Final Female-To-Male Gender Reassignment Surgery Before And After Female

Cid Isbell hadn’t been nervous about the seven-hour operation until the day before he went into the hospital. But once he made it to his San Francisco hotel room, he began burning sage for good vibes.

“Advanced surgery for female-to-males has been way behind male-to-female until now,” Isbell said. “The surgeons always told me, ‘it’s easier to make a hole than a pole’ but now we’re catching up.” And catch up he did.

Inside the operating room, a surgeon lifted up a six-inch length of flesh that looked exactly like a penis but had been crafted out of a chunk of Cid’s arm. He handed it, almost ceremonially, to the lead surgeon, who began sewing it between Cid’s legs, just above where his vagina used to be.

The whole procedure took most of the day, and when Cid finally woke up and glanced down, he said: “Wow, I have a penis! That looks freakin’ amazing.”

Cid, an IT consultant, travelled from his home in Santa Fe for the operation. It was his 50th birthday present to himself.

Fifteen years ago, Cid had a double mastectomy as part of his transition, and was taking testosterone. But like many female-to-male transgender men, he had never bothered with “bottom” surgery to alter his female genitals.

In the last few years, techniques to craft a functioning penis of five or more inches in length – a penis that can pee and get an erection – have advanced in leaps and bounds, with fewer complications and more tactile and sexual sensations.

Cid’s lead surgeon, Dr Curtis Crane, now performs two or three such operations a week at the California Pacific Medical Center, and has done about 150 in all. That’s a tiny count by surgical standards, but far ahead of the one or two other surgeons in the US with the necessary skills in urology and plastic surgery.

The operation costs $100,000 but after a long fight, Cid’s health insurance is paying for it.

The operation began with a large flap of skin being meticulously harvested from Cid’s forearm, along with some fat “to help give it girth”, according to the surgeons.

Micro-surgeon Dr Bauback Safa then rolled up the flap into the shape of a penis, and raised a little band of flesh at the end to make a “head”. The resemblance was uncanny.

While Safa and his team were poring over the arm, Crane and his surgical crew were preparing Cid’s urethra and clitoris with its bundle of potent erotic nerves. They connected them to the penis, and attached it a few inches above where they shut the vaginal opening (Cid had a hysterectomy in February).

After nine months of healing, Cid will return to the hospital so that doctors can put an implant into the penis, which is connected by a pump hidden in Cid’s scrotum. A supply of saline in a plastic reservoir is embedded in the abdomen. Squeeze a ball and voila, you have an erection. No sperm, of course, but urinary and sexual function a go-go by all accounts.

After the surgery, Cid was cleaned up and the swarms of nurses and doctors, buzz of medical chatter, acres of surgical bedsheets and nests of tubes and machines receded like a wave.

Cid looked serene, his hairy chest rising and falling, his penis lying neatly to one side as he snored loudly. They wheeled him out.

Over an Italian dinner in downtown San Francisco two nights before the surgery, Cid explained why having the surgery was so important to him. “I want to be able to undress freely in the locker room at the gym. And what if I have a car accident and they cut my clothes off and the paramedics freak out and won’t treat me? That’s happened to trans friends of mine. I want to unzip my fly and just take a whizz standing up – and not all over my shoes. I’d like to penetrate a partner sexually and feel that sensation in my own penis.”

Outside his home, he’d always worn a soft latex phallus in his underwear.

“You go through the scanner in the airport and they say ‘Sir, there’s something in your pants!’” Cid said, giggling and rolling his eyes. “I’m pretty direct about these things. I say: ‘I’m a transsexual.’ But you don’t want to be taken off to the little room for a big search, you don’t want to be looked at like a freak.”

Cid was raised as a girl named Diana. He remembers posing in front of the mirror with balled-up socks down his pants when he was four, and never grew out of being a tomboy. “When my breasts arrived I was absolutely horrified. I always hated them,” he said.

His transition to manhood came in stages. In his teens and 20s, he was a butch lesbian, and didn’t have a lot to do with men.

