The medical transition is an important yet sometimes costly route to pursue for transgender men and women hoping to align their anatomy with the gender to which they identify.

 
For this installment, Basement Medicine will explore some of the various operations, recovery procedures and costs associated with medical transition from the experiences of several of JSC’s students and community members in Vermont.

 
Before any surgical procedure takes place, some within the transgender community opt to take either estrogen or testosterone to develop either more feminine or masculine characteristics, replacing the dominant hormone of their assigned sex. This is a process called hormone replacement therapy (HRT).

 
According to Dr. Scott Mosser’s Gender Confirmation Center based in San Francisco, HRT is not a prerequisite for specific procedures such as female-to-male chest or male-to-female reconstruction surgery, which either remove the breasts and leaves the chest more masculine-looking, or build in silicone or saline implants to create a more feminine chest. These surgeries are commonly referred to as ‘top surgeries.’

 
However, JSC music theory major Peython Echelson-Russell says he opted to undergo HRT after some personal research when he was 18 and decided it was the avenue he wanted to pursue.

 
“Once my mom decided that she was going to approve of me getting hormones and pay for them herself, she even helped me with the process of actually going on hormones,” said Echelson-Russell. “This was in 2012; I ended up seeing a therapist at the tail end of my senior year of high school and had a few months of being with that therapist. Some therapists will be like, ‘Okay, we’re going to talk about medical transition right now and we’re going to talk about that for the entire specific length of time that you need to get hormones and surgery.’ It all depends on who you get and what you want.”

 
“I ended up talking with my therapist for a couple months. Then he referred me to an endocrinologist and sent a letter stating that I was diagnosed with—at the time it was ‘gender identity disorder,’” he added. “I had a consultation and had some bloodwork done, then I was on T [testosterone].”

 
JSC Pride Alliance member and student Randy Raymond says he felt hopeful when he first began his physical transition on testosterone over three years ago, in September of 2013.

 
“[It feels] like nothing can get here fast enough,” said Raymond. “It’s a very hopeful feeling, but also kind of like, ‘What am I getting myself into?’ This huge thing that you get a little overwhelmed about, but you’re also really excited. That definitely translates to your friends and family because they can tell that you’re just so ready for it. I was really lucky that everyone around me was so supportive.”

 
Biology and Education major Blair Koonz says when she started on estrogen, with costs covered by Blue Cross Blue Shield Vermont as a co-pay, slightly over a year ago on Dec. 10, 2015, she had to sign off on the risk factors that also make the physical transition from assigned male to female.

 
“I actually had to fill out a whole thing of all of the side effects and sign off on all of them,” said Koonz. “Stuff like liver damage, higher risk of breast cancer, blood doesn’t clot as well — so if I ever needed to get a surgery, I would need to get off estrogen ahead of time. For the most part it’s just basically regular risk factors that any woman has like me. All of the risk factors that they have increase, and all of the [health] risk factors for men decrease.”

 
And despite the expected changes from the male-to-female transition, such as the decrease in facial and body hair and the eventual development of breasts, Koonz acknowledges the changes that estrogen can’t produce.

 
“Outside of just hormones and surgeries, a lot of trans people have a lot of mental stress or anxiety based on cultural expectations and non-acceptance,” she said. “Specifically, outside of hormones and bottom surgeries, there’s also… vocal training, because hormones don’t do anything [to your voice], so you have to manually train your voice up. Which, as you can imagine can be quite difficult.”

 
South Burlington resident and one the keynote speakers at last year’s 2016 Ally Dinner at JSC, Marcus Pizer, says he understands the medical transition process may be different for everyone.

 
“It’s different depending upon each person and how they feel,” said Pizer. “I wanted hormones to replace my estrogen as soon as possible to become more masculine looking and sounding. There are some folks who are comfortable with the way they present themselves and feel. There’s no one way to be, you don’t have to present [yourself as] masculine, some prefer to present [themselves as] feminine… and that’s totally okay.”

 
For some, the next step after a period of counseling and HRT could be to elect a gender-specific “top surgery.” For a female-to-male surgery to remove or reduce the size of their breasts, the process can be longer for those hoping to receive it.

 
English and secondary education major Shane Wyman, who recently reached his eight-month mark on testosterone, insists the decision to proceed with top surgery has to be made by the individual and also says that the long waiting period is to make sure the individual is sure about their intentions to transition.
“There’s a couple different routes with [surgery],” he said. “You have to make the decision for yourself before you do this so that you have no doubt whatsoever. Because there have been instances where people have de-transitioned or canceled their first surgery consultation or actual surgery appointment just because they think they need to wait a little bit longer. Which is perfectly okay; a couple of trans guys have done that and they really have been happy that they’ve waited to make that decision a little bit longer.

