging with care for, you know, a hundred different reasons partially because at one of my, the folks that train me and did a ton of fibroid, look work, would say, you know,
Elena Wagner WA-Seattle: I would have patients that would say, Well, every doctor I saw, I told me I needed a hysterectomy, so I stopped going to doctors. And now I'm here with my fibroid, my uterus up to my xiphoid. And so, you know, that's probably somebody that's gonna end up with an open myomectomy, but that certainly still an option and somebody who feels comfortable with that skill set. So,
Queer Doc (they/them): Yeah, and we've definitely like weird a little bit into like more assist population and trans people of color can have vibrates as well.
00:30:00
Elena Wagner WA-Seattle: Problems. Absolutely.
Queer Doc (they/them): And a lot of my listeners are primary care clinicians. And so I think like what I'm really pulling out of this and my mind is like,
Queer Doc (they/them): When it's possibly access of care, like, access to care is always hard, right? And in our populations, that is marginalized. Access gets harder and then the time will work to access multiple opinions gets harder, and, but it sounds like,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): um, definitely like encouraging multiple opinions or having as a referring clinician vetted. Like the people were referring to to know like, Where like where are their rates of hysterectomies in their black patients versus their right patients for the same condition,…
Elena Wagner WA-Seattle: Yeah. Yeah.
Queer Doc (they/them): right? And like, Yeah, there may be some pathology basis behind that but also like, explain the discrepancy in rates to me and help me understand why it's happening. And like does that feel valid to me as a clinician who has like pretty decent clinical reasoning? Or does it feel like, you know, implicit bias and like on on exam and racism and institutional racism, which is like very present in our work and those are hard conversations to have as a referring provider when you're talking to a surgeon because like, oftentimes Differential between us feels like. Present and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): some surgeons are more approachable and less approachable. But in my mind, if the surgeon can't have that conversation with me, they're not going to treat my patient. Well, enough that I want to send them there. If I have another option and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): because like, while they are hard conversations, if we don't start having them, these rates will never change. And so, I just like, tend to think. If we time to do
Elena Wagner WA-Seattle: And if the person just like, what do you mean? There's different rates. Like that's that's also a problem.
Queer Doc (they/them): Concerning.
Elena Wagner WA-Seattle: so, I think There's half of the. half of solving a problem is understanding that you have a problem to start with and…
Queer Doc (they/them): Yeah, right. Right. Yeah,…
Elena Wagner WA-Seattle: certainly we there's a lot of work to do but Yeah.
Queer Doc (they/them): yeah. I feel like okay, I feel like I could talk to you for like seven podcasts. I'm gonna try Circle back to like one of our other questions which was I'm definitely. Like, let's talk about some tips and tricks and like this episode. Gosh, I had so many other questions I wanted to ask Dr. Wagner and like we haven't even talked about like a new vagina and you got up like uterine transplants which I also have lots to say about like and I'm not gonna get to any of that today but um I definitely would love to take some time. I think tips and tricks for trauma informed and pelvic exams is like great for community clinicians, you know? So like what are your thoughts about that?
Elena Wagner WA-Seattle: Okay.
Elena Wagner WA-Seattle: Yeah, so I always so first of all, sometimes I'll just say at the beginning of an appointment or a new console like you know, a public example, probably be helpful at some point in this, we don't have to do it today and that gives some some patients will just spend the entire appointment for several or like just laser focused on the possibility that they may need to have a pelvic exam. And sometimes just saying You know what, we don't have to do that today it may be part of it sometimes it's easier to come back at a later date and do that. And so that's kind of the first thing is to say, you know,
Elena Wagner WA-Seattle: With, you know, we don't have to do that today. Um, the second thing is one, I try to ask new patients or patients that I have an examined before. Like, Do you know, do you have a history of any sexual trauma and specifically? Because folks with that sort of history, often have more challenges with public exams or kind of logic procedures? Is there anything I need to know about you to take care of that and so some folks will say, Yes, I have a history but no problems with exams and some people will say, like Yes, I have a history and yes, exams or challenging to me, or I've ever had an exam and trying to kind of get a sense for where they're coming from, is always the first step and then I usually tell folks, You know, is it helpful for me to talk the whole time? That's generally. My default. Just because, you know, people are jumpy and can be, and knowing what to expect is half the battle. I always tell people like, you say the word and I will stop.
