Gender identity ideology, the worldview surrounding the core belief that sometimes men are women and other times women are men, has gotten the foothold that it has because people naturally trust that medical authorities, especially surgeons, know what they are doing. We believe that if patients were being harmed, those patients would certainly speak up first. Proponents of gender ideology claim that fewer than one percent of people regret surgical sexual transition, often contrasted with the 20 percent regret rate for knee surgery. But is this purportedly low regret rate reflective of reality? Rather than prove that sex-organ origami is wildly successful, what this reflects is that patients who are subjected to these highly-experimental procedures are unable, for whatever reason, to express levels of regret one would reasonably expect from an evidence-based surgical intervention. 

Could it be that other factors, including withdrawal of community support and loss of reputation and standing, once one becomes known as a “transphobe” who was “never really trans,” are discouraging patients from being open about their regret? Could mental illness or emotional immaturity be preventing these individuals from rationally evaluating their situation or acknowledging and naming their emotions? Having looked at dozens of these first-hand narratives of individuals who “do not regret their surgery,” yet take to the internet to warn others anyway, I have concluded that these patients fear backlash for saying their actual, authentic truth out loud. Even people who suffer horrific complications requiring unimaginable revisions—likened to open hot dog buns by the surgeons themselves, as Ashton Williams discovered—are loath to say, “I regret having my arm skin cut off, stitched up, and sewn to my pubic area, and it was foolish of me to dream of peeing standing up at all costs.” But instead, she dreams of the day when it will all have been worth it, when she will look back on this hardship as a “bump in the road.”

Gender-affirming surgery patients face community scorn if they discuss the harm being done to them, their bodies, their pain levels, their wallets, their career or educational advancement, and their sexual-urologic function. The opportunity cost of the time spent dilating, tending to a colostomy bag, or financing a revision, is significant. And yet, patients who discuss the cost are cast as contributing to the zeitgeist that is “taking life-saving healthcare away from trans kids.” A predictable comment on any such surgical narrative is, “Be careful! Your story might be used by a transphobe to hurt trans people.” “Regretters,” as some term them, detransitioned or not, are accused of being “cis” because only “true trans” benefit from these interventions (making them tests of faith). The same network which “doxxes” (publicizes documents containing identifying information about) activists pushing back against gender identity ideology is ready and willing to subject even members of the trans community who have given their literal pound of flesh to this same mistreatment. For a movement so focused on the importance of inclusivity and tolerance, they are quick to scorn and shirk those branded non-believers.

Doxxing ignites firestorms many of us, including myself, have been subject to. This behavior seeks to divest us of our jobs, our homes, and our sense of personal safety as punishment for misgendering and other crimes. I have had the names and addresses of myself and my family members identified and circulated. As a former trans person who has become a vocal critic of the ideology and its attendant policy demands, I have received threats and other attempts at intimidation, such as frivolous professional complaints from foreign nationals and harassing phone calls. I’ve had long-time friends condemn me as a bigot on the basis of my gender-critical views, despite knowing first-hand that I would aid and befriend a trans-identifying person.

Surgical Simulacra

So what are these surgeries? Let’s discuss them in more depth. Graphic description of genital modification surgery will follow. Reader discretion is advised. Many of these interventions were initially designed for and continue to be performed on people with disorders of sexual development, some of whom are minors. It is important that people with a medical necessity for obtaining these surgeries still have access to them, in light of legislative attempts to ban these interventions. However, these interventions have the same complications regardless of reasons for obtaining them, and there is a significant complication rate for genital construction performed for any reason. The following will be a discussion of these surgeries as they relate to transgender-identifying individuals. These surgeries all fall under the general category of “bottom surgeries.”

Vaginectomy is performed on trans-identifying female patients alone or as part of another procedure. Using either a scalpel or a laser, the interior wall of the vagina is surgically excised, and the remaining flesh is then sewn together so that it scars shut. Patients are typically told this eliminates the need for routine pap smears to check for cervical cancer. Hysterectomy (removal of the uterus) including removal of the cervix may or may not be done at this time.

