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Dr. Curtis Crane, Transgender Surgery Expert and Advocate for his Patients

Dr. Curtis Crane is a fellowship trained reconstructive urologist, Board-certified plastic surgeon and one of the most sought after surgeons and experts in the area of gender confirmation surgeries. With offices in Austin and San Francisco, his wait-list is a testament to his skill. He joins The Alamo Hour to talk about his time in San Antonio and the misconceptions and misinformation surrounding his practice area.

Transcript:

[music]

Justin Hill: Hello and Bienvenidos, San Antonio. Welcome to the Alamo Hour, discussing the people, places and passion that make our city. My name is Justin Hill, a local attorney, a proud San Antonian, and keeper of chickens and bees. On the Alamo Hour, you’ll get to hear from the people that make San Antonio great and unique and the best-kept secret in Texas. We’re glad that you’re here. All right. Welcome to this episode of the Alamo Hour. Today’s guest is Dr. Curtis Crane of Crane Center in Austin and San Francisco, right?

Dr. Curtis Crane: Correct.

Justin: Dr. Crane is a board certified plastic surgeon, he’s fellowship-trained in reconstructive urology, as well as transgender surgery. Did I get that correct?

Dr. Curtis: That seems absolutely, correct.

Justin: All right. He’s one of the most sought after experts in the United States, and likely the world on issues regarding transgender surgery and transgender issues. He has a really robust practice in Austin. He’s got a long wait list for people to get his services. How many doctors do you have working under you, Dr. Crane?

Dr. Curtis: Let’s see, at this point, five and then October it’ll be six.

Justin: Where are you all located in Austin?

Dr. Curtis: We’re at 5656 Bee Cave Rd, right next to Bee Cave in 360.

Justin: Pretty far out there off Bee Cave?

Dr. Curtis: Yes, it’s probably. I live downtown, it takes me a little less than 15 minutes to go from downtown to here. It’s always reverse traffic from downtown out, so it’s not too bad.

Justin: Not a lot of people have that, live downtown, drive out and then come back when you come back. It’s good.

Dr. Curtis: Everyone should, it’s a lot of fun.

Justin: It’s good life. We got Dr. Crane on here today to talk about a few things, mostly it’s fascinating what you do in the realms of transgender surgery. You and I met probably, I can think back by a few– Probably seven years ago, eight years ago probably?

Dr. Curtis: I think it was like 2010, 2011.

Justin: Yes, it had to be. We met and became good friends. It’s always been fascinating hanging out with you because you’re real passionate about what you do, but you also do something that is very out of the norm for everybody.

Dr. Curtis: Well, thank you. Yes, it definitely keeps life interesting.

Justin: I’m sure. You have a San Antonio connection, our show is San Antonio based. You were here for three years?

Dr. Curtis: I was from ’09 to ’12.

Justin: All right. With all my guests, I do a top 10 list. I’m going to walk through, it’s just a little color commentary on who you are and your relationship to our city. You’ve answered the first one, how long you lived here? Three years. From here you went off to San Francisco though, right?

Dr. Curtis: Let’s see. Actually, I went to Europe for a fellowship and lived in Belgium, Amsterdam and Belgrade, Serbia. Then I moved to Alaska for three months, and then I moved to San Francisco.

Justin: That’s right, you were in Alaska, I remember, that [chuckles] is a strange part of life. Okay. You were here for three years, the city has changed so much in the time that you’ve been here, but when you were here, what were your favorite spots in town? Bars, restaurants, whatever.

Dr. Curtis: Well, I’ll tell you, I lived downtown at the Vistana and I lived in that tower at the top with two other guys, and my favorite place was our place and our parties. [chuckles] Were you at the party, when we had a bouncy house on the bottom floor and people were jumping off the balcony on the second floor inside to the bouncy house on the first floor?

Justin: I was a very early participant, and nobody was trying to paralyze themselves whenever I left, but funny story, I had a deposition of a surgeon here in town and somehow or another your name got brought up. He told me some story about how you walked him through a circumcision over the phone in Ecuador or something, it was some crazy story, but your life is surrounded by these stories since I’ve known you.

Then anyway, he goes on to tell me, he goes, “One time he invited me to his birthday party and he said, ‘bring your kids, we’re going to have a bouncy house’.” He said, “I got over there,” and long story short, he said it was very much not a kid friendly party and so he left. [laughs]

Dr. Curtis: Well, when the kids show up because I figure then they can be designated drivers, maybe depending on their age.

Justin: Okay. Well, I don’t know how old his were, but it was funny. I don’t think I’ve met a surgeon in town yet who has not at least known of you. So far all good stories, all stories also have a, and this one time, so you left an impression. Okay, Vistana was your favorite spot, I’m sure when you were here there were a few random spots you ran into once or twice and you thought, “Holy crap, this is really neat, I didn’t know–” For me, the Japanese Tea Garden, the first time I went I thought, “How did I not know this existed?” Do you have any spots here in town you thought, “This is a really unique spot?” You’ve been all over the world.

Dr. Curtis: I love San Antonio. It’s got so much charm and history and living right near the Alamo or what do you call it? The walk-

Justin: River Walk

Dr. Curtis: River walk, thank you, living right next to the Alamo and the River Walk. Me, you, I think George a few times, we used to go to this bar right down the street from the Vistana that was an old bank. You had to walk through this big bank– no, there was a big bank vault door behind the bartenders

Justin: That was George’s spot, Soho, right?

Dr. Curtis: Yes, it was Soho. I used to love that place. You go there and get a few Manhattans.

Justin: Martini bar is kind of their thing.

Dr. Curtis: Exactly.

Justin: Vistana now they’ve done this whole sort of River Walk 2.0, this lido creek build out, they spent a $1 billion. You probably saw this dirty crappy creek that had trash in it, well, now that’s a whole River Walk expansion through the, I guess that would be the West side of downtown, it’s beautiful. Where you were, is even nicer now than it was then.

Dr. Curtis: Well, I used to love it. I really miss it. It’s a lot of fun and I’m really impressed with what San Antonio has done since then.

Justin: I’m wearing my Fiesta garb, for people that are wondering why the hell I look like this, because we would be in Fiesta right now, but COVID-19.

Dr. Curtis: I thought this attire was totally normal for you, I wasn’t surprised at all. [chuckles]

Justin: Let’s not pull the curtain back, I don’t normally wear medals around, but maybe. What would be the correct term for your practice? How would you describe it?

