JoAnne Keatley: Judy Van Maasdam is going to present on surgical considerations. Please welcome Judy.

Judy Van Maasdam: Thank you. I'm not a surgeon. I'm not here to promote surgery. But I think it's important for a behavioral health care professional who sees a transgender person who says that they want to do surgery. It's a part of what that -- to me one of the goals of counseling in psychotherapy includes education about treatment options. And surgery certainly is one of the treatment options. I would not say that any person transgender should seek surgery. But I think it's important for you to know what exactly is done in terms of surgery. I'm not gonna be showing the stages of surgery as much as post-op results. The reason I am talking about this is I have been always associated with a surgical program, and I've been very involved in working and preparing persons for surgery.

The operating room. (View the slide) Wake people up a little bit. This, we do call it Gender Confirmation Surgery. We're changing the sex to fit the gender. (View the slide)

Now a little bit about, you know, castration is well recorded in ancient history. And so that was a kind of sex reassignment surgery back then. And I already reported to you earlier this morning that surgery first occurred in Germany, at least written reports back in the 1930s. There's approximately in the United States eight major resources or centers for surgery. And that would be in California, Colorado, Florida, Michigan, Oregon, Texas, Virginia and Wisconsin. Quite a bit of work is done in Europe and here in California, the West Coast, I know that you have a lot of people who have gone to Thailand. There's two surgeons there that are doing quite a bit of work, and at not much cost either. (View the slide)

Now, what we're actually calling Gender Confirmation surgical procedures would be the removal of the penis, removal of the testicles, vaginoplasty, mastectomy in the female to male patient, hysterectomy, oophorectomy, and the phalloplasty, construction of a penis. These are the actual genital or Gender Confirmation surgeries that are talked about in the Standards of Care that should meet the so-called standards. (View the slide)

Vaginoplasty, the more technical term is Neocolporraphy. I'm going to be talking about metoidioplasty, which is one of the penis construction in female to male, and then phalloplasty. (View the slide)

A male to female. (View the slide) Another. (View the slide)

Now in male to female surgery, penile inversion which is a skin graft, is the most popular and most procedure that's done in the world. It's penile inversion. There's also another surgery which is done by about four surgeons, or four places, in the United States. And that's utilizing part of the upper, the upper colon, large intestine, the rectal sigmoid portion. Other feminizing surgeries which don't have to meet criteria which could be done in preparation for the real life experience, or done at some time during the real life experience, would be the cartilage shave, augmentation, mammoplasty, any facial feminizing surgery can be done. (View the slide)

As I said the penile inversion method is the most popular worldwide. (View the slide) The [inaudible] position, they're gonna start surgery. (View the slide)

This slide kind of shows you that the penis is denuded and that skin is used to line the vaginal cavity that is made. The scrotal tissue, once the testicles are removed, are used for the labia and part of the labia minora.(View the slide)

Again just showing you the anatomical structures that do form the neo-vagina. (View the slide)

Now I put this slide in here because this is one of the innovations that's been done in the past ten years by the surgeons doing the work. And that's the formation of a clitoris and a clitoral hood. Now how that's done is taking a small portion of the glans penis and the nerve that is attached to the glans penis, then that triangular portion of the glans penis is placed under the clitoral hood, and that nerve gets wrapped around it. Now the surgeons these days -- post-op result -- are really good technical surgeons. And that state of the art has been reached. Some of this depends on the instructing of post-op care after the patients have surgery. (View the slide)

This isn't showing up very well, sorry. (View the slide) Another post-op result on vaginoplasty. (View the slide) And that incision on the abdomen is where the incision is made to do vaginoplasty using the intestine, the rectal sigmoid portion. (View the slide) And a male to female. (View the slide)

Now in female to male surgery the situation gets a little more complicated, in that many female to male patients elect to do mastectomy only, and or hysterectomy. So the mastectomy is really the Gender Confirmation surgery, and they don't go on to do any kind of genital construction.

Now in the metoiddioplasty procedure, which takes the -- utilizes the clitoris that's become enlarged from taking testosterone. Phalloplasty is a multi-stage procedure, obviously more costly. And I can answer your questions regarding cost, and I'll give them at the end. Because that's pretty standard throughout the US. Phalloplasty, the word physicians in the crowd who rotated on surgery is "flaps." Flaps are tissue rearrangements. And that's the big word in plastic surgery. So there's probably about 20 different ways to construct a penis, and each surgeon has his own way of doing that. And it's important when you're counseling a patient that they, when they're feel they're about ready for surgery, they want to explore it, that they contact the surgeon and find out what their particular technique is and what the requirements might be for the surgeon in terms of body fat, smoking and things like that. (View the slide)

This is a female to male patient, pre- and post-hormones. And these pre- and post-mastectomy in female to male. (View the slide) Another post-op mastectomy. (View the slide) This is also mastectomy. This guy got pretty big from testosterone from body building.

Now, in the female to male I said there were different, they had different options and choose different things to do. But the problem there is no penis. (View the slide) And the metoidioplasty which I just talked, mentioned, I'm going to show you now. (View the slide)

Now this is on the surgical table with the testicular implants in place, and that is the enlarged clitoris. Now what happens there is the clitoris is moved upward into the anatomical position of a penis. And part of the labia minora get wrapped around the clitoris, although we do have patients that ask for an uncircumcised penis in this surgery. And then the labia majora are used for the testicles. (View the slide) Wanted to show this. This is a patient I, if I recall, was changing his implants. (View the slide) And another post-op of the metoidioplasty, you could also call it genitoplasty. (View the slide) And other version. (View the slide)

Now one of the reasons that people choose to do the surgery -- it's considered a one-stage surgery, therefore less costly. But there's not body disfigurement. We're not rearranging tissue from elsewhere on the body. (View the slide) It also leaves complete sensibility to the patient because we're using the clitoris as tissue. When I get into phalloplasty, you'll see that it may or may not be sensitive. It's not a sensate phallus. This one is. The disadvantage here is there's not enough length for complete intercourse. (View the slide)

And we do do urinary extensions or urethra extensions. (View the slide) The other surgeons do this, too. And I, there are surgeons who specialize more in female to male surgery then in male to female surgery. A female to male patient ready for phalloplasty. (View the slide) Now this is someone who's already what's called first stage Phaloplasty done, which is creating a [inaudible] flap on the abdomen And the patient's coming for the second stage of surgery. And these surgeries can take up to a year, if you're gonna do urethral extensions and penile implants and all that. It's also gonna get very costly.