“I didn’t really like men very much and then I became one. It was quite a shock,” he said.

He dug out a picture of himself at 30, back when he was into bodybuilding and living in New York. He was taking testosterone to boost his workouts, and was becoming increasingly masculine in both physical characteristics and self-regard.

He recalls: “I was standing on a corner in Brooklyn one night, waiting to cross the road, and a guy came up alongside me to cross the road. We glanced at each other and he just said: ‘Yo, chief.’ And I thought, holy shit, I’m really over on the other side. I was stunned, but I also felt good about it.”

Did he feel as though he’d defected?

“Not exactly – I felt like a spy,” he said.

Not long after, he went to a conference on transgender issues in Ithaca, New York, and met a female-to-male transgender man for the first time.

“I was, like, oh. That’s me, that’s what I need to be.”

Cid changed his gender on his driving license and had “top” surgery – at age 35. He felt much more comfortable with himself by then, even better than the bodybuilding had made him feel.

“But I realized I knew nothing about male culture from a man’s perspective. So I made a point of getting to know men and understanding more about them as passionate, emotional beings. It helped me ‘pass’ as a man as well as make friends,” he said.

He looked apologetic as he explained what happened next.

“I was instantly offered better jobs and paid about 40% more than I had been for the same kind of job before, while my qualifications hadn’t changed. I’m not kidding. And my credentials weren’t questioned at interviews in the way they always had been.”

He noticed that some guys at work now shared dirty jokes and chauvinistic remarks with him. At first he was tempted to indulge his new privilege and join in in order to fit in – but it felt alien and rude, he said, and he made a conscious decision not to “go there” but to challenge it when he felt that was necessary.

“I promised myself I wouldn’t forget what it was like to be a woman. Being a girl, being a woman, that’s part of my experience and it will never change for me,” he said.

This kind of wording angers some transgender advocates, who would argue that Cid was always a man, born with incongruent body parts. But Cid said: “I’m pretty loose around language. For me it’s not that cut and dry.”

He added that in his experience, some people who transition are very bitter at having been forced to live as the gender they knew instinctively they were not. The anger, post-transition elation, or mix of both can lead to what he calls “over-compensation” stereotypes – the very macho trans man, the ultra high-femme trans woman – which may give way to a more nuanced attitude later on.

Cid dated bisexual women for a while, then married a straight woman in 2004. They recently got divorced but are good friends, Cid said.

He wasn’t macho enough for his wife, he said. It wasn’t a genital problem, it was an emotional problem.

“She thought of me as a dude, but she wanted the strong, silent type. I’m very chatty, I have to express myself, otherwise I feel trapped,” he said. He now regards himself, in his words, as an effeminate man. Maybe a bisexual one, even – he’s been feeling attracted to gay men of late and thinks he might go in that direction when his penis is all geared up and ready for action.

Growing up, Cid recalled wanting to be a boy and suppressing that urge – not so much because society or his parents wanted him to conform, but because his mother was a strident feminist, often criticizing the patriarchy and insisting girls could do and be anything they wanted to be.

“She made it sound like, why on earth would you ever want to be a boy? I felt guilty about it,” he said. When Cid began taking male hormones and transitioning in his 30s, however, she supported him, and now campaigns for transgender equality issues.

His parents split up a long time ago and Cid’s father, Bill, and stepmother, Judy, flew across the country from their home in Binghamton, New York, to support him during his surgery.

Sex reassignment surgery

Definition

Also known as sex change or gender reassignment surgery, sex reassignment surgery is a procedure that changes genital organs from one gender to another.


Purpose

There are two main reasons to alter the genital organs from one sex to another.

  • Newborns with intersex deformities must early on be assigned to one sex or the other. These deformities represent intermediate stages between the primordial female genitals and the change into male genitals caused by male hormone stimulation.
  • Both men and women occasionally believe they are physically a different sex than they are mentally and emotionally. This dissonance is so profound that they are willing to be surgically altered.

