I'm a surgeon who helps transgender people live the way they feel inside Surgery can transform the lives of people with gender dysphoria. And when a transgender person is at death's door, talking of suicide, it can even save lives.

Jonathan Keith | Opinion contributor

Early one morning, in the summer of 2005, I entered Allegheny General Hospital in Pittsburgh in a fresh shirt and tie to give Grand Rounds — a formal, weekly conference — to the city’s plastic surgeons. In my final year of medical school, I was auditioning to join their ranks after graduation, and this presentation was the culmination of a grueling four-week long rotation known as the acting internship.

Usually dressed in scrubs, my tie felt too tight around my neck as I stepped to the podium to discuss the case that I had spent all night practicing. The procedure is known as a vaginoplasty, or a male-to-female gender reassignment surgery. I lingered on photos of the procedure and stepped away from the lectern to describe certain steps for clarity.

As I concluded, there was mild applause. Then one surgeon raised his hand and commented, “Jonathan, nice presentation. But that is a lot to take at 7 in the morning.”

Desperate for surgery

It has taken time and an act of Congress for medical treatment to become more widely available to those Americans suffering from gender dysphoria. Defined as a condition that causes intense discomfort or “incongruence” with the assigned birth sex, conservative estimates suggest that 0.5-1 percent of the U.S. population suffer from this condition. At present, that could be more than 3 million of our fellow Americans.

The evolution of our understanding of gender identity was reflected in part by the 2014 Obama administration decision to allow Medicare to cover gender reassignment surgeries, reversing a ban that had been in place since 1981. In addition, the 2010 Affordable Care Act mandated equal treatment of the sexes, which translated into more private and Medicaid coverage for gender reassignment surgery as well. A Johns Hopkins Medicine study found that these surgeries increased four-fold between 2000 and 2014 as coverage increased.

Though surgery may seem a drastic step for someone who does not suffer a physical malady, such as cancer or trauma, the psychological distress caused by the transgender person’s physical state is no less lethal. Studies suggest that nearly 40 percent of the trans population have attempted suicide. This is likely underreported and much higher in at-risk populations, such as minorities and those living with HIV.

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I began providing “Top Surgery” for transgender patients early in my practice. In these procedures, the outward sex characteristics from the waist up are altered to conform to the societal norms of the preferred gender. A female chest is masculinized via a mastectomy and nipple repositioning, and the male chest is feminized through breast augmentation with fat or silicone implants. Facial procedures may also be performed.

Several of my patients were desperate for genital surgery, however. They brought in letters from psychiatrists and discussed at length their need for gender affirmation through surgery. Many were open about their plans for suicide should they not be able to have surgery. I had never experienced such a demonstrable need for urgent medical intervention outside the Trauma Bay. My patients were at death’s door and needed someone to act.

More than a physical transformation

I'm now co-director of a multidisciplinary center for the care of the transgender person. In February of 2018, we successfully performed a female-to-male genital reassignment surgery or phalloplasty, the first in New Jersey. In this procedure, we transplanted skin, along with nerves and blood vessels, from the patient’s forearm to create a penis. In May, we performed the first vaginoplasty in our part of the state. Later, the patient told me that she would now celebrate her birthday on the anniversary of her surgery. Both patients have had return of sexual sensation within months of the operation.

Recently, a trans patient of mine returned to the clinic several months after undergoing a chest masculinization procedure. He asked for a hug and told me that I had cured 30 years of dysphoria with a three-hour operation. He was the happiest I had ever seen in our time together.

It was in the operating room of my mentor, J. William Futrell, back in the summer of 2005, that I witnessed my first vaginoplasty. I was enthralled by the daring act of creation at the hand of a scalpel-wielding surgeon. Weeks later, in his office, I spent time with that patient and came to understand that the transformative power of the gender affirming surgery was much more than physical.

The patient could finally live as she felt inside.

Dr. Jonathan Keith is co-director of the Rutgers Center for Transgender Health and an assistant professor of surgery at Rutgers New Jersey Medical School.