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Interview

Phalloplasty

The topic engenders polarized debate within the transgender community. Nowhere more than on internet support groups where, in the same thread, you will see some regard it as lifesaving and others as “frankendicks” that lack sensation and are “never good enough.” This body shaming would be unacceptable in any other context, yet it is routine with phalloplasty.

There are several possible reasons for this. The scarcity of surgeons and funds to pay for surgery can cause some to decry these procedures as something they wouldn’t want even if they could access them. The scientific evidence, however, reveals that, despite complications, phalloplasty satisfaction rates reach 100% and, overall, 97% in one review of several different studies.

On the other side, there is tremendous pressure placed on transmen who’ve had phalloplasty to portray their experiences as universally positive for fear of negatively impacting its availability or contributing to stereotypes about their genitals. In any case, with the possible exception of those who have had the procedure, phalloplasty tends to be seen in absolute terms; as good or bad, terrible or wonderful, life-saving or life-destroying. In reality, it is much more nuanced and individual than either of these extremes capture.

Matt has been advocating for transgender health for over 15 years. In this time he has moderated several groups for transgender men who, like him, pursue phalloplasty. Matt graciously agreed to be interviewed about his experiences though, as always, it’s important to emphasize that everyone’s experiences are unique, no more so than in major surgeries like phalloplasty. This interview has been edited for length and to protect his anonymity.

Thanks for joining me, Matt. I often hear and, in fact, I was listening to a recent Trans Advocate podcast that shared a similar sentiment, that phalloplasty, and transmasculine surgical services more generally, are bad or lacking.

Matt: Yes, that sentiment is widespread. That one drives a lot of silence, both among those who want phalloplasty, but don’t want to be judged for wanting it [and] those who’ve had it, because most of us don’t want our genitals to be put down, nor [do we want to] have to drop our trousers to silence our critics. And few people will accept a defense without visual proof.

Could you elaborate on some of the offensive things you’ve heard other trans people say about phallo?

Matt: Calling them carrot-shaped, rolled up dough, Frankenstein dicks. Saying they never have feeling.

Where have you seen/heard this?

Matt: PTWC [The Philadelphia Transgender Wellness Conference], in information gathering and open discussion sessions, phalloplasty information gathering Facebook groups, in discussions with community acquaintances. Pretty much any trans discussion space not confined to post-bottom surgery guys.

What does it feel like for you when folks say this stuff and why do you think they say it?

Matt: I used to feel stigmatized by it. They’re putting down my genitals. It’s body shaming. I put out a lot of information online [on various platforms and through workshops] to challenge it. I suggest ways to request information that doesn’t stigmatize post-op guys. There are more and more guys echoing these messages. I call-in people who seek me out for information using gross language, or otherwise positioning themselves as the vulnerable ones, to remember it’s the post-op guy’s genitals being discussed and shared. If they continue to argue, and/or start calling me an information gatekeeper, I block and move on. I’ve put out a lot of my experience in open online forums. I co-moderate a few spaces and I participate in conferences as money and time permits. I know I contribute my fair share. I’m fine with my hard boundaries. I think they say it because it’s what the ‘leading’ voices among pre-lower-op guys say. I think some guys say it because bottom surgery is out of reach for any number of reasons and it’s easier to put down something they can’t have [rather] than pine for it.

Some people are upset about the recent Salgado story because it casts aspersions on their surgeon which, by extension, may call their own surgical experience into question. What are your thoughts on that?

