1 Arakinos

Makkunrai Gender Reassignment

It would be an understatement to say that the gender-sex binary is complicated. So why do people today still insist that there are only two genders?

Sure, most people are born either one sex or the other. And depending on your biological makeup – your chromosomes, hormones and primary and secondary sex characteristics – you are either anatomically male or female. But what most of Western society fails to acknowledge is that your biology doesn’t always determine your gender expression.

Gender, instead, is determined by your culture. It’s made up of gender roles, which are assigned to you based on whether or not you’re biologically male or female.

But outside of this way of thinking, there are various cultures that acknowledge the complexities of gender expression.

For starters, Bugis people believe in what they call the 5 genders.

The Bugis people are the largest of the three major ethnic groups in South Sulawesi, Indonesia. Their society recognizes five genders – the makkunrai, oroané, bissu, calalai and calabai – and break it down as follows:

  • The makkunrai are comparable to cisgender women. In other words, they are women whose sense of identity and gender correspond with their birth sex: female.
  • The oroané, on the other hand, are comparable to cisgender men.
  • The bissu are androgynous shamans.
  • The calabai translates to “false woman” and are similar to trans women.
  • And lastly, the calalai translates to “false man” and are similar to trans men.

Within this culture, the calabai and calabai are accepted as a completion of the gender system as opposed to an abnormality. In their society, the calalai are biologically female, but they function and do the work that men do. And the calabai, vice versa.

As for the bissu, they’re both born male and female, or hermaphroditic. And instead of being ostracized by the community, this rare combination of physical sexes is honored. Bissu people in this culture often become priests.

Native American people, on the other hand, believe in the “two spirit” tradition.

Similar to the Bugis people, some North American Native American tribes, including those of the Plains, the Great Lakes and the Southwest, recognize and celebrate gender ambiguity.

Instead of focusing on the person’s biological makeup, they focus on the individual’s “spirit.” Regardless of one’s sex, two-spirit individuals can fill both male and female gender roles within the tribe.

The phrase “two spirit,” however, didn’t gain traction across Native America until after 1990. During that time, 13 men, women and transgender people from various tribes met in Winnipeg, Canada to try and find a term that could unite the LGBTQ Native community.

The attendees settled on “two spirit” because they wanted a term that “reflected the combination of masculinity and femininity which was attributed to males in a feminine role and females in a masculine role,” writes author Sabine Lang in “Men as Women, Women as Men: Changing Gender in Native American Cultures.”

Historically, many two spirit folk were keepers of traditions, story tellers, religious leaders and healers. In other words, this difference was highly valued and respected.

Similarly, Indian culture acknowledges the existence of a third gender, the Hijra.

But unlike the Native American “two spirit” tradition, the “hijra” term only applies to people who were assigned a male gender at birth but don’t identify as men. Many hijra people even wear bold makeup and traditionally feminine clothing.

And although Western society may be tempted to dismiss these practices as “transgender,” that term is seldom used in Indian context. Instead, the term most commonly used is “third gender,” which the country’s Supreme Court acknowledged as a legitimate identifier. So, those wishing to indicate the “third gender” status on their government-issued identification can now do so.

The main difference between “transgender” and “third gender” (or “hijra”) people is that hijras leave their home and undergo an induction to a clan of hijras. This clan is led by an elder known as a “nayak” or guru and the new inductee is known as a “chela.” These people have their own codes of conduct.

So overall, yes, gender is complicated. And, acknowledging more than just the traditional binary can get confusing. But as the three cultures above show, it’s not impossible.

For many people today the limitations of the man-woman binary is restricting and frustrating. The way you experience your gender can change over time, depending on factors like your age and environment. So why should we be limited to just two?

Edited by Angelica Pronto

Tags:gender|LGBTQ

He gets misdiagnosed with Attention-Deficit Hyperactivity Disorder and put on drugs, and although he's basically a happy, active kid, becomes depressed enough to make a noose for himself and hold a knife to his chest. He figures no one will ever listen, or believe what he knows to be true: he is a girl.

'That's 1700 lives you've saved'

I met Natalie in December 2017, at Mount Sinai Hospital's Centre for Transgender Medicine and Surgery in Manhattan, an hour before she was due in theatre for gender reassignment surgery: a vaginoplasty, in which the penis is essentially turned inside out to become a vagina, plus breast implants and a tracheal shave to reduce the size of her Adam's apple.

As the anaesthetist told her what to expect, I chatted with surgeon Dr Jess Ting, his mentor Dr Marci Bowers, who was visiting from California, and Dr Bella Avanessian, a young transgender surgery fellow who had been studying at Ting's side for six months.

Ting described Bowers as the centre's "spiritual leader" and "probably the most experienced vaginoplasty surgeon in the United States". When she demurred, he asked how many of the operations she had performed. "That's 1700 lives you've saved," he said.

