Factors Which Influence Individual’s Decisions When Considering Female-To-Male Genital Reconstructive Surgery

by Katherine Rachlin

Citation: Rachlin, Katherine (1999) Factors Which Influence Individual’s Decisions When Considering Female-To-Male Genital Reconstructive Surgery. IJT 3,3, http://www.symposion.com/ijt/ijt990302.htm

Author’s Note: Parts of this research were presented at the XV Harry Benjamin International Dysphoria Association Symposium in Vancouver, Canada. September 10-13, 1997 and at The Third International Congress on Sex and Gender in Oxford, England, September 18-20, 1998.

Acknowledgments: I would like to thank Dr. Myles Schwartz for reviewing earlier drafts of this paper.

• Abstract
• Method
• Discussion
• Results
• Implications
• Suggestions for future research
• References

Abstract

This research examined the factors, which influenced the decisions of people who had considered female-to-male genital reconstructive surgery. The sample consisted of 27 people who had been born as female and had male gender identities. Subjects were recruited from a support group for female-to-male transsexuals (FTMs) in New York City and from participants at a conference for female-to-male transsexuals in San Francisco. A questionnaire was designed to explore subject demographics and surgical decision-making. Respondents rated contact with other FTMs and information from within the FTM community as the most important sources influencing their decision. Lack of money and inadequate medical technology were the most frequent obstacles to implementing their choice. Results illustrate the growing influence of community and peer support services. Results also challenge the expectation that FTMs will request genital reconstructive surgery (phalloplasty in particular) and identify some of the numerous reasons why FTMs may not undergo such surgery.
  

Factors Which Influence Individual’s Decisions
When Considering Female-To-Male Genital Reconstructive Surgery

 A transsexual or transgendered person usually makes decisions regarding sex reassignment surgery (SRS) with the support of his or her health care providers. For several decades providers have been the primary source of information about the gender transition process. Today, due to the growing educational opportunities available outside of the clinical setting, contact with professionals may be only a small portion of an individual’s preparation for gender transition. The internet has transformed people’s ability to share information and peer support groups and information networks are widely accessible. In many major cities in the United States specialty bookstores have "transgender" sections which include biographies, textbooks, and information on hormonal regimens and surgical procedures. This study is the first to look at where female-to-male transsexuals (FTMs) in the United States get information about SRS and how they weight the different information sources.

Research into SRS has generally focused on psychosocial functioning and satisfaction with surgical results (Barraett, 1998; Mate-Kole, Freschi, & Robin, 1990;). Research into postsurgical outcome has found that people who are emotionally healthy, who have more social support, who will more easily "pass" in their chosen gender, and people with good surgical results, are most satisfied with life after surgery (Bodlund and Kullgrem, 1996; Ross and Need, 1989). Follow-up studies to assess people’s satisfaction with their surgical results have included variables such as genital size, genital appearance, and excretory and sexual functioning (Kockett & Fahrner, 1988). The literature on sex reassignment surgery generally looks at who went for surgery and how that surgery changed their life. The goal of most such research is to assess the effectiveness of SRS as a treatment for gender identity disorders (GID) and to minimize postsurgical regrets (Kuiper & Cohen-Kettenis, 1998, Pfaefflin & Junge 1998). It is only recently that FTMs have a number of surgical options. It is also a recent development that information regarding these options is available from a number of sources.

The relationship between gender identity and the request for surgery

Transsexual people have historically been defined by their requests for surgery. Harry Benjamin’s 1966 Sex Orientation Scale (Benjamin, 1966) describes seven categories of sex and gender roles. This scale includes diagnostic criteria for three types of transvestites and three types of transsexuals. The two categories of "true transsexual" are reserved for those who request surgery. How do these categories reflect the experiences of FTMs today? Benjamin’s original scale was intended to refer to Male-to-Female transsexuals but has been applied to both MTFs and FTMs. At the time he had seen only 20 FTMs and of their surgical concerns he wrote:

They long for a penis, yet mostly understand realistically that the plastic operation of creating a useful organ would be a complicated, difficult, highly uncertain, and most expensive procedure. Only one of my twenty patients had the operation performed in several stages, but the final result is still questionable. (p. 150)

Benjamin understood the gap between FTM desire and the reality of surgical choices. He did not see this same phenomenon among MTFs, but Schaefer and Wheeler addressed it in their 1988 paper "The Nonsurgical True Transsexual". Schaefer and Wheeler wrote the following:

It is our belief that the concept of gender emanates from one’s mental perception, … being perceived authentically in the preferred gender has little to do with the set of genital organs one may have. We say it is not genitals that make a MF TS but the feelings of wanting to be a woman and the total inner (as well as outer) identification with women. Transsexualism is much less an issue of sex than it is of gender, and perhaps much more of an issue of identity. (p. 7)

Kuiper and Cohen-Kettenis (1988) looked at the therapeutic effect of sex reassignment surgery in a study of 141 Dutch transsexuals. Their sample included 25 FTMs.

