One Procedure, Two Realities

The double standard for navigating breast surgery

T here is a before and an after when it comes to breasts. The before, for many, is excruciating. The anticipation for a flat chest to miraculously fill out is never-ending. For others, the after is even more agonizing. In the case of A.R. Ditesheim, there is only the after. And the agony is very real. For as long as they can remember, A.R. felt that their breasts were attached onto their body without their consent. They do not remember the before.

For A.R., this is because of gender dysphoria, unease caused by a misalignment between a person’s gender and their sex assigned at birth. A.R., twenty-four, is non-binary and has identified this way for the past four years. But questions of their gender loomed long before then. Despite not having the words for it at the time, developing breasts in middle school left A.R. feeling disoriented.

“This is the part where I want to say that there was so much more that I didn’t know,” they told me recently. “Maybe that deeper discomfort had so much more to do with gender than I even knew.” But they were always critical of their breasts.

To A.R., the foreign objects on their chest looked strange. They were dense and tubular, stretchmarked and sagging. Their father, a plastic surgeon who regularly operated on breasts, told A.R. it was because they developed so quickly.

When they were sixteen, A.R. had a consultation for a breast reduction surgery at a private practice. They told the surgeon that their greatest concern was how their breasts looked.

“I couldn’t understand why the aesthetic of them made me so uncomfortable, that when I looked in the mirror, I felt so disconnected,” they said. “It had to be the fact that they didn’t look like they should. At the time, I believed that.”

The surgeon proposed to reduce the size of their breasts, lift them, and insert implants at the top to help round out their chest. Soon after the consultation, A.R. fantasized about removing their bandages after surgery.

The surgery went fine, but A.R. did not experience the relief they had hoped for.

They remember crying to their mom in the laundry room two weeks into the healing process. Their breasts were now too large, too round. They were “what any woman would have wanted” and yet, they hated them. In just a year’s time, after getting the implant deflated and removed, they were back to square one, with a chest they did not want.

A.R. and I went to the same private school in Charlotte, North Carolina. We graduated together in 2018 and share many of the same core memories, including school dances.

Freshman year, A.R. came out as bisexual (they now identify as queer). Our junior year, A.R. brought their girlfriend to the Sadie Hawkins dance. At this dance, traditionally, the girls asked the boys instead of the other way around. A.R. spent the entire day getting ready. They put together their outfit — a long-sleeved, teal, velvet dress, a gold pendant, and heels — and went to the mall to have their makeup done, and straightened their long, dark hair. Everyone told them how beautiful they looked, how much they looked like their sister and their mother. But they felt “so fucking uncomfortable” with their appearance.

A.R. took pictures that day in one of our friend’s backyards. The group gathered to take one last photo in front of the pool. The girls stood in front of their dates, their hands resting on their shaved and lotioned thighs, while the boys stood in line behind them.

Where exactly to stand suddenly became a point of tension for A.R. Encouraged by parents equipped with cameras to stand with the girls, A.R. took one of their friend’s hands and stood up in the back row amongst the boys.

“That was one of the key first moments that gender and sexuality ran into each other for me in a huge way,” they said over a video call.

At this point, A.R. had been post-op for just under a year. It didn’t mean that they should have been prevented from getting the surgery, but it did mean that their education on gender and sexuality, their exposure to queer people, should have been much greater. Perhaps they would have known that the size and shape of their breasts was not the source of their discomfort — the very existence of them was.

Throughout the rest of high school and into college, their chest made them think more about their gender. In 2021, at the age of twenty-one, A.R. came out as nonbinary. When they dove into the world of top surgery videos on YouTube, they knew that surgically removing their breasts was an important next step in living comfortably.

They started the process of getting the surgery. Despite being an adult, it was far harder than getting their breast reduction surgery at sixteen. They had to get a medical clearance and bloodwork from their primary care physician; then they had to get a letter of support from their therapist, a note, only required for patients seeking gender-affirming surgeries, that tells the surgeon that the patient is mentally fit for surgery.