Hysterectomy is the removal of the uterus. For trans-identifying females, this is either for non-medically necessary alleviation of “dysphoria” (a Greek term meaning “bad mood”) or in many cases, it is made medically necessary through the administration of cosmetic doses of testosterone, which cause fibroids to form, resulting in pain. These fibroids can form after just a few years on testosterone, as confirmed via dissection of removed uteruses of trans-identifying women. A child put on testosterone in middle school may require a hysterectomy before she graduates high school. Testosterone (a known human teratogen, i.e., a substance which causes birth defects) can also change the endometrial tissue (the tissue which is excreted during menstruation), raising the risk of endometrial cancer. This has been confirmed by microscopic examination of uteruses removed from trans-identifying young women. The ovaries also become scarred due to exposure to high doses of testosterone. In addition to pain, fibroids can cause excessive bleeding and reproductive problems such as uterine-factor infertility and pregnancy loss. Oopherectomy, removal of the ovaries, may or may not be completed at this same time. Either procedure can put the trans-identifying woman into early menopause and place her in an increased risk category for early-onset dementia.

Metoidioplasty is a surgery performed on female-to-male transgender individuals. The vaginal tissue may be discarded or utilized in urethral lengthening (see below). The clitoris, which has been irreversibly enlarged through the use of cosmetic testosterone, is “released” from the connective tissue that holds it in place, allowing the head of the clitoris to point outwards from the body when erect. The inner labia are then sewn together, partially or fully, and connected to the elongated and “released” clitoral head, leaving a tube down the middle through which the individual can complete the holy trans rite of “standing to pee.”

Phalloplasty is a term that refers to the construction of a neophallus using skin from elsewhere on the body. This skin may be a transplanted radial forearm free-flap phalloplasty, a rotated (non-free) flap of skin from the abdomen, or transplanted from the leg or back. When transplanted from the leg, the thickness is typically excessive, resulting in a girth that has been likened by recipients to being the size of a soda can, requiring multiple “de-girthing” procedures that involve liposuction. Of course, if the person gains weight, their neophallus may again enlarge. The phalloplasty recipient also faces the issue of “shrinkage,” as the lack of connective tissue structure of a penis means that over time, the transplanted skin will change in size and shape to become smaller. This has been documented in photos by recipients and their providers, published in peer-reviewed journals and to social media platforms like Reddit. This lack of structure also makes the individual prone to pressure sores internally, which result in strictures where the skin inside the tube has become inflamed and scarred together, obstructing the flow of urine and requiring an individual to wear a second, suprapubic catheter that goes into the bladder through the abdomen, as well as a catheter inside the skin tube to keep it open.

Repeated insults to the bladder itself in some cases result in severe and recurrent bladder stones, all of which may contribute to the eventual loss of the bladder and need for a permanent urostomy bag. Additionally, individuals who get vaginectomy are vulnerable to fistula, which is an abnormal connection between two areas of the body. For one person I interviewed, “Ryan,” a fistula formed between the excised vaginal space, the “natal” (original) urethra, and the colon, allowing bacteria from the colon to repeatedly infect the urethra and bladder. To prevent sepsis, Ryan’s doctors re-routed the intestine to a stoma, or opening, cut in the side of the abdomen, to which a colostomy bag was attached to collect stool. This reduced the frequency of infections, but did not stop them. At the time of the interview, Ryan had been living half a life due to this imposed, severe digestive disability for a year and a half, with no end in sight.

Overall phalloplasty complication rates range from 60 percent to 100 percent higher when performed on females versus males, depending on the nature of the complication, with studies loath to provide an overall complication rate across complication subtypes. The studies that do provide such a figure estimate rates as high as 76 percent. “[C]urrent evidence of the various phalloplasty surgical techniques and their expected postoperative outcomes is weak.” Even without complications, “post void dribbling,” which many “trans men” liken to a “squirt gun” they have to “milk,” was found by one study to occur in 72 percent of female phalloplasty recipients.

One unfortunate phalloplasty recipient has needed eight surgeries (and counting) including the initial and all the revisions. She also spent five weeks in the hospital, of which two were spent in the ICU on a ventilator during COVID because her arm-skin phalloplasty had predictably become septic. She nearly lost her leg from a giant blood clot that formed as a result of a combination of factors, including the sepsis and the extended time spent immobile. The clot was likely partly a result of testosterone poisoning, which may have caused her, as she stated in a video response to me, to discontinue testosterone shortly after that incident. Yet this individual is still looking forward to having an erectile device implanted into this transplanted skin tube. These erectile devices, which are acting within floppy arm skin, are typically either balloon-based (requiring a pump to be implanted in the labial skin which has been revised to look like a scrotal sack) or a rod that clicks into place, similar to a futon frame. Romantic partners of phalloplasty recipients that have agreed to be in their videos state it does not work well for sexual intercourse, and this reality can leave recipients despondent.

