Guest Blogger

Top Surgery for Transmen: A Short History

Filed By Guest Blogger | July 29, 2011 12:00 PM | comments

Filed in: Living, Transgender & Intersex
Tags: breast reduction surgery, David Yonkin, female to male, FTM, Jackson Darling, Michael Brownstein, Syd Peterson, top surgery, trans men, transgender men, transmen

balian_buchsbaum_torso.jpgEditors' note: Syd Peterson is Managing Editor at LGBTPOV.com and works as a communications specialist and social entrepreneur based in Los Angeles. Syd has been an LGBT rights activist for 13 years, working for Lambda Legal, the International Gay & Lesbian Human Rights Commission and Renna Communications, among others.

I published a version of this article on July 13 my blog, LGBTPOV.com. The article is part of a series I'm writing on transgender experiences, as inspired by the journey of my friend Jackson Darling. While writing the article, I researched the histories and particulars of top surgery procedures, including interviewing two experts in the field: Dr. Michael Brownstein, a surgeon who performs top surgeries, and David Yonkin, a social worker in private practice who works primarily with transmen.

The main purpose of the article was to educate my readers about top surgery: why Jackson, and various other transmen, wanted to have the procedure, how the procedure was developed and done, and a bit of the history. I didn't plan to cover other surgical procedures that some transgender men and women seek, notably those known as "bottom surgeries" (surgeries addressing male and female genitalia such as penises, vaginas, ovaries and testicles). Exploring and writing about such procedures could, as Jackson says in the article, be an article unto itself. I debated whether to mention bottom surgery at all, as I didn't plan to perform comparable research about these procedures, speak with surgeons who perform them, or interview a transman who had undergone the surgeries.

In the end, I decided to include a short section about bottom surgeries. As the author, not mentioning bottom surgeries would have felt odd, as if I had left an important set of questions unanswered. As such, I imagined that my primary audience consisted of people who knew very little about the surgeries trans people sometimes have, and a certain subsection of this group likely didn't know any transgender people on a personal basis. Surely, after reading the portions of my article about breast and top surgeries and why people want to feel comfortable in their own skin, they would be curious about whether trans people might choose to undergo additional surgeries on other parts of their bodies. Further, I wanted to note a difference in the experience of some transmen and some transwomen, based on my understanding that "bottom surgeries" for transwomen tended to be more successful.

I received feedback from a number of sources the bottom surgery section: some people were critical that I portrayed an opinion that many trans men do not desire bottom surgeries and that I reflected experts' concerns about whether the resulting organs were "functional." These comments opened me up to a larger discussion in the trans community right now, and it's become clear to me I need to write an entire article on bottom surgery to flesh out the full situation. As such, in this version of my article which appears on Bilerico, I have removed the bottom surgery section.

Many thanks to all who have responded to my article; I find your thoughts and ideas inspiring and empowering

On June 13, I wrote about my friend, Jackson Darling, and his experience as a transgender man: what he was like as a little kid, how he realized he was transgender, and what it's been like to begin his transition from Jessica to Jackson - a process that's included choosing a new first name, coming out to his family and friends, and beginning to take testosterone.

The next step in Jackson's process is to have "top surgery" this November; the procedure is sometimes called "chest surgery" or "male chest contouring." "It's a surgery to remove my breasts so I can have a flat chest," he explains. "Much of a transition is mental and emotional, but this is one physical aspect that's pretty important to me. Not every transgender man chooses to have this surgery, since each transgender person has their own feelings about their bodies and their transitions. Some don't do it because they can't afford it. In my case, it's a part of integrating my body with my heart and my mind."

I use the terms "transmen" and "transwomen" in this post. A transman (also called transgender man, trans male, transguy) is someone whose gender identity is male, or who identifies as male, but who was assigned the sex of female at birth. Similarly, a transwoman (transgender woman, trans female, transgirl) is someone whose gender identity is female, or who identifies as female, but who was assigned the sex of male at birth.

Life With (& Without) Breasts

In our culture, breasts are one of the most telling gender signifiers. "Breasts are one of the most obvious physical attributes that identify someone as a women," says Dr. Michael Brownstein, MD, a plastic surgeon based in San Francisco whose practice is limited exclusively to top surgery. "Unlike other sexual attributes, you can often see breasts through a person's clothes."