Dr. Curtis: We are a surgical practice, dedicated to serving the transgender community. We perform, I think almost every surgery that a trans man or a woman, could want.

Justin: I heard in one of your videos I watched, you all don’t really do elective plastic surgery, even though you’re a board certified plastic surgeon. Is that fair to say?

Dr. Curtis: Yes, that’s fair to say. In fact, I think the last time I did an elective general plastic surgery case was probably seven years ago.

Justin: That would have been in San Francisco then, right?

Dr. Curtis: Yes, that’s right.

Justin: Next thing I wanted to ask you, what are the correct terms as we speak here, you and I talked about this a little bit on preproduction, I feel like this is one of those areas that the terminology has changed just significantly and quickly because partly the procedures have changed, and partly because the way people identify themselves have changed. Talk to me just generally, what are the terms, what are the procedures, not all of them, but just generally what are we going to be talking about here today?

Dr. Curtis: The procedures we perform?

Justin: Yes.

Dr. Curtis: I think we’re most commonly known for phalloplasty, just because there’s fewer people in the world that know how to do that, but phalloplasty is when you build a phallus. You’ve got a donor side of the forearm, the back or the thigh, then the phallus with the urethra, you can have sensation, you build a scrotum, this is for someone born with female genitalia.

Justin: Sure, and then you build them a penis.

Dr. Curtis: You build them a penis. It’s like a 17 hour surgery. It’s a microsurgery. Me and another microsurgeon get under an operating microscope and we sew tiny one, two millimeter blood vessels, nerves, arteries, veins together under an operating microscope using suture that you really can’t even see unless you’re under the microscope and we build a penis.

Justin: Phalloplasty is building a penis. I’ve heard you call something a vaginectomy?

Dr. Curtis: Ectomy is removable, like appendectomy you remove an appendix, so vaginectomy would be for a trans man that was born with a vagina and does not want that, so we do a vaginectomy and remove it, but then speaking to the trans female population, we do facial feminizing surgery, breast augmentation, vaginoplasty. Vaginoplasty as opposed to vaginectomy, vaginoplasty would be building a vagina.

We do for trans men, we also do chest masculinizing surgery, liposuction, so that if a trans man has a female body fat distribution, we can sculpt that into a masculinized body fat distribution. Women tend to have fat in their breasts, buttocks and thighs, men don’t really have fat there, they more have, if they’re obese they have a truncal obesity, it’s in their trunk unless it’s all in those areas.

We can sculpt, we perform chest masculinizing surgery, phalloplasty. I mentioned there’s a cool procedure called metoidioplasty. It’s made up, it’s a Greek origin, meta means towards, oidio is male genitalia and plasty is plasty. It’s towards male genitalia, metoidioplasty and that’s basically releasing all the suspensory ligaments around the clitoris and making the clitoris as long as possible. Sometimes I can get it two, three inches long and then building the urethra underneath it. It ends up being a microphallus that the patient can stand to urinate through.

Justin: I saw that, you all did a question and answer recently on your Facebook page about that, and I had to look up the term. Not a term I’ve heard before. We’re going to get into more of that. Got a few more questions. How many Burning Mans have you been to?

Dr. Curtis: Man, sore subject, it just got cancelled yesterday or two days ago, two days ago, I think. I was going to be this year and that would have been my second time back. I went the first time in 2013 and I’ve just been still busy, I haven’t made it back since, but I always want to. It’s such a great time, so many wonderful people, so much creativity and expression.

Justin: I remember your pictures. It looked very expressive. [laughs]

Dr. Curtis: You can do what you want.

Justin: I always like to tell people whenever I was younger, I grew up in the country. All the terrible things I did, I wore overalls backwards, I had a mullet. What terrible trends did you follow growing up?

Dr. Curtis: Oh, man, what terrible trends did I follow growing up? Man, compared to life now, my life as a kid was probably relatively boring. I wore parachute pants in grade school.

Justin: The MC Hammer.

Dr. Curtis: What’s that?

Justin: The MC Hammer?

Dr. Curtis: No, parachute pants were before MC Hammer. This is mid-80s, where you wore these– It was pants made out of like some kind of tent material it felt like, maybe it was waterproof.

Justin: [chuckles] I know what you’re talking about.

Dr. Curtis: Back then it wasn’t child abuse to leave your kid out in the rain, but this had zippers all over it. It felt like it was more Michael Jackson inspired. That was the thing. We wore parachute parents in grade school and then instead of playing– I guess occasionally you get in a soccer game or a foursquare game out on the recess, but we would try to breakdance. [chuckles]

Justin: Did you carry a round cardboard?

Dr. Curtis: We had either a mat or one time there was cardboard. I grew up in the suburbs of Peoria, Illinois, not exactly known for its breakdancing, but we were trying to make it known. We were trying to put it on the map for breakdancing, and I never found out if we were successful. Is Peoria known for breakdancing?

Justin: Not last time I looked, but I don’t know a single thing Peoria is known for.

Dr. Curtis: Me too. Maybe Richard Pryor.

Justin: Is he from there? [crosstalk]

Dr. Curtis: Yes, Jo Jo Dancer was filmed there.

Justin: I didn’t know that. Was that before or after he set himself on fire?

Dr. Curtis: That was before, that was the down part of his career [crosstalk]

Justin: I would think so. When you set yourself on fire from freebasing cocaine, I hope that’s not the up part of your career.

Dr. Curtis: I guess it depends how-

Justin: [chuckles] What your career is-

Dr. Curtis: [crosstalk] much of an influencer you are in these days.

Justin: There you go. What’s the one thing you miss about living here?

Dr. Curtis: You.

Justin: Well, I was going to say me. I actually wrote down me. I was going to prompt you, but you beat me to it. I went between that questions–[crosstalk] What’s that?

Dr. Curtis: I got that question right. What am I, one for five now?

Justin: Yes, one of eight. Were you student of the decade for University of Texas Health Science Center here, or was that your friends joking with you?

Dr. Curtis: No, I actually was. You’ve really done some background reasons.

Justin: I do my research and I saw on Facebook when that happened and I thought, “Is his friends just screwing with him or is that a real deal?”

Dr. Curtis: No, I got invited to their plastics graduation first in 2016. I was the speaker, the commencement speaker. I think that speech was famous for me finishing the graduation speech by saying, “Don’t wait to wish upon a star, because by now that star is a million years old and dead just like your dreams,” which I think is a nice thing to say too, right.

