Transvox Podcast - Chadwan Al Yaghchi talks Gender Affirming Voice Surgery

[00:00:07] Hi and welcome back to Transvox. And today another guest with me and I'm very excited to talk to Chadwan Al Yaghchi who's sitting in front of me looking resplendent. I'm not sure if it's a background or a very posh study, but we're going to talk all things surgery today. So strap in because I think it's going to be absolutely fascinating. And it'll be interesting to hear from a surgeon about surgery and the different types and what are those things and such and how it all works. But first of all, let's welcome our guest, Chad. How are you? Tell me, what's the weather like where you are today?

[00:00:38] Hi, Gillian. Thank you very much for having me. It's an absolute pleasure and it is actually my study. So it's very tidy. And I have a Lego set from my daughter as well. You can just see it in the background for Father's Day. Yeah, weather is great today. Unlike yesterday when it was like hammering down, today is nice and sunny outside. So looking forward to getting out of the house later. Tell us a little bit about yourself.

[00:01:04] As you kindly introduced me, my name is Chad Aliaghchi. I'm an ear, nose and throat consultant. My interest, I'm a laryngologist. So I manage exclusively everything related to the throat. So that will be voice problems, swallowing problem and airway breathing problem originating from the throat. And by extension, my main area of interest is around gender affirming voice surgery. And that's something that has been developed since I was like early years trainee. And it's large part of my practice today.

[00:01:34] That's fascinating. So for trans people, obviously, we actually hear by my voice. I'm a trans woman. I have a, obviously the voice I have. So I've tried all sorts of methods to affect my voice. I've heard about, is it a tracheotomy or something? I'm not sure of the phrase. The shave of the Adam's apple or what it's called. Is that the sort of thing you're talking about? What you're referring to is what's commonly known on the internet, if you are within the community as a tracheal shave. That's it.

[00:02:02] It is a shave. It's a shave, but it has nothing to do with the trachea. So the trachea is the windpipe. What we're shaving is the Adam's apple, which is part of the voice box. But that's not to do with voice. That's mainly to reduce the Adam's apple to give a more feminine profile to the neck. Yeah. And so it's gender affirming, but it is mostly as part of facial feminization, neck feminization. So it's just to get off that masculine prominent Adam's apple. The surgeries I do.

[00:02:31] So I do perform that when it is required. Yeah. But the surgeries for voice is mostly we're trying to adjust the pitch of the voice surgically. So something to have a permanent change to the pitch of the voice. So tell me how that works then. So obviously I'm a trans woman. We can start with me, but I know we want to talk about trans mask people as well. So, yeah. So in general, the vocal cords behave similar to any strings of a musical instrument. It's a bit simplified because they're muscles, so they are adjustable.

[00:03:00] But in general, so the pitch of any string instrument or the vocal cord is determined by one of three things. The weight of it or like the bulk of the string. So you will see them on the guitar. The top strings are heavier. The tension. So how much you tighten the string and the length of the string. So longer string vibrate slower compared to shorter one. And the surgery will aim to adjust one of these three parameters. And there is like a surgery for each one of this.

[00:03:26] So you can do laser reduction. So to remove some of the muscles from the vocal cord to make them lighter. So they vibrate quicker. You can increase the tension by stretching the vocal cord and holding them in that place. And that's the old style operation called cracothyroid approximation, which was the mainstay of treatment since the early 80s up to five years ago. That was the main operation that was being performed, but it has a lot of downside to it. So now there are much better techniques.

[00:03:54] So that's pretty much gone out of practice unless you have a very specific patient requirement. So the operation that we do the most is the modified Windler's glottoplasty. And the surgery aimed to shorten the part that vibrates from the vocal cord. So if you play in the guitar and you press on the string, the note goes up because you isolate part of that string out of the vibration. And we do exactly the same with glottoplasty. So it's a keyhole surgery.

[00:04:21] You go through the mouth endoscopically and you remove some of the lining of the front of the vocal cord and then you stitch them together. So when it's all healed, that half of the vocal cord no longer vibrate. And what's left vibrating is 50 percent of what you originally where you started. So that vibrate quicker and the pitch of the voice increase accordingly. Wow. OK, so talk me through that. So how long would that sort of operation take to carry out? It's not a long operation.