In both cases, technical considerations favor successful conversion to a female rather than a male. Newborns with ambiguous organs will almost always be assigned to the female gender unless the penis is at least an inch long. Whatever their chromosomes, they are much more likely to be socially well adjusted as females, even if they cannot have children.


Demographics

Reliable statistics are extremely difficult to obtain. Many sexual reassignment procedures are conducted in private facilities that are not subject to reporting requirements. Sexual reassignment surgery is often conducted outside of the United States. The number of gender reassignment procedures conducted in the United States each year is estimated at between 100 and 500. The number worldwide is estimated to be two to five times larger.

Description

Converting male to female anatomy requires removal of the penis, reshaping genital tissue to appear more female, and constructing a vagina. A vagina can be successfully formed from a skin graft or an isolated loop of intestine. Following the surgery, female hormones (estrogen) will reshape the body's contours and stimulate the growth of satisfactory breasts.

Female to male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals. Penis construction is not attempted less than a year after the preliminary surgery to remove the female organs. One study in Singapore found that a third of the persons would not undergo the surgery again. Nevertheless, they were all pleased with the change of sex. Besides the genital organs, the breasts need to be surgically altered for a more male appearance. This can be successfully accomplished.

The capacity to experience an orgasm, or at least "a reasonable degree of erogenous sensitivity," can be expected by almost all persons after gender reassignment surgery.


Diagnosis/Preparation

Gender identity is an extremely important characteristic for human beings. Assigning it must take place immediately after birth, for the mental health of both children and their parents. Changing sexual identity is among the most significant changes that a human can experience. It should therefore be undertaken with extreme care and caution. By the time most adults come to surgery, they have lived for many years with a dissonant identity. The average in one study was 29 years. Nevertheless, even then they may not be fully aware of the implications of becoming a member of the opposite gender.

In-depth psychological counseling should precede and follow any gender reassignment surgical procedure.

Sex change surgery is expensive. The cost for male to female reassignment is $7,000 to $24,000. The cost for female to male reassignment can exceed $50,000.


Aftercare

Social support, particularly from one's family, is important for readjustment as a member of the opposite gender. If surgical candidates are socially or emotionally unstable before the operation, over the age of 30, or have an unsuitable body build for the new gender, they tend not to fare well after gender reassignment surgery. However, in no case studied did the gender reassignment procedure diminish their ability to work.


Risks

All surgery carries the risks of infection, bleeding, and a need to return for repairs. Gender reassignment surgery is irreversible, so a candidate must have no doubts about accepting the results and outcome.


Normal results

Persons undergoing gender reassignment surgery can expect to acquire the external genitalia of a member of the opposite gender. Persons having male to female gender reassignment surgery retain a prostate. Individuals undergoing female to male gender reassignment surgery undergo a hysterectomy to remove the uterus and oophorectomy to remove their ovaries. Developing the habits and mannerisms characteristic of the patient's new gender requires many months or years.

To change male genitalia to female genitalia, an incision is made into the scrotum (A). The flap of skin is pulled back, and the testes are removed (B). The skin is stripped from the penis but left attached, and a shorter urethra is cut (C). All but a stump of the penis is removed (D). The excess skin is used to create the labia (external genitalia) and vagina (E). (

Illustration by GGS Inc.

)


Morbidity and mortality rates

The risks that are associated with any surgical procedure are present in gender reassignment surgery. These include infection, postoperative pain, and dissatisfaction with anticipated results. Accurate statistics are extremely difficult to find. Intraoperative death has not been reported.

The most common complication of male to female surgery is narrowing of the new vagina. This can be corrected by dilation or using a portion of colon to form a vagina.

A relatively common complication of female to male surgery is dysfunction of the penis. Implanting a penile prosthesis is technically difficult and does not have uniformly acceptable results.

Psychiatric care may be required for many years after sex-reassignment surgery.

The number of deaths in male-to-female transsexuals was five times the number expected, due to increased numbers of suicide and death from unknown cause.


