By: Mike Givens/TRT Assistant Editor—

Boston Medical Center recently released the results of a study quantifying the number of transgender patients opting for gender affirmation surgery (GAS) between 2004 and 2015.

GAS procedures can range from “top” surgeries—breast reduction or bindings, breast enhancements, etc.— to “bottom” surgeries—male-to-female or female-to-male genital reconstruction—and also facial feminization and several other medical interventions. Just last year, Boston Medical Center opened the Center for Transgender Medicine and Surgery, a near-comprehensive program that provides most gender affirmation procedures except for female-to-male genital reconstruction.

“The purpose of the study was to set a baseline for surgeries done among a defined group of transgender individuals,” said Dr. Joshua Safer, the medical director of the Center, noting that the study was the first of its kind in the nation. “In this case, all were patients in the Endocrinology Clinic at Boston Medical Center … meaning that they were transgender individuals who had chosen to have a transgender medical intervention at least in the form of hormone therapy.”

The findings

According to Safer, 71 trans women and 28 trans men who were seeking care at the clinic agreed to have their medical charts reviewed dating from as far back as 2004 to January 2015. In June of 2014, Massachusetts Governor Deval Patrick announced changes in statewide health insurance policies to ensure that transgender people receive comprehensive coverage for gender affirmation medical services.

The study found that only 35 percent of patients chose to pursue any form of GAS. Of that number, only 15 percent chose genital reconstruction surgery. It also found that trans men were twice as likely than trans women to opt for surgical procedures. Trans men typically opted for chest surgery more so than genital reconstruction, according to the report. Trans women were less likely to pursue genital surgery and often opted for facial feminization or top surgery.

“Trans men seem to overwhelmingly be interested in chest reconstruction surgery … “ Safer said. “The surgery is more modestly priced than other gender affirming surgeries. It is also available and considered very effective by trans men who then can feel comfortable removing their shirts or at least walking around with clothes on confident that there is no feminine appearing breast tissue.”

Safer noted that the three typical surgeries for trans women—top surgery, facial feminization, and vaginoplasty—can be expensive, are less available, and also less reliable compared to surgical procedures for trans men.

The response

Johanna, a trans woman who wanted to speak on the condition of anonymity said that, in her opinion, the percentages are low for several reasons.

“Trans people tend to be poor and have little resources,” she said, noting that she’s had her testicles removed and genital reconstruction surgery. “Without insurance coverage, there was basically no way to pay for transition.

“Between electrolysis, facial surgery, top surgery, bottom surgery, [and other procedures] there is just simply no way most of us can afford to have [without it being] covered by insurance. Not to mention the fact that trans people are discriminated against in the workplace, in the doctor’s office, and even when we attempt to get therapy.”

Ray Bernoff, a trans man, echoed Johanna’s opinion, but also stressed more global concerns about the effectiveness of GAS procedures.

“Some trans people don’t pursue surgery because it’s not for them and they don’t feel strongly enough about that part or parts of their body to want to make a permanent change, because there are too many risks in comparison to the benefits for them …” he said, noting that he’s had top surgery.

Safer said that the Center at BMC currently doesn’t offer female-to-male genital surgeries because of the high risk attached to them.

“Genital surgeries for trans men are more difficult and carry much higher risks of complications,” he said, but also stated that BMC is “actively exploring” the possibility of providing the procedures. “Therefore that is the last major category of medical intervention for us.”

Jaime Matheny, a trans woman from Newton, is currently considering facial feminization and GAS procedures.

“It’s a big step. And even though insurance companies cover it … even the the best insurance companies don’t cover all of it … It’s still expensive, it’s permanent … ”

Michelle Hirsch, a trans woman considering GAS, said the low percentage of participants opting for bottom surgery makes sense.

“Looking beyond the absolute numbers, it certainly seems reasonable that lots of people haven’t had surgery and that even fewer elect to have bottom surgery,” she said. “While bottom surgery is critical for many transgender people, it typically requires the most difficult, expensive, and time-consuming procedures.”

Hirsch also noted that standards of care typically require that a trans person live in their true identity for an extended period of time before receiving authorization to pursue surgery and that bottom surgery may not be high on the priority list for many trans people.

“Bottom surgery has a smaller impact on social aspects of transition, since most people with whom we interact won’t be aware of our bottom surgery status,” she said. “As we prioritize and stage procedures for our transitions, bottom surgery can feel like one that can wait the longest.”

Where we are today

“I believe that, over time, the percentages will change,” Johanna said. “The more genital surgery is available, safe, covered by insurance and accessible, the more trans people will feel empowered to be themselves and will take the necessary steps.”

Dr. Safer agreed, but with the caveat that he doesn’t feel that genital reconstruction surgery will be the primary medical intervention for most patients.

“Were the study conducted today, I think that modestly more trans men would have had their chest reconstruction surgery, but that most trans men would still avoid genital surgery,” Dr. Safer of BMC said. “For trans women, I think that in 2017 we would be seeing the beginning of an increase among those having genital reconstruction surgery due to insurance coverage and ease of access to Boston Medical Center’s program. However, I think that many trans women would still prioritize facial feminization surgery and breast augmentation surgery over genital surgery.”

Matheny said that years ago, trans people were pressured to fit into a binary identity and now more people are learning to accept themselves as they are, for who they are, without the need for medical procedures or a rigid gender binary.

“I think a big part of it is that people who were not willing to identify as trans in any way shape or form would be willing to do as such,” she said. “I can’t say it’s becoming more accepted, but there’s a lot more movement behind it. People are coming out of the woodwork, as it were.

“I think so many more people are just loving themselves as trans …”

Hirsch said that practical considerations will still take precedent in decisions around pursuing GAS.

“We are finding it very difficult to get insurance companies to cover the procedures we need from the specialists with the experience to perform them safely and effectively,” she said. “Insurance still has a big blind spot regarding the procedures [that] need to be covered. My insurance company … still considers all procedures related to hair to be cosmetic, including hair removal through laser or electrolysis and hair regrowth through transplants.

Similarly, they don’t cover scalp prosthesis for gender [dysphoria]. It’s pretty crazy—[my insurance] will help a trans woman get breasts, a vagina, and a well-sculpted face, but she will still have a beard, a hairy chest and back, and be bald. This is not a recipe for a successful transition for the person who needs or desires to present within the gender binary.”

Though controversy still surrounds transgender identities and GAS, Matheny contends that trans people are no different than anyone else when it comes to identity:

“Trans people just want to be left alone. We just want to feel comfortable in our bodies, like everyone else.”