My Completely Quotidian Top Surgery Experience
Part 1: Why it took me so damn long to just let myself live. Plus: why are plastic surgeons better at gender affirming care than queer clinics?
This piece was originally published on June 1 of 2023. Why I am moving my archive to Substack.
Hello! By the time this piece drops on the afternoon of June 1st, I will have already undergone bilateral, double-incision top surgery in the early morning hours and will hopefully be recovering comfortably at home. While I’m away from my keyboard, let me tell you a little bit about what into this decision, and what my process in navigating it has been like so far.
If you’ll forgive the stereotypical trans narrative, I’ve never been comfortable with the idea of having boobs. I dreaded puberty like the plague as a young teen, and honestly believed that traditional “female” development was so ill-suited to the person that I was that it couldn’t even conceivably happen to me.
I had my first period later than many of my peers, and didn’t begin to develop body hair or breasts until late in eighth grade, and for a while I privately hoped that I had some intersex condition that would prevent me from ever having to deal with bleeding, possible pregnancy, or growing a convex chest.
What I now understand is that intersex people are actually the most violently subjected to coercive gender assignment of any group of people, and so fantasizing about having been intersex as an escape from an unwanted puberty is absolute nonsense. If you aren’t well versed in the subject, you can read more about the surgeries still frequently forced upon intersex kids and adults here.
After puberty finally began for me, I developed an eating disorder in hopes of preventing the further growth of my hips and chest. But I always knew I was fated to develop big boobs, because my mother had them, and soon I was weighed down with D-cups that drew attention — and my shoulders forward to the floor.
It was unusual, having a body I so viscerally hated but which everybody else told me that they liked. Girls and women commented that I was an ‘hourglass’ and that I was ‘perfect.’ Boys called me fertile and asked me about whether I wanted to have kids, even when I was so young the question seemed absurd. I recognized my chest was something of a social asset, so I really tried to take pride in it. I could see other girls wore their attractiveness like armor. But my buxomness only made me self-conscious and vulnerable.
I spent much of my twenties trying to capitalize on my curvaceousness in a variety of terrible ways. As an ardent Mad Men fan, I started dressing in va-va-voom hourglass silhouettes like the character Joan. This left me with a real talent for matching jewel tones, but even more discomfort. After that, I tried covering up my chest in loose, sack-like tunic dresses and sheaths. Then I discovered loose-fitting men’s t-shirts.
I experimented with all shapes and sizes of bras. I tried hiding my boobs and then revealing them in low-cut tops. I titty-fucked boyfriends and posted bare-chested photos online. None of it made me feel any better. Instead it gave me a hollow, staticky feeling I didn’t know to identify as gender dysphoria. I fantasized about getting breast cancer — another highly insensitive, yet common trans masc fantasy. Fighting off death from cancer seemed more tolerable than living forever as cis, but both seemed more comprehensible than becoming trans.
Then one day, when I was about twenty-five, my boyfriend at the time splurged on an expensive Victoria’s Secret gift card for my birthday. I picked out a few ultra-supportive bras with big, hulking straps. One of them gave me the sensation of my breasts fully being held for the first time.
“This bra is amazing!” I gushed to my boyfriend. “It feels like I don’t have any boobs!”
That was the first time I put words to the sensation that I craved. I wanted to feel unburdened by my boobs. But I could see in my boyfriend’s reaction that this wasn’t a normal thing for a woman to want.
…
Once I realized I was transgender, I kept the desire for top surgery at bay for a very long time. When I came out as to my boyfriend back in 2016, I initially told him that I was nonbinary, not that I was a man. His first question was whether I wanted to start hormones or get surgery. I told him no, by which I meant not right this second. I never bothered to fill him in once my feelings changed.
I transitioned by half-measures for years, hoping not to lose him. I started low-dose testosterone, then stopped it, then started and stopped it again. I bought binders at the sex toy shop Early to Bed and passed them off as crop tops. I delighted when hormones reduced my cup size, but then I donned clothing to play up my diminishing curves. For a truly embarrassing length of time, I could only see myself as I imagined my boyfriend’s eyes did. I tried living a male life while still remaining attractive to someone who was soley interested in women, and it didn’t work.
