Parts of this post speak about my current weight, the Body Mass Index, and the need to lose weight for the sake of my transition goals. This post is also entirely about and around transgender surgeries. Not all trans people pursue bottom surgery, this post is exclusively about my own journey.
Monday afternoon I took the first big step towards a dream I’ve had for over 30 years: I had my surgical consult for gender affirming vaginoplasty. It is rather fitting that the surgeon who I am seeking to perform this operation began her own career just over 30 years ago, around the same time that I was learning that this procedure even existed.
Dr. Marci Bowers is the foremost genital restorative surgeon in the United States. She has now conducted over two thousand vaginoplasty operations for transfeminine patients, hundreds of transmasculine surgeries, and is the nation’s top clitoral restoration surgeon for victims of female genital mutilation. She is an extremely busy woman, conducting 3-4 surgeries every week to meet the ever-increasing demand for transgender surgical correction. It is a strong passion of hers, for good reason, as she is herself transgender, and understands just how important these surgeries are.
From the time I reached the conclusion that I wanted to pursue vaginoplasty, I knew that Dr. Bowers was the surgeon I wanted to pursue. She and her protegés (Dr. Jess Ting and Dr. Jennifer Hyer) are ever constantly pushing advancements, further refining their technique, and sharing that knowledge with other surgeons in order to better the entire field. Bowers has pioneered numerous advancements in penile inversion, most famously the use of erectile tissue to recreate the intra-labial clitoral legs for greater sexual stimulation.
Unfortunately, because she is so well known, she also has the longest wait list in the United States: approximately 3-4 years (2-3 if you get on the cancellation list). Many patients are not willing to wait that long, but I have a pressing reason to wait… my weight. There is overwhelming evidence that recovery times from this procedure are significantly better if the subject is under a BMI of 35 (yes, BMI is crap, but there’s no other basic measure to use). Healing goes faster, risk of complications drops significantly, and the results just tend to be far more satisfactory.
For a person of my height, that is 220 pounds. As of today, I weigh 285 pounds, so I need that wait list time to get my weight down to the needed level. Assuming a minimum of two years’ wait, that means I need to lose three pounds per month, minimum. More than achievable, and I have taken that up to five pounds per month just to make it more of a rounded goal. I’m not exactly thrilled about the prospect; I loath dieting and the mentalities that come with it, but I can think of no finer motivation than correcting my genitals.
Because Bowers’ time is so limited, I had to schedule my consult four months in advance back in January. Her practice is based out of San Mateo, California, on the south west side of the San Francisco Bay. I live in San Diego, so visiting in person for a consult was less than ideal. Thankfully, Dr. Bowers is used to working with remote patients, and I was able to schedule a telehealth appointment. This proved even more valuable as the COVID19 outbreak started, halting all surgeries and closing her office.
Thus it was that I ended up sitting in my bedroom yesterday afternoon, my laptop in front of me and my stomach full of butterflies, waiting for Skype to ring an incoming video call. Yes, that’s right, I said Skype, that is apparently still a thing. I had to actually create a new account because I have no idea what account I had seven years ago when I last used this elder of video conferencing software… but I digress.
Any preconceptions I had for Dr. Bowers were immediately tossed out the window when she appeared on video, lounging on her couch at home in a big fluffy knit sweater, her hair down, a coffee cup at hand. We chatted a bit about the pandemic and the effect it’s had on our lives, and she commented that one very small positive of all this is that it has given her the first real break she’s had in a long time. She lamented how that break has come at the cost of her patients, who she feared for. We both know just how desperate some trans folk can become when these kinds of delays occur.
A commonality with seeing a new doctor for gender affirming care is the time spent explaining your gender history. Every doctor wants to know when and how you learned of your gender incongruence so that they can document in their records exactly why you deserve this care. Dr. Bowers did not ask this question; the only thing she wanted to know is how long I had been on HRT and presenting female, since that has a bearing on insurance expectations.
She did ask about my family, how many kids I had, and how they and my wife had handled my transition. It never felt, however, like she was asking for the record, just that she was genuinely curious to know more about me. This is a striking difference in comparison to the cis doctors I’ve worked with, and I have to attribute that to the fact that she knows what this is like. She has the evidence that I am transgender right in front of her; she doesn’t need to know more.
