In A Bind- My Top Surgery Journey

By: Kofi O.

(EDITOR’S NOTE- Today we will start a new column called “My Top Surgery Journey” where I have opened my space up to my trans brothers to document their Top Surgery journey. I asked my friends to share their journey because I know so many that would like to have surgery but are scared of both the procedure and the insurance hurdles. I am so happy that they have chosen to share their stories! If you would like to share your story as well you can contact us here: theknockturnalproject@gmail.com)

In a few short weeks, I will be flying from my hometown in New York to the San Francisco Bay Area. I will be meeting with a surgeon, Dr. Michael Satterwhite, at a hospital in Greenbrae, where I will go under general anesthetic for two to three hours. My doctor and his surgery team will remove all of the breast tissue and some of the fat from my chest, and graft and reposition my nipples onto the upper outer quadrants of my torso.

In short, I will have top surgery.

One well known top surgeon’s website describes the process of Top Surgery as thus: “The nipple and areola are removed, resized, and replaced as ‘free nipple grafts’ in a new position to give a ‘male’ appearance to the chest.” Afterwards, I will be unable to move around on my own for about a week, and unable to go to work for two more after that. For a while, I will be dependent upon friends and family for basic necessities, like reaching above my head and washing myself.

I’m going to be real. I’ve never had surgery before. I’ve never been anesthetized for longer than it took my dentist to remove a wisdom tooth. I’ve never even broken a bone. And yet, I’m not nervous. I’m more excited for the end of May to come than I have been about anything I can remember. In a word, I’m stoked.

My journey to top surgery began twice: once, when I went through my first puberty in my early teens, and again when I began binding. The first time I wore a binder​—an​ elastic compression shirt that is worn tightly enough to compress breasts and flatten the chest​—was​ sometime between January and March 2012, during the spring semester of my junior year at NYU. A friend and coworker of mine was giving away his ratty old binder​—he​ had just bought a fancy new one from Underworks. I decided to give it a try. For months, I had been stealing glances at the flat chests of some of the transgender men and butches in my life with curiosity and, in retrospect, longing: howwere they doing it?

He brought it to work one day, rolled in a bundle under his arm. It was faded gray and uncomfortable­looking, a simple tank top made of itchy polyester and black Velcro straps. I surreptitiously stuffed it in my backpack and took it into the bathroom, where, after pulling it over my shoulders with some difficulty, I stared at my reflection in the full-length mirror. Like the first time my friend used the little word “he” to describe me, like the first time my father called me “Kofi” and “son,” the moment expanded seconds into days. My flat chest looked and felt so right as to not feel like a choice. I looked in the mirror and I saw, well, I saw myself.

I’m not going to mince words: binding has changed my life, but in my experience, binding is also terrible. Binders are extremely compression shirts that need to be tight enough to conceal breasts. They are extraordinarily uncomfortable, and unsafe if worn for long periods of time. I cannot wear my binder to the gym, I cannot wear my binder out in the sun or to the beach or if I eat too much. In fact, many people have asked me why I don’t just stop binding, why I don’t just take my binder off in the middle of the day if it makes me so uncomfortable. The short answer is that I can’t. At the end of the day, binding is not a sartorial choice. For me, it is a necessity. I cannot leave my house or go to work or run errands if I am not binding. Without my binder, I am uncomfortable to the point of nausea and distraction. At the end of the day, I am thankful to my binder for giving me the blueprint for the body I need, and it is through binding that I learned about top surgery.

Following the #binder and #binding hashtags on Tumblr (the great equalizer) led me to #topsurgery­related posts, and eventually to the transition blog of a young Polish trans man named Oliver. I spent hours scrolling through his posts: endless photos and low-quality webcam videos of his incision lines and his nipple grafts and the remedies he was using for the scar tissue​—​this is my chest at 1 week post­op​these are my nipples at 5 months post­op​… ​this is me swimming shirtless for the first time at 2 years post­op​. I familiarized myself with his body in what felt like the most intimate ways. It all felt so thrilling and furtive and intoxicating, and yet it seemed so impossible for me.

