A double bind | Australian Greens

A double bind

People seeking gender reassignment surgery in Australia face two challenges: exhorbitant costs and lack of Australian surgeons willing to perform the procedures. Yet most states still require the surgery in order to change legal documents.

By Derek Hamilton
Thursday, April 20, 2017

Understanding the terminology

Gender dysphoria is a developmental disorder, essentially a neurological mis-wiring, locked deep in the still somewhat mysterious regions of foetal sexual development.

People with gender dysphoria generally identify as the gender 'opposite' to their assigned sex, and are usually referred to as transgender, though that term is sometimes used today to encompass the wider gender-diverse community. Many problems for transpeople can be alleviated by social transition and acceptance but there is also an internal distress, often physical, that can only be addressed by physical transition towards their internal gender and many transpeople will desire this.

Physical transition is made possible by hormone therapy and, in many cases, some form of surgery. Unfortunately, transpeople in Australia are cut off by cost and availability from some of the surgical options that may be necessary for them to lead full and healthy lives.

Gender Reassignment Surgery (GRS) or Gender Affirmation Surgery are the best terms for what has been popularly called “sexual reassignment surgery” or “sex-change surgery”. It covers surgical procedures performed to help affirm a person in physical aspects of their internal gender.

For male-to-female transpeople (MTFs) or transwomen this involves vaginoplasty and some will also want breast enhancement and other procedures to help produce a more feminine voice or face. For female-to-male transpeople (FTMs) or transmen, most will want to have a mastectomy and many will have a hysterectomy. Additionally, transmen may seek surgery to help approximate male genitalia. Two main types of procedure are being done today, the metoidioplasty and the phalloplasty. 

Mastectomies and breast enhancement are generally referred to as “top surgery” and all surgeries related to the reproductive organs and genitalia are often referred to as “bottom” or “lower” surgery.

Australian transpeople seeking gender reassignment surgery (GRS) in Australia are disadvantaged by two major factors.

The first is cost: transmen in Australia have not been able to access mastectomies and hysterectomies on Medicare; vaginoplasty is covered, but it is unclear how many transwomen are able to access this through Medicare or private health insurance due to the provision of certain coverage to only patients of one sex. Furthermore, many surgeons insist on working only from private hospitals (particularly cosmetic surgeons, so most top surgery for both transmen and transwomen) which result in large hospital costs. The costs related to surgery not covered by Medicare, such as anaesthetists, must also be considered.

The second and most fundamental factor is the lack of surgeons both willing and able to perform genital GRS — I have been able to confirm only two surgeons in Australia currently performing bottom surgery for transwomen, and none at all performing bottom surgery for transmen. This means that Australian transmen must travel to Thailand, the US or Europe to access surgery. It becomes apparent how isolated Australia is, geographically, when the potential travel and accommodation costs must be calculated on top of surgeries that will probably cost upwards of US$30,000. There is no assistance for Australian transpeople seeking surgery abroad and most have no hope of affording it. Surgery for transwomen in Australia may cost between AU$10,000 and $30,000.

Is surgery necessary?

Surgery can be a difficult topic in the transgender community, particularly bottom surgery. This is in part because, in the public imagination being trans has often been all about “having the operation” i.e. genital surgery. Some transgender persons have few issue with their bodies, and others, after hormone therapy, will find they can accept and live in their bodies without surgery or, for transmen, with only top surgery. Hence not all transgender persons want surgery and pretty much all believe that surgery should not be part of what defines us as trans. It is also always important to stress that not all GRS is genital surgery: top surgery is an important part of their transition for most transmen and many transwomen.

But with that pointed out, genital reconstruction is important for many Australian transpeople. In all states and territories, excepting the ACT, WA and, from this year, South Australia, some form of surgery is required to change one’s legal sex on birth certificates. The inclusion of a third gender designation on Australian identification is a welcome move and will benefit many, particularly the intersex and wider gender-diverse communities, but many transgender persons wish to be legally recognised in their correct gender. For transwomen in particular this involves undergoing difficult and costly invasive surgery that some would otherwise choose not to have.

Does not compute

Beyond this legal issue, there is the considerable distress experienced by many trans persons due to physical dysphoria. Most transmen experience dysphoria related to their breasts, and many transpeople experience dysphoria associated with their genitals that can range from mild to extreme, leading to depression, self-mutilation and thoughts of suicide. This is not a socially produced body-image issue, it is produced by the clash between the brain’s internal map of the body and the body’s physical reality.

The only way we have to alleviate this distress is through surgery and the difficulties of accessing surgery have a negative impact upon the lives of many transpeople. My own experience is that the lack of surgical options in Australia and the inability to access surgery overseas due to prohibitive costs leads to a hopelessness and sense of a lack of control over what happens to my own body contributing to depression already being fuelled by physical dysphoria.

I have been suicidal, and at times feel that I cannot endure the knowledge that I will have to suffer this distress, this extreme physical discomfort, for the rest of my life. I cannot be certain that surgery would alleviate it, but it is the only thing that could, and I, like most Australian transmen, have very little hope of ever finding out.

Derek Hamilton is a 37 year-old autistic transman who deals with severe chronic depression aggravated by social isolation, chronic illness, and, most of all, the physical aspects of gender dysphoria. The image above is a stock image sourced from pexels.com and not intended as a representation of Derek.

If you are distressed, call QLife on 1800 184 527 or visit https://qlife.org.au for online chat or Suicide Line on 1300 651 251 or visit https://www.suicideline.org.au