Justin: They had to know what they were doing inviting you to speak at a graduation, honestly. It’s their fault. Whatever had happened, if you had taken your clothes off, it’d been their fault. Okay. What do you find to be the biggest misconception about what you do and the community of your patients?

Dr. Curtis: It’s interesting, there’s a lot of misconceptions. The most personal one is a friend is talking to someone else and says, “Oh, I know a transgender surgeon.” They immediately assume that I’m transgender and obviously we’re very supportive of the community. It’s just that I’m not. I’ve had situations where someone meets me and they’re like, “Wow, you really passed,” and I’m like, “Yes, I was born male and I identify with male pronouns.” Being a transgender surgeon, sometimes means that you are a transgender individual, but it doesn’t have to.

Justin: Because there is a famous one of your competitors who is herself a transgender surgeon, correct?

Dr. Curtis: That’s right, there’s a few. Obviously, you can be either and still serve the community.

Justin: It’s funny you point that out because I was crafting how I’m going to post your episode on our hosting platform, and it kept being transgender surgeon and I kept thinking, “Well, that could be misinterpreted.” At least I was cognizant of it and I didn’t do it.

Dr. Curtis: I’m not opposed to it being for a while when I would go to these conferences and a parent would stand up and say, “Hi, I’m so and so. My kid is transgender,” you’d say, “Congratulations, you got a transgender kid. Let’s talk about how to help him or her.” Not opposed to it, but if someone is looking for facts, I actually am not transgender.

Justin: Since this is on video, I’m just pointing it out, your Zoom says Kristen’s phone and you showed up. This is take four we talked about. You had a terrible computer at home and then a phone that was about to die, and so finally found somebody in your office that was kind enough to let you borrow their phone. Just so we’re clear, you’re not Kristen. Even though we’re talking about whether you’re a transgender surgeon, I think it’s important to point that out.

Dr. Curtis: I will respond to Kristen. I’ve been called worse. I think Kristen looks like me.

Justin: [laughs] I don’t know if she appreciates that or not, but-

Dr. Curtis: Not at all.

Justin: -you’re good looking man. I think it’s also worth pointing out that you have your phone propped, which we’ll put a picture up on our website. You have the phone propped up on a anatomical model of a scrotum and phallus is my understanding. At least it comes in handy in other ways as well.

Dr. Curtis: It should. Do you want me to turn the camera around for a moment and show you that?

Justin: No, because as hard as it was to get this set up, just afterwards, send me a picture and I’ll put it up.

Dr. Curtis: The penis is real wobbly. You got to get the camera just right on there. Then when you let go, it will oscillate for a few seconds.

Justin: Does it have a noise when it does that?

Dr. Curtis: Yes, it sounds-[crosstalk]

Justin: Like a spring?

Dr. Curtis: [making sounds]

Justin: [chuckles] All right. That’s one of the things about what you do, there is your day to day discussions are a lot of people’s day to day punch lines. You’re talking about genitalia and people make punch line jokes about genitalia. There is just a– One of my favorite memories with you was, you had me meet you at a bar that I did not want to go to and I only agreed to go because you were in town and you wanted to go to this bar.

We go and you pull your phone out and most people would be showing pictures of children, but you’re showing me reconstructive surgeries you performed and they are very graphic photos. Honestly, I hadn’t had enough drinks at that time to be comfortable with it, but this poor waitress comes up and she sees your phone and it’s a penis or something. Then you’re like, “No, no, no, this is what I do,” and you just start scrolling through these pictures, but in telling her face, she thinks you’re just showing her pictures of genitalia. I’m trying to describe, “No, he’s actually a surgeon. This is what he does.” I didn’t want a MeToo. It was this very awkward, hilarious moment.

Dr. Curtis: I remember that. Regarding your first comment, the genitalia we build are my children. I was showing you my children, I was showing her the children. It’s just not the typical child, but I feel like she- Sometimes I don’t perceive situations accurately, but I felt like she walked away a better woman. What did you think?

Justin: I think I saved it because I sure as hell didn’t want us getting kicked out and the bouncer saying, “She said you all just showed her 40 pictures of penises,” and I’ll be like, “No, we have a reason for that. It’s hard to describe.” I think we saved it, tipped well. She had a funny story.

Dr. Curtis: There’s a cultural and scientific reason for this and Mr. Bouncer, you should probably get in on it.

Justin: I doubt those guys are going to be heady enough to really consider the gender considerations of what you do. Before we put this up, I put a bunch of stuff on our social media about, I was going to be talking to you and I got a few questions we’re going to go over, but the one question that I got more than once was, how the hell did you get into this? I mean, walk me through how, I know you were a mechanical engineer and that was the start of this process, but talk to us about how you went from mechanical engineer to one of the most sought after transgender surgeons in the world.

Dr. Curtis: Yes, that’s true. Thank you. Basically it was a circuitous path, but I started in mechanical engineering and I got a job co-oping at Depew orthopedics and I built hip implants. Then, at the end of mechanical engineering, I thought, “Well, I got to go to a surgery and see how a hip implant was put in.” I thought, “Well, that’s pretty cool. I want to try that.” I was like, “Wow, I’ll try to medical school, apply to medical school, see what happens, if I don’t get in, then I’ll go into fluid dynamics.”

I always thought food dynamics and heat mass transfer were pretty cool and I could see myself getting a PhD in neither of those. I was like, I started talking to a bunch of premed students and I was like, “Yes, I’ll apply.” They said, “Oh, I took so many months off.” At the time you had to type up each individual application and use correction tape and all this shit. It makes it sound like it was medieval.

Justin: You’re not that much older than me.

Dr. Curtis: [laughs] I feel it and I look at it. They were like, “You’ve got to take time away from your classes. Take a take a smaller workload.” I’m like, “Are you kidding?” I got an electrical engineering lab, a machine design lab, what it controls and all these other classes. I’m like, “I don’t have time for that.” I’m like, “Why does it take so long?” He said, “Well, you got to apply to like 20 or 25 schools.”

I’m like, “I’m going to apply to four, and if I don’t get in, I’ll do something else.” Applied to four. Got into too. That was cool. I was the last student to be accepted to the University of Iowa. I got a phone call, I was already going to Rush in Chicago and I got a phone call on Friday night. This lady on the other end says, “Congratulations, you got into University of Iowa medical school.” I said, “Oh, that’s great.”

