First Stage - June 2000
Surgery by David Ralph, Surgeon at St Peters, The Middlesex Hospital
Sunday Evening: Arrived this afternoon at the Middlesex Hospital. The hospital is a 10 minute walk from Goodge Street Tube station, but if you don't want to walk that with your bags, just £5 in a cab from Euston Station.
Arriving has left me none the wiser than I was after I had spoken to Karen, 'my' clinical nurse practitioner earlier this week on Wednesday. Having seen David Ralph over 18 months ago in January 2000, and albeit that appointment was lengthy, I felt I had many questions to which I had not received the answers. When I had seen David, he had outlined the 2 possible procedures. The first was the free - forearm flap phalloplasty. This is where the skin of your non-writing arm is stripped off (down to the muscle) from the forearm. Though this was a tempting option - the resulting phallus I had seen on a friend was very authentic in appearance - my partner was worried at the prospect of the resulting scars. As she put it, she saw much more of my arm than my dick! The second option, which is the route I am following, is that pubic phallus. This involves taking skin from the lower belly to form the new phallus. One advantage is that the car potential is greatly reduced. By mobilising the skin from the upper belly downwards, the resulting 'gap' is filled, and the only scar is very similar to a hysterectomy scar only slightly longer. Again I have seen the results, and though not as aesthetic as the forearm flap phallus, the resultant phallus is good.
I decided to take the second route about 3 months after my appointment with David Ralph, and wrote to tell him. There is however a minor problem with this path, for people, like myself, who have had a hysterectomy in the past using a lateral (across the body) incision. The blood supply to the flap that is to be used needs sorting out. As the flap is dropped it is crucial for the new phallus to have a good blood supply in order to survive. The lateral incision from the hysterectomy has significantly reduced the blood supply upwards, from the legs, into that section of skin. As the flap is dropped, and separated from the torso at the top and sides, as there is a limited blood supply from the legs, the flap quickly necroses unless something is done. If it necroses, it becomes gangrenous, parts will slough off, and eventually the new phallus may have to be amputated. The solution is to reconnect to blood supply across the lateral incision. This is a first stage operation, and it is for this operation that I believe I have come into St Peter's today.
Unfortunately though, the nursing staff are busy, no-one has the time to talk, and the nurse in charge thought I had come in for the next operation, the full forming of the new phallus. A doctor has called by and taken a blood sample from my arm, but the first thing she pointed out was that she was too busy to talk to me.
Earlier this week I took the afternoon off work. Living in Manchester, the hospital arranged a telephone appointment to discuss my admission. After no one had rung by 5pm, I rang the hospital. It took 25 minutes of hanging on the telephone to get through to the clinical nurse, Karen. Karen said "Sorry - not got round to calling anyone, have been in a very busy clinic all afternoon". She and I spoke for less than a minute. She asked whether I had a cold or a chest infection, I said "no", she said "I've got to go, speak to you at the weekend". At that point, and now quite cross, I insisted on continuing the conversation with a couple of questions of mine. One concerned an anti-emetic drug that my GP had suggested, as I am always violently sick after an anaesthetic. Karen replied "I don't know anything about that - ask the anaesthetist when you see him". I continued "I'm coming from Manchester, I'm due in at noon. Is there a possibility I could arrive at 2pm which would mean I could catch a train down that morning rather than the day before?" Karen replied "No- the doctor will want to see you". So yesterday (Saturday) I left home at lunchtime having arranged for friends in Reading to put me up. That added £22 to what had already been a £44 ticket from Manchester to London. This morning I was to call the hospital to check there was still a bed available. After almost 40 minutes on the phone this time, I finally got through to someone who seemed to know what they were talking about. They said I had a bed on Barrington ward at 2pm. I asked what had happened to the bed on 'Winsbury' at noon. Their reply: "I don't know who told you that, but Winsbury is shut at weekends".
