Rules/policies re FTM top surgery
January 19, 2010 11:52 AM   Subscribe

Trying to support my butch lesbian trans-y friend. Would like more information about top surgery options for a person who does not fit into the classic FTM model.

My good friend is a female pronoun-using, male-clothing-wearing butch lesbian who also identifies as trans or at least trans-y. She does not want to transition to being a man. She does not want to take hormones or to have any kind of bottom surgery. But her dream in life is to have top surgery. Please assume for the purpose of this question that she would be much more comfortable in life, body, clothing, etc. with top surgery.

I am trying to get a handle on how possible it is within the US medical system (or perhaps Mexico or Argentina?) to have top surgery without asserting an intention to fully transition in the classic FTM model/manner. Are there surgeons who will take on such a patient?

My friend is a capable person who lives in a progressive city and has access to basic trans resources. But I think she is discouraged from the idea that surgery is possible for her or she thinks she doesn't fit the model enough. So I thought I would check here.
posted by anonymous to Health & Fitness (19 answers total) 3 users marked this as a favorite
Forgive what may seem like an obvious question, but what exactly IS "top surgery"? I'm not familiar with the term. (I mean, I have a guess, but I've learned never to assume anything.)
posted by EmpressCallipygos at 11:56 AM on January 19, 2010

Most the 'top' surgery is cosmetic, and could be done by plastic surgery as a breast reduction.
posted by French Fry at 11:58 AM on January 19, 2010

EmpressCallipygos, top surgery refers to an extreme "breast reduction" resulting in a masculine-looking chest.

Via googling, I found this thread on a butch/genderqueer message board that seems to include at least one person who has had it done (sounds like he now identifies as male, but says he did not look at the surgery as the first step in reassignment and did not have a therapist's letter regarding transitioning et cetera at the time). You might want to have your friend contact him.
posted by PhoBWanKenobi at 11:59 AM on January 19, 2010 [1 favorite]

Stu Rasmussen, mayor of Silverton, OR has had breast implants, even though he identifies as a heterosexual male, so it is possible to have cosmetic surgery without following what I've heard called "The Path".

I wonder if perhaps your friend is putting up obstacles to the surgery because she is feeling some unexpressed anxiety or even unnecessary shame? If your friend is serious about the issue, she should be able to get a free consultation with a plastic surgeon who will be able to walk her through what sorts of authorizations are required. I would be very, very surprised if it was anything more than a signed waiver and a big check.
posted by muddgirl at 12:05 PM on January 19, 2010

Also, if it counts for anything, "bottom surgery" is rare in f to m transitions, the surgical options for making male genitalia are poor.
posted by idiopath at 12:09 PM on January 19, 2010 [1 favorite]

Top surgery (in the FTM direction) is the removal of breast tissue and reconstruction of the chest to be masculine in structure.

I've looked into this too. Although it can probably technically be done by any old plastic surgeon, your friend is likely to be better off with a surgeon who is known to be FTM-friendly, so they won't be fazed by the request, and who is experienced with reconstruction, if she's hoping for a masculine-looking chest.

It used to be the case that most known FTM-friendly surgeons required "the letter" (from a therapist treating you under the Benjamin Standards of Care), but it looks like this is relaxing a lot. I've seen a lot of people saying Brownstein didn't require a letter, and he has free phone consults (or used to). Ditto McLean in Canada. The best bet may be to go through a list of FTM-positive surgeons (FTM communities often have these, or memail me) and check with their offices individually.

MeMail me if you want more details.
posted by dorque at 12:11 PM on January 19, 2010 [4 favorites]

"Top surgery" is similar to bilateral mastectomy. It's never called that in FtM circles, but it amounts to the same thing: removal of breast tissue, and suitable reconstruction - but in typical male shape/form.

Some surgeons definitely do require that patients are diagnosed and referred for surgery, and that they adhere to WPATH guidelines (Standards of Care). Here is a list of a couple of surgeons by their requirements, it may be useful for your friend, but only one says no requirements. It's probably best to draw up a list of surgeons and start asking around, as that's the quickest way to find a surgeon.
posted by Sova at 12:13 PM on January 19, 2010

Marci Bowers in Trinidad, CO is probably the most outspoken and famous of the SRS surgeons in the US. She does not do chest reconstructions, per her own website-- but I'm willing to bet she refers people for it if they want it. You might try contacting her and asking if she knows surgeons who are sympathetic to butches looking for top surgery and not transition.
posted by fairytale of los angeles at 12:15 PM on January 19, 2010

I should add that two things seem to be very common in FTM top surgery: (a) traveling some distance to see a relevant, well-regarded surgeon (not just somebody who happens to be in your city) and (b) paying for it out of pocket, which your friend should be prepared for. On the other hand, most of the FTM-positive surgeons are used to people having to do this and are reported as more than willing to set up payment plans.
posted by dorque at 12:15 PM on January 19, 2010

search google for genderqueer "top surgery". it seems like quite a few people have gotten it done. start emailing and asking for references.
posted by nadawi at 12:27 PM on January 19, 2010