[00:04:50] It takes possibly will take around 60 minutes, start to finish, including anesthetic time, waking up time. So it is, as I said, it's keyhole surgery. It's minimally invasive. We do it all through the mouth. It's very delicate operation. We do it under the microscope because the full length of the vocal cord is somewhere around the 15, 15 millimeter. It goes from 10 to 20. So in most trans women who has gone through puberty with testosterone, the vocal cord will be dimension of a cis male vocal cord.

[00:05:20] So there will be between 15 to 20. So the whole operation, you're operating on a seven millimeter and then you need to put stitches down an endoscope. So it is quite a delicate operation, but it's not majorly invasive surgery. So that's interesting. So I'm just flipping over to trans masc people for a moment then, because I'm assuming the reverse does not apply because you can't lengthen something that's not already has the capacity to be lengthened. So how does that work? Exactly that.

[00:05:49] So you cannot adjust the length. You can shorten. You cannot lengthen the vocal cord. Yeah. So you have to address one of the other two parameters. So the majority of trans masculine people, when they start on testosterone treatment, the muscle bulk within the vocal cord increased naturally. So it's as with the rest of the muscle bulk on the body. And that leads to drop of the pitch. So that will happen with testosterone treatment almost 100% of the time. Yeah.

[00:06:17] Possibly 70% of trans masculine who are treated with testosterone within six months, 70% will have a voice that they are satisfied with within a cis male range. And that leaves 30% who may not. So you adjust the bulk of the vocal cord. So that's one of the three parameters. If you have testosterone and your vocal cord has not dropped enough, and then you go for therapy and the therapy can address like with different techniques, trying to relax the vocal cord, try to deepen the voice.

[00:06:47] But then if that doesn't work, then you have a couple of options available for trans masculine. Traditionally, you will have the voice deepening surgery, which you aim to relax the vocal cords. So this is taking away the tension from the vocal cord. And there are a couple of operations we do for that. It's not an operation I perform as common as trans feminine because unfortunately for trans feminine person, estrogen does not change the voice. So it is a one-way street.

[00:07:15] Once you've gone through puberty, that's no way back. Alternative option, which is just brand new to the UK, we haven't done our first patient yet, is really new treatment that's being used in the US, which you do direct testosterone injection into the vocal cord muscle. So this is a targeted treatment. And it is either to supplement the systemic testosterone that the person has taken, but their voice has not.

[00:07:39] Or it's very good for non-binary people who do not want to be on systemic testosterone, but they would like a deeper voice. I see. That makes sense. So you can go and you target that specific muscle. There might be some systemic effect because some of that testosterone will be absorbed into the system, but we're injecting small amount in a small muscle. So the systemic effects are likely to be very small. Yeah. But you can target the muscle directly with an injection. And we do that in an office environment, so in clinic.

[00:08:08] So you don't need to operate in theater, et cetera. So we can do it in clinic with EMG guidance. So this is brand new. Yeah. So hugely less invasive, I'm guessing. And it recuries really fast. Yeah. Yeah. And then especially with pitch-deepening surgeries, they have some quite significant effect on the voice. It can lead to roughness of the voice, reduced volume. With a testosterone injection, you will have none of that.

[00:08:34] So apart from any expected side effects for an injecting directly into the vocal cord, the worst that can happen is that it doesn't work or it doesn't give you the strength. But it's not going to affect the quality of the voice or the projection of the voice. So it's possibly a very attractive first time. Yeah, that makes sense. And how much for the testosterone thing, how much for a trans mask in the region of one?

[00:08:57] I don't want to talk actual fees, but what's the ballpark figure that someone would need to expect to be saving up to think about this? For the testosterone injection, it will be around the £2,000. For the surgery, it will be around £5,500, £6,000 with consultation costs, etc. And what about the trans femme side of things? Pretty much around the same thing.

