We in the trans community know it at Sex Reassignment Surgery, or SRS for short. It is known more widely as "sex change" surgery, and it is a major concern for many transsexuals. It seems to be a hot topic for many other people, too; more often that not, soon after learning that I am a transsexual, total strangers somehow overcome the barriers of polite conversation and ask me about The Surgery. Sometimes I'm tempted to ask prying, personal questions about the state of their genitalia, but generally I find a civilized way to suggest they mind their own damn business. For many years I tried to avoid the topic or told white lies because I was ashamed that I had not yet had the surgery. Now that I am completely out with my situation, I can admit that "Dea" in the story below is based mostly on my own travails.

Given that SRS is considered so important by many, that the desire for SRS is often held as the hallmark of the "true" transsexual, why would a transsexual person not undergo that procedure? This article delves into the reasons why some transsexuals forego this "radical" surgery.


This piece appeared in the Autumn 1998 issue of Transsexual News Telegraph. What you see here is the orginal, unedited piece I submitted. To editor Gail Sondegard's credit, she did little to edit or censor some of the more inflammatory bits. My thanks to her for helping keep our community informed and connected through her excellent magazine.

Chicks With Dicks

by Christine Beatty

I thought that title might get your attention. To FTMs I apologize for not being able to imagine something equally “witty.” “Gents with Cunts” didn't feel right, so I resolved to forge ahead. I also beg the indulgence of the intersexed, to whom this story may be of some interest but who are not specifically mentioned (other than here). The whole point to beginning this article with a headline calculated to outrage and annoy, a phrase used by pornographers exploiting pre- and non-operative TSs, is to drive home the point that many of us in the transsexual community take our surgery very seriously. If you felt a stab of anger or discomfort reading it, you may want to consider reading further.

Many, if not most transsexuals consider sex reassignment surgery (SRS) a crucial step in the process of their transition, complete vindication of the gender with which they identify. Yet relatively few transsexually-identified people go under the knife for a variety of reasons, both voluntary and otherwise. Furthermore, many if not most of us are reticent to discuss their surgical status—sometimes even with other transsexuals—and for good cause.

In this article I use several transsexuals to composite characters for the purpose of illustration. Not only are these people composites, I have changed names as well for reasons which should become obvious. I applaud those who have the courage to come out with such truths, but the fact is that they are taking a huge risk in doing so.

To begin, I'd like to establish some terminology for the purpose of this discussion. These handles are not universally agreed upon by any means, but hopefully they will do for this purpose. I will use the term “post-operative transsexual” to refer to a person who has had surgery to change all visible traces of secondary sex characteristics, specifically penectomy and vaginoplasty for MTFs, and medioplasty or phalloplasty for FTMs. I will not include orchiectomy (castration) or hysterectomy as full qualification for post-op, even though many transsexuals decline to go further and may consider this “post-op.” “Pre-operative” will include any transsexual who has not completed the full surgical process but who wants to do so. A “non-operative” transsexual would be a transsexual who may have had hormone therapy, cosmetic surgery and even orchiectomy or hysterectomy, but has no intentions of proceeding any further. This leaves one other label to define. To greatly simplify discussion, I will term as a “transsexual” anybody who defines hermself as one. For sake of brevity as well as to keep to territory I best understand, I will contain most of this discussion to MTFs, although these tenets apply equally to FTMs.

Although all transsexuals are subject to discrimination, an MTF who possesses a penis can also be charged with “impersonation” in some jurisdictions. Furthermore, basic human needs such as bathroom usage may present a problem if herm surgical status is known. When I transitioned on the job in 1989 (for which I'm grateful they didn't fire me) I was compelled to use the single occupancy restroom in the basement of the office building. I consider this a minor annoyance compared to the traumas that many transsexuals have endured trying to answer nature's call, although I must admit it didn’t exactly suffuse me with self-esteem. Then there is the Crying Game syndrome. “Dil” was lucky only to have been cuffed across the face. An acquaintance of mine working the street was kidnaped, beaten up and then run over with a car, an ordeal she was lucky to survive. Finally, there is perhaps one of the most insidious hazards of gender non-congruence: the stigma, both external and internalized.

“I feel like a failure,” is how “Chris” explains it. “It's no fault of mine I can't get [the surgery] done, but somehow I blame myself. I hate being caught in the middle, like I'm less than a woman or a man... like I'm some kind of freak.”