 
“The personal choice and personal decision is first in making sure that this is really what you want to do,” Wyman added. “From there, most doctors or surgeons ask for at least six months in therapy to make sure that on the professional level there’s nothing else going on — no mental illness or anything like that that could be affecting your decision to do a life-altering surgery.”

 
Wyman, who has been fundraising to pay for his top surgery, says the steep price ranges for such a procedure aren’t always covered by medical insurers. His insurer, Harvard Pilgrim, is not accepted by any doctor who specializes in the surgery.

 
“Unfortunately, my top surgery is coming out of pocket,” he said. “The surgery itself, not including travel to get there or having to be out of work for a month, the expense for the surgery itself is about $9,000. I need about $10,000 to actually be able to have surgery. This is out of pocket and I’m trying to fundraise it like crazy. It’s extremely difficult and frustrating to try to raise $10,000 when you wish you had this surgery six years ago.”

 
Wyman’s chosen doctor is Dr. Charles Garramone of Davie, Florida, who specializes in female-to-male top surgery. Garramone’s patients have regularly posted to YouTube over the years revealing their chests with his surgical work.

 
In contrast, Echelson-Russell came to Vermont because of a Division of Insurance regulation under the state’s Department of Financial Regulation, banning exclusion of what is deemed as “medically necessary care for transgender people,” according to the nonprofit organization Transgender Law Center, based in Oakland, California.

 
Echelson-Russell’s previous insurer through his mother, ConnectiCare, at the time did not cover his hormones or any potential transitional surgeries.

 
“When I came [to JSC], I started on the school’s insurance and they’ve covered my hormones ever since, and they’ve covered a good amount of my top surgery as well,” he said. “At first, it was $15 a month, but it’s gone up to $20 a month for my prescription.”

 
Aside from the financial burden of his physical transition through hormones and surgeries, Echelson-Russell says the hardest part of his transition was when he was binding his chest, a practice in which someone flattens the breasts with constrictive materials such as fabric or tape to achieve a more masculine appearance.

 
“I had been binding ever since before I actually came out,” he said. “I bound for so long, and didn’t bind according to the safety procedures. I came out in the beginning of my junior year of high school and I started binding at the end of my sophomore year of high school. The year after my senior year of high school when I went to another college for half a semester, at the end of [my time] there, I developed pleurisy [serious lung illness constricting regular breathing] due to binding improperly. It was really bad.

 
“It was definitely time for surgery because I was still trying to bind way more than I should’ve,” Echelson-Russell added. “Just because of personal discomfort. I was on the school’s insurance at that point; that was between my freshman and sophomore years [of college].”

 
For his “keyhole” surgery, done with an incision on the underside of the areola, Echelson-Russell went to Dr. Melissa Johnson of Bay State Medical Center in Springfield, Massachusetts. He regards her as one of the more commonly sought surgeons for top surgery in New England.

 
Several other types of top surgeries for the female-to-male transition include the aforementioned keyhole surgery for those with a smaller chest, ‘donut’ surgery [periareolar] around the nipple for average-sized chests and double-incision made across the breasts for people with larger chests.

For male-to-female surgeries, saline and silicone-based implants for breast augmentations can be pursued with incisions below the chest muscle and through the armpit, according to Dr. Mosser’s website.
The more complicated and expensive surgeries tend to be what are known as ‘bottom surgeries.’ These are less common due to their expensive and complicated nature.

 
Some types of bottom surgeries can be performed to take away the male set of genitals [penectomy and orchiectomy] and then construct female organs with a procedure called vaginoplasty, a surgery to create the vagina. Other procedures can be read about on nonbinary.org, a medical terminology wiki for gender-related issues.

 
The Philadelphia Center for Transgender Surgery provides price lists of their various female-to-male and male-to-female surgeries.

 
A simple breast augmentation or breast removal surgery could range from $6,000 to $8,200 while their bottom surgeries range from $19,750-$21,250 for transgender women and men, respectively.

 
Echelson-Russell admits he isn’t 100 percent sure what his next step will be with his medical transition having undergone top surgery and has experienced everything from binding his own chest, to the compression vests to reduce swelling in the chest, to the drain tubes which filter out excess fluids after surgery.

 
He adds that despite some internal pressures to pursue a specific route of medical transition, most people within the transgender community are open to any path of transitioning.

 
“Being a trans guy, what I see in that community is a lot of time there’s a general order that people do things and sometimes people feel pressured to follow that,” said Echelson-Russell. “But what I’ve found is that even though there is that perception of pressure, most people at least when you talk to them individually will not care what aspects of transition you choose to pursue or not pursue.

 
“I found that there’s pretty overwhelming support for people approaching transition however they want to,” he continued. “People can be reassured by that and feel less afraid to pursue or not pursue various options and to talk about their decisions.”