[00:09:20] So without tracheal shape, it will be around that £5,500, £6,000 to include therapy, to include consultation and all of that. So this is a ballpark figure. Because obviously it's a sum of money and when you're working your finances out to do the whole transition process, you've got so many things to think about. Do you recommend that people attempt voice training? I don't know, there's techniques first or what for you is the best process to go through? So I think the jury is out on it.

[00:09:49] If you asked me this question five years ago, I would say absolutely go for therapy. And if therapy fails, then come for surgery when we didn't have any option but cracothyroidal approximation because the downsides are quite significant. So I would say this is the last result. Now you will have two ways. So you either choose therapy as your primary intervention. So you go with full feminization therapy. It will take between 10 to 20 sessions.

[00:10:15] So it's not something that's going to happen overnight or like you go for one lesson and your voice is good. Some people have the ability, but the majority of people will require a good 10 to 20 sessions and practice in between. But there is pretty much no downside to it apart from money and effort. Like if you do not mind trying, that's absolutely great. And it works for a lot of people. There is nothing invasive about it. So that's perfectly appropriate way to start.

[00:10:44] Well, the alternative way is you have surgery as your main method of your pitch elevation, but you have to supplement that with therapy. So you can't do surgery on its own. So the therapy in the surgery case, you can look into it in two ways. One is the rehabilitation part. This is the physiotherapy part of therapy. This is how to use your vocal cords correctly, how to stabilize the pitch, how to improve projection, how not to get into muscle tension. Exactly.

[00:11:13] If you break your elbow, you need to go to a physiotherapist. So that you have to do. So you will have to do a session before surgery and like a few short sessions after just to get the maximum effect. And then once you finish that, if you're satisfied where your voice is, that's done. If you still want to look into other aspects of feminine voice, you can look into doing more feminization because, sorry, I've talked a little bit too much.

[00:11:39] But voice, the femininity, perceived femininity of the voice is not purely pitch. Pitch is one aspect. Yes. You will have the pitch. You will have the resonance, which is related to the shape and length and the size of the tract. And then you will have speech characteristics, how we speak, how we intonate. Unfortunately, how we look, that's hand gesture, non-lingual communication. All of that plays a part. And surgery, of course, does not address any of these.

[00:12:07] So surgery will address one aspect, which is the pitch. So is this sort of the surgical approach about speed? Is that what it's really about? No, it's not about speed. It's therapy needs a lot of ability. So it needs some people have inherent ability. Some people can sing. Some people cannot sing. Some people cannot hold the note, no matter how much. There is inherent ability. There is musicality to the voice.

[00:12:33] Some people simply can't, don't have the time, don't have the, they don't want to put the effort in or it just doesn't suit them. And there is another important aspect. A lot of people find therapy quite triggering in terms of dysphoria because it makes, it brings that aspect that you are most dysphoric about into the forefront of your thought every single time you speak.

[00:12:58] Because what surgery offers you, apart from the speed and then you get results, you don't get instant, you get pitch elevation pretty much instantly. You still need to work on your voice. But what surgery offers that therapy does not offer to a certain degree is security. How do you mean by that? When you have therapy, you need to think about how you speak. You need to get yourself prepped. You need to get your larynx in the right space.

[00:13:25] In some people, it becomes spontaneous and becomes second nature and you never think about it. In some people, it's a lot of effort. You need to make a conscious effort. So when I open my mouth to speak, the only thing I need to worry about is what I say. For a trans person, often they need to think about how do they sound, how are they perceived and what are they going to say? And you put the techniques and you can get good voice.

[00:13:51] Then you get into a work meeting when you start discussing things in depth and you find your voice drops down. Or you meet a new person that you're uncomfortable with and you find your voice drops down. So it's not that you do see that. And then you will have this, what we call a, not particularly nice expression, but this is the medical term, the vegetative sounds. So the sounds that are not under our conscious control, cough, laugh, sneeze. Yes.

[00:14:19] People cough and their voice, it's just the masculine voice comes out. Yes. So surgery does not, surgery takes that element of risk and unreliability of the voice away. And if you look into some, there is some good research out there to show that despite having surgery and not getting pitch increase, voice related quality of life does increase. Right. Despite the pitch has not gone up because of that security element that the surgery has.