Buck Angel is a very high profile FTM porn star/producer and trans awareness educator. He chose top surgery and hormones, while leaving genitals famously intact. Your friend might also appreciate his video podcast. (Complete with sign language interpretation!) Anyway, Buck comes off as a genuinely nice guy and serious about building a trans-friendly world, starting with the personal. His email address is provided on the education/advocacy section of his website. Pics in that section are safe for work, but mentions of his professional work may or may not be. He must field this question often. Worth asking him, anyway. That man has one hell of a nice body.
posted by nakedcodemonkey at 1:26 PM on January 19, 2010

I have a friend who went through this recently. She went to counseling, found a trans friendly surgeon as part of her counseling/community and had the surgery all in the space of a year or so. My friend is on horomones and did have to pay out of pocket for the surgery. She lives in a different city then me, so I'm a little detached from the specifics, but I think that what your friend is trying to do is definately within the realm of possibilites.
posted by Phoenix42 at 1:35 PM on January 19, 2010

I would definitely encourage her to talk with surgeons who are experienced in doing top surgery for trans men.

Non-genderqueer cis women have elective breast reductions and even elective mastectomies (though admittedly the latter is motivated by concerns about cancer, not about wishing to change one's appearance) quite frequently, so I would think that this wouldn't necessarily fall under the "you need a Benjamin Standards letter" standard of practice.
posted by Sidhedevil at 2:04 PM on January 19, 2010 [1 favorite]

so I would think that this wouldn't necessarily fall under the "you need a Benjamin Standards letter" standard of practice

...for every doctor and every hospital and every HMO, I mean. There might well be some who would have that as part of their care guidelines, so asking (asking around as well as asking directly) is the only way she's going to find out.
posted by Sidhedevil at 2:08 PM on January 19, 2010

Genderfork might be a good place to ask about this. (They have an "ask genderfork" section.)

Also, this youtube blogger basically did this. (Recent blogs mention considering testosterone, but I believe the blogger planned surgery while still using female pronouns and not planning to take testosterone or transition per se--the surgery wasn't predicated on changing pronouns or wanting hormones eventually.)
posted by needs more cowbell at 2:29 PM on January 19, 2010

Buck is a total sweetheart and gives out a lot of helpful FtM, trans-issue advice on his podcast and talks.
posted by The Whelk at 5:23 PM on January 19, 2010

My friend is a capable person who lives in a progressive city and has access to basic trans resources. But I think she is discouraged from the idea that surgery is possible for her or she thinks she doesn't fit the model enough.

If she seeks out other FtM transsexuals, she'll find out pretty quickly that it's more typical to only have top surgery, though hormones are pretty typical too. What may be less accepted among some is her use of feminine pronouns, so she might want to specifically seek out genderqueer resources in addition to transsexual resources.
posted by desuetude at 6:22 PM on January 19, 2010 [1 favorite]

Dorque has good info.

Most top surgery is done by by surgeons who specialize in it; it's very, very rarely (though occasionally) done by general plastic surgeons. It is distinct from a bilateral mastectomy, because it is a bilateral mastectomy with male chest reconstruction, which often includes such things as surgically adjusting the size and shape of the nipples to match the typical male chest.

My understanding is that most of the surgeons who specialize in top surgery (there are a handful of them in US - many/ most people do seem to travel to get top surgery, unless they happen to live near one of the surgeons) do require a letter from a therapist stating the individual's desire for a permanent transition. Your friend may need to contact several surgeons to find one that doesn't require that kind of letter.

The letter that is/was typically required doesn't fit your friend's situation at all - it generally asks for the therapist to confirm that the patient truly wants to live as a male full-time. Sometimes the surgeon wants the letter to confirm that the patient has been living as a male full-time for a certain number of months, or has been taking male hormones, etc.

As people are saying, this kind of letter is no longer required by all surgeons. I imagine that a few surgeons will be fine without a letter, and even more will accept a therapist's letter stating your friend's genderqueer identity and her real, lasting, desire to have a male-typical chest. Your friend (or you) should just start contacting surgeons with her specific situation - you can email most of them - to see who will be willing to perform the surgery.

Also - agreed with those who say that your friend will be paying out of pocket for this. Unfortunately, that's true for virtually all gender reassignment-related surgeries; almost no insurance plans in the US cover top or bottom surgery in either direction for transpeople.
posted by insectosaurus at 7:39 AM on January 20, 2010

Harvey Katz is a ftm public speaker and activist.

The surgeon who did his mastectomy did not receive a glowing recommendation, if you catch my drift.

Just because someone is qualified to do the surgery does not mean they have any concern for the patient as a person.

One thing he mentioned about the decision to start using testosterone was that without breasts he was viewed as a teenage boy. That was the closes identity match strangers could make. And they treated him thusly. He wanted to fit in society as an adult. Your friend's mileage may vary.
posted by bilabial at 5:22 PM on January 20, 2010

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