This narrative is of a particularly touching interaction I had with a transgender immigrant. I was lucky to be his Personal Patient Navigator at the Penn Center for Surgical Health. It was a multidisciplinary effort involving everyone at the CSH and Penn Plastic Surgery, including Dr. Serletti, and we were ultimately able to provide him a transformative surgery. This experience is certainly one I won't forget.
Patient information has been deidentified.
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Born in a village in El Salvador, Mateo knew he was different since he was a little child. He could not quite understand his emotions at the time. Only when he was a teenager did he realize he was transgender. When he came out to his family, his sisters, brothers, and mother were supportive. His father and grandmother, on the other hand, could not understand Mateo’s plight. Once his mother left to the United States in 2014, his father became abusive to try to make Mateo conform. El Salvador, in general, is a hostile place for transgender individuals. “We usually do not last long”, according to Mateo, because transgender people are often targets of gang attacks. Further, their mental health is so poor, many induce self-harm – something Mateo, himself, considered for a time. Despite this, Mateo continued to dream about the day he could live freely and transition. His opportunity came when his mother advised him to join her in the United States.
The journey was arduous. Many transgender people from El Salvador attempt to come to the United States seeking a better life; only a select few lucky ones complete the journey. Crossing the border was a terrifying undertaking for Mateo. In 2018, he and his sister migrated up to the Rio Grande along the border of Texas. Together, they joined 20 other people in paying coyotes for a tiny boat to cross the turbulent river. Once they reached the other side, the group managed to hike only an hour before an army tank spotted them. The tank took the entire group and brought them to the “doghouse”, where the immigrants were sorted. Still children at the time, Mateo and his sister were nearly separated until he pleaded law enforcement to keep them together. Unfortunately for them, they were then sent to a U.S. Immigration and Customs Enforcement (ICE) facility (“the freezer”). As Mateo recollected this story to me, he declined to describe life at the freezer, saying it was too traumatic to relive. Only when their mother was contacted, Mateo and his sister left the freezer and joined her, their uncle, and their cousins in Philadelphia.
Since arriving in Philadelphia, Mateo’s life has certainly been strenuous. He and his mother work the night shift, 6 pm to 6 am, six days a week, baking and delivering bread for restaurants. “It’s hard work” Mateo remarked. Quite an understatement, I thought. He gets through it with his loving family. His mother, sister, uncle, aunt, and cousins all share a household in South Philadelphia. They spend their weekends and holidays together, and help each other out in every way. In fact, Mateo was initially hesitant to explore medical transition, but it his family that encouraged Mateo to finally pursue his “American dream”.
Two years ago, Mateo began seeing a primary care provider. He was started on weekly testosterone injections. While this gave Mateo increased body hair and larger muscles, he sought more. In particular, he hated having feminine breasts. “Every day I looked at myself in the mirror, and I hated myself.” Mateo wanted chest masculinization therapy.
Fortunately, his primary care referred Mateo to the Penn Center for Surgical Health, a nonprofit organization started by medical students and surgeons to provide care for the uninsured and undocumented populations in Philadelphia. While most patients come in seeking hernia repairs, fracture care, or cholecystectomies, Mateo took the initiative to ask for gender-affirming surgery. This was a first for our Center, and a challenge our team embraced. Doing so would require a lot of coordination in getting his care approved, paid for, and completed. But if we could help Mateo, it would mark a major milestone. While I was lucky to be one of Mateo’s Personal Patient Navigators, it was a herculean team effort to get Mateo the care he needed, from the top down.
The process took nearly a year, but, sure enough, we were able to secure medical assistance to pay for all Mateo’s surgical and peri-operative services. At his first preoperative visit, Mateo was understandably apprehensive. However, Dr. Serletti and the surgical team quickly made sure Mateo was comfortable and open about his goals. “All my questions were answered” Mateo remarked. Despite being in a world that tends to marginalize non-native English speakers and transgender people, “it was easy to talk to them”. Together, Mateo and the team planned for surgery just before Christmas, so Mateo could realize his dreams for the holidays.
The following January, as Mateo and I attended his one-month postoperative visit, I was curious to understand Mateo’s perspective of the care he received.
“How do you feel now that you’ve had your chest surgery?”
Mateo’s eyes locked with mine, glinting. “Un sueño! It’s a dream come true!” he exclaimed.
His response struck me. In an era where the notion of transgenderism is highly politicized, his claim was a true confirmation of how vital surgery is for their wellbeing.
“Now when I look in the mirror, I don’t hate myself.”
The stark change in his self-perception was heartwarming. He even described how he used the men’s bathroom for the first time. “No one gave me any weird looks!” Mateo gushed.
These benefits from chest masculinization surgery are well-known to the plastic surgical community. However, Mateo’s surgery did even more for him. When Mateo came out of surgery, his whole family was there waiting for him to wear off the anesthesia. While he was still sedated, Mateo’s mother took a photo of him lying on the gurney, wrapped in bandages and hooked up to a monitor. She sent this photo to his father in El Salvador. His father was absolutely jarred by the photo. A stunning realization overcame him: that this is who Mateo truly is, and he is willing to go through great lengths to pursue his dream. When Mateo eventually woke up, his father called him.
“He was crying.” Mateo reminisced. “He apologized to me. And he said he wants to understand me better.” Since his surgery, he and his father have talked regularly. The family is even trying to get his father a visa to come to the U.S! In Mateo’s case, surgery improved his life in multiple dimensions: within himself and with his family.
The goal of medicine has always been to alleviate the suffering of patients. Over time, our model for suffering and care has evolved from a focus on disease, to a focus on holistic wellbeing. This wellbeing is derived from one’s physical, mental, and social mileu, and permeates through all aspects of life. Plastic surgery has lead the charge in patient-centered care because it uniquely focuses on patient-reported outcomes.[1–4] Our field is constantly in search of novel ways to augment patient quality of life; that is why we are at the forefront of gender-affirming surgery. Mateo’s story is a testament to how our work can profoundly enhance a patient’s life. It reflects the ethos of plastic surgery, a field grounded in ingenuity, openness, and a dedication to serve.
The partnership our Division has with the Center for Surgical Health, while still nascent, has built the foundations for us to continue to help those who are most vulnerable. The Center has grown exponentially since its inception and has served hundreds of patients. We look forward to building our collaboration with the Center to serve more members of the transgender community.
My own personal connection with Mateo is one I will not forget. As I progress in my training, I hope to continue to realize the multi-dimensional benefits that our special field can offer patients of any shape, size, or background.
1. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine. Plast Reconstr Surg. 2011;127(3):1361-1367. doi:10.1097/PRS.0b013e3182063276
2. Chung KC, Pusic AL. Patient-reported outcomes instruments. Outcomes measures in Plastic Surgery. Clin Plast Surg. 2013;40(2):xi-xii. doi:10.1016/j.cps.2012.10.010
3. Zhong T, Pusic AL. Future of outcomes research in plastic surgery. Clin Plast Surg. 2013;40(2):351-357. doi:10.1016/j.cps.2012.10.009
4. Ortega G, Allar BG, Kaur MN, et al. Prioritizing Health Equity in Patient-reported Outcome Measurement to Improve Surgical Care. Ann Surg. 2022;275(3):488-491. doi:10.1097/SLA.0000000000005169
