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Everything You Ever Wanted
to Know About Sex Change*
*but were afraid to ask

Last updated in 1997

Surgeons

The following section provides copies of the letters several prominent sex reassignment surgeons send out in response to requests for information.

Eugene A. Schrang, M.D.

EUGENE A. SCHRANG, M.D., S.C.Plastic and Reconstructive Surgery Office: 414-725-6661

240 First Street FAX: 414-725-1925Neenah, Wisconsin 54956

Dear:

This letter is intended to present you with the most pertinent information you will need regarding your transsexual surgery. It is meant to be informative about our requirements, our monetary policy and all of those things that will be necessary for you to know about your operation. Keep in mind that everyone's experiences are different and what material is presented here may not be exactly what happens to you, rather, it is intended to provide a general overview of the entire procedure.

The transgender operations are done at Theda Clark Regional Medical Center located in Neenah, Wisconsin. The town has a population of about 25,000 people and is located about 100 miles north of Milwaukee and thirty miles southwest of Green Bay on Highway 41. The city is covered by air service out of Appleton airport eight miles to the north, or Oshkosh airport eight miles to the south. The area is also serviced by Greyhound bus from Milwaukee and Green Bay. Most travel services can assist you with your travel plans.

If you have never been seen by me, you will be evaluated in my office around 1:00 PM the day before surgery. It would be advisable that you arrive either that morning or, the day prior which would give you an opportunity to get a good night's sleep before you are seen in my office. We suggest you stay at the Valley Inn (414)-725-8441 or the less expensive Twin City Motel (414)-725-3941 if you are coming a day prior to your office appointment or if you intend to remain in a hotel after you have been discharged from the hospital before making a long trip home. Neither hotel is within walking distance after your surgery but Taxi service (414)-832-8890 is available, both from the hospital and from the airports. If you plan to stay at the Valley Inn, give them your flight number and time of arrival when you call for reservations and they will have their airport shuttle pick you up. If you have already been seen by me in my office, you may proceed directly to the hospital the day before your surgery but please be there no later than 2:00 p.m. so the necessary lab work and preparations can be done before the personnel leave for home.

It would be a good idea to bring only the necessities which you will need in the smallest and lightest carrying case that you have. This is to prevent tearing of the sutures and damage to the new vagina following surgery. You will spend most of your time in bed and, therefore will not need numerous changes of clothes. It is suggested that you bring only one outfit and wear it both arriving and departing. It is advisable to wear something loose fitting as there will be some tenderness and swelling following surgery. Tight fitting jeans and panty hose may cause discomfort. It is certainly possible that there will be some discharge and light bleeding in the genital area after surgery. Although you will be required to use sanitary napkins to absorb the blood, there is a chance that some will leak through, therefore, dark clothes will help conceal any stains on the return trip. You will need to bring your personal toiletries and robe if you want to leave your room after you are up and around. The hospital provides gowns which you will be wearing while you are confined to bed. Personal items to entertain you such as cassette players, reading materials, etc. are suggested but we strongly recommend that you keep your baggage as light as possible.

Theda Clark Regional Medical Center is located on the Fox River at Lincoln and First St. and one block from my office which is at 240 First St., just north along First St. on the corner of First and East North Water Streets. A map is enclosed which should be helpful.

As mentioned before, if you have not been evaluated prior to hospital admission, it will be necessary for you to be seen in my office early in the afternoon before the day of your surgery. At this time you will be interviewed and undergo a physical examination. You will sign consent forms, have your photograph taken, receive instructions and take care of any remaining financial matters.

We must have TWO PSYCHIATRIC EVALUATIONS WHICH SPECIFICALLY RECOMMENDS SRS OR SPECIFICALLY STATE THAT YOU ARE A GOOD CANDIDATE FOR SRS OR ANY SEX CHANGE PROCEDURE SUCH AS AUGMENTATION MAMMAPLASTY. These are to be done by Psychiatrist or Psychologists who are recognized, licensed workers in the gender or sex-oriented field. A letter is required from your Endocrinologist outlining the history of your hormone therapy. We strongly recommend and advise you that you do not call to schedule your SRS operation until you have completed at least nine months of psychiatric evaluation and understand that the final evaluation for SRS is done by me the day before your surgery.

If it is determined that you are eligible for transsexual surgery, you will be sent to Theda Clark Regional Medical Center for admission. At that time you will sign hospital consent forms, check your valuables, pay any remaining fees and get your lab work done.

Very little lab work is necessary which will be done together with an AIDS test at Theda Clark Regional Medical Center the day before the operation.(on rare occasions a false positive is obtained from rapid HIV test) SRS will not be done for anyone who is HIV positive, has Herpes, or has any other venereal disease, therefore, it would be wise to know your HIV status before you arrive.

[Editor's note: Although some surgeons will not perform the procedure on those with HIV or other sexually transmitted diseases, there are other who will.  If you suffer from these problems, don't be discouraged.   You can obtain current information about various surgeons on the internet or through your local support group.]

The hospital staff is courteous, friendly and competent and although they will be as helpful as possible, any technical questions regarding the surgery are best reserved for me.

It is most important to prepare the patient both inside and out, therefore, you will be given a thorough bowel prep to make the inside of your body as clean as possible for the operation. You will be asked to take a shower with a shampoo. There will be a perineal and perianal prep which amounts to having those areas shaved. This will be followed by painting the middle part of your body with an antiseptic solution to keep the bacteria count down. A liquid supper is served around 6:00 p.m. and you will be given a sleeping pill around 10:00 p.m.

