THE OFFICIAL TERM IS "gender dysphoria." It describes a strong conflict between the gender a person is assigned at birth and the gender with which that person identifies. Transgender surgery, also known as gender affirming surgery, gives some trans people a new sense of congruence between their outward bodies and true inner selves. But it's not an easy journey. Four years ago, Johnny Boucher, a public school teacher in Grand Prairie, Texas, had "top" surgery – removal of both breasts and reconstruction of his chest – at an outpatient surgical center in Plano. The two-hour operation went well and later that day his wife drove him home. By scrimping, saving, fundraising and "begging," Boucher was able to afford the procedure. Boucher never thought he'd have the financial wherewithal to afford the much more complex and expensive step of "bottom" or genital surgery. But a series of events – his taking leave for an unrelated medical condition, enrolling in an online doctorate program and learning that students had access to trans-inclusive health insurance – gave him his chance. After careful consideration, he decided to undergo the procedure known as phalloplasty. Johnny Boucher recovering after surgery at Johns Hopkins Center for Transgender Health.(COURTESY OF JOHNNY BOUCHER/JOHNS HOPKINS CENTER FOR TRANSGENDER HEALTH) Female-to-Male Transgender Surgery Phalloplasty means making an entire penis out of tissue from other parts of the body. It's the most common bottom surgery for people transitioning from female to male, says Dr. Devin O'Brien Coon, medical director of Johns Hopkins Center for Transgender Health. Metoidioplasty involves making a penis from the clitoris that has already been somewhat enlarged from the testosterone a patient takes as part of his therapy, O'Brien Coon explains. Hysterectomy and oophorectomy – removal of the uterus and ovaries – is usually done by a gynecologist in a previous surgical procedure. Vaginectomy is surgery to remove the vagina and close the vaginal opening. "There are adjunct procedures, like testicular implants and penile prosthetics for phalloplasty, and urethral lengthening so people can stand and pee," O'Brien Coon says. Boucher realized his surgery and recovery would be intense. He wanted to receive care at a dedicated transgender center, and ultimately chose Johns Hopkins. His phalloplasty involved complex microvascular surgery, skin grafts and 10 hours spent under anesthesia. "You have these large wound-care areas that are so intense that if you didn't have a comprehensive team working with you – physical therapy, occupational therapy, wound care – and every aspect working together, you would feel really lost and on your own," Boucher says. "And possibly in a great deal of pain on your own, and experiencing complications far from home." Spending time away from his wife, Ashley, a transgender woman, and their two young children was difficult. Follow-up procedures are needed to complete the transformation. "It takes a long time to be finished with this," Boucher says. "You have to be comfortable with being a work in progress." Transgender Surgery Boom Demand for gender affirming surgery is on the rise. "It's exploding – well beyond what we can keep up with," O'Brien Coon says. "It's a confluence of different factors. Certainly the two biggest ones are more societal acceptance as there have been more transgender public figures. The other one is essentially insurance coverage." A study released Feb. 28 in the journal JAMA Surgery confirms this. Among the estimated 1.4 million transgender adults in the U.S., more than 4,100 gender affirming surgeries were done between 2000 and 2014, according to the analysis of a national surgery database. About half of the patients paid on their own earlier in the study time frame, rising to 65 percent from 2006 to 2011. But by 2014, only 39 percent of patients paid out of pocket, while private insurance, Medicare or Medicaid provided coverage for other patients. The World Professional Association for Transgender Health provides guidelines for optimal transgender care. Readiness evaluation and counseling are part of that care. Most providers use WPATH standards as a touchstone for developing their own systems and patient criteria for surgery, O'Brien Coon says. When making treatment decisions, patients should inquire closely into each surgeon's and health care facility's experience specific to gender affirmation. "For better or worse, it's realizing that just because somebody offers a gender affirming surgery in the United States, it does not mean they're actually trained in it," O'Brien Coon says. "We have a sort of laissez-faire health care system, where anybody can say they can do anything. I see more and more patients who need revisions of surgeries that had extremely bad outcomes." The long-term solution is for academic institutions to develop formal training for surgeons in these procedures – just as trainee surgeons learn in all other types of surgery, O'Brien Coon says. Johns Hopkins is working on creating such programs, he adds. Hopefully, clear, consistent standards will be put into place within the next few years, O'Brien Coon says. "For now, I think prospective patients should really try to find someone who says they devote a significant portion of their practice to gender affirming surgery and they have some form of credential or evidence that they're well-trained in it." Male-to-Female Transgender Surgery Breast augmentation – using implants to enlarge the breasts – is a common feminizing surgery. Vaginal creation, or vaginoplasty, is a surgery that involves removal of the penis and testicles. Surgeons use tissue from the penis to construct the vagina, clitoris and labia. Facial feminization may include treatments such as hormone therapy, electrolysis, laser hair removal and facial plastic surgery. Nose-reshaping, brow lifts and chin, cheek and jaw reshaping are just some of the possibilities. A surgical procedure called chondrolaryngoplasty, or a tracheal shave, involves shaving down cartilage to diminish the Adam's apple. For any patient interested in having biological children someday, fertility-preservation options should be discussed before lower-body surgery. This could involve sperm banking or egg freezing.

Giving New Voice

Changing a voice to make it sound masculine or feminine requires a multidisciplinary approach, says Dr. Paul Kwak, an assistant professor in the Department of Otolaryngology–Head and Neck Surgery at NYU Langone Health's Voice Center. Structural or anatomical changes comprise about half of the treatment involved in changing the character of a voice, Kwak says. "The other 50 percent of it is functional or behavioral – having to do with the way people use their voice; the way it coordinates with breath and the muscles of the larynx," he says. Raising pitch is one goal, among others, in the effort to feminize the voice, Kwak says. Voice training, for which he often refers patients to a trans-voice expert, includes work on modulation, speech rhythms and pattern and cadence of sentences and phrases. "There are patients who are born male who transition to female voice and they're born with very low-pitched voices," Kwak says. "Then we do consider surgery. It's a complex set of decisions, including whether we even proceed with a surgical procedure to adjust the voice." One option is vocal-chord shortening, an endoscopic, minimally-invasive, laser-assisted procedure. Recovery is fairly easy, Kwak says, with patients put on voice rest for a week to enable wound healing. Afterward, patients continue voice training for several more sessions. "The speech-language pathologists here do the heavy lifting in terms of getting to know the patient, their voice and the way their personality can really have a significant impact on the character and quality – and the gender – of a voice, for sure," Kwak says. Gender affirming surgery can greatly improve a patient's sense of congruence, but it's not a panacea. "It's the same thing with any type of surgery," O'Brien Coon says "Everybody has to recognize that there are certain things that the surgery will change and things it will not change. Part of that readiness process is making sure that patients have realistic expectations about how all this will change their life and how it won't change their life." Regardless of their readiness, many people in the transgender community don't have access to gender affirming surgery, Boucher points out. Medical, surgical, travel and related care costs can easily reach $200,000 and much more, he says. In the absence of local, comprehensive transgender centers and lacking insurance coverage, they must go without. "It's not a cosmetic procedure," Boucher says. "It really is medically necessary care. And we jump through so many hoops, even when we have insurance coverage, to prove to the insurance company that it's necessary. It's not anything that we decided upon frivolously." For Boucher, gender affirming treatment has been worth the difficult journey. It's brought a sense of what he likes to call gender euphoria. "You're just yourself," he says. "You can go about your business like anyone else."