[00:14:49] Surgery is not for everyone. There are downsides to surgery, of course. There are risks and complications associated with surgery. But it is something you can consider and it is we tailor it to an individual person. So that's interesting that you say it might not be for everybody. So I'd like to unpack that a bit more. But can we start with age ranges? Because what's going through my head is I'm guessing this needs to be done following, you know,

[00:15:13] there must be a minimum age for this sort of type of work because you can't work on a system that's not fully developed. 18 years is my cutoff. Part of that is legal within the UK regulation. You're absolutely right. A person needs to have gone completely through puberty. So in theory, you can operate on 17 years old or quite mature, mature 16 years old. So we don't.

[00:15:41] So 18 is my cutoff limit as lower limit. I have no upper limit. My oldest patient is 80 years old. I was going to say 80. Because, yeah, because that's interesting, isn't it? Because I'm thinking of myself, who's someone a bit older. But I guess the key criteria here is the level of dysphoria you have, isn't it? Because there are people who it's just priorities, isn't it? Where do you start? Some people have extraordinary voice dysphoria, especially if you're working on the phone.

[00:16:07] And I obviously have less dysphoria than some in the voice area. But for some, I know it's a real issue, isn't it? And they really find that sort of death of a thousand cuts on the phone. Yeah. And then it impacts your career progress. It impacts your socialising. All of these aspects. We take our voices for granted. This is like basic human function that we can speak and communicate. And if it's a chore every time you speak, the impact on quality of life is quite significant.

[00:16:37] But as you rightly said, it's not everyone have the same level of dysphoria. And some people are perfectly happy with their voices. And that's absolutely fine. This is individual. This is dysphoria. This is quality of life issues. So there are these two aspects. And as I said, we tailor our approach to the individual needs rather than it's not a blanket. Everybody needs to go through this or everybody needs to do it this way. It's a two-way discussion. It's a two-way decision making. I can say what I can offer.

[00:17:07] And I can address what's right and what's wrong. And what's the positive and what's the negative. Like everything else in life has ups and downs. And then it's for the individual to make sure that this is for them. And this is going to address their needs. Yes. And other people, I mean, you mentioned the age thing. But are there other people that you are reluctant to work with or don't work with at all? Sorry, I missed that.

[00:17:32] Are there, aside from the age issue, which I understand, are there people with whom you would not work or you'd be reluctant to work with? No. There is no one that I'm not willing to work with. In certain people, we need extra support, mostly around psychological support. So people with, sometimes you will see people that need that extra layer of support from psychology because sometimes worse is unrealistic expectation. Or people who have, I want to sound like that person.

[00:18:00] I will never, ever be able to make you sound like that person. You will sound like you with a higher pitch. And that concept can be, especially now we consume a lot of information from social media. And that's where people find, see, we see this person, they sound absolutely fantastic. They came to you, they had surgery with you. Can I have the same? I can never promise you the same. So sometimes we need that extra psychological support. And that's the main thing.

[00:18:27] And apart from that, medically, some people are not fit for surgery. I would have to say because this is not majorly invasive, but you need to take that into account. It's still a surgical operation under general anesthetic. So that needs to be taken into account. But we will work with every individual to their needs, really. The whole subject is tricky, though, isn't it? Because I'm an ex-musician, which I talk about a lot in different places.

[00:18:53] And I'm very familiar with this concept that a lot of people don't hear their own voice. Yeah. And they don't like the sound of their own voice. So I get the gender dysphoria thing, put that to one side for a minute. But it's quite hard to be objective about one's own voice. So I just wonder how that's dealt with. Because often the way we hear our voice is very different to the way others hear. You know, we can sound wonderful, but in our head it's awful. So the dysphoria can be a bit of a challenge. Is that what you mean by the sort of psychological element,

[00:19:22] making sure that people are aware of those sorts of things? Yeah, there is that. So there is that aspect, because this is an important point. None of us like our voice in recording. When I listen to this tomorrow, I'm like, oh, man, what did I say? How did I sound? But that's part of it. And part of it is listening to your voice back recorded. So for a trans person, this can be difficult. I appreciate.