Brownstein has performed female to male (FTM) chest reconstructive procedures for almost 30 years; he estimates that he performs 200 top surgeries for transmen annually. "[After the surgery], my patients are able to achieve a great degree of comfort with their bodies," says Brownstein. "They tell me that they gain comfort and a sense of relief. It takes the psychological pressure off."

This psychological pressure is real for many transmen. "I wake up every morning with anxiety about my chest," Jackson tells me. "Having top surgery will make a huge difference in my everyday life and will give me a new sense of freedom around my body."

Jackson is especially looking forward to eliminating his daily "binding" routine. Binding is the process that transmen use to make their chests appear flatter, sometimes accomplished with an Ace bandage. Jackson uses a mesh top that's almost like a sports-bra but much tighter. "I just can't wait to stop binding. It's hard to feel like I have to put on all these layers--like in the summer, I end up wearing like four layers sometimes. And that's just not how I want to live my life. I want to be able to just throw on a t-shirt and feel free and, you know, feel the wind on my back."

What is Top Surgery?

Transmen have the option to have one of two surgeries to remove their breasts and flatten their chests. According to Hudson's FTM Guide, the Double Incision/Bilateral Mastectomy is most effective for individuals with medium or large breasts, whereas the Keyhole/Periareolar Incision is best for individuals with small amounts of breast tissue. The surgeries involve carefully planned incisions, liposuction or scalpel "scooping out", attempts to preserve sensation in the nipples, nipple repositioning, and trimming of excess skin. Temporary drains are installed to draw off excess tissue and fluids over the days following surgery. Both surgeries usually take 3 to 4 hours; healing time varies. Brownstein notes that the Double Incision/Bilateral Mastectomy procedure gives a surgeon more control over the end result but may result in more scarring, while the Keyhole/Periareolar Incision procedure affords the surgeon less control but also has less possibility of scarring.

I was interested to learn that top surgery for transmen is somewhat different from mastectomies for people with breast cancer. "In mastectomies for cancer, a greater attempt is made to remove as much breast tissue as is safely possible, to include the cancerous tissue and the remaining breast tissue," says Brownstein. "The nipples and areolae may be removed in some of these operations. Also, in some of these a lumpectomy is performed, removing the cancerous tissue with some surrounding breast tissue and following up with radiation and, perhaps, chemotherapy."

In his top surgeries for transmen, Brownstein tries to leave enough subcutaneous tissue so it matches the thickness of abdominal tissue. "This works to avoid having a sunken chest," he notes. "I essentially remove all the tissue, but it's not a cancer operation (although risk of cancer is greatly diminished). I preserve the needed portions of areolae and nipples as grafts to perform the reconstruction of these tissues, and I'm meticulous about position and symmetry."

The Development of Top Surgery

The history of transgenderism is rich, lengthy and complex. In Western culture, transgender history overlaps with other histories, including histories of gender, medicine, psychology, and LGBT political movements. In many cultures, transmen, lesbians and others have dressed in masculine clothes and led lives as men, with varying degrees of tolerance and support.

According to OutHistory.org, the first gender confirmation surgery (sometimes called gender reassignment surgery) took place in Berlin in 1912, and the patient was a transwoman. In 1923, Magnus Hirschfeld coined the term "transexualism" and created the first modern medical gender clinics.

TransgenderZone.com states that Sir Harold Gillies, internationally renowned as the father of modern plastic surgery, and his colleague Ralph Millard carried out the world's first sex change of a woman into a man in 1945; their patient was a young aristocrat, Michael Dillon, who lived until 1962.

The social and political climate for transmen seeking surgery has changed substantially in the years since. Brownstein says that when he started performing top surgeries for transmen in the 1970s, the surgery was not popular among his surgeon colleagues. "They didn't understand transgenderism," he says. "'Why are you dealing with these people?" Despite these pressures, Brownstein continued his work. "I was willing to help anyone; that was my training. What I was doing was helping them adjust their lives; helping them transition."

David Yonkin, LCSW, is a psychotherapist in private practice in New York who specializes in working with transmen. During his work in the 1990s, he heard disturbing stories about the several-day hospitalizations his patients endured for their chest surgeries (this was before current out-patient procedures could be completed in a day).

