Mercedes Allen

The Cisgender Everyone Else Standard of Care

Filed By Mercedes Allen | July 02, 2009 11:30 AM | comments

Filed in: Living, Media, Transgender & Intersex

Every so often, I receive an email through the albertatrans website feedback form that challenges me with something I hadn't thought of before. Recently, a query came in from a cisgender male who thought that I might be a good person to ask about finding a surgeon willing to do an "enhancement phalloplasty."

Now, FTM phalloplasties I'm fairly familiar with, having dated a post-operative transmale and having had some pretty frank discussions with others. Enhancement phalloplasties are something altogether different though, designed to lengthen and/or widen existing tissue, and weren't really something I'd ever had occasion to look into or care about. But ultimately, the conversation brought up some interesting and troubling thoughts about social preconceptions, the existing transsexual standards of medical care, surgical intervention and, well, human nature.

Let me backtrack for a minute, and mention that since the delisting of health care funding for Gender Reassignment Surgery (GRS) in Alberta and the media events surrounding it and Bill 44, some of the increased mail I've had coming in from the website has been a bit suspect. Some letters have shown no familiarity with trans issues, come from people who obviously haven't taken the time to read anything (including the website), and are poking around for pushy answers. I'm pretty certain that at least a few of them have come from people who are wanting to goad the local trans activist into responding with something like "why yes, you should encourage your 12-year-old to get a sex change, tomorrow if possible" or "here's where you can get black-market hormones," thus validating some preconception or other. Most of them are hard to tell, though, and I kind of have to assume that there's a human being with a human question at the other end of the email until there's enough evidence otherwise. And even in cases where I'm pretty sure that someone is trying to lead me somewhere, I take a bit of delight in playing dumb and responding matter-of-factly, throwing in a few insights and facts that they probably never would have thought of -- backhanded education, perhaps? This email may have been one such baiting experience, perhaps fishing out how "cosmetic" GRS is, since that's one of the main misconceptions we've been fighting. But whether or not it was baiting, it did get me thinking.

In replying, suddenly all of the cautions and roadblocks that I've tended to try to warn people about in advance were all gone. There's no two-year waiting list to see a therapist, no year or more real life test to see if a man really wants and can live with a bigger penis, no letters from therapists required to show that penis enlargement is the medically moral thing to do, no change in how people in the everyday world perceive him, no questioning why he would ever want a penis enlargement, no ostracization from family, friends or church, no risk of being fired or getting the magic bonus doubling rent increase because people don't want a man with a bigger dick around, no identity documents that need to be changed once the surgery is completed so that he can be accepted as bigger, sex and relationships don't have to be suspended for much longer than just healing time following surgery, no one will ever accuse him of being deceitful (or kill him in a fit of anger) because he was once a small man, he doesn't find himself thrown into the aloof and competitive world of men after having been socialized to be sensitive and show his feelings -- none of that, he just wants a bigger dick. All of a sudden, it becomes a question of "Where's the surgeon(s)? How much does it cost? How soon can I get in?" Add to these conflicting concepts the fact that penis enlargement is something obviously done for sexual purposes yet not generally thought of negatively, while GRS -- which is not done for a sexual kick -- is vilified exactly because it's perceived to be.

Comparing the procedures gets into a bit of gruesome details, so if you want to opt out of the surgery talk and get to the philosophical ruminations, skip the next two paragraphs. I'll get into it a bit though because we sometimes don't really touch enough on the challenges transmen face, and sometimes information on things like phalloplasty are hard to get straight, frank answers on. For comparison purposes, cisgender enhancement phallo can involve surgically releasing the suspensory ligament holding the penis cradled from the pubic bone to lengthen, and / or Free Fat Transfer (using fatty deposits from elsewhere on the body) to thicken the penis -- grafts are occasionally mentioned, though I haven't gone far enough to find out anything about this option. Female-to-male phalloplasty, on the other hand, requires a graft of donor tissue taken from somewhere on the body (which varies per surgeon's preference, sometimes hip, sometimes inner thigh, most of the ones I've seen have been from the Montreal clinic which uses tissue from the non-dominant forearm), is an 8-hour 2-surgeon procedure in some cases, requires careful microsurgery to ensure that the neural network will rewire properly, requires an extension made to the urethra (another graft -- most minor complications post-operatively have tended to be recurrent urinary tract infections, which the body becomes more vulnerable to following this aspect of surgery), requires six months of healing before another surgery in which a pump implant is put in to make it all functional and able to erect. In some procedures, testicle implants are done in yet another surgery; in others, the reservoir for the implant provides the testicle shaping. Obviously, I don't speak for the guys, and certainly there are more types of phallo than I've seen, they can correct me if I've missed or misconstrued anything. Post-op satisfaction has seemed to be pretty high (at least in Alberta), but I think that's largely because transmen tend to do a lot of meticulous research and get a lot of advice before deciding to proceed with phalloplasty (also note that there is an alternate surgery for transmen, metoidioplasty, which is not being discussed here).