She said, “Are you going to come?” I said, “Well, I don’t know. I’m already going to Rush. Can I call you like Tuesday?” This was Friday. She goes, “Can you call me Monday?” I said, “Why? When does school start?” She goes, “School starts Wednesday.” I go, “Am I going to be the last person to be accepted?” She goes, “Only if you accept.”

[laughter]

Justin: What was Rush. You said you were going to go to Rush. What’s Rush?

Dr. Curtis: That’s a medical school in Chicago.

Justin: I didn’t know if you’re joining a frat or going to see the awesome nerd band of the 1970s, 1980s.

Dr. Curtis: As it turns out, you can learn transgender surgery either in a fraternity or by going to medical school.

Justin: It’s a Canadian rock band. [laughs]

Dr. Curtis: I ended up going to University of Iowa. The orthopedic surgeons were pretty intense. The urologists just told a bunch of dick jokes all day long. I was like, “Okay, I can do that.” Went into urology, but did a lot of medical missions, did a bunch of surgeries in Africa, Southeast Asia. The time that I felt most useful was when I was helping someone that nobody else wanted to help.

One of my trips, I went to Belgrade, Serbia, and operated on a lot of trans patients. It was actually the first time I ever met a trans patient. Shockingly, most of them were Americans. This was in like maybe 2003 or 2004. I thought, “Why is an American going to Belgrade, Serbia for healthcare?” Then, I realized there was an underserved patient population right here in the US, and I thought, “Wow, I could really help these people and really feel valuable.”

Then, I had this plan to just travel around the world and learn how to do it, but then through a bizarre scenario, if there’s time I can tell you about this. Basically, I hadn’t talked to a friend in five years and prank called him, and I can go into that, but he suggested that I try to do a fellowship with his residency director, Dr. Santucci. I said, “Well, I don’t want to do a fellowship.”

He said, “Well, you should really talk to him.” I talked to him, I flew out, and interviewed, got his fellowship in reconstructive urology and then Dr. Santucci said, “If you want to be one of the best in the world at this, you should really do a plastics residency.” I said, “Yes, Dr. Santucci, I didn’t even really want to do the fellowship, your fellowship, I’m done with training.” [laughs]

He said, “Well, you could be the best in the world.” I thought why deny that opportunity? I picked up three years of plastic and reconstructive surgery, was fortunate enough to go to San Antonio for that at UT Health Science Center, where there was a strong focus on microsurgery, which I needed to do these surgeries. Then, after that I thought, “Well, I might as well round out 10 years of training to 11, let’s pick up another transgender surgery fellowship.”

I would’ve done two residencies in two fellowships and picked that up overseas. As I mentioned, trained, worked in Alaska for a little while and then opened my own practice.

Justin: I guess my first question is how did you end up in Belgrade or Serbia? You said you went on missions and then you ended up turning straight into transgender surgery. What was the mission you were on that you ended up in transgender surgery or in Belgrade?

Dr. Curtis: I had never been to Serbia. I want to go there and operate. There’s a famous urologist there, Miroslav Djordjevic, he’s done tremendous things for the trans community. I sent him an email and I was like, “Hey man, I’m Curtis, can I come to Belgrade?” He was like, “Yeah.”

Justin: You just like stayed in a hostel and do transgender surgeries.

Dr. Curtis: I stayed on the couch of his resident Vladi. Vladi had a couch.

Justin: Only you do.

Dr. Curtis: I stayed on his couch. Vladi is an amazing guy. One time he loaned me his car because I wanted to go check out Budapest and he wanted to put snow tires on it and fill it up with guest. Serbians are incredible hosts and finally gives me this car. I wanted to leave at like six at night to get into Budapest at a reasonable hour, but I ended up leaving at like 10 at night.

I’m crossing the Serbian Hungarian border and he gives to me this letter written in Serbia, because apparently it’s a big problem where Serbians can take their car to Hungary and then sell their car for a lot more in Hungary and it’s illegal. Here I am, American and driving over there and it’s Vlad, he gave me this letter. He said, “If they give you hassle at border, give him this letter.”

I’m like, “Okay, so I can pull it up.” There’s a border patrol agent with an assault rifle. He comes walking up to the car and it’s midnight and it’s snowing out. He comes walking up and he goes, starts speaking to me in Hungarian, I assume. I say, “Dobro, Dobro“which is like good in Serbian. I then asked him to speak English. He did. His English was broken, but it was better than my Hungarian.

He says to me, “Is this your car?” I go, no. I handed him the letter thinking I’m cool in the gang. He goes, “Oh, so your friends Vlad, he give you this car to come here?” I go. He goes, “Vladi must be very good friend.” Literally, I had met him like a few days ago. I was sleeping on his couch and I considered him a very good friend and would be an incredible host to him, but I never got around to like learning his last name.

It was something surreal like Djordjevic or, and I was just called him Vladi and he says, “Vladi, is a good friend? I go, “Yeah, he’s a very good friend.” He goes, “Good, what is Vladi’s last name?”

[laughter]

I go, “Well, I always just call him Vladi.”

[laughter]

He says, “Yes, get out of the car,” [laughs] and they tore the car apart.

Justin: Really?

Dr. Curtis: Yes. Looking for drugs, I mean it was incredible. I was just standing there in the snow, watching them take apart the car. I think it took like an hour.

Justin: Like pull the seats out?

Dr. Curtis: Everything. It was incredible. Everything in the trunk. Then, at the end they’re like, “Okay, go ahead.” I go, “Are you going to help me put that stuff back?”

[laughter]

He just looks at me like, “I could show you, or you can put it back to yourself.” No actually, they’re very nice, actually.

Justin: [laughs] Actually wonderful people. They left all the car in the roadway.

Dr. Curtis: Then I went to Budapest. It was beautiful.

Justin: All right. That’s your Vladi story and that’s who puts you up during this, I mean, very formative moment in deciding your career path.

Dr. Curtis: Yes, very.

Justin: Then, Dr. Santucci was also very important in your career path, and now he’s one of your surgeons, right?

Dr. Curtis: That’s right. I got done with all the training that he recommended, kept in touch with him and he saw some of the work we were doing, he said, “Hey, man, in my final decade of practice, I would love to focus on transgender surgery. How can we do this?”, and I’m like, “I’ll hire you. What kind of salary do you want?” He told me and I was like, “Geez, holy shit. Is that what you make?”

Justin: Is that in dollars?

