Visible Man
Jamison Green offers a man's POV on life in the trans lane. Opinion,
advice, and information from an internationally respected leader of the
FTM community.
Under the Knife -- Part 3
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.
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