IN "Under
the Knife, Part 1" I wrote about chest
reconstruction for transmen, and in
Part 2 about transmen's genital
reconstruction. But, wait -- there's more! FTM
transpeople may also have to worry about a
hysterectomy.
For male-to-female (MTF) transpeople, genital
reconstruction includes castration or removal of
the gonads (the testicles in a male-bodied
person). For FTMs, creation of a phallus does
not necessarily include castration, that is
removal of the ovaries. Thus, even some FTMs who
have had genital reconstruction still retain the
female reproductive system. For some transmen
this poses no problem, either physical or
psychological. But some transmen have a strong
desire to be rid of all vestiges of female parts
for psychological reasons. Others will find that
the female internal organs may become a source
of severe medical problems and their removal a
medical necessity.
PCOS
According to Sheila Kirk, M.D., a
board-certified gynecologist, 1 to 5 percent of
the female-bodied population is afflicted with
the disease known as Polycystic Ovarian Syndrome
(PCOS). For FTMs, the number is 25 percent. (FTM
Newsletter #36, March '97, page 5) In 70% of
cases, PCOS is accompanied by elevated levels of
a particular androgen released into the
bloodstream by the adrenal glands:
dehydroepiandrosterone. In more than 50% of
cases, another "male" hormone from the adrenal,
11 beta hydroxy androstenedione, is elevated.
These substances increase the risk of heart
disease and hypertension. Combined with
exogenously administered testosterone, the
effects "could lead to serious lipid metabolism
alterations and consequent heart disease," says
Dr. Kirk. PCOS also increases the risk of
ovarian cancers and uterine endometrial
malignancy, and there is evidence of increased
risk of breast cancer when PCOS is present.
PCOS is often characterized by obesity;
irregular, prolonged, or heavy menses; and some
masculinization (voice pitch changes, temporal
balding, facial hair growth, altered hair growth
patterns on body trunk and around the genitalia
and extremities, and distinct clitoral growth).
But many people with PCOS show no obvious
symptoms.
Dr. Kirk recommends that prior to starting
testosterone all FTM individuals have pelvic
and/or transvaginal ultrasound to study the
ovaries, and a blood test to determine possible
elevation of the two adrenal androgens mentioned
above. If PCOS is diagnosed, it is possible to
treat the disease, sometimes using female
hormones (estrogens), and until the transition
process is begun (testosterone use initiated) it
could be reasonable to treat the condition in
the "normal" manner (for women). If the
transition process is already underway, surgical
removal of the uterus and polycystic ovaries may
be advisable, even if genital reconstruction is
not anticipated or is planned for the distant
future.
However, it is not always easy for an FTM
person to obtain treatments that some people
believe are too frequently forced on women by a
scalpel-happy medical establishment.
Hysterectomy/oophorectomy (removal of the uterus
and ovaries) is an expensive procedure,
especially in cases where an abdominal incision
is necessary (vaginal entry is not always
possible) and a hospital stay of several days is
required. If an FTM person is transitioned or
cross-living and insured as a man, his insurance
company is likely to balk at the revelation of
his female body parts that need attention.
Ironically, if the FTM individual is known as a
female, doctors may be reluctant to remove
reproductive organs, fearing that the person may
want to have a child someday. And if the person
has revealed his FTM identity, doctors may be
reluctant to perform a hysterectomy/oophorectomy
because they see the procedure as assisting in
the masculinizaton process, and may not wish to
be involved in treating medically what they view
as a psychiatric condition. Or insurance
companies may deny payment for the procedure if
they deem it associated with sex reassignment,
which is almost always (in the U.S.) excluded
from coverage.
Trans-positive health care reform must
include the acknowledgement that our bodies
deserve medical care regardless of our gender
identity. PCOS is not a psychiatric condition,
and just because someone with the disease is an
FTM person does not mean he should not be
treated with every consideration given to
relieving both the physical distress caused or
threatened by the disease and the emotional
distress caused by being male-identified and
living in a female body. Until such reforms are
in place, each FTM person must negotiate his own
solution to the hysterectomy problem. With the
help of understanding and supportive physicians,
we may someday win the battle for
trans-inclusive health care.
Loose Ends
Now it's time to close the incisions and tie
up a few loose ends. There are a few scattered
items I'd like to throw in here as food for
thought.
1) In any surgical procedure where general
anesthesia is used, there are accompanying risks
that must be weighed -- namely, you may not wake
up. (It happens.)
2) Chest reconstruction is often performed in
clinics rather than in hospitals, and the
recovery time is so rapid for FTM patients
because they are usually happy about the
procedure, as opposed to mastectomy procedures
for women, who are having diseased tissue
removed. Mastectomy in women usually requires
recovery times partially due to the physical
compromises brought on by the disease that has
necessitated the procedure, but also due to the
psychological resistance that most women have
toward breast removal. FTMs should not let the
fact that we are not hospitalized for this
procedure lull them into a false sense of
immunity from procedural risk or post-operative
complications.
3) Dark-skinned (especially black) people
have a higher incidence of developing keloids,
thick, ropy scars where incisions were made.
4) Hysterectomy can result in a loss of
bladder support, and it's common to have urinary
problems like leakage and increased urinary
frequency. The bowel moves down to take up the
place where the uterus was, and some women have
reported eventually having great difficulty with
bowel movement, though I have not yet heard of
this result in FTMs.
5) If an FTM has a hysterectomy prior to
declaring himself as FTM or otherwise not in
conjunction with an FTM genital reconstruction,
he should ask his surgeon to make sure to leave
as much of the vaginal mucosal tissue and
glandular complexes as possible. Most doctors
will do this anyway to preserve a woman's sexual
functioning, but the special concern for FTMs is
that this tissue is necessary for urethral
lengthening in some phalloplasty and/or
urethroplasty techniques.
6) A hysterectomy procedure takes a lot out
of you! An FTM's recovery from this operation,
whether or not it is done in conjunction with
genital reconstruction (a handy way to avoid yet
another general anesthesia) may take
considerably longer than imagined, and there is
no way to predict what this will be like.
7) Many surgeons are busy or lacking in
communication skills and don't automatically
give you all the information you need about the
procedures they are performing on your body. You
need to be informed about what to watch out for
and expect by gathering information from many
sources. Don't be afraid to ask your doctor any
questions you have. Your surgeon is the only one
who knows what she or he will do, or what was
done, to your body. It is important to have
trust and confidence in your surgeon and to feel
that he or she respects you and is honest with
you.
8) Bodies are mysterious. No matter how much
science knows about the body, every one of us is
essentially an unregulated living organism with
unpredictable and uncontrollable forces at work.
Surgeons are only human; they cannot guarantee
results.
Surgery is serious business. Be absolutely
positive you can live with the outcome, good or
bad, before you go under the knife.
