Amy Hunter

Sex Reassignment Surgery: When Things Go Wrong

Filed By Amy Hunter | June 06, 2010 10:00 AM | comments

Filed in: Living, Transgender & Intersex
Tags: AMA, APA, GRS, sex reassignment surgery, SRS, transgender health, transsexual

Sometimes, things go wrong with the surgery.

It has many names and many acronyms, SRS, GRS, GCS-Sex Reassignment Surgery. Whatever you call it, it is an irrevocable commitment and irreversible step should you choose to take it.

surgeon-putting-on-mask.jpgMale to female (MtF) transpeople talk about it a lot. You know: Are you, or aren't you? Is she pre-op, or post-op? Who did yours? Whom are you going to have do yours? We talk about it a lot, except...when things go wrong. Then--we don't say much at all. In fact, we won't talk about it publicly, but it happens. We cover it up as if we should be ashamed. We feel damaged.

Something odd ensues, much like forty or fifty years ago. Back then, people spoke in hushed tones, if at all about the family member, colleague, or friend who had certain illnesses-the "C word"-only whispered. Many times this lack of openness about such matters led directly to preventable consequences--even deaths.

We need to talk about healthcare for the transgender individual and I want to talk--openly about my experience--about what can happen when things go wrong with SRS.

After the jump-- a story.

I Knew There Were Risks

While death is an unlikely result of complications from sex reassignment surgery, things can and do go wrong with the procedure. Even the most skilled of surgeons are, after all, human and as with any surgery, there are risks.

The information packet sent to me from my surgeon's office listed the possible things that could go wrong. I had read extensively about what my body would have done to it after Propofol sent me to a dreamless sleep. Everything I found on the internet listed possible complications. One was a worst-case scenario, but the websites always mentioned it last and even then, it happened so seldom, most said, that it was a risk hardly worth mentioning.

My pre-operative appointment, a scant two hours before I signed the waiver, was brief. The surgeon asked a few questions, looked me over, pronounced me suitable for surgery and added that I had enough tissue for good depth. Almost as an afterthought, she said we needed to go over "this stuff". We got to that last, not worth mentioning but still possible, worst-case scenario thing. Of course, it needed to be brought up but in almost four hundred surgeries "it had only happened just once, so we don't worry about it". I didn't.

Just before I walked into the surgical suite, I signed the waiver.

I slumped to the floor of the shower that morning in Trinidad Colorado, water and reality raining down on me. Bewilderment and terror replaced hope, which swirled toward the drain along with the feces and the blood. Emergency surgeries there, four more at home in Kalamazoo and another in Denver have all failed.

Chronic pain, heavy narcotics addiction, and bouts of deep depression are the hushed legacies I have battled. Left with a possibly permanent colostomy and a painful, fibrous lump between my legs where a vagina should be, it is nearly impossible not to revisit the devastation daily. It is now two and a half years later.

The infrastructure of a natal male body is not the same as a natal female. The male pubic bone is lower and in my body, tipped somewhat, making it hard for my surgeon to get the geometry just right. In my case, there probably wasn't really quite enough space to allow for the proper thickness of septum between the new vaginal wall and the rectal wall.

A slight tear in my colon from a retractor, was all that was necessary to compromise an otherwise flawless procedure. I had developed a rectal-vaginal fistula. This problem happens to natal women too, often as a complication from difficult childbirth or certain cancers. Frankly, the success rate for repairing the defect in natal women is not good either. It often takes multiple surgeries for them too. What makes it even harder for the transwoman?

The Endemic Problems In Transsexual Healthcare

My story--and my surgeon's-- illuminate important problems endemic to healthcare for the transgender and specifically, the transsexual person.

  • Lack of access- Discrimination by doctors and hospitals and inability to get insurance or pay outright makes it difficult, if not impossible, for many transgender people to access care - primary or specialized.
  • Lack of knowledge- Documentation of protocols for care of patients undergoing transition is severely limited. Additionally, techniques for remedial care of complications are not well developed; instead, procedures designed for amelioration of fistulae in natal females are used.
  • Lack of training- There exist no specialized courses of study or teaching hospitals for SRS surgeons.
  • Lack of experience- While some surgeons learn techniques from other doctors already performing SRS, there are no residencies for those wishing to become SRS surgeons.
  • Lack of inter-disciplinary collaboration- Ignorance, discrimination and arrogance on the part of specialists often block those needing specialized post-SRS care.

In 2008 both the American Medical Association and the American Psychological Association issued white papers - policy statements calling for equal and fair access to healthcare for the transgender community. Both organizations recognized lack of access to health care as a growing crisis among transgender people.

Significantly, however, while both bodies asked the insurance industry to remove discriminatory blocks for transpeople, neither the APA nor the AMA asked for better training and documentation of skills. Neither organization called for unilateral coverage of transition related care and procedures. The APA resolution reads thus (emphasis mine):

THEREFORE, BE IT FURTHER RESOLVED THAT APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments;

And the AMA:

RESOLVED, That our American Medical Association support public and private health insurance coverage for treatment of gender identity disorder as recommended by the patient's physician.)

Ok, pretty strong statements, right? Look again and in particular, consider the italics. The APA resolution makes one BIG assumption-that you will be able to be "appropriately evaluated" , this requires you to have found and be able to pay for a psychologist, assuming of course, that you want to be evaluated. The AMA resolution assumes much the same thing; that you have a physician and that he or she is willing to make such recommendations, if, in fact, they are so qualified.

Whom Should I Go See When No One Will See Me?

I am associated with a LGBT resource center so, I get calls for things like, "Who is a trans-friendly electrologist" but the most frequent call I get is "My family doctor won't prescribe me hormones. Whom should I see?"

To my knowledge, there are only two therapists in this area who take transgender clients, neither is a clinical psychologist who can render a surgical readiness opinion for SRS. There are one or two primary care physicians in the area who will prescribe hormones but, after hearing stories of one of them prescribing the exact same regimen for every patient, I am more than reluctant to send people to him. The nearest endocrinologist who takes transgender patients is ninety minutes from here. My own primary care doctor, admittedly, has no knowledge of how to dose a transwoman either pre-operatively or, post-operatively. He has left it up to me to tell him.

There is no curriculum, no specialization, no residency, and no board certification for SRS surgeons. No medical texts detail the procedures. Most SRS surgeons have followed in the footsteps of pioneers.

In my doctor's case, the pioneer was legendary Colorado surgeon, Stanley Biber M.D. whose compassion for a social worker led him to develop the most celebrated sex reassignment practice in the States. The surgeon who did my SRS learned from him and took over his practice when he retired. Soon, she began refining his technique and developing and teaching her own. Today, she routinely performs SRS as many as two hundred times a year.

There are surgeons who want to do SRS-who have trained under doctors as mine did, but find it difficult, if not impossible, to find a facility that will grant privileges for SRS. Often, these surgeons may have the technical skills for SRS-urology, gynecological and plastic surgery, but hospitals will not grant access because there is no accredited course of specialization or board certification.

This may not be all bad. While there are a few new surgeons doing SRS every year, are they really getting the training necessary to accomplish not just the surgery itself but, adequate follow-up care too? Again, no curriculum, no specialized course of study, no board certification, but perhaps more significantly, certainly for the patient, there is no roadmap for what to do when things go wrong.

My Surgeon Doesn't Know How to Fix It

Then, seemingly, neither does anyone else. My SRS surgeon attempted to fix the two-inch tear in my colon while I was still there, the repair failed in less than twelve hours. Next, a colon-rectal surgeon was found in the nearest large city and brought in to look at me. He aborted his attempt to repair the defect and instead, performed a full colostomy.

