Dr. Angela Rodriguez: Gender-Affirming and Trans Healthcare

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): The Good Men Project

Publication Date (yyyy/mm/dd): 2025/04/16

Dr. Angela Rodriguez, a board-certified plastic surgeon and founder of ART Surgical, specializes in craniofacial, pediatric plastic surgery, and gender-affirming care. Initially focused on pediatric surgery, she transitioned to transgender healthcare in 2018, offering procedures like facial feminization surgery (FFS) and gender-affirming surgeries. She trained at Stanford and Harvard and contributed to tissue engineering research. Dr. Rodriguez discusses increasing demand, legislative barriers, and socioeconomic challenges in transgender healthcare. Technological advancements, including scarless surgery and 3D surgical guides, improve outcomes. She emphasizes resilience, visibility, and education, advocating for better access and understanding of gender-affirming care.

Scott Douglas Jacobsen: This is everyone’s favourite part because they can fact-check a journalist live. Today, we are here with Dr. Angela Rodriguez. She is a board-certified plastic surgeon and the founder of ART Surgical. Her earlier career was in pediatric plastic surgery. With over 20 years of experience, she specializes in craniofacial, pediatric plastic surgery, and gender-affirming care. In 2018, she shifted her practice to focus exclusively on transgender patients, providing procedures such as facial feminization surgery (FFS), rhinoplasty, and chest and genital gender-affirming surgeries. Dr. Rodriguez completed her plastic surgery training at Stanford University and her craniofacial fellowship at Harvard University. Beyond surgery, she contributes to scientific research in tissue engineering. She is recognized for her compassionate approach and remains a leading advocate for inclusive and patient-centred transgender healthcare. Thank you for joining me today. I appreciate it. Have you seen improvements in access to gender-affirming care in recent years, or have barriers increased?

Dr. Angela Rodriguez: We have seen an increase in demand, and with that, there are barriers to providing care for everyone who needs it. Legal rulings requiring insurance coverage for gender-affirming care have driven demand because more people are now seeking treatment who previously lacked access. They were not visible in society before, and now we have more patients but fewer doctors and healthcare systems equipped to meet their needs. We have made progress in expanding access, but barriers remain.

Jacobsen: What are the biggest challenges transgender individuals face when seeking gender-affirming healthcare?

Rodriguez: One major challenge is discrimination at the most basic level. I have had patients from other states, especially those outside of California, who struggle to find a primary care physician or dentist. Part of the problem is that many providers lack education on transgender healthcare needs.

Additionally, insurance coverage is often inconsistent, creating financial barriers. Patients also face privacy concerns, misgendering, and a lack of knowledgeable providers, making accessing safe and affirming care harder.

Jacobsen: The United States has a unique healthcare system. In my interviews with Dr. Gordon Guyatt, a pioneer of evidence-based medicine, he noted that Nordic countries, Western Europe, and Canada emphasize equity in healthcare, which leads to stronger support for universal public healthcare.

In contrast, the United States values autonomy more, resulting in a greater reliance on private healthcare.

Is there a difference in the quality of gender-affirming care between public and private healthcare systems in the U.S.?

Rodriguez: I believe that there is a difference. I don’t think there is a difference in quality—you’ll find good doctors in both systems. It’s more about what is better for the patient and how we can integrate them into these large institutions. I own a small boutique practice in San Francisco, which was created with the understanding that patients have unique needs and require specialized care. Many prefer not to go to large hospitals, though we perform surgeries at major institutions.

At this point, there isn’t a significant difference between public and private systems regarding gender-affirming care. More providers are receiving training. When gender-affirming care gained broader recognition around 2014–2015, major hospitals, institutions, and universities began developing programs. Now, we have strong fellowship programs focused on gender-affirming care.

However, this field’s initial supply of doctors came from private practice. For many years, private practice surgeons primarily met the demand for gender-affirming care. Some of the best surgeons, including those who trained me—I had already been practicing for 13 years when I entered this field—were in private practice and had established systems to meet patient needs. In the United States, private practices had more experience with gender-affirming care than public institutions for a long time.

Jacobsen: What strategies have helped expand access to gender-affirming procedures? You mentioned that developments in this field are relatively recent, but what effective strategies have been used to increase access?

Rodriguez: If you look at the Bay Area—particularly in California—we have seen community growth and the involvement of LGBTQIA+ organizations working to bridge the gap between the transgender community and medical providers. These groups have helped reconcile differences and provide education and information to patients. Expanding access to care has been a community-driven effort.

Jacobsen: How have recent legislative changes impacted transgender healthcare—both positively and negatively?

Rodriguez: They do? Is that a question?

Jacobsen: Yes, they do, but how have they?