Not to mention the number of questions from the people around them. “I was questioned so much more as an adult about my surgery than I ever was as a teenager, as an adult wanting to get top surgery than I was as a teenager wanting to get a breast reduction,” said A.R. The questions came down to two contentions: was A.R. “trans enough” to be getting top surgery and were they “mentally stable enough” to get it in the first place.

In the end, when the surgeon called to move A.R.’s surgery to a different location and date, due to concerns about their Body Mass Index (BMI), A.R. called it off. It wasn’t the change of venue itself, as everything that came before.

“People think that they are putting what they think are checkpoints to ask if someone is sure. But honestly for me, they were not checkpoints. They were fucking roadblocks. I just got too fucking tired.”

The first generation of American plastic surgeons emerged during the First World War according to Elizabeth Haiken, author of Venus Envy: A History of Cosmetic Surgery. Haiken writes that soldiers’ facial disfigurement shifted surgeons’ goals from strictly restoring function to restoring appearance. This shift made way for plastic surgeons to focus on different parts of the body, including breasts.

Since the 1930s, writes Haiken, American plastic surgeons agreed that “huge breasts were a mental and physical handicap to their bearers.” Even still, breast surgeries were controversial. Some Americans believed breast reductions “smacked of vanity” while others were concerned about disrupting “the most obvious marker of femininity.”

In the years following the Second World War, plastic surgery was becoming even more popular among American citizens. By 1958, more than one hundred thirty thousand Americans had undergone plastic surgery.

However, in the ’50s and ’60s only a small handful of providers were willing to supply medical services for trans people, according to Stef F. Shuster, author of Trans Medicine: The Emergence and Practice of Treating Gender. Christine Jorgensen, a war veteran, was the first American spotlighted for having “sex reassignment” surgery, according to The National WWII Museum. Initially, she underwent hormone treatment until she had surgery to remove male genitalia in the early 1950s.

Some surgeons who provided gender-affirming care wanted to help their patients, whom they perceived as “severely troubled”; others were hoping to explore “a new terrain of medical innovation,” wrote Shuster. This new terrain came with avid criticism from some providers who questioned whether providers should intervene at all with trans bodies.

To avoid questions about a field that was quickly evolving, surgeons at this time turned their attention to the character of trans people. Trans people, in the early 1960s, were understood as “liars, deviants, and morally corrupt” members of society. This meant that trans people would need to prove themselves as “credible patients.” Thus began the expectation in the medical community for trans people to prove and quantify their transness.

In the 1960s, providers mandated that patients pass the “real life test” where, for a year, a trans person would live their life as though they had physically transitioned before they were eligible for surgery. Physicians still struggled to determine who should receive hormone therapy or surgery, according to Shuster. Throughout the decade, physicians found that they needed help from psychiatrists to verify trans patients.

Despite “legitimacy wars” between the two communities about how people should go about transitioning, by the 1970s, physicians and therapists would agree that trans people would only be eligible for medical intervention if they were “gender conforming.” This meant trans women should be interested in finding a husband while trans men should be interested in providing for a wife, “free from familial constraints, passive, and model citizens,” wrote Shuster.

In the ’70s, Dr. Michael Brownstein, based in California, was likely the first American surgeon to perform a top surgery, or the removal of the breasts and chest reconstruction, according to The University of Chicago. Even decades after medical interventions for trans people began, Dr. Brownstein’s colleagues were unsupportive of his practice.

Evidence-based medicine (EBM), a movement that pushed for medicine to become more objective and standardized, emerged in the 1980s. Although the movement impacted all kinds of medicine, it urged providers of trans medicine to create stricter guidelines and tools to warrant care, according to Shuster. Providers “constructed evidence to support the legitimacy of trans medicine” which outlined, as they saw it, a “proper” gender transition. Deciding when a person is fit to receive gender-affirming medical intervention led to specific diagnostic codes for “gender dysphoria.”