I flew home to Michigan with a bag attached to my abdomen and thick pads between my legs to soak up the blood.

A local colon-rectal surgeon, persuaded to see me by my primary care physician, was upbeat. Each time I went into surgery with him he would encourage me, saying "this time we'll get it". Coming out of surgery, my spouse Cindy would hear from him how well it went and that he was "optimistic this time" the closure would take and a new defect would not open up.

Another surgeon who has had some success with other fistula patients seemed promising, but eight months later, under the pressure of a barium test, that repair too, failed.

I have had stitch-overs, mucosal flap advancements, and pelvic floor muscle mobilization; each new approach diminishes what viable tissue I have for another attempt. I have tried to go into every surgery with a realistic outlook; multiple failures however, become difficult to bear.

Still, I am one of the fortunate ones with this complication; I stand a chance, albeit small, for an eventually favorable outcome. Many transwoman are not able to find a colon-rectal surgeon who is willing to work on a transperson, much less "someone else's problem", nor do all of us have the means.

Even if you are fortunate enough to locate a doctor--and in my case, privileged to have insurance and financial means to cover remedial procedures, then there is still only a slim chance for alleviation of this humiliating and debilitating condition. One surgeon, out of frustration no doubt, finally washed his hands of me saying, "well, you did this to yourself".

Losing the Patient

I am not writing this to slam the physician who did my SRS. Far from it, she is a dear friend. We have shared much together, laughing, and holding each other; the two of us have grappled for footing. We have cried together, and yes, yelled at each other. She is an icon in the transgender community and heroine to many transsexuals. She is also perhaps the most accomplished of the few surgeons doing primary SRS in the United States.

However, even a surgeon as accomplished as mine cannot overcome obstacles that she has no training for and little experience resolving. There are unseen and unsaid barriers that come into play when someone with complications from SRS must seek treatment aside from their original surgeon.

As I mentioned before, most surgeons just do not want to deal with what they may perceive to be another doctor's mistakes, if they are willing to look at you at all. A person would be hard pressed to get a doctor to admit that they are closed-minded, yet there are many doctors who simply will not work on-or treat a transsexual.

My surgeon has told me, and has repeated often, that she would see me through this. I believe she has tried, but somewhere in the mix of discrimination, ego, and fear, the patient has been lost.


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diddlygrl | June 6, 2010 11:28 AM

I am so sorry to read about your problem with GRS. The possibility of developing a fistula was one of the things I worried about most with my own surgery.
My best wishes and prayers go out to you.

rose white | April 30, 2011 5:08 PM

I think my pubic arch is too low or small to make a satisfactory vagina though it is OK with small dilators and probly OK for average man to penetrate. It seems it blocks a straight line into the vagina.
But I wonder if the surgeons should carve away some of the bone in order to give a straighter line with less risk of getting close to the rectum and causing a fistula?

Thank you, thank you, thank you, Amy, for your personal bravery and your willingness to speak about this difficult experience. I have heard of this complication before, but only as a vague warning in a long list. I think it's so important that people begin to understand that complications can occur. I had a complication myself. Even though it was not severe, it took a year to heal completely. I also think you are spot on about the lack of training and research in the profession. We must move that conversation forward so that more people don't have to suffer as you have.

Your courage and forthrightness are inspiring and moving. Thank you for being a true leader.

Thank you, Amy, for courageously bringing to light this probably often swept under the mat so personal an experience... my best thoughts go out to you...

George Byrd | June 6, 2010 12:28 PM

Thanks so much for sharing, Amy. You have made me aware of issues I didn't even realize existed. It is through efforts like yours that progress will be made. Please keep it up!

Amy, I'm so sorry. Here's hoping that the next repair will go better. There may be less viable tissue there (locally), but every time they've learnt more.

I had severe granulation develop at 4 months. Repeated cauterisation failed to clear it, and having your external genitalia burnt off a few times hoping that "this time it will heal" is ... unpleasant. The attempts at anaesthesis were ineffective.

My surgeon said it was his worst result in two years. Them's the breaks.

So I had to go back to him for free repairs. I lost an inch of depth (some granulation was internal), and just about all my labia minora to the surgery. But had a good result.

He's offered to do a free cosmetic repair, but I look no different from many women after a difficult pregnancy, according to my OB/GYN. I haven't felt the need. Depth is more than enough too.

I hope your outcome is as good. Hugs, Zoe

Amy Hunter Amy Hunter | June 6, 2010 4:52 PM

Zoe,
I'm glad you shared about the granulation problems you've had. I am not glad to hear you have had difficulties. Granulation is an unfortunately common and widely varied complication in terms of severity. I also understand that it and treatment can be incredibly painful.

You are correct about every attempt being a learning experience for my doctors. I think that's great for them and wonderful for those after me. I will say however, that It kinda sucks being (at least feeling) like a guinea pig. I told my primary surgeon a couple of months ago that we needed to quit playing "whack a mole" and arrive at a coordinated and comprehensive treatment and after-care plan.

As my anatomy was by no means usual before surgery, the "guinea pig" effect is something I have to take for granted.

Many IS people are in the same boat.

Psychologically, I'm vanilla-normal trans, but my biology is anything but usual.

There's just so little research on the issue. This is perhaps understandable for the rarer IS conditions where the numbers are so small. But this shouldn't be the case for standard GRS. Even Australia generates ~200 cases per year, based on passport data (change of sex from initially assigned one). Local surgeons account for about 30 surgeries per year, the rest, including all FtoM bottom surgeries, have to go overseas, so the passport metric is an accurate one.

We should have an adequate dataset just from 200/year. We don't.

Long-term effects will still have to wait to be measured, given that "production line" rather than prototype treatment only started 40 years ago, if that. The initial results from long-term HRT look promissing though. There may be some "gotchas", but if so, they're not catastrophic ones, at least in the medium term.

One of the few studies - less than a handful - on the subject is Endocrine intervention for transsexuals A.Levy, A.Crown and R.Reid Clinical Endocrinology Volume 59, Issue 4, 2003.Pages: 409–418

As is usually the case with us, we know more than those who have been through med school about this specialised area. We have to, as it's not taught there, and we need to know this stuff for our own health. The paucity of knowledge about this issue amongst the medical profession, the misinformation and common misconceptions, in the US, the UK, Canada, Australia, and the whole of Europe bar the Netherlands, can only be described as scandalous.

Kerri Ellen | June 7, 2010 11:22 PM

Thank you for sharing about your post-op granulation problem. I'm in my 10th month post-op and still experiencing granulation. My surgeon has told me I am "officially" her patient with the most complicated recovery she has ever had. I'm still using silver nitrate sticks weekly, and hopefully in a few more months my recovery will be complete. Still difficult to get up from a sitting position and I have to sit down very gingerly.

I never thought it would be this long for recovery, but even after all of this I have no regrets and would undergo GCS again. I still have all of my depth of over 5" and thankful I've not lost any. Bacteria seems another problem, or perhaps related to the granulation problem. All told, there certainly are complications every person needs to carefully weigh before surgery.

Thank you for sharing a personal and painful story.

The trans community is underestimating the problems with medical conditions and procedures we will begin to encounter as the current transgender population ages and increases. Arthritis, heart disease, stroke, hip replacement, Alzheimer’s, it is a very long list of medical conditions an aging population must deal with and so shall we with the modifications we’ve made to ourselves.

At times it feels as if the community places greater emphasis on insurance coverage and access to pay for HRT, SRS, FFS, therapy, rather than proper and objective medical care for the common ailments of the transgender patient. I too worry about events such as a heart attack, where a cardiologist has an attitude of, well get off that damn estrogen and maybe this wouldn’t have happened.