In the morning you will be given your pre-operative medication which will make you feel groggy. You will then be taken down to the operating suite where a general anesthetic will be administered. You will remember nothing until you wake up in the recovery room.

Depending on what is done, the operation can last anywhere from three to five hours. If you are having additional work such as a skin graft, more time, of course, is required.

It is important that you know about a basic fundamental problem regarding the depth of your new vagina. I try to make the neo-vagina as deep as I can - up to six or seven inches is common and obviously, the longer your penis, the more skin will be available to line this newly created opening. Sometimes however, the new vagina may not end up being as deep as one would like. If future sexual intercourse is in your plans, and your penile length is adequate, the standard genital procedure without a skin graft would be done. On the other hand, if your penis has relatively little length, I would suggest that a skin graft be used to help make the vagina deeper, unless of course, you have NO plans for future intercourse. The skin graft comes from the area beneath the umbilicus and above the pubic hair or it can be taken from the thigh or buttocks. The donor site does leave a mark and is noticeable. The determination whether or not to use an ancillary skin graft would be made at the time of the physical examination. In general, the shorter your penis and the greater your desire for future intercourse, the more likely a skin graft would be considered. If you have a relatively short penis and insist on SRS without a skin graft, the inadequate depth of your vagina for future intercourse must of necessity be YOUR RESPONSIBILITY.

The question of secondary scarring from the skin graft donor site is always raised... Yes, there is a mark where the skin graft is removed. The color of this area varies in intensity from person to person and in some patients it can become red, raised and last a long time. Although it invariably fades out in time, this involution process can be hastened by applying sheets of silicone to the area for several months. Again, the response of this new technology varies from patient to patient.

We expect our results to be good to excellent; however, complications can occur. Although most problems can be readily and successfully dealt with, the Recto-Vaginal fistula is the most serious possible problem that could happen. Should the rectum be inadvertently entered, the opening would be closed, but a future fistula could result. Your bowels are cleansed thoroughly before surgery to prevent this problem but if a fistula does form, it would be necessary to do a temporary diverting Colostomy until the fistula could be adequately closed at a later date. Keep in mind that the dissection of the Neo-vagina is delicate and hazardous with the possibility of rectal damage always present.

I WANT TO EMPHASIZE AS STRONGLY AS I CAN THAT THE FIRST SURGEON TO DO THE SRS WITH OR WITHOUT A SKIN GRAFT HAS THE BEST CHANCE FOR SUCCESS. Experience has taught us that redo's to deepen the vagina can be (but are not necessarily) very difficult and run the risk of being unsuccessful. The rectum could be entered due to the fact that scar tissue is present in the deep vagina making secondary dissection perilous. Once the secondary dissection is complete, a skin graft must be used to line the newly created, deep vaginal area which had previously contracted. This newly created opening has the TENDENCY AND GREAT ABILITY to contract again and obliterate itself in spite of diligent dilating on the part of the patient resulting in NOTHING GAINED. Therefore, we suggest for anyone who has had SRS done elsewhere and develops a vaginal contracture that they return to their original surgeon for treatment.

While in the recovery room, we make every effort to avoid the feeling of nausea and vomiting which we do with both drugs and the administration of oxygen. You will have a Foley catheter in your bladder which may give you a feeling of wanting to urinate. This feeling will pass. Once you are awake, you will be returned to your room where you will sleep for much of the remaining day. The IV in your arm usually stays until you no longer have pain which is about five to six days. Your pain medication (Demerol or Morphine) is given through the IV. Sleeping pills will be given every night that you are in the hospital.

Not counting the day of surgery, you will be confined to bed for six days. For example, if your surgery is on Tuesday, you will not be able to get up and out of bed until the following Monday. Since this may seem like a long time to you, it is best that you bring reading material or paper work to occupy your time.

Constipation is not unusual and you may not have your first bowel movement for three or four days. Of course, it will be necessary for you to use a bed pan as we cannot allow you out of bed until more healing has occurred.

Ice packs will be applied to your groins continuously; your sanitary napkins will be changed as necessary and sponge baths will be given while you are in bed. You will find a wire tied over cotton in your pubic area this along with your urinary catheter will be removed on the sixth day after which you will take a shower or bath when your strength has returned. At first you will feel weak, but your strength will recover rather quickly. If urination is difficult, it is because of swelling and the presence of the vaginal pack. Should you be unable to urinate, the catheter will be temporarily replaced.

You will be leaving the hospital on the eighth day. For example, if your surgery was done on Tuesday, you will be discharged on Wednesday of the following week. The day you leave, your vaginal packing will be removed and you will receive instructions as to how to keep your own vagina dilated. If you are sent home on additional drugs, they can be obtained at the hospital pharmacy but be prepared to bring enough money to cover costs. In order to make your trip home easier and more pleasant, especially if you live far away, we STRONGLY SUGGEST that you stay in one of the area hotels for several days after your hospital discharge. Because we have experienced non-payment of our fees in the past, we have formulated the following fee policy. If you consult with me in my office any time other than the day before your surgery, I charge $75.00 for this time and this $75.00 is to be paid IN ADVANCE BEFORE YOUR OFFICE CONSULTATION IS SCHEDULED. To avoid cancellations, no shows and people who are not serious, this fee is NONREFUNDABLE. The basic fee for the genital surgery is $4750.00. If your penis is so small as to warrant a skin graft procedure along with the usual inversion technique, there will be an additional $500.00 charge.

