Sex reassignment and plastic surgery with Dr. Pierre, Brassard, Montreal, Canada

Here it the information send to patient in the USA who looks for a MTF Sex Reassignement Surgery (SRS):

We are pleased to send you a detailed information package on gender reassignment surgery male to female.
Enclosed you will find: letter of introduction
Information document on male to female GRS
Medical history document
GRS in Montreal brochure
Our modern and safe hospital care is personalized and our staff has a high
experience with transgender patients. Low overhead combined to favorable exchange rate are responsible for
the low cost of procedures with GRS in Montreal.
In choosing Montreal you do not settle for less. On the contrary you pay for state of the art procedures and
unsurpassed results based on a vast experience with transgender surgery. Also with the residence, you
benefit from a unique care concept which is not available anywhere else in the world.
We and our staff would like to thank you for your interest in our surgical services and please do not hesitate to
contact us if you need anymore information.

INFORMATION DOCUMENT ON MALE TO FEMALE GRS

CRITERIA FOR ELIGIBILITY:
To be eligible for Gender reassignment surgery, one must, first of all, answer to the criteria of the Harry
Benjamin International Gender Dysphoria Association’s standards of care for gender identity disorders (sixth
version).

1. Usually 12 months of continuous hormonal therapy
2. Successful continuous real life experience for 12 months
3. Two letters of recommendations for genital surgery and one letter for breast surgery

If the first letter is from a person with a master’s degree, the second letter should be from a psychiatrist or a
Ph.D. clinical psychologist, who can be expected to adequately evaluate co-morbid psychiatric conditions. If
the first letter is from the patient’s psychotherapist, the second letter should be from a person who has only
played an evaluative role for the patient. Each letter, however, is expected to cover the same topics. At least
one of the letters should be an extensive report. The second letter writer, having read the first letter, may
choose to offer a briefer summary and an agreement with the recommendation.

The Mental Health Professional’s Documentation Letters for Hormone Therapy or Surgery should
succinctly specify:

1. The patient’s general identifying characteristics :
2. The initial and evolving gender, sexual, and other psychiatric diagnoses;
3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent;
4. The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery;
5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance;
6. Whether the author of the report is part of a gender team;
7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document.

SETTING A DATE FOR SURGERY:
The medical history document and the two recommendation letters for G.R.S. must be well detailed and must
arrive at our office before a date can be set for the surgery. Also, we wish a report from the doctor who is
supervising the hormonal therapy as to the type of hormones being administered, the dosage and the duration
of the treatment.

PRE OPERATIVE CONSULTATION

It is preferable to meet your surgeon prior surgery during a preoperative consultation. However, if one lives
very far from Montreal, it is possible to meet a few days prior to surgery. If the latter is the case, the patient’s
file must be complete: the two recommendations, the laboratory reports and the medical history document and
the physician letter on hormonal therapy, must be at our office before the visit. If a document is missing, the
surgery could be cancelled.

PRE OPERATIVE ANALYSIS: LABORATORY REPORTS :

As this is a major surgical procedure, under general anesthesia, the patient must pass the following tests about
two months before the date of the surgery and the results of these exams must be sent to our office one month
prior to the date set for the surgery. Without these test results, there will be no surgery. PLEASE WAIT TO
HAVE A DATE OF SURGERY BEFORE HAVING YOUR PRE-OPERATIVE TESTS DONE. Tests that were
done more than 3 months prior the surgery date will be considered unusable and will have to be redone.
Following is a list of the obligatory tests:

• CBC (complete blood count)
• BUN (blood urea nitrogen)
• Glucosis (blood sugar)
• Urine analysis
• E.C.G. (over 40 years of age)
• H.I.V. test

Unfortunately we are sorry to inform our prospective patients that insulino-dependant diabetic patients will
not be accepted for surgery.
This systemic disease is for our Center a contraindication for major procedures because of the absence of
competent consultants in the field of endocrinology.
GRS insulino-dependant diabetic patients should be performed in major hospitals where all the internal
medicine expertise is available.
Thank you for your comprehension.

HOSPITALIZATION

Normally, the surgery is performed on a Monday or a Tuesday. You enter the hospital around 7:00 p.m. the
day before. You leave the hospital on the third or fourth post operative day. The vaginal stent and the urinary
catheter are removed on the sixth, seventh day. You must remain another 2 to 3 days in our residence home
to master your vaginal dilations.

ANAESTHESIA FOR YOUR SURGERY

Gender reassignment surgery (vaginoplasty) can be done under general anaesthesia or regional spinal
anaesthesia. Both work equally well but patients like having less side effects with the spinal. However, there
are some contraindications. The anaesthesiologist will decide if you are a good candidate for a spinal.
General anaesthesia is always used if you have another surgery at the time of your vaginoplasty.