I think we can learn a lot from gay men who experienced similar problems with HIV and medical procedures not related to the illness. They seem to have built a better awareness and acceptance from doctors and medical professionals for objective evaluation and care.

Amy Hunter Amy Hunter | June 6, 2010 3:55 PM

Geena,
Thanks for your comment. While I wrote this piece from an understandably parochial point of view (at least I think it is understandable), the undercurrent of discrimination runs through it and speaks implicitly to the "non-transition" related care crisis for the trans community. Indeed, as we age, more and more of us will undoubtedly experience heart disease, arthritis, alzheimers, stroke etc...What about long term care for the transperson? What happens to the non-op or pre-op who needs nursing or assisted living home care?

Amy,

Outstanding piece. Truly.

Fistula is something I have to consider each and every time I look at surgery. It is something that is "possible" in my personal case, and the term is used as a synonym with "likely" here, so I give it great thought.

But, more than that, I want to say thanks for writing this, because it's something that we don't talk about it. Something that is buried under the mountain of "oh, that's really unlikely", ignoring the fact that even with a 1% chance of such happening, that there are going to be a lot of them, and it's something to consider for those who, like me, have had typically unpleasant experiences with surgeries of any type (died once, I scar badly no matter what is done, etc).

And thanks for pointing out what I think is even more important than all of that. THank you for bringing up the issues of how to get a space for it, how to get training for it, the issues that surround certification and all the rest.

Right now, in Barcelona, Spain, trans folk of all sorts are talking about the importance of human rights and among them is the need for access to health care.

Here in the US, we have huge issues getting health care as it is, and yet we have it a hundred times easier than many in other countries. In some cases, everything is done under the table, and surgery isn't even something that can be considered as a possibility (including places like Malawi).

In our own US history, remember that the earliest surgeons to do this work often had to face having their license revoked and the end of their careers under the rubric of "mayhem" -- making it illegal for them to do the work.

It is easier to get treatment for HIV than it is to learn about transmedicine, and in most major cities, the people with the highest risk are trans folks.

You had one of the best doctors -- someone who is on my personal short list -- in the United States for this. We're talking about one of the most experienced people in the world.

More attention to transmedicine needs would result in fewer people having to suffer as you have, fewer people dealing with the effects of this.

And when it comes to a certain organization that exists for the purpose of dealing with transmedicine, you'd expect them to have worked on such.

Yet, to my knowledge, there's no such thing in the works or even in planning.

So thank you -- this is the sort of thing that needs to be covered more widely.

Amy Hunter Amy Hunter | June 6, 2010 4:10 PM

Toni-
Thanks for your usual thoughtful commentary.

Surgeons performing SRS have amoung the highest malpratice premiums of any doctors in the US. Of course, what makes it to the media is the shortage of OB/GYN's because of the potential for wrongful injury lawsuits they encounter.

There are a myriad of issues I didn't even begin to touch on opened by this topic. The sorry atate of FtM surgical options for instance.

You struck a nerve for me with your non-mention :) of a certain organization which appears to be more occupied by SOC considerations than with adequate training and protocol developement for the transperson.

Amy. This was the first time that I have seen a post on the very real complications associated with these complex medical procedures. I'm going to start pointing people to this post as I think it should be required reading as part of one's evaluation on whether or not to go for surgery.

Now were I a doctor, I think I would go from the worst possible complications FIRST. This could make patients a bit more aware that there are very real risks that must be considered and maybe might shock someone out of pre-surgery euphoria enough to know exactly what they are subjecting themselves to, the good and the bad.

I'm so sorry to hear of all you have been through and are still going through.

I was just thinking today how fortunate I am to live in a city with some of the best trans health care available by three physicians who have been doing it for many years. I was also fortunate to be able to have my SRS done by someone whose track record I knew was very good.

Even so, the possibility of recto-vaginal fistula was something that caused me a lot of concern. I told myself that it rarely happened, but rarely is not never. As it turns out, I have had excellent results.

Hypergranulation, however, is something I have had to deal with. It has not caused me undue pain, but the internal tissue has been slow to respond to treatment. And I know what you mean about being a Guinea pig. My doctor is going after the hypergranulation quite aggressively, twice a week, which is a change from his previous practice. Each time, that involves a speculum insertion into a still fairly new vaginal canal. Who knows whether this is better or not? We're still works in progress.

I hope that in the end you get a good result. Thank you for being open about something that, yes, we'd rather not talk about.

Thanks for posting your story. I know very little of the experiences that people go through when it comes to surgical procedures. I'm very sorry for your ongoing problems, too. It helps me understand how important access to health care for everyone truly is.

Amy, I'm so sorry you went through all this. We know it's a risk we take and I can honestly say none of the surgeries I've had has been perfect. Nor is transition. I know it's not what you want to hear, but I have to say my SRS in Montreal was the easiest of all the transition-related surgeries I had. I was literally walking around in the hospital the next day, and when I returned to the recovery house (apart from some discomfort from the surgical stent, I was quite mobile and healing fast. Nor did I take any pain meds, but I'm a little freaky that way.

I do wish to clarify what you said about your surgeon's training. She does nothing from the Biber procedure, which was very old school. She learned virtually all she currently does from Brassard and Menard's one step procedure which she observed for several months. The "improvements" she made upon is procedure are minimal and, honestly, I think more for PR. While I respect her skills and she usually does a good job, I do have a problem when she is regularly introduced as "North America's premiere SRS surgeon. Brassard (and Meltzer) have done many more thousands of procedures than she has and, other than a tiny amount of granulation tissue, mine went off without a hitch. Of the dozens of people I know who've gone to Brassard, no one had a fistula.

One should be careful about engaging in religious debate, and which surgeon is best is definitely such!

For the record - my surgeon was Suporn, in Thailand. I've observed in 3D multiple samples of the results of his work. Also that of Brassard in Montreal. Sample size about 6 in each case, gathering data specifically to compare results for others.

I have no hesitation in recommending either, but with no guarantee of success. Suporn has never had a fistula. Or rather, and this is the really important thing, he hasn't had one yet.

Chettawut, one of the best surgeons worldwide, had a case of compartment syndrome a few years ago, despite all possible precautions. No surgery from any surgeon is risk-free, and people have died while having teeth extracted. One can only bias the odds, not completely prevent problems.

The best surgeons are constantly applying "tweaks" to procedures, trying to improve. Sometimes these result in improvements overall, but may cause an unacceptable level of relatively minor complications in other areas - hypergranulation being one of the most common. They can't know till they try, and every patient is subtly different.

It's still an art. One should go into it remembering this. Of course, even if minor complications like mine happen, they can often be fixed with time. And speaking personally... the system works. Delicacy forbids me from going further, other than to say OMG IT WAS WORTH IT!!!!!

Amy Hunter Amy Hunter | June 6, 2010 9:18 PM

Gina/Zoe--
Absolutely, please, let's not debate which surgeon is the best. Constructive commentary about one's experience with a surgeon is of course, welcome.

I took great pains not to call my surgeon by name in the original piece as the potential impact of bad internet traffic/press could be devasting to her practice and reputation--something that I do not in anyway believe she deserves.

I also stated quite frankly that she is a dear friend, in fact, I've spoken and exchanged texts with her just today.

In light of this Gina, I have edited your original comment slightly.
--A.H.

Amy, my issue is not who is best, but rather a lot of the press which your surgeon repeatedly gets which makes her indisputably sound as if she's miles above other SRS surgeons in North America and ignores how her connection with Brassard. She is a "better story" than Brassard or Meltzer (or Suporn) but she's not a better surgeon. I honestly didn't care if Brassard was my friend or an icon for the trans community, all I cared about was his surgery, his staff's care and results. I wish discussions of surgeons would stick to those key issues and not which surgeon is the most iconic or best represents the trans community.