Once we set a surgical date, whether or not you have been seen by me in my office, we require a $500.00 deposit to reserve that time. The $500.00 is to be received in our office NO LATER THAN ONE WEEK FROM THE DATE THAT YOUR SURGERY IS SCHEDULED. Once we set the surgery date and you cancel for any reason whatsoever, the $500.00 is ABSOLUTELY NONREFUNDABLE . The only exception to this would be if I determine, at the time I first see you in my office, that you are not a candidate for transsexual surgery. Only then will your $500.00 be refunded. Remember, the $500.00 advance deposit is to secure your surgical time. If your deposit is not received per our office policy, you may lose you surgery date to someone else.The remainder of your bill is to be paid at least two weeks prior to your surgery and NO PERSONAL CHECKS PLEASE.

 

Hospital and anesthesia fees MUST LIKEWISE BE PAID IN ADVANCE. Please have separate cashier's checks made out to each provider in the designated amount. The hospital fee is $5,400.00 and should be made out to Theda Clark Regional Medical Center. The anesthesia fee is $924.00 and should be made out to the Association of Hospital Anesthesiologists, Inc.

 

The following is our basic fee schedule including the other ancillary operations done to feminize the face, chest and genitalia:

SURGERY SURGERY HOSPITAL *** ANESTHESIA***

PROCEDURE Sched. A* Sched.B**

Genital Surgery (SRS) $ 4,750.00 $4,950.00 $5,400.00*^ $890.00

SRS with Aug Mam 5,850.00 6,100.00 6,000.00*^ 1,117.00

SRS with skin graft 5,250.00 5,450.00 5,400.00*^ 924.00

SRS w/graft & Aug Mam 6,350.00 6,550.00 6,000.00*^ 1,151.00

Later deepening of 7,750.00 8,050.00 5,400.00 920.00

Vagina with skin graft

(for stenosis)

Chin shave 1,500.00 1,600.00 250.00 160.00

Orchiectomy

unilateral 1,000.00 1,200.00 510.00 450.00

bilateral 1,700.00 1,800.00 510.00 450.00

Labiaplasty 1,500.00 1,750.00 750.00 452.00

Tracheal Shave 1,300.00 1,400.00 510.00 452.00

Malar Implants 1,300.00 1,400.00 670.00 452.00

Augmentation 2,200.00 2,300.00 680.00 454.00

Mammaplasty

Implant fees are not quoted due to constantly changing prices. They are sold to you by us-not the hospital--- at our cost in order to keep the price down for you.

Total Reduction 3,600.00 3,800.00 1,450.00 636.00

Mammaplasty (Female to Male)

Testicular Implants 1,200.00 1,300.00 250.00 160.00

* Schedule A - Surgical fee if paid by cash, (cashiers check or money order) and RECEIVED BEFORE OR NO LATER THAN 14 DAYS PRIOR TO SURGERY.

** SCHEDULE B - Surgical fee if received WITHIN the 14 days prior to surgery or if paid by any means other than cash.

*** If you wish to pay the hospital and/or anesthesia by any means other than cash, such as by credit card, you must contact them for permission to do so.

*^ - There has been an increase in the prepay hospital fee which allows for coverage of unexpected hospital expenses incurred over and above the usual charges. However, should your operative and post-operative courses be uneventful and you do not require additional costly medical care or if you are medically able to be discharged one day early, a rebate in an amount up to $600.00 will be refunded to you within five working days after you are discharged. In the past, added expenses were absorbed by the hospital and the patient was never billed for them; now, the hospital can be covered without having to collect from the patient after she returns home.

If procedures are staged, such as orchiectomy followed later by SRS, the initial procedure will be full price. When the second procedure is scheduled a price break will be given; we will reduce the SRS fee by subtracting 1/2 the price of the initial procedure. This policy applies ONLY if the initial procedure was done by me. If done by someone else, the FULL PRICE for SRS will still be charged.

Regarding Secondary Genital surgery to correct problems from a previous operation; experience has taught us that Sex Reassignment Surgery to correct cosmetic or functional problems occurring at the time of or after the first surgery are FAR MORE DIFFICULT the second time it is done because distorted anatomy and scar tissue interfere with meticulous surgical dissection. Complications such as operative and post-operative bleeding are more common and patient stay in the hospital can be prolonged over the usual 8 days. For these reasons, the surgical fee for an SRS redo is $7,750.00. The hospital and anesthesia fees will be the same as primary SRS, HOWEVER, there may also be INCREASED OR ADDED HOSPITAL, ANESTHESIA AND SURGICAL CHARGES if complications arise necessitating more surgery or if the eight day stay is exceeded.

Any additional charges will be the patient's responsibility, so please come prepared to pay these extra costs at the time of your discharge. I will continue to be responsible for my own patients and will do whatever I can to improve upon any complications that may have arisen from surgery that I have performed. This however, does not make the degree of difficulty of any additional procedure less, but I would prefer that other surgeons deal with their own complications.

If more than one operation is done (for example: Genital Transformation plus Augmentation Mammaplasty), it is customary for the surgeon and the anesthesiologist to cut the cost of the lesser procedure in half. However, this is NOT the policy of the hospital; their fees are additive because they have already discounted their prices well below the standard going rates as a special favor to cosmetic and transsexual patients.

