Notes on Gender Role Transition

By Anne Vitale Ph.D.

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Preparing for sex reassignment surgery

Preparing for Gender Reassignment Surgery

January 29, 1998

Genital Reassignment Surgery (GRS) --as it is referred to in SOC 7-- has a way of being safely in the back of most people's minds when they start transition. That is as it should be. However, as one problem after another is resolved and people get into the seventh or eighth month of living the Real Life Experience, a time comes when what was once a faraway dream becomes "The Next Step."

Sex Reassignment Surgery in the male-to-female (MTF) transsexual means the removal of the testes and the reconstruction of the penis or a portion of the bowel into a vagina. For female-to-male (FTM) transsexuals, GRS may mean any or all of the following: breast reduction (reduction mammoplasty) or complete removal of both breasts (double mastectomy) with chest contouring (top surgery), removal of the ovaries (oophorectomy), removal of the uterus (hysterectomy), the removal of the vaginal lining and closing of the vagina (vaginectomy), the construction of a penis out of muscle tissue (phalloplasty), or the release of the post-hormonally enlarged clitoris (metoidioplasty).

Here in the United States, where there is no National Health Program, financing the surgical procedures is an important issue. Male-to-female transsexuals who are fortunate enough to have medical insurance that covers the procedure (a rarity), or who can afford the up-front costs, tend to have their surgery upon completion of the first year of the Real Life Experience. For those who have to find a way to finance the procedure, surgery typically comes a year or two later. For FTMs, Sex Reassignment Surgery usually starts with reduction mammoplasty and eventually full chest contouring. The other procedures, if they are ever done, come much later.

In the more civilized parts of the world, where medical care is covered by a National Health Plan, the problem changes from how to finance the surgery to one of gaining clearance from a formal gender identity program for the procedure(s). Choice of surgeons and procedures in this case will be limited by the program. Even within such programs, some individuals choose to accept financial responsibility for the privilege of going elsewhere for surgery.

For those who choose to go outside their program or for individuals in the United States who need to make their own decision, the first step toward surgery is usually one of inquiry. There are, of course, the obvious concerns about financing and specific procedures. However, keep in mind that in all likelihood when the surgery is performed you will be alone in a strange city, hundreds or perhaps even thousands of miles from home. Getting there will be relatively easy, but once you have the surgery, recovery and the return trip can be problematical. Many surgeons keep the costs down by releasing the individual from the hospital in three to four days. That is obviously not enough time to recover. Some doctors handle the problem by providing out of hospital recovery facilities as part of the surgery package. Others will simply advise you to bring along a friend and have them tend to you at a nearby hotel for a week to ten days.

An excellent source of information, short of talking to the surgeon, is your therapist. A therapist specializing in gender issues typically knows most or all of the surgeons performing GRS or has a way to get the information you need. If all goes well, you should be able to get an address or two to check on waiting times, prices, procedures, and post-op recovery facilities. It's also a good idea to set up a preliminary consultation visit with one or two surgeons. This usually requires a letter of introduction from your therapist. What you learn may surprise you. For the price of a small car and two letters of recommendation, the famous Dr. X will indeed surgically change your sex. Heady stuff indeed.

At this point I suggest you give yourself a break. Like the rest of transition, the reality of the availability of GRS takes getting used to. Try to remember that the procedure is not going to go away. Once you have satisfied the minimum waiting period, you can have the surgery whenever you are ready.

Being ready is also going to vary from day to day. One day you'll be certain that you want your sex to be surgically reassigned and the next, rethinking the immensity of that idea. Combine this with a very natural fear of having something go wrong with the surgery (and there are some real possibilities no matter how careful the surgeon) and second thoughts about the whole idea regularly occur. Nursing a good dollop of doubt at this stage is very common. In fact, periodic concern is actually a good indicator that you fully understand the seriousness of what you are about to do.

Now that you are in the seventh or eighth month of your Full Life Experience, you should have most of the unnerving and social obstacles safely behind you. The hormones are working overtime, all the pesky little name changing errands have been run, nobody "reads" you anymore, and all you seem to have to do is wait out the rest of the mandatory year. Well, waiting is the last thing you should be doing. This is the time in transition when you can begin to reclaim your life.

Sure, it is an awkward time. Despite a lifetime of fantasy, MTFs find that in reality they look more like an image from a medical text book than the center-fold of Playboy. FTMs have quite a different experience: they are busy learning how to control testosterone-fueled sexual impulses. No matter which way you are going, start paying attention to your health, secure your job or look for a better one, expand your education, enjoy your new friends and your new social interactions. Relax into those physical and psychological changes. Let the magic of transition happen.

I suggest that you make your health a high priority. For those of you who are over 40 or are heavy, your physical condition can be crucial both in surgery and in recovery. Even younger people, who expected GRS to be a piece of cake, are shocked at just how much GRS took out of them. As my friend Dr. Rebecca Auge tells her clients "Train for Surgery." This is a good time to take an aerobics class or join a hiking or bike riding club. Smoking is a no-no, especially if you are on massive doses of hormones or are overweight. Eat for recovery. Take mega-doses of vitamin C and get plenty of sleep.

