Withhelde Gender Reassignment
He gets misdiagnosed with Attention-Deficit Hyperactivity Disorder and put on drugs, and although he's basically a happy, active kid, becomes depressed enough to make a noose for himself and hold a knife to his chest. He figures no one will ever listen, or believe what he knows to be true: he is a girl.
'That's 1700 lives you've saved'
I met Natalie in December 2017, at Mount Sinai Hospital's Centre for Transgender Medicine and Surgery in Manhattan, an hour before she was due in theatre for gender reassignment surgery: a vaginoplasty, in which the penis is essentially turned inside out to become a vagina, plus breast implants and a tracheal shave to reduce the size of her Adam's apple.
As the anaesthetist told her what to expect, I chatted with surgeon Dr Jess Ting, his mentor Dr Marci Bowers, who was visiting from California, and Dr Bella Avanessian, a young transgender surgery fellow who had been studying at Ting's side for six months.
Ting described Bowers as the centre's "spiritual leader" and "probably the most experienced vaginoplasty surgeon in the United States". When she demurred, he asked how many of the operations she had performed. "That's 1700 lives you've saved," he said.
Two years ago, Ting was "a regular plastic surgeon", and he retains an evangelical devotion to his new vocation.
"I'm frequently on the verge of tears talking to patients," he told me. "Our oldest patient was 77 years old. She came in for a post-op check, we gave her a mirror, she saw herself for the first time and she cried. She said she had waited since she was five years old for this operation and it finally felt like she was herself."
For Natalie, early manhood was the hardest time. She was an overtly masculine adolescent: a lifeguard and Eagle Scout who enjoyed hang-gliding and rock climbing. Alone at home, she dressed in her mother's clothes. "It was as if I was trying to fill this void with something that wasn't fitting … I suppressed it all. It was like knowing something but actively trying to ignore it," she said.
At State University of New York at Geneseo, in her early 20s, she began to "present" as a woman for the first time. To summon up the nerve to tell her parents, and help them understand, she filled an encrypted USB flash drive with information about transgenderism and links to parental support groups, then wrote the password on a Post-it note and handed it to her dad. No going back.
An endocrinologist prescribed testosterone blockers and oestrogen injections, and although she cried every time she inserted the needle deep into a muscle, after three months she could feel her body starting to change.
The Centre for Transgender Medicine and Surgery opened in March 2016, in response to new regulations requiring medical insurance plans to cover gender reassignment in New York. As this included Medicaid, the state-run program for the most needy, hundreds of people who could not previously afford the operations were suddenly eligible.
Zil Goldstein, a nurse specialising in HIV treatment and hormone therapy who is herself transgender, was appointed director. "I had patients who were forcing themselves to live in poverty so they could save up the money to get these surgeries," she told me. Although the centre didn't advertise, within two months there were 100 people on the waiting list (there are now more than 400).
Penile inversion vaginoplasty was pioneered by Dr Georges Burou in 1958, but until fairly recently in the USA, it was only offered by a handful of surgeons, for cash.
"If you didn't have the means, then you didn't have the surgery," Ting said. "You would go to an unlicensed provider and have them inject your body full of silicone to maybe make yourself a little more feminine, and suffer the consequences of those botched operations."
These days, 19 US states require insurers to cover the operation and most corporations include it in their health plans.
It is still far from easy to get. In New York, patients qualify once they have been receiving hormone therapy and "presenting" in their preferred gender for a year, and must provide letters from two mental health professionals confirming a "persistent and well-documented case of gender dysphoria" - the official term from the latest Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.
The previous edition of DSM referred to "gender identity disorder", a term many found pathologising, and it remains controversial that the distress felt by people who feel trapped in the wrong body is listed as a disorder at all.
"Does this thing called gender dysphoria exist? The question is ongoing in the community right now," Goldstein said, "but we do know that 40 per cent of transgender people attempt suicide. It's not a stretch that these are life-saving procedures."
Mahogany Phillips, a former male model who had a vaginoplasty and breast augmentation at 47, described gender dysphoria as "a trial and a tragedy, every day … You feel so incomplete. It's a struggle just to get dressed. Physically, you're trying to tuck and you're trying to bind all these parts into smaller undergarments, and then you have to go out and face the rest of the world that wants to put you down."
In December 2016, she successfully sued New York state, winning the right to get facial feminisation surgery to remove a masculine bump on her forehead, a procedure Medicaid administrators had deemed cosmetic. "People say 'wasn't having the surgery a lot of pain?'. It can never amount to the pain that a transgender person feels every day," she told me.
Reborn in the USA
The next time I saw Natalie, she was unconscious in the operating theatre, on her back with her legs in stirrups, like a woman about to give birth. It occurred to me that she was being reborn: the chill and the bright lights reminded me of when I last wore hospital scrubs, to see my youngest son delivered by caesarean section.
Bowers took the lead, assisted by Ting, Avanessian and two other surgeons. To create a vagina, the shaft of the penis is inverted and used to line the cavity created in the perineum. The urethra is shortened and repositioned. A clitoris is fashioned from the glans of the penis, and the foreskin becomes the labia.
Ting spent a long time trimming fat from the scrotum, then sewing the skin into the shape of a windsock, to become the deepest part of the vagina. He advised the surgeon working up top to use the 470-cubic-centimetre Natrelle breast implants - "not too big, not too small" being Natalie's request. The smell of burning flesh filled the room, as surgeons cauterised blood vessels and made laser incisions.