[laughter]

Dr. Curtis: I was like, “Yes, okay. Let’s do it.” We brought him here, trained him, and it’s been amazing. He’s a really great addition to our healthcare providers here and has helped us perfect some surgeries that used the improvement and it’s really good to have. You never turn down an opportunity to work with someone brilliant.

Justin: What a privilege and honor to be able to hire one of your mentors. I mean, I can’t imagine, it has to be a real heady feeling.

Dr. Curtis: Yes. There was a moment where I was like,”When the student becomes the master”, but then– He comes here and I have other surgeons here that I call– I call Dr. DeLeon Ashley and I call Dr. Wachtman Galen, but I call Dr. Santucci Dr. Santucci, because although he’s my employee, he was my fellowship director.

Justin: Yes. How long has he been with you now?

Dr. Curtis: Let’s see, I guess about going on three years.

Justin: All right. You said you’re at six surgeons now and you’re about to be seven. Is that right?

Dr. Curtis: Let’s see. Including me we’re six. Yes, we’re about to be seven.

Justin: Okay. Let’s get into it. I want to talk to you about a few things. I watched a bunch of your videos and really I had just my own personal questions. My biggest personal question is, what is the guiding ethics behind what you do? I mean, you’re doing a lot of things that are new, you’ve invented procedures. There’s got to be sort of– Do you have a medical ethical group that you all turn to when you have weird questions?

Because one of the things that I found very interesting is you were talking about somebody coming in and wanting a non-binary procedure. One of the first things you thought was, “Can I do this?” You said you went for a jog, you really thought about it and thought, “We represent people on the spectrum and we should provide procedures on the spectrum too,” which I thought was genius and it showed your heart in this. What do you turn to and where do you turn for guidance on some of these really tricky ethical considerations?

Dr. Curtis: It’s a great question. You’re a very good listener, you really picked up a lot from that, from that Facebook ask me anything.

Justin: Thank you.

Dr. Curtis: I’m impressed. The ethics in medicine comes down to, “Are you acting in the best interest of your patient?” If you are, then you are ethical. Your patient is numbers one through a hundred. Top of 100 important things is the patient. I use that belief system to ignore social and cultural norms. Yes, back in 2012 some people gave me some shit for building a phallus for someone that wanted to keep his vagina.

I had one doctor say, “Well, how can you justify making a medical hermaphrodite?” It was during a lecture, he raised his hand and stood up and said that in front of a large group, and I just looked at him, I said, “I actually think that’s putting a negative spin on things.”

Justin: Which he was trying to do, obviously. I mean, that’s what he was doing.

Dr. Curtis: Yes. I said, “You have your belief system and your question is to fulfill an agenda. My belief system is that a patient’s body is their own and a trans man is no less of a trans man if he never gets any surgery.” Your gender identity is in your head, it’s not what’s between your legs. The majority of trans people don’t get any surgery and they are still trans. A trans man can have a vagina.

If a trans man can have a vagina, and the day we do the phalloplasty, it’s not as though he becomes a man that day. He’s always been a trans man since he discovered his true gender identity, so I thought, “Well, he’s no less of a trans man, and if he happens to have a phallus and a vagina.” Some of my patients are so dysphoric around gender incongruence that they are unable to hear the word “vagina”. Some are less dysphoric and actually-

Justin: What do you mean by dysphoric?

Dr. Curtis: Sorry?

Justin: What do you mean by dysphoric?

Dr. Curtis: Dysphoric is the opposite of euphoric.

Justin: Okay. I mean, that’s what I thought, they have a hang-up or an issue with it.

Dr. Curtis: Yes. Dysphoria describes the stress and suffering that someone with gender incongruence experiences.

Justin: Sure.

Dr. Curtis: It was called gender dysphoria for a long time. Then, the community rightfully got away from that because it implies– No one wants to live their life dysphoric. They have stress and suffering around this gender incongruence issues. Now, you hear the term more gender incongruence, but dysphoria can still be used to describe stress or suffering for any reason. Adding “gender” dysphoria to it would describe stress and suffering for someone with gender incongruence.

I was talking about if a patient had a phallus and a vagina. Excuse me. First, some patients are so dysphoric they can’t even hear the female anatomic terms. Then, some patients have enough dysphoria that they need to have a surgery to correct it, but they found a good use for their vagina. They get sexual gratification from it, even though they’re a male.

If someone is enjoying their vagina, I feel like it’s assault to force them to remove it. The trans community taught me that gender, and really sexuality, everything exists on a continuum, so why then should the surgeries I offer be binary? They should exist on a continuum as well.

Justin: Yes, I know. I thought when you said that in a video, it made so much sense to me. I consider myself a well thought-out, considerate person, especially in issues like this. Even for me it’s just an eye-opening perspective. I remember when you were in town, you pointed out that surgery to me. I did not at the time understand the import of how proud you were about what you were doing new and how this was something new and providing something for people. I’m libertarian about a lot of these things. If that’s what people want and it’s not going to harm them, that’s fine.

I think it’s great that you’re allowing people to liberate themselves, essentially, and not in a binary way to where, “Oh, you’re this or you can be that, but you can’t– There’s nothing else in between.” The reality is some people are born with both sex organs, right?

Dr. Curtis: Yes. That was that other doctor’s point on like, “Why are you creating a medical hermaphrodite?” Hermaphrodite would be a term for someone that’s actually born with both sets of genitalia, which obviously is totally different than being trans, but yes, this occurs in nature. I feel like you can’t just pay attention to the 95% to 99% that fit in the Bell Curve. The ends of the curve, the 0.1% and the 0.3%, they matter in society and to me that’s what makes society, our culture, the most interesting. It’s the 0.3%.

Justin: To that 0.3%, it matters a whole lot.

Dr. Curtis: Yes.

Justin: If you’re not harming anybody, that’s always my take on it. You’re not harming anybody. We talked about sort of, when you and I met one time, I remember you talking about how some people travel to get surgeries that could not be performed in America. I remember you talking that some were because people didn’t perform them, and some just because they were outside the medical– I don’t know what you’d say, the medical tolerance of what we do in America at the time. What are the bookings on what type of surgeries that you start thinking, “No, I can’t do this or I don’t feel comfortable doing that?”