Matt: I feel for the guys who had positive experiences with him. Salgado is rightfully being criticized for what he posted on social media; but, painting all of his work as necessarily tainted is putting down a lot of guys’ genitals. I’ve seen several surgeons raised to high praise, only to have their reputations later on [destroyed, which coincides with], putting down anyone who went to said, surgeon. I’m all about trans people having measured relationships [with] our surgeons. Yes, they’re great for operating on us, but they make a living off of us, we don’t have to elevate them to rock star status. Any and all surgeons have bad days. Sometimes, by no fault of the surgeon or the patient, a flap dies. But when stories of total flap failures come out, a significant proportion of people researching their options will effectively victim blame. They try to find ‘the fault’ that explains it, and it must be something they can avoid so that they can guarantee their [own] future outcome. People will immediately ask who was the surgeon, what was the technique and is there anything in the guy’s health history that explains the bad healing. Most of the time, these questions come out before anyone even considers expressing basic empathy to the guy who’s just had total flap failure. And this quest to find ‘the sure outcome’ leads to wanting to believe that if they go to the ‘best surgeon’ for the ‘best technique’ they will not have a serious complication. It leads to this bizarre popularity contest, [like] which surgeon has the best track record.

Why is that?

Matt: [It] is largely driven by the guys based in the US. [This is] for a few reasons, but the two main ones are that in many countries with smaller populations there’s only one surgical team offering trans men bottom surgeries; and most guys can only access bottom surgeries if it’s paid for by public health care, which will only cover [it] if they stay in their country.

But in the US, there are several different surgeons.

Matt: The US’s large population results in far more demand and far more surgeons willing and able to provide these [surgeries, which], coupled with private health care plans that offer both in and out of network options, leads to many more options. So the guys in the UK are, by and large, being sent to the team in London because that’s what’s covered by the NHS. The guys in Belgium are all sent to the team in Ghent. Those guys are not going to be invested in finding out what potentially better options there might be in other countries. They care about what their options are, which is with the sole surgical team they can access via public health care. But with access to multiple options, many Americans don’t have to [limit] their options [in the same way] and their greater number means that their voices are more numerous in most English language forums, [where] they dominate the conversation.

It seems like that would give folks space to compare which practitioner was better.

Matt: Framing it that way to me assumes that there is a better practitioner, one that will be better for all. But surgeon selection, for those of us who are privileged enough to have some choice, rarely starts and ends with surgical merit alone. A lot of us will consider differences in costs that aren’t covered by our health insurance; [like] travel, out of hospital accommodations, [and] childcare expenses. And no surgeon offers all surgical techniques for phalloplasty. Many will offer one, some will offer two or three, [but many] people prefer a [particular technique, like] free flap versus pedicle, the way [a] surgeon does glansplasty, or [type of] penile implant.

How do you square these difficulties with people who say that phalloplasty isn’t worth it?

Matt: I don’t see the need to do some self-reflection and a little homework as a difficulty, but you’re right that it probably comes across that way to people who stigmatize phalloplasty. I think the baseline answer has to be that phalloplasty isn’t worth it for everyone, any more than hormone therapy, chest reconstruction, or gonadal removal is. Phalloplasty is worth it to those who need it to resolve their discomfort with their bodies. I see the need to do a lot of self-reflection, but not the kind imposed by gender identity clinics.

Trans guys researching their bottom surgery options should do so with a critical lens while being honest with themselves. I’ve been at [many] conference presentations where surgeons made claims that either defied what I knew from firsthand accounts of their prior patients or were framed in such [a] misleading way as to distort any value the statement might have otherwise had. The stand out example for me was the surgeon who said his complication rate was 0 [when] I knew from a closed online forum that [at least one of his patients had] suffered a severe complication that required another graft to correct.

I’ll pick on my own surgeons. [The plastic surgeon] told me at my consult that he’d never had a complication occur. I [immediately] gave him 3 examples that I knew of from guys reporting on a closed online forum. He conceded those 3 cases had occurred and said they were the only 3 as if I could then believe that. I asked my [urologist] at my consult his preferred method to handle a stricture, a common complication among my friends. I asked if he favored dilation. He said he’d consider it a failure if it required dilation, and [that] there would be no complication.

So it wouldn’t be a complication if it required dilation, but he would consider it a failure?

Matt: No, he was affirming strictures weren’t something that happened in his practice. By then, I’d spoken to enough other surgeons, and attended enough conferences, that I couldn’t write him off because of this, because they all say a variation of ‘you’re in good hands.’

