Surgery; The Elephant in the Room
By: Tara Martin
Tags: LGBTQ, Transgender, Surgery, LGBT, Transgender Rights

Have you had it done? This is one of the most often asked questions we as trans women face. Everybody wants to know our status below the belt, and no it’s none of their business, but as we approach the time to face GRS and other feminizing procedures most of us have no idea where to begin. Partially out of my own self interest, I’ve decided to delve into the topic, but first the disclaimer. I am not a medical professional and the information in this article is not intended to replace the direction of your doctor. This is based solely on my own research and. for reference only. There’s many terms and definitions that can get all too confusing, but hopefully we can sort our way through the topic and get down to the nuts and bolts of GRS.

Most surgeons follow WPATH or Transgender Standards of care when screening candidates for surgery. While every surgeon is different, expect to see requirements like being on hormones for an extended period of time, diagnosis of Gender Dysphoria, letters of recommendation from a treating MD and/or psychologist, living full time as a female for at least 1 year, as well as the sacrifice of 3 fainting goats and the soul of your firstborn child. Obviously those last 2 are a joke, but meeting the requirements are often frustrating, as if a sane person deciding that removing their penis, turning it inside out, and stuffing it back inside their body is a realistic option isn’t enough. The WPATH guidelines do provide a kind of road map to transition, so it is worth the read and is easily available via google. Some of the terms you’re going to encounter include SRS/GRS/GCS, vaginoplasty, orchiectomy, and more. Basically what it boils down to is removing the penis, scrotum and other genital tissue and construction of a neovagina, clitoris, and labia. There are multiple ways of going about it, and I’m sure I’m going to miss a couple, but I’ll cover the most popular as well as one up and coming method I intend to pursue myself at some point in life.

Orchiectomies are generally the first recommended surgery, as getting this accomplished eliminates the need for T blockers such as spironolactone or finasteride. getting off of Spiro has become a life goal of mine, as it has turned my memory to swiss cheese. It’s highly advisable to only take as little as necessary for as little time as possible.

First in the vaginal world is the intestinal (sigmoid) vaginoplasty. a small section of the colon is removed and used as the lining of the vagina. The tissue is self lubricating and the surgery is done laparoscopically, but there have been reports of foul odor and excess mucus using this type of surgery. Penile Inversion is another option, and the surgery is exactly that. the head of the penis is used to create the clitoris and scrotal tissue can be used to form the labia, but prior to surgery all hair must be 100% removed, the tissue is not self lubricating, and the patient must do dilation for the rest of their lives, particularly if they are not engaged in penetrative intercourse. Another is the McIndoe method, using a skin graft and mold to form the vagina. This method is also not lubricating and requires a lifetime of dilation to prevent the vagina from growing closed.

Now comes the newer up and coming method, peritoneal vaginoplasty. This method uses tissue removed from inside the abdomen to form the lining of the vagina. The tissue is self lubricating, has less chance of prolapse, and does not require nearly as much dilation. The biggest issues with this method include the risk of rectovaginal fistula, a tear in the tissue allowing a passage between the 2, and a lack of surgeons currently conducting this style of work. From my research I’ve been able to identify 5 or 6, although i’m sure that list is not exhaustive. This method is becoming more and more popular, and Dr Marci Bowers is currently teaching the method to students, so it’s only a matter of time before it becomes more readily available.

Shifting gears, there are a number of other cosmetic surgeries available. Slowly these are starting to be covered by insurance as they are labelled “medically necessary to transition” by physicians. Facial feminization surgeries include brow bone and forehead contouring, nose, chin and jaw, lip and cheek augmentations and more. Almost anything can be done today by cosmetic surgeons. One of the biggest issues we as trans women face is upstairs, as in hair, that is. A new style of hairline correction surgery, called a coronal incision, has been pioneered by a team in spain and is slowly gaining traction here in the US. This type of hairline correction allows for hair follicle replacement to be performed at the same time as the hairline correction without risk of rejection and also hides the scarring underneath the hairline. Tracheal shaves and breast augmentations are also routinely performed, although as with any surgery risks are always involved. Breast implants for example carry risks like scar tissue distorting the implant, pain, infection, loss of sensation, implant leakage or rupture and even cancer are all possible, so be sure to discuss all inherent risks with your surgeon prior to your surgery date.

Surgeons today can do what we only dreamed of 30 years ago and bring us even closer to aligning our physical appearance and characteristics with what our brains expect to see in the mirror, but all surgeries come with risk. The best thing you can do is talk to as many surgeons as well as patients as you can, ask plenty of questions, and keep realistic expectations. We as trans women at times can become unrealistically obsessed with “passing”, but it’s important to remember that surgery does not equal validation. Trans is beautiful, and no one can ever take that away from us. Just keep all of these things in your mind as you begin to address the elephant in the room.