"They were stared at and laughed at by hospital staff, who refused to use correct names and pronouns. They were ignored when needing help using the bathroom. They were even discharged with no clear after-care plan," says Yonkin. "Significant others were excluded. People had difficulty getting hospitals to respond to requests for help with post-procedural complications and infections, which sometimes became emergency situations. Botched or substandard results were considered to be the norm, and revisions were seldom offered, or even discussed as an option," he continues.

Brownstein echoes these sentiments. When he owned a house in Montana 15 years ago, he offered to perform top surgeries at the local hospital; patients in need hailed from as far away as Eastern Washington and Idaho. "I wanted to be a good member of the community and offered my expertise, but the hospital administrators were terrified about having the surgeries performed there," he says. "They were sure it would shut the hospital down and begged me not to do 'that' there."

Circumstances Have Improved

Yonkin says that, more recently, circumstances have improved greatly for many transmen seeking gender confirmation surgery. "Around the year 2000, trans people started to stand up for themselves in far greater numbers, and demanded that they be given the same professional courtesies as any other patient," he says.

"Transmen were true pioneers in the cause for better healthcare for their communities," says Yonkin. He notes that many transmen have created websites sharing information about their surgical experiences, including before and after pictures as well as their opinions about their doctors: good, bad, indifferent, transfriendly or not. Posts on Youtube.com have furthered such endeavors, he adds.

Both Brownstein and Yonkin agree that more surgeons are performing top surgeries these days. Brownstein chalks it up to two changes. First, the surgery itself became more accepted in medical and surgical communities: "They're not going to be an outcast surgeon," he explains. The second reason is economic: surgeons who previously would never have touched this type of work realized the growing phenomenon and saw the potential to make money.

This change brought the surgeon's world and the transmale world in closer contact than ever before--and not without conflict. "Savvy surgeons, seeing a specialty niche emerging, began showing up at trans conferences to promote their services in the spirit of competition and promoting consumer education," relates Yonkin. "Ironically, it was at these conferences that the doctors often revealed their arrogance, ignorance and misconceptions about the trans community, who in turn educated the doctors in fierce and funny ways."

Yonkin believes that the transmen who engaged the surgeons played a significant role in the development of transgender health. "These front-line events were major factors in developing, in the U.S., appropriate standards of care and ethics to trans health on many levels," he says. "I watched doctor's presentations quickly transform as they themselves evolved into true advocates for their patients and their families."

Surgeons' attitudes and transgender health aren't the only aspects that have changed radically. Brownstein reports a major change in the circumstances of his patients' lives over the years. "Early on in my work, the patients I saw were isolated: they came to me alone and, rarely, with their partners," he says. Nowadays, I meet many of my patients' parents and siblings, and sometimes their own children."

Brownstein enjoys his unique career. "It gives me great pleasure to help my patients achieve their goals through this surgery," he says. "What keeps it interesting is the people and their families I meet along the way. Every patient is different, and the relationships between parents and children--and my patients can be either, or both--have been especially interesting to observe."

A quote on Brownstein's website reads, "Everyone should have the opportunity to be who they really are."

"With my transition and my upcoming chest surgery I've finally given myself permission to do the things I most feared, all in the name of becoming my full and true self," says Jackson. "When who you are becomes so big and full of life you can't escape it; no amount of fear can keep you from it. The beauty of all of this was that most of the things I feared turned out ok. And ultimately, I overcame my biggest fear that I would never get to fully be myself. Here I am, being myself as fully, openly and often as I can."

Further Reading

Autumn Sandeen: What Genital Reconstruction Surgery, And When

Hudson's FTM Resource Guide

Lambda Legal Sues State of Oregon to Defend Health Care Rights of Transgender Man

Michael L. Brownstein, MD, FACS: Plastic, Reconstructive and Gender Related Surgery

TransgenderZone.com

Stone Butch Blues, a novel by Leslie Feinberg

Transgender History, by Susan Stryker

You can learn more about A Little Off The Top, our fundraiser for Jackson here. You can also follow the event on Twitter @alittloffthetop.

