As of today, I have been on testosterone for 18 months and 3 days, or just over a year and a half. Since last month, I think I’ve dropped some weight around my waist. Also, muscle cramps have decreased. But the biggest transformation over the past few months has revolved around body hair growth. I can barely believe how furry I’m getting! This weekend, my GF actually mapped out the dwindling places on my body where there’s no hair—they are few and far between. In particular, my torso is getting particularly overrun with fur. Need evidence?

Exhibit A – Fur Fest ‘09

Now onto the regular Vogue poses for month 18!

At one of the follow-ups after the diagnosis of my post-hysterectomy vesico vaginal fistula (VVF) I asked my gynecologist if he thought the effects of testosterone on vaginal tissue could have played a role in my complication. He thought for a moment, then replied that he didn’t think so.

I was certainly not the first trans man that my surgeon had performed a hysterectomy for, but I don’t know just how much recent experience he has with trans men. There’s also very little data out there about the effects of testosterone on vaginal tissue. (Trans men are a very understudied population.) However, I have come across references that state the following:

• Testosterone makes vaginal tissues weaker, thinner, drier, more brittle.
• Testosterone changes the pH of vaginal tissue to be more alkaline.

If vaginal tissues in a trans man are weaker and thinner, wouldn’t that call for a surgeon performing hysterectomy to be more cautious with the pressure used in suturing?

Isn’t is plausible that my androgenized vaginal tissues were weaker and thinner and thus more susceptible to the pressure of that slipped stitch that went through the vaginal wall and into my bladder?

When I was asked to facilitate the Hysto Stories discussion group at the 2009 Gender Odyssey Conference in Seattle, I knew this would be an opportunity for me to share my story about VVF and also consult with some of the leading minds in FTM surgery to get their thoughts about my theory of increased risk.

Dr. Toby Meltzer’s presentation, FTM: GRS, was particularly eye opening. He stated:

• Atypical bacteria is found in the androgenized vagina.
• Androgenized vaginal tissues are not preferred for urethroplasty because they are weakened.

While not referencing hysterectomy and VVF specifically, this information seems like supporting evidence for my theory.

I attended Dr. Burt Webb’s presentation on hysterectomy the next day. Dr. Webb is the OB/GYN who works with Dr. Meltzer in Scottsdale, AZ. Dr. Webb performs vaginectomy (colopocleisis) and hysterectomy for FTM patients. I asked Dr. Webb if he thought testosterone had negative effects on vaginal tissues that could weaken them and put trans men at higher risk of complications. He didn’t think so. I cited Dr. Meltzer’s comments from the day before and he seemed surprised, then said he didn’t know. (Which I think is a fine answer. It’s better than bull.) Hoping I wasn’t dominating the Q&A, I went on to briefly tell him about my VVF. It then seemed obvious that Dr. Webb didn’t have much clinical experience with VVF. I don’t mean that disrespectfully, it’s just that he said a few things that are not true:

• VVF’s often heal spontaneously.
  FALSE: The chances of spontaneous healing of VVF with conservative treatment (catheterization) is less than 5%. With no treatment, that drops to less than 1%.
• VVF’s aren’t caused by a stitch.
  FALSE: Biopsies performed on excised fistula tracts have shown them to be caused by sutures. The presentation of my VVF indicated quite clearly that it was the result of a single misplaced stitch—not a scalpel nick.

Like my own gynecologist, I can’t expect Dr. Webb to be an expert on VVF if he hasn’t seen them in his own practice. They just aren’t that common.

But wouldn’t you know it… Shortly after leaving Dr. Webb’s presentation, I got an email on my Blackberry from another trans man who recently suffered a post-hysto VVF, had two repair surgeries, and is still experiencing related pain and discomfort. Similar stories have been trickling into my inbox since I first published information about my own VVF. I think it’s quite possible that trans men are at higher risk of VVF due to the androgenization of vaginal tissues, and I’ll keep looking for more facts that might support this. I don’t need to be right about this—in fact, I’d prefer to be wrong—but if the theory holds true, trans men and gynecologists need to be aware of this heightened risk.