After this catalogue of minimal misinformation, I arrived this afternoon, expecting at the very least to know what I was here for, and maybe to be given some information. No such luck. It is now 8pm, I've had around 3 minutes conversation in the preceding 6 hours, the most awful and minimal meal (pea and clove curry - who on earth thought that up), and I am still none the wiser. How do I feel; bored, lonely, anxious, scared and not very brave.
Prior to all this, for the last 6 months I've been undergoing' preparation' for this surgery in an entirely different atmosphere. Chris, a very jolly and warm woman who owns and runs the Cristianos Laser Clinics, had approached me at the Gendys conference. The clinics (based in London and Altrincham) were commencing a clinical trial of hairy pre- and post- phalloplasty trans men. The laser treatment removes hair by burning the hair follicle using a light laser. Having a body that resembles a door mat, I took up their offer.
The treatment requires you to be light skinned with dark hairs. The laser works by burning the melanin in the dark hair follicle. It burns anything dark in fact, so it will not be effective on fair hair, or if you are dark skinned it will burn you.
The first time I went to the Cristianos clinic, Chris explained the trial to me. Her teams are amazingly well versed on trans issues, and work with a vocational zeal that one would normally find in overseas aid workers or nuns. They have a mission to remove hair, and this was what they would do for me. Thus I found myself in the ironical position of having removed what I had struggled so hard to get, but hopefully it would be worth it in the end, after all I did not want to end up with a dick that looked like it belonged to a were wolf.
The treatment was to remove a 10 cm square down from the navel to the pubic hair line. The clinical trial was to discover whether permanent hair removal would work on trans guys who take testosterone on a regular basis. If it was successful it could prove to be an essential pre-operative treatment and could lead to the development of much more successful urethral extensions, resolving many of the problems surrounding 'peeing standing up'. Forming a new urethra is problematic anyway, but hair bearing skin lining the urethra means the collection of ureic acid and the development of stones on the hair follicles. This can lead to a life time of pain and regular catheterisation.
A test patch was made on my first visit. The treatment looked like it would work with my hair and skin colour, then Chris explained that the treatment worked best on newly growing hairs, so she was going to wax the patch. The waxing took 5 minutes, no more, but to the sound of every expletive in my vocabulary. I gained a new respect for women with neat bikini lines. Fortunately waxing only has to be done once at the very start of the treatment, and it ensured that the tiny static shocks from the laser itself were nothing after that initiation.
I've been attending the clinic now for 6 months, once every 4 weeks, each treatment taking about 40 minutes in the beginning and around 15 mints by the end. It appears to have worked well, I now have a bare patch, with little regrowth and as Chris said herself "the fell and texture of a nice penis". We evaluated what such treatment would cost and reckoned that to date I would have normally paid £500 to £600. However I do intend to continue until the next stage of my surgery in 6 months time, so overall it might amount to near £1000, but it may well be less for those who are not as hairy as I was.
It is important to use a reputable clinic, Chris told me the 'rip-off' tales. Clinics with under-powered machines, operators with no training other than how to switch the machine on or off, and of one clinic she personally experienced where the boss had insisted that patients were treated despite the laser machine not working that day.
But back to Sunday night. It is now 8.30pm, still no joy as regards information. They tell me I mustn't eat from midnight or drink form 2pm (a matter contradicted later by the night sister, who says that as my op is to be early afternoon, no food from 3am, no liquids from 5am, - a big difference). They have finally told me that I'll see David Ralph or his registrar, and the anaesthetist, in the morning. In the meantime I'd just like a response to my request for a blanket, hospitals may be warm but I suspect I'll be cold at 3am if left with only a sheet on the bed.
Monday (over 1 week later): I had thought I'd write up this diary as things went along. But it didn't happen. I felt I had gone through the surgical procedures well but in fact have been much more tired than I expected, and the wound site has been sore and uncomfortable.