Diagnostic codes are required for insurance reimbursement, but they also exist as “cultural artifacts symbolic of the medical community’s sense-making of diseases and illnesses,” according to Shuster. Diagnosing “gender dysphoria,” for example, reinforces the belief that transness is an illness.

Trans visibility emerged in American culture in the 1990s, but trans activism only ramped up in the early 2000s. President Obama’s Affordable Healthcare Act included, to some extent, coverage for trans healthcare, through expanded Medicaid eligibility and reforms to prevent discrimination, according to an article by The Center for American Progress. Between 2016 and 2020, according to Jama Network, 48,019 people in the United States had gender-affirming surgeries, and over half underwent breast or chest procedures.

But in the same timeframe, bills specifically targeting gender-affirming care started popping up across the country. According to the Trans Legislation Tracker, an independent research tool that monitors legislation in the United States, two bills that targeted gender-affirming care were proposed in 2018. By 2023, 185 bills were proposed.

Dr. Elizabeth Loeb, author of “Cutting it Off: Bodily Integrity, Identity Disorders, and the Sovereign Stakes of Corporeal Desire in U.S. Law,” argued in the early 2000s that the American legal system allows greater bodily autonomy for those who meet the gender norm. For those outside of it, more barriers are put into place.

“Some of us can go to a surgeon and have our breasts technologically removed without legal or medical approval,” she wrote, “and some of us can’t.”

Emma Chinn, the communications and policy manager at the Campaign for Southern Equality, said that while no states have outright banned gender-affirming care for adults, more and more proposed bills are looking to target adults in covert ways. According to a recent article from Chinn, in Florida, a 2023 bill prohibits Medicaid coverage for gender-affirming care for all ages.

In Idaho, the governor recently signed a policy that bans state-sponsored insurance programs from covering gender-affirming care. It also prevents government-owned facilities from providing this care. According to Chinn, Kansas and South Carolina have proposed bills with similar language.

In some states, like Texas and Ohio, government organizations have jurisdiction over healthcare regulations, and they are starting to restrict care this way. In others, like Arkansas, Kentucky, and Mississippi, the states are proposing religious exemption bills, which allow providers to deny serving people due to their religious beliefs.

Overall, Chinn said, “The laws really create an environment of confusion and fear that ends up restricting care even more than it already is.”

M y mother, like most women in my family, has large breasts. When I was young, sometimes I sat on the bathroom floor while she took a bath. We often talked about mundane things like work or school as she settled into the water. Her breasts, always hidden beneath a sheen of soapy water until she emerged and wrapped herself in a white robe, were always what was normal to me.

Around the age of fifteen, my chest was growing/started growing at a faster rate than my friends’. I remember sleeping over at a friend’s house. She wore a striped training bra while I had advanced to a thick-padded sports bra, oftentimes two.

My breasts slowly became the source of great discomfort in my life. No one knew why I wore the same purple windbreaker — zipped all the way up to my neck — each day at school regardless of the weather. Or that under my prom dress, I had wrapped my breasts in ace bandages to conceal and flatten them. Despite all my efforts, my breasts became the topic of conversation among my peers, especially the boys at school who asked me to tie their shoes just to see if they could take a closer look.

Around sixteen, when I first learned about the existence of breast reduction surgery, I assumed that it was far out of my realm of possibility. I had a trusting, loving relationship with my parents, and we could have covered the potential costs, but talk of non-essential plastic surgery was something foreign. So when I finally brought the idea to the table, as my mom remembers, it was quickly dismissed.

My dad worried about altering the body that God gave me. My mom shared similar concerns, along with worrying about the potential long-term impacts: medical botching, scarring, the ability to breastfeed.

Even years later, on the phone, I still hear the internal conflict my parents faced leading up to surgery. “Dad and I both were like, ‘Are we really even considering this? This is crazy. We’re supposed to take care of our kids and protect them, and this is insane,’” my mom said.

At the same time, my parents could see I was struggling to live comfortably in my body. “You see your daughter that’s just so sad about these things and having such a time, and if it was going to affect your confidence as a young girl, we wanted you to be empowered, not cowering,” my mom said.