Please remember that all hospital quotations for ANCILLARY cosmetic and transsexual surgery are for ONE DAY STAY ONLY. There is an additional $80 charge to stay overnight if I feel it is medically necessary for you to be observed for another 12 hours;the charge will increase to $225.00 if you elect to stay overnight for no other reason than it would be a convenience for you. If you remain in the hospital longer than 24 hours, - No matter what the reason - your quoted fees will no longer apply and you will be charged A GREAT DEAL MORE than those original quotations. Therefore I suggest you limit the procedures you want to a reasonable number. There is a limit to how many different operations I can do on one person at any one time. I will determine how much surgery will be judicious and prudent on a one day stay basis.

ALL FEES ARE SUBJECT TO CHANGE. Regarding insurance - experience has taught us that insurance does not pay for cosmetic surgery nor gender dysphoria problems. There is, however, always that rare exception but since the hassle with insurance companies is so great, we ask that if you have insurance which will cover your procedure, PLEASE HAVE THIS FACT NOTED IN WRITING from your insurance company and we will then, and only then, SEND WHAT FORMS YOU GIVE TO US into the insurance company. However, WE WILL STILL ASK FOR PAYMENT IN ADVANCE and any monies received from insurance companies will be refunded to you.

Lastly, please do not ask this office to send letters to insurance companies trying to convince them that your problem is medically necessary. This is just the hassle we wish to avoid. We suggest that this be done in advance of your being seen by me. The matter of the overweight patient has come up on a number of occasions. Without having seen you prior to surgery, it is impossible for me to determine the feasibility of doing your surgery if you are markedly overweight. SRS can be done on most people, however in the morbidly obese, the operation is still very difficult and the final results are compromised because of the presence of great amounts of fat tissue. Overweight people simply do not do well during and following surgery and the results of our efforts are not as good as they would be if the person were of normal weight. Some obesity can be dealt with, but I just want to emphasize that anyone over 200 pounds may have a very difficult time. I realize that 200 pounds on someone over 6 feet is not a problem, but 200 pounds on someone 5 feet tall is a weight problem very difficult for any surgeon to overcome. The final determination of whether or not your surgery can be performed because of your relative weight, will be determined at the time of your physical examination. If you are markedly overweight, do not be disappointed if your surgery is postponed giving you a chance to lose some excess poundage.

Much discussion has evolved around the discontinuing of hormone therapy prior to SRS surgery. When the genetic female undergoes routine surgery, nature has provided protective mechanisms (not entirely understood) against the formation of thrombotic emboli (which can cause death) that are not present in the genetic male taking female hormones. Therefore, even though the likelihood of this dreaded eventuality is remote, we STRONGLY RECOMMEND for your own safety, that you discontinue taking hormones three weeks prior to and three weeks after your surgery - ANY SURGERY! Withdrawal symptoms are uncomfortable, but temporary, and much better than dying. Also, please stop taking Aspirin as well.

Since the operation cannot be completed in one stage, some patients elect to have the Labiaplasty portion done three months later. This is intended to feminize the operated area and cannot be done at the time of the SRS because important blood supply would be cut off from vital tissue. Whether or not to have the Labiaplasty is your option.

Because we live in an age of high technology, computers, etc., it has unfortunately come to our attention that psychological evaluations can be and have been falsified. Since we have no way of knowing the credentials of very psychologist and psychiatrist who refer patients to us, we must CONFIRM the fact that you are indeed a candidate for SRS. If your evaluations are in doubt, we will have our own Clinical Behavioral Scientist evaluate you on a one time basis either at her office in Chicago for $250.00 or, if it is more convenient for you, at my office here in Neenah for which she charges $500.00. Because this surgery is irreversible, we do not want you to enter into a situation which you will later regret. Dr. Randi Ettner's interview will be on a one time basis and keep in mind that this is necessary for your protection as well as ours. If it so happens that you only have one psychological workup, Dr. Ettner will be asked to evaluate you as a second opinion which may take several sessions or even a complete course of evaluation may be required. In any case, great weight will be placed on her final recommendations.

Enclosed find a map of the area. If the Appleton Airport is used, cab transportation is readily available by a phone conveniently located in the airport. The number is (414) 832-8890 and the cost is around $11.00, also, the Valley Inn provides shuttle service. If the Green Bay Airport is used, patients have told us the "Fantasy Limousine Service" for $45.00 would be less expensive than renting a car since they take you to the hotel and it would not be necessary to drop a rented car off at the airport. Their number is (414) 730-3866.A copy of the Male to Female consent form is enclosed. You may find it helpful.

Hopefully the above has provided adequate information, but if not, please call our office and any one of us will gladly answer what questions you may have. It is our sincere wish that your transsexual operation will be a relatively pleasant experience and we will do everything we can to make it so.

  • Very sincerely yours,

    Eugene A. Schrang. M.D.

     

GENDER DYSPHORIA

OFFICE POLICY INITIAL OFFICE CONSULTATION

We have established the following guidelines for setting an initial consultation with Dr. Schrang. We ask that the patient to send the following to our office when scheduling the initial consultation. No operation of any kind to change a person's sex will be done until the following are completed and/or received.

1. Name2. Address

  • 3. Telephone number

4. Date of Birth5. Social Security number

  • 6. $75.00 check for prepayment of pre-op consultation. The $75.00 fee will be waived if the consultation is done the day before surgery.

