Top Surgery and the Nipple Double Standard

Friends:

Yesterday, I had what is known as “top surgery.”  Basically, a plastic surgeon took my breasts and turned them into a male-contoured chest.

I did not have big breasts to begin with, but 10 months of testosterone and lots of weight lifting made them even smaller.  Basically, I had what would be typical for a male breast reduction.

I went to see Dr. Brian Eichenberg in Temecula, California, which is about an hour and a half from Los Angeles.  He was amazing and so was his staff.  He was kind, respectful, and took every opportunity to show me that he understood and respected me.

The procedure was supposed to be a fairly simple one.  I went under IV sedation and local anesthetic (no general anesthesia, thank goodness) and the procedure was done in about 2 hours.  Immediately afterward I felt fine.  I wasn’t too groggy, and went to Jamba Juice for a smoothie to celebrate being able to eat again.

Then, about an hour after I got back to the hotel (the doctor wanted me and my nurse friend to stay overnight in case there were complications, and for a check up in the morning), we noticed that there was a blood stain on my compression vest.  The doctor had me in an ace bandage wrap, a binder, and I have two drains (one under each armpit) to collect the extra fluid from my chest.

So through the ace bandage and the binder we noticed a blood spot about the size of a quarter.  Christina, my nurse, went to go get water and some other supplies.  By the time she came back, the spot was the size of a coaster.  We immediately got into the car and went back to the doctor’s office.  They rushed me right in and the doctor came in to look.

Turns out, I had a small artery about the size of a human hair that was bleeding into my chest.  Because it was an artery, with every heartbeat it was pumping more blood into my chest.  Because I ate after the first surgery (doh!) the doctor had to call in an anesthesiologist to put me under general for the second procedure.  In the 30 minutes we waited for him to arrive, my chest swelled considerably.  It was tight and by the time I went under, I was in real pain.

Turns out, this is a complication that only happens in one out of every 8,000 or so procedures.  The doctor said he hadn’t had one happen in about 8 years.  Luckily, it was an easy fix.  They drained the fluid, cauterised the vessel, and put me back together.

Needless to say, I was WAY more out of it after the second procedure. General anesthesia is SO GROSS and leaves the worst taste in your mouth. Christina let me celebrate being done with an extra big Coke from Chipotle. I haven’t had a real Coke in so long!  The taste and the bubbles did the trick and I felt much, much better.

I spent the rest of the night getting up and down to empty my drains and take more meds, but slept okay.  Today, I woke up feeling like a whole new person.  I went in for my check up and got rave reviews.  Everything already looks amazing!

I have to keep the drains in for another few days and wear the binder for another two weeks.  But in the moments where I have glimpsed my chest in the mirror, it’s hard to believe what I see.  Is that really me?!

I have gotten a lot of questions from people about what it will be like to be able to go shirtless in public.  I’m not going to lie, it’s going to be weird.  After 31 years of being told to always keep my chest covered in public, it will be a power force to overcome.  I have been practicing around the house and in front of my friends, but no doubt it will still be strange for a long time.

This is the double standard of chests and nipples and nakedness for men and women.  Yesterday, at 8 am, I could have been arrested for walking around with no shirt on.  Today, at 8 am, it would have been perfectly acceptable and normal.  This is insane to me.  What is it about women that needs to be covered?  Men have nipples, too.  People sexualize men’s chests, too… just check out any Abercrombie bag, Calvin Klein ad, or an other ad aimed at men.

Are women’s nipples really so offensive?  What do we, as a society, think will happen if women suddenly go topless in public?  In Europe it’s no big deal, and they are still functioning just fine.  There are many societies in the world where women are topless on the regular and the earth keeps rotating.  We need to get over it.  We need to stop telling little girls to wear “training bras” (which are basically just under shirts) when they go outside but little boys roam free and shirtless.  Women should be able to wear bikinis or go topless if they want to at the beach or pool.

My nipples are exactly the same today that they were yesterday.  Is it all the fat and skin they took away that was so offensive?

#freethenipple

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The Trans Healthcare Gap

In exactly a week, I’m having surgery. More specifically, I’m having what is known as “top surgery,” which is female-to-male chest reconstruction surgetumblr_inline_mxmeg4kxqA1snsabvry. The procedure is fairly common for FTM trans folk, and the surgeon I am seeing has done about 300 of them in the last few years.

The procedure is performed by plastic surgeons, whose main practice is usually breast implants, Botox, face lifts, etc.  To be honest, it was a little strange being in the waiting room of the facility, which felt more like the reception area of a Massage Envy location than a surgery center.  Warm brown tones, low lighting, candles and scented oil diffusers, overstuffed chairs, etc.  The staff wear all black and little name tags.  There was probably a fountain filled with river rocks somewhere.