Rodriguez: How have they? Initially, as I mentioned, everything was handled privately. Then, around 2014, the courts ruled that gender dysphoria should be covered by insurance. This was part of the Affordable Care Act’s effort to address the needs of the transgender community. However, as we see daily, numerous legislative efforts have since aimed to restrict access to care in many states.

Thankfully, this is not the case in California, but across the country, access to gender-affirming surgeries and hormone therapy has been significantly limited. Some states that are more understanding of transgender patients’ needs have enacted shield laws to protect patients from these restrictions. These laws help ensure that individuals can still receive care without facing legal consequences.

Yes, legislative changes have had a profound impact on transgender healthcare, and we want lawmakers to recognize the importance of understanding this population. They need to sit down with transgender patients and truly grasp how these treatments impact lives. Gender-affirming surgery can be life-changing, allowing individuals to integrate fully into society. It is essential to protect and support these vulnerable populations.

Jacobsen: There are different demographic perspectives on transgender issues. Some people do not accept transgender individuals—that is just how they see the world. Others are completely affirming and supportive. Then, there is a third group that falls somewhere in between.

This middle group may struggle with specific topics, such as pronoun use, types of surgery, or the concept of “passability.” They might have transgender family members and be generally supportive, yet they hesitate when it comes to legislation around pronouns, medical care, or the extent of treatment. Others may not personally know any transgender individuals but still support transgender rights in an abstract sense.

What areas do you find to be the most gray—both legislatively and culturally—when it comes to transgender care? Not just in San Francisco, but perhaps across the Southwest United States more broadly?

Rodriguez: The Southwest United States? To clarify, are you asking about the gray areas regarding transgender healthcare and legislation?

Jacobsen: Yes. We have clear opposite ends—strong opposition versus full acceptance. But then there’s this middle ground—people are uncertain about certain aspects of transgender care.

Some may have transgender family members and no issue with it personally, but when it comes to laws on pronouns, medical access, or levels of care, they have mixed opinions. Others may not know any transgender people but still express general support—though only in an abstract way.

This nuanced debate is rarely discussed, but I would love your perspective since you have more experience dealing with these issues.

Rodriguez: Yes, I agree with you. The public discussion often focuses on very specific issues that affect only a small number of transgender individuals, such as transgender women in sports or bathroom access laws. These debates dominate media coverage, even though they impact a relatively small percentage of the population.

What we should focus on are real numbers. A person with gender dysphoria is four times more likely to attempt suicide. Mental health, life satisfaction, and overall well-being improve significantly when a transgender individual receives appropriate care, whether that means hormone therapy, surgery, or psychological support.

Not every transgender person needs surgery, but if someone experiences gender dysphoria, they will likely require some form of treatment, whether that is therapy, hormones, or surgery.

When we provide that care, we give people the tools to participate fully in society. It’s not that they didn’t contribute before, but they can find greater fulfillment and stability in their lives. By multiple measures, access to care improves the quality of life for transgender individuals.

The biggest issue, in my opinion, is ignorance. The way the media portrays transgender people does not reflect their daily lives. What people see in the news tends to focus on extreme cases or controversial issues, not the basic, everyday struggles of transgender individuals.

This is about providing essential healthcare, just like we do for any other medical condition.

Jacobsen: And how do these issues get framed in the media in ways that influence the course and direction of legislation? Some individuals argue that gender-affirming care should not be part of public healthcare because they see it as purely cosmetic. These are more sophisticated arguments, certainly—they’re more thought out—but they often stem from similar misunderstandings about what constitutes healthcare.

Rodriguez: Yes. Exposure and education are our only hope. The fact that transgender individuals were not as visible in the public eye before does not mean they didn’t exist. They were always someone’s aunts, uncles, mothers, fathers. They have always been part of society. The difference is that now they have the possibility of living openly. Unfortunately, change is difficult, and to make progress, the first step is visibility.

There will always be people for whom transgender visibility is unacceptable for one reason or another, but we must keep moving forward. More importantly, we cannot allow the majority to decide human rights and healthcare access. If that were the case, no civil rights movement would have succeeded. Civil rights are not about majority rule but about protecting vulnerable populations.

So, it comes down to visibility and education. I encourage anyone uncertain or resistant to sit down with transgender individuals. The vast majority are people just like you and me—ordinary people with their own stories, opinions, and feelings—who happen to have gender dysphoria. They did not choose this. It is not a choice. It is not a lifestyle. It is a medical condition, and as a society, we are judged by how we treat our most vulnerable members.

Jacobsen: If you analyze any population and divide it differently, everyone eventually falls into a minority group. So the point you’re making—that a majority should not dictate healthcare decisions for a particular minority—is necessarily relevant.

When patients come to see you, what concerns do they bring up? What are some misunderstandings that patients or potential patients have about what gender-affirming surgery entails?