FTM phalloplasties are not new or experimental procedures -- in fact, they were originally developed before vaginaplasty was, for the benefit of wounded soldiers, if I recall correctly. There have been two principal reasons that the quality of the transmale procedure has lagged behind its MTF equivalent: the underlying infrastructure has developed somewhat differently, and the penis is an impossibly complex and mystifying organ to try to replicate medically. I know of some guys who are waiting for cloning to provide a better answer, but they may be waiting a while.

I guess the first stunning point that becomes obvious is just how non-cosmetic GRS really is. This is a life-changing procedure that affects every aspect of our lives. In some ways, I suppose, I'm angry that the Cisgender Everyone Else Standards of Care make things just that easy -- find a surgeon, put your money down and it's done -- but I also realize that comparing the decision to have GRS to a decision for penis enlargement (or breast enlargement, or face lift, etc) is like comparing New York City to the road that runs in front of my house. It's so life-changing that there's no real comparison.

Still, there are some intrinsic problems with the gatekeeper-style system(s) that we have, including the dearth of GID-aware and WPATH-adhering medical professionals, the power that the SoC places in the hands of the therapist (witness one notorious clinic where patients are expected to conform to the Autogynephilia/Heterosexual Transsexual model or be rejected outright, and other clinics that require several years real life test), and the fact that in many areas, legal recognition of gender change doesn't take place until the several years of transition are long completed (plus a few extra bands of red tape for good measure).

Yet there are such deep changes in how we adjust to life that it's ridiculous to take the therapist out of the equation completely. Yes, we're the gender to which we identify, but we were socialized quite differently growing up, and there are always behavioural things that we discover we need to unlearn before completely slipping into the proper gender naturally. Too, the social dynamic we experience with the people around us changes completely also, as they first accustom to thinking of us as trans, and eventually as women or men. And the potential losses we face, of spouses, children, family, friends, jobs -- we absolutely need a support network. Having therapy as a key element in transition ensures that there is at least one option.

I know that people are pushing for Gender Identity Disorder to be removed from the DSM-V. I've written before about the dangers of doing this without an alternate medical-based model in place, such as the way it affects health care coverage where it exists. To my thinking, an inclusive health care model is where we need to be aiming -- a system that favours the few and lets the poor fall through the cracks just isn't enough. Certainly, we need to lobby for changes that improve access and quality of care. This needs to be done strategically, though, rather than dumping the works, therapist included, for a wholly cosmetic (and probably stymied in places) model.

Something that needs to be considered is the ethical dilemma that we pose to surgeons. It is a fundamental concept in medicine that healthy organs should not be altered unless it is medically necessary to do so. I've already heard this from uninformed medical professionals as a reason not to help us in any way medically. Things like EP slip under the radar more easily because they're less invasive, but even they have their controversies. For us, a diagnosis, currently psychiatric but alternately medical, provides this. Without any such model, access to surgery becomes much more complicated, and perhaps not just in the short term. Are there areas where it becomes potentially possible for surgeons to face legal action or loss of license by performing GRS in a situation that is viewed as not medically prescribed? Will other physicians (endocrinologists, urologists, etc) gravitate away from assisting us because they feel there is no medical justification to do so? I don't know the answer to that, but think it's important to ask the question.