Two years ago, Ting was "a regular plastic surgeon", and he retains an evangelical devotion to his new vocation.

"I'm frequently on the verge of tears talking to patients," he told me. "Our oldest patient was 77 years old. She came in for a post-op check, we gave her a mirror, she saw herself for the first time and she cried. She said she had waited since she was five years old for this operation and it finally felt like she was herself."

For Natalie, early manhood was the hardest time. She was an overtly masculine adolescent: a lifeguard and Eagle Scout who enjoyed hang-gliding and rock climbing. Alone at home, she dressed in her mother's clothes. "It was as if I was trying to fill this void with something that wasn't fitting … I suppressed it all. It was like knowing something but actively trying to ignore it," she said.

At State University of New York at Geneseo, in her early 20s, she began to "present" as a woman for the first time. To summon up the nerve to tell her parents, and help them understand, she filled an encrypted USB flash drive with information about transgenderism and links to parental support groups, then wrote the password on a Post-it note and handed it to her dad. No going back.

An endocrinologist prescribed testosterone blockers and oestrogen injections, and although she cried every time she inserted the needle deep into a muscle, after three months she could feel her body starting to change.

The Centre for Transgender Medicine and Surgery opened in March 2016, in response to new regulations requiring medical insurance plans to cover gender reassignment in New York. As this included Medicaid, the state-run program for the most needy, hundreds of people who could not previously afford the operations were suddenly eligible.

Zil Goldstein, a nurse specialising in HIV treatment and hormone therapy who is herself transgender, was appointed director. "I had patients who were forcing themselves to live in poverty so they could save up the money to get these surgeries," she told me. Although the centre didn't advertise, within two months there were 100 people on the waiting list (there are now more than 400).

Penile inversion vaginoplasty was pioneered by Dr Georges Burou in 1958, but until fairly recently in the USA, it was only offered by a handful of surgeons, for cash.

"If you didn't have the means, then you didn't have the surgery," Ting said. "You would go to an unlicensed provider and have them inject your body full of silicone to maybe make yourself a little more feminine, and suffer the consequences of those botched operations."

These days, 19 US states require insurers to cover the operation and most corporations include it in their health plans.

It is still far from easy to get. In New York, patients qualify once they have been receiving hormone therapy and "presenting" in their preferred gender for a year, and must provide letters from two mental health professionals confirming a "persistent and well-documented case of gender dysphoria" - the official term from the latest Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

The previous edition of DSM referred to "gender identity disorder", a term many found pathologising, and it remains controversial that the distress felt by people who feel trapped in the wrong body is listed as a disorder at all.

"Does this thing called gender dysphoria exist? The question is ongoing in the community right now," Goldstein said, "but we do know that 40 per cent of transgender people attempt suicide. It's not a stretch that these are life-saving procedures."

Mahogany Phillips, a former male model who had a vaginoplasty and breast augmentation at 47, described gender dysphoria as "a trial and a tragedy, every day … You feel so incomplete. It's a struggle just to get dressed. Physically, you're trying to tuck and you're trying to bind all these parts into smaller undergarments, and then you have to go out and face the rest of the world that wants to put you down."

In December 2016, she successfully sued New York state, winning the right to get facial feminisation surgery to remove a masculine bump on her forehead, a procedure Medicaid administrators had deemed cosmetic. "People say 'wasn't having the surgery a lot of pain?'. It can never amount to the pain that a transgender person feels every day," she told me.

Reborn in the USA

The next time I saw Natalie, she was unconscious in the operating theatre, on her back with her legs in stirrups, like a woman about to give birth. It occurred to me that she was being reborn: the chill and the bright lights reminded me of when I last wore hospital scrubs, to see my youngest son delivered by caesarean section.

Bowers took the lead, assisted by Ting, Avanessian and two other surgeons. To create a vagina, the shaft of the penis is inverted and used to line the cavity created in the perineum. The urethra is shortened and repositioned. A clitoris is fashioned from the glans of the penis, and the foreskin becomes the labia.

Ting spent a long time trimming fat from the scrotum, then sewing the skin into the shape of a windsock, to become the deepest part of the vagina. He advised the surgeon working up top to use the 470-cubic-centimetre Natrelle breast implants - "not too big, not too small" being Natalie's request. The smell of burning flesh filled the room, as surgeons cauterised blood vessels and made laser incisions.

Pop hits played from a speaker in the corner, occasionally causing the nurses to shuffle as they worked. When "My Humps" by The Black Eyed Peas came on - "my lovely lady lumps" - I laughed out loud into my surgical mask. Mostly, I was awestruck by what modern medical science is capable of, and by the transformation being wrought.

After a little over three hours, Bowers and Ting left the junior surgeons to put in the final sutures. A hospital videographer was filming the procedure, for a clip to accompany this article, and Avanessian wondered if the footage would be too graphic, even now the skin had been sewn up and most of the blood drained and wiped away. "It's a vagina," she pointed out.