… 21 had undergone mastectomy, hysterectomy, and oophorectomy, and 4 had had penoplasty. In view of the grave risk of complications and the often-disappointing results, penoplasty is likely to be omitted in the remaining FMs. This means that medical treatment can be regarded as completed in a total of 25 FMs. (p. 442)

The current limitations of sex reassignment surgery for FTMs require that we reconsider how surgery is used to determine gender status. In Devor’s 1997 book FTM Female-To-Male Transsexuals in Society, she interviewed 39 FTMs and found:

These participants had done research into the surgical outcomes available to them. They had seen articles in professional books and journals or spoken with other transsexual men who had gone before them. They learned that phalloplasties were extremely costly, involved multiple surgeries spanning a number of years, and produced phalluses which were cosmetically questionable, generally oversized, awkward for intercourse, and probably unusable for urination. (p. 406)

FTM Options for physical transition

A thorough discussion of surgical options is beyond the scope of this paper. However, it is important, for the purposes of this research that the reader understands the options available to FTMs and the risks and costs involved. Desire for surgery and requests for surgery have often been considered diagnostic of the degree of GID. Medical practitioners and mental health professionals who work with this population should be aware of the current advances in hormonal and surgical treatments. For a more complete discussion please consult the medical literature (Hage, JJ. 1996; Hage et al. 1993; Kirk, 1997; Sengezer and Sadove; 1993). Hormonal and surgical options available to FTMs, and expected outcome of transition, differ notably from those for Male-to-Female transsexuals (MTFs). FTMs are truly transformed through the use of hormones. The effects of testosterone: deepening of voice, growth of body and facial hair, changes in skin texture, reduction in subcutaneous fat, redistribution of fat, and frequently, male pattern baldness, result in a distinctly male appearance. Though FTMs are often smaller than other men in a given ethnic group, the cultural norms for men are flexible enough to allow for men of their size. FTMs are not generally perceived as being visibly different from other men.

In addition to taking hormones, some FTMs elect to have some combination of liposuction, mastectomy and/or chest reconstruction/contouring. This surgery can create a chest passable enough so the man can comfortably take his shirt off at the beach or locker room (though there are often considerable scars). In many ways an FTM can function socially as a man without any genital reconstructive surgery.

Many FTMs will chose to have to have their female reproductive organs removed (ovaries, uterus, and/or vagina) and may have more masculine genitals constructed. Options for genital reconstruction for FTMs currently fall into two types; phalloplasty and metoidioplasty. Phalloplasty refers to a variety of different operations which attempt the construction of a full-size phallus. Virtually all of these operations take the tissue for the phallus from other parts of the body (forearm, abdomen or leg). Phalloplasty is associated with a large number of complications including urethral fissures, tissue necrosis, neuropathy, and scarring of the donor sight. The procedure is extremely costly. Multiple operations are usually necessary both because phalloplasty may be done in many stages and because complications requiring follow-up intervention are the norm. There are a limited number of surgeons who can perform this surgery, so individuals must frequently travel long distances for both the initial and follow up procedures. Depending on the type of phalloplasty, individuals may chose options such as standing urination, ability to achieve an erection, penile sensation, penile length, and testicular implants. Different phalloplasty techniques are more or less adequate in these areas. Cosmetic results vary widely. There is not yet a phalloplasty which can provide a fully functioning and completely authentic-appearing phallus. All phalloplasty methods involve major cost, compromises, sacrifices and risks.