Dr. Curtis: Really only ones that are anatomically impossible. I’ve built a vagina for someone born with male genitalia, and did not want to have to sit to urinate, so he kept– He actually used– No wait, that was the deformation. She actually used female pronouns, I apologize for that, even though she had a phallus and wanting to keep her phallus, so that she wouldn’t have to sit to urinate, but she felt female and wanted a vagina. No problem, I did that.

There’s kind of every combination. Sometimes, as I mentioned, we build the phallus and keep the vagina, sometimes we build the phallus and if the patient says, “Why do I need the scrotum? What is it going to do?” “I don’t know. You don’t have to have one,” so we don’t do that. There’s all kinds of degrees. Surgeries I wouldn’t do? One time a patient asked me to make a tail for her, I was like, “Well, that’s very interesting.” I guess I could drop down a pair of spineless flap, and then skin graft it and I’m like, “Would you want it to move?”

[laughter]

She’s like, “Yes, that’d be cool.” And I’m like, “Let’s think about the nerve innervation.” I was like, “I don’t know if we should do this.”

[laughter]

Justin: That brings me to the next point. What is the screening process on this? Because there’s no going back from some of these surgeries. Is there any sort of screening process to screen out people who are either making decisions that are impulsive or not well thought out or well informed?

Dr. Dr. Curtis: Yes, there’s a really important screening process. One of my first comments is, first do no harm that’s the part of the Hippocratic Oath that all doctors take. I said that’s what I used as my belief system is, don’t harm the patient.

Well, the worst mistake possible that we could make is operating on the wrong patient. Operating on a patient that is not trans, or non-binary or gender fluid. Operating on someone that for some reason, would want to have reconstructive surgery to go back. That’d be the worst mistake we make.

I work very closely with our mental health colleagues, psychiatrists, psychologists and they help. They really are instrumental in establishing the diagnosis because they would have a relationship with a patient for six months, a year, five years I’ve seen. They make the diagnosis and then help the patients if they want to start cross-sex hormones, meaning a trans woman would start estrogen, and when I say a trans woman that was someone born with male genitalia opposite of a cis woman, cis and trans are our chemistry terms, it’s like whether the [unintelligible 00:42:17] was coming off the thing on the same side or not.

Justin: That can be my chemistry lesson for the day and I’m good for a month.

Dr. Dr. Curtis: I think we all learned a lot.

[laughter]

Justin: I think you’re fixing to go down. Let’s just go back. One of the questions I got was, what on earth is the process? I could walk in tomorrow and have a mole cut off. Nobody’s going to require a bunch of hoops to be jumped through. Do people have to have a diagnosis? Do they have to have been on therapy or hormone therapy? Do they have to have had any mental health screening prior to having surgical reconstruction?

Dr. Dr. Curtis: Yes, I follow the WPATH criteria. WPATH is the World Professional Association of Transgender Health. They put together some guidelines and they’re not hard-fixed rules some times, I can give you some examples. There are outliers as I mentioned, I don’t like to ignore. There are times where you should break the guidelines and do what you think is best for the patient.

In general, if a patient wants say, a chest masculinizing surgery, then they get one letter of recommendation from a mental health provider they’ve been seeing for months to years and that letter in support of them basically says they have decision-making capacity. This is the next step in their transition. This is healthy for them. They are transgender, non-binary, gender fluid there’s a lot of different terms or reasons why someone would want a chest masculinizing surgery and then we go, we go forward.

It used to be you needed to be on testosterone, but that’s no longer a requirement because there are some non-binary or gender fluid patients that aren’t interested in being on testosterone, but they should still be able to get a chest masculinizing surgery if that’s best for their mental health.

For genital reconstruction, a patient needs to be on a year of cross-sex hormones. So if you’re a trans man, testosterone and as I mentioned, if you’re a trans woman, often spironolactone to a block testosterone and estrogen, and there’s all kinds of other both possibilities. A year of living as their true gender, meaning they go to work as their true gender socially, they go to the grocery store, a year of cross-sex hormones and two letters of recommendation. Occasionally three, insurance companies might want from mental health providers and endocrinologists. With all this, we make the determination of who this surgery will help and who it won’t.

Justin: I want to get into some meteor issues because this is all really fascinating to me. There was a time in life in which transgender issues were considered a mental illness fair?

Dr. Dr. Curtis: Yes, definitely.

Justin: I don’t really know how to phrase this question in the correct way. Requiring people to have a medical procedure that matches their gender identity, requiring them to go through multiple layers or at least even one layer of mental health screening. Is that a relic of that? Is that to protect you to make sure that you’re not basically performing an irreversible surgery on somebody that doesn’t need it? Or what is the reasoning for that? Maybe it’s just an insurance requirement? I don’t know.

Dr. Dr. Curtis: That’s a really good question and it’s very thoughtful. I appreciate the way you presented it. There is a lot of debate. Should it be considered a mental illness which has a negative stigma attached to it? Should it be? Is it something physical? Is there a chromosomal thing that we haven’t seen? Is it possible that maybe the brain in someone that’s trans is mosaic meaning they have some male and female parts?

You can certainly find maternal cells, maternal being like XX chromosome, and that’s a woman has two X chromosomes. You can find maternal cells in a male fetus. There should be no reason why a male fetus would have XX but they should all be XY, but you can find that. Is there some mosaicism and all that? Honestly, as soon as you divorce yourself from the thought that mental illness has a negative connotation, then it doesn’t matter as much to me. I can see why it matters to the community but to me, I don’t care if it is, at some point categorized as a mental illness or not.

I know a lot of amazing people that are afflicted with gender and congruence and I want to help them no matter how it’s decided that it’s categorized. They’re wonderful people.

Another reason why it’s important for patients to see mental health care providers is because transitioning is like some heavy shit. I’ve had a lot of parents and girlfriends and friends say, it says, when you get on cross-sex hormones, your personality changes. I’ve had parents say, “It’s as though my daughter died and now I have this guy in front of me, and he talks differently. His voice inflections are different, he walks differently, he sits differently.” Gender just permeates through our entire personality and when we get on cross-sex hormones, it totally changes. It’s important to have help with that.

In addition to that, because of the judgmental society we live in, we live in an extremely judgmental society. If you view yourself differently than the way society views you, it causes profound stress. You feel like you’re lying, you feel like you have to hide things, things that you and I take for granted, like going to the grocery store, can be a really frightening experience being the victim of hate crimes or assault because of who you really are.

It’s absolute nonsense, but this is the society we live in. Because of all that, unfortunately, for the trans community, there is a higher incidence of depression, anxiety, other psychiatric diagnoses that need to be in check to help with a successful transition and a successful surgery.

