A woman wearing purple surgical scrubs stares into a camera, looking frustrated but doesn't speak. Superimposed over her head is the text "Just realized I only get to Yeet 4 Teets next week," and a crying emoji. Rain appears to drip down over her while "Stan" by Eminem plays in the background.
That October 2020 TikTok by Sidhbh Gallagher, MD, a Miami-based plastic surgeon known as @gendersurgeon, had almost 10,000 likes and was tagged #topsurgery, #masculoplasty, #ftm, and #transman, among other hashtags.
"What health check do I have to get in preparation for teetus deletus?" is the question in another Gallagher TikTok. Gallagher is a prolific user of social media with over 268K TikTok followers and over 44K Instagram followers. Another Gallagher TikTok account, @thevagicianmd, has some 7K followers.
Another cosmetic surgeon, Tony Mangubat, MD, known as @Tikdoctony to his more than 200K followers, uses similar hashtags — like #teetusdeleetus — in his TikToks.
Clearly not medical terms, hashtags like #yeettheteet and #teetusdeletus are often used by the transgender community. The posts by Gallagher and Mangubat are part of an ever-growing wave of social media activity by medical professionals.
Plastic surgeons have never been shy about advertising their work — and many have taken to social media to do so, including showing before and after photos. A 2020 study published in Plastic and Reconstructive Surgery found that the majority of such surgeons, especially those in private practice, use social media.
But the use of TikTok, Instagram, and other social media platforms by surgeons who specialize in gender reassignment raises questions about the appropriateness of promoting such procedures, especially to a younger-skewing audience.
Because of the limits on pornography and nudity on social media platforms, most social media posts by gender surgeons are about female-to-male (FTM) mastectomies, the fastest-growing transgender procedure.
The American Society of Plastic Surgeons (ASPS) started separately tracking gender-affirmation procedures in 2015. That year, members reported doing 1360 FTM procedures.
In 2020, the ASPS further separated procedures into additional categories. That year — when many surgeries were postponed because of the COVID-19 pandemic — FTM mastectomies grew by 15%, with 8548 procedures performed, a far greater number than for any other transgender surgery, and a sixfold increase in the number of procedures done in 2015.
#teetusdeletus "Gimmicky," But Building Community
Surgeons interviewed for this article said they use social media primarily to connect with patients and to educate in a light-hearted way.
While Gallagher acknowledges that using #teetusdeletus is "kind of gimmicky," she said she doesn't view it as unprofessional because she is "using the words of the community I serve." Many of her patients have seen a medical professional "who just didn't understand what it is to have gender dysphoria, didn't understand what it is to be trans, so going from that experience to somebody who uses the same language as the community uses can be quite a comfortable experience," she told Medscape Medical News.
Mangubat, a Seattle-area plastic surgeon who has been doing mastectomies for trans male patients since 1988, said he tailors his TikToks to that group. He likes TikTok — which he started using in early 2021 — because it has rules against bullying, swearing, and pornography, he told Medscape Medical News.
"It's really not...advertising...it's a community-building platform," said Mangubat. "If you build community, people will trust you, and if you provide good accurate information, then people will be safer," he said.
But, "I'm not telling them to come to me," he stressed.
He always appears in scrubs and doesn't do music, doesn't dance, and doesn't post before and after photos, but he still gets thousands — or sometimes hundreds of thousands — of likes.
His mission, he said, is to answer the community's questions. "We're reaching patients that have had their top surgery, that are going to have their top surgery, that are looking for how to get top surgery, that are just starting on testosterone, that haven't started on testosterone — it's the whole spectrum of patients," said Mangubat.
Other surgeons have expressed concern about ethical boundaries and the tendency of social media posts to downplay risks of what are life-changing procedures.
A 2020 study of YouTube videos on top surgery, for instance, concluded that "there were no unbiased videos by board-certified plastic surgeons explaining the risks, benefits, treatment options, and alternatives to surgery."
Alison Clayton, MBBS, an Australian psychiatrist, said that social media posts can create false expectations because they emphasize style over substance, omit risks, and can create an unwarranted sense of trust in the doctor that can spill over into the physician–patient relationship.
Clayton also believes that "the gender-affirming surgical procedures being offered to these youth have a scant empirical evidence base for benefits to psychological health and well-being."
It is known that a number of those who transition, using either opposite sex hormones and/or surgical procedures, later have regret and "detransition," but statistics are lacking. It is also a controversial area, with many detransitioners saying they didn't get appropriate care and weren't properly assessed before being given hormones or heading to surgery.
Most of the gender surgeons interviewed for this article said they see almost "zero" regret if proper mental health evaluations are performed before surgery, and they added, the procedures can relieve dysphoria.
Nevertheless, posts should not be "all fun and games," said Josef Hadeed, MD, chair of the ASPS Patient Safety Committee and Public Education Committee, and a member of its Social Media Subcommittee.
"When someone makes a decision to undergo a surgical procedure, they should be very aware there are some risks and potentially serious risks involved," he told Medscape Medical News.
The ASPS "wants members to use social media in a judicious manner" in a way that educates the public, encourages patients to learn about a procedure and to consult with board-certified plastic surgeons, said Hadeed.
