Frequently-Asked Questions
These are some of the most common questions from visitors to the TWR web site. The usual disclaimer applies: This is medical talk, not medical advice. For medical advice, always consult your personal physician.
Contents:
- I'm trying to decide which surgeon I
should go to for SRS. What are your candid opinions?
- I'm considering facial feminization surgery.
Can you recommend any surgeons?
- Can you recommend a good therapist
(doctor, electrologist, support group) in my area?
- What are some typical hormone regimens
-- usual medications and dosages?
- Will you write a prescription for hormones
for me?
- What do you think about herbal estrogens
(phytoestrogens, dong qwai, black cohosh, etc.)?
- I am considering having a tracheal
shave to reduce the size of my Adam's apple. What can you tell me
about this operation, and where can I read about it?
- I can't afford SRS, but I would like to
undergo castration to reduce my testosterone levels. What do you think
of this idea and how can I find a cooperative surgeon?
- What is your opinion of the requirement in the
HBIGDA Standards of Care for a one-year Real-Life experience (RLE) prior to
SRS?
- I am a teenager and I think I am transsexual.
What can I do?
- What do you think of on-line gender tests, such as
the COGIATI, and the Moir-Jessel Brain Sex test?
- How can I just develop breasts, without
feminizing myself in other ways?
- Is there an operation that can make my hips
wider or my buttocks larger?
- Will the hormones I am taking show up on the
drug tests my employer requires me to undergo?
- I'm a female-to-male transsexual; can you
suggest any resources for me?
#1. I'm trying to decide which surgeon I should go to for SRS. What are your candid opinions?
-
The following are my personal opinions as of November 2004. They reflect the surgical results I have seen and the reports of individuals I have talked with and corresponded with. They also reflect my personal values as to what is important in a surgeon and in a vaginoplasty result. Others may have different values. I advise anyone seeking SRS to interview as many surgeons and former patients as possible and to look at as many post-op results as possible before making a decision. Personally, I would never undergo SRS with any surgeon unless I had seen actual examples of that surgeon's results.
One of the most disturbing trends I have observed in recent years is the widespread use of colon segment procedures for primary vaginoplasty. Although using a colon segment may sometimes be acceptable for reconstructive work after a failed penile inversion vaginoplasty, in my opinion this technique should never be used routinely for primary vaginoplasty. Situations that justify the use of a colon segment in primary vaginoplasty are, in my opinion, very rare: An example might be in someone who had undergone complete amputation of the penis and scrotum prior to SRS. Therefore, my personal opinion is as follows:
In most cases, if a surgeon suggests that you might be a good candidate for a primary colon segment vaginoplasty, you should choose a different surgeon.
I believe most people should give serious consideration to Dr. Toby Meltzer in Scottsdale if they can afford his fee (about $18,000 as of early 2003, including hospital stay and anesthesia), and if they can tolerate his backlog. Dr. Meltzer's waiting list theoretically goes out about 12 months, but if you have the necessary letters of recommendation and are flexible about dates, you can usually be scheduled much sooner, sometimes within a few months. In my opinion, Dr. Meltzer is one of the best SRS surgeons in the world in terms of aesthetics, function, and predictability of results. He is technically proficient, does a state-of-the-art operation, has a great bedside manner, and is very experienced. I've watched him perform four vaginoplasties over the years, and have been impressed by the way he constantly refines his technique. Dr. Meltzer performs a two-stage procedure, and the second-stage labiaplasty, which is really required for best appearance, costs an extra $3600. He does not use urethral mucosa to construct the vaginal vestibule, so if you value that shiny pink (or sometimes angry red) appearance, you might want to consider another surgeon. Dr. Meltzer has personally confirmed to me that he will perform vaginoplasty on HIV+ patients who are otherwise in good health. If you can handle the expense and the possible wait, Dr. Meltzer is an excellent choice.
Another excellent choice among North American surgeons is Dr. Pierre Brassard of Montreal. His one-stage procedure costs about $16,000 US as of early 2006, a good value in my opinion. I had the opportunity to watch Dr. Brassard perform four vaginoplasties in July 2001 and I was very favorably impressed. He constructs the clitoris using innervated tissue from the glans penis -- the so-called sensate pedicled clitoroplasty technique -- which is rapidly becoming the international standard. His recent vaginoplasty results look very good, and his patients also report good depth and sensation. I have received no reports of serious complications in his patients. Dr. Brassard uses urethral mucosa to construct the labia minora and the vaginal vestibule. Some people like the resulting appearance; I'm more ambivalent. I have some mild concerns about how the labia minora will look during sexual arousal, since the urethral mucosa from which they are constructed includes some underlying erectile tissue. I also wonder about the inflammation that often seems to develop in urethral mucosa when it is used to create the central portions of the vulva. Dr. Brassard supposedly will not perform SRS on HIV+ patients. In my opinion, Dr. Brassard's results set a very high standard for quality. Dr. Brassard wrote to me in September 2006 to report that he is now licensed in Michigan State: "Having this license will help former and future patients change their identity papers, because of the changes provoked by the Patriot Act."