I’ve heard some people say, “Well there’s a higher incidence of X, Y, and Z, mental health conditions, and someone that’s trans, that’s proof they’re crazy.” I’m like, “No, that’s actually a reflection of society and you.”

[laughter]

If we lived in a non-judgmental society, maybe some trans people wouldn’t even want surgery, maybe less. They’d say, “I’m trans. I’m a guy, it doesn’t matter what’s between my legs and nobody gives a shit.” Unfortunately, that’s not where we are as a community as a society.

Justin: The reason for having the psychological evaluations is sort of multi, it seems faceted, partly because they’re preparing to go through a very stressful situation, partly to make sure there’s no weaknesses in their ability to get through that situation, but then also preparing them for just the general– There’s no coming back from some of these, right?

Dr. Dr. Curtis: It’s an irreversible surgery and I’m happy to say that at this point, after treating thousands of trans patients, I do not know of any of my patients that transitioned back. I took over Dr. Brownstein’s practice and he did about 7,000 chest masculinizing surgeries in 35 years. He said he knew of two patients out of 7,000 that went back and got breast augmentation. Obviously there could be some, I don’t know about, but those are pretty good stats.

Justin: When you say chest masculinizing, that’s somebody that was born with breasts that has them removed.

Dr. Dr. Curtis: Exactly.

Justin: Okay. I just got some general questions that everybody who would ever talk to you probably is going to ask so I’m going to ask them. How functional is what you create and let’s, just generally, this is a family-friendly topic, but is it functional or is it all just, just cosmetic?

Dr. Dr. Curtis: No, it’s extremely functional. In fact, it’s all very much reconstructive and not cosmetic at all, in fact, they are super functional. For example, when I perform a phalloplasty, build a phallus, and then we put a penile implants in it, that is a human-made mechanical device that can be pumped up and that phallus will remain erect until someone pushes the relief valve and lets it down. That person could be erect for an hour, a day, a week, a month. [chuckles]

Justin: It would be a good pump if it kept the pump that long, I would think.

Dr. Dr. Curtis: Yes, they can.

Justin: That’s technology that’s also just been around for a long time. I hate to say this, we had a family member that whenever they died in the autopsy, that’s the family-like hubbub that went around, “Did you know, he had the pump?” He was eighty years old when he died and that was like all anybody talked about.

Dr. Dr. Curtis: Yes. You become superhuman, you become part cyborg and your penis has a superhuman capabilities.

Justin: All right. Like the TV commercials, if it lasts longer then call your doctor, not in this situation because it’s there.

Dr. Dr. Curtis: Not in this situation. It’s actually sailing that gets pumped in there. They want to be erect all of burning man, they can.

Justin: [chuckles] Okay. What about a urinary function, all work all the same?

Dr. Dr. Curtis: Yes. The biggest risk of the procedure is the urethral reconstruction. There’s risk of scar tissue building up in there which is the urethral stricture in that would limit that function but there’s corrective surgery to fix that. Our goal is if a patient wants a phallus and wants to be able to stay in the urinate, then that’s absolutely our goal. It’s a reasonable goal and we’re very good at achieving it.

Justin: Talk to me, you said it in your video, but I’m sure plenty of my listeners probably haven’t watched your video. I thought it was really fascinating the way you frame what you do. You don’t frame it as cosmetic procedures, you don’t frame it as like an elective procedure and you describe that. You compare it to somebody who wants to have their nose reshaped and have a bump shaved off their nose.

You say you are providing reconstructive surgery under the idea that these people need to have their sexual organs or genitalia reconstructed to match their gender identity. Talk to me about the way you frame it, the way you see it and the way you talk to insurance companies about it.

Dr. Dr. Curtis: Yes. That’s a great question. Basically a cosmetic procedure is when something is normal, but somebody wants it enhanced or altered to become more aesthetically pleasing or bigger or whatever. Just the example you gave, my nose looks reasonable, but I could be better looking if it looked different, if I wanted like the bump shaved off or some better tip defining points or dorsal aesthetic lines or all this other stuff I would look better and probably have more friends.

Justin: [laughs] You got friends? Good for you man.

Dr. Dr. Curtis: I got one. I would look better but my nose is normal now, it’s considered within the range of normal. That’s a cosmetic procedure. If you are a trans person and you have a masculinized face and you are a trans woman, it is not normal for a woman to have a masculinized face. I believe the facial surgery we do is reconstructive. We lower her hairline, we raise the brow, we brow down the brow.

We can do rhinoplasty, chin setbacks, jaw contouring, it’s all very important mainly because society is so judgmental. That patient is at a higher risk of being the victim of violence if someone perceives them as being a man that– who knows what or perceives them as being someone that they aren’t. Trans women reasonably want facial feminizing procedures or tracheal shave, bringing down the thyroid cartilage or the Adam’s Apple.

Same with genital reconstruction or chest surgery. If someone is a trans man it can be considered abnormal for him to have a vagina. He wants a phalloplasty and I gave those other examples, maybe he wants both and that’s fine with me too. These are reconstructive procedures because we’re not going from normal to enhanced. We’re going from something that shouldn’t be there or something that should be different to normal. We’re trying to achieve normal, normal is the goal

Justin: Normal for that human being who has gone through a lot of process to get there. This isn’t a rash decision after what you just walked me through.

Dr. Dr. Curtis: That’s exactly right.

Justin: It’s good you point out the violence that the trans community can suffer. You hear about it all the time, but in your backyard of Austin, Leslie, the famous homeless guy who had breast implants but always had Daisy Dukes on me, everybody knew who Leslie was in Austin and he was the victim of violent crime and was killed. He was in TV commercials in Austin and was beat to death one night. It’s crazy that that is a targeted community in my mind.

Dr. Dr. Curtis: It’s awful. It’s dangerous. As a society, we should try to make things as safe as possible.

Justin: One of the things that really changed, you and I had talked a lot about this back when you lived here because we talked more, we talk less now but back then I remember you talked about how the majority of your work was paid for out of cash pay. People had to pay for their procedures. Before we got to talking today, you said how you’ve written letters to governors and legislatures, there have been changes in whether or not insurance policies can be discriminatory against the trans community.

Talk to me about how the practice works now and if we have a listener who eventually wants to transition at some point or have gender confirmation surgery, is there a chance their insurance covers it? What is the way that world works now?