But no one who points out these discrepancies between what surgeons say and the reality of many guys’ experiences [is] well received. People either see these sorts of statements as a reason to attack your results, say that you regret your surgery, and/or [that] you must have had a crap surgical outcome. Or those who had generally positive experiences drown you out with their [insistence] that great, less great, or [even] awful experiences cannot co-exist. As though any critic of their surgeon is an attack on their surgical outcome. A common outcome is silence around this stuff and echo chambers of ‘this surgeon is the best’ until that surgeon is raised to rock star status. [This continues] until enough people have awful experiences that [the] surgeon [is] knocked off his pedestal, [then] there’s a scramble to find the next rock star surgeon.

I have a friend whose penile implant didn’t work out the first time. He opted to have it removed and not replaced [which has] happened to several people I know, but is seldom discussed. And some might read that as regret or [that] phalloplasty isn’t worth it if it can’t ‘do everything,’ but I don’t. What works depends on the unique experience of each of us. I was essentially sexually stone in the lead up to bottom surgery. When people asked me how I could ‘risk’ my erotic sensation, [they] assumed I was able to make use of it as it was at the time, and that wasn’t the case. Not having phalloplasty wasn’t an option for me. I was increasingly dysfunctional as I was.

It kind of seems like it reflects the TERF argument that transition is never worth it.

Matt: That argument could be said about chemotherapy. The side effects are brutal, there’s no guarantee, and even if the cancer goes into remission, it can come back years later. It’s a dreadful argument. As is the proposition that not getting bottom surgery is necessarily ‘sticking with what I know,’ because what I knew was less and less functional. Sure, physiologically, it was remaining as it was, but psychologically the accumulation of more and more time without changing was shattering me. On a smaller scale, there’s not a lot to celebrate about the awkwardness and acne-ridden process of puberty. Taking 2-3 years for our voice[es] to crack and settle, acne to come and go, our body odor changing, etc. The outcome is worth it to most of us, but the process is awkward at best. I miss having head hair, but I put that in balance that, had I not gone on T, I would have continued menstruating, which really didn’t work for me. Phalloplasty doesn’t have to be 100% great, with no negative side effects, to be worth it or worthy. Honestly, I was so happy after stage 2, I almost didn’t go for stage 3. I didn’t have to be ‘done’ all the surgeries I set out to get to feel at peace. In the end, I went for the penile implant and I love it, but I was resolute that had anything gone wrong with it, I would get it removed and not replaced. I’ve considered, what if 10-30 years down the line stem cells or some other process enables an alternative that would, say, produce a penis that changes in length from flaccid to erect. To be honest, I don’t know if I’d go for it. That’s how much I love my dick and balls as they are now. And in the meantime, my mental health has been so dramatically improved I wouldn’t regret my phallo.

So it’s sort of a matter of perspective and balance?

Matt: And experience. I defied the odds, not the ones published in the journals, but from among my friends. I can count on one hand the number of guys I personally know who didn’t have a fistula, stricture, or issue with their 1st penile implant and have fingers to spare. I’m in generally good health, I certainly credit some of it to my outstanding primary care team for all of the follow up they provided back home, and surely some of it goes to selecting surgeons who had decades [of] experience. But, all the same, I held my breath those first 6 months [and] I wish things had gone even smoother, meaning fewer administrative hick-ups that, combined, added literally 2 to 2.5 years to my process.

I wish my public health care had covered surgeries when I was younger and [that] I could have completed my process much faster because all those extra years of struggling added up and I still struggle with their aftermath. The things I put on hold because I knew I couldn’t do them until my mind was in a better place. The things I did to cope in the meantime. It’s easy to envy those who get through the process so much faster than we could and it’s easy to get bogged down in ‘if only’ there had been better support, better services, etc. That all adds itself on top of my improved body image, my improved mental health, and my much healthier sex life.

So when people ask ‘is phalloplasty worth it?’ I know they either can’t comprehend how miserable I was and/or, if they’re trans themselves, they just don’t have the same experience and struggle with their bodies as I did. And I don’t mean that in a ‘one of us is more trans or male than the other’ way, just in a, ‘we’re all unique and your mileage may vary from mine.’ The faulty logic is in projecting their experience onto mine. My experience reflects the decisions I took, some of which are quite different from many of my friends.