SURGICAL TECHNIQUE-ONE STEP-PENILE INVERSION

We perform the penile skin inversion technique. The penile skin is inverted to create the vagina (vaginoplasty).
When the penis is too short, we use the excess skin from the scrotum (graft) to have a sufficient amount of
skin for the vaginoplasty. The clitoris is made from an innervated island of the glans (sensate clitoris). In fact,
part of the glans is pedicled to the dorsal nerves and vessels of the penis (island flap) shaped to construct the
clitoris. The labia minoras are made with mucosa from the urethra and penile skin during the same procedure
(one step procedure).

ELECTROLYSIS:

Hair removal on external genitals before male to female reassignment surgery is debatable.
Hair bearing skin on the penis shaft base with the one step technique stays outside on the neo vulva. The skin
that will become the internal living of the new female genital is the rest of the penis skin, scrotal skin and a
small « perineal flap » (a one square inch of skin that is located one side above the anal margin on the midline)
If you want a perfect hairfree vagina you need to be sure that no regrowth of hair has occured on the area for at
least one year after you have finished electrolysis on laser. Even then this does not garant that no hair will ever
grow.
The hair roots are either killed or weakened by electrolysis or laser. Those only weakered regrow. During
surgery hair roots are killed with the cauthery on the scrotal skin that is used as a graft ( not on the « perineal
flap » ) During surgery the hair roots that were weakered are less visible because they are much smaller than
those found untreated areas and could be missed by the surgeon and regrow later. For this reason, in our
experience expeditive laser or electrolysis treatments are worse than not having hair removal at all. In fact, we
can get most hair roots during surgery if they were not weakened. Regrowth after our surgery is possible but
very sparse.
If you want no regrowth at all you will have to face hours of painstaking hair removal and a one year
nonegrowth period.
At this time we do not feel that hair removal is indicated.

COST

Please contact us for pricing.

YOUR STAY IN MONTREAL

Your stay in Montreal should be between 12 to 14 days : between 2 and 4 days before the operation, 4 days in
hospital and finally 5 to 6 days after leaving the hospital.
It will be possible to have companying with you at the residence.

To make your recovery more pleasant and secure, we have a convalescence residence for pre and postoperative
period. They supply care, lodging and meals. Do not forget that post-operatively you will need help
and it is the only place where you will receive adequate, professional care. The address of the residence
care is 908 Gouin ouest Montreal, Qc H3L 1K8 Phone number is: 514 333 1572.
Three weeks before your surgery, we ask you to confirm with the office if you are arriving by plane,
train or auto, the date of your arrival, the time of arrival, airline or carrier, flight or train number. Please
note if you have a criminal record, you may buy a visa at your arrival at the airport to be allowed to stay
in Canada (around 100$ u.s.). When we will confirm your date of surgery, we will send you a form to complete
concerning your travel information. At the Customs, be sure to have a passport. Since January 23rd
2007, you need a passport to return to United states.

ADDITIONAL SURGERIES

If you wish to have an additional surgery done at the same time of your GRS., (e.g. breast implants, Adam’s
apple shave, nose, eyelids surgery etc.) you will pay a little less for the surgery.
If you wish further information, you may write, e-mail or call our staff.
Yours truly,
For :

PIERRE BRASSARD, M.D., F.R.C.S.(C)
P.S.: It is absolutely forbidden to smoke at the hospital.

As you know, transgender people often use various cosmetic surgeries. I say cosmetic because they are considered as such by a large majority of the population. Everyone knows that many rock star and movie stars have used rinhoplastie, the breast implants or face lift. They use these surgeries only to improve their image. They want to match the idealized image of the body of their gender. Every women want look like what they believe to be the ideal woman. That’s why I say cosmetic surgery.

But what about those who might really need these surgeries? Let’s try to find a few cases. First, I believe that people who had an accident really need these surgeries. In their cases, interventions are known as reconstructive and not cosmetic. It is often the same surgery or a very similar technique for cosmetic or reconstructive. There are also people who were born with malformations. The fact that they are different makes their life more difficult and they are victims of prejudice. They may also have a hard time to find a job. Those  we need these surgeries to help them to function better socially.

