Editors' note: Syd Peterson is Managing Editor at LGBTPOV.com and works as a communications specialist and social entrepreneur based in Los Angeles. Syd has been an LGBT rights activist for 13 years, working for Lambda Legal, the International Gay & Lesbian Human Rights Commission and Renna Communications, among others.
I published a version of this article on July 13 my blog, LGBTPOV.com. The article is part of a series I'm writing on transgender experiences, as inspired by the journey of my friend Jackson Darling. While writing the article, I researched the histories and particulars of top surgery procedures, including interviewing two experts in the field: Dr. Michael Brownstein, a surgeon who performs top surgeries, and David Yonkin, a social worker in private practice who works primarily with transmen.
The main purpose of the article was to educate my readers about top surgery: why Jackson, and various other transmen, wanted to have the procedure, how the procedure was developed and done, and a bit of the history. I didn't plan to cover other surgical procedures that some transgender men and women seek, notably those known as "bottom surgeries" (surgeries addressing male and female genitalia such as penises, vaginas, ovaries and testicles). Exploring and writing about such procedures could, as Jackson says in the article, be an article unto itself. I debated whether to mention bottom surgery at all, as I didn't plan to perform comparable research about these procedures, speak with surgeons who perform them, or interview a transman who had undergone the surgeries.
In the end, I decided to include a short section about bottom surgeries. As the author, not mentioning bottom surgeries would have felt odd, as if I had left an important set of questions unanswered. As such, I imagined that my primary audience consisted of people who knew very little about the surgeries trans people sometimes have, and a certain subsection of this group likely didn't know any transgender people on a personal basis. Surely, after reading the portions of my article about breast and top surgeries and why people want to feel comfortable in their own skin, they would be curious about whether trans people might choose to undergo additional surgeries on other parts of their bodies. Further, I wanted to note a difference in the experience of some transmen and some transwomen, based on my understanding that "bottom surgeries" for transwomen tended to be more successful.
I received feedback from a number of sources the bottom surgery section: some people were critical that I portrayed an opinion that many trans men do not desire bottom surgeries and that I reflected experts' concerns about whether the resulting organs were "functional." These comments opened me up to a larger discussion in the trans community right now, and it's become clear to me I need to write an entire article on bottom surgery to flesh out the full situation. As such, in this version of my article which appears on Bilerico, I have removed the bottom surgery section.
Many thanks to all who have responded to my article; I find your thoughts and ideas inspiring and empowering
On June 13, I wrote about my friend, Jackson Darling, and his experience as a transgender man: what he was like as a little kid, how he realized he was transgender, and what it's been like to begin his transition from Jessica to Jackson - a process that's included choosing a new first name, coming out to his family and friends, and beginning to take testosterone.
The next step in Jackson's process is to have "top surgery" this November; the procedure is sometimes called "chest surgery" or "male chest contouring." "It's a surgery to remove my breasts so I can have a flat chest," he explains. "Much of a transition is mental and emotional, but this is one physical aspect that's pretty important to me. Not every transgender man chooses to have this surgery, since each transgender person has their own feelings about their bodies and their transitions. Some don't do it because they can't afford it. In my case, it's a part of integrating my body with my heart and my mind."
I use the terms "transmen" and "transwomen" in this post. A transman (also called transgender man, trans male, transguy) is someone whose gender identity is male, or who identifies as male, but who was assigned the sex of female at birth. Similarly, a transwoman (transgender woman, trans female, transgirl) is someone whose gender identity is female, or who identifies as female, but who was assigned the sex of male at birth.
Life With (& Without) Breasts
In our culture, breasts are one of the most telling gender signifiers. "Breasts are one of the most obvious physical attributes that identify someone as a women," says Dr. Michael Brownstein, MD, a plastic surgeon based in San Francisco whose practice is limited exclusively to top surgery. "Unlike other sexual attributes, you can often see breasts through a person's clothes."
Brownstein has performed female to male (FTM) chest reconstructive procedures for almost 30 years; he estimates that he performs 200 top surgeries for transmen annually. "[After the surgery], my patients are able to achieve a great degree of comfort with their bodies," says Brownstein. "They tell me that they gain comfort and a sense of relief. It takes the psychological pressure off."