Something else that stands out from looking into enhancement phalloplasty is the societal double-standard placed on what we do to our bodies. I don't know if there are more or fewer surgeons that provide EP versus ones who perform GRS (although I do suspect that surgeons who perform FTM GRS are fewest in number), but I did notice that there are two Canadian clinics on a cursory glance that perform EP, versus only one clinic where GRS can be obtained. One of the EP surgeons, Dr. Robert H. Stubbs happily performs penile enlargement, but refused to perform other surgeries to two transwomen, who ultimately took him to the Ontario Human Rights Tribunal (the original Globe and Mail article is now accessible to subscribers only).

The attitude persists in the mainstream that bigger dick = "good," but GRS = "bad." And I can guarantee you that the SPAM in your inbox and / or deleted by your kill filters would largely support the first half of that equation.

I don't mean to imply that all society would embrace the penile enlargement procedure -- certainly the far right would take issue with it. For a huge swath of religious folks (as in, not all Christians, and also not limited to Christians), sex for any other purpose than procreation is an abomination, and anything that might be done for one or both partners' pleasure is a sure ticket to Hell. Even so, mainstream society still accords to men a kind of nudge-nudge wink-wink assent to and even expectation of promiscuity and sexual conquest, while placing infinite limits on what women can do with their bodies. There's misogyny at play, and its reach extends as easily to most transfolk, regardless of FTM or MTF.

Of course, many of us have sensed that transphobia derives in part from a larger sense of misogyny entrenched in society. Women are still seen as lesser, and thusly "men who want to be women" (still the common misconception, both of MTF transsexuals and other MTF trans people) are seen as weak, weak-willed and improbable. FTM transsexuals are a bit more readily accepted (outside lesbian circles, where they can sometimes be seen as "betraying" women by abandonment) because they're seen to be aspiring to masculinity... although the fact that they weren't born with gallons of testosterone coursing through their body is still certainly used against them as well. (And please note that this does not mean that FTMs are "better off" -- as with any subcommunity or individuals, we all experience differences in our lot, some better here and some worse there).

All of that's probably a lot to derive from one inquiry -- medical roadblocks and gatekeeperism, misogyny, the necessity of keeping therapy in the transition process, how cosmetic GRS obviously ISN'T -- some of it possibly obvious, but it seemed to me to be worth sharing.

(Crossposted to DentedBlueMercedes)

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mixedqueer mixedqueer | July 2, 2009 1:37 PM

great article. certainly the double standard between enhancement/cosmetic genital surgery and GRS is rich for deconstruction. may i point out that labioplasty is an increasingly popular surgery among ciswomen, and probably fits somewhere into this train of thought as well.

This is really interesting, and I never even thought of it that way. Although from what I hear very few men who undergo cosmetic penis enhancement surgery are very satisfied with the results.

But thanks for sharing, mercedes - I learned a lot!

No therapists? No gatekeepers? No real life test? What if he changes his mind?! Aren't the doctors worried about malpractice lawsuits?

gender queer riff raff | July 10, 2009 11:00 PM

That was an excellent post - it shows in stark clarity the double standards and the rigamarol the pathologicalization of GRS - its examples like this, all the surgical procedures that the non trans people are able to access as long as they have the money. These kinds of consciousness raising posts that are very VERY good imho for helping people understand just what cis privilege is and how it plays out in the lives of the Transgendered who don't have it and how slanted and easy surgical procedures are , readily available upon request for the cis gendered. No matter how questionable medically or totally unnecessary - they want it, have the money and get it. Plain and simple but society erects endless hoops , oppressive horrifically burdensome "real life tests" wacky subjective tests at the whim of any therapist to decide who qualifies for treatment i.e. the way one dresses for their therapy appointment

These are sadistic tests in many cases for the Trans folks for example making someone have their RLE without the benefit of hormones - that one in particular to me is just wrong wrong wrong.

Thank You Mercedes for taking the time to write this post and share it here.

Obviously selective surgery as in cosmetic surgery is largely accepted and even promoted in society, but as soon as it comes to SRS, which I think is clearly not cosmetically and selective, but necessary for the persons well being, it is for most, especially those who do not have a clue, absolutely not acceptable.
Double standards? How can you say so!