My Dalliance with Detransition
At the emotional low point of the pandemic, I tried becoming a woman again.
Even after I dumped that boyfriend, the shame and self-consciousness loomed for another year. Nick and I had been together for over a decade. Every word that came out of my mouth passed through a simulation of his ear; I sulked every time I gazed in the mirror and saw a mannish, wide-shouldered, angry creature that he’d hate, instead of the soft, gentle, unfailingly patient girl he loved.
Things started getting better once I started fucking queer men. I found recognition of my queer manhood on the floor of the leatherbar, with my legs spread and my latex catsuit zipped up in the front. I had trains run on me in the gay bathhouse, and felt stunned by the sheer number of men who lined up to have a go at me. On apps like Grindr and sites like Fetlife, I discovered that there were countless men who desired the person I was becoming, and who didn’t look at me with distant disgust.
I share all of this not to brag but to emphasize to any closeted or self-doubting queer people reading this that a queer life cannot be lived alone. Queerness is not a personal identity so much as it’s the recognition of social belonging. For me, much of that belonging has been found getting railed on the dancefloor and in the darkened passages of Steamworks. But it’s also been fostered in my close friendships, and at concerts, conferences, house parties, and in late night conversations on Discord and Facebook messenger with people who accept me.
It was also seeing and having sex with other trans men at Steamworks that finally cemented a desire for top surgery within me. For a long time, I’d seen top surgery as an unpleasant, imperfect solution to the problem of hating my physical form. I didn’t really want the outcome of it so much as I didn’t want the body that I already had.
But after months of caressing and admiring the bodies of other trans men in hookup spaces, I finally began to see a body that had undergone top surgery as a thing to really want. Double incision scars, glimpses of pectoral muscle behind taut-pulled skin, and even surgical “imperfections” like puckering and dog ears became lovable and erotically charged for me. That was when I finally took steps to book a consultation.
…
I’m lucky to live in Chicago, where the are many qualified and well-reviewed top surgeons. I used the r/FTM and r/TopSurgery subreddits to inform my decisions, and did a lot of Googling and calling around. Ultimately, my decision tree narrowed to two options: Dr. Marco Ellis of Northwestern’s Gender Pathways Program, and Dr. Lawrence Iteld, a private plastic surgeon.
I was drawn to both surgeons because I liked the appearance of their results, and both had experience performing double incision mastectomies without any nipple grafts.
I knew that with breasts as large as mine, double incision would be necessary, and I also knew I wanted my surgeon to create a relatively ‘natural’ masculine-looking chest contour. Some people’s top surgery results look a bit too concave for my tastes, and I didn’t want straight incision lines, I wanted ones that curved upward, creating the shape of pecs. I also knew I didn’t want nipple grafts because they can have all kinds of complications, I don’t always like the look of them, and they may never regain any nerve sensation anyway.
Plenty of other surgeons can perform the type of surgery I wanted, but Dr. Ellis and Dr. Iteld both seemed accessible to me, having both lengthy track records and calendars with openings some time this year. The moment I admitted to myself that I really wanted top surgery, the need felt urgent.
A long-suppressed floodgate of longing and bodily awareness had been unleashed. It was Aries season, I was thirty-five, and spring was budding on the trees. I didn’t want to spend another summer covering up my chest. It was time to chase after what I had not permitted myself to dream of for a very long time, for fear of squandering the supposed beauty I’d never asked for.
So I called up both surgeons. I booked consultations. I asked my primary care physician and a therapist for letters attesting to my preparedness for surgery. The time had come to make moves.
…
I had my first consultation with Dr. Ellis at the end of April. His office is located downtown on Northwestern’s medical campus, in the imposing Galter Pavilion building. Everything about the space looked state-of-the-art and incredibly clean.