Everyone was lovely.  The surgeon is a very nice man who I guess is in his late 40s– but then again, he is  a plastic surgeon.  He was in good shape and seemed lively, not like the very nervous/stressed/bro-y three surgeons I had met with previously.  No, this doctor made me feel comfortable immediately.

The first thing he said was “I’m really excited about this.” I asked him why and he told me that FTM chest surgeries are his favorite procedures to do. I asked him why that was.  I’m not sure what I thought he was going to say, but in my head, I was thinking “at $5k + a pop, I bet they’re your favorite!”  Instead, the doctor said:

“Every one of my patients comes here because there is something about themselves they’re unhappy with.  But what I do for trans guys is different.  There’s something about helping someone realize who they truly are. They are the happiest of all my patients, which makes me happy.”

Okay, McDreamy, you can stay.

We talked over how things would go, he took some photos, drew all over me with red marker, and then left me with the nurses for the rest of the visit.  The nurses were super respectful and kind, and I could tell that they were used to having folks like me around.  I’m really excited.

As excited as I am, I also have a great deal of frustration going into this procedure. It has been a long, complicated road to get here.  That, friends, is the real focus of this post.

It used to be, not that long ago, that a trans person would have to see a psychiatrist/psychologist for a year before being able to start hormones.  Then, surgeons usually required a year of hormones and living out as your true gender before they would do anything, and even then you had to have two letters of recommendation from healthcare professionals to certify that you *really are trans* and you’re not crazy.

Thank goodness, this model of “care” has gone by the wayside.  As policies toward trans healthcare have changed, the process has become shorter, if not simpler. Under my insurance, which covers hormones and surgery (more on that in a minute), the only requirement is that I have a letter from one mental health professional certifying that I have gender identity disorder. No hormone requirement, no “out” requirement necessary.

Okay, insurance.  Health insurance is a bureaucratic mess at best and a nightmare at most for just about everyone.  Just imagine how hard it is when you have some medical condition that is 1. uncommon, and 2. socially unpopular.  Until 2014, insurance companies could outright refuse to cover any trans-related care, calling it a “pre-existing” condition.

In 2014, after the dust settled for the most part around the Affordable Care Act, some states began interpreting the ACA’s prohibition on gender-based discrimination and mandate to cover pre-existing conditions and issuing their own guidance requiring insurers in the state to cover transgender-related care. Thankfully, California is one of those states.  New York recently joined the fray.

So theoretically, my care should be covered by all insurance that operates in California.  Except, my work uses a “privately funded” insurance plan, which means it gets to control what is and is not covered, not the state. And wouldn’t you know– trans care is not covered.  I raised a stink about this and HR is “working on it.” Truthfully, they’ve never had a trans employee (that they know of) and so they never had to consider transition-related care. Hopefully my struggles with this will help make it easier for the next trans person at my firm.

So I had to drop my work healthcare and enroll in Covered California, the CA branch of Obamacare. EVERY SINGLE PLAN COVERED TRANS CARE! I picked my PPO, double-checked all the paperwork to make sure surgery is covered, and immediately sought out a surgeon who could do it.

Wouldn’t you know, there are NO SURGEONS who do top surgery who also take insurance. None (except for Kaiser, which has their own plastic surgeons). I even called the insurance company to see if they could somehow figure out if any of their customers had ever actually had the procedure done, and if so, where they went.  No such luck.  And just imagine my trying to describe my situation and top surgery to the poor customer service lady that answered the phone…

A friend of mine who is in medical school at the moment told me that plastic surgery (“plastics,” she calls it) is the most competitive residency out of med school. It’s no secret that plastic surgeons make tons of dough, so I guess that is a big part of the reason why.  Because they perform services that are largely “elective,” plastic surgeons exist almost entirely outside of the insurance world, because insurance simply doesn’t cover cosmetic procedures. There are also only a few surgeons that do top surgery for trans guys, so they pretty much have control over the market.

So, even though I have insurance that covers this procedure, I cannot get it covered because there are no doctors that actually take insurance. It is a gap in the policy and practice of trans healthcare that begs to be closed. However, as the market stands, surgeons have little incentive to get in-network with insurance carriers because there are plenty of trans guys that scrimp and save to be able to fork over the $5-15k it costs to have the surgery done.

I am fortunate to have a job and a support network that can make paying for this on my own possible. But the reality is that most trans people can’t afford surgical procedures or hormone therapy without insurance coverage.I can only hope that some doctors and surgeons see this gap between policy and practice, and take the steps to get affiliated with insurance networks, even if it ends up being just out of the goodness of their own hearts. The trans community could really use the help.