Regan DuCasse | October 5, 2010 6:02 PM

Thank you one and all for your very informative comments. Only one of my transgender friends, f-m, wrote a diary about the entire experience and was the only one I knew well before the transition. I do try to keep informed about all of the procedures, but especially, about the issues around kids born intersexed.

I'm interested in the issue of stigma around these surgeries. And the pressure from the medical establishment that might make being a skilled practitioner, unattractive.
Sort of the way some OB/GYN medical students, don't want to learn how to perform abortions.

Which to me, has more to do with willfully not wanting to be fully able to care for the needs of a patient and being prepared for any eventuality of complications from pregnancy.

I would think there are many OTHER uses for someone skilled in the surgeries perhaps most accessed by those undergoing SRS, but could be useful to anyone in need.

What about cis men and women whose genitals or other sexual organs become diseased or they have an accident? What about the intersexed who are being corrected at a much later age than infancy?

Stigma shouldn't dilute the availability of skilled doctors and support. But I was wondering about the political implications, and if demonstrating how more universally people could benefit might help take stigma away.
Your thoughts?

Brenda Jean Louise | June 7, 2010 3:53 AM

In reading this story, I recall all the events that led up to the problems I had with my surgery. I need to point out that it wasn't the fault of the doctor, but more the fault of my body and decision making process.

I have diabetes, it was slight at the time that I had the surgery. However it became more serious through the years after my SRS. I was plagued with many UTI's and the related vaginal yeast infections from the UTI penicillin medicine. When I finally went on insulin injections all of that problem cleared up.

The next problem I had was with the pubic bone geometry. Dialation was very painful for me because of the bone interferance. Perhaps a pre-operation x-ray of the bone area may have been helpful in the determination of the feasibility of the SRS for me.

Another thing that I overlooked was the skin of my pre-op genitalia that had the propensity to get easily inflamed with too much friction during intercoarse. It also would get easily chaffed with the continued presence of moisture. Now for someone that needs to undergo a strict regimon of dialation, that, plus my pubic bone problem, frequent dialation became quickly out of the question.

At risk for me, was the gender documentation that I really needed both for human rights with my discriminating employer, and to be recognized as a female in any legal transaction. The government doesn't recognize a M2F as a female untill they get their SRS operation (which includes vaginoplasti). I developed the attitude of "vagina or bust". So I was ready willing to take my chances with the operation. We really need the government (state & federal) to relax the laws about the SRS requirement to recognize the M2F orchi procedure as a valid form of SRS.

And, if you had the problem of having very frequent urination before you went on "spiro", you will still have that problem after the operation. You'll still be in need of a "Flomax" pill. I have to take Flomax and Detrol LA for the rest of my life. When medical help sees that I take Flomax, they question it's use, ergo I always have to spill the transgender beans every time I am in a doctor's care. Then I get all the "sir's and he's" from the confused medical help. FUN !!!

Now I am happy with what I have, but knowing all the crap I would have to undergo after surgery, it might have been more better to just get the orchi. Perhaps even to just get a superficial SRS procedure whout making a vagina, but working on fabrication of the the labia and clitoris instead.

What I also can state, is that there is enough crap and bogus horror stories out on the net to confuse the hell out of any M2F when the're trying to make a decision about the SRS thing.

That being said, I'm glad that you took the effort to share your story.

Amy Hunter Amy Hunter | June 7, 2010 4:58 AM

Brenda Jean,

The geometry of my pubic bone and the acute angle needed for dilation most likely played a role in the rupture of my anterior rectal wall and the susequent formation of a rectal-vaginal fistula. As I mentioned in the piece, the rectal wall had already been compromised by a small tear from a suction retractor during the procedure.

The condition of my intestinal tissue may also have played a part. It was noted by another surgeon that my tissue appeared to be somewhat "brittle" a condition that may occur from prolonged oral steroid use. As a child, I had been very ill with chronic ear, sinus and bronchial infections necessitating frequent and large doses of steroids to fend off or alleviate pnuemonia. Although these two factors might be pointed to, no one can say for certain and my doctors seem to be of varying opinion, particularily about the "brittle tissue".

I would like to thank you for including thoughts about your decision making process and the outcomes.


Brenda Jean Louise | June 7, 2010 10:08 AM

No problem, Amy. Glad to share. The more good information out there can definately be of service to a pre-op candidate for SRS.

Thanks for sharing your personal story, Amy. It took quite a bit of courage and heart to share it so forthrightly.

Amy,

I can't thank you enough for coming forward and talking about this, because it echoes many of my own concerns about the absence of literature on outcomes. I've known and I think we all know some women who've wound up with "just" granulation, but tragically I know others who wound up with little or no depth or sensation--and despite having their procedures with industry leaders here in the States.

The worst example was a friend who, on her second or third night back home in her recovery, had her neovagina prolapse on the night I was with her; calling her surgeon at 1:30 AM and getting her on the first flight out that morning to get repaired was not what I would call a great example of how these stories are supposed to turn out.

And none of these stories are of ancient vintage: they involve practicing surgeons and procedures from the last decade. So no one should understate the risks involved.

Maybe it's the day job of working with statistics talking through me, but I would suggest that seeing a big body of data would be a great way of cutting through the more subjective statements about surgeons and surgeries. To be blunt, as a generation, we owe it to future generations of practitioners and patients to see these kinds of results collected and published.

With regards to which surgeon is best, there is a very old saying that, in essence, is this: ”The best GRS surgeon is the one who did my GRS surgery.” Meaning, the best surgeon is the one of whom the person chooses. Post ops are extremely loyal to their surgeons, suffice to say.

Honestly, for a full four years I researched GRS surgeons upside down, backwards, and sideways. For the record, as Zoe says, Toby Meltzer did mine, though after all that research there were at least another half dozen world wide I would have felt comfortable with.

Unlike many, I went through GRS completely alone; no one but a very, very few close friends even knew I was having it. For those who choose Meltzer (likely the same for all the GRS surgeons), I was on a strict liquid diet the day before, being instructed to drink at least eight ounces of water every hour all day long before then taking the laxative cocktail later that afternoon and then early evening. That day before GRS, I questioned myself over and over as to my decision…that decision not being whether or not GRS was what I wanted, but because of the “what if there are complications” issue. What if there was a colon tear? What if there was a major infection? And, to me, most importantly (perhaps ill advised, though it did seem to be the overriding concern), what if I was not sensate after GRS? It almost drove me crazy as I went over my complete life history innumerable times and whether or not I was doing the right thing…always concluding with “yes, as far back as I can remember this is what I’ve wanted”, and then immediately followed by..."But…what if there are major complications?" I ran this scenario through my brain so many times I became exhausted. Nothing could have stopped me from having GRS, but when I signed the waiver, believe me, I knew the risks involved.

My surgery was just after lunch. When I came out from under anesthesia it was late afternoon, the very first thing I asked the nurses was if everything went fine. They said things went great; I punched the morphine button and went off to sleep. The next morning when Meltzer made his rounds, it was the very first thing I asked him as well: had there been any complications. He said there had been none and that I should expect a routine recovery. As it turned out, he was right. Someone above in a previous comment said their GRS was the easiest of their transition related surgeries; In my case, at least, I have to agree...compared to FFS, GRS was a mere scratch.

I also have to agree with another comment above which says, emphasis mine and paraphrased:

Amy, my issue is not who is best, but rather a lot of the press which your surgeon repeatedly gets which makes her indisputably sound as if she's miles above other SRS surgeons…She is a "better story" than Brassard or Meltzer (or Suporn) but she's not a better surgeon. I honestly didn't care if Brassard [or Melzer, Suporn, Alter, insert the surgeon of your choice] was my friend or an icon for the trans community, all I cared about was his surgery, his staff's care and results. I wish discussions of surgeons would stick to those key issues and not which surgeon is the most iconic or best represents the trans community.

