Like many other surgery patients, Hayley Anthony has a daily physical therapy regimen. But unlike other post-ops, the 30-year-old marketing consultant is recovering from a procedure she helped invent. Five months ago, she became one of the first people in the world to have a piece of tissue incised from the cavity of her abdomen and turned into a vagina. A surgeon in New York City may have pioneered and performed Anthony’s procedure—but the idea to try it in the first place was all hers.
With only about a dozen doctors in the US who specialize in gender affirmation surgery, it’s nearly impossible to keep up with demand, let alone innovate new ways of doing things. But that’s what Jess Ting, director of surgery at the Center for Transgender Medicine and Surgery at Mount Sinai, has been up to for the last two years. What started as a Google search on Anthony’s computer is now the most sought-after surgery Ting performs. In the last six months he’s given 22 trans women something that they weren’t sure they’d ever have—a vagina that looks and feels and secretes like the real thing.
Anthony had known her whole life that she was female, but she didn’t begin transitioning until about four years ago. Then, in the fall of 2015, after months of working with a therapist to better understand herself and her options, she accepted that she had to do whatever it took to have the right body for her mind. She scheduled a consultation with Ting and they made a date to make her a new vagina. Then she went home and down a deep internet hole. “I had gone into the process, eyes wide open, understanding all the compromises and willing to accept them,” Anthony says. The procedure she was mentally preparing for involved slicing open the penis, removing most of the inside parts, and then folding the penile skin into the space between the urethra and the rectum (kind of like turning a sock inside out). In what has become the standard surgery for a male to female bottom transition, the outside of the penis then becomes the inside of the vagina.
But a vaginal cavity made out of skin doesn’t do some things the inside of vagina should (like get wet when aroused) and does others it really shouldn’t (like grow hair, even after electrolysis). For trans women with genital dysphoria, it’s been the only real option for bottom surgery, and it’s been a pretty good one. But the procedure can still leave many disappointed.
During her research though, Anthony came across a paper describing the work of some doctors in India who were building vaginas a bit differently. They were performing surgeries on women with a rare disorder that causes the organ to develop abnormally or not at all. So they had to start from scratch, which requires a lot of material. They found a way to do that with tissue from the peritoneum, which is basically a bag of loose tissue that encircles the inside of your abdomen and holds your guts in place. She brought the paper into her next consultation and showed Ting. “At first he was like, ‘What is this girl doing?’” Anthony says, laughing. “I have no medical training. I’m not a scientist. But then he looked at it and said, ‘Oh, there might be something here.’”
Surgeons have tried before to harvest other parts of the body to make more vagina-like vaginas for trans women. About 10 years ago some doctors attempted the procedure with small portions of patients’ colons. That didn’t work out. “No one wants a vagina that smells like a stool,” says Ting.
No indeed. But alternatives remained elusive, and brainstorming them kept Ting up at night. “I kept thinking, there’s got to be something better,” he says. “But where were we going to find a large amount of pink, hairless, inner skin that secretes fluid?”
The peritoneum, it turns out. After Anthony first brought his attention to the Indian research, Ting started doing some research of his own. The peritoneum, he found out, regenerates naturally after just a couple days. He was even more intrigued. Then he shadowed a colleague at Mount Sinai who was a laproscopic surgeon, watching him remove gallbladders from a tiny incision in a patient’s abdomen. And he watched videos of surgeries that gave him a better look at the tissue to see how much of it he could harvest with the same technique. “It’s just like taking a tool you’re well acquainted with from a toolbox and using it in a new way,” he says.
Ting’s first patient went under the knife about six months ago. It wasn’t Anthony. Though she wanted to be the first, a change in insurance plan forced her to push out her surgery date to April of this year. But she’s glad she got in when she did. There are more than 100 people waiting for gender affirmation surgeries at Mount Sinai, and Ting is the only one doing them.
Though, that should soon change. In July, Mount Sinai launched the country’s first medical fellowship dedicated explicitly to transgender surgery. Ting will be training one fellow each year and he’s hopeful they’ll stay on staff once they’re done to help meet the city’s growing demand. Another important part of their job will be to follow up with these surgery patients over the next few years; while the new procedure is showing superior results so far, it will be important to monitor to see how it holds up long term.
Today, more and more transgender men and women are scrambling to schedule gender affirmation surgeries, scared that the Trump administration is sliding shut their recently opened window to accessible healthcare. In May, Health and Human Services Secretary Tom Price told a federal court that he’s reworking a provision in the Affordable Care Act that requires states to cover transgender care through their Medicaid programs. The rewrite is likely to free states to refuse coverage for hormones, counseling, and surgeries for transgender men and women. Not that they have to wait; Price said he’s declining to enforce the rule in the meantime.
Patients that live in left-leaning states that have passed their own protections for trans health care, like New York and California, will have a better chance of retaining access. About 70 percent of the transgender patients at Mount Sinai have insurance through the state’s Medicaid program. But many still have to fight to get the coverage they need. For those living in other parts of the country, the situation is even more dire. “There are few populations for whom if you started to play games with people’s access to health care it would be more detrimental.” says Anthony. “Trans people’s attachments to stable sources of income and legal protections are as precarious as they come. The progress we have made has been very limited, very contingent, and very easily lost.”
And while she’s afraid for how the current political climate (and the new administration) might erase protections for trans communities, she is grateful to finally be in a body that does all the things she wants it to. Like, have sex without needing lube. Good sex. Sex with orgasms. “I know that I didn’t always have it, but the way it feels now, I just can’t imagine my body being any different.”
Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.