This psychological pressure is real for many transmen. "I wake up every morning with anxiety about my chest," Jackson tells me. "Having top surgery will make a huge difference in my everyday life and will give me a new sense of freedom around my body."
Jackson is especially looking forward to eliminating his daily "binding" routine. Binding is the process that transmen use to make their chests appear flatter, sometimes accomplished with an Ace bandage. Jackson uses a mesh top that's almost like a sports-bra but much tighter. "I just can't wait to stop binding. It's hard to feel like I have to put on all these layers--like in the summer, I end up wearing like four layers sometimes. And that's just not how I want to live my life. I want to be able to just throw on a t-shirt and feel free and, you know, feel the wind on my back."
What is Top Surgery?
Transmen have the option to have one of two surgeries to remove their breasts and flatten their chests. According to Hudson's FTM Guide, the Double Incision/Bilateral Mastectomy is most effective for individuals with medium or large breasts, whereas the Keyhole/Periareolar Incision is best for individuals with small amounts of breast tissue. The surgeries involve carefully planned incisions, liposuction or scalpel "scooping out", attempts to preserve sensation in the nipples, nipple repositioning, and trimming of excess skin. Temporary drains are installed to draw off excess tissue and fluids over the days following surgery. Both surgeries usually take 3 to 4 hours; healing time varies. Brownstein notes that the Double Incision/Bilateral Mastectomy procedure gives a surgeon more control over the end result but may result in more scarring, while the Keyhole/Periareolar Incision procedure affords the surgeon less control but also has less possibility of scarring.
I was interested to learn that top surgery for transmen is somewhat different from mastectomies for people with breast cancer. "In mastectomies for cancer, a greater attempt is made to remove as much breast tissue as is safely possible, to include the cancerous tissue and the remaining breast tissue," says Brownstein. "The nipples and areolae may be removed in some of these operations. Also, in some of these a lumpectomy is performed, removing the cancerous tissue with some surrounding breast tissue and following up with radiation and, perhaps, chemotherapy."
In his top surgeries for transmen, Brownstein tries to leave enough subcutaneous tissue so it matches the thickness of abdominal tissue. "This works to avoid having a sunken chest," he notes. "I essentially remove all the tissue, but it's not a cancer operation (although risk of cancer is greatly diminished). I preserve the needed portions of areolae and nipples as grafts to perform the reconstruction of these tissues, and I'm meticulous about position and symmetry."
The Development of Top Surgery
The history of transgenderism is rich, lengthy and complex. In Western culture, transgender history overlaps with other histories, including histories of gender, medicine, psychology, and LGBT political movements. In many cultures, transmen, lesbians and others have dressed in masculine clothes and led lives as men, with varying degrees of tolerance and support.
According to OutHistory.org, the first gender confirmation surgery (sometimes called gender reassignment surgery) took place in Berlin in 1912, and the patient was a transwoman. In 1923, Magnus Hirschfeld coined the term "transexualism" and created the first modern medical gender clinics.
TransgenderZone.com states that Sir Harold Gillies, internationally renowned as the father of modern plastic surgery, and his colleague Ralph Millard carried out the world's first sex change of a woman into a man in 1945; their patient was a young aristocrat, Michael Dillon, who lived until 1962.
The social and political climate for transmen seeking surgery has changed substantially in the years since. Brownstein says that when he started performing top surgeries for transmen in the 1970s, the surgery was not popular among his surgeon colleagues. "They didn't understand transgenderism," he says. "'Why are you dealing with these people?" Despite these pressures, Brownstein continued his work. "I was willing to help anyone; that was my training. What I was doing was helping them adjust their lives; helping them transition."
David Yonkin, LCSW, is a psychotherapist in private practice in New York who specializes in working with transmen. During his work in the 1990s, he heard disturbing stories about the several-day hospitalizations his patients endured for their chest surgeries (this was before current out-patient procedures could be completed in a day).
