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Beyond the Basics: Gaines Blasdel on Genital Surgery, Community Wisdom, and Trans Health Justice Today

July 9, 2018

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JD: And for context, revision surgeries for some people can go on for years, right? Can you talk about what revision means, what that looks like?

GB: It's a vague word. It could be really minor -- you know, the scar here tugged a little bit, so we're just going to release the scar -- or it could be a complete redo kind of a situation. And absolutely, people have found happiness doing major revisions. But it's not ideal.

It could be for a lot of reasons. It could be an infection or something, that there's just a percentage that happens. It could be that maybe the patient stops doing aftercare: They didn't have adequate care systems around them; their housing became unstable; post-op depression went untreated -- stuff like that caused them to stop doing necessary aftercare. Dilation after vaginoplasty is the big one.

Or it can be a major complication that could have been avoidable. Sometimes it's a combination of the two: Someone had a fistula, where there was a hole in their vagina after vaginoplasty. It's really painful to dilate. They stop dilating. And that causes them to have to have a big redo surgery.

A lot of these things are multifactorial, or have a lot of factors going into them, and are not easily just the patient's fault, the surgeon's fault, the environment's fault.


JD: It seems important for people and providers and advocates to recognize that it's often not just one surgical moment. There's a period of life of preparing for surgery and, then, aftercare that could come in a lot of different forms, and it can involve someone having the most gender-affirming surgical experience, yet having to go to a local emergency room that is absolutely not gender competent.

GB: And that denies them urgent care, which there are countless stories of. You know, even for trans people who are not accessing trans-specific care, we have lots of narratives of that. And with genital surgery, there have been some really awful stories of people who had emergent complications just being told: "Go talk to your surgeon. I don't deal with that."

JD: Is it likely that surgical options may expand, or procedures may be improved, in two, three, four, five years? Are some people choosing to wait it out? Or is it more about working with what we have now, doing advocacy for each person to be able to have the best possible experience?

GB: I think that in trans masculine bottom surgery, there's what I would call a community myth that has been very constant: "Oh, the technology just isn't there yet; we're just not ready for it" -- which means, "It's just not good enough yet."

On an individual level, that's an individual decision. But from a higher-level perspective, nothing's good enough. Having surgery is not a good thing, right? Having any medical intervention is not a good thing.

But it comes down to this: What are the pros? What are the cons? How would this work for you, in your experience?

If someone who is a new-to-the-table person says that to me, I say, "OK. And? Are there likely to be penis transplant surgeries for trans men in the next five years, ten years? No. Are we going to have completely lab-grown penises in the next five years, ten years? No." We actually are already lab-growing some tissues, but it doesn't negate the larger challenges involved in trans-male bottom surgery.

I don't like to engage in the "we're waiting for the big Hail Mary change to come." I see the work now as being more about learning curves and systems. If you look at the data from Belgium, where Professor Stan Monstrey is, they've been doing these surgeries for decades. And if you look at their data, they show their complications in the early '90s, in the late '90s, in the early 2000s, in the late 2000s. And they slowly fall over time. It's about new infection control, and stuff like that.

But it's also that the team has gotten good, and dialed in. And the physical therapist learned from a physical therapist who'd been treating trans people after these surgeries. This institutional knowledge builds what's needed to care for people, and specifically, in the hyper-local context -- not just on a big level of "what's the technique?" -- like who's the transportation company that doesn't jostle people on their way home? These little things actually really add up.

So, I see it as more about institutional learning curves, and institutional knowledge building, where doing these surgeries for two years right now actually kind of puts you towards the top of the pack in experience. And that's a little bit wild in medicine.

These aren't [emergency] appendectomies in [rural] Alaska. They don't need to be seen once, or read from a book, and then done. They should be done under the supervision of someone who's been doing them for years and years and years at first, before someone's doing it independently.

JD: What would be the top three questions that people could ask the providers they're considering for surgeries? Is the first one about complication rates?

GB: Before you ask, "What's your rate of complication? What's your rate of second operation?" I would actually ask, "How long do you follow your patients?" And of course, people come back for other surgeries that are unrelated or whatever. But if you do a top surgery and the follow-up visit is in a week, then that's the kind of dataset that they're actually pulling from for everyone [for their complications rates] -- it is that one-week follow-up.