There are also those who are suffering psychologically from their physical appearance. Beware, I am talking about heavy cases. I’m talking about people who are completely unable to leave their homes. Those who when someone looks at them, they automatically drop in anxiety crisis. Those also have a real need for these surgeries. We can say that the line is thinning between people who undergo these surgeries to improve their look and those with heavy psychological suffering. For both cases, it is a matter of acceptance of their difference. We must not forget that it was a time when these people did not had these surgical remedy to their psychological distress. We all already heard about the village fool. These people had no choice but to accept their social role of “fool” and not to expect in a better life. This is where the concept of suffering degree, associated with their position, start. It is therefore important to explain this difference.

It is necessary to identify the motivation of each one towards surgery. It is this motivation which changes the cosmetic surgery in an surgery that improves life quality of patients. It is really difficult to judge their motivation. In the case who someone is rebuilding his nose because he does not love his nose, the motivation is cosmetic suffering. This suffering may have different degree. For some, it’s simply that they wants improve their look and suffering just their own vision for themselves. Others imagine what others think them. This vision is distorted and they believe that the others just watch their nose. Personally, I think these first two cases need to work on themselves or receive psychotherapy.

In another way, there are people who are looking differently and actually live a traumatic experience every time they leave home. I resume my example of the village fool who can not hope better that the rank of fool because of his different body. Today we have surgeries and people who are really suffering of their differences, have a solution. It’s because they experience traumatic experiences often, that they eventually want these surgeries. It is because they are in contact with others that they start to suffer of their difference. The eyes of others and the comments they makes. Le village fool wasn’t  born fool, he became fool because others said that he has fool.

The same applies to transsexuals. They may have their differences. Take the case of a transsexual woman with very masculine facial features. It is impossible that people will not look at her? Even she looks as normal as possible, peoples will always looking at her. From that day when she decided to live as a woman, psychological distress related to their physical difference is about to begin. Like the village fool, this person will suffer of unsightly look and comments of the people around him.

There is nothing wrong to be different but in the social context in which we live, it’s hard to live this discrimination. Peoples should be able to accept differences of others but that day has not arrived. Meanwhile, people who are different have two choices: continue to live their difference or expect to have access to surgery, which could make their appearance more in line with social norms in which we live.

I believe that in the context where people are having trouble being accepted socially and it was identified that the suffering is heavy and it is caused by the eyes of others, body modification surgeries should be accessible to all. In a context of public health services, the cost of surgeries needed to transform the body of transsexual patients, should be covered by the public system. The same goes for private systems, where insurance companies should cover such cases.

Since a while, there is a major fight in my head. My attraction to women is real indeed! I feel good when I’m in the arms of a woman. I would add that I feel understood, loved, important, etc etc etc. All my life I have been in a relation with few women in an heterosexual relationship. During all these years of “closet” (32 years in my case), I dreamed of sex with a men. I wanted to see myself in the position of the women in my relationship, the relation that I knew, of course.

Today I am a woman and I still have that attraction to women. I still have that idea of me having sex with a man. Can we say that it is simply bisexuality? Maybe, but I would say that unlike bisexuality where people have full relations with the two genders, I want a part of a relationship with one gender and another part with the other gender.

We can say that I have explored and developed my sexual orientation with a wrong gender identity and perhaps that what has caused this situation.

Before going further, let me give you an image that I use often to explain gender identity and sexual orientation. I use just the orientation arrow. This arrow points to the gender of our choice:

Obviously for bisexual people, this arrow points to the two genders. To lighten the text, I will not talk about bisexuality here. So we see that the tip of the arrow, indicates the gender of our choice. But this arrow has an origin. The origin of this arrow is attached to our own person. For most people, it does not go further than that. But in fact it is our person as a man or woman. So we can say that our sexual orientation is closely linked to our gender identity.

As a person this gender, I am attracted by this gender.

When gender identity and sexual orientation are different, it is a heterosexual relationship and vice versa for homosexual relationship. People are living these two types of relationships based on gender identity in conjunction with their sexual orientation.

What to remember is that the origin of the arrow is not just a person but a person with his gender identity.

You see the concept. Where I am getting with this image is for people who change their identity. Most people are exploring their sexual orientation since puberty. So, based on sexual identity, they define their orientation. When identity is wrong, it necessarily develops in the wrong manner. When I say “wrong manner” I do not mean bad choice of gender. It is necessary to distinguish the two. Wrong sexual orientation can be a wrong type of relationship.

For transgender who are still in denying, they explore, define and consolidate their orientation with the wrong gender identity. They must adjust to the reality that people see them as man when they are women or vice versa. What to do: There are social pressures that drives people to be heterosexual, on the other hand, our body is not  of our gender, Am I gay because I feel like a woman inside? Even for homosexuals who gender identity is not an issue, it is very difficult to define their orientation. Many succumb to social pressures and choose heterosexuality. So when the identity is uncertain or bad, orientation is almost randomly decides. People must adapt to the reality of their own.

