A man in full

About two years after first visiting a doctor, Jimmy had his breasts removed.

“Was I scared? I was horrified. But I told myself I have to be a man about it,” the 32-year-old, who was born female, said.

The surgery went well, and Jimmy’s recovery period was short. As he stood in the mirror and surveyed his upper body, he said it felt like the first day of his life; he had been reborn a man.

But while Jimmy told himself he was getting there, the transformation wasn’t yet complete.

Six months later, he would take the final step.

BODY REBUILDING

Jimmy awoke on the morning of the operation four years ago realising his life was about to change completely. As he arrived at hospital and was told the details of the procedure, Jimmy hung off every word.

He knew the procedure would leave him with a large scar on his thigh. He understood the risk of serious infection and equipment failure. The benefits, he thought, far outweighed the risks.

“I’m ready,” he told the doctor. 

The surgeon began by removing a large piece of skin from the front of Jimmy’s thigh, a pedicled flap which already had a urethra inserted and would be rolled up to form Jimmy’s new penis. The phallus was surgically attached to Jimmy’s groin area, and joined to nerves and arteries.

A few months later, when the nerves had healed, it was time to receive an implant that would allow normal use of the phallus. Jimmy opted for a pump implant, which uses fluid to allow the penis to become erect or flaccid at will — an option also popular for men with erectile dysfunction.

After so many years of preparation and waiting, Jimmy said he was surprisingly unexcited when he saw his penis for the first time.

“I just felt relief that my body finally matched my mind,” he said. “I felt like I was a disabled person all my life, and now I had finally got the missing organ back.” 

‘I AM A MAN’

Sporting a goatee and speaking in a deep, masculine voice, Kritipat "Jimmy" Chotidhanitsakul easily blends in to a crowd of men as he sits down to speak with Spectrum. But it wasn’t always that way.

Jimmy was born the only daughter in a warm and loving family, who named her Jin. For her entire childhood, Jin was raised as a typical girl, attending an all-girls school and studying ballet and music.

But when Jin turned four, she started to act more like a boy. Without even being aware of what her sexuality was, Jin began standing when she urinated; she used her father’s razor to shave her smooth chin until she bled; she refused to wear a skirt out of embarrassment.

As she grew towards adolescence, Jin realised she was different from other children around her, but didn’t understand why.

One day, the realisation hit. “I am a man,” she told herself.

Jin tried to be honest about her feelings with the people around her, but not everyone took it well, especially her parents. At the age of 19, Jin’s family life was as though an “atomic bomb” was being detonated in the living room on a daily basis.

She fled, and soon found herself homeless.

Desperate to leave her past behind and start fresh as the person she had always wanted to be, Jin went to see a doctor to ask about transforming her body.

UNDER THE KNIFE

The mental transformation began before the physical one. Jin — or Jimmy, as he decided to be known from then on — began dressing as a man and ending his sentences with “krub” instead of “ka”.

With a small but somewhat masculine frame, Jimmy didn’t have to try that hard to look like a man. He started simply by cutting his hair.

He began seeing a psychiatrist, so that a legally required diagnosis of gender dysphoria could be confirmed before surgery was performed. Jimmy was assessed by two psychiatrists. Although he found many of the questions ridiculous and offensive — such as his preferred sexual position and other intimate details — he understood it was something he had to endure to get where he wanted to be.

Once the diagnosis was confirmed, Jimmy saw an endocrinologist for a complete health check to ensure his body was ready for the major changes it was about to go through.

Given the all-clear, he was finally able to start the physical transformation with his first testosterone injection.

As he heard the needle being peeled out of its packaging, Jimmy was overcome by a wave of excitement. His heart was pumping, but not from fear. “It felt like I was finally going to be reborn in the right body,” he said.

The needle pressed through his skin around the hip area. “It felt really painful. I could feel where the [testosterone] ran through my body. But I knew the result would be worth the pain.”

Receiving the injections twice a month, Jimmy soon stopped menstruating and his body slowly began to show signs of change. His voice began to deepen.

After about two years of regular visits to the doctor for hormone treatment, Jimmy received a mastectomy. A short time later, surgeons removed his uterus and ovaries, and performed vaginal obliteration surgery.

Once the major surgery was done, the doctor began to construct Jimmy’s future penis on his thigh. When Jimmy woke, the pain was so intense he felt as though he had been hit by a truck.