Excessive weight is generally considered to be critical for all surgical procedures. However, when it comes to GRS, most surgeons will not work with anyone over 200 pounds. Big apparently is one thing, obese is another. Keep in mind that MTFs tend to be tall and because of the naturally heavier bone density, weigh more than they appear to. The bottom line is, if you are a big person, you may need to train a lot harder.

Age. This always amazes me. One of the first transsexuals I ever met, back in 1978, was 72 years old. She just had her surgery and was recovering very well. The oldest individual I have worked with so far was 61 at the time of her surgery. She came through the surgery just fine but had a significantly longer recovery period than some of my younger clients. It is especially important for those of you over 40 to use this time to get in the best possible physical condition.

At this point in transition, if all has gone reasonably well, you should have been living full time in your new gender role for about a year. If you are like most transsexuals, you are probably living two lives: one with those who are aware of what you are doing and one with those, the uninitiated, who don't have the slightest idea that you are not exactly what you appear to be. The important family members and friends who have seen you regularly -- no matter what they think of what you are doing -- should be somewhat adjusted to the fact that you are now living in a new gender role. The new friends, which now usually include other transsexuals and people in whom you have confided and who think the idea is great, serve as a support network. Other new friends, who don't have the slightest idea that you have had a different life and who relate to you accordingly, provide unqualified proof that you are not participating in a mass deception. In their non-knowing way, they provide very important support.

Logistically, the beginning of the end of transition is straightforward. Once the surgery is scheduled and all the referral letters are in hand, it is time to get down to the travel and housing details. The details vary from location to location, but one thing you must keep in mind is that the surgery will more than likely be more than you bargained for. If you are flying back from the surgery, arrange now for a wheelchair to meet you at both the departing airport and the arriving airport. This is major surgery and you will be unable to care for yourself for at least three weeks. Being able to go back to work will take even longer. If there are complications -- and complications are common -- it could be considerably longer. Too many people plan to return to work too soon. Prepare for the possibility of using extended sick leave or disability insurance now in case you should need an extension.

Psychologically, be prepared for a wild roller coaster ride. Knowing that you are about to become physically correct is certainly exhilarating. However, the reality of undergoing major surgery is naturally frightening. In addition, second thoughts begin to return. Beyond your own healthy re-considerations, it is not unusual to excitedly tell others that you have a surgery date in a couple of months only to find out that your friends and family were secretly hoping that you would not carry this "sex change thing" that far. Be prepared for the possibility of your decision to go ahead with the surgery being placed under direct attack. If you have small children, threats that you will never see your children again have been known to occur. Another common response from parents and siblings is that you will be disowned and never again be allowed to be part of the family. To make matters worse, your transsexual friends may get very jealous, especially if their surgery is held up or not in sight because they don't have the money to pay for it.

Instead, look for support from people who have nothing to lose because you are having GRS. This usually includes people who have already had their surgery, new friends outside the family circle, people at work and, of course, your therapist. See your therapist often during this period and be frank about your concerns. Any therapist who has been through this period with others knows that this is a critical time.

Fortunately, if your transition has been paced properly and you have established a secure base for yourself in your new sex, going back appears to be even harder than going forward. By this time the die is cast. In fact, very few people are deterred by last minute hardships. If anything, most people become convinced more than ever that going through with GRS is the right thing to do.

As the actual surgery date approaches, it is common to experience a "relaxing into it" phenomenon. The moment of self-definition is finally at hand. People often speak with great concern of improbable accidents occurring ON THE WAY to the surgeon. Interestingly, there is little or no similar concern expressed about the return trip. I think that says a lot about how important the surgery is to some people.

The actual surgery may take four or five hours but your conscious experience of it will be non-existent. It is over so quickly that people hardly remember the gurney ride to the operating room. Typically all they remember is waking up in the recovery room. The rest of the first day of post-op life is usually spent in a Demerol haze. The second day is only slightly better. I make it a point to call and congratulate my clients on the second day but I often wonder if they really remember that I called. I would wait a day or two longer but I know that hearing a familiar voice of congratulations as soon as possible is very important to good recovery.

One of the saddest aspects of GRS is that more often than not, the new post-op finds him- or herself alone and helpless in a faraway place. If you are about to go off to surgery, get the number of the hospital now and, not so subtly, pass it out to all your friends. I also advise my clients to set up a visiting schedule for these same friends before they leave for surgery. Having well paced and helpful visitors once you return home can be very healing.

Arriving back home is usually a great relief. Even though there probably won't be a brass band to greet you, you had better have arranged for a friend or two -- and that wheelchair I mentioned earlier -- to meet you at the airport for the drive home. Members of your family may or may not be up to the greeting. For some reason, it is common for family members to experience initial difficulty with the new post-op status.

Finally, once in your own bed, MTFs can begin their new life with a long overdue dilation. Alas, a woman's work is never done. FTMs on the other hand can simply exercise their male prerogative and start with a long nap.

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Copyright, 1996 by Anne Vitale, Ph.D. Dr. Vitale is a Licensed Psychologist specializing in gender related issues. Her office is located at 610 D Street, San Rafael CA 94901, (415) 456-4452. This Note may be reprinted in any non-profit organization's newsletter if Dr. Vitale's name and address appears with it. Other publications must obtain written permission from Dr. Vitale. A copy of any reprints must be sent to Dr. Vitale.