On the Monday of my surgery, the morning events still left me unhappy and uncertain as to what was to take place. Mr Ralph's registrar came to see me at 8am, and assured me I was to have a full pubic phalloplasty. He examined my hysterectomy scar, and said it was no problem as it was a very old scar. I insisted that I saw David Ralph before I agreed to any surgery. I really did not mind if the full forming took place, but I wanted to know exactly what I would wake up to. The registrar, whose bedside manner was somewhat full of bluster, and who did not leave me very confident finally agreed that he would send David up before I went to theatre. I rang home and spoke to Sarah, we were both by this time rather unhappy with what was taking place and I agreed with her that I would not sign any consent form until I had enough information.
At 9.30am, Karen, the clinical nurse practitioner arrived to see me. Finally I felt reassured. She explained that the registrar had been away the previous week, so did not know the details of the case and hence the mis-information. She assured me that it was to be only the first stage and I finally signed the consent form.
The anaesthetist then visited. I spoke at length with him about the extensive nausea and vomiting I had suffered previously after surgery, and he took a great deal of care to set up a care plan to try and control that aspect of post-surgery experience.
At 1pm David arrived, in his theatre clothes, again he reassured me and within 10 minutes I was being taken down to theatre. Before going to theatre I had been given a gown to wear (which fastened at the back and left one's bum visible to the whole world) and I was also given some rather nasty white stockings to wear - these were to prevent deep vein thromboses, and I was to wear them until I left the hospital. They were a little uncomfortable, and hideously ugly, but I felt worth it as I wanted to leave hospital alive and well.
I was taken into a side room near the theatre. There was the anaesthetist, my nurse for the day and a technician. They fitted a vent in my hand, through which I was to receive a drip, intravenous anti-biotics and a PDA. The PDA is a machine you control yourself which provides small doses of morphine post-operatively. It was excellent. When I woke I didn't feel too bad, just rather groggy, but when I realised I needed to pee, and that meant moving so as to sit on a bed pan, the PDA came into it's own. A quick press of the button and 30 seconds later I felt the move was possible. I remember nothing of the surgery, nor the recovery room. It was 5.30pm when I first came round (as far as I was concerned). Immediately I wanted to vomit - and amazingly immediately there was a nurse at my side holding a bowl in front of my face, and getting another nurse to administer an anti-nausea drug.
Much of that evening passed in a haze, with the occasional need to urinate, which was the most difficult aspect. At about 10pm I finally begged the nurse on duty for a commode, I simply couldn't pee whilst balanced on a bed pan.
All in all, the immediate post-operative aftermath was very well managed, and by the next morning (Tuesday) I was able to eat a bowl of cornflakes and have a cup of tea.
Later that day I was to see the results of the work performed on me. As you can see from the diagram, there was a large scar from the top of one thigh, across my gut where it is heart shaped, and back down to the other thigh. The wound outlines the skin that will be used to make the phallus eventually.
The wound was stitched internally with gut which should dissolve, and then there were steri-strips across the whole scar, and finally a large wound dressing. I was a little horrified when I realised I had hair removed up as far as my naval, and the area to be used as the flap for the phallus didn't approach that. David told me later, that we had been a little over enthusiastic with hair removal towards my naval, and it might have been better to remove more at the pubic hair end. However I'm not too unduly worried as there is still some hair growth on that area, and when the phallus is finally constructed it may well mostly be hidden.
By Tuesday afternoon I was feeling almost like a human being, and David Ralph's registrar came and told me I could go home the next day, Wednesday. As it was I couldn't actually get help to travel until Thursday and was glad for that, as it was hard enough on Thursday and I suspect I would have been really struggling on Wednesday.
The registrar also told me that they would have me in, in October, for the second stage, but I have asked them to delay it until January as the Autumn is a very busy time for me in work. I also wish to have time to consider exactly what I intend to have done at the second stage. It would appear that there are several options, which include constructing a neo-urethra, but I am very concerned that my ability to orgasm should not be compromised in any way. David Ralph was talking about embedding the clitoris in the phallus, and I really want to know the implications of that. I have an appointment to see him at the end of August, and intend to talk through the options.