Dr. Dr. Curtis: Yes. I’m really proud to say that at this point we’re probably 85, 90% insurance-based. I have a whole team dedicated to dealing with insurance companies and fighting for the patients to have the financial burden paid for by an insurance company. These are truly medically necessary procedures and that’s why we have insurance. Typically, I’ll speak with a patient, find out their surgical needs, write up a note, we give it to our insurance team, and then they start working.

They look at each individual patient’s policy, what we’re capable of, what their copay and deductible might be. Would their policy cover phalloplasty? There used to be caps put on it. Well, there still are sometimes meaning we only offer $30,000 in transgender surgery, which is ridiculous. Like there’s no cap on knee replacements or gallbladder surgery. It’s obscene. We find out, is facial feminizing surgery going to be covered, because unfortunately a lot of insurance companies and employer view that as cosmetic because that’s the way we view nose jobs.

I even described where liposuction can be reconstructive. If a trans man has a female body fat distribution, that’s abnormal. That person should have a male fat distribution in their body and so we can do liposuction as a reconstructive surgery.

Justin: Have you found that the insurance companies are receptive to these ideas that– well, you can’t discriminate against trans community in the insurance policies now, but are you finding that they’re becoming more accepting of it, or are you finding that the legislation and the government entities are whipping them into shape.

Dr. Dr. Curtis: It’s both. I worked in California before it was illegal to have transgender exclusions on insurance policies. A lot of insurance companies did it. Then I think Kaiser out there was one of the first ones that said, “Okay. We’re going to cover surgeries.” Then the governor of California, this is maybe 2013 or ’14 said, “Okay. It’s illegal to have transgender exclusions. That’s discriminatory.” I agree it absolutely is. Then more and more states followed suit.

Last I checked there were probably more than 14 or 15 states where it’s illegal to have transgender exclusions. Some still do. Transgender exclusion is when insurance company says, “We don’t cover any trans surgeries.”

Justin: Sure. We’ve had exclusions and insurance policies through our history and the only way those ever change are whenever the legislation requires them to. The preexisting conditions and all kinds of things. We just try to exclude anything that they don’t like.

Dr. Dr. Curtis: Yes. It’s bizarre. It’s literally the same as saying, “We just don’t specialize in appendix. We don’t cover any surgeries for the appendix. We just don’t believe in that. If you have an appendix problem then you should hopefully have some money to pay for that.”

Justin: I’ve appreciated your stories. I remember one early on and I won’t say the name of the carrier. They did not like the deal they had cut with you and decided they wanted to renegotiate that deal because I guess they started bidding you against others and you said, “No. I’m not going to do that. You all can just not reup your long-term contract you signed with me.” I appreciate when I hear a story of somebody sticking it to the insurance company because we’ve all been stuck by the insurance company.

Last thing I want to talk to you about is just look this is my podcast. I’m going to do things I think are interesting. You actually had a chance to go on behalf of some nationalized health insurance companies or national health service companies. Are you able to talk about the work that you’ve done on behalf of national?

England’s got nationalized health insurance. Everybody is covered by being a citizen of the country. You’ve actually been hired by some of those countries insurance/health systems to come do transgender surgeries in other countries. If you can talk to me about it I think it’s just fascinating.

Dr. Dr. Curtis: Yes. I’ve done surgeries for the New Zealand Health Ministry. Trans BC, British Columbia. For the Ontario Health Ministry.

Justin: Did you do Israel?

Dr. Dr. Curtis: Yes. The Israeli Health Ministry flew me out there probably three years ago. We did a whole bunch of phalloplasties. It was funny the first phalloplasty we did, me and Surgeon Dr. Walkman, we walked in and certainly a phalloplasty and there’s all these news cameras in the OR. I look at this lady, her name was Ola. I always thought that she just knew Spanish and then it turns out that was her name. It’s [unintelligible 01:03:23] in Spanish. She spoke Hebrew.

[laughter]

Dr. Dr. Curtis: I had a lot conversations with her in Spanish, but she [unintelligible 01:03:30]

Justin: You’re like, “Ola,” and she’s like, “Yes.”

Dr. Dr. Curtis: She’s like, “Present.” I asked Ola, “What’s with all these cameras?” She said, “Yes, that’s Good Morning Tel Aviv.” We were on Good Morning Tel Aviv doing a phalloplasty. That was cool.

Justin: Did they have their own version of Kathy and Hoda drinking wine in the morning?

Dr. Dr. Curtis: Yes.

Justin: Same thing. Okay. If somebody wants to learn more of– We’re about done. I like to try to keep these around an hour. Whenever you get your own set up and you have a better mic and all that that’s not setting up on a penis I’m going to have you back on because I think what you do is fascinating. I think people like to hear the stories because it’s a part of the world that so few people ever have any exposure to other than the crap you hear on the news which is usually just straight bathroom bills and these strange things.

You’re actually doing the work and doing the advocacy for an underserved community and I think it’s fascinating. Thank you for being on here. If anybody wants to get more information about what you do where can they visit your website? It’s on alamohour.com but you can go ahead and say it as well please.

Dr. Dr. Curtis: Yes definitely. Thank you very much. It was an honor being on here. I appreciate you wanting to educate on this issue that’s near and dear to my heart. Thank you. The website is www.crane, C-R-A-N-E, cts.com. CTS is Center of Transgender Surgery.

Justin: Awesome. Hey Dr. Crane sit tight real quick. I’m going to read my little thing I do and then play my little thing and then I’ll be right back with you. Okay.

Dr. Dr. Curtis: Okay.

Justin: All right. That about does it for this episode of The Alamo Hour. Thank you Dr. Curtis Crane a longtime friend and really just an expert in a really fascinating area of medicine to me. My guest wishlist continues. Robert Rivard has agreed to come on. He’s going to be on the show in May. Coach Pop, I’m going to probably never get you on the show but I’m going to keep trying. Steve McCue, I’m going to get on the show eventually. He’s on my wish list. Jackie Earle, Haley Rorschach, I loved your character so if we can get you on we’d love it. Thanks for being here. See you the next episode. Curtis sit tight real quick.

[music]

Justin: Thanks for joining us on this episode of The Alamo Hour. You are what make this city so great. We hope you join us next week. In the meantime, subscribe to our podcast, check us out on Facebook at facebook.com/Alamohour or our website alamohour.com. Until next time. Viva San Antonio.

[01:06:02] [END OF AUDIO]

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