     

     

CHECKLIST FOR TRANSGENDER SURGERY

 

1. Letter confirming a year of hormone therapy from:

  • Dr.______________________________________ ___

  1. Two Psychiatric Reports recommending SRS must be sent to our office pre-operatively and will be verified.

  • A) From Dr. ____________________________ ___

    B) From Dr. ____________________________ ___

3. Advance payments:

 

  • A) $500.00 to secure operating room time. Due one week after surgery is scheduled. ___

B) Balance of surgical, hospital & anesthesia fees due two weeks in advance of surgery by three cashier's checks sent to our office. ___

C) If implants (Mammary, malar, chin, testicular, etc.) are to be used, advance payment for their purchase. ___

4. Signed consent form. ___INFORMED SURGICAL CONSENT AGREEMENT FOR MALE TO FEMALE TRANSSEXUAL SURGERY

 

1. I, _________________________ hereby authorize Eugene A. Schrang, M.D. to perform any or all of the following operations intended to transform male anatomy into female anatomy: total penectomy (removal of the penis), bilateral orchiectomy (removal of testes), construction of a vagina from the penile skin and/or with a split thickness skin graft in the area where the scrotum now exists, a clitoris and a new urethral opening, labiaplasty, tracheal shave (reduction of tracheal cartilage), revision of a previously constructed vagina and/or urethra.

 

2. This operation has been explained to me by Dr. Eugene A. Schrang and I understand the nature and consequences of the procedure. I understand that during the course of the operation and/or medical treatment, unforeseen conditions could become apparent that may necessitate an extension of the original procedures or different procedures than those set forth above. I therefore authorize and request that Dr. Schrang perform such surgical procedures or render such medical treatment as are necessary and desirable in the exercise of professional judgment. The authority granted under this paragraph shall extend to treating the conditions that are both known and unknown to Dr. Schrang at the time the operation is commenced. I also understand that it is impossible for a surgeon to disclose every conceivable risk, however remote. Although good results are expected, complications cannot be anticipated; therefore, there can be no guarantee either expressed or implied, as to the result of this surgery since the practice of medicine is not an exact science. The following points have been made specifically clear and are intended to provide information and not to cause alarm:

A. Scars result from any surgical procedure but, every effort is made to conceal or make them as inconspicuous as possible

B. The signs of inflammation do occur such as tenderness, swelling and discoloration (redness or black and blueness) which may last for several weeks or until the wound is completely healed. Residual swelling and redness can last a year or more.

C. Numbness in or around the operative site may occur and may persist for an indefinite period of time. Occasionally this may be permanent. Numbness may also occur in the hands, arms, or legs due to the position of the body during surgery. This may or may not be permanent.

D. Infection in the operative site, hematoma (local collections of blood in the operative site), dehiscence (wound edge separation) could possible occur. Severe bleeding after surgery may occur necessitating a blood transfusion - you will be responsible for this additional cost.

E. Unintentional interruption of blood supply to a flap, skin graft or part of the operated area may result in its loss.

F. Asymmetry (noticeable difference in the size and shape) between two sides of the operated area may result when both right and left sides are operated upon.

G. Inadvertent entry into the rectum may occur which could necessitate immediate closure of the opening; closure of whatever vagina has been created; and the immediate closure of the opening; and the immediate or later creation of a colostomy (exteriorization of the colon in order waste does not pass through the rectum)

H. Inadvertent entrance into the urethra, urinary bladder or peritoneal cavity is a possibility and could cause later scar contracture or other unforeseeable problems in the future.

I. Although very rare, embolism from a blood clot may happen which could result in death.

J Completely unpredictable and unusual complications, although extremely rare, including even death may occur.

K. Shortening of the newly made vagina may occur secondary to scar contracture deep within the vaginal vault. I understand that this complication is generally due to failure on my part to diligently dilate my new vagina.

L. The Tracheal procedure can result in hoarseness and deepening of the voice which can, in some cases be permanent.

M. I understand that because of the nature of the above procedures, it is impossible to predict all the possible psychiatric and psychological results.

N. Some of the possible complications explained to me which can be involved in these procedures include in addition to those set forth above but not by way of limitation, are the following: severe loss of blood, infection, cardiac arrest, poor cosmetic results, permanent pain and discomfort, adverse affects from anesthesia, and psychiatric disorders.

3. I understand this operation is totally irreversible and that I no longer will be able to have intercourse as a male or to conceive children, I also understand that Dr. Eugene A. Schrang does not guarantee any sexual pleasure or function as a result of the above stated procedures.

4. I consent to the administration of such anesthetics as may be considered necessary or advisable by the physician or anesthetist responsible for this service.

5. I consent to be photographed before, during and after treatment, and understand that these photographs are the visual part of my clinical record and are the property of Eugene A. Schrang, and may be published in scientific journals and/or shown for professional reasons.

6. I have been informed by Dr. Eugene A. Schrang that his professional fee for this operation is $___________. I consent to pay this amount which I understand includes the surgical procedure and all postoperative hospital and office visits up to six months. This fee does not include the hospital fee and anesthesiologist's fee, preoperative office consultations and examinations and surgical intervention to correct operative or postoperative complications.

7. I certify that I am not presently married and will not be married prior to the operation contemplated herein or if I am, my wife has signed the Spousal Release Form.

