And it Begins!

 My first blog post! I must really be on the right track now. I'm writing this from the public library in Ann Arbor, Michigan, about six hours after getting out of my consult for metoidioplasty with Dr. Miriam Hadj-Moussa at the University of Michigan, Ann Arbor. This was my third consultation for metoidioplasty - I have had two virtual consults (one with Dr. Safir at the Crane Center and one with Dr. Chen, both located in San Francisco) and this was my first in-person appointment! Navigating all of this during COVID-19 (and a resurgence due to the Delta variant, at that) is a little different, but overall hasn't impacted my experience all that much (yet, G-d willing). 

I went into this consult believing that I would most likely end up having surgery with Dr. Hadj-Moussa, and I left the consult certain that she is the right choice for me. I have heard wonderful things from previous patients of hers, she is (as far as I have been told) covered under my insurance plan (BCBS of MN), is relatively close to home (at least closer than California), and she is willing to do the specific set of procedures that I am looking for, which not all surgeons are willing to do.

I'm pursuing metoidioplasty with urethral lengthening (UL), scrotoplasty and testicular implants, and mons resection. I am not going to have a vaginectomy, nor have I had any of my internal reproductive organs removed. The biggest reason for that decision is that I want to have the possibility of carrying children in a few years if I so choose. The other reason is that I don't have any dysphoria from my front hole or the fact that I have a set of internal organs that is not traditionally considered "male," and I would rather not add more surgeries than I need to! Some surgeons are not willing to do this set of surgeries, specifically UL without vaginectomy, because there is an increased risk of a fistula (a hole in your urethra where there isn't meant to be one), specifically at the junction where your natal urethra ends and your surgically reconstructed urethra begins (AKA the "neo-urethral junction"). I think about it this way - my current urethra is pretty much pointing downward, and to get it through the tip of my neo-phallus it needs to be pointing outward from my body, at about a 90 degree angle. This angle puts a lot of pressure on the junction (and gravity doesn't help, since it's essentially pulling your stream downwards where it is used to coming out pre-op). With a vaginectomy, there's still absolutely the possibility of a fistula here, but there's a lot more padding to get through than without a vaginectomy.

I understood all of that leading up to surgery, as I am a planful person in general and had a lot of extra time to research because of a few different things that delayed my consult. I'll get into that a little more now, in case anyone reading this is looking to schedule with Dr. HM in the future.

The first step to getting any gender affirming care at the University of Michigan is to go through the Comprehensive Gender Services Program (CGSP) with Michigan Medicine. You can go to their website and click on the "Patient" tab on the lefthand side of the screen, and from there you can select what exactly you're looking for. For some reason they have one tab for "Orchiectomy, Metoidioplasty," which are two very different things, and that's where you can access their "Service Inquiry Form." This form asks for information about you, your medical and surgical history, what you're seeking, and what your insurance looks like. You can fill it out online and email it to genderservices@med.umich.edu, fax it, or print it out and mail it. 

After I emailed my Service Inquiry Form to the CGSP in early October, I got an email back one week later detailing my next steps. From there, I had to register my information (specifically my insurance information) with Michigan Medicine, and get two mental health practitioners to write referral letters for my surgery. I had a therapist I was seeing at the time so he wrote one letter, and I reached out to a previous therapist (who is also trans) to write my second letter, which he was happily willing to do after a short catch-up session over Zoom. I had both letters faxed in by my therapists, one in late November and one at the beginning of December. I was initially told by the CGSP that these letters would be processed within 1-10 business days... and this is where things start to get a little dicey.

As a disclaimer, I don't not recommend working with the CGSP, especially if you live in Michigan and/or are already in the Michigan Medicine system. I know other people who had no problems (and I know other people who had several problems). Personally, I had to do plenty of following up and had lots of unanswered emails, which was frustrating and disheartening, to say the least. I sent an email to CGSP every other Friday for almost three months, which felt annoying on my end and probably came across similarly to them as well. I was told that "due to COVID-19 among other delays, this process has been taking significantly longer" than the 1-10 business day turnaround that they were usually working with. Which makes sense! But they were unable to give me any sort of timeline, and I got tired of it. By the end of February and after sending lots of emails (and phone calls!) that were only sometimes returned, I pretty much gave up and decided to try a different route.

