Because of my special interest and
training in microsurgery, I saw the opportunity
of performing gender reassignment surgery as an
exciting one. When I realised that no-one else
in Australia or New Zealand was doing this
surgery on a regular basis I also regarded it as
a real technical challenge, and perhaps an
opportunity to break some new ground.
I met with Trudy Kennedy and Herbert Bower
(Monash Gender Dysphoria Clinic) and
found them to be a fascinating couple of
professional psychiatrists who had been (and
still are) the cornerstone of the Monash Gender
Dysphoria team for many years and they were very
interested in having another surgeon involved in
the management of their transsexual patients. It
became clear from talking to them that the
medical profession were very anxious regarding
any connection with transsexual patients, and my
interest was warmly welcomed.
There appears to be enormous misunderstanding
among the medical profession as well as the
general public, about the needs and desires of
transsexuals. The overall impression I got when
speaking with even the most highly educated
people, was that all transsexuals must be nuts
and that I must be equally mad to be even
slightly interested in helping them. I was
encouraged by Trudy Kennedy and Herbert Bower's
enthusiasm, however and agreed to become
involved with the team.
Before embarking on any genital surgical
procedure both Simon Ceber and I visited Joris
Hage in Amsterdam and were very fortunate to be
able to work with him, meet his staff and
patients and also to perform a number of genital
operations in Holland. We learned about the
metoidioplasty operation and the history of the
evolution of this procedure. We assisted him and
quizzed him extensively regarding the details of
the surgery.
We were then privileged to perform a radial
forearm flap phalloplasty with him and our
techniques since that initial operation have
been based on his teachings (which are well
published in the medical literature) along with
some variations that Simon and I have
incorporated into our own practices.
When we returned from Holland we started our
surgical program. Obviously there was some
initial concern among the transgender patients
we met, however the overwhelming impression we
got was a sense of relief that at last there
were some people in Australia who were truly
interested in performing this complex
surgery.
Before meeting my first female-to-male
transsexual all kinds of ideas were running
through my head. For some reason I expected the
patients to be very unusual. I was surprised to
find them pleasant to talk to, highly motivated,
of normal intelligence and well presented -
quite a contrast to the anecdotal stories I had
heard.
The Monash Gender Dysphoria team
certainly insist on a fairly firm set of
criteria being met before patients are eligible
for surgery and because of this the patients we
see are very well informed and seem to have
realistic expectations.
We were fortunate to initially have a couple
of absolutely delightful patients. Our first
patient came from a very supportive family, was
quite young, with a terrific personality and
fortunately for him our initial attempts at
surgery was uncomplicated. I have to say that
since then our experiences have been very mixed
and we have encountered extreme highs and lows
from our involvement with this surgery.
I was asked to comment on our surgical
efforts by a 'reputable' journalist who was
writing a piece about transsexuals for a major
national newspaper. I spent two hours outlining
the general psychological aspects of surgery,
the dedication of the Monash Gender Dysphoria
team and the need for this type of
surgery.
I felt happy after the interview and couldn't
wait to read the article. When I opened the
paper two days later, the headline "Surgeons
Make Penis for Women" made my heart sink and
I vowed never again to speak to another
journalist. This sort of behaviour does nothing
for the confidence of mainstream doctors and
really works against our common goals.
There have been a couple of times when I have
given serious consideration to ending my
participation in the whole management process
but when my spirits are at their lowest ebb, the
next patient who comes through the door seems to
be one of the most grateful patients I have ever
seen and my enthusiasm is rekindled.
I believe there is a misconception amongst
some members of the transgender community that
we perform this type of surgery to 'feather our
nests' and rip off patients for pure monetary
gain. I can absolutely reassure people that
there are a lot of easier ways in surgery to
make a buck, and the amount of time and effort
we put into these procedures plus the after-care
associated with them, makes transsexual surgery
the most undesirable (monetarily) of all the
operations we perform.
One of the problems with performing this type
of surgery is that the total number of patients
we treat is very small and we spend so little
time with them that our experience is severely
limited. For me, the constraints of trying to
run a normal general plastic surgery practice
added to time-consuming interests outside of
medicine mean that there are further
restrictions on the degree of interaction I can
have with these people.