Complications in sex reassignment surgery (SRS) have many repercussions. Ross and Need (1989) examined the relationship between the adequacy of surgical results and postoperative psychopathology in 14 male-to-female transsexuals selected for the absence of preoperative psychopathology. The researchers found that the best predictor of postoperative psychopathology was poor surgical results. Tsoi (1992, 1993) studied transsexuals in Singapore. He found that five years after genital reconstructive surgery (GRS) only 39% of FTMs were satisfied with the results of their phalloplasty. In spite of disappointing surgical results, most people are more satisfied with life after surgery and very few have regrets (Lundstrom, Pauly, and Walinder, 1984; Kuiper and Cohen-Kettenis, 1998). Barrett (1998) studied 40 postoperative phalloplasty patients and found that they were more satisfied with the appearance of their genitals than were a comparable preoperative sample. Green and Fleming (1990) found overall satisfactory postoperative results for 97% of FTMs.

Metoidioplasty is a less costly alternative to phalloplasty. Metoidioplasty refers to a variety of operations, which utilize the individual’s existing genital tissue to create a more male appearance. The clitoris, which has been greatly enlarged by androgenizing hormones, is "freed" so that it is more prominent and may even be capable of limited penetration. The urethra may be extended to enable standing urination. The labia majora may be used to create scrotum and may receive testicular implants. The outcome most closely resembles a very small penis or "microphallus." Metoidioplasty is considerably less expensive and is associated with fewer complications than phalloplasty. However, as with phalloplasty, the individual does not have a phallus that functions in every way like a mature naturally-occurring penis. In spite of the limitations of the available surgery, there are individuals who benefit from the procedures. This research attempted to explore why FTMs chose to have, or not have surgery and the process they go through over time to make that decision.
  

Method

Participants

Subjects were female-bodied individuals who were socialized as female but had male gender identities. All had considered genital reconstructive surgery to assume a more male appearance. Subjects were recruited from a peer support/social group for FTMs in New York City and from The First FTM Conference of the Americas held in San Francisco in August of 1995.

Measures

A questionnaire was designed to assess what surgical procedures subjects had considered and which major factors guided their decisions. The questionnaire included multiple choice questions, rating scales, and open-ended questions. Demographic questions included: age, gender identity, gender presentation, sexual preference, and relationships status. With specific regard to surgical decision-making, subjects were asked if they had ever considered undergoing genital reconstructive surgery and what decisions they had made. They were asked how they learned about surgical options and then rated the sources of information in terms of which had most influenced their opinions. The instrument was reviewed by two FTMs who were not included in the research and by one psychologist who had expertise in survey design and decision-making research.

Procedure

This was an exploratory, non-randomized, non-clinical study. People who had attended the New York City support group were called on the telephone and asked if they would consider filling out a questionnaire. It was considered indiscreet to send such a questionnaire without explicit permission. Sixteen former support group attendees were contacted and all agreed to have the questionnaire mailed to them. One hundred questionnaires were given to people at the conference. Some conference attendees were approached by the researcher and were asked if they would be willing to participate. Other individuals picked up questionnaires on a table that displayed flyers, information, and research opportunities. Questionnaires included a self-addressed stamped envelope and a brief cover letter stating the basic nature of the research and assuring confidentiality. They were also asked to include their name and telephone number if they would be willing to be interviewed in the future.
  

Results

Respondents: A total of 27 completed questionnaires were returned, a response rate of roughly 23%. Nineteen people included their name and telephone number with invitations to call and notes of encouragement for the project. There are at least two likely reasons for the small response rate. People may have been somewhat confused by the cover letter which addressed "people who have considered having surgery, whether they decided to or not". Many people who had surgery seemed to think that this did not apply to them, and those who were not having surgery thought that it did not apply to them either. Another factor in the response rate from the conference may be individuals’ basic resistance to being studied. At several forums at the conference participants expressed resentment that they were commonly "treated like guinea pigs".

Age and gender identity. The majority of respondents identified exclusively as male (n=19). Because of their cross-gender identity these 19 were termed the "transsexual" group. Twelve of those subjects were presenting as male 100% of the time, 3 were presenting as male 75% of the time and the other four were at an earlier stage of transition (presenting as male from 0 to 50% of the time). Ages ranged from 21-50 with a mean of 37. The remainder of the sample (n= 8) did not identify exclusively as male. They had unconventional gender identities or were at a stage of gender transition at which they felt they were between genders. Because of their non-traditional or gender-blended identities these individuals were termed "transgendered". Three people in this group said that they identified as "both male and female", three identified as "neither male nor female". The other two subjects identified as "lesbian" and as "butch dyke, queer, transgendered". Of those people who considered themselves "neither" one was presenting as male 100% of the time (and had undergone mastectomy and male chest reconstruction), one was presenting as male 75% of the time, and the third reported presenting as male 25% of the time. Of those identified as "both male and female" only one presented as male as much as 25% of the time. Because female-to-male transsexuals are generally defined by their male identification, only the 19 individuals who identified exclusively as male were included in the analysis of results below. Due to the small sample size it was not possible to analyze the statistical significance of the differences between the transgendered and transsexual groups, but some differences will be noted in the discussion section.