There also might have been people who flew across the country, who [then] went to their primary care provider. So asking, "How long are you following your patients?" is really the first question to understand the context for the rest of the answers.

My second would be either, "What's something you don't do that would be done better by someone else," "what's something that I should actually go to someone else for" (even if it's something I'm not interested in?), or "what's a technique that you don't do?"

That gives you a sense of what's on the table and what's not on the table. Two surgeons could give you completely different answers to the same question, "Is trying this thing a good idea?" And they can actually both be right, just because they have different trainings, different experiences. And in one person's hand, it could be a bad idea; in another person's hand, it could be a good idea.

That doesn't mean you should go to 10 -- you know, get nine no's and then the 10th, yes; you're like, "Finally!" There are some things that are just shades of gray.

So asking, "What don't you do?" can be a good way to gauge: What are this person's strengths? What's their own accountability towards what they can't do?

So, "How long do you follow your patients?" "What are you not good at?" and with providers, often asking, "If you were in this situation, what would you do?" can be helpful, just in terms of cutting through them presenting the options fairly and equally -- what do they really think is the gold standard?

JD: What else is good to find out from them?

GB: What are their priorities? Plastic surgery is the restoration of form and function. Form and function are both cultural. There is actually no singular truth of what the human form is or what human bodily function is. People use different things in different contexts. So, it's normal for us to bring those things into the room, as patients and as providers. It also gives you a chance of seeing their package of what is the ideal.

JD: That's so important. Are there obstacles based on a certain assumption of what trans people want out of surgeries, based on a binary standard or a cis standard?

GB: Absolutely. Yes. There is. Lots of trans people do want binary surgical options. But at the same time, not everyone does.

Within the trans community, it is going to take a long time to culturally recover from the historic lack of access in the U.S. between when Medicare stopped covering trans surgery in 1982 until 2014, when Medicare started covering trans surgery again, in terms of the information and all the experience we have access to, and the aftereffects of that denial. Part of the vacuum in not having other people in our community who have had surgery to learn from is that we don't always have realistic expectations.

Anytime I do a surgery education workshop, I always start with anatomy. Just like, what's the male/female, etc., anatomy? Because Americans, people in general, don't listen during sex ed class -- if they even got sex ed classes. And, if you can imagine a trans person, even maybe before that was part of their named experience, before that was part of their spoken identity, sitting in a sex ed class -- there's a whole other layer of stuff to interpret through.

Having really grounding, trans-competent sex ed goes a long way. I've found that it's universally helpful. I know for myself (and I know where a urethra is), after surgery I was like, "Oh, my urethra is here." And my surgeon was like, "Um, no; It's here."

We're humans. We all have bodies. Our own bodies are really hard to decipher. And then, when you're adding in this body that you're trying to obtain, there's actually a lot to filter through and dig down into, like, OK; what's our reality here?

JD: For trans people who are on their own journey that may include surgery, where would you recommend that they turn to get more information and support?

GB: My number-one recommendation would be to find humans to talk to. And maybe it's not in-person; it's online. But, just find humans.

There's in-person support groups or conferences -- a lot of places have what are called show-and-tells. You can look at pictures online, and even if you're finding accurate ones, and well-labeled ones, it's really cropped -- just the genitals, or whatever you're looking at. It's really different to see a person with a body in space.

So, finding experiences like that. Or, if nothing exists, create a support group for other people who are going through surgery, or planning or thinking about. Pool your research, your emotional resources, everything.


Additional resources recommended by Gaines Blasdel include two public Facebook groups:

FTM Bottom Surgery Discussion: "Once in this group you can be added to 'secret' setting groups for those who are seriously planning surgery," Blasdel explained.

SRS / GRS / Breast Augmentation / Body Feminization Surgery / Transgender: "This is for all transfeminine non-facial procedures," he clarified.

For a list of surgeons as well as other resources, you can check out

This transcript has been lightly edited for clarity.

JD Davids is a senior editor and the director of strategic communications at and

Follow JD on Twitter: @JDAtTheBody.

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