Elena Wagner WA-Seattle: There's something that we have to do sometimes in a procedure that, you know, I tell them I'll stop. If I can, You know, sometimes there's things that are going on that you may not be able to stop immediately but that's a minority. And then I offer them to, you know, if they want to listen to music if they want to have a support person there, I almost always have a medical assistant with me for genital exams and so some patients will actually prefer not to have a chaperone. And and I that's okay with me. Um, and then having access to tools.
Queer Doc (they/them): It.
Elena Wagner WA-Seattle: So kind of depending, you know, the pediatric speculums along skinny ones, can often times be there, they don't come in a plastic so they only have the little ones. And so, you know, I just talked through. You know what, part of the exam we're doing? What we're looking for, what I'm doing and I think,
00:35:00
Elena Wagner WA-Seattle: Reading the patient. So you know I see all the time, you know? I work with medical students and trainees a lot where you
Elena Wagner WA-Seattle: You touch the inner thigh of the patient and…
Queer Doc (they/them): and,
Elena Wagner WA-Seattle: they squeeze their needs together. And you can see all of their muscles clench up and that is not the right time to try to put the speculum and so just kind of being aware of what's going on. So a lot of times I'll, you know, oh, really focus on on and I think one thing that I've learned a lot about in the last couple years is trying to avoid kind of reflective comments, like relax, which you know, is it flips out on occasion. Now and again but really trying to retrain myself to use language. That's not potentially triggering like that and focus on letting me soften and these fall away letting the bottoms take into the table and then kind of one thing that I do a lot is, you know, I'll expose it and try this. And then I'll just touch with the speculum. I'll say, Okay, we're gonna, you're gonna feel this bad feeling here and I'll touch and if you touch and they go, then you pause and say, Okay.
Elena Wagner WA-Seattle: Take a big deep breath, blow it out, and I'll just leave the speculum. Just touching the introitus right there and see if I can get them to soften all their muscles again before trying to insert and that can sometimes make a huge difference. in comfort and so, yeah, it's complic ated.
Queer Doc (they/them): Yeah. Yeah. I love all of all of those things. I think, you know, I'm telling us and based now. But, um, when I was still doing in-person care at my clinic and I was like, I was in clinic when Trump was getting elected. And so the number of IUDs I had to put in like Skyrocketed and,…
Elena Wagner WA-Seattle: Okay. Yeah.
Queer Doc (they/them): you know, I think also being like a femme presenting person you just end up with more people. And so, like the number of pelvic exams, right? I've done in my life is like
Elena Wagner WA-Seattle: Very high.
Queer Doc (they/them): And I think, you know, some of the things I always think about that. I think are especially pertinent to trans and gender diverse patients. And, and this can be harder in a busy practice. I understand like as I've done it, like we've have these 21 appointments, we're seeing 22 people a day and but like, I like always meet my patients with their clothes on. I have my doctor myself in a paper gown and it does not feel good, you know, and similar to you like actually, you know, not only do I say like, we don't have to do the pelvic exam today. I, one of the things I say in every visit I do is that I think consent is essential and…
Elena Wagner WA-Seattle: Uh-huh.
Queer Doc (they/them): that this is your body and you get to say what happens to it and if you know and in primary care, it is rare that I would be doing something that I could not stop.
Elena Wagner WA-Seattle: Yeah, exactly.
Queer Doc (they/them): Like, I did do cool past this. Someone was bleeding, obviously, I would have to attend to the bleeding before. I could stop…
Elena Wagner WA-Seattle: Yeah. The kind of a standard exam. Yeah.