Dr. Brassard's senior partner in Montreal is Dr. Yvon Menard. His fees also run about $16,000 US. Most of his clients report that they are very satisfied with their results, but some have expressed concerns to me about aesthetics, complications, and consistency. The most recent results I've seen from Dr. Menard are quite good, and I'm pleased that he has been using the sensate pedicled clitoroplasty technique favored by so many others. Like his colleague Dr. Brassard, Dr. Menard supposedly will not perform SRS on HIV+ patients. I give Dr. Menard great credit for the recent improvements in his procedures.
In November 2004 I finally was able to see a surgical result from Dr. Marci Bowers, who performs SRS in Trinidad, Colorado. Overall, I was impressed by the quality of her work, especially at that early stage in her SRS practice. Vaginal depth and diameter were good and the overall appearance was satisfactory, especially since Dr. Bowers apparently is now performing a two-stage procedure and this patient had completed only the first stage. I had received some reports of urethral stenosis among Dr. Bowers' early SRS patients, but I have not heard about any such problems recently. As readers of this site are aware, I am not enthusiastic about the use of externalized urethral mucosa in SRS. In the example I saw, Dr. Bowers had used urethral mucosa more extensively than any other SRS surgeon I know. I predict that with time her enthusiasm for this technique will diminish and her results will become even better.
Dr. Harold Reed, who practices in Miami, Florida, is another surgeon with whom I have limited experience. One of my patients who went to Dr. Reed for SRS had a disappointing outcome, but her experience may not be representative.
Perhaps the best known Thai SRS surgeon is Dr. Preecha Tiewtranon of Bangkok, who has reportedly performed over 1600 vaginoplasties. Dr. Preecha uses a traditional penile inversion technique with a sensate pedicled clitoroplasty and use of scrotal skin grafts to extend the vagina. The most recent results I have seen from Dr. Preecha have been good to excellent. He will operate on HIV+ patients, but he changes a 30% premium for this. The all-inclusive cost for vaginoplasty, including hospitalization, is about $6000 US. Adding the cost of staying several more days in a nearby hotel, and a round-trip plane ticket from the West Coast, total cost should be under $7500 US.
Another Thai SRS surgeon very much worth considering is Dr. Chettawut Tulayaphanich of Bangkok. Dr. Chettawut uses the penile inversion vaginoplasty technique with sensate pedicled clitoroplasty. The results I have seen from him have been very good.
Dr. Suporn Watanyusakul practices in Chonburi, Thailand and is widely regarded as one of the best SRS surgeons in the world. I concur with that opinion. Dr. Suporn's SRS results appear to be excellent and he receives consistently positive reviews from my informants.
In late 1998, I traveled to Thailand to observe Dr. Sanguan Kunaporn of Phuket perform SRS. I came back quite impressed with his procedures, but these have changed somewhat since my visit. Dr. Sanguan now delays the placement of his vaginal grafts by five to seven days, apparently because of his extensive use of electrocautery to control bleeding in the vaginal cavity. He feels that the resulting char must be allowed to resolve before he can guarantee viability of the vaginal graft. As a result, his patients have their hospitalizations prolonged by up to a week. This waiting period can somehow be avoided by most other surgeons. Dr. Sanguan also keeps his patients at bed rest for approximately five days following the delayed graft placement. Based on recent examples I have seen, he appears to have become less aggressive about displacing the penile skin downward to line the vaginal cavity, apparently preferring to use the penile skin to drape the central vulvar area. Some people may find the aesthetic value of this technique compensates for the functional consequence, which is less skin with which to line the vagina. Even with the routine use of scrotal skin grafts, this sometimes results in the need for a second skin graft from the thigh or the abdomen, a secondary colon segment procedure, or else a vagina of limited depth. In some cases, Dr. Sanguan has performed primary colon segment vaginoplasties, a technique that many experts do not recommend as a primary SRS procedure, due to its invasiveness and additional risks. On a personal note, I found Dr. Sanguan to be one of kindest, gentlest, and hardest working surgeons I have ever had the pleasure of observing. The inclusive cost for penile-inversion vaginoplasty in Phuket, including thirteen days of hospitalization, is about $6000 US. Adding the costs of aftercare accommodations and round-trip airfare from the US, the total cost should be under $7500 US.
