"The Wild, Wild West of Surgery"
by Scott Newgent
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It's Experimental, Ya'll - Yeehaw. Trans Surgery VS Reality by Scott Newgent
Deciding to get a Phalloplasty is a personal journey. The surgery itself is a hot-button issue in the transgender community and I believe it will continue to be for quite some time. These explanations, experiences, and opinions are from my personal knowledge from a clinical perspective. Some incidents are mine, some I have read in medical malpractice cases, and others are ones I listened to over coffee with friends. Warning, the following accounts are going to be explicit but necessarily so in order to put the complexities and expectations into a realistic viewpoint—it would have benefited me when I started this journey.
Let's start with a quick synopsis of the most popular FTM (female-to-male) bottom surgeries and then finish with the "Flagship"—Phalloplasty.
This is a lower body surgery that creates a penis by cutting ligaments around the clitoris to release it from the pubis.
(As though it’s somehow being held down by forces unknown to us; quite comical because medically it just about mirrors how women have been treated since the beginning of time.)
Once the clitoris is released, the surgeon then wraps around the labia minora skin to create a little penis. A scrotoplasty (just what it sounds like - a constructed scrotum) can be designed to give an even more realistic appearance, and a urethra lengthening can be added to provide the patient with the ability to pee while standing.
Metoidioplasty was developed in the 1970s and is a far less invasive surgery than phalloplasty. You get a realistic-looking little penis and can stand to pee. But, let's face it, penetration is most likely out of the question. With testosterone treatment, the trans man does grow a more extended and bigger clitoris, but having one grow big enough to penetrate is a rumor that I have not been able to clear up. I have had a couple of FTM patients tell me they can penetrate, but I always have questioned that in my mind.
Pros: Cheaper than the other options at $5,000-$20,000 depending on what you choose to do, and if you add on a urethra lengthening and a scrotum. There is less downtime in terms of recovery and fewer chances of complications. The surgery is not incredibly long, 2-5 hours, depending on what doctor or website you read.
Cons: Just one—penetration…NOPE.
The Centurion procedure which releases the round ligaments that run up the labia and uses them to surround the new penis was invented and performed by Dr. Peter Raphael in Dallas, Texas. I had my top surgery and a couple of other procedures done by Dr. Raphael. This guy is an artist. He has an impressive background; his father was a surgeon and his mother a talented artist, and he kind of blends those disciplines into his skills in plastic surgery. If you walk by his office, sometimes you can catch him sculpting implants trying to figure out better ways to create the most realistic scrotum—great guy, sincere with helping people in the transgender community, careful and adept. Dr. Raphel is a little more costly but worth the investment. This procedure can also add urethra lengthening, giving the patient the ability to pee and have a scrotum.
Pros: It's a Metoidioplasty on steroids, more prominent and more realistic. Cheaper than a Phalloplasty $8,000-$20,000
Cons: Again, sorry guys, penetration is not really an option.
Ok, so now let us get to the "Flagship," of female-to-male bottom surgery……drum roll please.
If you research this bad boy online, you will think you hit the jackpot. Realistic penis, penetration, pee while standing—an all-around winner-winner-chicken-dinner. But things are not always what they seem to be especially with marketing experts and the capricious powers of the internet creating smoke and mirrors.
In the 1940s, Sir Harold Gillies of New Zealand was the first surgeon to take skin from another part of the body to create a penis. But the first surgeons to try and tackle this colossal surgery didn't do so here in the USA until the 1970s.
With this surgery the surgeon takes skin from two different sites on the body; one harvesting area is cut into deeper and full recovery to the skin's initial appearance is never regained. The surgeon then creates a urethra lengthening procedure and takes the skin from the site where it is harvested then molds and stitches a penis. Once completed, the skin is re-attached and put back onto the body.
Awwww, penetration, maybe?
Wow, where do I begin? Well, first the surgery can take anywhere from 10-20 hours to complete, and you can have anywhere from 2-22 operations, depending on complications—and complications are vast, numerous, and frequent. Since the skin is not able to become erect, the actual penis is long and cumbersome all the time. Recovery is brutal, not a, "Hey boss, I need a couple of weeks off to have surgery." NOPE! You can expect this recovery to take months and months if not years, depending on what type of complications you have. This is an expensive surgery—$50,000 on the super low end up to hundreds of thousands of dollars. If your insurance does cover this surgery, make sure they will cover the additional operations to complete the surgery and all the complications that may arise.
