How exactly do you transition?

By James Branson

While I know a few trans people, I know very little about the technical procedure involved in changing sexes. I briefly humoured the idea that perhaps people simply wait for those of opposite genders to request the surgery and then simply swap their bits over, like Face/Off but for your junk. Crotch/Off. In order to learn more about gender reassignment and the world surrounding it, I spoke to Peter Haertsch, one of Australia’s leading gender reassignment surgeons, to find out how on earth you’re supposed to create a vagina.

How long have you been performing gender reassignment surgeries for? Has it changed much over the years? 

Since 1988. It has changed quite considerably. Expectations have risen in terms of the cosmetic outcome, and the surgical procedures have changed quite considerably. It’s one of the more testing cosmetic procedures that I do. Just a few weeks ago I saw a girl I did quite some time ago – she’s been married for 22 years and her husband does not know. So even 22 years ago it was… very difficult to tell the difference. That’s when we’re talking about the more common operation, which is male to female. Female to male is less common and it’s not an operation that I am personally comfortable with. The gold standard for constructing a penis nowadays is a piece of tissue taken from the forearm and hooked up on arteries and veins down below. There’s only one fellow around who really does it very well [named] Joris Hage. He’s in Amsterdam.

Is that because it’s technically quite difficult? 

It’s not that it’s technically difficult. In fact, the more difficult something is technically, the more interesting it is to surgeons.

How do you go about the process of psychologically assessing a person to ascertain whether or not if they’re appropriate for the surgery?

It’s very rare that a person would come to me telling me they want the surgery. There are two groups, basically; there’s a primary transsexual and a secondary transsexual. The primary transsexual is a much younger person who has realised all their life that they’re not right; they’ve got organs that don’t belong to them and want them removed. Their parents then take them to psychiatrists and psychologists and there comes a point in time where it’s felt that they truly are transsexual. They then receive appropriate treatments so their hormones are more aligned to those of their desired sex. In the case of a male wanting to be a female, he gets feminising hormones and as part of that deal, he tends not to grow hair anymore and he develops breasts. Eventually they get to me with everything worked out – the psychiatrists, the psychologists, and the endocrinologist who looks after their hormones – then I take it from there.

The secondary transsexual is somebody who realises all of these things but represses it, gets married, does all of the things expected of their gender. I’ve operated on professional people, lawyers, doctors, specialist doctors, crocodile wrestlers, oil rig workers, farmers, people in the armed forces – it’s a whole spectrum of people. They’ve realised they’re desperately unhappy and decide that they’ve got to come out. I’ve got a patient at the moment who had a near-death experience, is married, has grandchildren… and he’s decided he’s not going to die as a male. So we’re in the processes of dealing with that.

How many of these surgeries do you perform yearly? 

I’ve probably done 700 or 800.

How do you actually go about constructing a vagina? 

When a baby is developing it is initially female. Then it goes on to develop the male organs. So from a surgical point of view, it’s easy to go backwards because all the tissues are there and you just have to reverse the situation. It’s much more difficult to go from female to male because those bits were never there.

Are people able to choose what their new genitals are going to look like? 

I show the patient a series of photographs, which gives them an idea. What you can fashion is based on what they’ve got. A classic example is that if I want to make a functioning vagina, then I need sufficient penile skin because that’s how we make the vagina. If they’ve been circumcised or they have a smaller penis, then I’m not actually able to create a functioning vagina, so I have to go up into their tummy to harvest a bit of bowel to use, to give me the length that you need.

If they have been circumcised, they tend not to have enough skin to create a functioning vagina because, after all, the penis is turned inside out and that skin is used to line the neo vagina (that’s what it’s called). That bit of bowel we use is, of course, kept connected to its blood supply; it’s not just a bit of free-hanging bowel.

Does the neo vagina have the same amount of sensitivity as a natural vagina? 

I actually make a clitoris out a small tip of the penis, which is kept on its own blood supply. I advise people that they should be able to achieve orgasm, however, I’m not talking about orgasm during sex because orgasm during sex is a pretty complex issue and a lot of ‘regular’ women don’t actually achieve orgasm during intercourse. They can achieve orgasm and the vast majority, that I’m aware of, have a very satisfying sex life.

Do your patients often come back and talk to you after their surgery? Do you keep updated on them? 

They stay with me for life really, because while it’s less common now, there always used to be something that had to be revised. Gilding the lily, I suppose you’d call it. I’ve got one who sends me a card every Fannyversary. Every year she sends me a card that starts, ‘On My Fannyversary’.

Do you solely perform operations in Australia?

I’m based here. I would not do this sort of surgery anywhere else. I need to be here to see the patients because it is a major surgery and it can have some very serious complications. I’ve had all the complications in the book – you do enough of something, you’ll see all of the complications. I need to be here, I need to be contactable. Certainly once they’ve left hospital (they’re only in hospital for 5 to 6 days), I see them on a regular basis until I know that all is healed and they’re becoming sexually active – which is usually about three months down the track.

Do complications arise solely from the surgery failing to heal properly? 

The complications arise from untoward events occurring during surgery because the dissection has to be made between the urinary system with the prostate and the bladder and the bulb of the penis in front and the rectum and anus behind. It’s between the bowel and the bladder and you can get into trouble with damage to the bowel but that, touch wood, is a pretty rare thing.