Queer Doc (they/them): what I was doing, but outside of that. Pretty. Yeah, yeah. And so I'm and also right? Sometimes when you pull off the I can't remember what that clamp was called. We use when we did on click the cervix now but that would lead. But otherwise like you know, I'm gonna be able to stop and and you know one of the things I've seen happen and heard happen that many many times is patients have said, stop and clinicians. Have not or Not and it's not I don't think clinicians are intentionally trying to assault people or be mean or…
Elena Wagner WA-Seattle: No.
Queer Doc (they/them): be harsh. But we get so focused on. Like I have to check this box, I have to get this exam done. I have to go see another patient and eight minutes and and we're like this is something we do every day. So it's like such a like Every day occurrence for us.
Elena Wagner WA-Seattle: Forget. Yeah.
Queer Doc (they/them): And we're like, I'm so close. We're almost done and that's what I always hear that.
Elena Wagner WA-Seattle: That's really good.
Queer Doc (they/them): I hear someone said I asked them to stop and they were like, I'm almost there.
Elena Wagner WA-Seattle: Trouble.
Queer Doc (they/them): I'm just gonna finish and like, that is always one of my cautions to clinicians if they have told you to stop. And you have said that to them, that is technically assault. Like, I know that sounds harsh, but really, that's what that is. It just, we don't think about it that way, because we're so used to this being like a normal part of our lives.
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): And I'm a queer person who has accessed a lot of healthcare who has had clinicians like tried to continue with exams when I have told them to stop and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): like they know I was a physician you know and I'm like absolutely not like I have told you not to touch my body, do not try and do not try to talk me into it and like a controlling patronizing way if you want to have a conversation about my risk and benefit of why you think this exam is important. We can do that. But like don't don't do this thing that you're doing right now, so that's like one of my big Big, big things and…
Elena Wagner WA-Seattle: Yeah, you're absolutely correct.
Queer Doc (they/them): Yeah, it's like can sound intense but I think again.
Elena Wagner WA-Seattle: But I think that just it's important to use that sort of language to underscore how important it is.
Queer Doc (they/them): Right, because it is like we do. I understand both sides. Like, I've been that clinician. That is trying to fit 22 patients in, you know, and like, get this person's iudn and get them out of the office. And then they just like also vagold. And I'm like, Okay, now we're sitting here for an hour, okay? So I understand that side of it too.
00:40:00
Elena Wagner WA-Seattle: Yeah. Yeah.
Queer Doc (they/them): But like, um, Trans people that bodily autonomy is assaulted every day. We every day we are told we do not have a right to our body. We're told that by the news, we were told that by the media, we are told that by your legislators. And then as a fem-presenting person I am told that by like everyone else in society who thinks they have a right to my body when I do not just because I just chose to wear lipstick today and so I actually asked my patients and I especially emphasize this with my kids to say no to medical things with me in a safe environment so they can have that practice when they know the clinician is going to be supportive of it. Because at some point, they are going to be asked
Queer Doc (they/them): To do something, you know, that is not because it's medically necessary, but because of someone's like morbid curiosity, every trans person in my life, every trans patient. Every one of my partners has had a medical provider of some fashion. Ask them like for genital exams or to take their pants off, you know, or whatever. When they're there for like, You know, you are I or…
Elena Wagner WA-Seattle: Related read.
Queer Doc (they/them): ear pain or like a spring and wrist, like, everyone has that story like every single one. Like I haven't done a research study on it, but like my Anecdotally.
Elena Wagner WA-Seattle: Anecdote is, you know? In.
Queer Doc (they/them): It's too high and so I asked them to practice saying No, when it's like they know it's gonna be well-received and That's another approach I use and then you know definitely we talk about like this is what a pelvic exam will look like Do you want me to talk through it or Do you want to like Listen to music? Do you want to bring the support person? Do you want to bring a comfort item? Like Do you want to have like a stuffed animal? A blanket. A fidget toy. Like you know Do you need a Xanax?
Elena Wagner WA-Seattle: You need it.