So, you still want to get a Phalloplasty. The idea of “penetration” is just something you have to have? Sure, I get it, and that's the reason I did it too, as well as my ex-wife wanting the elusive, "Penetration." The allure is appealing, but the drawbacks have the potential to change many things in your life that you need to be aware of.
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This surgery is no joke. When I first was looking into Phalloplasty, I obsessively searched the internet, and the plethora of information that pops up is like Disneyland for the FTM. Oh my God, it's too good to be true—like Cinderella married the FTM with a Huge Penis and they lived happily ever after enjoying penetration after penetration.
As you open different sites, a handful of surgeons become the most relevant, and they look so esteemed with awards, dual residencies, and success after success. If fact, if you dive deep into investigations, you can find fictitious accolades and awards that boast the potential surgeon's competencies.
If you base your decision to have a Phalloplasty on what is on the internet, you are making an ignorant decision with lots of moving parts. Imagine yourself skipping down the yellow brick road just like Dorothy from The Wizard of Oz. Do you recall who was behind the curtain? Do you? Now imagine deciding something as drastic as a Phalloplasty with a couple of clicks of a mouse. It's dangerous and downright insane.
Be sure your surgeon behind the curtain doesn't resemble the all Powerful Oz from The Wizard of Oz.
If you research some of these doctors you will find medical malpractice cases, but you must do your homework, merely checking a doctor's state board license is not enough.
Malpractice cases can be hidden by settling or leaving the state and starting anew. If you investigate, you will find that the decision to get a Phalloplasty obliterated quite a few people's lives. The complication rate is enormous. Prior patients have been shattered physically, spiritually, and left in financial ruin.
Having a big penis that you can use to penetrate is not a fair trade for having to wear a colostomy bag for years or even the rest of your life, not in my estimation. Again, I'm not revealing anything about my experience; this was something I read in a malpractice case.
First, let us take the skin that needs to be removed to create the penis. You have three choices, the forearm, the thigh, and the upper back. To be able to use the leg for harvesting the patient needs to have a specific body-to-fat ratio for the procedure to work, this skin also must have a certain elasticity. Depending on the age and body fat of the patient, this might or might not be an option. The benefit to the thigh is the harvesting site on the leg can be covered; this part of your body is never going to look the same—you need to understand this. You will look like a burn victim in the area where the skin was harvested. The con is that it's not the best site for sensation, but that’s not the worst part. You may or may not be able to orgasm. I'm not bullshitting you—this is your life; you need to understand this stuff.
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The second place for harvesting skin is from the upper back. Again, this area can be covered, but the sensation is less. Your odds of orgasming goes down even further. Who wants to go through all this pain, money, and suffering to have a penis that doesn't allow you to orgasm?
The last area is the forearm and the pros to this area is that the sensation great—the bad news is that your arm will never look or work the same. For some reason, this information is almost nonexistent when you search the internet. The surgeons’ websites quickly skim through this as if it's no big deal. You can useGoogle images though and these images are realistic. Look at them. Don't ignore these pictures of what you will be putting your arm through.
My surgeon downplayed using the forearm site to the point where I allowed myself to feel silly for being troubled about questioning whether or not I should use the forearm. In fact, as I look back, my surgeon was the pivotal point in my entire decision to get the Phalloplasty. Sure, my wife wanted it, but if I knew what I know now, I would have never made the decision to have a Phalloplasty. My surgeon had this arrogance and gave me so little time to consider it pushed me into believing him, and so I did. It reminds me of a cult where the followers start to question things, but they look around, and everyone else is so obedient and faithful that they figure it's just them. Little do they know in the background the leader is shuffling people and rumors around, so they don't eventually meet up and figure out the leader is full of shit.
The authenticity, for me, is that my arm is handicapped for the rest of my life. It hurts to type on the computer, I can't play sports, and my hand remains swollen years after the surgery and it...well, it hurts all the time. Not the pulsing pain that ravages you, but the, "Damn my hand hurts and I'm having a hard time holding a fork to eat," type of pain. Pain that gives you a glimpse into what your body might feel like as a 100-year-old man, but just in your arm. It's depressing, I can't lie.
Another predicament is nerve damage; the surgeon cuts so deep that nerve endings are exposed, and they may never close for the rest of your life. For me, I must wear a brace because a graze on my forearm skin sends me through the roof with shock.
Another delightful feature of this method is that the skin from the forearm (or other places) is not all the skin that needs harvesting. Another area is used to gather more skin, usually the thigh, but it's not as deep, so the scar is quite unnoticeable. But, wow, talk about a road rash gone wild!! Hurts, hurts and hurts some more. The good news with this harvest site’s pain recedes in six weeks.