The doctor showed him where a tube had been implanted in his left thigh. It would be part of the donor site — the doctor would later cut it off and use it to construct the penis. Despite the pain, Jimmy said he was only ever scared at the start of the process, only excitement at finally becoming the man he had always wanted to be.

FORM AND FUNCTION

Sukit Worathamrong is a 16-year veteran of performing female-to-male sex reassignment surgery at Yanhee International Hospital, which is renowned for its plastic surgery.

He said gender dysphoria can be treated or managed if detected at a young age. But many parents take the issue the wrong way and try to “solve” the problem themselves.

“Parents can bring young children in at a very young age — as young as three to five years old — if they detect that their children react in a way that is opposite from their assigned gender,” Dr Sukit said. “Then the psychiatrist can attack the right problem. That is the best and most effective way.”

But most transgender people seek support too late, and as they get older begin to feel uncomfortable in what they feel is the wrong body. That’s where medical technology comes into play.

Dr Sukit explained the two main things he is concerned with when providing gender reassignment surgery are form and function.

“Not only must the new sexual organ look very close to an actual one, but it also has to be able to perform at its full function,” he said.

Male-to-female reassignment surgery has reached the point where form and function are close to 100%. But for female-to-male, the procedures and technology, while good, still have room for improvement.

Dr Sukit said treatment of gender dysphoria can be tackled three ways: psychological treatment, non-surgical and surgical treatment. Most of Dr Sukit’s biologically female patients are satisfied with receiving hormone treatment and breast removal.

Others want to resemble a man in every way.

SEX SYMBOL

When it comes to love, there is very little “Som” hasn’t tried before. When she was in her early high school years, she identified as a tomboy and began dating girls.

When she became a bit older, she started to date other tomboys.

“Girls are more romantic than boys," Som said.

"All my girlfriends can remember all the little details of my life. But having a boyfriend is the complete opposite.”

Once Som left the all-female environment of her high school, she went to college where she fell in love with men.

But four years ago, Som was asked to act as matchmaker for her classmate and Jimmy, who was her senior at high school. Som contacted Jimmy through the alumni Facebook page. Then, Som had no interest in being romantically involved with a woman again, but agreed to contact Jimmy on behalf of her friend.

The two talked every day via Facebook chat, but soon Som started to feel that Jimmy was hitting on her instead of her friend. At the time, Som had no clue Jimmy had already undergone sex-change surgery.

But things started to change when Jimmy showed he would always support her, even in her weakest moments. Jimmy, who was working as a cable TV host in Pattaya, drove to Chachoengsao province every day to be with Som, who was at the bedside of her ill mother in hospital. Eventually, he won Som’s heart.

“All my life, I have been looking for stability and security from my partner. I don’t know how far this relationship will take us, but for me I feel like I have found what I am looking for,” Som said. “Jimmy is not a romantic person like a lesbian. He seems to be more like a man, and even more masculine than many men I know.”

Jimmy makes it clear that he didn’t undergo the phalloplasty surgery for sexual reasons. Even though Jimmy is a man now, there is one part of him that still thinks like a woman.

“Men need space for sex, but women need heart for sex,” Jimmy explained. “I was happy with my sex life even before the operation. I am still happy since I only make love with the person I love.”

Jimmy explained that Som was also sexually happy and satisfied, with or without the penis.

“I don’t care much about the penis for sex,” he said. “For me it is more of a symbol that I have already crossed over from that disability I was born with.”       

KEPT IN CHECK

Because of the long and invasive process of receiving female-to-male gender reassignment surgery, the Medical Council of Thailand requires patients to be aged 20 or over. They must also be assessed by two psychiatrists before undergoing a complete health check.

“Unlike male-to-female sex-change surgery, female-to-male surgery is far more complicated because the female body in general is more complicated than the male body,” said Chongdee Aojanepong, from the faculty of medicine Siriraj Hospital, Mahidol University.

Once a patient's mental and physical health is confirmed, they will be transferred to an endocrinologist where they will get advice on how much testosterone they have to take. This is based on their weight, body size and blood work results. The patient will have to inject testosterone twice a month for at least one year before they are allowed to undergo the next procedure.

The next step is to remove the uterus and ovaries. Then the doctor sews part of the vagina up in preparation for connecting the penis to the patient’s body. A recovery time of three to six months is required before breast removal surgery, to avoid infection and reduce the chance of complications.

The final procedure is to attach the constructed penis to the patient’s body, which carried the greatest risk. But Dr Chongdee said he has never received any reports of major problems with the surgery.