Everyone commenting here knows the name of your surgeon; surely you know that. That any of the surgeons have/have not had GRS before or do/do not represent the GLBT community better than another should have absolutely have no play into the decision making process of one who is contemplating GRS, only the surgeons's technique, results, complication rate, experience, and the care and consideration they get from the surgeon's staff. On any given day, any surgeon can perform flawlessly, but in the end, I think it comes down to just those variables.

Amy, like everyone who has commented my heart goes out to you, and I sincerely hope that your issue is resolved as quickly as possible.

A very brave essay; I applaud you for sharing your experience.

polargirl360 | June 7, 2010 2:44 PM

It stories like this is why I would never go to your surgeon. A narcassist who spends too much time promoting her "IMAGE" in the community and not enough on patient care improvement is not what I need.

Besides, politics would only work against me and leave me isolated if I needed to sue for damages. This doctor, (yours) has too much political clout for anyone to back me (or just about anyone else for that matter) over her.

Amy Hunter Amy Hunter | June 7, 2010 3:00 PM

Polargirl,
This has been brought up once already. Please do not engage in character asassination...

I will call your attention to a previous entry about this very thing:
"Gina/Zoe,
Absolutely, please, let's not debate which surgeon is the best. Constructive commentary about one's experience with a surgeon is of course, welcome. I took great pains not to call my surgeon by name in the original piece as the potential impact of bad internet traffic/press could be devasting to her practice and reputation--something that I do not in anyway believe she deserves. I also stated quite frankly that she is a dear friend, in fact, I've spoken and exchanged texts with her just today."

In light of the above, I have (gently) edited your use of the surgeon's name out of your comment.- A.H.

polargirl360 | June 8, 2010 2:05 PM

My comments were not about debatuing what surgeon was better than another.

I was merely pointing out the pitfalls of going to a surgeon that has more political and social clout than just about any other trans person.

Your defensiveness and that of everyone else's is EXACTLY what to expect for a patient who needs to sue for malpratice will be up against in the event they have the audacity to survive and possibily even have some genital restoration.

Amy Hunter Amy Hunter | June 7, 2010 3:20 PM

Hi Susan,
Thank you for your comments.
I think, perhaps I should clear up one or two points since this has come around a couple of times already.

This piece was not written as a spur to debate the relative merits of one surgeon vs. another. When I spoke of my surgeon as being an "icon", I did so to lend gravitas-as in an appreciation of the fact that no matter how well known (she is), or skilled, or experienced--there exists a large gap in being able to provide/find remedial care, should a serious complication occur.

The other point I think is worth mentioning is that I did not choose my SRS surgeon because she was my friend. I chose her based deserved or not on her excellent reputaion and a number of conversations with women who had gone to her. I also, wanted a one-stage procedure AND she participated with my insurance carrier.
We became friends during my stay and over the ensuing months...years seeking aftercare. Today, she is indeed my friend and will remain so-even though I am now seeking care apart from her assistance.

lisa-lane lisa-lane | June 7, 2010 8:30 PM

Hi Amy,
First of all, I want thank you for your honesty in raising this matter. And, I really hope you eventually have a successful outcome. You were unlucky, and I do feel for you. But our health care needs do not have to be the way you describe. There are other choices for those willing to study what surgical treatment is on offer and are prepared to travel, if necessary.

The point I wish to make concerns your focus on the specifically TS healthcare problems you address. You write that your story will "illuminate important problems endemic to healthcare for the transgender and specifically, the transsexual person."

I feel you should have added "In the US".

Because, whilst I'm sure everything you describe, from your own experience, is correct. It is not necessarily universal.
I point this out because there are other options in other countries, where the shortfall in treatment and surgical training, you describe, is not the standard practice.

In the UK for example (where I live) it is much better. There is free access to surgery and free revision if necessary. Several other European countries offer similar treatment. (ok, I understand that means waiting lists, but the treatment is guaranteed and free)

Also, in Thailand (where I had my own SRS, FFS, and BA) there is very good market driven customer satisfaction, and after care, at the higher end of the market. My SRS surgeon guarantees his work for life (of the surgeon, that is) and any revision is free. I already took advantage of this for a slight revision two years after surgery.

With a different Thai surgeon, I picked up an infection, when I had my BA, in Bangkok. This didn't immediately show itself till after I'd returned home to England. The result was I had to have one implant removed (completely free on the NHS) then after the infection site cleared I returned to Bangkok and had it replaced, free of charge inc. hotel bills and travel expenses. My Thai surgeon even paid for my food and entertainment bills.

I'd hope no pre op girls reading your story would be scared off from having surgery based on the healthcare problems you cite. There are choices, and other options in different countries, even for those with very limited funds. We don't have to just put up with the lack of proper TS medical treatment. My advice to anyone is do your research well (worldwide) and spend your money wisely.


Amy Hunter Amy Hunter | June 8, 2010 10:15 PM

Lisa-Lane,

I am afraid MY arrogance as an American is showing. You are quite correct-the piece was written with only a US venue in mind as I truly have no knowledge of the state of transition related care elsewhere in the world.

There have been some developements in what comes next in my quest to "get it fixed". When I write the addendum, I will most certainly correct the semantics.

You seem to have done a great deal of research and traveled widely for transition procedures. I am afraid that many of us here-the U.S.-really are stymied by lack of access.

A large percentage of transgenders here are unemployed, under-employed, homeless, or otherwise disenfranchised. The ability to pay for care or travel for it often seems completely out of reach for many; A situation which may and does lead some to seek less than favorable solutions to their desperateness.

At one time I seriously considered going to Thailand for SRS, in part because the overall cost, including travel and accomodations would have been less than paying for SRS, BA and a tracheal shave out of pocket in the States. After some discussion with my spouse and hegotiation with our insurance, I made the choice to have it done here.

Thank you for sharing your thoughts, experiences and for letting me know my smugness was showing.

hugs...

I am so sad and so sorry to hear what you have gone through. The suggestions you make about their being some sort of formal education or certification for SRS surgeons is a great idea. However I don't think the economy of scale is there to justify it.

If I were you I would sue. I think you have a case for malpractice. Some people would not like you for doing that. Afterall the doctor, we all know her name, screwed up and you have to live with it... not the "transgendered community".

Instead what we can do is look at certain websites, and frankly ask around. Ask post op transwomen we know well about their surgery and results. Ask as many as possible. To be frank considering the intended use of the Neovagina the more sexually active the person is likely the better their result.

The surgeon you went to I had dismissed as I had heard nothing good about the actual result of surgery. I had heard that she has really good bedside manor. I heard that she "really understands because she's one of us". To be honest that is not a good reason to have surgery with a specific doctor.

One of my girlfriends, a Meltzer girl, also had a fistula post-SRS. She struggled for a few years, visited a few different surgeons who tried to help but her story sounds amazingly like yours Amy. She has now accepted the colostomy bag as part of her life. We don't talk much now ... I'm not sure if she will try again.

I am sorry for her, as well as for you Amy. My heart goes out to you.

Sara ...

Amy Hunter Amy Hunter | June 8, 2010 10:50 PM

Thanks Sara,

I am at this moment in Minneapolis at the University of Minnesota Fairveiw Medical Center. I had a two hour long consultation with the chief of Colon and Rectal surgery and a plastic surgeon who has reconstructed vaginal structures for women who have had rectal cancer. The chances for success are uncertain at best. Still, I don't think I want to stop just yet...