Pop hits played from a speaker in the corner, occasionally causing the nurses to shuffle as they worked. When "My Humps" by The Black Eyed Peas came on - "my lovely lady lumps" - I laughed out loud into my surgical mask. Mostly, I was awestruck by what modern medical science is capable of, and by the transformation being wrought.
After a little over three hours, Bowers and Ting left the junior surgeons to put in the final sutures. A hospital videographer was filming the procedure, for a clip to accompany this article, and Avanessian wondered if the footage would be too graphic, even now the skin had been sewn up and most of the blood drained and wiped away. "It's a vagina," she pointed out.
Since the procedure was made available on Medicaid in New York, in March 2015, there has been an explosion of interest from surgeons and clinics seeking a share of the profits. A vaginoplasty that used to cost $11,000 in cash runs to around $29,000 now insurers are on the hook.
"Every week I hear about hospital X, hospital Y, everybody wants to start a transgender surgery program. And having been through it myself, learning these operations, I know how difficult they are," Ting said.
"So many people are jumping on the block with little or no training, knowing that they're going to get paid, but leaving the patients basically experimented upon," added Bowers. "We're seeing a decline in the quality of the outcomes overall. And then for those of us who are qualified, the waiting lists are so long."
Jaco Erasmus, head of the Gender Clinic at Monash Health in Melbourne, says that there are two surgeons performing vaginoplasty in Australia, one in Sydney and one in Melbourne.
"Because the surgery occurs in the private system, there is no process in place to collect data about how many surgeries are being performed," he says. "My understanding is that about 8 to 10 vaginoplasty surgeries are performed per month."
People seeking vaginoplasty in Australia need private health insurance for a minimum of 12 months, with surgeons recommending a further 12 months of insurance after surgery. Erasmus put the out-of-pocket costs for the procedure, covering surgeon's and anaesthetist's fees, at $12,000.
Natalie was lucky: her surgery was booked for September 2019, and only happened sooner because it could double as a masterclass while Bowers was in New York.
Ting has recently developed a new phalloplasty technique that he says has the potential to revolutionise female-to-male transitions, creating a fully-functional penis, something that hasn't been possible until now, but having only performed three of the operations, he remains cautious about the long-term results.
Earlier this year, researchers at the Mayo Clinic surveyed 400 endocrinologists, and discovered that only one in five had received training in how to treat transgender patients. In a National Center for Transgender Equality poll, 24 per cent of trans respondents said they sometimes have to educate their own doctor (and 23 per cent said they avoid seeking health care at all, because of ignorance and prejudice they have encountered).
Goldstein noted that when surgeons replace a mitral heart valve, there is an acceptable rate of complications. For the relatively untested operations required for gender reassignment, there is no agreed-upon quality metric yet.
"There are also more trans people than there used to be, and the medical industry, right now, doesn't have the capacity to take care of everyone," she said.
Surgeons working on gender reassignment in Australia follow guidelines published by the World Professional Association for Transgender Health. Two approval letters are required from mental health professionals with expertise in the field, and patients seeking genital surgery must have a well documented history of gender dysphoria and be able to show that they have 12 continuous months of living in "a gender role congruent with their gender identity" and receiving hormone therapy appropriate to their gender goals.
New resources, old divides
Today's trans teenagers have vastly more resources at their disposal than Natalie did a decade ago. There are transgender characters in several major television shows, and countless YouTube channels following the transition process (including Natalie's). But there is also fierce cultural resistance to transgender rights, particularly in red states: in a recent Pew poll, eight in 10 Republicans said whether someone is a man or woman is determined at birth.
"There's much more acceptance. There's much more integration. People are much less likely to be fired from their jobs," Bowers said. "So in that sense, there's been a bit of an emancipation. But there are places where violence is essentially sanctioned against transgender persons." At least 28 trans people were violently killed in the US in 2017, the most on record.
At college, Natalie was raped in an alley by a gay man she thought was her friend, and later chased by a pack of drunk male students intent on making her "prove" she was a woman, after a barman at a Halloween party questioned her gender for laughs. Whether she uses the gents' or the ladies' toilets, she is liable to be told "you can't be here" - prejudice she will still encounter despite her newly feminine appearance.
Sometimes, strangers congratulate her on her transition "to prove their own openness", and although it feels a lot better than being hated or ostracised, that can grate a bit too. "I try not to view myself as transgender," she said. "By scientific definition, I guess, I would be considered a trans woman, but in my own identity, I just consider myself a woman."
In the weeks leading up to her surgery, she often dreamed about it, so vividly she would check her body when she woke up. Regaining consciousness as the anaesthetic wore off, she knew this time was different.
"When I looked down at my body … I felt as if it was all completed. As if everything was done. It was a sense of relief," she said.
Eleven days after the operation, she was still getting used to having a vagina. "It's a new apparatus. I joke about wanting a user's manual, because I keep running into new, unseen territory and sensations," she told me, adding that her clitoris felt "fricking amazing" but she was wary of touching it.
When she has recuperated, and been cleared to return to work as a flight attendant, she will do so as a woman in ways that, growing up, she didn't believe possible. "I never thought it was going to come true, and then it did come true," she said. "You see it, and it's not just a dream: it's reality."
Support is available for anyone who may be distressed by phoning Lifeline 13 11 14; Kids Helpline 1800 551 800.
Anyone seeking support and information about suicide can contact beyondblue on 1300 22 46 36.
Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.