She also asked the routine medical questions: do you smoke, do you drink, do you have any medical conditions such as diabetes or high blood pressure. We talked about my previous surgery in 2018 and my recent investigations into whether I might be intersex, since that would have an effect on how the surgery is conducted. One question that is often asked at these consults is what your sexuality is, which is a sort of backwards way of asking if you expect to ever have penetrative sex and will need full depth. She never asked this question, or even alluded to it; she simply assumed I would.
Her bedside manner through all of this was, quite frankly, incredible. She was very down to earth and relatable through the entire call, unexpected of someone at the top of their field. She was informal but still respectful, sweet and personable, and I noticed how much she was putting me at ease; my butterflies were gone within minutes. By the end of the call, I didn’t feel like I had spent the time talking to a doctor. It was more like I had just talked shop with a colleague over coffee. I find myself wondering if this is because she’s just that good, or if it is because we are both trans. There is often a sort of underlying camaraderie between trans people; a shared experience that cuts out a lot of awkwardness.
She complimented my feminine voice twice during the call, in what almost seemed like an envious tone. She herself has a very beautiful voice, well fitting of both her personality and her appearance, so I was taken aback that this woman, now over twenty five years into her own transition, would be envious of my voice work.
After she had gathered what she needed for her records, she asked me what she could answer for me to help me move ahead. That was her phrasing: “move ahead”, not “do you have questions for me” or “to help you make your decision”. She knew where I stood and what my motivations were; she was focused on putting me at ease.
About an hour before the appointment, it suddenly occurred to me that I had no idea what questions I wanted to ask her, and hastily scrambled to come up with a list. Typically, when going into an appointment like this, you ask about their proficiency, their complication rates, expectations for recovery, or what the post-op schedule is like. Half of that was already answered for me on her website, and the other half I didn’t need to know because her reputation already speaks for itself. I commented on this, and she demurred a bit, expressing a humility that I didn’t expect.
Advancements and Improvements
The first question I asked was what sort of advancements she has made in penile inversion vaginoplasty over the last five years that differ from what other surgeons in her field are doing. She chuckled and said that you could probably fill a book with all the techniques that her team has developed independently.
Recently a major area of advancement has been in clitoral development, in terms of presentation, but also in function both above and below the surface. The amount of sensation that her technique provides is unrivaled, and I have heard corroborating accounts to this effect. She is also applying new suturing techniques in the construction of the labia minora, producing a more aesthetically accurate vulva.
They have changed the way they perform hair removal from grafted tissues. Most surgeons either scrape the upper layer of the skin, removing the follicles, or use a high powered laser to burn them away. Both of these techniques leave the tissue rather traumatized and in need of extra healing. Instead, her team has now borrowed a technique from the hair transplant field, removing each entire follicle from the skin. This significantly reduces the amount of total healing, and eliminates any risk of hair growth within the vaginal canal.
I asked if that meant her patients no longer needed to have pre-surgery hair removal, and she said that they still strongly advise at least some laser or electrolysis, just to reduce the total amount of hair that has to be excised, but it is no longer necessary to completely remove all the hair before the surgery.
Another major advancement recently is that she has now moved the primary external sutures into the folds where the legs meet the groin. This helps to hide the scar tissue left behind after recovery, a common source of dysphoria among post-op patients. She mentioned that iterating on these kinds of things can be challenging, because moving something in one place affects all of the other pieces, like a sort of balancing act.
This led me to ask her how frequently she has had a patient need to have a follow-up revision. She commented that many surgeons choose to deliberately conduct two stage surgeries, but she aims to save the patient from needing to go under the knife again. Despite that, however, her goal is to ensure you are completely happy with your results, and if something does bother you, then she wants to correct it. That said, however, of the two thousand GAVs she has performed, less than 130 of them felt a need for a revision. This is, quite frankly, an astonishing ratio that is simply unheard of from other surgeons.
I commented that I know about a dozen women who were the early entries at Mayo Clinic when they began doing bottom surgery, and we both shared our disappointment and sorrow over the pain of those women. She said she does not understand how that went so horribly wrong, since the surgeon performing at Mayo had trained under Dr. Pierre Brassard, Canada’s top gender affirming surgeon, himself also an expert in his field.
