Last month we had a medical grand rounds on Transgenderism. The speaker portrayed a very positive and relatively innocuous transformation. When asked the cost of this transformation, “he” simply stated that it was the usual cost of the require procedures. The required procedures for transgender conversion for a female would entail the following:

1) Cost of bilateral mastectomies; 2) cost of hysterectomy; 3) cost of bilateral oophorectomy;
4) Cost of bilateral salpingectomy; 5) Cost of vaginectomy; 6) Cost of life-long male hormone therapy. Hence, “he” did not see any unusual cost in transgender transformation.

A further question hinges on whether the estimated $60,000 to $100,000 costs of these operations and hospitalizations can be considered medically indicated or elective procedures. Taking out normal organs is generally not considered a medical indication. If elective procedures, these are generally not covered by health insurance. If not indicated medically, is this massive amount of surgery psychiatrically indicated? If psychiatrically indicated, what are the psychiatric criteria? Is it a neurosis? Is it a psychosis? Is it a depressive psychosis? Is it schizophrenia? Is it a manic-depressive diagnosis? Is it a bipolar disorder? Is it adolescent hysteria?

 “He” glossed over any significant adverse effects. The American Academy of Pediatrics, however, does mention that all non-heterosexual adolescents have an increase in suicide attempts. Nearly 14% of adolescents reported a previous suicide attempt; disparities by gender identity in suicide attempts were found. Female to male adolescents reported the highest rate of attempted suicide (50.8%), followed by adolescents who identified as not exclusively male or female (41.8%), male to female adolescents (29.9%), questioning adolescents (27.9%), female adolescents (17.6%), and male adolescents (9.8%). Identifying as non-heterosexual exacerbated the risk for all adolescents except for those who did not exclusively identify as male or female (i.e., nonbinary). For transgender adolescents, no other sociodemographic characteristic was associated with suicide attempts.

My primary experience was with a normal appearing hairy, mustached, bearded short statured “male” with considerable hair on his chest. Two large scars on either chest were well camouphlaged by his hair. He then stated that he was a former woman, was married, and had two children, when he felt like he was a man in a woman’s body. As my examination progressed to his abdomen and then his genitalia, his female clitoris was about three centimeters long with no male foreskin. Hence, his entire organ was sensitive like the male glans penis or phallus. There was no urethra in the clitoris and so he still had to urinate sitting down on the toilet. Hence, when he entered the men’s room, he  had to use a stall to urinate.  Between his enlarged clitoris and his urethra, his surgeon had formed a scrotum with a smooth skin which contained two aluminum artificial testicles. Since he had no urethra in the clitoris, he had to urinate sitting down as he always had before. Now his urine flow was behind his aluminum testicles from his female urethra. He had no sensuous feelings in these structures.

 “He” also carried the diagnosis of schizophrenia. “He,” however, appeared to be well oriented with a normal flow of speech. This was apparently of some concern to his female wife. The wife, married to this transgendered female appearing as a male, made a separate non-scheduled appearance at my office for the sole purpose of telling us that his new psychiatrist said he was not schizophrenic but bipolar. They appeared to be celebrating this diagnosis.

To understand the new family constellation, we must remember that “he” formerly was a wife and woman and mother with two children. He (she) and His (her) former husband had two children who still had a biologic father and a transgendered male (formerly female, wife and mother—my patient) as a stepfather to his own biologic children.

The appearance of the professor at our Medical Grand Rounds was quite similar to this transgender patient. The waist and hips were somewhat reminiscent of the female silhouette with a short stature. None of the physicians in attendance asked him whether he was a “trans” and he did not divulge it either. However, his delivery of the presentation left little doubt since he thought it was no big deal to change genders and the costs were irrelevant.

At our American Association of Physicians and Surgeon’s annual conference we had an address by Michelle Cretella, M.D., President, American College of Pediatricians. She presented the alternate point of view from the American Academy of Pediatricians, which we will discuss in this section of the July Journal next month.

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