The Beverly Hills, California-based surgeon does gender-affirmation procedures himself and uses Instagram, on which he has 53.4K followers, to educate patients and highlight his work using before and after photos.
"I like to think I do it in a very tasteful way," Hadeed said. "It's not in a way that's sort of suggestive to patients, including minors, that this is something they need to get done because if they are thinking about getting it done there is a lengthy process that they have to go through before they even set foot in our office."
And he said, "It may be inappropriate" to use certain hashtags or terminology, "even if it does 'speak' to the patients. Professionally, plastic surgeons should maintain a higher standard and maintain that even with their social media."
Marci Bowers, MD, a gynecologic surgeon who performs gender-affirming procedures, and who is transgender herself, agreed.
"Some of the posts out there seem sensational, distasteful, and risk compromising patient confidentiality," Bowers told Medscape Medical News.
"Much of this seemed to cross the line of good taste and appropriateness," added Bowers, who is the incoming president of the World Professional Association for Transgender Health (WPATH). "Creating an idealized video without addressing risk is inappropriate and misleading," she stressed.
"These surgeons would perhaps better serve their clients by focusing on and improving their clinical care," she added.
Bowers said that although WPATH has not addressed social media use in the past, its ethics committee will be taking on the topic this year.
Social media posts about gender-affirming procedures "don't usually talk about the barriers, they don't talk about bad outcomes, they tend to just focus on success stories," said Gwendolyn P. Quinn, MD, a bioethicist and the Livia S. Wan, MD, professor of obstetrics and gynecology at the NYU Grossman School of Medicine.
But she also sees some positives. The posts can help normalize gender-affirming surgery, and post-procedure photos might "help people realize that they can't just have everything exactly the way they want it to be," said Quinn.
Does Social Media Influence or Educate?
Studies have documented the power of social media to influence desire and decision-making, especially when it comes to cosmetic surgery.
"The use of social media creates a vague area between patient confidentiality and entertainment," writes Nisha Gupta and colleagues of the UCLA David Geffen School of Medicine in a review published in the Aesthetic Surgery Journal.
While social media use is on the rise by plastic surgeons and has the potential to educate, it also has "compromised the integrity of the doctor–patient relationship," they add.
Surgeons can use tools to place themselves higher in searches and patients might assume that those who have hundreds of thousands of followers "are the most qualified or trusted, although this is not always the case," they note.
Markus Rach, PhD, a researcher with the University of Applied Sciences and Arts Northwestern Switzerland, analyzed the impact of TikTok's plastic surgery content on how adolescents perceived themselves and how it influenced their decision to have a procedure.
Most TikTok users are under age 24, and #plasticsurgery has a huge viewership with some 3.8 billion views at the time of publication, said Rach. He found that influencers tended to make adolescents feel bad and want surgery, but that plastic surgeons had a moderating effect on both negative feelings and the intent to get surgery.
Bowers said that, despite her concerns, she does not "believe social media influences like TikTok and Facebook create artificial demand."
However, Mangubat said social media can make plastic surgery seem enticing. "It can happen, and it does happen," he said, but he added that's true for any cosmetic procedure, not just gender-affirming surgery.
The pitfall with social media is that "patients are being sold a vision of themselves that may or may not be possible," he observed.
Quinn worries less about people being talked into a procedure and more about those who don't want surgery.
"There are people who identify as transgender but do not feel the need to change any parts of their body," she said. "And that should be okay."
Concerns About Minors
New guidance from WPATH, their Standards of Care (SOC) 8 — the first update in 10 years — is due to be published this month. As Medscape Medical News understands, and as stated in the draft of the SOC 8 published for comment in December 2021, the organization has recommended lowering the age for "top" surgery from 18 to 15 years.
Clayton has concerns about young people with gender dysphoria, who she says are "often vulnerable youth, many of whom have comorbid psychiatric and neurodevelopmental disorders."
"This may contribute to a greater vulnerability of this population to undue influence," added Clayton.
Sean Devitt, MD, and Jeffrey M. Kenkel, MD, of the University of Texas Southwestern Medical Center in Dallas, expressed concern that social media posts by plastic surgeons could be especially dangerous for young people.
"Given that the prefrontal cortex, which is largely responsible for impulse control, is not fully developed until the age of 25, is it ethical to allow younger patients to make life-lasting decisions under the guise of education?" they ask in a commentary on the review by Gupta and colleagues about plastic surgeons' use of social media. The review did not focus on gender-affirmation procedures.
Many surgeons — but not all — steer clear of genital ("bottom") surgeries in minors. However, bilateral mastectomies are being performed in those as young as age 13 based on surgeons' risk–benefit calculus for the patient.
A study published in the Annals of Plastic Surgery in May showed there was a 13-fold increase in the number of bilateral mastectomies performed on under 18s between January 2013 and the end of July 2020. Of the 209 minors (age 12 to 17) who had the surgery, two (0.95%) expressed regret by the time of follow-up, at 3 and 7 years postoperatively, but neither had reversal surgery.