Even if a transsexual is personally able to transcend the anatomical definitions of gender, sometimes social gender—one's “face value” to society—fills herm with doubt. Many people, even if they discount the genetic aspect of gender attribution cannot see past the genital definition, no matter how “passable” someone is. For these people “biology is destiny,” at least in terms of penises and vaginas.

“I try to not talk about it,” says “Dea.” “If someone asks if  I've had the surgery, I try to avoid the question. Sometimes I lie about it. I have no problem being a woman with a penis—well, mostly—but I don't want to hear myself get called 'he.' It hurts to hear someone say that, like I've done something wrong.”

Furthermore, the implied class system within the transsexual community can lower the self-esteem of a pre or non. The annual “New Women's Conference” specifically excludes non-post-ops, a practice that seems highly questionable if not hypocritical given the Michigan Women's Music Festival's policy toward post-ops and transsexuals in general. The NWC message to pre- and non-ops is clear: “you are not yet women in our eyes.” Thus the stigma come from all sides.

The constraints against SRS are numerous, but may be reduced to three broad categories: financial, social and medical. You must have the money, the personal support (or at least the lack of opposition) and meet all of the health requirements of providers. Significant shortcomings in any of these areas could severely hinder the acquisition of SRS. Let's examine them in detail.

The sheer cost of surgery and its near-total exclusion under most healthcare plans drastically limits the ability of people to obtain it. While some courageous transwomen such as Margaret Dierdre O'Hartigan have successfully fought for third party funding of SRS, this has not proved an option for most. Although certain foreign clinics do perform surgery much more cheaply that other providers, some of these resources have unproven track records and may present an even greater risk of complications. Until public and private health plans, and society in general can be persuaded to see that the benefits of providing SRS far outweigh the costs, money will be a huge stumbling block.

Then there is social pressure. Loved ones, friends and community all have varied opinions about “the surgery,” and might make judgements about the suitability of SRS for a given person. A person's significant other, children, natal or extended family, close friends, employers and other authority figures may forbid or greatly hamper the route to SRS. They may utilize emotional, financial and other forms of manipulation to block access to or dissuade from surgery. Often these people believe they are doing the transsexual a favor, not understanding their dilemma. And sometimes the greatest obstacle is the ultimate authority figure in the quest for surgery: the healthcare professionals who guard the gateway to surgery.

Up until the last ten years it was virtually impossible for any lesbian-identified MTF or gay FTM to find providers willing to look past the heterosexist, gender-stereotyped cultural imperative, judging such transsexuals unfit for SRS. Ironically, while these attitudes are changing, the last fourteen years have raised a new barrier to surgery: HIV. This constraint may be the most heartbreaking of all. Most reputable SRS surgeons have policies that exclude even asymptomatic seropositives. Dea had an earful on this subject, which I've edited for brevity. [Note: the HBIGDA standards were actually changed the year this article was written. While it is now considered unethical to deny SRS based on HIV, hepatitis, etc. it is still up to the individual surgeon.]

“It really fucking hurts sometimes,” she said. “I tested positive eight years ago, but I've had no symptoms the whole time. It never crossed my mind it would keep me from surgery. I had all the letters, met all the requirements back in late '91. Two years cross-living, full-time employment—everything. I had a few thousand in savings and was thinking about how to raise the rest when my uncle died. When escrow closed I had a check for ten thousand, and I was jumping for joy... Well, I was kinda worried. See, I read somewhere that Stanley Biber said he wouldn't do [the surgery] for anybody with AIDS. So I wrote him, told him I had HIV but was healthy, asked him if that would be a problem. It took like, over two months for him to get back to me. And he said flat out he wouldn't do it. So I started writing every surgeon on this list I got from my therapist, and each reply was like another slap: no, no no! There was one jerk in Detroit who wanted $26,000—twice what Biber wanted—but that was right out of  my reach. I suppose I could go to Tijuana, but given the health risk... I'm just lucky to have a lover who sees me as female just like I am, who doesn't want me to risk getting an infection... I don't know. Part of me still wants to do it, but I’m afraid to take that gamble.”