8. I certify that I have read and fully understand the above consent and agreement which has been preceded by explanations by Dr. Eugene A. Schrang. I also certify that I have read and understand Dr. Schrang's standard form letter regarding Sex Reassignment Surgery. His explanations in no way vary from the contents of this consent statement or his form letter and are understood by me. I agree not to revoke, limit or alter this consent except in writing delivered to Dr. Schrang prior to commencement of the operation or procedures hereto described:

I FULLY UNDERSTAND ALL OF THE ABOVE. I HAVE NO FURTHER QUESTIONS. I DO AUTHORIZE EUGENE A. SCHRANG, M.D. TO PERFORM ANY OR ALL OF THE PROCEDURES OUTLINED IN PARAGRAPH ONE, OR SPECIFICALLY THE FOLLOWING:

____________________ _____________________

Date Patient

Witness

 

 

Toby A. Meltzer, M.D.

OREGON HEALTH SCIENCES UNIVERSITY

3181 S.NW. Sam Jackson Park Road, L352A

Portland, OR 97201-3098 (503) 494-7824

  • School of Medicine, Division of Plastic and Reconstructive Surgery

     

September 2, 1994

Name Address City, State Zip Dear Ms. _____________: This letter is in response to your request for information regarding surgery for sex reassignment at Oregon Health Sciences University. At OHSU we have a gender dysphoria team which consists of Dr. Paul Kirk of Obstetrics and Gynecology, Dr. Steve Skoog of Urology, and myself of Plastic and Reconstructive Surgery. Our team adheres to the same guidelines and principles of the Harry Benjamin International Gender

Dysphoria Association. Prior to any surgical procedure, the prospective patients must fulfill the criteria established by the Benjamin Society and have a letter from a therapist (psychiatrist, psychologist or psychiatric social worker) who has had a long-term

psychotherapy relationship with the patient and feels comfortable referring the patient for sex reassignment surgery.

Although we did not create these guidelines, patients who are generally considered good candidates for surgery are those who meet the following criteria:

1. Identification as the cross gender which is lifelong.

2. Inability to adapt to the biologically assigned gender role.

3. Ability to pass convincingly in society and to be gainfully employed.

4. Not a fetish cross-dresser.

5. Demonstration of emotional stability.6. Willingness to accept and actively engage in psychotherapy before and after surgery.

7. Adequate social and family support systems.

8. Completion of a one-year period where the patient lives in the cross gender role without relapse.

9. At least one year of medically supervised hormonal treatment.

Male-to-female cross gender surgery is performed by me. The construction of the vagina and removal of the penis and testes usually requires a 2 to 3 day hospitalization. The penile skin is used to reconstruct the vagina, which avoids the use of skin grafting. A sensate clitoris is formed from a small portion of the glans of the penis and the nerves that supply it. The total cost of surgery, including hospitalization, surgical foes, and anesthesia, is $10,850.(These fees have increased recently due to an increase in anesthesia charges.) Breast augmentation can be done at the same time for $3000, or as a separate procedure, for $3500. Other aesthetic and reconstructive procedures are available, and these can be discussed. The fees are dependent upon the procedure itself. We hope this information has been useful to you. If you feel that you are a good candidate for surgery, we encourage you to meet with us in our clinic. Prior to that visit, it is customary to have your therapist send us a letter of referral. We look forward to meeting with you.

Sincerely,

Toby E. Meltzer, M.D.

Assistant Professor of Surgery

Division of Plastic and Reconstructive SurgeryTRM:gm

Montreal, November 29th 1994.

 

Yvon Menard, M.D.

In reply to your request, it is with pleasure that I send you the following information concerning sex reassignment surgery (male to female).

CRITERIA FOR ELIGIBILITY:

To be eligible for S.R.S., one must, first of all, answer to the criteria of the "Standards of Care of the Harry Benjamin International Gender Dysphoria Association, Inc".

That is: "Hormonal sex reassignment recommended by a clinical behavioral scientist.

Full-time living in the social role of female sex at least 12 months.

Two recommendations for S.R.S. made by two clinical behavioral scientists. One of the two recommendations must be made by a person possessing a doctoral degree (e.g. PhD, Ed.D., D.Sc., D.S.W., Psy. D., or M.D. in a clinical behavioral science granted by an institution of education accredited by a national or regional accredited board. The clinical behavioral scientist making the primary recommendation in favor of S.R.S. shall have known the patient in a psychotherapeutic relationship for at least six months prior to making said recommendation".

The patient has the responsibility to see that the behavioral scientists have the necessary qualifications mentioned above and that they are clearly stated in the recommendation. Also most important is the fact that one of these recommendations has been made by a scientist who has followed the patient for at least six months.

The medical history and the two recommendations for S.R.S. must be well detailed and must arrive at my office before a date can be set for the surgery. Also, I wish a report from the Doctor who is supervising the hormonal therapy as to the type of hormones being administered, the dosage and the duration of the treatment.

PRE OPERATIVE CONSULTATION:

It is preferable to meet with the patient a few months prior to surgery. However, if the patient lives very far from Montreal, it is possible to meet a few days prior to surgery. If the latter is the case, the patient's file must be complete : the two recommendations, the laboratory reports and the medical history must be at my office before the visit. If a document is missing. the surgery could be cancelled.

PRE OPERATIVE ANALYSIS:

As this is a major surgical procedure, under general anesthesia, the patient must pass the following exams about two months before the date of the surgery and the results of these exams must be sent to my office before three weeks prior the date set for the surgery. Without these test results, there will be no surgery.