It was [also] far rarer, or at least much less spoken about back then, to go into bottom surgeries while single. I found myself having to downplay my singleness in order both to get approved faster and get [a] penile implant. My partners early in my social and medical transition [also] fought [it] every step of the way. I watched one guy after the other compromise on their dreams for phallo [by getting meta] because their partner didn’t want them getting bottom surgery.

It was less common to have bottom surgery while single?

Matt: Most of the guys I knew a decade or so ago [that] got phallo were married. A lot of people around me assured me that if I was single going into phallo I would never date again. That aligned with my experience with every step of my transition. I should frame this that I’m queer, and prefer to date queer people, whatever their gender.

The only partners I had throughout my transition process, who were consistently supportive of my transition, were my trans girlfriends and 1 cis bi girlfriend. Everyone else had limits on ‘how far’ I could take my transition. There were those who insisted that I would become violent if I went on T, would become a misogynist, [or] stop being queer (not sure how as a bi person… but logic isn’t the forte of transphobia and cisnormativity). Some said T was ok but getting chest reconstruction would kill their sex appeal for me. Among the cis women, there were pleas that chest reconstruction would make us seem ‘too straight’ and erase their queerness. Among the trans guys, there was a lot of jealousy that I was accessing things they themselves wanted, or that I was becoming ‘more male,’ which would make them feel insecure or increase their dysphoria. Among cis men, there was confusion as to why I would give up the ‘bonus hole,’ which was apparently the main thing that attracted them to me, even though I was never interested in having sex using my frontal cavity. I was not popular for stipulating ‘my body, my choice.’

There was this bizarre shift among some of my friends, as we were [among] the first queers who came [out first, at a younger age, and then considered] becoming parents afterward. Within that cultural shift was the notion that, as a trans guy, I should want to maintain the option to contribute a gamete, carry, or at least prioritize having kids over bottom surgeries. At the time, there were [also] very few surgeons offering phalloplasty without removal of the reproductive system, so stating a desire for phallo was framed as necessarily wanting to become sterile. Transition generally, but bottom surgery, in particular, was framed as the epitome of selfishness. It was placing oneself ahead of romantic relationships, emerging family, community and, in a way, I bought into that. I decided I couldn’t ask someone to go through surgeries with me, so I opted to remain single. I had other motivations for that decision as well, but [that] was a part of it. I was tired of being told I had to choose between maintaining a relationship and getting phallo. That’s one of the ways dating post-phallo has been more satisfying. Dating me today is dating me as I already am, love it or not.

Within trans men’s communities, I think part of the problem is that up until bottom surgeries, for the vast majority of us, we don’t have a frame of reference for [the process]. You go under for chest [surgery], you wake up, [and] it’s a fairly straight forward recovery. Hysto is generally similar. [For] phallo, [if] all goes well, you’re heading back to the OR in roughly 6 months. In the meantime, your genitals are bruised and battered. There was no wound dressing change for my chest. I didn’t have to wear ‘hospital lingerie’ for more than a few days post hysto. I couldn’t get out of the hospital following chest and hysto fast enough. My chest surgery was done out-patient and I spent 2 nights in hospital post hysto. I begged to stay in hospital when I was discharged 2 days post phalloplasty and it wasn’t for the horrendous food or bland room decor.

So, when I’m asked by trans guys to confirm that waking up from phallo was the best day of my life, [I] think ‘you need to do a LOT more research and reflection.’ But saying anything besides ‘yes, it was the best day of my life!’ results in scrutiny for ‘what went wrong.’  Waking up from [stage 1 was] physiologically horrible, even if psychologically it’s what [I] wanted. There’s no parallel with hysto or chest. Like just none.

Thank you so much for joining me to share your perspective, Matt. I hope it will help to dispel some of the stereotypes and myths about phalloplasty. I appreciate all your work in raising awareness of this issue and in advocating among transgender men.

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