As for the phallus I am going to have I do know that it will be shaped as shown in the diagram .
Overall I felt the whole operation at this first stage was manageable. Having a family, a full time job, and being very involved in Press For Change as well as the Network, means I have to manage my time well. And, I've waited 26 years for all this, I can confidently say it isn't the most important thing in my life, but I am looking forward to the end result. If nothing other than to go to the gym or to swim without feeling self conscious.
I will write up the second stage and hopefully include photographs at that stage, so watch this space early next year.
Finally - I have written this up as comprehensively as possible. To be honest, I do have a busy life and don't wish to spend hours on the phone or in letters repeating what I have written here, so please don't ask.
Wednesday night, 9 days after the surgery. The steri-strips came off today (in the bath, that I was just dying for). The last week I have been tired and sore, and I'm glad I decided to take this week off work. But I've been getting back to my life slowly but surely. The wound site is still a little painful, the flap itself is rather numb, but (I checked) I still have full sensation to my clitoris. Oh and I've watched some crap television.
Sunday night, 14 days after surgery. The area around the wound seems hard and swollen, and is quite painful at points. I'm now sleeping most of the night which is a relief, and intend to go back to work tomorrow. I'm still tired - today is the first day I've not had a nap - but I did go to church and sleep through the sermon, but that's not new.The most irritatingly painful part has been the regrowth of body and pubic hair. It is so itchy, and very inflamed - I thought I was going to go mad, but in the end used a scream called Eurax (available from the chemists) and that was well worth it. They seemed to have shaved me in an entirely random way - bald bits here and there, but I can live with that. I'll be glad to get back to the gym - but 2 weeks to go.
As for the kids, colleagues and friends , I've been honest and just said I'm having the first operation to have a big willy made. They have all been supportive and excited for me. However my 6 year old son Gabriel asked if he could have one made also. He was surprised when I answered "But yours' will just grow".. "Will it?" he replied.

Pubic Phalloplasty: an update - Dec 2000
I'm due to go back in to St Peter's in the new year, for the next stage of this surgery. But just to keep you up to date:
The wound has healed well, no post-op infection, it was a little sore in places, and in fact there is one point where the new scar meets the old hysterectomy scar and that is still a bit painful, and it certainly feels the cold damp weather before it has actually arrived.
I've continued the laser treatment for hair removal-it appears to be going well, but it is a bit of an uphill task. Originally too large a patch of skin was treated, an in effect we now have a control patch to see what the long term effects are. Much of the hair has grown back in this patch-but it is considerably thinner I.e. it appear that some of the hair follicles have actually been destroyed completely.
I had a follow up visit with the urologist in August. A bright and cheerful woman, she spent 10 minutes, steaming ahead telling me what they were going to do to extend the urethra. I finally got a word in edgeways (and if you think that I found that difficult, god help anyone else) and said I was a little concerned at the clitoris being covered up and also the risk of ongoing problems with strictures and fissures (this is crucial to me, as with having young children I really don't want repeated trips to hospital in London albeit for relatively minor procedures) . She said "yes, I must admit they rarely are successful in the short term and in fact we stand around the operating table saying 'why on earth do they want this doing, it just is a so complex ". I replied that this what I really needed, a realistic assessment. She said "well we try to do that, but as you all insist on it anyway…….".
I pointed out that I for one was not insisting upon it, a point she did finally concede. And then she went on to say that anyway any urethral connection would not be done at the next stage -- so I did wonder why she started discussing it at all. I did try and explain to her that perhaps a little more time discussing the options and listening more to patients would be helpful , but I suppose we are all working within the vagaries of the NHS.
I do know I'll need around 6 weeks off at the next stage, and meanwhile I'm thinking of organising a rota of people to bring in some decent food-if I'm in for longer than 4 days I'm sure to starve to death.