Since the procedure was made available on Medicaid in New York, in March 2015, there has been an explosion of interest from surgeons and clinics seeking a share of the profits. A vaginoplasty that used to cost $11,000 in cash runs to around $29,000 now insurers are on the hook.

"Every week I hear about hospital X, hospital Y, everybody wants to start a transgender surgery program. And having been through it myself, learning these operations, I know how difficult they are," Ting said.

"So many people are jumping on the block with little or no training, knowing that they're going to get paid, but leaving the patients basically experimented upon," added Bowers. "We're seeing a decline in the quality of the outcomes overall. And then for those of us who are qualified, the waiting lists are so long."

Jaco Erasmus, head of the Gender Clinic at Monash Health in Melbourne, says that there are two surgeons performing vaginoplasty in Australia, one in Sydney and one in Melbourne.

"Because the surgery occurs in the private system, there is no process in place to collect data about how many surgeries are being performed," he says. "My understanding is that about 8 to 10 vaginoplasty surgeries are performed per month."

People seeking vaginoplasty in Australia need private health insurance for a minimum of 12 months, with surgeons recommending a further 12 months of insurance after surgery. Erasmus put the out-of-pocket costs for the procedure, covering surgeon's and anaesthetist's fees, at $12,000.

Natalie was lucky: her surgery was booked for September 2019, and only happened sooner because it could double as a masterclass while Bowers was in New York.

Ting has recently developed a new phalloplasty technique that he says has the potential to revolutionise female-to-male transitions, creating a fully-functional penis, something that hasn't been possible until now, but having only performed three of the operations, he remains cautious about the long-term results.

Earlier this year, researchers at the Mayo Clinic surveyed 400 endocrinologists, and discovered that only one in five had received training in how to treat transgender patients. In a National Center for Transgender Equality poll, 24 per cent of trans respondents said they sometimes have to educate their own doctor (and 23 per cent said they avoid seeking health care at all, because of ignorance and prejudice they have encountered).

Goldstein noted that when surgeons replace a mitral heart valve, there is an acceptable rate of complications. For the relatively untested operations required for gender reassignment, there is no agreed-upon quality metric yet.

"There are also more trans people than there used to be, and the medical industry, right now, doesn't have the capacity to take care of everyone," she said.

Surgeons working on gender reassignment in Australia follow guidelines published by the World Professional Association for Transgender Health. Two approval letters are required from mental health professionals with expertise in the field, and patients seeking genital surgery must have a well documented history of gender dysphoria and be able to show that they have 12 continuous months of living in "a gender role congruent with their gender identity" and receiving hormone therapy appropriate to their gender goals.

New resources, old divides

Today's trans teenagers have vastly more resources at their disposal than Natalie did a decade ago. There are transgender characters in several major television shows, and countless YouTube channels following the transition process (including Natalie's). But there is also fierce cultural resistance to transgender rights, particularly in red states: in a recent Pew poll, eight in 10 Republicans said whether someone is a man or woman is determined at birth.

"There's much more acceptance. There's much more integration. People are much less likely to be fired from their jobs," Bowers said. "So in that sense, there's been a bit of an emancipation. But there are places where violence is essentially sanctioned against transgender persons." At least 28 trans people were violently killed in the US in 2017, the most on record.

At college, Natalie was raped in an alley by a gay man she thought was her friend, and later chased by a pack of drunk male students intent on making her "prove" she was a woman, after a barman at a Halloween party questioned her gender for laughs. Whether she uses the gents' or the ladies' toilets, she is liable to be told "you can't be here" - prejudice she will still encounter despite her newly feminine appearance.

Sometimes, strangers congratulate her on her transition "to prove their own openness", and although it feels a lot better than being hated or ostracised, that can grate a bit too. "I try not to view myself as transgender," she said. "By scientific definition, I guess, I would be considered a trans woman, but in my own identity, I just consider myself a woman."

In the weeks leading up to her surgery, she often dreamed about it, so vividly she would check her body when she woke up. Regaining consciousness as the anaesthetic wore off, she knew this time was different.

"When I looked down at my body … I felt as if it was all completed. As if everything was done. It was a sense of relief," she said.

Eleven days after the operation, she was still getting used to having a vagina. "It's a new apparatus. I joke about wanting a user's manual, because I keep running into new, unseen territory and sensations," she told me, adding that her clitoris felt "fricking amazing" but she was wary of touching it.

When she has recuperated, and been cleared to return to work as a flight attendant, she will do so as a woman in ways that, growing up, she didn't believe possible. "I never thought it was going to come true, and then it did come true," she said. "You see it, and it's not just a dream: it's reality."

Support is available for anyone who may be distressed by phoning Lifeline 13 11 14; Kids Helpline 1800 551 800.

Anyone seeking support and information about suicide can contact beyondblue on 1300 22 46 36.

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