I see my transsexual patients as a special
interest and have confined my involvement to
female-to-male (F2M) transgenders. They often
ask me why there isn't more research and money
spent on the development and advancement of
surgery. When you stop to consider the lack of
understanding within the community and the
limited budgets that health departments and
various governmental bodies have to work with,
you start to understand that transgender surgery
gets a very small allocation of available funds
within an already stressed framework.
It became very clear to me at an early stage
that my patients' main priorities were:
1) the ability to stand to void
2) issues relating to the fear of discovery,
and
3) the sense of completion.
I do not believe that I have yet met a
transsexual whose primary goal in undertaking
surgery is sexual. This may seem surprising to
some people, however, being a bloke I can relate
very well to the gender issues regarding
maleness.
I would like to explain in layman's terms,
the procedure that I perform in genital
female-to-male transsexual surgery. The first
operation involves the creation of a
micro-penis. The clitoris is lengthened and part
of the vagina is used to create the urine tube
from the native female bladder to the tip of the
clitoris. The labia minora are fashioned into
flaps that cover the newly created urine tube
and testicular implants are inserted into the
labia majora. The fistula rate and stricture
rate with this operation sits around the 30%
range - which unfortunately seems to be the same
around the world.
Once this operation has settled and all
complications have resolved, we then allow
patients to proceed with the second stage of the
operation - usually 3-6 months later. To date we
have predominantly used a flap of tissue raised
from the forearm. This involves taking skin,
fat, and deep fascia, to create a penis of
reasonable size. A urine tube is formed within
this structure and it is transferred along with
the blood vessels that supply the tissue to the
groin. The blood vessels are microsurgically
anastomosed to the blood vessels in the groin
and the nerve to this tissue is joined up to one
of the clitoral nerves. When this nerve
anastomosis recovers, sensation will return to
the penis giving some feeling (hopefully some
erogenous feeling).
The third stage operation involves the
insertion of a penile stiffener and to this
point we have only a semi-rigid device. Although
pump devices are available, the complication
rates internationally seem to be very high and I
am yet to be convinced that a terrific
inflatable device exists.
The surgery is complex and necessitates long
spells in hospital and it is stressful both
physically and mentally for our patients. At
this stage surgery is only carried out in
Melbourne and because of this long periods of
time away from home are required. Fortunately a
small network of support people is developing
which seems to be helping patients cope with
this sense of isolation and separation from
their own home.
As things progress I am hopeful that there
will be refinements in surgery and improvements
in currently used techniques. I am exploring the
possibility of tissue engineering with a
microsurgical colleague, particularly in
relation to construction of the urethra (urine
tube). As ideas develop internationally they
will be applied at a local level and we should
be able to engineer a better penis in the
future.
There appears to be no doubt that surgery for
female-to-male transsexuals can be extremely
beneficial. I often see an amazing change in
behaviour and mood after successful surgery. Not
only are our patients reassured to find that
there are people willing to help them, they also
show dramatic improvement both physically and
psychologically from the effects of surgery. I
have always tried to help people as much as I
possibly can in the hope that one day they will
feel totally comfortable and relaxed in their
correct gender identity.
EPILOGUE
Our results compare favourably with those of
international colleagues and much collaboration
and cross-fertilisation exists between various
units internationally. It is still difficult
getting more plastic surgeons involved with this
field of surgery because of the mind block that
exists in the medical community and the
abundance of other work available in the field
of plastic and reconstructive surgery.
I believe that there are many things, which
remain to be done regarding the treatment and
understanding of transgender patients. We have a
long way to go in refining techniques and
developing new procedures that will minimise
complications and simplify the operative
procedures currently used. In my opinion, the
future of gender reconstructive surgery may well
lie in the use of tissue engineering and tissue
transplantation. Once the immune system problems
have been sorted out with transplantation
surgery this will be an obvious technique to
use.
Editor's
Note: Dr Huntersmith no longer carries out
this surgery.
All enquiries should be directed to Monash
Gender Dysphoria Clinic, Melbourne - 270 Clayton
Road, Clayton, Victoria.