Donor site information seemed to be glossed over and lessened by the websites for the surgeons and the surgeons themselves when you have the consultations. I encourage you to Google pictures of the body parts and how they harvest the skin. Look at those images with both eyes open. If you are speaking with a surgeon and he or she minimizes the harvesting of skin, I would be worried because this is not a walk in the park and can leave you damaged in many ways if you make the wrong decision for yourself.
Are you prepared for the never-ending question you will get if you leave your arm exposed, "What happened to your arm?" You can come up with your own explanation. But I like to say, "Oh, I used the skin to create a penis. It doesn't work right because I was born with a vagina. But my wife wanted me to be able to penetrate her and pee standing up. She didn't want me to embarrass her if I was ever in a gym locker with any of her friends or family. One always has to look after their reputation!” Don't you agree?
Recovery from the harvest area on the forearm is years. From my experience, you never get the full use of your arm again so be prepared to look like a burn victim and be ready to have a disabled forearm for life.
You want to pee standing up? Who wouldn't really? What a convenience to pee standing up and if I had the choice, I would choose to pee standing up too. But think about this: It is not easy to go from a female urethra to a male urethra. The urethra has to lengthen and run through the skin that is being used to create a penis. Creating something in surgery is much harder than cutting something off. When you create, you invite the opportunity for complications and the Phalloplasty is generating a ton of different things simultaneously. The complication rate ranges from 39% - 95%. The complications vary depending on the length of the desired penis and urethra length. My “on the street” poll for complication rates with Phalloplasty is 100%. 100% of the people I have talked to and read about have had complications.
If you Google surgeons that have the Phalloplasty in their wheelhouse you will be pleasantly surprised by websites bolstering 100% success rates with limited explanations of complications and risks. Do not be fooled. My inquisition question would be to ask, "At what cost?" If I told you, "Hey bud, ride your bike 10 miles to the next town but the probability you are going to get hit by a car and maimed for life is between 39%-95%.” But if you hang in there and endure having surgery up to 22 times, we guarantee 100% you are going to pee standing up. Are you ducking nuts man?
The most frequent complication of Phalloplasty urethra lengthening is fistulas. Aw, fistulas, those little inconveniences, inconsiderate small holes that develop between where the vagina was and the new path up to the bottom of the penis. These tiny holes cause significant problems and pain, my God the pain can be horrendous and cause serious infections as well as a detectable stench of urine that drains out of the holes throughout the day. Fistulas cause pain, swelling, incontinence, and the embarrassment of smelling like an infant or 100-year-old-man that needs to have their diaper changed. The problem is the stench will be coming from you, and you will have to learn how to carry diapers so that you can change them several times a day. Take that as a confidence boost and an excellent intimacy motivator between you are your lover. Sexual spontaneity will most likely be nonexistent. Good news though—you might be able to pee standing up, but your fistula will dribble urine on the floor.
Lastly, fistula correction has a high probability of not being successful in surgery. If you do need additional operations, be prepared to continue the process several times to get the issue resolved. But, in the end, you may still have to get rid of the urethra lengthening altogether and re-route it back to the same place it was when you started. Peeing will again require that you sit down. Yup, that's right peeing sitting down. I hope you can still reach orgasm because that would be a real bummer!
For weeks you will have what is called a “super pubic tube.”This is a tube that comes out of the side of your body and travels inside you, inserted into the bladder to allow your Phalloplasty to heal. Some surgeons are okay with removing it after 4-6 weeks, and some won't remove it for months and months. It's uncomfortable but in my opinion the least evasive part of the surgery. Enjoy! No middle-of-the-night bathroom breaks.
Sepsis. Ever heard of this medical delight? I like to gauge the bench of a Phalloplasty as inhuman and grotesque. With the invasiveness of this surgery, the odds of infection are high. If you add a sepsis infection, it can knock a patient back light years in recovery. Sepsis feels like you went ten rounds with Mike Tyson during the day and then spar with Bruce Lee jumping in the ring adding a roundhouse kick that catapults you back into your bed that is made up of steel nails. The tiniest amount of movement feels like you are moving a house with your bare hands. Psychologically, you feel defeated even by the idea of having to change the channel on TV with a remote. It's bad, guys. Sleeping is something you can forget about with the restless leg symptoms. You can look forward to the haze of insomnia as it leaves you feeling hopeless and lost.
