BETA

Operation confirmation

Graphic by Joseph Valdez

The video opens with a smiling brunette woman in a gray cardigan and blue jeans standing in front of a truck with her arms loosely crossed. “My name is Randi Maton,” she says. “I drive a truck for a living.”

Maton was one of the first patients successfully transitioned at Yale Medicine Urology’s newly launched Gender-Affirming Surgery Program, the first of its kind in New England. In this video, produced by the Yale School of Medicine, Randi describes her journey. “When I was about 16, 17 years old, I realized something was missing in my life,” Maton says, as the video presents a series of photos from her adolescence. Randi was born with male genitalia but “felt like [she] was more female than male…. [I] decided that this [being female] was what I want to be. And what I’m going to be in life: to match my inside with my outside.” Last year, Maton was finally able to realize this vision of herself, 25 years in the making.

Maton is a resident of Fairfield County and a tractor-trailer driver. She is sometimes asked whether she’s using the correct bathroom, but says she has never experienced any sort of discrimination from strangers or colleagues. She’s legally changed her driver’s license from male to female, and enjoys hunting, fishing, and spending time with her four-year old dog, Bert, whom she rescued. Recently, she made a trip to New York, and while unloading the truck, a man approached her and said he’d never seen a woman truck driver.

“That made me feel really happy and proud that somebody recognized me for who I am,” says Maton near the end of the video. “Life is just great.”

Dr. Stanton Honig opened Yale’s Gender-Affirming Program last spring. He’s treated eight patients so far, but with 60 more on the waitlist (most from the tristate area), he and his partner, Dr. Deepak Narayan, are struggling to keep up with demand. All of these patients have been male-to-female surgeries; the program does not yet cover female-to-male transitions.

Honig has been practicing urology, the study of the male and female urinary tract and the male reproductive system, for 24 years. Although he’s been performing male-to-female surgeries on and off for about a decade, he feels that now is the perfect time to launch the program in Connecticut. Six years ago, the state added “gender identity and expression” to an anti-discrimination law concerning employment, public accommodations, housing, credit, and public schools. Just three years ago, Connecticut became the fifth state to require health insurance providers to cover treatments related to sexual reassignment surgery. This eases much of the economic burden on potential patients — male-to-female surgery can cost between $15,000 and $50,000, depending on how involved the process is. The Yale Health Plan has covered sex-reassignment surgeries for faculty and staff since 2011 and unionized workers and students since 2013, joining Harvard, Brown, and the University of Pennsylvania.

To determine whether patients are eligible for surgery, Dr. Honig refers to the guidelines provided by the World Professional Association of Transgender Health (WPATH). Criteria for “bottom surgery” — another term for sex reassignment surgery, specifically referring to the genitalia as opposed to alterations of the face — are extensive. Patients must begin to make a social transition by dressing as the gender they identify as for at least a year. They must meet with endocrinologists to develop a plan for hormone therapy — estradiol pills, for example, help develop breast tissue, feminize the body, and reduce body hair growth — and must undergo this therapy for a year. Patients must also have a letter from a mental health professional familiar with transgender care acknowledging the patient’s understanding that the procedure is irreversible. Once the patient meets these criteria, they are admitted to the program.

There are other, optional steps, including vocal surgery, laser hair removal, and sperm-freezing using cryopreservation techniques in the event that the patient is planning for children.

Honig offers patients a range of bottom surgeries, including removing only the testicles. A complete sex reassignment takes about six hours and requires a hospital stay of two to five days. The surgery consists of a remarkable anatomical reorientation that leverages the existing male genitalia rather than adding anything new: the penis becomes a functional clitoris that allows for clitoral orgasms, the urethra is shortened so that the patient can urinate sitting down, the skin of the penis becomes the inside of the vagina, and the skin of the scrotum becomes the labia. Because each part of the operation is useful to Honig’s urology practice — for example, he removes patients’ testicles for cancer treatment — putting all the components together into one surgery is straightforward for him.

That doesn’t mean it’s easy for most surgeons.

“The average urologist doesn’t do a lot of this stuff,” Honig said. “But I do. It’s not a common operation. There aren’t enough people who are dedicated enough to do this and there aren’t training programs to do it.” Yale’s is one of the few programs that trains residents in transgender surgery.

Clinical program manager Diana Glassman also stressed how resource-intensive the process is. To comply with WPATH guidelines, she has assembled a group of surgeons, endocrinologists, nurses, social workers, and mental health professionals that support the patients throughout their experience. Though Glassman has never worked with transgender people in the past, she understands the importance of providing a holistic treatment package for patients, and as such has increased staffing and implemented diversity training for employees.

“We want to make sure our staff knows how to interact with patients,” she said. “We want to create a warm and comforting environment.”

Honig echoed the sentiment. “We’ve trained people so that [from] the first person who answers the phone, to the person who talks to [the patient] about booking an appointment, to the social worker, to the nurse, [everyone] understands the concept of gender identity and understands the importance of using particular pronouns. We spent a lot of time and energy to do that.”

While the surgery that the school provides isn’t unique, the extra attention to the experience of patients and the complementary mental and social support available are what make the program’s institution noteworthy.

“They treated you with respect, and you’re not just a patient, you’re a human being,” Maton says in the video. “You get that warm feeling that they accept you for who you are.”

The first high-profile recipient of male-to-female reassignment surgery was Lili Elbe. Born in 1882 as Einar Magnus Andreas Wegener, Elbe was a successful artist who specialized in landscape paintings. Elbe began wearing women’s clothes for the first time when she began filling in as a model for her wife, who illustrated fashion magazines. Elbe felt comfortable in the clothing and began presenting as a woman, often pretending she was her own sister in order to prevent discrimination.

