bottom surgery

BMI Cutoffs are unscientific and harmful

As I’ve written about before, BMI (Body Mass Index) is an unscientific concept that is often used to deny trans people life-saving surgeries. It is treated by far too many surgeons as medical fact, despite the vast body of evidence that it is wildly inaccurate, scientifically useless, and never intended by the creator to be used on an individual basis.

Recently, the only surgeon in Washington State, Geoffrey Stiller, formerly one of the few surgeons who would accept fat patients, updated his policies quietly to exclude people over the arbitrary and oft-used cutoff of 35 BMI. That means that at least two people close to me are now being denied gender affirming surgery without so much as a notification about the change. So I wanted to take the opportunity to share some scientific research recently published on the topic.

  1. Recent research shows that there is no correlation between BMI and surgical complication rates in trans people in either vaginoplasty (bottom surgery) or mastectomy (top surgery)
  2. “Obesity” (aka normal body variation) is very common in trans people seeking surgery (26% at Mount Sinai) and did not change despite efforts to lose weight prior to surgery
  3. BMI is not an empirically based method of denying gender-affirming surgery

Trans people should not have to bear the burden of educating providers about our care but all too often we are put in that position anyway. So next time a surgeon tells you they won’t perform surgery because of “policies”, please feel free to use this research to push back on them. Even if you don’t win a single conversation, hopefully you will plant a seed and prompt them to actually read the scientific literature on the topic. I found these articles with only a cursory review of the topic and I’m not even a doctor.

Citations

  1. Ives GC, Fein LA, Finch L, Sluiter EC, Lane M, Kuzon WM, Salgado CJ. Evaluation of BMI as a Risk Factor for Complications following Gender-affirming Penile Inversion Vaginoplasty. Plast Reconstr Surg Glob Open. 2019 Mar 13;7(3):e2097. doi: 10.1097/GOX.0000000000002097. PMID: 31044103; PMCID: PMC6467628.
  2. Rothenberg KA, Gologorsky RC, Hojilla JC, Yokoo KM. Obesity is Not Associated with Complications or Revisions after Gender-Affirming Mastectomy in Transgender Patients. Plastic and Maxillofacial Surgery. 2019 Oct 1;229(4):sup1. doi: https://doi.org/10.1016/j.jamcollsurg.2019.08.494
  3. Martinson TG, Ramachandran S, Lindner R, Reisman T, Safer JD. HIGH BODY MASS INDEX IS A SIGNIFICANT BARRIER TO GENDER-CONFIRMATION SURGERY FOR TRANSGENDER AND GENDER-NONBINARY INDIVIDUALS. Endocr Pract. 2020 Jan;26(1):6-15. doi: 10.4158/EP-2019-0345. Epub 2019 Aug 28. PMID: 31461357.
  4. Lisa M. Brownstone, Jaclyn DeRieux, Devin A. Kelly, Lanie J. Sumlin, and Jennifer L. Gaudiani. Transgender Health. ahead of printhttp://doi.org/10.1089/trgh.2020.0068

5 Month Post-Surgery Update

It’s hard to believe it’s already been 5 months since bottom surgery. Though then again, it is very easy to believe it has been over 5 months since I’ve orgasmed because I can definitely feel that frustration.

I had my “6 month checkup” a little early yesterday. The doctor is impressed at where I’m at and reassures me that it is totally normal to not have orgasms until 9 months (which feels like forever!). I’m now at the biggest size dilator they gave me after surgery and I’m planning on buying an even bigger one soon to open up more options for toys and partners.

The one concern is that I’m still having some bleeding sometimes when I turn up my toys too high near my clit area. She had me send her a photo and confirmed that it is from some leftover granulation tissue that is persisting. I talked to my PCP about it and she is prescribing me some silver nitrate to apply to the area to heal it over. I also have a steroid cream to apply to aid healing. It’s a relief to know it’s not because of trauma I’ve done to the area but just tissue that bleeds easily and is treatable.

Other than that, I just need to keep practicing and hope that the orgasms come soon. I have 2 more checkups at 9 months and again at 1 year (hopefully in person). By that point I should be fully healed and just need to keep up on dilation once to twice a week.

41 days until surgery!

I’m down to less than 6 weeks before gender confirmation surgery and I’m so nervous! I’m not anxious about the surgery itself other than a natural concern about the rare complications. I’m nervous that something will happen between now and then to prevent me from getting the surgery. Because the idea of delaying it sounds like torture. When I did my consult a year ago, I was ready. And now I am wishing I had started the process sooner.