Rodriguez: Patients have an incredible level of understanding. Think about someone diagnosed with colon cancer—by the time they see a specialist, they already know the available surgical options and medications. It’s similar to transgender individuals.

It’s not a case of someone waking up one day, realizing they have gender dysphoria, and deciding to get surgery tomorrow. That’s a misconception. In reality, once someone identifies their gender dysphoria, they go through therapy, hormone treatment, and years of preparation before reaching the stage of surgery. As a surgeon, I am the last step in a long process.

However, as with any type of surgery—including cosmetic and reconstructive procedures, which I perform—setting the right expectations is crucial. Unrealistic expectations lead to future disappointment, so I take the time to explain everything clearly.

There is significant post-surgical pain involved, and many of my patients have waited for years for their procedures, so they want things to move quickly. But we must follow proper protocols. Patients need to have the appropriate documentation, including letters from mental health providers diagnosing gender dysphoria. They must be over 18, can consent, and obtain letters from their hormone providers—sometimes even two separate letters from different mental health professionals—to confirm their diagnosis.

Surgery is just one part of a thorough, structured process, and we take seriously the responsibility of ensuring that patients are prepared physically and mentally.

Rodriguez: Patients sometimes push us to make quick decisions or move through the process faster in desperate times. Unfortunately, that’s not possible. The process takes time—insurance approval, proper documentation, and mental health evaluations. Patients often go through a long series of bureaucratic hoops, and while they are typically very well informed, they can sometimes have misconceptions about pain, recovery, and timelines. Our job is to set the right expectations so they are fully prepared for the journey ahead.

Jacobsen: What about socioeconomic factors? Do financial barriers affect access to gender-affirming care?

Rodriguez: Of course. There’s a major divide between those with insurance and those without insurance. And who is less likely to have insurance? Historically, people from lower socioeconomic backgrounds haven’t had the same access to education or resources to navigate complex insurance systems. Even as a physician, I find dealing with insurance daunting, so imagine how difficult it is for someone without medical training.

That’s why it is heartbreaking to see some states closing off access to gender-affirming care. Right when we have better education, better-trained surgeons, and gender-affirming programs at nearly every major university, lawmakers are restricting physicians from treating patients in their states.

This forces people to travel across the country to places like San Francisco and the Bay Area, where they must spend weeks paying for lodging, flights, and post-operative care. I cannot perform a major operation on someone and send them home immediately. They need proper aftercare and monitoring to ensure they are stable and ready to return.

So yes, socioeconomic barriers add another major layer of inequality to access.

Jacobsen: I’m losing track of time—it’s already been six minutes. Since this is such a new and evolving field, there are likely to be rapid technological advancements. Given the pace of medical progress, what new techniques and technologies are emerging in gender-affirming care? And how might these advancements shape advocacy efforts and legislative discussions?

My previous interview focused on ear, nose, and throat (ENT) surgery. The surgeon mentioned working on scarless surgery techniques, particularly for tracheal shave procedures—reducing the Adam’s apple. Instead of an external incision, they operate through the mouth, leaving no visible scar. For trans women and cisgender women with a prominent Adam’s apple, this can make a significant social and psychological difference.

So, how do you see technological advancements helping to drive more rational, evidence-based advocacy and influence legislation?

Rodriguez: I don’t know if we can apply legislative pressure shortly, but every advancement in science pushes us forward. For example, facial feminization surgery (FFS)—which is one of the procedures I perform—involves up to 20 different surgeries on a single patient’s face. We must be efficient, precise, and cohesive as a surgical team to complete such a significant transformation within an eight-hour operation.

New technology is making these procedures more effective and streamlined. We now use 3D guides from CT scans to assist in jaw and forehead reconstruction, making surgeries more accurate and efficient. Scarless techniques, such as rhinoplasty performed internally through the nose, allow quicker procedures with no visible scarring. Each of these advancements improves patient outcomes, self-confidence, and recovery experiences.

There isn’t just one breakthrough—we are making incremental improvements over time. The beauty of plastic surgery is that it draws on decades of knowledge from reconstructive and cosmetic surgery. Modern plastic surgery originated after World War II to reconstruct facial injuries and other physical traumas. Today, we continue to refine and advance techniques across all areas of facial surgery.

Jacobsen: What is your biggest takeaway from your many years of experience—whether in surgery or in tracking progress in legislation?

Rodriguez: Change is hard. It takes time and requires resilience—something the trans community, like many other marginalized groups, has demonstrated time and again. There may be difficult times, but remember that you always want to be on the right side of history. That belief is why I do what I do.

Jacobsen: Dr. Rodriguez, I appreciate your time today. It was great to meet you.

Rodriguez: Thank you so much. I appreciate it.

Jacobsen: Bye, and thank you.

Rodriguez: Bye, thank you.

 

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