In my appointment, Dr. Ellis was focused and methodical. He explained to me that when seeking out top surgery, there are three primary considerations: scarring, shaping, and the presence of nipples. I had clear preferences on each of those attributes: I was fine with large scars, I wanted a masculine convexity, and I didn’t want any nipples, thank you very much.
After outlining these goals, Dr. Ellis opened my medical gown. He was able to estimate my chest dimensions purely by sight, like some kind of titty-measuring Rain Man (if you’ll indulge the self-aware, self-cringing Autistic reference). Then he indicated to me where my incisions would be, and how far into my armpit they’d have to go, in order to remove all the excess tissue and skin that I had. He was the very picture of competence and capability, and I felt safe in his care. I also loved the look of his surgical results.
I found it relatively easy to get set up in Northwestern’s patient portal, and found the platform synced my medical records and blood test results from my doctor at Howard Brown automatically. What I found far more difficult was navigating Northwestern’s institutional bureaucracy to try and interact with any human being, or even to be viewed as one. The system is simply too large, anonymous, and imposing to reckon with as an individual, and even though the Gender Pathways program professes to be queer affirming, it’s hard to self-advocate within it because of these factors.
After my consultation with Dr. Ellis, I sat down with an administrative coordinator to book my surgical date. Dr. Ellis said I could get on the calendar as soon as July, but then his coordinator said I’d be looking at September at the soonest. He also said we couldn’t book a surgical date yet, actually, as he’d need to apply for insurance approval first. I was told to expect this to take between eight and ten weeks, which stunned me.
After I left Dr. Ellis’ office, I couldn’t get on the phone with the coordinator very easily. And ultimately, my application for insurance coverage was denied within a day of submission. My Jesuit employer, Loyola University Chicago, refuses to cover any gender affirming care of any kind, on religious grounds.
I didn’t hear back from Northwestern about any of this. I only found out about it some time later, when I happened to log onto my insurance account. When I reached out to Dr. Ellis’ office about it, and said I was interested in scheduling surgery and paying for it out of pocket, the coordinator told me he’d need to get a quote on the cost. It took a few weeks to receive an email back.
I don’t blame the administrative coordinator or Dr. Ellis for any of this, to be clear. I’m certain both are doing the most they can with their caseload. On the whole, I get the sense Northwestern’s system is significantly overburdened. I had tried switching my primary care over to Gender Pathways as well, and it took their offices over a month and a half to even call me to schedule an appointment. When they finally did call in May, the soonest available appointment was in August.
Generally speaking, every email I send or call I make to Northwestern takes a long time to get returned. I don’t get any sense of continuity of care or that anybody really knows who I am. This closely mirrors my recent experiences with Howard Brown, which has become overwhelmed and understaffed, and which has sadly been exploiting its workforce extensively of late.
This is a common theme among queer clinics: the needs of a huge population of marginalized patients are not being met, due to a dearth of resources. This strain bleeds into how providers treat their patients. When compassion fatigue and COVID trauma meets underfunding and a scarcity mindset, trans patients often find their care geting deprioritized, and numerous other patients also fall through the cracks.
…
I had a much more positive experience at Dr. Iteld’s office, which makes sense as he’s operating as a private plastic surgeon. The very moment I filed a request online for information about surgery, a patient coordinator called me up on the phone. She made it very easy to email all my doctors’ letters and medical records without getting lost in the shuffle, and to schedule a consultation. That same senior coordinator carried me through the entire process of scheduling all my appointments and completing all my paperwork, and she could recall who I was and established a chipper, easygoing rapport with me.
A few weeks ago, in mid-May, I visited Dr. Iteld’s office on North Avenue for the first time, and instantly made a fool of myself putting a decaf pod in the wrong way in the lobby’s fancy coffee machine. The same surgical coordinator who’d spoken to me on the phone and via email led me into the back office and prepped me for my consultation. She was a Loyola graduate like me, and incredibly personable, and we spent some time trading stories about life on campus and bad Lakeview apartments we’d each had.