I’ve done literally everything I can do. I’ve bought medical supplies, collected comfortable clothing for the recovery, changed our original flight plans to a roadtrip, booked an accessible AirBnb, and even scheduled my pre-op bloodwork. But my brain can’t stop focusing on all the things that could go wrong.

What if there’s a new wave of COVID-19 cases now that we are re-opening businesses prematurely? What if I get sick right before surgery? What if I get down there and find out that the hair removal wasn’t sufficient because I missed 2 months due to COVID shutdowns? What if the doctor says that my weight is too much of a problem since I’ve put on 20 pounds in the last year?

The last one is the one I hate the most. I’m a very fat positive person and generally I don’t care about my weight. But last year I had a bad experience with Dr. Satterwhite when I consulted with him and he was hyper-focused on my high BMI. He claimed that if I gained any more weight it would be “unsafe” to do the procedure. Thankfully Dr. Wittenberg, the surgeon I ended up choosing, told me that they are more like guidelines for optimal results which I absolutely agree with, but my brain is still anxious about it. Fatphobia is one of the few remaining socially acceptable forms of overt discrimination.

In the end, there’s not much I can do about it. I know all the data about how fad diets don’t work and can cause more medical issues than they solve. And luckily the nutritionist/therapist I’m working with agrees and is helping me balance my food in a way that feels appropriate to me. But the voice of that fatphobic doctor still haunts me. I also wonder how many fat trans people he’s turned away and made believe that they can’t get surgery.

On a more positive note though, my job is being super supportive. They have hired new permanent and temporary staff to take on my workload while I’m gone with enough time to train them before I go. So now I know I can leave even in the midst of a busy period of running COVID research studies and know my work is in good hands.

Currently I am hoping to be able to return to at least part-time work after 6 weeks which is the minimum time my surgeon recommends. Since we are completely online now it should be more accessible. But there is a potential that I may need the full 12 weeks before I’m lucid and off pain meds.

For housing I was lucky enough to find a basement apartment owned by a gay couple to rent that not only is ground floor but has a kitchen and even AC! It was very expensive at $3,400 but it’s centrally located in San Francisco so I can easily make it from the hospital and to my follow up appointments without sitting in traffic. I’ll be staying for a full month since I need to arrive 5 days prior to surgery for my pre-op and stay for 3 weeks after for post-op check ins before I’m cleared to travel. I’m really hoping that I can handle the 800 mile drive home without too much pain since I don’t feel very safe about airports right now.

I’m in the final countdown period and I am so excited! Thank you to all my friends who donated over $2,500 to make this happen. And I couldn’t do this without the support of my wonderful spouse who will be my caretaker after surgery. I guess you could say it takes a village to make a vagina.

Bottom Surgery is still a Go!

I’ve been on edge ever since this pandemic started because I have been so worried that my bottom surgery this summer would be postponed. But today I got confirmation that I can re-start laser hair removal to prep the area this weekend. And based on what the surgeon’s office has said, I think I should still be able to get enough of it in by July 29th to head down to San Francisco for my August 3rd gender confirmation surgery.

I’ve changed my plans and instead of staying with a friend-of-a-friend, I will be staying in an Airbnb so that we can maintain social isolation. My spouse and I will also be driving down instead of flying because as asthmatics, airports are a pretty big risk. And I don’t know what the visitors policies will be like at the hospital during my 3 days there after surgery. But damn am I glad that it is still happening.

Lately all the little things have been bothering me because my body just can’t wait to get this finally resolved. I am grumpy about having to use my hands to pee. And I hate everything about my balls. But it is only 68 days away now! I am almost there.

First surgery prep laser

I had my first laser hair removal session on my genitals today to begin prepping for bottom surgery. I’ve been dreading it all week because it is so extremely painful when I do it on my face that I assumed it would be even worse on such a sensitive area. But I was pleasantly surprised. I don’t know if it’s because the numbing cream works better on the thinner skin (it did last longer), or because it is a wider dispersal laser head but it was a breeze and over really quickly. It honestly hurt a lot less than waxing or sugaring.

Turns out the worst part of laser down there is the shaving. It is a pain in the ass (literally) to try to get it all and the aesthetician still  had to clean it up. I recommend having a friend or partner help you shave. The other part that sucks is the insurance approval process which took me three months of pestering.

But session 1 is finally over. I have 6 more months of doing this every 6 weeks and hopefully it is enough for surgery. I’m also going to finish laser treatments on my face since I had to stop because it is expensive to pay out of pocket ($300 every 6 weeks). But the stubborn hair patches that have come back are giving me too much dysphoria to keep waiting.

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My skeptical face as I wait for the numbing cream to work

I need new genitals like, now

Content warning: I’m going to be talking explicitly about sex here so proceed at your own risk.

