Surgery is becoming more available for transgender people as a growing number of academic centers and hospitals offer the procedure and insurance companies provide coverage.
Stacey Parsons, a 45-year-old from Kent, Ohio, had genital surgery in August at Cleveland Clinic, which last year launched a transgender-surgery-and-medicine program. For years the procedure was unattainable for Ms. Parsons because it costs upward of $20,000 and was rarely covered by insurance.
Other medical centers also have begun offering transgender surgeries, including Boston Medical Center, Oregon Health & Science University in Portland and Mount Sinai Hospital in New York City. Baltimore’s Johns Hopkins Hospital, which had one of the first such centers in the 1960s, is in the process of re-establishing a transgender program and will begin accepting patients by early next year. Previously, patients wanting transgender surgeries had to seek them out through private-practice plastic surgeons or in countries such as Thailand.
Demand is high, say doctors. Boston Medical Center, which opened its Center for Transgender Medicine and Surgery this year, began performing vaginoplasty, which creates a vagina, earlier in September. It currently has 200 people on a waiting list for the procedure, says Joshua Safer, the transgender center’s director.
“There’s much greater buy-in [for transgender surgeries] in the conventional medical community than there ever was before,” says Dr. Safer.
In 2014, the U.S. government’s Centers for Medicare and Medicaid Services began to allow coverage of transgender-related surgery. Currently, Medicaid programs in 12 states and the District of Columbia cover transition-related care, according to the National Center for Transgender Equality, in Washington, D.C. Many commercial insurers also have begun covering such procedures.
Research on the surgeries is mixed. Critics point to a 2011 study published in the online journal PLOS One by researchers at the Karolinska Institute in Sweden that followed more than 300 transgender people after surgery and found they had a higher rate of psychiatric care, suicide and mortality than a control group. But a number of other studies have shown that transgender people undergoing various surgeries report greater quality of life and satisfaction years later. Doctors say with more academic institutions tracking the procedures, higher quality studies in the future should produce more evidence-based outcomes.
Ms. Parsons grew up as Scott Orms. “I never really knew that I was transgender as a child,” she says. “The words weren’t there.” She self-identified as gay when she was younger, but still didn’t feel like she fit in. When she saw the process of transitioning to a woman documented on television in 2004, she realized it was a possibility. “My whole outlook on life changed,” she says.
She then came out as Stacey. “My former employer did not make it an easy journey for me,” requiring her to use the men’s bathroom, for example. Ms. Parsons, a former factory worker, stopped working in 2008 because of a heart condition.
She started therapy, joined a support group and began hormone-therapy treatments. In 2008, she had an orchiectomy, or removal of the testicles. A year later she had breast-augmentation surgery, but a vaginoplasty was out of reach financially. She was dating a man, Mike Parsons, whom she eventually married in 2012.
In December, Ms. Parsons and her husband met with Cecile Unger, the director of Cleveland Clinic’s transgender-surgery-and-medicine program, which performed its first vaginoplasty that month. Dr. Unger told Ms. Parsons she could help her get coverage through her insurance.
Centers performing vaginoplasty surgeries generally follow guidelines from the nonprofit World Professional Association for Transgender Health. The guidelines require that patients have letters from two medical professionals confirming a diagnosis of gender dysphoria, or feeling that patients’ identity is the opposite of their biological sex. They also must be on hormone therapy and living in their self-affirmed gender continuously for at least a year.
In a vaginoplasty, parts of the penis are used to create the vagina, clitoris and labia. Nerve endings are preserved to maintain sensation. The urethra is shortened to construct a female urethra.
“I want to make sure they are happy and comfortable living as themselves full-time before I commit to doing an irreversible surgery,” Dr. Unger says.
Vaginoplasty complications are rare but can include wound infection, excessive bleeding or injuries to the bladder or rectum. It takes about six to 12 weeks before the wound is healed and the reconstructed anatomy is functional, says Dr. Unger. Long-term healing can take up to a year.
Before Ms. Parsons had her surgery, Dr. Unger told her to lose weight for optimal results. The surgery took just over four hours. She was in the hospital for three nights and then transferred to a hotel for four nights.
Nearly two months after her surgery, Ms. Parsons says she still has some discomfort but is pleased with the results. “I’m just at peace with myself now,” she says. “I didn’t even realize how much I still had an issue of how I was living in my body.”
Dr. Unger, who is 34, says she received training from a Philadelphia surgeon, who allowed her to assist in more than a dozen of the surgeries while she was completing a fellowship in pelvic reconstruction at Cleveland Clinic. She says she has performed vaginoplasty on five patients and is scheduling one to two surgeries a month. Her practice also includes doing reconstructions or revisions on patients who have had previous surgery. She and her team hope to begin offering transgender men phalloplasty surgeries, which create a penis and are a more complex and costly surgery.
A phalloplasty is usually performed in stages. First, the vagina is removed. The penis is constructed using tissue from another part of the body, such as the forearm or thigh. About a year later an implant may be inserted to allow for sexual functioning.
Jens Berli leads the plastic surgery component of the transgender health program at Oregon Health & Science University. He performs breast augmentation and facial feminization surgeries on transgender women. He and his team are scheduled to perform their first phalloplasty this week. A colleague, a urologist, began performing vaginoplasty surgeries there in May and currently has 180 patients on a waiting list, Dr. Berli says.
Phalloplasty surgeries are more complex than vaginoplasty and complications aren’t unusual. Most of the cost is increasingly covered by insurance and can range from $50,000 to $125,000, experts say.
One of the first fellowships in transgender surgeries will begin this fall at Weiss Memorial Hospital in Chicago, says Loren Schechter, medical director of the hospital’s Center for Gender Confirmation Surgery, who has been doing the surgeries for nearly 17 years.
“The patient population is very, very grateful. To change somebody’s life in a few hours is really rewarding,” says Rachel Bluebond-Langner, an assistant professor of surgery in the division of plastic surgery at the University of Maryland School of Medicine. She says she now works almost exclusively with transgender patients since insurers in the state began covering them over the past two years.