Dr. Iteld had a straight-shooting, charmingly sarcastic personality and I found him easy to speak to. Where Dr. Ellis was focused and all business, Dr. Iteld had a lightly ball-busting air that encouraged me to open up with more questions than I would have shared otherwise. He rattled off the basic parameters of the procedure, then jokingly asked me what Dr. Ellis had shared with me that he’d forgotten.
Dr. Iteld spoke with me in detail about the recovery process, and shared with me that contrary to what many other doctors advise, he actually encourages patients to lift their arms (carefully) following surgery. Most other surgeons tell patients not to raise their arms much at all for a week or two after the procedure. Since he doesn’t prescribe narcotics, Dr. Iteld says his patients tend to bounce back from surgery pretty quickly, energy wise — enough that he has to remind them not to work out. I found all of this appealing to hear.
Dr. Iteld understood the results I wanted innately, and explained to me how the kind of results I didn’t want could be avoided. After our consultation, his senior coordinator sat down with me and showed me photos of Dr. Iteld’s past work. She explained how his technique had evolved over time, demonstrating that he now draws scars upward on the sides of patient’s bodies, creating a realistic pectoral shape rather than an artificial-seeming straight line. She could also easily pick out past patients whose bodies resembled mine and who had similar results. I could see the evolution in the surgeon’s style and understand the differences in the procedure.
The office staff also understood that my insurance could cover the cost of the consultation, but not the cost of the surgery, and we processed some of the initial billing right there during my first appointment. Similarly, I would be paying for my surgery, hospital time, and anesthesia, but my insurance company would pay for a cancer screening of my removed breast tissue.
This was the kind of complicated billing situation I’ve never been able to trust a large health clinic to handle. But Dr. Iteld’s staff handled it beautifully. Since I wasn’t waiting for insurance approval this time, I was able to get a surgery date on the calendar right away — for June 1st, just three weeks after this initial appointment.
I felt a bit giddy sitting in the office, marking up my calendar with pre-surgical and checkup dates and making my initial payment. I hadn’t expected everything to happen so fast. But Dr. Iteld’s entire team and operation had inspired such confidence in me that I requested we move forward that fast.
The entire process was well organized and transparent. I had an exact quote of expenses laid out for me and a full schedule of appointments established within an hour. When I ran into trouble processing my payment, because of my debit card recently getting hacked, the staff was patient, and good humored.
I am highly aware that I was only able to access this responsive, boutique quality gender affirming care because I could afford to pay out of pocket for my surgery. Most trans people have no choice but to apply for insurance coverage for their surgeries, which requires letters of support from a therapist and a doctor, and often leads to a series of rejections that the surgical team must appeal.
Since the majority of trans people live in poverty, many have to fight for a very limited number of surgical slots among the handful of practitioners who accept Medicaid. It’s quite common for trans patients to wait anywhere from nine months to a year to just book their first consultation appointment. After that, securing surgical letters and receiving insurance approval can delay booking surgery for another six to twelve months pretty routinely.
I was able to skip past all of this because I had the $10,000 in savings necessary to cover my surgery entirely on my own. I can also afford to buy medicine, ice packs, a wedge pillow, a rental car for my ride home from the hospital, food deliveries for myself and my partner, comfortable clothing to recover in, games to play and books to read, all manner of scar healing gels, and just about anything else I need while I’m recovering. This isn’t the typical trans experience.
I’d also be remiss if I didn’t mention that accessing this care came so easily and quickly to me because I am thin. At Dr. Iteld’s office, I heard a few off-hand comments about body size and weight and the desirability of thinness. At both surgeon’s offices, staff assumed that I was healthy because I was thin. It didn’t bother me, but if I was still in the depths of an eating disorder, it might have.
Because of my size I was trusted to be a good steward of my own body. A fat patient would likely either be expected to lose weight before surgery, or would be subjected to a barrage of comments about their body from professionals who specialize in other cosmetic procedures, such as tummy tucks and body sculptures, that are motivated by societal fatphobia.