We'll see.

Amy Hunter Amy Hunter | June 8, 2010 10:34 PM

HFarmer,
You may well be right about the "economies of scale" premise. However, med schools do typically touch on transsexualism and when they do, it is often still taught as abnormal psychology--a paraphilic disorder. I get asked often to speak to the students in the Abnormal Psychology courses for the graduate program at a university here in MI. I jump at the chance to set the record straight.

I probably do have a good malpractice case...I don't know. Not my style, although,as you point out, this is not merely about me.

What you said about medical schools is just the problem. My thinking is that most surgical students never take any more than basic psychology let alone anything that would touch on transsexualism. They don't even get that much "information".

Any idea why WPATH does not organize some meaningful accreditation or certification for SRS surgeons?

Weather you eventually try to sue or not good luck to you. Thankyou for bringing this possibility to the worlds attention.

Name (Required) | June 10, 2010 12:45 PM

regarding "economy of scale", I don't think that makes sense. there are other conditions and procedures which impact fewer individuals than genital surgery for transitioning women and men. yet these others do get funding, board certification, training. the difference is not numbers- it is bias.

she is absolutely right to point out what is missing from the white papers.

I often get the feeling that those working for trans health care don't even have issues like this on their radars. it's thought of as a "low priority" if at all.

wishing you the best, Amy

Amy, thank you for your willingness to publicly share such a heartbreaking story. I went into surgery trying to be as realistic as possible about the potential risks, but it's so hard to truly be adequately prepared for life's curve-balls. I have been lucky in that I had a relatively typical recovery and am very happy with my result. I am so sorry for your struggles. You will be in my prayers, and I hope that you have a successful resolution to your struggles.

Deborah Lee Deborah Lee | June 9, 2010 7:26 PM

Amy, thank you so much for sharing your story. Recently my brother asked me weather I thought that it wise to; at my age (67) undergo what he referred to as elective surgery. I said, without a second thought, that I would rather die, on the table, then not have, what I would call, the life affirming surgery. I think that he finally got it.

my surgery was by no means "sorry", and neither are my body nor my genitals.

how incredibly rude of you to suggest otherwise.

Amy Hunter Amy Hunter | June 10, 2010 10:58 PM

MHS,
Did you receive a disrespectful comment via this comment thread? If so, please do let me know by e-mailing directly to: amy@bilerico.com
Regards,
Amy

this was a response to your offensive comment about "FtM surgeries". I don't know why it did not appear in the appropriate comment thread (Antonia's).

the surgical options are perfect, successful, and appropriate for the men who pursue them.

Amy Hunter Amy Hunter | June 12, 2010 10:16 AM

MHS,
After our conversation off-site, I feel it necessary to issue an apology. The comment I made, "the sorry state of surgical options for FtM's" was ill informed. Thank You for bringing my lack of knowledge and experience in this area to my and our readers attention.
Sincerely,
AH

Yes, I think it's time to retire the meme about FtM surgeries being so poor. I know many trans men who are extremely happy with the outcomes of their metoidioplasties (which are no more expensive than MtF SRS and often cost less) and I know a few transmen who are very pleased with their phalloplasties and even had them paid for by insurance or the Canadian government.

No surgery is perfect. Period. Even though Amy got a raw deal with hers, most people are extremely happy (and thankful) for their SRS results (including myself). While real world experiences such as Amy's are important consumer information to know, I hate to see negative generalizations made from them, which is what I hear a lot of conservatives/transphobes who think SRS is mutilation, Queer ID'd peeps who think it's buying into the binary and societal body images, and a sizable portion of non-ops who rag on SRS as a way of answering what they view as attacks on their own choices concerning their bodies.

Acceptance of SRS is NOT a done deal in this society. It is under some form of attack from a lot of different corners. Yes, let's know the real risks but let's not make uninformed generalizations about what it does or doesn't accomplish nor denigrate the needs and satisfaction of those who've done it.

I know a few transmen who are very pleased with their phalloplasties and even had them paid for by insurance or the Canadian government.

As a Canuck, I'd like to clarify this. The Canadian government does not pay for SRS. (*I think* the exception to this is if you're in the military.) Health care is managed by the provinces individually, and only two provinces to my knowledge fully cover SRS: Ontario and Quebec. Alberta used to, but slashed SRS funding in a cost cutting move about a year ago (with a grand total savings of less than $1M, a drop in the oil pan.) Here in BC, SRS is covered for women, but guys only get some funding: $1500 towards top surgery (which costs $6-8000), full hysterectomy coverage, and nothing--NADA--for bottom surgery. This is sex discrimination and it will be legally challenged.

Amy, thank you so much for sharing. I wanted to reach out and hug you while reading this, because I understand some of what you've endured. I suffered a post-hysterectomy vesico-vaginal fistula and it was quite terrifying. The published rate of this complication with the procedure I had is about 1%. I spent long nights pouring over urology journals. The statistics for successful surgical repair were discouraging, and depending on the method used could have compromised my plans for further SRS. The urologist I saw wanted to do the repair even though he'd only ever assisted with one as a resident. It was only after I explained how much I knew about the procedure and risks that he decided he didn't have the skills. The gynecologist who accidentally caused the fistula accepted responsibility and was helpful in arranging a consultation with an expert in Vancouver--who I located. Everyone told me I wouldn't heal without surgery yet that's just what I did. I spontaneously healed.

I blogged about my experience and while I was writing and processing, my posts were discovered by another trans guy right here in BC who was pulling those exact same all-nighters reading journal articles because he too had just suffered a post-hysto VVF (with a different surgeon.) He was not as lucky as me and had a very difficult time getting compassionate care from his surgeon and finding the right specialists. While he too ultimately prevailed, it was a hellish year before he got his surgical repair. We were glad to have found each other, to be able to share with someone who understood.

My research into this complication has lead me to conclude that trans men are at higher risk for post-hysto VVF than women. My primary physicians have no trans health experience, and my gyn/ob only has some, so I have found myself educating my docs regularly. I don't go to any doctors appointments anymore without a clipboard and some handouts.

Amy, thank you again for sharing your story. I wish you health and happiness, and you will remain in my thoughts.
With love,
Joshua ;)

Dear Amy,

I am so sorry about your on going travails. I will remember you in my prayers. Your courage and forthrightness goes a long way in furthering a conversation that MUST be had. Among the many comments the one that stood out the most for me was the one asking about WPATH. It seems to me that such an organization SHOULD provide some comprehensive study of surgical results as well as alternatives to surgery for those who for whatever reasons, (medical, social, psychological, financial) are not good candidates for this obviously difficult and life changing procedure.

Another point that was made that (IMHO) deserves some recognition is that ..." To be frank considering the intended use of the Neovagina the more sexually active the person is likely the better their result." Even after 40 years I remember my surgeon's admonition to "use it or lose it." Happily that is one doctor's order that I still follow religiously.

Further I would like to applaud Christina Kahrl's statement...."To be blunt, as a generation, we owe it to future generations of practitioners and patients to see these kinds of results collected and published."

It seems that if all the political rhetoric and "one-upmanship" could be avoided alternative procedures like those mentioned by Brenda Louise might suffice.

Again Amy, Thank you for your obviously heartfelt contribution and my very best wishes,

Anna

First, let me add my kudos and my sympathies to you, Amy. Thank you so much for your bravery in posting this.

I think that WPATH's lack of progress in pushing for improved medical school teaching on transgendered/intersexed medicine, for the establishment of surgical standards or certifications and for any consolidated outcome data from all surgeons in this field are some of the group's primary shortcomings.