I often compare this period of my life to a jail. From the point of view that I was trapped in my body is very true but also from another point of view: The people who are in jail for a long period of time, have homosexual behavior during their stay in jail. They must adjust to the reality that prisons are unisex as transsexuals adjusting to the fact that their identity is incorrect. For several years, transgendered peoples or prisoners, practice and consolidate “forced” sexual orientation. In both cases, they reprogram themselves and they force themselves to like it and ends up loving it.

What will happen when they leave prison? What will happen when they change their gender identity?

Prisoners returns to heterosexuality but with a certain lack of man. Often, we see bisexuality starts. For transsexuals, there are usually two cases: 1 – the choice of the preferred gender change and type of relationship stay. 2 – The type of relationship change and the preferred gender remain the same. In both cases, the transsexual person has to adjust to a new reality.
I am one of those whose type of relationship change and the choice of genre remain the same. But with the difference that I still want sex with men. Maybe my 32 years of jail, my heterosexual programming and my wrong gender identity made me a bisexual lesbian? I do not know? Maybe I am a heterosexual woman in become? I feel completely deconstructed.

Who am I?

What’s that, Stonewall? Why looking behind? Events and claims are done. There is no more police repression against gays and lesbians. Even same-sex marriages are legal. Community members are not going to jail for being what they are. The Canadian Chart of Rights and Freedoms recognize sexual orientation as a choice and protects individuals. Even the sexual activities that take place in saunas are tolerated. What remains of the community? At the time of the sexual revolution, the gays villages in America have been formed and people have come together to show and show how they stood and fight against oppression and injustice. What remain of this injustice and oppression today? Why even stay together? Witch fight remains ?

Several claims social equality for gays and lesbians! Yes, actually is this battle remains. Sometime we see insidious or hidden discrimination. But everybody agree that beatings with truncheons is something is done, yep?

The gains produced by these events and even a small civil war as Stonewall was, it benefited the gays and lesbians but also for trans-identified persons who at that time were automatically regarded as homosexual. But for the trans-identified people, there is still much work to do. Of course, if they are homosexual or bisexual, they can take advantage of the chart and be protected against such discrimination.

Today, I realize that false beliefs of the police at that time are still valid. People generally believe that the trans-identified people are automatically homosexual. How is this belief is still present and even within the gay community (at large)? The gender identity and sexual orientation are two very different things. For the vast majority of the population, were gender identity has never been questioned, they are not even aware of this important part of their person. Ask yourself the question: “Do you feel like a man or a woman? The vast majority of people do not feel their genders. They are simply what they are and are hardly able to imagine being of different gender. Sexual orientation is much easier to understand and imagine being the other direction causes the revulsion for many.

So, as soon as you understand that the orientation and identity are two separate things, you realize that the Canadian Chart of Rights and Freedoms does not protect trans-identified people. You realize that transsexualism is considered mental illness. How do you want to be respect when you’re mentally ill?

The trans-identified people must hide themselves in order to live healthy lives. You know what? It is not always easy to hide an identity different from what they are biologically! People say we are sick because we need surgeries, medical treatment and psychological follow-up to change gender. In fact, the psychological difficulties experienced by the trans-identified people come in large part from the society marginalization. The multiple surgeries to feminize or masculinize, are necessary because they waited after their puberty to make their transition. Male transsexuals undergo complete bilateral mastectomy because their breasts have grown at puberty.

Why people wait after their puberty to become what they are and make the transition? The answer is simple: Fear!

Fear and misunderstanding of what they are themselves. The education received from parents who don’t know. We raise our boys like guys and same for girls. If your little boy have a little too feminine behavior, parents say: “It may become gay.” Nobody had questioned their identity and even some parents admonish their children if their behavior do not match their biological gender.

If, people in general learn the difference between orientation and identity, they would be able to identify a disorder with their children and also able to provide them the help they need as soon as possible, this mean: before the puberty.

I feel that the improvements, for my community, made since Stonewall, are simply the side effects from the gain of homosexual struggles. Now your war is over. You have the legal equality, maybe not the social equality, but time will settle this. We need to take the rights of trans-identified people:

1 – The withdrawal of the gender dysphoria of mental disorders in DSM-V and the ICD-11.

2 – Include gender identity in the Canadian Chart of Rights and Freedoms.

3 – Allow trans-identified people to have the help they need.

4 – Facilitate the medical and legal procedures to change the designation of sex and give access to surgery.

5 – Train staff on this reality and give them the information they need to do their work with trans-identified people.

6 – Change the public image of trans-identified people.
This is my Stonewall!

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