In the nearly two years since Caitlyn Jenner first went public with her gender identity, she’s been upfront with her struggles as a transgender role model and advocated for transgender students. In her new book, The Secrets of My New Life (out April 25), she opens up about undergoing gender-affirming surgery, Radar Online reports. However, experts say it’s important to remember that what transgender individuals—or any individuals—do or don’t do with their bodies isn’t anyone else's business but their own.
Jenner says she underwent the surgery in January 2017, calling the surgery a “complex decision” because of the health risks of the operation.
“I am telling you because I believe in candor,” she explains in the book. “So all of you can stop staring. You want to know, so now you know. Which is why this is the first time, and the last time, I will ever speak of it.”
She goes on to add that a penis “has no special gifts or use to me other than what I have said before, the ability to take a whiz in the woods. I just want to have all the right parts. I am also tired of tucking the damn thing in all the time.”
According to the Encyclopedia of Surgery, an estimated 100 to 500 gender-affirming surgeries are performed in the U.S. each year, but since many surgeries are performed in private facilities with no reporting requirements, statistics are hard to obtain. The Mount Sinai Center for Transgender Medicine and Surgery performs about three male-to-female gender-confirming surgeries a week (156 a year), Jess Ting, M.D., lead surgeon at the center, tells SELF. Marci Bowers, M.D., a transgender obstetrician and gynecologist in Burlingame, California, tells SELF that she performs about 140 male-to-female surgeries a year.
Jenner’s choice to undergo the surgery is her decision and one that every transgender person has the right to make on his or her own. The reality star has the luxury of resources and finances, but all transgender individuals face a range of options—and challenges—when it comes to how they transition.
These options can be broadly categorized into:
Social: This choice involves how individuals would like their gender expression to be recognized in public. Choices can include asking to be called by a certain name and pronoun, as well as the type of clothing you wear.
Legal: Individuals may choose to change their assigned name and sex on their birth certificate and other identification, such as a driver's license and passport.
Medical: Individuals have the option to undergo hormone therapy for the development of male/female secondary sex characteristics.
Surgical: Individuals can pursue surgical intervention for the purpose of masculinization or feminization.
“Transitioning is a very personal thing. It can look like a lot of different combinations of [options]. They’ll choose the options that best fit them,” Dane Menkin, CRNP, the clinical operations manager at Mazzoni Center Family & Community Medicine in Philadelphia, tells SELF. He notes that safety is a big factor when it comes to a person’s transition choices, “especially in the climate we’re in now. If you don’t pass well enough to be in whatever bathroom people deem you should be in, your safety is in jeopardy.”
Some trans individuals choose none of these options. “It’s important to recognize that there are people who make decisions to be their authentic selves, and they don’t want any intervention that involves anybody but themselves. They never set foot in an office like mine,” Menkin says. “There’s no less validity to their gender identity.”
The cost—financially and personally—of gender-affirming choices is prohibitive for many. Trans individuals risk losing their jobs, disrupting their relationships with their families and partners, and more, Andrew Goodman, M.D., AAHIVS, associate director of medicine at Callen-Lorde Community Health Center in New York City, tells SELF. “We’re lucky in New York state that many insurance companies cover hormone therapy and surgery. Many people in many other states don’t have access to that care and can’t afford it,” he says. “If you’re really poor, you don’t have the money to go to court and make a legal name change. If you’re living in a 40-year relationship with a spouse who loves you and doesn’t want you to leave or isn’t ready or willing to do this with you, you may only make private changes like only wearing [gender-expressing] clothing on vacation,” Menkin says. (Coverage for gender-affirming surgery varies by state and insurance plan. The Human Rights Campaign has resources for understanding trans health-care access.)
Male-to-female genital reconstruction, or penile inversion vaginoplasty, involves taking the penis and scrotum and reconstructing them into a vagina, clitoris, urethra, labia minora, and labia majora. “It’s a difficult and complicated multistep surgery and involves multiple organs, the urinary system, skin, nervous system, and blood vessels,” Ting says. “The operation is also aesthetically challenging because we want the vagina to be functional—so the patient can have receptive penetrative sex and be able to have orgasms.” At Mt. Sinai, the surgery involves a plastic surgeon, a urologist, and a gynecologist and is done in three to four hours, but Ting notes that it can take six to eight hours at other centers.
Recovery is painful, Ting says, and patients can’t be active and must be careful with even walking because of the tension at the surgery site. Health risks for male-to-female genital reconstruction include bleeding, poor wound healing, and development of a rectovaginal fistula, which occurs when a hole is accidentally made in the rectum and, if untreated, passed stool can exit through the vagina. This condition is rare and usually correctable, Ting says. One of the big downsides to the operation, he adds, is the maintenance of the newly created vagina, which includes daily dilation for a year to ensure the organ doesn’t shrink.
Among those who choose to undergo surgery, experts say it’s more common for transgender individuals to have chest reconstruction (also referred to as “top surgery”), which can include breast implants or partial mastectomy, than genital reconstruction. Female-to-male genital reconstruction (metodioplasty) is less common and more complicated than a vaginoplasty, Ting says. All that being said, surgery is by no means a requirement or expectation of trans individuals. “There are plenty of people who don’t want to have these surgeries done for their own reasons, and that’s fine. We definitely support people for whom that’s the case,” Goodman says.
It’s important to remember that, like with any celebrities and their aspirational lives, they can be an inspiration for us, but they’re not setting the rules or the norm. “When we have visibility with people like Caitlyn Jenner, Laverne Cox, and Chaz Bono, we see a lot of people who have been able to and desired to complete all aspects of transition," Goodman says. “Many people don’t have the desire to complete all those aspects or for many reasons are unable to.”
Individuals' gender identity and gender expression are theirs and theirs alone. What's in someone else's pants or dress shouldn't matter to anyone else. Or as Menkin puts it: “Unless you are sleeping with someone or medically taking care of their genitalia, it doesn’t matter what’s behind their zipper."
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