Dea went on to say that she did venture to Mexico for castration in deference to the potentially dangerous level of hormones typical of pre-op therapy. Given the relatively few hazards of this procedure and lab results showing her liver increasing dysfunctional, she felt it justified to prevent serious health problems.

“I felt a little bit guilty about not mentioning my status, but since they asked absolutely no health questions, I didn't feel too bad about it. They were doctors. They knew what they were doing. And I couldn't believe the effect it had on me. It accomplished feminization that years of hormones didn't.”

She had a lot more to say about the benefits of her orchiectomy, but those are beyond the scope of this article. It is as final a step as penectomy and vaginoplasty, a permanent alteration of gonadal sex, and one which carries its own hazards as well as benefits. Dea said that, in general, she doesn’t discuss her surgical situation or HIV status except on a need-to-know basis, even among other transsexuals. Her public silence on these issues is very much understandable given the double-whammy of discrimination against women with penises and people with HIV.

HIV is but one medical constraint to SRS. The physical health conditions that potentially contraindicate surgery are too numerous to list here, and there are a number of psychiatric diagnoses which will deter a therapist from writing The Letter. But one can always find a doctor to overlook these things if you're willing to take the chance on quackery and have the cash up front. In the end, despite the medical watchdogs, surgery may often be obtained anyway by those who feel they must have it.

However, a significant number of transsexuals have decided, in fact, they do not want SRS. With the surgical procedures far from perfect, with the potential medical complications, some of us opt to decline taking the chance. In addition to this, some MTFs have financial concerns beyond the cost of SRS. Furthermore, a growing number of transsexuals are declining surgery on the basis of a slowly popularizing new view of gender: female, male and Third or Other.

Infection, even in seronegative and otherwise healthy transsexuals is still a risk associated with surgery, especially urological procedures. There are a number of other complications with SRS including difficulty in urination, numbness, fistulas and other problems that deserve more space than we can offer here. However, one potential negative side-effect is worthy of mention: sexual dysfunction.

The jury is still out on the percentage of “sex-change” operations that result in the patient's ability to experience genital pleasure, including orgasm, but the preliminary results are not all that encouraging. In her groundbreaking work Sex Changes: The Politics of Transgenderism lesbian author Pat Califia (who identifies as transgendered, by the way) theorizes that the sexual pleasure of patients is one of the lesser concerns of many SRS surgeons. She suggests that gender doctors' concepts of female sexuality are seriously out of date, and that few of them understand that erotic pleasure is of no minor concern.

Another person who might decide against surgery is the MTF transsexual who “passes” only marginally, who has few employment options, and who supports herself from sexwork. She might be doing herself a grave disservice by removing that part which is her greatest selling point. [I hesitate to call it a marketing tool.] These and many other reasons may compel us to forego SRS.

Perhaps the most intriguing motivation is that of the transsexual (or otherwise transgendered) person who identifies as a “third” or “other”gender. Other self-definitions I've heard include “both,” “neither” and “no” gender. And I've heard these definitions from transsexuals of every surgical status including post-ops, Kate Bornstein being the most notable example. These are people who shun the bipolar gender system, who recognize genders beyond “male” and “female.” In Ms. Bornstein's latest work My Gender Workbook she exhaustively dissects the concepts of gender and proposes an identity of “no gender.” While this topic is far too complex to synopsize here, it is worth noting that Bornstein's gender theory provides a space for non-operative transsexuals to reconcile their “discordant” genitalia and gender identity, a refuge from a gender system that would force them—all of us, trans and non alike—into one of two pigeonholes.

There are so many ramifications of SRS it is impossible to delve very deeply within a few thousand words. Obviously there are consequences both positive and negative to obtaining surgery and, conversely, to not. Many transsexuals claim SRS as an absolute need, and some would even deny the identity of “transsexual” to non-operatives. For others in our community, surgery is much less important than living in the gender role (or roles) that one prefers. And there are those who have no desire to go under the knife at all, for onw or more of the aforementioned reasons.

The most important thing is for people to have the freedom to choose their own path without imposing their ideas and values on others, and to be able to make their decisions based on their own hearts and minds without another informing them what the “must” or “must not” do. We must be free to identify as we please without being judged and without judging others.

When we can learn to respect each other’s ideas, to agree to disagree on labels, when we can learn to stop fighting within our own community, that's when we can start move forward to our mutual benefit.

Then we may begin the true gender revolution.

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