UPDATE, 09/21/09: Dr. Kate O’Hanlan is a Gynecologic Oncologist based at Sequoia Hospital in Redwood City, CA. Dr. O’Hanlan has significant experience with trans men, and is the lead author of a 2007 study that I have referenced here before, Total Laparoscopic Hysterectomy for Female-to-Male Transsexuals (PDF.) In Dr. O’Hanlan’s pre-op info handout for trans men (PDF), it states:

At your physical exam, Dr. O’Hanlan may have prescribed low-dose Estradiol suppository tablets… these tablets help maintain mucosal tissues and will play an important role in your internal healing…  Once we are sure the internal scar line is cleanly healed, you will no longer need the tablets. In any case, the hormone dose is local and so low that it will not interfere with your testosterone treatment.

This is the first time I’ve come across a recommendation for Estriadol pre-hysterectomy to “maintain” vaginal tissues and help with healing. This isn’t clear cut support for my theory of androgenized vaginal tissue and higher hysto risk factors for trans men, but I’d love to get Dr. O’Hanlan’s thoughts about it.

Hat tip to Nico for sending me this reference! Thank you for contributing!!

UPDATE #2, 10/18/09: Estrogen suppository tablets are also prescribed to trans men who experience bleeding with penetration, restoring integrity to weakened, androgenized vaginal tissues.

Dr. Toby Meltzer

Originally, Dr. Toby Meltzer was not on my radar as a potential surgeon for metoidioplasty. I hadn’t researched him very closely because I knew his costs were high, and I liked Dr. Miro’s aesthetic results a little more. However, Dr. Meltzer’s reported 2% complication rate stuck in my head. Inspired by my hysterectomy experience, reducing the risks of complication is my top priority.

I had the chance to see Dr. Meltzer’s presentation, FTM: GRS, at the Gender Odyssey Conference last week in Seattle. These are the points that stuck out for me in his talk:

• The complication rate with urethral lengthening without vaginectomy (colpocleisis) can be 15%-20% higher. (Dr. Webb states this is actually 40%-45% higher.) Vaginal secretions into the surgical site just don’t contribute to good healing.
• In his practice, vaginectomy takes just over an hour, has limited blood loss, and has a less than 1% complication rate. (He recalls one bladder injury.)
• Metoidioplasty with urethral lengthening takes 2 – 2.5 hrs.
• Pumping works. It enlarges corporal bodies and skin. Recommended both pre- and post-op.
• Growth can continue post-operatively.
• Atypical bacteria is found in androgenized vagina (re: weakened vaginal tissues from testosterone use.)
• Hardest part of urethral extension is getting the curve right. There are no “L” or “J” urethroplasty procedures or methods. The goal is an “L” shaped hook-up; poorly executed the result is a “J.”
• There are no long term complication risks to his knowledge. Once you’re past 6-12 months post-op, there’s no complication that could occur that couldn’t be handled by any urologist.
• Dr. Meltzer displayed photos of excellent looking metoidioplasty results from his patients.
• See further notes below about complication rate and tissues used for urethral extension.

That evening, I also had the opportunity to have an in-person consultation with Dr. Meltzer. I found him and his two staffers to be friendly, easy to talk to, and very knowledgeable. I told him how impressed I was with his complication rate (which is even lower than 2%!) We briefly discussed why he doesn’t use vaginal tissue for urethroplasty and how that relates to my theory that trans men are at higher risk for post-hysterectomy VVF than women are.

We also talked about scrotoplasty. At this point, I’m not interested in the scrotal implants but I would like to keep my options open. When Dr. Meltzer talks about “scrotoplasty” he’s referring to the surgical procedure of moving and rotating the labia majora, then fusing them into a scrotal sac–without implants. If the patient desires implants, expanders and implants can be done at a later date. Dr. Meltzer sees no issues with waiting years for implants, or not having them at all, and he will do scrotoplasty–without expanders or implants–in combination with vaginectomy, and metoidioplasty with urethral lengthening.

Dr. Meltzer offered to do a simple visual exam to ascertain my suitability for urethral lengthening based on my dick size. I mentioned to him that I’d used DHT for three months. He said, “Well, keep doing whatever you’re doing because you’ve got great growth!” I thought to myself, you really know how to talk to trans men! I asked him what kind of post-op length I could expect and Dr. Meltzer gently grabbed my dick between his gloved fingers and pulled it straight out. “There’s your length!”