When I came out as transgender a year ago, I felt simultaneously relieved and terrified. It seemed as though one door flew open exposing a dozen trap doors where lived fiery chimaera and angry hippogriffs and other metaphors for Danger and Certain Death. I was Out, yet I still inhabited a body that on some days made it hard to go outside. I was Out, yet I was young and comparatively broke (how could I ever afford the $7000 minimum price tag for a double mastectomy?). I was Out, yet I felt immense pressure to wait for some Unbeknownst Amount Of Time before pursuing my medical transition. Hormones and surgeries seemed “too serious” for someone who had only come out as trans two months ago. I was Out, yet I have also suffered for a long time from depression, low self-esteem, and bouts of virulent self-loathing that often make it difficult to let myself have what I know I need so desperately.

But in August, with the support of my partner and friends, I began going to a community health center in Manhattan called Callen­Lorde to meet with doctors and therapists and receive a prescription for my hormones (I now take a weekly dose of testosterone cypionate as part of my medical transition). Among other services like general health care, legal services, and psychiatry, Callen­Lorde also offers case management for folks who have insurance questions or are struggling to receive the care that they need from their insurance companies. Callen­Lorde and its patients celebrated a victory in early December, when Governor Cuomo of New York had issued a statement reprimanding the private insurance companies who were continuing to deny medically necessary coverage to their transgender and gender non­conforming clients. In a letter to the insurance companies, Cuomo wrote: “An issuer of a policy that includes coverage for mental health conditions may not exclude coverage for the diagnosis and treatment of gender dysphoria.” In short, I might be able to afford the procedure I had been low-key obsessing over for years.

Armed with this news, I met with a transgender case manager in order to sift through the labyrinth of legalese that is United Healthcare’s transgender coverage policy. The social worker I worked with was a godsend and I left that conversation feeling empowered enough (with phrases like “now that New York mandates coverage for transgender clients…”) to make long, necessary phone calls to my insurance companies. Surprisingly, I encountered minimal hostility during these phone calls. The customer service folks were mostly just confused about the existence of transgender people in general, but after asking extremely pointed questions (i.e.​ Does my particular policy include coverage for transgender​ services?​) and some long stretches of hold music, I was able to receive answers about my policies.

After confirming that my policy excluded coverage for hormone ­replacement therapy (#boo) but partially covered certain surgeries (#yay), my next step was research. For weeks I created stacks and stacks of spreadsheets, compiling information about dozens of surgeons across the country. The charts included rows and columns of qualifiers such as: each surgeon’s location and distance from New York, the fees associated with each individual surgeon and hospital, the cost to fly and stay there for a week, whether the surgeon takes insurance, the contact info for their administrative offices, links to their websites and photos of their results, each surgeon’s requirements before surgery (some surgeons require patients to have been on testosterone for a year or more, or to have been in continuous psychotherapy for even longer).

While I was compiling this research, my therapist and I drafted my “letter of medical necessity” for top surgery, a crucial component required by my insurance company before they would even consider covering me. This letter is essentially a psychiatric diagnosis of gender dysphoria, along with professional rationale of the patient’s transition goals, whether they include hormone treatment or surgery or both or neither. In our sessions, my therapist and I spoke extensively about my childhood, my gender dysphoria, my transition, and my process of coming to know that I need top surgery. This drafting process took place over several months and over the course of many (expensive) sessions.

In the end, and months of research and hard work and waiting, my insurance approved my request. I am still paying steeply for surgery, dipping deeply into my paychecks and savings to afford the co-pays and hospital fees, and traveling across the country for a week. But, I am finally having top surgery and it is being paid for in­part by my insurance.

I am having top surgery in less than a month. Sometimes I wonder why I do this, why I blog my transition, why I write narratives explaining mundane phone calls and processes. But then I think about the kid I was a few years ago—desperately reading Tumblr entries about testosterone and top surgery while wishing for another life—and I know I’m doing this for him.

About KOFI- Kofi is a twentysomething Afro-Caribbean queer loverboy. His interests include navel-gazing, exposing the fragility of modern masculinity, and rugby football. He lives, writes, and sells hip eyewear in New York City.


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