Imagine having your skin ripped and burned from your body and placed on tables where a doctor creates a male organ and re-attached to your opened body carcass. The area where this exposed organ is being held together by stitches and gauze will be exposed to the outside elements for weeks and weeks. The wounds that need to heal are located inches from where you defecate. If you do develop a fistula, urine will meet the wound as well. You're afraid of touching a bathroom doorknob? Hell, honey—hold your breath, be strong, and if it gets to you— too bad. Break out the Xanax and don't think about it. Better yet, THINK ABOUT IT NOW and consider the risks.
Surgeons? So what's with the surgeons that get into this field?
Don't live in the “Fantasy Phalloplasty” land. Let yourself be in denial about the kind of person you are married to or pick up the size 30 waist jeans and convince yourself these would fit you great. But not with Phalloplasty and not with the surgeon you choose. We know that people in a marginalized part of society are less protected. Why do you think serial killers with the longest careers target and kill indigents and prostitutes? Because most people don't give a shit about them. I say most because there are good people in the world, but far fewer than you think. It’s human nature to act like Pirana's feasting on a wounded fish in the water. That is why racism will never leave our world, it will always be there. Face it guys—we are low-hanging fruit to be mistreated. Know that and understand you have to protect yourself because no one else will. That includes picking a competent surgeon.
You must ask yourself; Why would surgeons choose this type of surgery to perform?
A general surgeon averages a $220,000 salary a year. A specialized cardiologist almost doubles that at $512,000. A standard appendectomy in the USA costs $21,000. A Phalloplasty with a scrotum, urethra lengthening, and pump averages $85,000-$200,000 and insurance is covering it now. Think of the complication revenues from Phalloplasty alone. Hell, it might even be worth it to skimp here or there in surgery because who's going to care? It's just a transgender person and the additional revenue could be a plus.
I believe you can figure out the reason why this field is selected. A surgeon who is not good at anything else can jump into this area of practice and make a fortune, be sought after, have articles written about them, and have a narcissistic personality fed like royalty. To perform this surgery, you don't have to have any specialized education other than being a general surgeon. I can't find any medical guidelines or regulations or checks and balances. It's like the wild, wild west of surgery.
In my opinion and experience with going through this surgery, I believe Phalloplasty surgery should be illegal until regulations are in place to assure the surgeons that are administering the operations adhere to a strict set of guidelines.
Since it is still legal and I do believe there are incredible and genuine surgeons like Dr. Peter Rapheal. You need to ask your potential surgeons questions. If he or she is arrogant, doesn't allow you to see additional pictures of the past patients, or denies a request to speak to a previous patient—move on to another who will. Ask questions like, "How many medical malpractice cases have you had filed against you? Not ones that you have settled, so they are not on your record. How many have been filed?” Check the medical boards on your potential surgeon’s license, and review the superior courts where your doctor is practicing. Look up medical malpractice cases on the surgeon you are working with; read them. Ask your potential surgeon if they are creating the male organ themselves or if they pay another surgeon to do it. In business, we call that subcontracting and the responsibility for issues that arise tend to be ping-ponged back and forth between the surgeons. Who is going to be in the room during the operation, and who are the doctors? Ask if a specialized arm surgeon will be doing the work that is needed to harvest the skin. How much medical malpractice insurance do you have? Do you know that surgeons don't have to carry medical malpractice insurance?
What part of society do we represent to people other than our friends and family? If we think about facts and not how we wished our culture was, what would that say to you? As transgender people, we are exposed to mockery, bigotry, loathing, judgment, and treated with the lowest form of virtue at times. How many times can you count where you have been out and overheard a joke about the transgender community only to watch the wine glasses click together with hilarity and approval. Hell, up until just recently we were the red-headed stepchild of the LGBT community. The last letter in the acronym of the least accepting society in the world. Even our kind, the LGBT community, rejected us, derided us, and only left a crack in the door for acceptance. It has only been since Jenner that we have been revered as even a species of the human race, and that was only 5 or 6 years ago.
In the end, if you do choose surgery, be smart about it; you are worth it. At least I think you are. A person who endures the most obstacles in life can offer the most to society. Being different affords tremendous obstacles and you have a lot to offer the world because of it. You are worth a great surgeon, you are worth a great life, YOU are worth all your hopes and dreams. Unfortunately, the vast amount of our society is not going to feel the same way, it’s just the facts. Protect yourself and love yourself and count on yourself, because in the end, it’s all that you have.
by Scott Newgent