[00:19:48] But you can compare before and after, and that will help you see what you achieve. Because our brain adapts very quickly. You know, we have like amazing plasticity in our brains. You know, suddenly the new voice becomes your voice. And it's only when you listen to yourself before and how you are. So that's need to be, you know, then you realize how much of a change that have made.

[00:20:13] The psychological support that I was talking about is with people who have like if surgery doesn't work 100% of the time. And there are certain vulnerability in people and certain people have people who have self-harm, etc. background. And I want to make sure that if the results are not what you desire, how we're going to support you through this process, because it's not 100% guaranteed surgery.

[00:20:40] And I need to make sure that we have that right support network around either from family or either from a professional support, friends, family, people to offer you that support when the results are not what you desire. And even worse, you don't get the pitch increase, but you get the downside of the surgery, which there are trade-offs like worse of both worlds. So while there are revision surgeries, but I need to make sure that this support structure is available for that individual person.

[00:21:08] Yes. And it's interesting as you talk about that, we just need to reinforce that you're talking about risks. And there's, I imagine that's not the common thing that doesn't work. You're saying that these are the exceptions, aren't they? Yes. Yeah. So I normally would say... My voice is getting deeper and deeper as we're chatting. I can notice it now. Yeah. So the positive outcome from glottoplasty, I would normally say around 90%. Okay.

[00:21:33] So the operation fails either because the stitches break down after surgery and that's correctable. And there is ways to prevent or reduce the risk of that, like good post-operative care, following instruction and all of that stuff. But there is a group that when you do the surgery, the operation is technically successful. All healed as it is, looks great, no complication. But the voice has either not changed at all or changed by a small amount. And that's the part that I can, I can't do anything about.

[00:22:03] And this is, I cannot predict beforehand. So I have, so people results comes on a spectrum, basically. So you will have that natural distribution. So the majority will get around the average, but you will get an outlier. You will get a person who gets 100%, 100 Hertz increased and a person who gets 20 Hertz increased. And I have no way for me beforehand to know where you're going to be on that spectrum. So, and I get, is there a difference in efficacy between trans mask and trans femme?

[00:22:34] Surgery in trans femme is a lot better, I would have to say. Okay. In both outcome, in terms of net pitch increase, but also in terms of quality of voice and the negative impact on the voice. So for the glottoplasty, the main downside is the loss of volume and projection. I see. So hopefully this new method might actually help with that. So for the trans masculine, you will get, if you do the surgery, there is a risk of roughness and loss of projection.

[00:23:04] But if we look into the testosterone injection, that will bypass that. Although the results, the net pitch increase may not be as high. There is risk reward balance, like with everything else. Some operations will give higher pitch increase or higher pitch lowering, but have a slightly more higher risk profile. And that's where you need to work with the individual needs, really. Yes. Oh, just before I ask that question.

[00:23:31] So is it, so for example, lots of trans femme people, I don't know about trans mass people, so forgive me on this one, but they often have facial surgery. And then does voice come before the face or face before the voice? Or does it not actually matter? It doesn't matter. It doesn't matter. But you wouldn't do the both at the same time? Not face, no, because face is quite invasive surgery. And then try to do that while doing, and then it will involve often operating on the mandible, which is the jaw.

[00:23:57] And these are areas that we work, I have to work through the mouth, etc. So not at the same time. I do tracheal shave and a glottoplasty at the same time. So it's two operations, one after the other. The one thing to keep in mind, after glottoplasty, you can't have any surgery under general anesthetic for three months. Okay. Until it heals. So that's something to keep in mind. And there will be some adjustment to the anesthetic.

[00:24:26] But these are like easy adjustments. It's not a major thing. So the order doesn't matter. You can do them in whichever order a person wish or where their priorities, where their dysphoria is. And is there an advantage to having someone based in the UK? Or there's a lot of people who are tripsing over to Turkey and the Far East and such. I know the answer to this question, but I'm going to ask it anyway. What's the advantage of having the operation done in the UK?

[00:24:52] We have very strict regulation in the UK from all aspects of our clinical practice. We adhere to GMC, best medical practice. We have strict criteria in terms of governance, in terms of auditing results, in terms of rights for the patients. Patients have rights and we all have to comply with the law, but we have to comply with GMC. For me, hospital standards are very tightly regulated.