I am extremely impressed with Dr. Meltzer, his low complication rate, the very swanky surgical venue and the North American location. His pricing is higher than my other options, but after my hysterectomy experience, I would pay twice as much to avoid a complication (and this is coming from someone who has saved $0 for bottom surgery.) If I were booking surgery tomorrow, it would be with Dr. Toby Meltzer.

Questions and Answers

What meta procedure do you offer for transmen?

• Metoidioplasty, with or without urethral extension, and scrotoplasty.

• “Scrotoplasty” refers to the surgical procedure of moving, rotating and fusing the labia majora. Scrotoplasty may or may not include expanders and/or implants.

What is your 2008 pricing for this procedure?

• Vaginectomy: $8,073
• Metoidioplasty with scrotoplasty – no prosthesis: $9,750
• Primary urethral lengthening: $12,950
• Total: $30,773 USD.

(Note: I’m not certain if this pricing includes all anesthesiologist and facility fees.)

Is an in-person consultation required prior to booking surgery?
Yes. The cost for this is $100 USD.

What kind of waiting list do you have?
It’s recommended to book your consultation 2-3 months in advance. The waiting list for a surgery date is about 6 months, but those with more flexible schedules may be able to take advantage of a short notice cancellation.

Do you perform this in one or two surgeries?
Vaginectomy, metoidioplasty, scrotoplasty (no prosthesis) and primary urethral lengthening can be done in one stage. If scrotal prosthesis is desired, expanders can be put in 6 months post operatively (Stage 2), and replaced at a later date with a permanent prosthesis (Stage 3.)

Where do you perform these procedures?
Greenbaum Surgery Center, Scottsdale, Arizona, USA.

Do you require patients to stop taking testosterone prior to surgery?
Yes, patient must stop taking testosterone 2-4 weeks before surgery and can resume normal administration post-operatively.

How long is the hospital stay?
2-4 days in hospital, then stay in the area for 14 days.

What tissue is used for the urethral extension?
Labial tissue and the urethral plate. Sometimes buccal mucosa is used (inner cheek) but it’s not preferred. Vaginal tissue (anterior vaginal wall, mucosa) is not used. Androgenized vaginal tissue is weakened and more prone to fistula. Future plans include experimentation using small intestine for urethroplasty.

How long is the suprapubic catheter left in?
This depends on the patient’s healing progress, but typically it is removed 21-28 days post-op.

What are the common complications with these procedures?
Since 2003, Dr. Meltzer has had just two patients with a complication: one with a fistula (which healed spontaneously) and one with a stricture (which was healed with a simple outpatient cystoscopy.)

How many times have you performed metoidioplasty with urethral extension?
Dr. Meltzer has performed more than 800 FTM lower surgeries. He has done metoidioplasty with urethroplasty many, many times, but I don’t know the exact number. My guess is that he has the most experience with these procedures in North America.

Contact Information

Based in Scottsdale, Arizona, USA.
Visit tmeltzer.com for complete and updated contact info.

Learn more about Dr. Meltzer:

• Dr. Meltzer’s website
• Dr. Meltzer at Wikipedia
• Ethan’s consult* with Dr. Meltzer

* UPDATES to Ethan’s consult:

• The vaginectomy now removes all vaginal mucosa.
• Dr. Meltzer no longer uses vaginal mucosa for urethroplasty.
• Dr. Meltzer’s OB/GYN Dr. Webb reports minimal blood loss with vaginectomy: 125 – 300cc. Only once did he have a patient require as much as 800cc. Many surgeons talk about 1 L of blood loss and multiple blood transfusions. Dr. Meltzer’s team has not experienced this.
• Dr. Meltzer will perform scrotoplasty at Stage 1—but without expanders or implants.

Please note: This information is provided for information purposes only and in no way should it serve as a replacement for your own research and consultations. My intent is not to find a “winner”, but to figure out which surgeon I am best suited to. We each have unique requirements and criteria, so please don’t go on my word. At the same time, there are plenty of questions that surgeons have to answer over and over, so hopefully this series will cut down on some of that repetition.

• Part 1: Surgeons I am not considering
• Part 2: Dr. Marci Bowers
• Part 3: Dr. Christine McGinn
• Part 4: Dr. Miroslav Djordjevic
• Part 5: Dr. Toby Meltzer

Tomorrow I head south for Victoria, BC, then on to Seattle, WA, USA on Friday to attend the 7th Annual Gender Odyssey Conference. This will be my first time at the conference, and I’m looking forward to meeting many new friends: the YouTube meetup at the Opening Night Party at The Garage, Joe Stevens of Coyote Grace at their gig on Saturday night,  the fine folks from Gender Spectrum (organizers of the conference), and many more.