Finally, with regard to the economies of scale issue, I would be curious to compare the number of thoracic organ transplants performed in the US (or the world) to the number of GRS surgeries performed. I'm guessing the numbers might be relatively close (although we can't be sure because only transplants are monitored), yet only organ transplant surgeons get specific training and certification.

Amy,

I regret that you experienced a fistula during your GRS! I very much appreciate your writing about it and helping to educate others considering the procedure.

I had the same surgeon for my GRS, and I am thnkful to have avoided a fistula. I did experience excessive granulation tissue, which caused great discomfort and bleeding. Ultimately, after several attempts by my family doctor to treat this proved unsatisfactory, I returned to Trinidad for a followup treatment with the surgeon. Thankfully, I am now healing well and feeling much better.

I wish the best of health, happiness, and prosperity to you.

My very best regards,
Emma Joy

Amy,

I am so sorry to hear what you have gone through and are still going through. I applaud you for posting your story and telling others what the real risks are in having GRS , as you stated these bad outcomes are usually swept under the rug and never talked about.


Also, I personally know the person that introduced your surgeon to see Dr. Brassard in Montreal and took your surgeon, to view his techniques in performing SRS. The longest amount of time she spent in Montreal was a week once when she visited.

Amy as you said its not right to compare or say who is the better surgeon here. But I could not let this comment go by that Dr.iber was, Old School! He was the Only School for many many years.

Amy, I wish you only the best and I thank you so much for your courage in telling your story.

Charley Renee Bowers | June 17, 2010 10:40 AM

Amy, I'm facing the issues of aging and the possibility of ending up in long-term health care facility. I was 70 when I started transition, that was 2 years ago. I had bilateral orchiectomy surgery but not vaginoplasty which I won't have because of my age and possible complications. Because I did not have vaginoplasty I cannot get a gender change on my Michigan birth certificate and, consequently, a change on my medicare or supplemental insurance cards. At this point I'm going to address the issue with my attorney and write health care instructions for my durable power of attorney that I be treated as female. Now, whether or not the health care facility will honor my instructions is another issue. Hopefully I won't have to find out the answer to that.

Regards, Charley Renee

Regarding GinaSf's comment:

"While real world experiences such as Amy's are important consumer information to know, I hate to see negative generalizations made from them..."

Transgender people are extremely *fortunate* that SRS is widely criticized, scrutinized, debated, and second-guessed.

As a doctor friend of mine says, "Surgeons would treat alcoholism surgically if they could get away with it."

The fact is that we live at a time when not only are prescription medications advertised in mass media, but surgical procedures, too, are presented to the public as if they were like any other kind of service a consumer might choose to spend his or her money on.

SRS isn't unique. ALL surgical procedures carry significant risks.

However, most laypeople and, unfortunately, a great many physicians, are so badly under-educated in statistics that it's difficult, if not impossible, for them to make well-informed decisions about surgical procedures.

Instead of regarding criticism of SRS as oppressive, transgender people should welcome it as a kind of rigorous "quality control," and as healthy encouragement for SRS candidates to do exhaustive research on their own before making any serious decisions.

If everyone considering any kind of surgery were to devote as much time as SRS candidates spend investigating their procedure, there'd be a great deal less human suffering in the world.

I don't know where you guys are living that the surgical options for FtM men aren't terrible, but last I checked, they still are. Surgery for trans women creates a neovagina that is perfect or near perfect in appearance and function. Surgery for trans men creates either a neophallus so small as to be unusable for penetration or an insensate neophallus that requires hydraulics to use. Yes, I'm sure many men are happy with their surgical outcomes, but you can't tell me that if a new surgery came along that would create more morphologically and functionally appropriate male genitalia, quite a lot of trans men would jump for it, no matter how happy they are/would be with a meta or phallo. Let's stop pretending problems don't exist to make ourselves feel better, shall we?

I'm sure it's a "perfect" vagina for those who have the attitude that vaginas are just holes to put penises in. It's perfect even though it is non-elastic (as compared to a bio-vagina), cannot self-lubricate, cannot self-cleanse, isn't connected to a cervix, uterus, fallopian tubes, ovaries. It's perfect even though the surgery won't menestrate or bear children.

Oh noes, surgical penis needs artificial hydraulics to get erect and can't emit sperm, it's not fit to have. That surgical vagina just needs to be a hole and you MTFs should be satisfied with it! Women are just holes to put penises into! Yeah! Take that you holes!

Oh wait...I thought the entire article is about how things can, and DO go wrong with MTF surgeries. Could it be, that MTFs have to put up with unsatisfactory surgical results and complications? That they don't walk into the surgical room and come out and live happily ever after, unlike what some FTMs think?

And it's not even just SRS. FFS, voice box shaving, all of these have risks. Ever heard of someone whose skull was cracked during FFS, or their vocal cords damaged so that they could ever whisper in a squeak after that?

And seriously. Maybe many FTMs go around thinking all men have 8" penises even when flacid. I dunno, I don't see how meta gives inferior to bio results when bio produces small penises. Want bigger, ok you do have to go for hydraulics. But phallos are insensate? Huge disservice to the FTM community to be spreading that "fact" that is years out-of-date. Tremendously harmful to those who want to have surgeries but are scared out of it by misinformation. Please do more research.

The standard observation relating to WBT "v." MBT surgeries is that "it is easier to dig a hole than to erect a pole."

Aside from that, I would leave the evaluation of satisfaction to the individuals themselves, and to those with whom they interact sexually.

There are also those of us who have a need for surgery but have pre-existing medical conditions that make us poor candidates for GRS. I think I would be happier with less-than-perfect results than no results at all. OTOH, it may very well be a matter for me of the grass appearing greener on the other side of the surgical "fence." Perhaps I should be happy with where I am, but I am not.

Thank you for having noted the lack of decent options in FTM bottom surgeries. Until things get drastically better, I'm not even considering surgery. "Sexually functional, able to urinate while standing, and normal-looking, pick any two" is a terrible choice to have to make, especially for the obscene amount of money we're charged for the privilege.

I think you should put that bit back in, personally.

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Randy. I have no idea who you are or where you acquired such bitterness. I am sorry for you. Nevertheless, you your comments are both ignorant, tasteless, vulgar and totally without merit. Your reference to a woman's vagina as a "hole" is so misogynistic as to defy description.

Perhaps a more lucid explanation of the current state of the art surgeries for ftm's, based on your first hand knowledge or experience might be more constructive.

You see, as was mentioned above, ALL surgeries come with inherent risks and potential rewards.

I'm a happily adjusted gay male. Thank you for your courage and honesty. I'm often in awe of my trans friends who have had the courage and commitment to be who they are and not what society tries to define for them. I want you to know I think your journey, although painful and disastrous from its failures, is certainly appreciated by those, like me, who is deeply honored to have you part of our community.

I'm a firm believer when gender expression is respected culturally, socially, and on a political level, then most of our issues will be resolved to our satisfaction. This, of course, does not include the risks and possible consequences of any kind of surgery that might be required for one to improve or live their live's honestly and deliberately. Again, I'm sorry for the pain you've gone through and the fact your journey has been so challenging but thank you for having the honesty, truth and courage to take that journey for ALL OF US, and to share it. You have sacrificed much to pave the way for yourself and others to live honestly and deliberately, and you have my gratitude for your bravery.

Too all the wonderful ladies who have told their very personal stories about their SRS experience. I feel a great deal of graditude. I am 58 years old, a Army TransVeteran of 17 years of proud service. Because I have not had SRS, the VAMC is quite bias about pre-op and post-op. I have lived 'real-life' since 1990. I was born a girl, even if I don't have the equipment, I am still a proud woman. I believe I was born with a birth defect. I need the corrective surgery for my own health. But do I need to take the risks? Of course these are questions I need to ask myself. So agains. Thank you for helping some of us like me think a little more harder about this important decision. I pray that everyone heals well soon.