When I was seventeen, we booked a consultation with a plastic surgeon who confirmed that for my age and frame, my breasts were out of proportion and that surgery could be a viable option. The surgeon’s opinion validated my insecurity and encouraged my parents to think more seriously about the procedure. Once I committed to playing field hockey in college, my parents knew that going through with the surgery was not only important for my sense of self, but my future as an athlete.

At eighteen, I was lying on the operating table. In just a matter of hours, I would walk away from the hospital with a new chest — one that fit into a single bra and could go undetectable in a crowded room, could help me run faster in my sport, and give me the confidence to be myself again.

Although she doesn’t quite remember it, I distinctly remember my mom crying when we first removed my bandages just a few days after surgery. We stood together in her bathroom as we took off my surgical bra. The sight was unpleasant, but I couldn’t have been happier if I tried. Despite my mother’s valid fears about the surgery–whether it was religious, monetary, or otherwise — I came out on the other side capable of accepting myself.

It was so easy to do. The only people I had to convince were my parents, the people in the world who wanted only what was best for me.

Just outside of Charlotte’s skyline is the “Big Pink,” a luxury apartment building with reflective, rose-colored windows. The building backs up to Southend, a strip of identical apartment complexes — each fit with rooftop pools and dog parks.

The first floor of the Big Pink is home to Cosmetic Concierge, a boutique surgery center specializing in gender-affirming procedures.

Dr. Hope Sherie opened the center back in 2014. At first, she offered general cosmetic procedures like mommy makeovers and injectable fillers. She also offered top surgeries to patients, the result of training under Dr. Antonio Mangubat, one of the most highly regarded top surgeons in the country, at the American Academy of Cosmetic Surgery. Over time, however, as her reputation grew, she started seeing more and more patients interested in gender-affirming surgeries.

By 2021, when the wait for consultations and surgeries became six months, the clinic started to turn down clients seeking general cosmetic procedures to focus on gender-affirming surgeries. Now, Dr. Sherie scrubs into anywhere between two hundred and two hundred fifty top surgeries each year.

Earlier this year, I asked Dr. Sherie if I could watch her perform top surgery. She said yes. A few weeks later, I walked into her office. The waiting room was fitted with fuchsia-padded seats and lavender walls. The back wall held a long prayer written in black ink. “With beauty before me, may I walk,” it said. “With beauty behind me, may I walk. With beauty above me, may I walk. With beauty below me, may I walk. With beauty all around me, may I walk.”

Dr. Sherie is a smaller woman with a blond bob, outfitted in dark scrubs and tortoise shell glasses that sit right above her surgical mask. In the operating room, she adjusted the overhead light to shine directly over the patient’s chest; at this point in the process, the patient had received anesthesia, and a layer of blue surgical drapes covered their entire body besides their breasts. Dark blue lines across the patient’s chest created a roadmap for her to follow throughout the two-and-a-half-hour procedure.

The surgery was a double-incision nipple graft, the most common and versatile technique for gender-affirming top surgery. In the most basic terms, surgeons use the technique to remove all breast tissue through a large incision on each breast, while resizing and relocating the nipple and areola as a full-thickness skin graft.

The entire procedure runs like clockwork; Dr. Sherie and Vera, the surgical technologist, work as one. Before Dr. Sherie can ask for a tool, Vera already has it ready in her gloved hand. The two work together to trace an ideal size for the nipples. Then they slowly remove them, saving them in a saline bath for the graft.

Dr. Sherie starts with the left side. She creates two mirroring incisions across the width of the breast, one above where the nipple once was and one below. They remove all of the breast tissue before stitching the skin back together. Dr. Sherie’s hands move with speed and precision as she closes the gap with three layers of stitches.

I leaned up against a stool, positioned just a few feet away. I crossed my arms over my chest, somehow feeling the impact of each incision. Below the teal scrubs, my chest ached. Squeamishness quickly turned to fascination seeing, for the first time, a surgery similar to mine on another body.

