- Gender identity: A person’s sense of being a particular gender—male, female, a blend of both, neither or another category.
- Gender expression: The ways in which gender is communicated through dress and mannerisms.
- Transgender: An adjective describing a person who identifies with a gender other than the gender typically associated with the sex assigned to them at birth.
- Transitioning: The process by which a transgender individual adopts the role that matches their gender identity.
- Sexual orientation: An individual’s physical or emotional attraction to particular genders. Transgender people may identify as heterosexual, gay, lesbian or bisexual. Or they may identify their sexual orientation in other ways.
Two years ago Randi Maton, a tractor-trailer truck driver, began a journey to affirm her gender identity, physically transforming herself to match the person she always felt she really was inside. The 42-year-old resident of Fairfield County is a transgender woman, which means she was born male, but in her teenage years, she realized she felt more female.
Spending many hours alone driving a truck across the country, she had time to think deeply about her identity. “I realized I didn’t want to go through my whole life feeling miserable and trapped in the wrong body,” says Maton, who had felt conflicted about her gender and finally decided to do something about it. She saw an endocrinologist to start taking estrogen and decided to have male-to-female surgery.
The doctor who helped Maton with the surgical steps of her journey last spring is Stanton Honig, MD, a urologist and director of the new Gender-Affirming Surgery Program at Yale Medicine Urology, which launched in 2016. Dr. Honig performs male-to-female surgeries. This is the first program of its kind in New England. At this time, the department does not perform female-to-male surgeries.
Transgender people can spend years transitioning. Gender-affirming surgery can be part of that process. “Our patients must be absolutely positive this is what they want to do,” says Dr. Honig, who has a social worker, a case worker and a team of nurses who support patients during the surgery process. The program focuses on "bottom" surgery, surgically transforming male genitalia to female. To have the surgery, patients must be at least 18. “We don’t take this process lightly. We have a goal of zero patient regret,” Dr. Honig says.
Approximately 1.4 million adults in the United States identify as transgender, according to the Williams Institute at the University of California Los Angeles School of Law. Feeling conflicted about one's gender identity can be psychologically painful, causing distress and depression. “This particular population is at a higher risk of stigmatization, discrimination and suicide than the general population,” says Dr. Honig. About 40 percent of transgender people report attempting suicide in their lifetime—compared to 4.6 percent of the general population, according to the 2015 National Transgender Discrimination Survey from The National Center for Transgender Equality.
“It’s a tremendously gratifying experience working with this population of patients,” says Dr. Honig. “At Yale Medicine Urology, we make it a priority to provide compassionate and comprehensive care to our transgender patients."
Affirming gender, transforming lives
To ensure the best outcome for patients, Yale Medicine Department of Urology's Gender-Affirming Surgery Program is made up of a multidisciplinary team of clinicians who follow the guidelines of the World Professional Association of Transgender Health, a nonprofit organization dedicated to the health of transgender people. Here are the steps patients complete before gender-affirming surgery:
Because gender-affirming surgery cannot be reversed, patients are required to consult with a mental-health professional who can submit a letter supporting the patient’s understanding of and decision to have the procedure. Patients also see the program’s social worker who works with patients before and after their surgeries. (For children and adolescents who are not old enough to have the surgery, the Yale Medicine Gender Program is available to support gender-nonconforming youth and their families.)
One year before surgery, Dr. Honig's patients begin to socially transition, consistently dressing and living as the gender they feel they are.
Pre-surgery patients work with endocrinologists to develop strategies for taking hormones, which is called gender-confirmation therapy, says Clare Flannery, MD, a Yale Medicine endocrinologist. Estrogen is critical before and after surgery, helping males transitioning to females (transgender women) develop breast tissue, minimize body hair growth and create a more feminine contour to the face and body, she explains. The hormone must be taken for at least one year before surgery.
Patients who wish to have biological children in the future are referred to Yale Medicine’s Reproductive Endocrinology group to freeze sperm before taking estrogen. “I counsel each person about cryopreservation and future fertility options,” says Dr. Flannery. And sometimes sperm can be collected at the time of surgery, says Dr. Honig.
As part of transitioning, some people may also opt to have vocal surgery or take vocal lessons to further feminize their voices. Electrolysis, laser hair removal, breast augmentation ("top” surgery) and facial feminization surgery can be part of the transition process.
Patients can choose among a range of bottom surgeries, including solely removing the testicles. Other patients may then choose to have the surgeons create a vagina, labium and a functional clitoris from the nerves in the head of the penis. Gender-affirming surgery takes several hours and requires a hospital stay of one to four days. In Connecticut, transition care including gender-affirming surgery has been covered by health insurance providers by state law since 2013.
Yale Medicine plastic surgeons help perform the outer work of gender-affirming surgery to create the labia and outer appearance of the vagina. They also offer several kinds of cosmetic surgery if desired. “It’s a matter of making them feel more comfortable about the image they project and making sure that image is consistent with who they want to be,” says John Persing, MD, chief of Plastic Surgery.
Life after surgery
Throughout the process of transitioning, Maton says she has not experienced mistreatment from the public or her co-workers, and she receives a lot of support from her family and friends. The only concern Maton admits having is when using public restrooms. “I sometimes am asked whether I’m using the correct bathroom,” she says.
Overall, her story is one of acceptance. “The world really has changed,” she says. “It’s OK if you’re transgender. As long as you’re happy and treat others with love and respect, people will accept you.”
Maton enjoys hunting and fishing and especially spending time with friends and her dog, Bert, which she rescued from a shelter.
Following surgery, she legally changed her driver's license from male to female. She is now at peace with herself. “I found my inner person,” she says. “I finally did something in my life that made me happy.” These days, whenever someone uses the right pronoun when talking about her—she or her—Maton can’t help but smile.
To find out more about Yale Medicine's care for people seeking gender-affirming surgery, call 203-785-2815.