This Dr. has somewhat of a history of botched surgeries. There was and maybe still is a Yahoo Group called the Broken Butterfly created by women who had bad experiences from her surgery.

The risk of genital surgery is significant. I never for a moment doubted what I was, from the moment I was old enough to reason. I never thought that, if I had the option to proceed to my next threshold, that I would gladly step through that barrier. I have made all the leaps, up to this one. It scares me to death. I want it, but the idea is accompanied by a healthy dose of pragmatism.
I sincerely hope that your trial soon comes to an end. The idea that a physician would say such a thing only implies their own flawed humanity.

Ethan Alister | April 8, 2011 10:35 AM

I know this article is old, but after reading it, and all the comments, I felt the need to add my thanks and condolences to the pile. Thank you Amy. Thank you for being honest and brave. Stories of failure are just as important as stories of success, if not more so. I sincerely hope that things get better for you.

My wife went with Brassard for her vaginoplasty. No complications. Textbook perfect. This is not always the case. I acknowledge this. I would like to affirm that a surgeon is only "the best" depending on what you want in a result. And there are always risks with every single surgeon on the planet. Even Brassard. He was skillful and she was lucky. That's all.

I, an FtM, would like to speak about the "sorry state" of our surgical options. I must confirm that it is true for a lot of us. Some of us are lucky to have better care. Some of us want particular results that we were able to get. What is an acceptable result for one person can be a mutilation to another. We cannot judge each others bodies.

The challenges facing transwomen versus transmen are different, and equally difficult. Just as the challenges facing cismen and ciswomen are different, and equally difficult. For example, it was once thought that women were much more likely to suffer from depression than men. Now we know that they suffer equally, only that men express their suffering differently.

Transmen get their voices "for free" with testosterone while transwomen have to work for theirs with practice and sometimes speech therapy. I know there is more to male and female speech patterns than octaves but you can see what I'm getting at. "Who has it easier?" is not a discussion we should be having. It profits no one.

As a transman, when I considered my phalloplasty, I was faced with the decision of which part of my body to mutilate. All doctors in Canada that perform phalloplasty perform the radial forearm flap. This was not acceptable to me. I went with what was, to me, the least offensive donor-site scarring; the MLD flap (from the side). This meant sacrificing sensation, and that I would have to travel to Serbia. The only doctors who do this procedure are there. I had to pay out of pocket.

The only information I could get about these guys was from them; their medical tourism site. It was unclear about what the stages entailed. They charged me more than is actually legal to charge someone for a medical procedure in Serbia. It cost twice my university tuition. Almost none of the staff spoke English and when we got there, we found out that travelers cheques were no good anywhere in the country despite what the liaison had informed us beforehand. Our embassy eventually had to bail us out so I wouldn't get kicked out of the clinic, seven tubes attached and bleeding crotch included.

Three years later, my surgeon is dead. I have an unfinished tentacle-THING that looks like it had its head bitten off hanging from my crotch that I can't pee out of, feel, or do anything with. I do not have the testicular implants I paid for and did not receive a refund for either. (I actually pee directly into my scrotal sack which is about as sanitary as you can imagine it.) I actually returned from Serbia with PTSD. Not kidding. Not going back. I can't submit myself to that again. I break down in tears even thinking about the possibility.

I'm having to look at having another surgeon try something experimental to at least hook up the urethra and make it look SOMEWHAT like a recognizable penis. Frankly, it scares the hell out of me but my options are, as you said, sorry. I might even lose the "phallus" I have now. What to do? No one knows, least of all me.

So guys, just relax. Amy means no offense. Some of us are lucky. If you find your genitalia acceptable to you, you have my profound and sincere congratulations. I hope to some day join you in those ranks. But I'm not in that camp yet and I intend to be noisy about it until I am.

JoAnne W Bland | April 22, 2011 11:47 PM

Life is filled with risks. There are no guarantees. Each of us is responsible for our own life and our life's choices. I am an attorney by profession. I just had my SRS in February of 2011. Without mentioning my surgeon's name, I will say that mine was performed in Scottsdale, Arizona. Prior to my surgery, my surgeon sent me 150+ pages of Releases and Warnings and Instructions. I was required to read each page and initial the bottom of each page and then sign the release and send it back to the surgeon before surgery. This was time consuming but very informative. I remember saying to myself that I cannot believe that so many things can go wrong. This information really is worthwhile. I praise my surgeon for providing so much information. My surgeon is possibly the only surgeon who can perform facial surgery and breast augmentation and SRS. I had 26 hours of surgery. 12 hours on the 8th of February and another 14 hours on the
15th of February. I had the complete works. Facial, breast
and SRS. And more amazing ---- I was 66 years old when I had my surgery. I am here to tell you that 26 hours of surgery in a week is hard on your body. But I made it. It was the most wonderful thing I ever did. My surgeon took an old 66 year old and now everyone tells me that I look like I am in my late 30's or my early 40's ! ! I am now a 42DD. And I have a perfect vagina. Everything went perfectly. My life is so wonderful. Like many of you, I researched surgeons before I choose mine. You should do the same. You need to have faith in your surgeon. I had the utmost faith in the skill of my surgeon. There may be another surgeon out there who can do what mine can - but I don't know who it might be. I am very partial to my surgeon, but I think that he does things the right way - especially with all the material you are required to read and sign off on before surgery. He let's you know what the risks are. And after reading the extensive list of things that can happen, if you have questions he will sit down and take as much time as necessary to answer your questions. I cannot speak for other surgeons, but from reading earlier posts, my surgeon seems to do a better job of warning about risks. They tell me at his office and at the hospital that I now hold the record for having the most surgery in such a short period of time. But as I said earlier, I made it -- and I made it without any complications. Maybe I am lucky or fortunate, but then maybe researching surgeons to try to determine who would be best for me paid off. Having surgery of any kind has risks. Reading and becoming aware of those risks is our responsibility. In my profession there are some lawyers who are better than others. In those areas of law that I practice, I am better at what I do than anyone else that I know. And similarly, whether you want to admit it or not, some surgeons are better than others. And it is our resposibility to get information on the performance of our intended surgeon - does he or she have problems such as less than satisfactory results. Doing this beforehand helps to give one faith in their surgeon's ability. Yes even this will not prevent every possible risk from happening. But it helps. I am living proof that an older, more mature 66 year old lady can have 26 hours of surgery and have a picture perfect outcome - and I knew every risk that I faced - but I had faith.

Lisa Ragsdale | April 25, 2011 6:12 PM

OK this is an old topic and my comments will not bring anything new or surprising.
I thought I was well informed before my surgery both before arriving in Canada and after my speaking with my surgeon. But something went wrong and even though I suspected something was wrong even before I left, I did not know what to say nor how to say it, how to just stop things before I left to go back to my Mid West home. Once I got home there was no longer any doubt that I had very little depth or width and the "stents" were totally inappropriate to fix the problem. I then spent a lot of time calling up and talking to one or two of the people at the residence. I finally got PO'd enough that every time they would tell me every thing was going to be OK I would tell them that NOTHING was OK and I wanted to talk with my surgeon.
Six months after the surgery he did call, but nothing was resolved. Since that time I have moved and found a colon and rectal surgeon who has offered to "fix things," but by the time he offered this I was unemployed and without insurance.
I am resigned that what I have is all I will ever have and it does not matter much any more. I am 60 years of age and as I am a musician, composer and writer, I can spend my time exercising, or with my arts or artist friends.

All I can say is thank god for the internet. Twenty years ago, these discussions couldn't take place, and people would never hear about all these stories.