This brings me to an important general idea that while these centers are ideally designed to support trans and gender-variant people in our medical journeys, they often end up putting up additional hoops for us to jump through. I'm not totally sure what to make of this, because I believe that their existence has the potential to do very well by trans people, even though experience doesn't always show this. So, instead of waiting to hear back from the CGSP, I called the University of Michigan Department of Urology directly to schedule a consult with Dr. HM. 

And it worked! Wild.

I was able to schedule a consult for early April, just a few weeks after my phone call. I scheduled this knowing that Dr. HM was going to have a baby and begin maternity leave right around that time, and my consult ended up getting canceled for just that reason. Which was a little disappointing, but it's also not in my nature to feel upset at something as exciting as a new baby in the world and time spent bonding and recovering. Consult gets shifted up past her maternity leave, to the new date of August 11th - today! And here we are.

Since this was my third consult for metoidioplasty I had a relatively clear picture of what to expect, though the new component of it being in person rather than virtual was a little different. I was the first appointment of the day (which is now something that I will always strive for, because it's much harder to be running late in the very beginning of the day - not impossible, but harder!) and arrived at the urology clinic a little after 7:00 AM. The nurse called me up a few minutes after I took my seat in the waiting room and brought me back to take my vitals, check my height and weight, and ask questions about my medical history. She then brought me to the examination room, where I sat for a few minutes to wait - I wasn't asked to undress at this time since the initial part of the consult was just talking.

Dr. HM walked in with one medical student with her (as I expected and appreciate, it is a teaching hospital after all!) and kindly introduced herself and the student, and then jumped in to start asking questions about what I'm looking for in this surgery. She talked through her staging, techniques, complication risks, post-operative care, and asked me some more about my own health history. After we had talked through all of this, she and the student left the room for me to get undressed (from the waist down) to prepare for the physical exam. In this examination, she's looking specifically at the amount of labia minora tissue (used to create the new urethra), the amount of mons tissue, and your "stretchable length" from the base to the tip of your neo-phallus (t-dick, clit, whatever you want to call it). Dr. HM said that she's looking for at least 4 cm in order to be able to pee standing up (and hopefully clear your fly). 

Nitty-gritty: I have plenty of minora tissue, a small mons, and meet Dr. HM's stand-to-pee-length criteria. I'm also thin, which is advantageous to being able to stand to pee. She said that I'm a good candidate for this surgery, which is something that I assumed beforehand - and is something that I'm curious to breakdown more re: fatphobia, cissexism, etc. Something that deserves its own post.

We talked a little bit more while I was sitting on the exam table with a sheet covering my crotch, and I asked a few more questions. I asked more about her timeline and scheduling, which she said was relatively open at this time. She told me that I could follow up on MyChart if I decide to schedule with her, to which I replied "What if I want to schedule now?" She seemed a little surprised - I wonder if it was because I talked about my other consults?? - and happily told me that her scheduler can give me a call to schedule the surgery! So now I'm waiting to hear from the scheduler, and am hoping to schedule surgery for the end of November this year!

All in all, a great experience with Michigan Medicine Urology and Dr. HM so far, and I'm really looking forward to what my future here will hold. 

As an aside, I hope to use this platform for two writing purposes: 1) to write about my surgical and recovery experience, because the more the merrier and 2) to do some more creative writing about my feelings regarding bottom surgery and everything that goes into it. My goal is to write enough of both that I can switch off consistently. Honestly, this writing is for me before anyone else, and and and I do really hope that it's informative to others who are pursuing (or thinking about pursuing) metoidioplasty. All for now!