Following is a list of the obligatory tests:

- CBC (complete blood count) BUN (blood urea nitrogen) Glucose (blood sugar) - Urine analysis - Chest X ray (the report only) - E.K.G. (over 40 years of age) - H.I.V.

[Editor's note: Although some surgeons will not perform the procedure on those with HIV or other sexually transmitted diseases, there are other who will.  If you suffer from these problems, don't be discouraged.   You can obtain current information about various surgeons on the internet or through your local support group.]

HOSPITALIZATION:

Normally, the surgery is performed on a Monday. Therefore, you enter the hospital around 7 p.m. on Sunday. The following Friday you leave the hospital for the week-end. You are re-examined the following Monday to remove the vaginal stent and the urinary catheter. You must remain another 2 to 3 days in Montreal to master your vaginal dilatations. With regard to your stay post hospitalization, we are enclosing a list of recommended places.

SURGICAL TECHNIOUE:

I perform the inversion technique. When the penis is too short, I use the excess skin from the scrotum to have sufficient amount of skin for the vaginoplasty. I am enclosing diagrams describing the technique used.

COST:

The total for the surgery, anesthesia and hospitalization is $ 7,285.00 CAN. Once a date has been set for the surgery, you must send a $ 500.00 CAN deposit within the following 15 days or the date will not be reserved. Also, if you decide to cancel your surgery less than 3 weeks prior to the date set, your deposit will not be returned. The balance due shall be $ 6785.00 CAN, $6685.00 payable the week before your surgery and the balance of $ 100.00 the day of the surgery. All payments must be made in cash, certified check or bank draft to CLINIOUE-DE CHIRURGIE ESTHETIOUE ST. JOSEPH. If you are unable to pay in Canadian funds, you could make a check in American money and when we will deposit it, we will reimburse you the difference if any afterwards. If you consult prior to setting a date for your surgery, the fee will be $ 50.00 CAN. This will be deducted from the total amount at the time of the surgery.

YOUR STAY IN MONTREAL:

Your stay in Montreal should be about 14 days: 2-3 days before the operation, 5 days in hospital and finally 5 days after leaving the hospital.

To make your stay more agreable and secure, we have set up a residence specialized in the field of transexualism. This organization is called TRANS P.O.R.S.. For a very reasonable price, they supply transport, lodging and meals. This enables you to come to Montreal unacompanied and to have someone to care for you 24 hrs\day. I strongly recommend that you reserve your stay at Trans P.O.R.S. only. Do not forget that post-operatively you will need help and Trans P.O.R.S. is the only place that you will receive adequate, professionnal care. If you come accompanied, Trans P.O.R.S. will be very happy to find shelter for the person who will be with you.

The document concerning Trans P.O.R.S. are included in this package and I repeat, I prefer my patients to be at Trans P.O.R.S. because I know they will be more secure and therefore, I am more secure.

  • ADDITIONAL SURGERIES:

If you wish an additional surgery at the time of your S.R.S. (e.g. mammary augmentation, shaving of the Adam's apple, nose, eyelid surgery etc.) you must contact my office and we will give you the additional information and cost for these surgeries.

I hope that this information will be to your satisfaction. If you wish further information, you may write to me or call me at my office on Wednesday or Friday between 10H00 a.m. and llH30 a.m.

Yours truly, YVON MENARD M.D. F.R.C.S. YM/ encl.

 

P.S.: It is absolutely forbidden to smoke at the hospital.

 

N.B.: PLEASE DO NOT SEND THE X-RAY FILMS, WE NEED THE WRITTEN REPORT ONLY.

 

Stanley H. Biber, M.D.

Here is a copy of the letter Doctor Biber sends out in response to an initial inquiry regarding Sex Reassignment surgery. The actual costs have gone up roughly 10% from the figures in this copy. Also, I believe the anesthesiologist named in the letter is no longer working with Doctor Biber. Finally, immediately after this letter, Doctor Biber added the requirement of a second HIV test to be done at the hospital before surgery, as several girls were faking their results in order to obtain surgery.

If you want the most accurate and up to date information, you should contact Doctor Biber yourself directly. If anyone has more current information, or information on other surgeons or procedures, please forward it to me for inclusion in The Subversive.

Stanley H. Biber, M.D., P.C. General Surgeon Office Phone 846-3301 406 First National Bank Bldg. Trinidad, Colorado 81082

09/03/91

Dear Melanie,

As per your letter asking for information Regarding the requirements for anatomically changing sexual characteristics in the transsexual.

We do not have a gender identity clinic here. We can do the surgery for you, which includes the genital surgery and breast implants, and other services like nose or chin surgery.

Our basic fee is $4,000.00 for the genital surgery and $1,200.00 for the breast implants. The hospital bill for the genital surgery will be $5,125.00. Any additional service above the average extended length of stay for any reason will be billed extra. WE AND THE HOSPITAL MUST RECEIVE CASH AT THE TIME THE SURGERY IS DONE. We do not work with any insurances, however we will fill out any insurance forms for you after surgery and you may collect directly from the insurance company or we will reimburse you if the insurance money is sent to us. If other procedures are done during the same hospitalization the hospital will require an additional $1,505.00 if you have the breast implant surgery: and additional $1,125.00 if you have the nose surgery, an additional $310.00 if you have the tracheal shave done. Our fee for the SMR with corrective Rhinoplasy (nose job) is $1,200.00: tracheal shave $850.00 providing they are performed during the same hospitalization with the above surgery.