Officially, I have two roles at the conference: personal gopher for a few of the organizers, plus I’m facilitating the “Hysto Stories” discussion group on Sunday morning. Here’s the official session description:

Hysterectomies are common but information about these procedures as they relate to transmen is difficult to find. Are there unique considerations to know about? Are there factors that change depending on whether you’ve been on testosterone for 5 years? 10 or 20? What about sex and orgasm – does that change after surgery? Was it difficult to find a surgeon who would perform the surgery for you? If you had insurance, was it covered? What was your recovery like? Hear the experiences of others and share your own in the session.

My angle on this subject is that while hysterectomy may be considered a “routine procedure,” trans men are not routine patients. I have a suspicion that testosterone puts trans men at higher risk for the complication I suffered from (vesicovaginal fistula or VVF) due to the effects of T on vaginal tissues. There is little data available about the effects of T on these tissues, but I’ve come across numerous sources that suggest it makes the tissues thinner and weaker. Wouldn’t this put trans men at higher risk of iotrogenic VVF, especially in the hands of a surgeon who doesn’t have much experience doing the procedure on trans men? I look forward to talking about this with Dr. Webb, the gynecologist who works with Dr. Meltzer in Arizona and who will be presenting at the conference on the subject of trans male hysterectomy.

Dr. Meltzer will also be at the conference presenting, and I have arranged to have a free consultation with him on Saturday evening to discuss metoidioplasty. Dr. Meltzer wasn’t on my radar for surgeons to consider, mainly due to his higher fees. However, I’ve heard he has a 2% complication rate, which is much lower than anything else I’ve seen, and after my own experience with surgical complication, I would gladly pay extra to avoid one.

I plan to blog, post pics, and/or tweet from the conference floor. If you’re coming to Gender Odyssey, I hope to meet you!

As of today, I’ve been on testosterone for exactly 17 months. Not too much to report since last month, though I did notice today that my skin seems better than it’s been in a long time. I’ve also lost another couple of pounds; I’m now hovering at 140-142 lbs. My workouts are going well, though I need to amp it up to bulk up more. I recently bought an Iron Gym and LOVE it. I’m up to 3 x 10 reps of chin-ups (various grips.) I’ll do a more detailed workout post soon.

Over the weekend, my GF reminded me that it was a year ago that she left for a retreat at the Ashram. It was during the time that she was away that I sunk into a place of bitterness about the future of my transition. The initial glow of starting HRT and getting top surgery was fading, and I grew increasingly unsettled about the female gender marker on my birth certificate (particularly with regard to my passport and international travel.) While I didn’t suffer much dysphoria at the presence of female organs in my body, my birth province of Quebec requires a complete hysterectomy to update a birth record from female to male. Now 5 months post-op from a laparoscopically-assisted vaginal hysterectomy (LAVH) with bilateral salpingo and oopherectomy (say that 10x fast!) I’m no less bothered by the fact that the government can legislate my body in this way. Identity documents aside though, other compelling reasons in favor of a hysto were starting to emerge last August, and I grudgingly realized that my medical transition was far from over.

A hysterectomy was not the only obstacle in my path to being certified male by Quebec though: I was informed by multiple agents at the Directeur de l’état civil that I was also required to move back to Quebec for 12 months. This is absurd of course; I have a business, and own a home on the other side of the country. I haven’t lived in Quebec since 1979! Alas, recent residency is a requirement, I was told.

I was born in Montreal in 1974 to Anglophone parents. In French immersion, I received a half hour of English instruction a day, with the rest in French. I dropped immersion in high school though, so my fluency in French is certainly not what it used to be. I decided that it would be a good idea to have a French-speaking advocate in Quebec who could possibly help clarify this ridiculous residency requirement. Surely, I was just misunderstanding something. My contact at Project 10 in Montreal confirmed the bad news though: the residency requirement was real. I was also in touch with a couple of other Quebec-born trans people who’d been denied their applications to have their gender marker updated because of this residency requirement. I heard about one woman who engaged a lawyer to assist with the application and was still denied. It wasn’t looking good.