Relationships. Twelve individuals reported being in a romantic relationship. The majority (n=9, 75%) reported that their partners were female. One person reported being in a relationship with a biological male. One person was in a relationship with another FTM. One person reported that his partner was "bigendered". Five people had been in relationships for a year or less. Seven had had been with their partner for two years or more. Duration ranged up to 13 years with a median time of 3 years.

Sexual preference - The majority of the respondents (n=12, 63%) reported that they preferred women as sexual partners (a relationship they considered to be heterosexual). Three (16%) reported that they preferred men as sexual partners (a relationship they considered to be homosexual). The other 4 (21%) experienced a bisexual orientation.

Gathering information regarding genital reconstructive surgery (GRS) Ninety-five percent (n=18) of the participants obtained information about surgical options from transgendered/transsexual peers and had seen photographs of surgery (see Table 1). More than half of the respondents (n=12, 63%) reported that they had seen in-vivo surgical results. Eighty-nine percent (n=17) relied on pamphlets, newsletters, books, and articles distributed through the transgender community. Seventy- four percent (n=14) had received information from a helping professional. Additional information was obtained from medical journals, film or television, and popular magazines.

Subjects then rated the relative influence of these sources of information on their surgical decision-making. Table 1 shows the frequency with which each item was mentioned as a source of information. The table also shows the percentage of people who rated that item as having the greatest impact on their decision (1 being most impact and 10 being least impact). Speaking with transgendered peers, viewing photographs of surgical results, looking at in-vivo surgical results, and reading literature from within the FTM community was rated as the most influential experiences. Therapists and Physicians were rated as most influential by only 21% of the respondents.

Decisions made regarding genital reconstructive surgery (GRS). Participants’ decisions regarding surgery are listed in Table 2. Four of the subjects reported that they had undergone GRS. Two of them reported having had phalloplasty, two had metoidioplasty. Sixteen of the respondents reported that they were considering having some type of GRS in the future (some specified that they were waiting for advances in technology). Of these 16, 8 had actually made the decision or were leaning towards surgery in the near future. More than twice as many were considering metoidioplasty as phalloplasty. Most had rejected phalloplasty. The questionnaire contained the open-ended question "What surgical options did you reject and why?" Individuals had rejected specific options because of unattractiveness (36%), inauthenticity of surgical results (42%), lack of functionality (16%), and risks and complications (42%).

Many factors contributed to surgical decisions. Table 3 shows that lack of money and dissatisfaction with surgical options were most frequently mentioned as a contributing factor. None of the individuals rejected surgery because they were satisfied with their own body and none of the individuals said that they were influenced by a partner’s resistance to their transition.

Obstacles to Surgery. After participants made decisions about the type of surgery that they would like to have, they were prevented from having surgery for a number of reasons. Lack of money and flaws in the medical technology, were major factors in making the decision, but were even greater concerns in implementing the choice. Some respondents did not feel that they had access to adequate information in order to make an informed decision. Some admitted to fear of physical pain and surgical complications. Some had realistic practical concerns such as difficulty taking time away from work and family, or poor health. Difficulty finding a surgeon and the long distances necessary to travel to a surgeon were also obstacles. None of the respondents reported difficulty getting a letter of approval from a mental health professional, a clinic, or medical professional.

The Transgendered Group. The 8 individuals in the transgendered group had similar patterns of relationships to those in the transsexual group, but they differed from the transsexual group in a number of interesting ways. None of the transgendered individuals had genital surgery or were actively planning surgery in the near future. Five were still considering it in the future (two specified that it was contingent on improved technology). Two reported that they were considering metoidioplasty, but were very ambivalent. Three of the transgendered subjects mentioned their partner’s resistance to their transition as a major obstacle to surgery, versus none in the transsexual group. Three of the 8 said that they liked their body the way it was, versus none for the transsexual group. Nearly half of the subjects in the transsexual group had seen actual live surgical results as compared with no subjects in the transgender group.
  

Discussion

Summary of Results

Even though the sample (27) is too small, and the response rate (23%) too low as to have any statistical power, the following clinical conclusions can be drawn from this study.