Image source: courtesy Balian Buchsbaum


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Syd, thanks for your thoughtful article... it's one of the better ones written by someone who isn't trans. One little comment... increasingly trans women prefer there to be a space between trans and women since "transwoman" is viewed my many (not all) as creating a "third gender" category which many trans women don't connect with.

I'm personally glad you didn't include a bottom surgery section since it's much more politically/personally charged and I think, honestly, a topic that's almost impossible for a non-trans person to not not step on people's feelings while discussing it. One thing I would say is that I have a lot of issues with people who don't opt for surgery making critiques of surgeries people have chosen to get. I'm not a fan of someone making comments about other people's bodies ("it looks fake, it doesn't work, it looks like Frankenstein") or making often uninformed judgments about what surgeries achieve or don't. The fact remains, overwhelmingly, the people getting bottom surgeries are very satisfied and happy with the results they've gotten, even if everything isn't someone else's definition of "perfect." I think the respectful way to speak about surgical choices is to say "it's not right for me" and leave it at that without subsequent critiques. Thanks again for the overview.

Thanks for your comment, ginasf. Writing this series, especially this article on top surgery, has taught me a great deal.

Based on the feedback I've now received from my original post of this article (the one that included a short section on bottom surgery) I feel committed to writing-- or editing, in in some way putting forward-- a new article on bottom surgery. My question for you: what's the best format for a topic that's so complex and controversial within the trans community? A regular article, like this one where I interview a wide variety of trans people? What about an Op-Ed series, where I bring together a group of trans people to share their own feelings and/or experiences on bottom surgery? Another format?

Also: great point re "trans woman" vs. "transwoman": makes complete sense to me. I will start using "trans woman" from this point forward.

Syd... that's a hard question. You could either speak to a sampling of persons who've specifically had 'bottom surgery' or a larger group of trans people about their attitudes towards it. The complications happen when you speak with varying groups who are giving attitude towards people of different experience. There are some people who've had bottom surgeries (not all) who tend to be quite condescending to those who are non-op. Then there are some non-op people who are fairly insulting about the surgeries, what they represent, whether they're worth it, etc.

It's a touchy subject also made more complex (among trans women) because those who don't get bottom surgery are often unable to get certain kinds of legal recognition of their change of gender (some states won't change the gender marker on driver's licenses and almost all will not change birth certificates until proof of surgery is given). This can create some real tension among community members and a kind of poisonous hierarchy.

Among trans men I find there are a lot of guys not getting surgery who tend to (IMO) unfairly disparage those who get and say pretty judgmental statements about other trans men's bodies who've had bottom surgery. Is it jealousy, or fighting a gender binary and social attitudes? Whatever it is, there are a lot of hurt feelings on both sides. Tread carefully and listen to a variety of opinions and experiences. It's a bit of a mine field.

Jay Kallio | July 30, 2011 5:29 AM

As a transman who developed a highly aggressive breast cancer following transition I want to highlight the fact that top surgery does not eliminate the risk of breast cancer for transmen, and it is not at all clear that it "greatly diminishes" it. While the procedure is technically called a "mastectomy", I believe it is more appropriately considered to be a breast reduction procedure than a therapeutic mastectomy, which does attempt to remove all breast tissue, nipples, and skin that could harbor cancer cells.

Screening for breast cancer may also become more complicated after top surgery since there is no longer enough breast tissue left to examine via traditional mammography. Transmen with a family history that places them at higher risk of breast cancer may need to consider having regular clinical screening by a breast cancer specialist, or alternate imaging via MRI (much more expensive). The presence of scar tissue may confound a physical exam, making it very difficult to discern scar from tumor. Early detection of breast cancer can be very, very important.

One of the risks of any surgery is that of scar keloiding, with incision pain and pruritis, which can occur years after the procedure, which there is no known way to prevent, and can be very difficult to treat. I live with constant pain and itching across my 17 inches of scars, so that is one of the concerns that has to be weighed against the emotional benefits of having a top surgery performed. These risks go with the territory, and I hope people weigh them carefully when they are deciding whether to embark on this course of action.

There are many more health considerations than the two I'm mentioning here, and all risks and complications for each individual need to be well thought out with his doctor, but I wanted to bring up these two considerations because they seem to be only rarely spoken of in the transmale literature.