Alternatives

There is no alternative to surgical reassignment to alter one's external genitalia. The majority of persons who experience gender disorder problems never surgically alter their appearance. They dress as members of the desired gender, rather than gender of birth. Many use creams or pills that contain hormones appropriate to the desired gender to alter their bodily appearance. Estrogens (female hormones) will stimulate breast development, widening of the hips, loss of facial hair and a slight increase in voice pitch. Androgens (male hormones) will stimulate the development of facial and chest hair and cause the voice to deepen. Most individuals who undergo gender reassignment surgery lead happy and productive lives.

Resources

books

Bostwick, John. Plastic and Reconstructive Breast Surgery, 2nd edition. St. Louis: Quality Medical Publishers, 1999.

Engler, Alan M. Body Sculpture: Plastic Surgery of the Body for Men and Women, 2nd edition. New York: Hudson, 2000.

Tanagho, Emil A. and Jack W. McAninch. Smith's General Urology, 15th Edition. New York: McGraw-Hill, 2000.

Walsh, Patrick C. and Alan B. Retik. Campbell's Urology, 8th Edition. Philadelphia: Saunders, 2002.

Wilson, Josephine F. Biological Foundations of Human Behavior. New York: Harcourt, 2002.

periodicals

Asscheman, H., L. J. Gooren, and P. L. Eklund. "Mortality and Morbidity in Transsexual Patients with Cross-Gender Hormone Treatment." Metabolism 38, No. 9 (1989): 869–73.

Docter, R. F. and J. S. Fleming. "Measures of Transgender Behavior." Archives of Sexual Behavior 30, No. 3 (2001): 255–71.

Fugate, S. R., C. C. Apodaca, and M. L. Hibbert. "Gender Reassignment Surgery and the Gynecological Patient." Primary Care Update for Obstetrics and Gynecology 8, No. 1 (2001): 22–4.

Harish, D., and B. R. Sharma. "Medical Advances in Transsexualism and the Legal Implications." American Journal of Forensic Medicine and Pathology 24, No. 1 (2003): 100–05.

Jarolim, L. "Surgical Conversion of Genitalia in Transsexual Patients." British Journal of Urology International 85, No. 7 (2000): 851–56.

Monstrey, S., P. Hoebeke, M. Dhont, G. De Cuypere, R. Rubens, M. Moerman, M. Hamdi, K. Van Landuyt, and P. Blondeel. "Surgical Therapy in Transsexual Patients: A Multi-disciplinary Approach." Annals of Surgery (Belgium) 101, No. 5 (2001): 200–09.


organizations

American Medical Association. 515 N. State Street, Chicago, IL 60610, Phone: (312) 464-5000. http://www.ama-assn.org/ .

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005, (888) 357-7924. Fax: (202) 682-6850. apa@psych.org.

American Psychological Association. 750 First Street NW, Washington, DC, 20002-4242. (800) 374-2721 or (202) 336-5500. http://www.apa.org/ .

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201-5559. (410) 727-1100. http://www.auanet.org/index_hi.cfm .


other

Health A to Z [cited March 24, 2003]. http://www.healthatoz.com/healthatoz/Atoz/ency/sex_change_surgery.html .

Hendrick Health System [cited March 24, 2003]. http://www.hendrickhealth.org/healthy/001240.htm .

Intersex Society of North America [cited March 24, 2003]. http://www.isna.org/newsletter/ .

University of Missouri-Kansas City [cited March 24, 2003]. http://www.umkc.edu/sites/hsw/gendid/srs.html .


L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Gender reassignment surgery is performed by surgeons with specialized training in urology, gynecology, or plastic and reconstructive surgery. The surgery is performed in a hospital setting, although many procedures are completed in privately owned clinics.

QUESTIONS TO ASK THE DOCTOR



  • What will my body look like afterward?
  • Is the surgeon board-certified in urology, gynecology, or plastic and reconstructive surgery?
  • How many gender reassignment procedures has the surgeon performed?
  • How many of the type similar to the one being contemplated (i.e., male to female or female to male) has the surgeon performed?
  • What is the surgeon's complication rate?

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