Depth and Grafting
One concern I had is whether I might not have enough tissue for proper vaginal depth. My atrophy over the last three years has been severe, and I was circumcised as an infant, significantly reducing the amount of tissue available for inversion. She said that ten years ago, this would have been an problem, but today it is completely a non-issue. Due to the increasingly large number of trans teens that are able to block their natal puberty and never experience male genital development, she has been forced to develop new techniques to expand upon the available tissue, such as the peritoneal pull through method that made waves two years ago.
This was the point in the conversation where she did not surprise me, because my therapist had warned me that Dr. Bowers is exceptionally proud of her involvement with Jazz Jennings’ surgery, and name drops Jazz in nearly every consult. Sure enough, she brought up the show and talked about the challenges that she had faced with Jazz’ operation.
I asked what her expectations were for halting medications. I knew that she had spearheaded a movement to get surgeons to stop demanding their patients cease their hormone therapy, but I had been curious about other medications such as antidepressants. She said that as long as the drug poses no issues with the surgery (such as drugs that affect blood behavior or heart rate), she does not halt any medications which may produce a fallout, especially antidepressants. She wants your body as baseline as possible.
The next thing I inquired about was, of course, my weight. I know that I am outside her desired weight limit and I wanted to make sure she understood what my goals and timetable are like, and that I fully intend to be where she wants me by the time I come off her wait list. However, I also wanted to know what risks it posed if I were not able to meet that 35 BMI limit. Would that result in losing my surgery slot?
She immediately understood my anxieties here, and commented on how her practice endeavors to avoid fat shaming their patients. She was disappointed with how much Jazz’ show had resorted to so much body shaming. To this, I remarked “Well, yeah, that’s fucking TLC for you,” and she laughed. She assured me that a person of my level of health (no outstanding medical issues, non smoker/drinker, etc) would not be held back from surgery as long as I am able to get below 40 BMI (250 lbs). My recovery may be longer, but I would still be able to proceed.
I inquired about what the follow-up schedule is like beyond the first week, since her website doesn’t address this. Some doctors expect you to return 6 weeks after surgery, or to stay in the area for several weeks afterwards (Hyer’s office said I should expect to stay in Denver for a month). Dr. Bowers said that this is all dependent on how my recovery goes. Most patients do not need to return to her office; the most common issue is a little tissue separation which usually heals itself. We agreed that, given the proximity within the state, it is a fairly short flight for me to return to the bay area, should I need to see her directly (her office is practically down the street from SFO Airport), but that they are usually able to handle most situations by way of my primary physician or gynecologist.
She did make clear that she always makes herself directly available to her patients, via her personal cell phone, and that as long as she isn’t in surgery or a meeting, she always replies quickly. Texting and email has become her best medium for helping her patients.
One concern I had was about how she handles payment. Some surgeons require payment up front, leaving you to deal with the insurance claims yourself. She was very clear that her practice was one of the first in the country to start doing pre-authorizations with insurance companies in order to ensure that the only thing patients have to pay are deductibles. This probably means that my GRS will cost me the same as my orchiectomy did.
The final question that I asked was how the outbreak has affected her wait list, and what she foresees for the future. She stressed heavily that her top priority once they are allowed to get back to work is to catch up on the surgeries that were delayed. She foresees that they should be caught up with the delays inside of six months from when they’re allowed to return to the OR. I found myself wondering what kind of hours she will be putting in to meet that timetable.
If you are reading through this and thinking to yourself “Jocelyn, this reads like a puff piece”, well… you’re not wrong. I left that consult absolutely smitten, both with her clear prowess in her field and with her as a person. I feel extremely confident that she will give me the best result of any surgeon. I shared with her the fears that my wife has, that I will go under anesthesia and then not wake up again, and she chuckled and said that in the entire 30 years that she has been operating, she has never once lost a patient.
Even though it is still years away, I feel closer than ever to finally fulfilling that wish that I made when I was 10 years old, to finally have my body made whole, not just aesthetically, but functionally as well.