Pubic Phalloplasty 2nd Stage with Mr Ralph - March 2001

I was to have my surgery on the afternoon list at 1.30pm, so I had to starve from 6am and then have no liquids from 8am. In the morning I was measured for DVT stockings. These are horrible long white stockings, to prevent thrombosis, which you are required to wear from going down for surgery until you are finally allowed to go home. Stephen Andrews explained exactly what was going to happen in my surgery, and after the surgery. The anaesthetist also visited me.
Just after 1pm, I put on my surgical gown and was taken down to the theatre. In a side room several staff checked all my details before placing a canula in my left hand. The canula is a very thin plastic tube which will remain in situ for a week. It is used to administer medicines and saves repeated injections. Then they injected a white fluid into the canula and I drifted off to sleep.
I first remember waking up about 9pm, though apparently had woken several times before then. I immediately threw up but very quickly a nurse appeared and injected a drug into the canula to stop the nausea and sickness. Throughout the rest of the night, I drifted in and out of sleep. I was aware that I had a large lumpy bandage in my groin area, and that I had several tubes attached to my body and an oxygen mask on my face.
I also felt a strong urge to pee, but in fact was reassured that I had a catheter and I just was not to worry about passing urine. That was easier said than done. The bladder is irritated by the catheter so wants to reject it all the time, which means the urge to pee is quite strong. I also had 2 tubes going into the canula in my hand. One was a morphine feed - all I needed to do was press a button and I would get a measured dose of morphine (in fact I only used it 5 times in 3 days and then only so as to move my bum). The other was a drip containing a fluid so that I would not become dehydrated.
I was vaguely aware of the other tubes that were attached to my stomach - these were drains to drain away blood, fluids, and pus - but over the next week very little filled the bottles attached to them.
At 5am on the Tuesday morning just after my surgery, David Ralph appeared at my bedside (I am still wondering which all night party he had just been to) and proceeded to cut through the bandaged pad on my groin - and hey presto, there it was - my dick. I will admit that right up to that point I had doubts about what I was doing, and wondered whether I was completely barking mad. I have lived for 28 years as a man without a big dick and life was fine, but the minute I saw my dick I just knew I had done the right thing for me. I felt over the moon at that moment and from then on things were uphill all the way. By breakfast time of that day, I wanted to eat, only a little, but that was a good sign and progress was good from then on.
One thing to realise is that when you wake up you will be sitting up, and your legs will be raised over pillows, but fortunately the hospital had new beds which were really comfortable. You will be like that for at least 3 days, maybe longer if there are complications or you are thin and don't have a big stomach to make the new penis from. When the skin flap is dropped to form the penis, the large gap has to be filled with skin from elsewhere and in order to achieve this the skin from your hips is pulled round and the skin from your tummy is pulled down.
What you end up with is a very large scar running right across your body from one hip bone to the other, then a short scar from the centre of this down to your new penis, and also 2 small scars at either side of the top of your legs to your groin. The fatter you are, the lower the large scar will be on your tummy, and the less your belly button will have moved. I was fortunate, being naturally fat, and having worked hard at eating chips, pasta and drinking Guinness, I had a good tummy on me and my scars are low down. Furthermore although my skin was stretched it wasn't stretched too tightly which meant that I was allowed out of bed after 4 days - although I was still bent double. The large scar is stitched and stapled (with metal staples) and I didn't really stand up straight until the staples were removed after 10 days.
For the first three days after the surgery, I was pretty uncomfortable but nothing too awful. The penis was quite large, and very fat at the base. I realise now that it was quite swollen, but the base is still too large and will have to be trimmed at the next operation in order to make the penis hang better.