"They were stared at and laughed at by hospital staff, who refused to use correct names and pronouns. They were ignored when needing help using the bathroom. They were even discharged with no clear after-care plan," says Yonkin. "Significant others were excluded. People had difficulty getting hospitals to respond to requests for help with post-procedural complications and infections, which sometimes became emergency situations. Botched or substandard results were considered to be the norm, and revisions were seldom offered, or even discussed as an option," he continues.
Brownstein echoes these sentiments. When he owned a house in Montana 15 years ago, he offered to perform top surgeries at the local hospital; patients in need hailed from as far away as Eastern Washington and Idaho. "I wanted to be a good member of the community and offered my expertise, but the hospital administrators were terrified about having the surgeries performed there," he says. "They were sure it would shut the hospital down and begged me not to do 'that' there."
Circumstances Have Improved
Yonkin says that, more recently, circumstances have improved greatly for many transmen seeking gender confirmation surgery. "Around the year 2000, trans people started to stand up for themselves in far greater numbers, and demanded that they be given the same professional courtesies as any other patient," he says.
"Transmen were true pioneers in the cause for better healthcare for their communities," says Yonkin. He notes that many transmen have created websites sharing information about their surgical experiences, including before and after pictures as well as their opinions about their doctors: good, bad, indifferent, transfriendly or not. Posts on Youtube.com have furthered such endeavors, he adds.
Both Brownstein and Yonkin agree that more surgeons are performing top surgeries these days. Brownstein chalks it up to two changes. First, the surgery itself became more accepted in medical and surgical communities: "They're not going to be an outcast surgeon," he explains. The second reason is economic: surgeons who previously would never have touched this type of work realized the growing phenomenon and saw the potential to make money.
This change brought the surgeon's world and the transmale world in closer contact than ever before--and not without conflict. "Savvy surgeons, seeing a specialty niche emerging, began showing up at trans conferences to promote their services in the spirit of competition and promoting consumer education," relates Yonkin. "Ironically, it was at these conferences that the doctors often revealed their arrogance, ignorance and misconceptions about the trans community, who in turn educated the doctors in fierce and funny ways."
Yonkin believes that the transmen who engaged the surgeons played a significant role in the development of transgender health. "These front-line events were major factors in developing, in the U.S., appropriate standards of care and ethics to trans health on many levels," he says. "I watched doctor's presentations quickly transform as they themselves evolved into true advocates for their patients and their families."
Surgeons' attitudes and transgender health aren't the only aspects that have changed radically. Brownstein reports a major change in the circumstances of his patients' lives over the years. "Early on in my work, the patients I saw were isolated: they came to me alone and, rarely, with their partners," he says. Nowadays, I meet many of my patients' parents and siblings, and sometimes their own children."
Brownstein enjoys his unique career. "It gives me great pleasure to help my patients achieve their goals through this surgery," he says. "What keeps it interesting is the people and their families I meet along the way. Every patient is different, and the relationships between parents and children--and my patients can be either, or both--have been especially interesting to observe."
A quote on Brownstein's website reads, "Everyone should have the opportunity to be who they really are."
"With my transition and my upcoming chest surgery I've finally given myself permission to do the things I most feared, all in the name of becoming my full and true self," says Jackson. "When who you are becomes so big and full of life you can't escape it; no amount of fear can keep you from it. The beauty of all of this was that most of the things I feared turned out ok. And ultimately, I overcame my biggest fear that I would never get to fully be myself. Here I am, being myself as fully, openly and often as I can."
Autumn Sandeen: What Genital Reconstruction Surgery, And When
Hudson's FTM Resource Guide
Lambda Legal Sues State of Oregon to Defend Health Care Rights of Transgender Man
Michael L. Brownstein, MD, FACS: Plastic, Reconstructive and Gender Related Surgery
Stone Butch Blues, a novel by Leslie Feinberg
Transgender History, by Susan Stryker
You can learn more about A Little Off The Top, our fundraiser for Jackson here. You can also follow the event on Twitter @alittloffthetop.
Image source: courtesy Balian Buchsbaum