Queer Doc (they/them): Do you need it? I'm like, I don't like the annex for many things but before exams, for flying and before mri's, I will hand them out,…
Elena Wagner WA-Seattle: Yeah. Yeah.
Queer Doc (they/them): I am happy to do that, right? All of these things and then a lot of times in primary care because like again, the exams we're doing, Probably let less skill based last like tools and…
Elena Wagner WA-Seattle: Different.
Queer Doc (they/them): instrumentation that's gonna happen. So like actually hardly ever use stirrups like or We don't even call them serves anymore foot rest, but quickly.
Elena Wagner WA-Seattle: But over.
Queer Doc (they/them): Yeah, typically just how people actually like butterfly their legs out with a bolster up under their hips. And that like also like loosens, I found like loosen everything much better than the rest do anyway. And, and then Yeah. Like
Elena Wagner WA-Seattle: I think it's harder to let your knees flop together. If you put yourself in butterfly,
Queer Doc (they/them): Right. And then yeah, checking every step of the way like this is what I'm gonna do next, is that, okay? Like, if that's what they've said, they want, you know, because similar to you my default is to talk through the whole thing and And unless they told me they don't want that or they want to listen to music or something. Like I'm checking every step of the way and then I often like
Queer Doc (they/them): If I see that right when I worked with learners like when something happens and everyone like we see all those muscles tense up you know I'll say I noticed all of your muscles 10. Step What are you feeling right now? Yeah what…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): what do you need to feel safer in this moment? So just observing back to the patient what I'm seeing and asking them where they're at. Um, you know, I don't ask about sexual trauma history as much and just because, like, in my line of work, almost everyone has had it. So I just function off the assumption that everyone has had sexual trauma that I'm seeing.
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): And so I ask Yeah.
Elena Wagner WA-Seattle: Which is. Always a reasonable assumption because there's going to be people that also don't mark the box or don't say no. But have that
Queer Doc (they/them): Yeah. And and it like rates a sexual trauma and interim, partner violence are higher in the LGBTQ over the population, higher in trans patients, I think the like last that I saw was like Somewhere around three,…
Elena Wagner WA-Seattle: History.
Queer Doc (they/them): quarters of gender diverse patients. Have also done sex work, which has higher rate of sexual trauma as well. So just like rates are so high. I tend to like function off the assumption that's happened and then Really explore more. Like you were saying, What's your experience with pelvic exams?
Elena Wagner WA-Seattle: Here.
Queer Doc (they/them): Like, What you're interested in doing a pelvic exam, What do you know about, why? We think you should do? A pelvic exam, you know, and try to come again? Cervical cancer. Screening like we do see more, LGBTQ patients and trans patients. Die from cervical cancer because they don't access cervical cancer screening, but we can't do self collected swabs. It's not the gold standard. We don't have the same kind of data on it, but like again, There are other options.
00:45:00
Elena Wagner WA-Seattle: Some here.
Queer Doc (they/them): Yeah, and we can individualize that like Screening. I think, you know, one of the things I always thought on primary care, I was at Kaiser and like we, you know, you want to check those screening boxes, you know,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): and And they just had a call center that would call patients and say You're due for this. And I'm like that is not true. There is no such thing as do for a screening exam. There is like You're eligible,…
Elena Wagner WA-Seattle: Are eligible for. Yeah.
Queer Doc (they/them): it is recommended. But like, but I hated that language so much because it makes it feel like it's like only.
Elena Wagner WA-Seattle: They're not doing things.
Queer Doc (they/them): Yeah, when I swipe my credit card and it says I'm approved. I'm like Can we change that word too? Because it makes me feel like, you know, like I'm seeking your approval and now I've gotten it. But um, yeah and so really talking about the fact that like screening exams are They're like general recommendations for the greater population but we should be able to have an individualized conversation with our patient about why we think it's important to them and then based off their values whether or not they want to choose to proceed with that and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): alternatives to that. Right? I'm similar to mammography again for gender diverse people. It's really interesting because I see with some of my patients who are like on estrogen therapy, Getting a mammogram is like very affirming. They're very excited to be able to have that experience and to do that and they're like, ready for it. They're like what my first, man? And, you know, and then some of my other patients, right? Who maybe aren't taking estrogen or who are taking estrogen blocking medications or taking testosterone or like absolutely like not interested in doing that. And it's like, Yeah, let's talk about, let's talk about screen for these cancers. Let's talk about other options like you know, and some of these aren't options because of insurance but like we can do other things.