I can’t wait for bottom surgery. As in the idea of waiting another 11 months seems like torture. I need it so badly and while it feels good to finally have it planned and even some of the money raised, it still feels like forever away.

I tried for so long to feel comfortable with the body that I had, but I only had mild success. There were times where I was comfortable with partners who I felt truly saw me that I was able to have enjoyable sex, but for the most part it always felt awkward and performative. I wanted the connection and release so badly but the means I had of accessing that weren’t great.

The best sex I’ve ever had has always been with queer sex. The kind of sex where someone’s fingers or toy is inside of me and they are using their mouth in the ways that it seems only a queer person can. And the most comfortable I’ve been penetrating others is when I’ve worn a strap on. Otherwise being in that role feels weird for the most part.

This week I decided to try having sex “the old fashioned way” one more time to see if there was anything I’d miss about it. I took some generic Viagra because I can’t have those kinds of erections otherwise anymore and had some anniversary sex with my spouse. And while I love having sex with her, it just felt awkward and I was distracted the whole time by how uncomfortable I was. It felt like I was using body parts that didn’t belong to me but that somehow still transmitted sensation to my body. And not in the good way like I’ve managed to access a couple times. We eventually stopped and switched over to the ways we know we both like.

I feel like that was the moment that any last shreds of doubt I had were banished. I’ve proved to myself that my dysphoria really is “bad enough” to warrant the amount of money I’m spending and the amount of pain it will take to get my new vagina. Which is a terrible way to feel. Like you have to justify not wanting to be dysphoric all the time by degrees of severity.

So this week when I met with the PhD level psychiatrist to get my letter for the red tape of insurance approval, I was able to say with confidence that I know I’m making the right choice. And luckily I can also say that I have the right support in my life now to make that plunge. My work and my spouses work are both being very supportive in giving us the time off to go down to San Francisco for a month. And my community has been so generous in helping me raise $880 in less than a month already (plus a promise of airline miles) to put me well on my way.

If you are able to donate to support me as well, I would be very grateful. I can’t wait to finally get this surgery. https://www.gofundme.com/f/haven-gender-confirmation-treatments 

Surgical Consults

I have a date for gender confirmation surgery! August 3rd, 2020.

I’ve decided to go with Dr. Heidi Wittenberg for my vaginoplasty. She is who I have been researching for the past year and my consultation with her last week confirmed that she is everything I had been hoping for. Her staff were all wonderful and friendly. And she was very approachable with a great bedside manner and excellent at explaining the process and answering questions. She seems very factual and will be straightforward with the risks and complications. She also has the training in alternate techniques such as peritoneal pull through that would allow her to perform a revision surgery with the latest technology if that was needed. More importantly, she feels like someone I can trust completely and it makes sense to me to have a woman with a background in gynecology and urology doing my care.

I did do a second consultation while I was in San Francisco with Dr. Thomas Satterwhite who trained with Dr. Wittenberg at Brownstein and Crane. He comes highly recommended from friends but I didn’t have the greatest experience with him. In both his intro video and in person he was very fixated on BMI (Body Mass Index) and treated it as medical fact, despite the vast body of evidence that it is wildly inaccurate, scientifically useless, and never intended by the creator to be used on an individual basis. He brought it up multiple times in my 20 minute consult to warn me that if I gained 10 lbs before next summer, I would be ineligible for the surgery. And yes, I have what many people would consider excess fat around my belly, but I am not objectively that fat of a person. I am tall and large and I am built that way naturally. In fact, I am pretty average in build for a white American.

If I, who have quite a bit of relative privilege, am receiving this much fat phobia from him, how much more pronounced would that be for the many trans people who are larger than me? And if he puts stock in pseudoscience like the BMI, what other areas does he make inaccurate conclusions in? To me, this is the kind of thing I would expect from a plastic surgeon that makes money off of fatphobia. And maybe that’s his background, but I’m not giving him money to support that. Even if he was the best surgeon around. Luckily, I have choices.

Now I’m not saying other people haven’t had wonderful experiences with Satterwhite, but I loved Wittenberg and I’m excited to be having her do my surgery. Next up, I am submitting documentation to get laser hair removal done on my genitals to prepare the area for surgery. Then I need to get 3 letters from my physician, therapist, and a PhD level psychiatrist because my insurance still goes by the outdated WPATH standards of medical gatekeeping.

In the meantime, I’m starting my countdown now for surgery. 377 days!

If you would like to contribute to my transition fund, you can donate at: https://www.gofundme.com/f/haven-gender-confirmation-treatments