Participants rated contact with other FTMs and information from within the FTM community as the most important factors influencing their decision of whether and what type of surgery to pursue. This was true regardless of age, sexual orientation, and/or relationship with a partner. Mental health and medical professionals were rated as less influential than peers. The majority of respondents had rejected phalloplasty in favor of metoidioplasty as an acceptable surgical option. Most reported that they did so because the present technology was in some way inadequate or because of cost. It is interesting to note that none of the individuals in the transsexual group rejected surgical options because they were satisfied with their own body. They wanted male genitals, if only they were attainable.

None of the respondents reported that they had difficulty obtaining a letter of approval from mental health or medical professionals. This may be because they had not requested such approval or because the sample was self-selected on variables which professionals associate with postsurgical success. This finding brings into question some of the controversy about "gatekeeping". Gatekeeping is a phrase used to refer to the ability of the therapists to control access to medical services based on whether or not they write letters to physicians in support of their clients’ desire for surgery or hormones. The results of this study did not support concerns about gatekeeping and suggest the possibility that, for this sample, providers were not reluctant to support requests for surgery and did not act as obstacles to treatment.

The Role of Peer Support

This sample was comprised of people who had sought out community resources either in a support group or at a conference. Virtually all of them had met other FTMs and had access to information provided by the community. The results demonstrate the significance of contact with others in shaping surgical decisions. The FTM community, as it is developing, places a high priority on information exchange among peers. The burgeoning peer support movement has implications regarding the nature of treatment decisions by consumers and professionals. It is particularly noteworthy that mental health and medical professionals were devalued as sources of information among this sample of subjects. The influence of professionals would no doubt be more prominent in a clinical sample or a group of subjects who did not have peer support networks and other resources.

Implications

Since the time of Harry Benjamin the desire for surgery has been treated as an inherent quality of the individual, symptomatic of their cross-gender identity. The results of this research suggest that surgical choices have to do not only with gender identity but also with available resources, technology and individual life circumstances. Research in this area is extremely important for several reasons. Attitudes towards GRS, and one's relationship with one's natural genitals, is frequently part of the diagnostic profile used to determine medical care and legal status for transsexual people. For example, a person who has not had, or does not plan to have, GRS may be denied hormones, surgery (particularly mastectomy or hysterectomy), a legal name or gender change, or ability to legally marry. It is crucial to be realistic and allow that many FTMs will choose not to have surgery not because they do not want a penis, but because we can not offer them an affordable, realistic, and fully functioning penis. They may also choose not to undergo surgery because of family obligations, the extensive convalescent time involved in numerous operations, or prohibitive health problems (such as diabetes or HIV status). Restricting the definition of an FTM to someone who requests a risky, costly, often technologically inadequate surgery is unrealistic.

The results of this research also have implications for the way mental health and medical professionals work with transgendered and transsexual people. Helping professionals have a unique contribution to make as facilitators of a decision-making process. The individuals in this sample placed a high value on information received through contact with FTM peers. These results suggest that it may be advantageous for professionals to work cooperatively with community and peer support services.
 

Suggestions for future research

This research was limited by the small sample size and by the lack of in-depth information about the subjects. While all participants in the transsexual group claimed to be male-identified, and even to live most or all of the time in the male role, the variations in the endurance, degree, and stability of that male identification was not examined. The small group of transgendered individuals demonstrated notable differences in gender identity and in surgical choice. As described above, there are many reasons why some individuals with a strong and stable male gender identity will not request the currently available surgery. For some portion of the transsexual population sex reassignment surgery is a desirable, necessary, and sometimes life-saving procedure. There are Female-To-Male Transsexuals who are intent on sacrificing everything necessary to obtain the currently available surgically-constructed phallus and there are FTMs who do not have that focus. Both groups have the potential to be accepted as men by their partners, family, friends, and associates.

What differentiates between FTMs who do and don’t pursue surgery? Apparently the desire for surgery is related to, but not completely dependent upon, gender identity. Further research is needed to examine how the intensity and stability of gender identity and desire to live as a man is related to the desire for surgery. This research does not answer the question "what drives some people to pursue surgery." It strongly suggests that gender identity is not the only factor.
  

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Correspondence and requests for materials to Katherine Rachlin, Ph.D. 153 Waverly Place, Suite 713. New York, NY. 10014. e-mail KRachlin@aol.com.