[00:25:20] And so I personally would not go have surgery outside the UK because I know exactly what my rights are. And I know that as long as I'm working with a reputable consultant in a reputable hospital, then you know that the regulation are tightly followed. So you'd imagine the same sort of level of care in Europe, for example, or maybe the States. Yes, but the thing is, it's very attractive for some people to think, actually, I could get this opportunity, maybe this operation for...

[00:25:48] I've seen differences in facial feminization, you know, up to half, maybe three quarters of the cost. Yeah. But all that comes with just increased risk, isn't it? It comes with increased risk and it's a quality control that we do not know. Like, you can't have... There is so much behind the scenes that, as a patient, you do not see as well. Like, from surgeon training, from regulation, from the governance around it and all of that.

[00:26:15] I know exactly what you get in a UK practice and Europe to a great degree. United States, for example, when it is like really tightly regulated. In other areas, it's not as that. It's not like that. Yeah. Okay. I thought you'd say that, but I thought I'd better ask that question because that's an important thing to say. Because I do think people get seduced by the hugely differential price of things. Yeah. And then most of the time it's possibly going to be all right.

[00:26:40] When you have complication or you have care has not been delivered or negligence, you have very little way of coming back, really. Yeah. Physically, going back is a problem. Is a problem. The cost, your rights. And would you be able to... Can you make a complaint? Can you get things rectified? Is your complication going to be dealt with? All of that stuff that you are guaranteed in the UK. You're not guaranteed overseas. Yeah. All right. That's great.

[00:27:08] It's always intrigued me about how we make the decisions we make to put our, effectively, our lives in the hands of surgeons. Now, if we have a heart attack, we're rushed into an ER room and we get what we're given and that's lovely. But things like elective surgery, what's the best way to actually, or what are the best criteria to look at in terms of picking a surgeon and deciding to work with someone? I'm suspecting it's a bit like we're picking a therapist. I suspect it might be similar, but I just wonder what your views were.

[00:27:36] Because I think a lot of people resort to online chat rooms and Facebook groups and such. And you see the worst. But I just wonder if there's a more objective way to be able to pick. I think it's the main resource within the community is the support network that you have. So either that online forums or word of mouth. And these do count. Listen to people experience. If you see somebody put something on Reddit forum, send them a private message and get a private. Yes. Something outside that on Facebook, the same.

[00:28:02] A lot of the people, my patient and other surgeons patient will be very willing to share their experiences, maybe publicly, maybe privately. But do reach out and most people will be willing to help because people want to support each other. So that's one thing. Look for a reputable surgeon. And most importantly, experience and volume of work. This is not occasional surgery for occasional surgeon. Like there are so many laryngeal surgeons.

[00:28:31] Do this operation once every couple of years is not the right thing. I do like maybe three, four every single week. So by volume, I have huge volume. And with volume come experience. And you learn and you keep developing and you keep pushing yourself and you keep refining this from things, from patients who had complications. You learn from every case is a learning experience for the surgeon. So going to the person with the right experience is essential. Look at academic credentials.

[00:29:01] People who publish on a subject in scientific journal. People who are like an organization. Like we have International Association of Transvoice Surgeons. Where, for example, our full membership is with the council. So people need to submit a certain level of number of cases. It's not an endorsement. I can't control. I don't have an insight into an individual. But I have to go back to the surgeon provided. So we have like minimum of 25 cases.

[00:29:28] Each surgeon will declare all their complications beforehand in their application process. So there are areas to look in. Like on scientific journal, on experiences. People who present in conferences, et cetera, have large volume of work. You know that they do this and they have the right experience. So I think that's essential as well as the word of mouth and social media and forums, et cetera.

[00:29:52] But of course, with increased client base, it's often the case that statistically, your satisfaction scores can look a little lower as well. Because if you've done one operation and everyone was 100% successful. Yes. And I think that's the thing what you're saying there is really interesting, which is actually it's that spread of research that you do is important, isn't it? Yeah.