Otherwise, it's just really nice to occasionally get to walk around without a shirt on. :)

Hey Jay! It's always good to hear from you.

My understanding of Dr. Brownstein's statement that top surgery can "greatly diminish" the risk of breast cancer was purely because breast tissue is removed. The less breast tissue a person has, the less chance that the person will contract breast cancer. However, as long as there is even one cell of breast tissue, there is a risk for breast cancer. That's why I wrote that "top surgery for transmen is somewhat different from mastectomies for people with breast cancer."

I think you make an extremely valid point that screening for breast cancer may become more challenging after top surgery: do you think trans men are adequately educated about this issue?

The "walking around with a shirt off" thing is, for me, the most compelling piece of why top surgery is important. I see it as a key illustration about what it means to feel comfortable in one's own skin. At the same time, I worry that the everyday-ness of the image might cause people who aren't knowledgeable about trans people to miss the significance. I'm curious if you have an insight on the best way to help the general public understand why this is so much more than a simple "cosmetic" surgery...?

Jay Kallio | August 3, 2011 6:26 PM

Hi Syd

We have never done the research to show that there is any diminishment of risk for transmen because of the reduction in breast tissue. I understand the physiology of that assumption, which is that there are fewer breast cells to manufacture aromatase, which transforms androgens into estrogen in the body, and any increase in estrogen increases the risk of breast cancer. And simply there are fewer cells that can turn cancerous. The concern may be offset when transmen add testosterone to our bodies, especially transmen who have not had a oophorectomy, to eliminate the hormone production by the ovaries.

I am simply saying that we do not know any of this for sure yet. Males have a significantly higher rate of cancer than females, so testosterone itself, with it's somewhat immune suppressive effects, many increase cancer incidence overall, including breast as well as other cancers. We need to track the effect of transition related services on the body for both FTMs and MTFs, because we do not know what the long term effects will be.

Gotta run out now, let me think more about the argument about top surgery being a cosmetic procedure or not. When cis men have gynecomastia and go for breast reduction, is that considered cosmetic? Does their insurance cover it? That is one parallel situation, I am not certain it applies, however.

Jay Kallio | August 4, 2011 8:44 AM

I think if we look at the embarrassment, shame, and great lengths that cis men who have gynecomastia go to in order to cover it up, or have it surgically removed, that in many ways is a compelling point to make with the public to explain what transmen feel about their chest.

Cis men with large, pendulous breasts often feel great embarrassment about the condition, and will bind, or get the breast reduction procedure, and if they have to live with the problem often refuse to go shirtless anywhere, also. The condition causes a great deal of psychic pain for them, as it may for transmen. If you ask a cis man what his reaction would be if he grew large breasts I bet he would start to understand how unpleasant that experience can be for transmen. It feels wrong for him to have breasts, and it will probably make sense to a woman as well. Describing that constant discomfort might be persuasive.

BTW, on the medical front, because I know paying for top surgery is such an issue for so many transmen, I checked with several surgeon friends in a couple of hospitals who do gynecomastia procedures and asked specifically whether they had any way of specially coding the work so that insurance companies would cover it and no one had found a way to sneak it through on any grounds, even in cases where the disfigurement was significant and painful. So for cis men it is still considered to be a cosmetic procedure, even though it is disfiguring, can be painful, and certainly interferes with their lives, and it is still not covered by insurance. All the insurance companies copycat the others, and most base their coverage and rates on what Medicare covers and pays, so perhaps the best strategy is to go after the feds to request coverage from Medicare or Medicaid to start with.

I assume that if someone has a really gold plated health insurance policy they can get coverage, simply because they are paying such a high rate. Insurance plans are generally scaling back their coverage, not adding anything new, so getting them to approve any new procedures is a very difficult task.

I think a messaging strategy wherein we challenge cis men with the "what if you grew large breasts" story could be successful. It would require additional dialogue, as I suspect that many cis men would initially reject the "what if," since the hypothetical doesn't happen often in real life (although many cis men do seem humiliated if they get "man boobs.") But it is by, even briefly, imagining that seemingly impossible situation that may help some cis men understand what it feels like to be a trans man.