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): Like mammography is not the only option.
Elena Wagner WA-Seattle: And I think the trap we fall into a lot of clinicians is that risks are not destiny, right? And so, you know, when you're talking to somebody, like your risk of this happening is is, you know, 20% or whatever. Um, sometimes we kind of Tilt like Think, Oh, 100%, you're gonna get this thing. Have had this, you know, say breast cancer. For example, like You're definitely gonna get breast cancer. Your lifetime risk is 20%, um, and you're like, well, Actually, the majority of people will not get breast cancer in that scenario. And so, you know, I think it's important to talk about like risks specifically, because everybody will will evaluate that risk very differently, all of those scenarios.
Queer Doc (they/them): Right. It's so true, right? And I think those are conversations as return clinicians. It's so hard to have because again, I know we're on this time schedule, we're on this budget and like, um, you know, one of the tools I use when I worked in a more traditional practice and still did this was like, set up this expectation with my patients that like We only have time to handle one issue like per appointment, right? We only have time to have to like really give it the time attention and like quality that it deserves to give you the best quality of care. And for some people that's like really impossible because they can only get off one day. Every six months to see a clinician. And so like I would talk about like to do my job the to the best of my ability. I can do one thing in this appointment, you know? And I would want you to come back for all these other things that can be a virtual visit it can be a telehealth visit, it can be a phone call.
Queer Doc (they/them): Um, but you know, and if we try to squeeze all these in, I'm not gonna be able to do the job, my job to the best of my ability and…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): might have suboptimal care. how does that feel like given your time and energy that you have to invest in this and like help like helping them understand like the limitations of my time and my expertise and the system and then helping them to like how they want to navigate it and right is just like, I always felt like,…
Elena Wagner WA-Seattle: Yeah.
Queer Doc (they/them): if I did that work up front, it made everything else. A little bit new here. Yeah.
Elena Wagner WA-Seattle: Easier. You know, something expectations is always better for everybody. so,
Queer Doc (they/them): Okay, I took up all your time and like it gets all the questions but like, thank you so much. I feel like I'm like,…
Elena Wagner WA-Seattle: Of course.
Queer Doc (they/them): we'll probably pester you another day to come back.
Elena Wagner WA-Seattle: Yeah. And I say I'd be happy to.
Elena Wagner WA-Seattle: So this is fun.
Queer Doc (they/them): You this is so informational and…
Queer Doc (they/them): so helpful and I feel like there's so many other things I wanted to ask you about and but yeah, thank you so much for your time and Dr. Wagner is at Virginia, Mason in Seattle for anyone, who's in the Greater Seattle area, and taking y'all take all health insurance. Um, so can take referrals for anyone who is interested in minimally invasive, gynecology. It sounds like also for anyone who's been told that they're not candidate or that, you know, to do an open procedure, maybe getting a second opinion, would be great as well.
00:50:00
Elena Wagner WA-Seattle: And I would say I'll also patients that are told, they cannot have a tubal sterilization or hysterectomy based on age. That's another one that comes up a lot.
Queer Doc (they/them): Oh yeah. Oh yeah, I had that one. I was like I'm ready to do this and everyone in Florida was like You're too young and I was like Mmm.
Elena Wagner WA-Seattle: That whole other camera worms.
Queer Doc (they/them): That is thank you so much for your time.
Elena Wagner WA-Seattle: Yeah. Good too.
Queer Doc (they/them): Have a great day. Bye.
Elena Wagner WA-Seattle: Thank you so much.