A small 2018 study among trans males who had top surgery found high rates of satisfaction; one of the 68 patients reported experiencing regret "sometimes." The mean age of patients in the surgical group was 19 years and the youngest patient was age 14.
"Most of us who practice heavily in this field will make exceptions, not for genital surgery, but typically for top surgery," said Gallagher, who added she operates on one minor [under 18] a month, while doing some 400 to 500 gender-affirmative surgeries a year. For some patients, "doing nothing isn't necessarily a no-harm option," said Gallagher.
"Arbitrarily picking the age of 18 and sentencing that patient to another year of dysphoria" might not be the best risk–benefit calculus, she said.
Mangubat agrees, especially if, for example, a trans man develops double D breasts by age 14. "You've sentenced them to 4 years of misery" before they can get insurance coverage, he said. His youngest top surgery patient was age 15. He said the person's family, mental health professional, and primary care physician were all in favor of the procedure.
Mangubat also noted that some insurers, such as Kaiser Permanente, now cover bilateral mastectomy starting at age 16.
Quinn, the bioethicist, said not every minor or young adult is equipped to make the best long-term decisions.
She works with younger patients who have cancer, for example, and said her suggestions that they consider fertility preservation are often met with protestations "that they will never have children."
The same issue arises with transgender patients. They may not want to think about having children or issues such as breastfeeding while in their teens or early 20s. "But you know from your experience that they may feel differently in 10 years, but they're just not in the mind frame to think about it," said Quinn.
Some young people may accurately never want children, said Quinn, "but there is a lack of maturity shown when a person just shuts down a conversation and won't even listen to infertility threats and potential preservation options."
Concerns About Regret?
Gallagher said she follows the WPATH standards, which require mental health evaluations, and as a result, "the risk of regret is incredibly low."
However, one of Gallagher's patients who detransitioned, Grace, who goes by @HormoneHangover on social media, said she has taken umbrage at some of the Miami surgeon's TikToks, including one, "Why might some patients feel sad after surgery…despite wanting it for so long??"
"This is actually not uncommon with ANY kind of surgery but it's temporary!" said the TikTok text. Gallagher is wearing a red dress and heels and flips her hair while the text scrolls above her.
But to Grace, the TikTok "really bothered me because sometimes there is regret and I think that sort of advertising paints a falsely rosy picture," she told Medscape Medical News.
And it is emblematic of what she feels was Gallagher's "breezy" approach to explaining the procedure to her. "The surgery itself was a shocking experience for me," she said. "The physical experience was very jarring. It was very disturbing in a way I hadn't anticipated or understood in advance," said Grace.
Mangubat, who does 100 bilateral mastectomies in trans patients a year, said he goes to great lengths to ensure his patients are good candidates. Everyone — even those who self-pay — must have counseling, and if the individual seems to be considering the surgery because it's "trendy," he steers clear.
"If they're not serious about it, I don't want to operate on them," said Mangubat. "There have been maybe two patients who have come back" to detransition, he said.
Hadeed also said he has not seen regret. He attributes this to his vetting process, which includes investigating the background of the mental health professionals who write support letters.
"We've turned away a lot of patients from our office either because of inadequate letters or because the person writing the letter just doesn't really have any proper credentials," he said.
Is Social Media Use by Plastic Surgeons the New Normal?
With so many plastic surgeons — including those who perform transgender procedures — using social media, it may increasingly be just part of doing business.
"Undoubtedly gender surgery teams will have a greater presence on social media in the future," write Alireza Hamidian Jahromi, MD, and a colleague of the plastic surgery department at Rush University Medical Center in Chicago, Illinois, in a letter published in Plastic and Reconstructive Surgery.
Kyle R. Latack, MD, and colleagues at the University of Southern California and the University of Michigan, have studied the use of social media by the transgender community and write that they believe "there should be an increased effort to develop high-quality and unbiased resources for patient education that can be made [available] on social media."
Gallagher said TikTok helped her erase fear. "A bilateral mastectomy is a scary surgery for an 18-year-old or a 20-year-old," she said, "but they have to do it for their well-being."
"That is a criticism I've heard — that I seek to minimize it, or that I'm flippant about it," said Gallagher.
For "top surgery the risk profile is pretty low," she said, "so what I try to do is educate people that it's maybe not as scary a procedure as they think."
Mangubat, however, is concerned about some of what he sees, especially the explosion of surgeons offering gender-affirming procedures. "Now everybody wants a piece of it," he said.
"Let's face it, it's money now. You get paid for doing this surgery. Hospitals get paid a lot of money for their operating rooms for doing the surgery," said Mangubat.
"There are some surgeons who believe the transgender community is just another market."
Alicia Ault is a Lutherville, Maryland-based freelance journalist whose work has appeared in publications including JAMA, Smithsonian.com, The New York Times, and The Washington Post. You can find her on Twitter: @aliciaault.
Lead image: @gendersurgeon/TikTok
Headshot 1: Tony Mangubat, MD: Kate Taylor
Headshot 2: Drew Bird Photography
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Cite this: Gender Surgeons on TikTok, Instagram: Appropriate or Not? - Medscape - Jul 11, 2022.