There will also be a charge for out anesthesiologist, a separate check must be made out to Dr. Frank Polanco. His fee for the genital is $800.00 and additional $200.00 if you have the nose surgery: an additional $200.00 if you have the breast implant surgery: an additional $200.00 if you have the tracheal shave done. These fees are only if they are done at the same time the genital is done.

We require a social history from yourself. We have to know that you have lived in your chosen gender for a whole year, 100%. Are you working in the opposite sex, etc.? Also you must be on hormone therapy for a whole year before surgery. Have you had electrolysis? Have you had any other cosmetic Surgery? Remember you must live one year in your chosen gender role prior to surgery.

WE MUST HAVE TWO PSYCHIATRIC EVALUATIONS, preferably one by a psychiatrist and the other by another psychiatrist, psychologist, or a recognized licensed worker in the gender or sex oriented field. You must understand that the final evaluation which will determine your acceptance for surgery is done by ourselves immediately prior to your surgery. We would appreciate the evaluations at the earliest possible time.

Please send us a picture of yourself, that we may keep for our files. Once we set a surgical Date, we require a $500.00 deposit to reserve the date. No personal checks, please. We must have received the $500.00 deposit in our office no later than one week from the day that you scheduled your surgery.

It will be necessary for you to have an HTLV-III or an HIV (AIDS) test done at a certified laboratory as close to your surgery date as possible, no later than six weeks. you will be required to have the negative results with you when you arrive for surgery. Please be sure you have the test done where the will put your name on the results and not just a number, our hospital will not accept the results with just a number.

[Editor's note: Although some surgeons will not perform the procedure on those with HIV or other sexually transmitted diseases, there are other who will.  If you suffer from these problems, don't be discouraged.   You can obtain current information about various surgeons on the internet or through your local support group.]

We will provide the necessary surgical consent forms on your arrival here.

We will be glad to help you if you can meet our requirements.

Sincerely, (His Signature) Stanley H. Biber, M.D.

Note: If your penis is so small as to warrant a skin graft procedure along with usual penile inversion technique, there will be an additional $500.00 fee.

Here is a copy of the letter Dr. Biber sends home explaining post-op care:

DISCHARGE INSTRUCTIONS:

Dilate five times a day, 15 to 20 minutes each time, utilizing the pair of rubber dilators provided and as instructed. Space the dilations over the 24 hour period as much as can possibly be done. it is very important to keep the depth in the vagina, especially the first two or three days after discharge. it is very important to utilize plenty of jelly and place the dilator in such a fashion down toward the rectum primarily for a small distance then directly inside into the vagina, without using a screwing motion, because when you use a screwing motion, the ribs on the dilator might harm the new baby skin that is healing in the vaginal cavity.

Graduate to a longer dilator between the fourth and fifth week. The easiest place to get a firm dilator is to go down to any adult bookstore and get a plastic dildo, get it the same diameter as the large dilator provided. Approximately 4.5 to 5cm in diameter and get it two inches longer, which will make it about 8 inches in length. Utilize this in a similar fashion as the original dilators and continue the dilation for a period of six months, however when you get to the fifth, sixth month, and everything is staying wide open, you may, with common sense, decrease the number of dilations too. May begin intercourse about the sixth week period. You will be somewhat moist inside, however not moist enough for penetration so it is important in the pre-sexplay period to insert some K-Y jelly and be prepared for penetration. If you do not use the K-Y jelly, you are going to tear yourself up. When beginning intercourse for the first time, take it slow and easy to avoid any damage that difficult and forceful penetration may cause.

We will send you home on Estinyl and Provera. Take the Estinyl one a day and cycle the Provera so that you can take it one a day for one week, perhaps the last week of the month, along with the Estinyl. It will place you essentially in the feminine cycle. We will send you home on urinary and tissue antibiotics and utilize them for a period of ten days. But even more important than the antibiotics is to drink copious amounts of fluids, 10 to 12 glasses a day. You may also drink a couple glasses of cranberry juice a day, which will acidify the urine and take away some of the smell. You may also douche, even once or twice a day because the vagina will present some obnoxious material while healing. You may douche twice a day if you wish with a tablespoon of white vinegar to a quart of warm water, not dark vinegar, but white vinegar. Do not do any heavy lifting for a period of six weeks. If you have any specific problems, call my office, the office personnel or myself will handle your telephone calls and should be able to answer all your pertinent question. If you have to see a doctor at home for any reason and he doesn't understand what is going on, please have him call me.

Also, remember that you are specifically female now. You are subject to all female diseases. You can get Trichomonas infections, you can get Yeast infections, and these have to be treated just like any other natural female. It is conceivably possible now that you have a cervix, that you may develop cancer of that cervix, even though we have never seen this happen. However, it is probably very wise once every six months or once every year to get yourself a Pap Smear, to rule out this possibility. Remember you are subject to other diseases as well. Be very careful with your exposes, you can still pick up gonorrhea, you can pick up syphilis, and all the other exotic diseases that females are subject to.

Keep in touch with me, fill out the six month questionnaire in six months, and please send it back, so I can add to our statistical volume and utilize it in our presentations.

Any time you feel like writing, let me know your general status, i.e. financially, socially, what you think about your body image, and what adaption you are making to your new role. I'd be more than happy to hear from you. In other words, keep in touch. Do not let us lose your address. We want to follow you for a considerable period of time. For any other complications that may arise, please call and let us share them with you.

Stanley H. Biber, M.D.

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