In addition to phalloplasty, recipients often get additional cosmetic procedures so that the skin tube more closely mimics a real penis. These may include “medical tattooing,” which seeks to create the appearance of veins or the glans from a distance. They may also get additional surgical interventions to create the cosmetic shape of a penis via additional nips and tucks. Nerves from the location of the graft site may also be transplanted and joined (similar to soldering) to the clitoral nerve itself, which may require severing the clitoral nerve from the tip of the clitoris, resulting in loss of clitoral sensation (in addition to the loss that occurs when the phalloplasty “buries the clitoris”). This may result in some amount of sensation in parts of the skin tube. Since it is an arm or leg skin tube, however, it does not acquire the erogenous sensitivity or specificity that a real penis has. Recipients will describe having mild sensation at the tip or base, to the extent they can feel if something is touching it or not.

In both phalloplasty and metoidioplasty, patients are increasingly asking that their vaginas be left open and accessible, known as a “vagina-sparing” procedures. One metoidioplasty patient had her vagina “spared,” and subsequently, she became pregnant from having heterosexual intercourse with her male husband. She expressed in a video, “we did not think it was possible and were very shocked,” because in her mind, she was a gay man having sex with another man. Her baby was exposed prenatally to her cosmetic testosterone use, which she resumed against medical advice shortly after her infant had to be born prematurely. Her daughter has had developmental issues, including apparent motor and speech delays, as well as plagiocephaly (misshapen head), which required a prescription helmet.

Buccal grafts may be required during phalloplasty, metoidioplasty, or vaginoplasty (explained below), all with the aim of providing the mucous membrane lining that is present in normal genitalia. Consequences of this procedure include nerve damage, scarring, and impaired ability to chew, control the muscles of the mouth, or speak clearly.

Urethral lengthening is a procedure done during metoidioplasty as well as phalloplasty (explained below). The purpose is to connect what’s termed the “natal urethra,” otherwise known as the urethra, to the skin tube extension so that the individual can pee from the tip of the skin tube. This may be completed in various ways. The doctor may utilize tissue from the vagina. The doctor may also implant a straw in the arm of the patient for several months in hopes of creating a tube around the straw, which will then transplant with the rest of the arm skin during a radial forearm free-flap phalloplasty. The surgeon may also utilize skin from the inside of the cheek (buccal graft) or mastectomy (“top surgery”) to create this new urethra. Because this tissue did not develop for the purpose of carrying urine through a skin tube, the neo-urethra and neo-phallus lack the internal structure to sustain itself and have a tendency to scar together as well as create holes or cul-de-sac pockets in which urine collects and bacterial infections can thrive. This neo-phallus is not regularly flushed with semen as in a healthy male, nor does it have normal tension and pressure of a healthy male urinary stream, both of which make neo-urinary tract infections easier to develop and harder to eliminate. These infections create conditions which promote chronic bladder and kidney infections, and from there an infection can advance to one or multiple episodes of sepsis (systemic bacterial infection circulating in the blood throughout the body). Sepsis can result in brain and other organ damage as well as necessitate amputation of limbs.

Men’s Department

Transgender vaginoplasty is a procedure in which tissue from the penis, scrotum, mouth, other portions of the digestive tract (sometimes from a pig), or a tilapia fish is used to line an excavated hole in a man’s pelvis. Patients such as Jazz Jennings, child star of the show I Am Jazz, will often start with a penile inversion, in which the bulk of the internal portion of the penis and the glans is removed, the shaft skin is separated and inverted, and the urethra is split open and connected to the shaft skin to create a wider canal, all of which is then sewn to the posterior of the pelvic wall. Unlike a woman’s vagina, penis shaft and urethra skin is, of course, not very stretchy, which allows these structures to resist the pressures of urination as well as engorgement with blood occurring during erection. Once these tissues are removed, dissected, and inverted, the tendency of this tube is to become inflamed. Inflamed tissue that stretches scars and calcifies. The doctors want it to scar to the interior of the pelvis (or else the result is neo-vagina prolapse), but this tendency to scar means it will also try to shrink, reducing in length and girth.

To compensate for this, doctors advise vaginoplasty recipients to dilate using rods of a fixed length and graded girth. Dilation involves lying back and inserting this rod into the neo-vagina in an attempt to either expand the internal volume or at least prevent collapse. This process is extremely time consuming, and dilation regimens seem to vary greatly from patient to patient, ranging from one hour a few times a week to multiple hour-long sessions per day. This process is typically painful and may be ineffective. Like the strictures that form in the skin tube neo-urethra of the neo-phallus, this penile-inverted skin tube was not designed to be resting against itself for long periods. This is, however, unavoidable. Therefore, the tissue within this tube is prone to strictures, or what doctors will call “vaginal stenosis” to get insurance to pay for the revision as a result of pressure necrosis (the tendency of tissue is to inflame, die, and scar to surrounding tissue as a result of extended periods of pressure).