According to my informants, Dr. Pichet Rodchareon of Bangkok is often unable to achieve more than a few inches of vaginal depth without the use of a colon segment procedure, a technique that I do not recommend. In my opinion, there are better choices among Thai surgeons.
I do not have sufficient information to comment on other Thai surgeons.
#2. I'm considering facial feminization sugery (FFS). Can you recommend any surgeons?
I no longer follow developments in FFS closely enough to make informed recommendations.
#3. Can you recommend a good therapist (doctor, electrologist, support group) in my area?
Except for Washington State and a very few other areas, I do not have the personal experience necessary to make informed recommendations. For my recommendations for Washington State, please see Washington State Resources. For a listing of other US resources I can recommend, please see Selected US Resources.
To find a local support group in the U.S., check Transgendered Network International's page U.S. Support Groups by Location. Local support groups, or individuals in them, can usually refer you to other local resources, such as therapists, prescribing physicians, and electrologists.
#4. What are some typical feminizing hormone regimens -- usual medications and dosages?
I have posted a summary of the most commonly-used medications and their suggested dosages elsewhere at this site. The page is called Some Typical Hormone Regimens.
#5. Will you write a prescription for hormones for me?
I am not currently prescribing hormone therapy in my private practice in Seattle. I do provide evaluations for hormone therapy and referrals to other prescribing physicians.
#6. What do you think about herbal estrogens (phytoestrogens, dong qwai, black cohosh, etc.)?
I am unaware of any reliable published data about the beneficial effects or side effects of these substances. Reputedly these are weak estrogens. As such, they may result in limited feminization and may be ineffective at suppressing testosterone. I think most people would do better with regular pharmaceutical estrogens. I cannot address any other questions regarding nonpharmaceutical estrogens.
#7. I am considering having a tracheal shave to reduce the size of my Adam's apple. What can you tell me about this operation, and where can I read about it?
A tracheal shave (thyroid cartilage reduction) is performed through a horizontal incision at the front of the neck. The incision is usually placed at a skin crease, so the resulting scar will be almost unnoticeable. The incision is usually about 1 inch (2.5 cm)long. The operation consists of the removal of the protruding upper anterior portion of the thyroid cartilage, or Adam's apple. A good article about this operation is:
Wolfort, F. G., Dejerine, E. S., Ramos, D. J., and Parry, R. G. (1990). Chondrolaryngoplasty for appearance. Plastic and Reconstructive Surgery, 86, 464-469.
The article is quite readable and has good photos and drawings. It should be available in any university medical library.
#8. I can't afford SRS, but I would like to undergo castration to reduce my testosterone levels. What do you think of this idea and how can I find a cooperative surgeon?
I think castration before (or instead of) SRS is often a reasonable idea. Castration will almost completely eliminate testosterone production (small amounts of testosterone produced by the adrenal glands will remain), allowing the use lower doses of estrogen and eliminating the need for anti-androgens altogether.
Finding a doctor to perform the operation is not always easy. Most SRS surgeons will perform castrations, but will usually adhere closely to the Standards of Care, which require two approval letters from mental health professionals prior to genital surgery. However, an increasing number of surgeons will perform castrations with fewer requirements. The practitioners can best be located through local inquiries.
#9. What is your opinion of the requirement in the Standards of Care for a one-year Real-Life experience (RLE) prior to SRS?
I think having SRS following a shorter RLE, or even without any RLE, is a viable option for selected individuals. In my opinion, there is no convincing evidence that undergoing SRS without a one-year RLE increases the risk of regret after SRS. The requirement of a one-year RLE in the Standards of Care is based on tradition, not evidence.
Of the half-dozen transsexual physicians I know who underwent SRS in the 1990s, not one completed a full year of RLE before undergoing SRS. I had SRS after less than six months of RLE and I nearly persuaded my gatekeepers to approve me for SRS without any RLE. I know several transwomen who successfully underwent SRS without any RLE. None of these individuals has expressed regret.
The Internet-based survey conducted I conducted in 1997 demonstrated an absence of regret after less than a one-year RLE among all 18 respondents, all of whom would definitely have undergone SRS again. Similar results were obtained in a second Internet survey I conducted in 2000; the results of this survey were presented at the HBIGDA Symposium in Galveston in 2001.
The follow-up study
#10. I am a teenager and I think I am transsexual. What can I do?
Transsexual and transgendered youth are the most neglected part of our community, although things are slowly changing in a few countries, notably the Netherlands.