…
I’ve noticed many times at this point that there’s a disjoint between the treatment trans people receive from supposedly queer-affirming institutions and nonprofits, and the treatment we receive from for-profit services that only cater to the richest among us.
At sliding scale queer clinics and LGBTQ community centers, I’m treated like something of an inscrutable freak or an incompetent much of the time. People condescend to me, remember nothing about me, and misgender me even when my identity and pronouns are marked on my chart. Other basic facts about me and my health get regularly messed up too. Even my own doctor keeps forgetting I’m on testosterone gel, not injections, and multiple times I’ve had the wrong blood labs ordered for me or had paperwork misplaced.
I can easily contrast that to the treatment I get at the spas, tanning salons, gay bars, and plastic surgery centers I’ve visited, all of which cater to a wealthier, more privileged clientele. I’m gendered correctly more often at LA Tan than I am at the queer clinic. The technician who performed my laser hair removal was more respectful toward my trans body than any nurse I’ve met at Planned Parenthood. At the gender clinic, I was a forgettable number on a spreadsheet whose phone calls go unreturned. At the plastic surgeon, I’m served fancy coffee and asked in depth about my aesthetic preferences.
The only way to escape erasure or institutional control under our present system is to have enough wealth to transform from mere patient into coveted consumer. With enough money, you can skip the clinic in all its bureaucracy, order hormones from an online service, book a major surgery within mere weeks, order UTI meds from an app, and pay a driver to take you home from the hospital rather than begging a friend.
Right now, I can afford to be a consumer, which means I am allowed to be a person and to do with my body whatever I wish. And I don’t know what to do with how good that feels.
…
Damn, I though this blog post was going to be a short one.
Writing about top surgery today feels so quotidian. So many trans masculine people have already rhapsodized about what their surgery means to them. We’ve collectively penned enough eulogies for our titties, so there isn’t much original left for me to say. Nearly all my trans masc friends have already had the procedure, so I feel a bit late to the party, and embarrassed I held back from showing up for so long.
It all seems so wack of me, trying to tell a compelling story about an experience that probably seem so humdrum to anybody else. But it’s meaningful to me. It took me a painfully long time to get here. I just know that by the time the scars are healed, I’ll feel as though I’ve been breastless my entire life. It seems so silly that I waited for so long to live my own life. I’m trying not to be resentful of the fact that I let the fear of others’ impressions restrict my options for so long.
Years ago, when I stopped taking the birth control pill and got a copper IUD, I chronicled the process on my Medium. You can read that chronicle here. Quitting hormonal birth control was the first real step of my medical transition, and its effects catalyzed a series of other choices that ultimately led me here. Six years later, I have no period, no breasts, no mood swings, no children, worse skin, more muscles, a bigger dick, no gloomy straight boyfriend, and a litany of new memories to cherish. Any resentment I do feel about lost time dissolves when I dwell on all that with gratitude.
I think I’d like to chronicle my top surgery recovery too. Maybe it will provide a helpful roadmap to somebody contemplating the same journey. Maybe the work will entertain and comfort the aging Millennial parent of a trans kid enough to convince them to support their child’s body autonomy. Maybe it will a slog of self-indulgent, neurotic diarying that only my most devoted of readers will tolerate. Who knows.
You can probably expect two or three more entries on this topic from me — one detailing my short term recovery experiences, one showing off my results once they’ve healed enough, and one reflecting on the whole experience about a year later. Perhaps I’ll write more if anything goes sideways.
I want to take this moment to say thank you to everyone who has followed my writing so far. I know some of you have been around for a very long time, and remember my last bouts of self-indulgent, neurotic diarying. Those of you that have read me since the Tumblr or early Medium days have watched me morph through a variety of identities and writerly voices, and put up with a lot of navel-gazing over the years. I hope you’ll indulge me returning my gaze inward, and downward, for a little while.
If you’re trans, or someone you love is trans, feel free to ask anything about this whole experience in the comments. I imagine I’ll have some bored, bedridden time to burn.