Top surgery, according to Dr. Sherie, is very similar to a breast reduction. The two procedures deal with the same anatomy and the same basic concepts. The main difference between these two surgeries is the patient’s desired outcomes and aesthetics.

This difference leads to a few main technical changes during surgery itself. The amount of breast tissue removed varies. During a double-incision nipple graft, all the breast tissue the surgeon feels and sees is removed, while during a breast reduction, surgeons leave some breast tissue. Nipple treatment also varies. With a typical breast reduction, to keep nipple sensation, surgeons leave the nipple attached to a pedicle, a stalk of tissue that brings blood supply directly to the nipple. When it comes to top surgery, nipples and areolas are typically grafted off of the skin and reattached later on.

Once Dr. Sherie completes the second breast, the patient is raised to an upright position. Typically, if a patient wants to walk away with a more masculine look, the nipples are placed more laterally on the chest. Together, Vera and Dr. Sherie draw outlines of where the nipples should go. Then they stand back to check their work.

Specific cases blur the lines even further between gender-affirming top surgeries and other commonly accepted breast surgeries. If a patient with a small chest wants top surgery, she told me, they might decide on the keyhole method, which is the same exact technique used for cis men who have breast overgrowth. Nipple grafts could be used on large-chested cis-gender patients who want a radical reduction, but do not want to opt into a full top surgery, she said.

Dr. Fan Liang, the medical director at the Center for Transgender and Gender Expansive Health at Johns Hopkins University, agrees that the surgeries are not all that different. “By and large, both surgeries take about the same amount of time, both surgeries are done on an outpatient basis, both surgeries have comparably low rates of serious complications,” she said over the phone.

But two things can be true at the same time. The surgeries are similar. Acceptance of and access to the surgeries are not.

O n top of legal limitations, gender surgery of any kind will require more before a patient can end up on the operating table, according to Dr. Liang. One of the many barriers to access, historically, has been the lack of consistent insurance coverage for trans patients. According to the American Society of Plastic Surgeons, there is no standardized policy across insurance companies when it comes to gender-affirming surgery. Coverage can vary substantially by “insurance company, state, and procedure.”

Many insurance providers still require a long checklist for patients seeking gender-affirming surgeries. Some, according to Liang, require a sustained history of gender dysphoria, a history of hormone therapy, a patient living in their affirmed gender roles for a set amount of time prior to surgery, and most commonly, letters of support.

“It’s hard to live in your assigned gender role, if you haven’t had the surgical modifications, because you can put yourself in unsafe scenarios,” said Dr. Liang. There are also nonbinary patients who might not use hormones as a part of their gender transition.

However, Dr. Liang said that insurance companies have become more permissive since she started practicing gender-affirming surgeries around 2021. One of the biggest changes, Dr. Liang noted, took place in November 2022 when the World Professional Association for Transgender Health (WPATH) came out with the eighth version of their Standards of Care, a guide that lays out best practices when treating trans people.

The newest guidelines eliminated some of the “behavioral health requirements for surgical readiness” that were difficult for patients to access. Before, only doctoral-level physicians could sign off on a letter of support. Now, a larger pool of providers can sign off. Although it has taken until January of this year to catch on, she said, some of the major insurance companies have adopted the new criteria.

Additionally, clinics across the country have implemented an informed consent model, a new model of care that allows for a “patient’s right to, and capability for, personal autonomy in choosing care options without the required involvement of a mental health professional,” according to the American Medical Association.

Since they opened, Dr. Sherie’s clinic has always used an informed consent model for top surgeries. This means that Dr. Sherie does not require letters of support. Based on medical history and consultation with the patient, Dr. Sherie may request a therapist’s referral after speaking with the patient. But mostly, she gives patients the space to make their own medical decisions.

Another limitation, Dr. Liang said, is the small number of surgeons providing gender-affirming care. One reason for this is provider fear. In states that have started placing limits on care, providers fear losing their medical license. Dr. Liang personally knows providers who have been targeted and doxed by extremist groups.