This is someone right after surgery after the phallus is complete. (View the slide) Post-op result in Phalloplasty. (View the slide) Another post-op result.(View the slide) ( View the slide) (View the slide) (View the slide) ( View the slide)

Now in phalloplasty this is a non-sensate phallus that really has not much feeling. The clitoris is at the base, and a rod is being inserted to be used at the time of intercourse, and that rod will connect with the clitoris that's at the base. We, most surgeons do not disturb the clitoral tissue because that is a sensitive organ for the person. (View the slide) (View the slide) ( View the slide)

Now one of the innovations in female to male surgery, and much, much work still needs to be done with this surgery, is we borrowed from the Chinese here. It's the Chinese forearm flap. And a nerve, a vein, an artery is removed from the forearm and that's transplanted over to the phallus. That nerve is sutured to the nerve supplied to the clitoris so we can do sensitivity in the whole length of the phallus. Or it can be done. I'm not a surgeon. (View the slide)

That's a urethral extension. Those are done these days, but there's complications involved with this. (View the slide) (View the slide)These procedures are safe. People don't die on the table from them. They don't die from infections. Surgeries in terms of phalloplasties is being done, but the surgeons who do female to male work in phalloplasty are trying to get better technique and more sensitivity to the phallus. (View the slide)

I will review costs, but I want you to know costs compared to other kinds of surgeries -- it is lower. You can spend a lot of money on back surgeries and hip replacement, other kinds of rehabilitative surgeries. (View the slide) A female to male patient post-op. This is an old-timer in the Bay Area, Steve Dane, well known, lost his job as a teacher. He's now a Chiropractor in the Bay Area. This surgery allows couples to become more intimate, which is one of the main reasons that they follow through the Phalloplasty. Another couple, the woman on the left is a male to female with her husband. And that's it (Slides not available).

Now, to answer your questions regarding cost. Because I always get that when I talk, and just to save you the time. Penile Inversion surgery in the US, and that's pretty standard, is $12,000 including surgeon's fees, hospitalization. The Intestinal Transfer/Rectal sigmoid transfer requires two teams of surgeons, is done about four places, is more costly, more invasive, and that's $26,000. I give a range for female to male surgery depending on what they do. A mastectomy will be somewhere between $6,000 or $7,000 all total, that's OR cost, anesthesiologist; and it can go up as high as $85,000 when you do all the extra procedures, such as urethral extension and penile implants. There are insurances that do cover this cost, if it's not excluded on the policy, and that should always be explored by the patient and the surgical team doing the work.

Am I done?

JoAnne Keatley: Actually you've got a couple of minutes for questions.

Judy Van Maasdam: Okay, a couple of questions I guess.

JoAnne Keatley: Any questions for Judy?

Audience Member: With all the knowledge that you have about surgeons, which one is the one that you'd recommend for male to female sex change?

JVM: I think that always these decisions are your decisions to make. I certainly wouldn't recommend one surgeon over another. It's important for you to contact the surgeon and see what their specific requirements are. You certainly can talk with other people who have been to that surgeon for surgery, get their experience on, and there's a lot of information on the Internet available these days. There's certain web sites that are actually showing the surgeon's results. So I think that's a good way to research it. I would not recommend a surgeon. That's an individual choice. Any other questions?

Audience Member: Yes. An HIV candidate, can she or he become....

JVM: Yeah, if all their values are, you know, their viral load and all that's within healthy means. Obviously surgery is done on only a healthy, physically healthy patient. Because this is very intricate, it can be complicated surgery. So you have to be in good health. Patients should not smoke. They have to be off estrogen two weeks prior to surgery and, as I said, in good physical health. Yes.

Audience Member: How many hours do these surgeries take, approximately?

JVM: From four to six hours. A mastectomy should take anywhere from three hours. Penile inversion in the hands of a really experienced surgeon should be about a four to five hour surgery. The intestinal procedure is about six hours, and if you do the microsurgery for the forearm transfer, that's an eight to ten hour surgery. And there are some surgeons that do all this work in one surgery. In the female to male it's really not recommended. I mean, most surgeons want to break it down into stages because that's way too much stress on a person's body. And the body can only heal in certain areas, so you're asking for a lot of complications if you elect to do a twelve, fourteen hour surgery.

JoAnne Keatley: This will be the last question for Judy.

Audience Member: My question is that for both SRS for MTF and FTM there is always a myth of sensation and how orgasmic it is. What, I mean, what is really the real answer to that? Is there any feelings or sensations?

JVM: Well, yeah. I can only speak from clinical observation. That's not really been studied scientifically. But nerves are left in place. And my take on that is if the person was sexual before surgery and experienced orgasm, they're gonna have it after surgery. If they didn't before surgery, that's gonna require some sex counseling probably with their therapist or someone else to achieve orgasm. It's not necessarily gonna come automatically.

JoAnne Keatley: Judy's name and phone number is listed with the conference participants, so if you have questions for Judy, I'm sure that she'd be happy to answer them.

JVM: I'd be more than happy. [applause]