In 1930, Elbe received gender-transforming surgery — an experimental procedure at the time — in Germany. She underwent four operations in two years under two different doctors: removal of the testicles, implantation of an ovary, removal of the penis and scrotum, and transplantation of the uterus. She was able to get her name and sex legally changed, even as her case became a European media sensation. Since she and her wife were no longer “man and wife,” their marriage was dissolved.

Three months after her fourth operation, Elbe’s immune system rejected the uterus and she developed an infection. She died in September 1931.

Despite Elbe’s considerable popularity in Europe, it was Christine Jorgensen who became the first major advocate for transgender rights in the United States. Born in the Bronx as a self-described “introverted little boy who ran away from fist fights,” Jorgensen served in the U.S. Army during World War II. After returning to New York, Jorgensen became concerned about her stunted male physical development and began taking estrogen as she researched sexual reassignment surgery. Jorgensen traveled to Denmark to undergo hormonal therapy and receive an orchiectomy (the removal of the testicles) and a penectomy (the removal of the penis). In a letter to her friends in 1951, Jorgensen asked: “Remember the shy, miserable person who left America? Well that person is no more and, as you can see, I’m in marvelous spirits.”

On her return to the U.S., Jorgensen received a vaginoplasty to complete her reassignment. The reaction was immense. The New York Daily News ran a front-page story in December 1952 under the headline “Ex-GI Becomes Blonde Bombshell,” incorrectly stating that Jorgensen had become the recipient of the first “sex change.” Vice President Spiro T. Agnew called another politician “the Christine Jorgensen of the Republican Party.” Radio host Barry Gray asked her if jokes like “Christine Jorgensen went abroad, and came back a broad” bothered her. She was unable to get married because her birth certificate listed her as male, and her fiancée Howard J. Knox lost his job in Washington, D.C. when his engagement to Jorgensen became public knowledge.

Jorgensen handled the attention with admirable courage and a generous sense of humor. She worked as an actor and a nightclub entertainer while also dominating the public sphere as a transgender spokesperson. Her efforts forced people to reconsider their definitions of biological sex, question their knowledge of gender norms, and consider the evolving concept of sexuality. Doctors began to distinguish between terms like transsexuality, transvestism, and homosexuality. In 1989, the year of her death, Jorgensen said she had given the sexual revolution “a good swift kick in the pants.”

In April 2015, Olympic gold medal winner Caitlyn Jenner came out as a transgender woman. She had not had gender reassignment surgery, but had undergone a cosmetic makeover and had begun dressing to match her gender identity. Cue a bevy of national awards, Twitter followers, and journalistic plaudits. She became the face of an issue that most Americans struggle to understand — as of 2015, only 35 percent of voters in the U.S. thought they knew at least one transgender person — even as she faced backlash for a sexualized Vanity Fair cover and her mischaracterization of the plight of the average transgender person.

In 2015, Jenner launched a reality show called I Am Cait that focuses on her “new normal.” In multiple episodes, Jenner has discussed whether or not to undergo gender reassignment surgery. While a reality television show like this one can’t be considered representative of all transgender experiences, Caitlyn’s dilemma reveals concerns that have arisen as the availability of gender reassignment surgery has increased. No longer simply a question of whether it is possible to undergo the process, transgender discourse today must engage in a more nuanced conversation about what the surgery might mean for individual people.

When I asked Diana Glassman if the Yale program had received any significant pushback, her answer was swift.

“No.”

“And did you anticipate any?”

“No. Maybe I’m naïve, but I really didn’t think about it.”

Dr. Honig was a bit more circumspect.

“There’s been no pushback yet. But I feel like we’ll see some with the change in administration. So far in Connecticut, we haven’t had any problems.”

The Trump administration indeed causes significant trouble for the 1.4 million Americans — 0.6 percent of the population — that identify as transgender. A week ago, the government withdrew protections instituted by President Obama that allowed transgender students in public schools to use the bathrooms and facilities that correspond with their gender identity. The decision will likely play a role in the case of Gavin Grimm, a 17-year-old transgender student who is appealing bathroom discrimination to the Supreme Court under Title IX.

Trump’s actions are particularly disappointing after a campaign in which he vowed to protect the rights of those in the LGBTQ community. They add further burden to an already struggling demographic. According to a 2010 survey conducted by the National Center for Transgender Equality, transgender adults are four times more likely to have a household income of less than $10,000 annually when compared to the general population. Even more worryingly, 41 percent of transgender adults have reported a suicide attempt, compared to 1.6 percent of the general population.

From a medical perspective, Dr. Honig estimates that there are only four or five large centers in the United States that do sex reassignment surgery — and even those can only handle 50 to 100 cases a year. He acknowledges that the transgender population has historically felt ignored by the medical community, and fears for the future of LGBTQ rights in states like North Carolina. But Honig has confidence in what’s happening in New Haven.

“The medical community at Yale feels strongly about what we’re doing here. We have no intention of stopping what we’re doing. We support the transgender population.”

Honig and Glassman spend less time preoccupied with the politics and social movements surrounding transgenderism, and instead focus their efforts on tailoring their treatments to each individual patient.

“Each patient is different,” Honig said. “Some think of this as the first step in the transition. Others think of this as their last step. They’re incredibly grateful for what we’re trying to do. So far, so good.”

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