Was there a way around the residency requirement? Yes: Persistance.

How I got Quebec to issue a new birth certificate with my new name and male gender marker

I called the Directeur de l’état civil again. “Je besoin d’aide en Anglais, s’il vous plait.” I pressed the agent: Didn’t it seem completely absurd that I should have to move across the country to change one letter on a document? She agreed,  checked with a superior, and returned to tell me that she thought maybe that would only apply to applicants currently living in Quebec. Well, now we’re getting somewhere! She referred me to “Mr. Ali” and told me to expect his call within a couple of days.

Mr. Ali was incredibly helpful and told me that there are “holes in law #137″ that allow them to update gender markers without the residency requirement to “help people like” me.

Here’s what I had to do:

• (Get a hysterectomy! Other medical requirements: 1 year HRT, top surgery.)
• Provide an original letter from each of my surgeons confirming my surgeries.
• Provide a letter from my Canadian-licensed physician confirming my surgeries and hormone therapy.
• To update my name, provide my original BC Change of Name Certificate.

Mr. Ali told me they would make the name and gender marker change in their records and confirm with me by mail, then I could apply for a copy of my updated birth certificate. I sent these documents (along with a cover letter) directly to Mr. Ali. Almost two months later, I received an envelope with my original BC Change of Name Certificate (returned) plus an application form for copies of my birth certificate. No confirmation letter. Did they update my birth record? Or, will I order a birth certificate and have it arrive with my old name and female gender marker? I called Mr. Ali and he assured me that their records were updated and that my new birth certificate would indeed bear my new name and an “M.” (Still, a confirmation letter would have been nice…)

I completed the application form, ordering one large birth certificate (for my safety deposit box) and one wallet-size, and paid the higher “Accelerated Processing” fee. I mailed in my package on July 31.

10 Days Later…

I opened the mail box and found a thick envelope from the Directeur de l’état civil. So fast! A rejection?

No, a redemption.

The thick black ink on the textured parchment spells out my full name and boldly states, Sex: Male.

Unbelievable. It worked!

Gender marker correction expenses

• Fee for support letter from GP: $25
• Cost to ship documentation to Quebec: $13
• Accelerated fee for 2 copies of updated Quebec birth certificate: $70
• Cost to ship birth certificate application to Quebec: $13.34
• = $121.34

Being Certified Male: Priceless.

Side note: Quebec issued me a new birth registration number. I wonder what happens to the old number? Is it linked to my new record? Is my female record easily retrieved or sealed away? I should find out from Mr. Ali…

Next up: Accelerated application for a new passport. I think I can get a new one within 48 hrs if I apply in person in Victoria, BC. I’d like to cross the border for Gender Odyssey next month on a Male passport…

Also, I need to update my Social Insurance Number account and confirm with credit bureaus that my records have been updated (I think this may have happened when I renewed my mortgage.) That will complete the name / gender / identity document part of my transition. Out of curiosity, I may order a background check on myself to see how my identities come up.

As of today, I’ve been on testosterone for 16 months and 3 days.

When I did my #36 injection today, I noted that the needle seemed extraordinarily large. Indeed, I purchased 1 1/2″ sharps on my last supply pick-up instead of 1″ needles. I’ll keep the larger ones around but I think I’ll go buy some one inchers as they are less intimidating.

I haven’t shaved at all this month and I’m looking a little “bushy,” as one friend put it. It’s probably not very stylish, but I’m having fun finally being able to grow something, so it stays. Curiously, my GF loves it! (I don’t think either of us expected this.)

I’m getting hairier all the time! It’s an effect of T that I was academically aware of, but I’d never visualized what I’d look like with a furry belly and thighs. I like it, a lot. Related to this, I’ve come to the realization that a lot of what I call “acne” is actually ingrown hair.

I was very active in July and managed to get some muscle tone back, swapping some fat weight for muscle weight. I’m hovering at 145 lbs, and could lose another 5 lbs of body fat.

I “pass” everywhere now, except… with people I know! About 1/4 my friends and associates still use female pronouns with me. Another 1/4 either don’t recognize me or pretend not to see me. The rest avoid pronouns completely, slip and apologize (they’re trying) or have no issues (these are my fav peeps!) Maybe one day we’ll all be on the same page about who I am (!)

Without further ado…