Once the catheter was removed I could get out of bed, but I didn't go very far. It took me a further 3 days to work up the energy to get as far as the day room. But it was a real relief to be able to use the loo. However, I was very constipated from the morphine and other pain killers and that really did add to the discomfort. After a couple of days they also gave me medication to help with that, thank god. The other thing that happened was that I got really bad thrush in my mouth and vagina because of the intravenous antibiotics and I had to request something for that. I was given Nystan for oral thrush, but I wish I had been given something for the vaginal thrust and in fact on my return home the first thing I did was get someone to go to the chemist and get a canestan pessary - a single dose thrush treatment, as I was really uncomfortable. I don't like vaginal pessaries, but I took my partner's advice and within a day was cured.
On days 5 and 6 the drains were removed, by pulling them out. The nurse did 2 the first day, and 2 the next. This was not pleasant but most were not very painful either. However the last drain was horrible, as the nurse pulled, halfway down my left thigh I felt pain as if someone had just put the tip of a red hot iron on my leg. I yelled, the nurse slowed down and we started again. It was horrible and in fact 8 weeks later I still have a very strange sensation running down my left thigh. It is as if it is a bit numb but also a bit over sensitive.
After 8 days, as I had recovered really well I was allowed to go home. We organised 'JourneyCare' through British Rail (you call them, they need 24 hours notice, but the arrangements they make are very good). We got a cab to Euston station where we were met by a JourneyCare 'buggy' car and we were taken to reserved seats on the train, close to the loo and all our bags were put on the train for us. At Manchester we were also met by staff with a wheelchair who took us and put us in a cab. I managed the journey quite well, but am very glad we chose not to try and do the journey by car.
Once home, I really did feel very knackered. The first week I was extremely uncomfortable - but it may have been daytime telly. The second week I was pottering slowly around, but very tired. In fact, tiredness has been the main side effect, followed by a sore back from having to sleep on my back for 3 weeks. I was so relieved when the staples were taken out after 10 days, then 4 days later the stitches were removed and then I could have a shower, which I was desperate for by then. I took 6 weeks off work after I came home - I could have gone to work a week earlier, but I know I would have really struggled.
All I had done during this operation was have the penis formed. No urethral connection has been made, or testicles etc. The clitoris is exactly where it was before. If you lift my new penis you will see it positioned at the very base of the penis, very close, but separate. Sexual sensation is as before, the penis itself has no feeling at the moment, though I can feel it through the rest of my body - don't ask me how, I just can.
I saw Mr Ralph 6 weeks after the surgery and I am going back in early May, when the head of the penis will be shaped, the base of the penis will be thinned and small 'dog ears' on the scars will be removed. If all goes well, I hope to go back in late summer to have a prosthetic implant in order to allow the penis to be made erect.
As I have said, I had doubts until the very last moment as they put me under. What I do know is that this was the right surgery for me. The penis will not be as authentic looking as a forearm flap phalloplasty, but for me the primary issue was 'time in hospital'. I wanted a penis that could pass in a changing room, but I know that on close sight it will always look surgically constructed. The other disadvantage of this surgery is the large scar across the tummy, but it is low down and I hope it will fade.
I felt great going swimming in 'proper' swimming trunks and feel good about how I look. My partner says I look more like myself, and that in fact I looked less like myself before the surgery. Overall I am very pleased with the surgery, Mr Ralph has done an excellent job and I feel very confident that 6 months from now I will have a penis that I will feel happy with in public spaces, although if I wish to have urinary function or testes that will be further surgery.

Pubic Phalloplasty 3nd Stage with Mr Ralph - May 2001

Have just had the 'glans' of the phallus shaped - from a skin graft on my leg.
This has in some ways been the most difficult op. The patch on my leg pured pus for about 3 weeks - and I mean poured. A rather horrible incident in the cinema when it 'burst' through the dressing and I could feel it dripping down my leg - yuk.
Also got an infection in the skin graft on the glans - so really felt quite poorly and had to take loads of antibiotics. It didn't help that I really felt I had to return to work quickly - so was very tired and exhausted, but all in all even though it took about 6 weeks to feel like a human being again I'm pleased with the result. Also had the base of the phallus thinned - but it is still pretty big, about 5.5" long, and 5" circumferance.