[00:30:13] And then on your point on the complication rate, like when your volume are small, you will have 100% success or you can have 0% success. Exactly. And then your numbers might drop a little bit as your experience is building up, as your learning curve going up. And then at some point it's going to level at the right level. And so you possibly have that phase and then go to a surgeon who are on the plateau part of their experience. But it's important.

[00:30:41] I think one of the things which you've indicated here, which is, I think, the thing which we rarely look at. And as someone with my own background in learning development, it's that thing about continuous professional development that you're doing. The fact that you're going and finding new treatments, new areas, because you do find people who are certainly on the facial side of things. They're still performing the procedures as if they were doing it 25 years ago. They don't seem to advance. Whereas I think bringing in new methods and ideas is something that you should look for. Absolutely.

[00:31:10] And then, as I said, I can talk to you through our International Association of Transvoys Surgeons. And this is, we established this. So I was like one of the founding members. We established this as a support network for us surgeons. When you have, when you do an operation that's commonly performed, you will have that your network of colleagues and you can benchmark yourself to your colleagues. If you're working as a one person in a country or two person in a country, you need to widen the network.

[00:31:34] So, for example, within our association, we have our annual meeting where we all go and present and discuss and get that peer feedback. We have three times a year when we do a grand round, when we discuss poor outcomes, complications, shared learning experiences. This is like closed forums for surgeons.

[00:31:53] But this is all with us for the aim that we're continuously learning and we're continuously refining our processes, our procedures, how we address things, how we approach things, and learning from others. Like I get a certain complication. My colleague will be interested to hear what happened with me. How did I address it? They will offer me something more insight from their point of view and so on. So that shared learning and that peer review process is essential as well. Perfect. Wow.

[00:32:22] I've just looked at the time and it's absolutely flown past. Sorry, I got really absorbed on the subject. And I know you're based in London, but how do people find out more about what it is that you do? Go to my website. My website is lvsclinic.com. You can Google me and then that will come first. There is a lot of testimonials either on my social media channels, but most importantly on independent patients. You will find testimonials on Reddit, etc. And on YouTube, Instagram. And or you can just drop us an email.

[00:32:52] So I have a fantastic secretary, Olympia. Shout out to Olympia. She's absolutely amazing. She responds very quickly. She's lovely. She's really helpful. So secretary at lvsclinic.com or we have a form on our website where people can put an application and then we respond normally within 24 hours. Fantastic. Look, thank you so much for spending time with us. It's been absolutely fascinating. I hadn't considered this. I haven't thought about it. And I think it's really amazing.

[00:33:21] And thank you for spending time and giving us a very sort of honest view of what goes on here. I think it's remarkable. So thank you very much for your time. Thank you very much for having me. It's been an absolute pleasure. And it's something I do feel passionately about. Like the impact you make to your, to a person's quality of life and then having your contributing to somebody's journey. It's really satisfying. It is my work and it's, I do this for a living.

[00:33:44] But the satisfaction it gives me that I know that I made a positive impact on somebody's quality of life is, I can't describe how satisfying professionally that is. Yeah, but something that have been affecting them all their lives as well. So that's remarkable. Yeah. Chad, you're a superstar. Thank you so much for your time. Thank you very much. You too. Thanks for listening to this episode of Transvox. It's been a joy to have you with us.

[00:34:11] If you want to make contact with us, you can contact us at gillian at transvox.co.uk. And all of our money goes to our nominated charity. And Jen, you've chosen the charity for the next number of episodes. Which one have you chosen? Our charity is called Beyond Reflections, which is a charity that provides support and counselling to trans people, non-binary people and their friends and their families across the UK.

[00:34:38] An amazing charity doing some amazing work, really important. So please, if you can give. Great. And if you want to go and have a look at Beyond Reflections, it's beyond-reflections.org.uk. But as I say, if you'd like to make a contribution to what we're doing, because we love to help the people who help us. Again, if you've got ideas for the show, things you'd like to ask us, questions, comments, applause, or brickbats, feel free to send it all in to gillian at transvox.co.uk.

[00:35:07] Until the next time, goodbye. Bye-bye.