This can make dilation impossible, resulting in a warm, moist, non-self-cleaning pocket that is an ideal environment for bacteria which is now adjacent to a shortened urethra, capable of causing chronic infections and sepsis. Additionally, dilation, which is sometimes performed by physicians under anesthesia so that more force can be used, may cause tears or fistulas between the neo-vagina and other structures such as the urethra or rectum. One unfortunate vaginoplasty recipient I covered learned he had a recto-”vaginal” fistula when he farted through it. This fistula was allegedly caused by the anesthesia-enabled, surgeon-performed dilation.

At this point, gender doctors may recommend a revision. This revision may be what is known as a “colon vaginoplasty.” In a colon vaginoplasty, an eight-inch segment of colon is removed, and the remaining colon is rerouted to the rectum and recombined (creating a risk of fistulas and internal infection which may show up years later). This colon segment is then sewn shut at one end and is used to replace the scarred, shrunken, strictured, and fistula-ridden inverted penile shaft skin. It is advertised as “self-lubricating,” but as one recipient explained, what the doctors may not tell patients is that this lubrication is tied to food consumption, not sexual arousal.

Orchiectomy is the removal of the testicles. Orchiectomy is typically performed to eliminate a biological source of unwanted male hormones and to salvage the tissue present in the testicles, including a portion of skin called the “vagina” (Latin for “sheath”), to be repurposed to line the neo-vagina.

Nullification surgery is a term for a procedure performed on either male or female people that results in an outcome that is reminiscent of female genital mutilation. The penis, vulva, vagina, and testicles, as applicable, are completely removed, and the overlying tissue is sewn together to create a smooth surface with a small hole for urination. This may be done in the name of “eunuch” gender identity. Eunuch is a term which traditionally refers to a castrated male with no penis, but in this modern era, of course, sex is not gender and so “gender identity,” which would include “eunuch gender identity,” is not limited to any particular “sex assigned at birth.”

Cui Bono?

As if the horrors of the surgeries themselves were not enough, the reality is that these interventions are mind-bendingly expensive, entirely cosmetic, and medically unnecessary, yet are covered by insurance (including tax-funded insurance such as Medicaid and Medicare because not funding these surgeries demanded by the trans lobby is considered “discrimination” equivalent to not covering medically-necessary care for a car accident victim who happened to be Asian). Some recipients have posted medical bills totaling hundreds of thousands of dollars accrued in just a few years, sometimes months—even during the COVID-19 pandemic—of which they brag they paid up to their deductible of, for instance, $5,000. Many are rushing to get as many cosmetic modifications as possible before they age off of their parents’ policy (which typically occurs at age 26). The reader is encouraged to recall a time where they or a loved one were denied or delayed coverage for a medically-necessary treatment, such as one which returned mobility, independence, or reduced chronic pain. Did their insurance cover gender-transition related drugs and surgeries at that time?

Transgender surgeries are medically-unnecessary interventions, not intended to diagnose or treat a medical problem, performed on physically healthy tissues for reasons of gender identity or subjective psychological distress perceived to be related to a sense of gender identity (two distinct justifications, only one of which requires a diagnosis of gender dysphoria, a term referring merely to the distress a person with a perceived conflict may experience). Not every trans-identifying person receiving these interventions is professionally diagnosed or experiencing subjective distress. When no distress (“dysphoria”) is present, individuals are able to still access these procedures via an Orwellian process called the “informed consent model,” which does not require a psychological evaluation to rule out delusional disorders or confirm a gender dysphoria diagnosis. 

When these interventions are performed on detransitioners, who no longer claim to experience a conflict in identity versus body, these interventions may not be covered. In fact, trans activists fight to remove guaranteed coverage for so-called detransitioners from laws guaranteeing “trans healthcare.” Gender-affirming surgeries, or as some call them, sex lobotomies, are as Byzantine as they are treacherous, an endless complexification of human-to-boondoggle body modification that the taxpayer and insurance purchaser, ultimately, have to fund, both directly at the time of the surgery, and forever after, as foolish and confused people purchase disabilities that are not as reversible as their good health once was.