I know of teenagers who are taking female hormones, cross-dressing at school (usually a different one), and on track for surgery at age 18 or even earlier; but this requires adult, usually parental, help. An important step is to try to find some trustworthy adult to talk with: parent, teacher, guidance counselor, family doctor, religious leader, or whomever you think you can trust.
It is also helpful to try to locate a support group nearby. Many groups for transgendered adults will offer advice to minors as well. Some areas also have support services for lesbian and gay youth; they can usually direct you to sympathetic caregivers such as doctors and therapists.
#11. What do you think of on-line gender tests, such as the COGIATI, and the Moir-Jessel Brain Sex test?
I think that both the COGIATI and the Moir-Jessel tests are little more than pseudo-scientific nonsense, and that anyone trying to figure out his or her gender identity issues would be well advised to ignore both.
Let's start with the Moir-Jessel. The book Brain Sex, from which the test is derived, is a sloppy piece of pop science, full of oversimplifications, unsupported inferences, and speculations presented as though they were facts. It simply cannot be taken seriously by anyone familiar with the neurosciences. (By contrast, Simon LeVay's contemporaneous book, The Sexual Brain, although a bit dated by now, is a superb work by a real neuroscientist and is highly recommended.)
The Moir-Jessel Brain Sex test is as silly as the book that spawned it. Perhaps its greatest weakness is that it has never been empirically validated. Despite its authors' claims, the Moir-Jessel cannot tell you whether you have a "female brain" (whatever that term might mean); it cannot even tell you whether the answers you give are more like those given by average males or by average females, because the test has not been validated by actual samples of male and female subjects. But even assuming that you, as a biologic male, did answer the questions in a way that was more typical of average female respondents, would that mean you were therefore more likely to be genuinely transsexual? No one knows, because the test has never been validated with a sample of transsexuals, either. The Moir-Jessel Brain Sex test has absolutely no demonstrated predictive value for persons struggling with gender identity issues. It is best ignored.
Regrettably, the COGIATI is even worse than the Moir-Jessel. It has taken many clichés and stereotypes about male-to-female transsexuals and combined them with many of the Moir-Jessel items, creating a pastiche that would almost be funny if it were not so tragic. According to the COGIATI, typical male-to-female transsexuals are hopeless at math and science, love to sit close to strangers and be hugged by them, can't park cars, can't tell directions, get lost easily, suffer from migraines, are not assertive, and (of course) do not eroticize their own femininity. Does that sound like many transsexuals YOU know? Somehow I didn't think so.
It should go without saying that there is no evidence that persons who conform to the stereotypes presented in the COGIATI are more likely to have successful outcomes from sex reassignment than those who don't. I suggest that gender-conflicted biologic males who are searching for their life paths ignore the COGIATI.
#12. How can I just develop breasts, without feminizing myself in other ways?
One technique would be to take effective doses of estrogen for a long enough time to develop breast tissue and then simply stop the estrogen. Most of the breast tissue that has developed will remain; but the other feminizing effects (i.e., on hair, skin, fat distribution, muscle mass, fertility, etc.) will dissipate, and previous male characteristics will return. Breast tissue that has developed might lose some of its tone and shapeliness when estrogen is removed, but it will not simply disappear.
There seems to be little published evidence about how long one can take fully feminizing doses of estrogen and still expect complete recovery of testicular function when estrogen is stopped. Anecdotally, periods of a year or less seem to be fairly safe.
#13. Is there an operation that can make my hips wider or my buttocks larger?
At present there are no good surgical techniques to widen the hips or enlarge the buttocks. Implants are not advisable: Existing implant materials look and feel hard, lumpy, and unnatural when placed in the hip and buttocks areas. Free silicone is sometimes injected into the hips and buttocks by unscrupulous practitioners. This can cause severe disfigurement and is potentially fatal. People who care about their appearance or their health should NEVER undergo injection of free silicone.
#14. Will the hormones I am taking show up on the urine tests my employer requires me to undergo?
No. They might if someone looked for them, but there is no reason an employer would do so. Estrogen and progesterone are not drugs of abuse and they are not tested for during routine urine screens for drugs. In the medical laboratory I use, the only drugs tested for in the most extensive screen offered are: alcohol, amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates, methadone, methaqualone, phencyclidine, and propoxyphene.
In some situations, such as athletic competitions, urine might be tested for anabolic steroids. Estrogens and progesterone are not tested for and they do not create false positive results on tests for anabolic steroids.
#15. I'm a female-to-male transsexual; can you suggest any resources for ME?
You might check out the web pages for FtM International, and the FtM Informational Network. Another very cool site is Transster.com - FTM Transsexual Surgery Results.
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© 2006 by Anne A. Lawrence, M.D., Ph.D. All rights reserved.