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Why Do Trans Men Have To Wait Up To Two Years For Gender-Affirming Surgery?

“I don’t know any other surgical sub-specialty that has that kind of wait list."

A person’s gender identity isn’t determined by their genitals, but trans men who decide they want a phalloplasty face a long wait.

That’s because so few surgeons perform the procedure.

But Dr. Curtis Crane of San Francisco’s California Pacific Medical Center is trying to change that.

Crane is one of only a few doctors in the U.S. performing phalloplasty on a regular basis: Even after he trained two colleagues on the eight-hour procedure, the demand is such that their patients have to wait a year to get into the OR.

The waiting list for most other phalloplasty specialists is two years or longer.

“I don’t know any other surgical sub-specialty that has that kind of wait list,” Crane tells Bloomberg News. "That in itself says there’s high demand with little supply.”

Since he started his practice three years ago, Crane has performed some 130 surgeries, on patients from across the U.S. as well as England, Canada, Israel, Australia and New Zealand.

“We do two a week,” he says. “About a year ago, it was one a week. And a year before that, it was a few a month.”

Female-to-male genital reconstruction is more complicated than vaginoplasty, but improved techniques mean it’s also the fastest growing gender-affirming procedure.

FRED DUFOUR/AFP/Getty Images

In a single operation, the patient undergoes a vaginectomy and scrotoplasty. A phallus with sensation is created from skin, blood vessels and nerves taken from the forearm, and the urethra is lengthened to the tip of the newly created penis.

In medical school, Crane specialized in urology. That was followed by training in functional and aesthetic plastic surgery, a fellowship in reconstructive urology, and self-funded training in Belgium, the Netherlands, Serbia and Thailand to learn specialized vaginoplasty and phalloplasty techniques.

None of his patients have faced major complications, which can include urethral stricture or fistulas, wound healing problems, bleeding, or the phallus “dying” because of a clot restricting blood flow.

Such outcomes affect less than 1% of phalloplasty patients, he explains, or 10-to-20% in the case of urethral stricture.

Christopher Furlong/Getty

The cost for the procedure is actually the biggest complication: The combined price tag for a hysterectomy, phalloplasty and chest surgery can be upwards of $100,000—compared to $30,000 to $40,000 for a vaginoplasty and breast augmentation for trans women.

But there is good news: When Crane started his practice, 90% of his patients were paying cash. Now 90% to 95% are covered by insurance.

“Finally our insurance companies are acknowledging that these are medically necessary procedures,” Crane says.

“Once the third party payers—whether it’s insurance companies or the government—acknowledge that it’s medically necessary and are going to pay for it, then we’ll see the true number of patients that there are in the community.”

Until then, he adds, "these people are just going about life as best they can.”

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