In Dr. Sherie’s operating room, floor-to-ceiling opaque windows lead out to Arlington Road, a small side street off South Boulevard, one of the busiest streets in Charlotte. Last April, around twenty-five members from Mom Army Charlotte, a right-wing organization, protested “drugging and mutilating kids” on the street corner.

The legal landscape of gender-affirming care is constantly changing. At the time of the protest, surgical-transition procedures weren’t illegal in North Carolina for those under eighteen. By August of that year, medical professionals in the state were prohibited from providing hormone therapy, puberty blockers, and surgical interventions for minors.

Now, the clinic deals with new issues. They receive falsified intake forms, including anonymous attempts to out an individual or phishing from individuals to see how the clinic responds to requests from minors. Recently, they had to take down “before and after” photos from their website due to legislation that prohibits nude images online.

“I am not an activist,” Dr. Sherie said. “I never got into this to be political. But in the great American tradition, there will be more and more and more encroachment on people’s rights to have different types of health care.”

“It always makes me tear up, but if you really think about it, how incredible it is that any of us would allow ourselves to be naked and unconscious and allow someone else to just do something to our bodies,” she said. “When I’m in the OR, there is nothing else.”

Across the clinic, Dr. Sherie helps a patient remove his bulky blue and black flannel jacket and binder to expose his healing scars. Al, who wished to only have their first name in this piece, had top surgery just a week ago, and even though he still isn’t allowed to lift his arms above his head, he beams. He is most excited to wear tank tops in the North Carolina summer and to hug people without space between them.

Atlas Jarvis, another patient visiting the clinic for a post-op appointment, will be twenty-six in May. He has been waiting to get this surgery for the past decade. Atlas, an artist based out of Winston-Salem, has not been financially equipped to pay out-of-pocket for the surgery until now.

“Leading up to it, it literally didn’t feel like it was going to happen because I’ve been anticipating this moment in my life for ten years,” he said. “Up until that point, my brain just had no ability to conceptualize that it was actually happening.”

Early on in his social transition, Atlas wore a chest binder for twelve hours or more each day just to counter the mental distress his chest caused. Two years ago, when the pain in his back and ribs became too much to bear from the binder, he decided to try and make peace with his chest.

Getting his IV in the pre-op room was the most “immediate sense of relief and peace” he had ever felt. On most days, he forgets he has gotten surgery until he feels the hug of the post-op binder or catches a glimpse of himself in the mirror. “It was something that took up all my mental space before, and now I have so much space to think about other stuff,” Atlas said. Before he got the surgery, he had “this apathetic attitude towards life and death.” Now, his perspective has changed. “I’m actually excited to live life. And that makes me a little bit scared of dying.”

“B y the time I get it,” A.R. told me on the phone, referring to the top surgery, “I will be a licensed therapist and I will still need somebody to sign off to say that I’m mentally fit to have the surgery.”

A.R. is currently working towards earning their master’s degree in clinical social work from the University of North Carolina, Chapel Hill. They are on a direct practice path with a concentration in LGBT adult and adolescent mental health. In the future, they hope to help couples, individuals, and parents with gender, sexuality, and relationships as a licensed therapist. This could even mean writing letters of support for patients seeking gender-affirming surgeries.

On the phone, the sound of A.R.’s voice is just as I remember it, and simultaneously new. “I’m not done yet when it comes to my identity,” they said. “That’s why I think it’s navigating a path that’s never ending, you’re always discovering, you’re always looking for more.”

On the inside of A.R.’s right forearm, underneath a thin-lined dragonfly tattoo, is a dark-shaded skeleton. It begins at the clavicle and runs down just to the pelvis. It is the inverse of an anatomy drawing from a science textbook. The white of their arm is the bone, while the negative space between the bones is shaded in with ink.

“I wanted a piece that was a reminder that I’m still a person with bones and flesh and organs that keep me alive,” they said. “It doesn’t really matter what the outside of my body is. There’s just bones and body and things that are created in my system.”