COMPLETING THE TRANSITION

After completing the surgery that changed his life, Jimmy has never been happier. He gets to live in the body his mind has always wanted, has found a girlfriend who makes life worth living, and has repaired his relationship with his family after speaking about his experience on national television.

Jimmy had not spoken more than three words with his mother since he left home. But the day the interview was broadcast on a TV show three years ago, his mother called.

“Hello son, how are you?” she said. From the tone of her voice, Jimmy could tell she was smiling.

“My parents might feel like they lost their little girl. But I want them to understand that I am still the same person,” Jimmy said. “I want them to be happy with me and congratulate me for becoming myself.”

Even now, Jimmy has a strict regimen of hormones and check-ups. If he stops taking the hormones, he risks suffering osteoporosis and severe mood swings.

But buoyed by his experience, he has turned his attention to helping others by establishing the Transmen Alliance of Thailand in 2010. He gathered 20 members to be part of the support group and set up a website, Tmat.asia.

“Information and knowledge on the female-to-male transition is very difficult to find. There is no in-depth information on the side effects of male hormone injections, for example,” he said.

“I don’t want anyone to go through what I have been through. If I can suggest anything to parents facing a similar situation, I would say please talk to each other, even if it means fighting and yelling. It is better than staying silent about it. Communication is the only key to getting everyone through a difficult stage.”

A long and difficult process

Eligibility

1. Must be at least 20 years old, or else have parents’ permission

2. Must have taken male hormones for at least one year

3. Must have lived as a male for at least one year

4. Must be certified by a psychiatrist

5. Must be physically fit

6. Must have received mastectomy and total hysterectomy-oophorectomy at least six months prior

TAKING SHAPE

Radial forearm free flap technique

A flap from the forearm is formed into a skin-lined tube that will eventually form the urethra. This tube is then rolled up within a larger flap which has the skin on the outside. The tube within a tube is then transplanted to the pubic area and connected to arteries, veins and nerves. A penile implant is added six to 12 months later, once the nerves have recovered. The procedure is the simplest to perform, but leaves a large and cosmetically undesirable scar on the patient’s forearm.

Anterolateral thigh flap technique

Similar to the radial forearm technique, except in this case a flap is taken from the front of the thigh to form the outer skin roll, while only a small amount of skin is taken from the forearm for the urethra. The procedure means scarring can be more easily hidden beneath shorts or pants, but is not suitable for patients with excessive thigh fat or thick skin.

Fibula free flap technique

The fibula free flap procedure is suitable for those who desire self-rigidity. The middle part of the fibula bone is cut for the neophallus, meaning there is no need for a penile implantation. Limitations for this technique include penile length (maximum 10cm) and longer recovery time, as well as a complete lack of flexibility and the potential to break if misused. In addition, the urethra connection needs to be performed in a separate operation.

Scrotoplasty

Tissue is recruited from the labia majora to create a pouch situated over the obliterated vaginal orifice. After stability is ensured, testicular implants may be placed. Although the skin is initially tight, over time the weight of the prosthesis stretches the skin to create a more natural appearance.

IMPLANT OPTIONS

Non-inflatable implant

One or two bendable and “positionable” rods are inserted into the penis. The rods have an outer coating of silicone and inner stainless steel core or interlocking plastic joints. These implants are always firm. They can be bent into different positions for erect and flaccid states. This is the simplest implant to insert and use, but can feel and look awkward.

Two-piece inflatable implants

These implants have two cylinders in the shaft of the penis, a reservoir that holds salt water, and a hydraulic pump to move the salt water from the reservoir to the cylinders, providing an erection. The release valve on the pump drains the salt water out of the cylinders and back into the reservoir. The pump and release valve are contained inside the scrotum. While easy to use and totally concealed, the erect implant can be less rigid than its three-piece counterpart.

Three-piece inflatable implants

A three-piece inflatable implant has the cylinders in the penis, the reservoir in the belly, and the pump and release valve in the scrotum. Compared to two-piece inflatable implants, the reservoir is larger and separate from the cylinders. It most closely resembles the process and “feel” of a non-assisted erection, and also offers the best flaccidity, but has a higher chance of mechanical failure and the highest complication rate.

COMPLICATIONS

• Tissue from the constructed penis can become infected

• The constructed penis can split from the body

• Urethral stricture

• Difficult to use since the constructed penis, especially if the patient has used the fibula free flap technique, is bigger than a natural penis