Weird conflict about top surgery.

[ratherslowseal]

It seems maybe a little superfluous on this site, where discussion about sexual topics, especially uncomfortable ones, is a given, but I'll warn anyone reading that my post contains discussion about my sexuality and the sexualization of my pre-op chest. Please take care of yourself and click away if it is too discomforting or triggers dysphoria, and it is something you'd like to avoid.

I have been thinking about the current state and likely trajectory of the quality and legality of trans healthcare recently, and how to prepare myself for changes to my formal access to hormone therapy (I'll leave it at that, I'd rather not skirt the boundaries of what could get me or the site in trouble, as long as it's in my control). As I have thought about it, I've come back to thinking about the possibility of top surgery in the next six years, so long as I continue to have insurance coverage and that my insurance will cover a gender-affirming subtotal double mastectomy ("top surgery"). At present, there is no material barrier that would keep me from initiating the process to get top surgery.

I do not really remember if I have brought this up before on this site, but the one thing holding me back now is that I do receive sexual gratification and pleasure from my chest and the sensation it provides, which I would all but lose with standard top surgery, unfortunately no insurance will cover nerve preservation/reinnervation and you have to instead fork out the money (about 10k USD, IIRC) and later struggle for reimbursement. I am not sure if that is desirable or if I am in the position to realistically pursue that, even if I had the money or a loan.

Also, a "little" side tangent, I think that trans male and transmasculine communities put too much emphasis on getting your ideal surgery or transition. A relevant example would be encouraging people to travel, or consider traveling, to the "best" surgeon (at least for individuals in the US), usually on either coast. I am not denying the amazing care and innovations in trans healthcare these surgeons or their teams provide and take part in (especially Dr. Scott Mosser and the GCC in California), but this is simply not a realistic option or expectation for most people. It is a financial privilege. This is even worse in discussions about bottom surgery, especially phalloplasty, but I don't read or engage in those so much as it isn't something I personally desire but rather a topic of interest and curiosity (and to support other trans people, there is no shortage of fearmongering about phalloplasty).

I enjoy touching my nipples, even through fabric or my K-tape (how I usually bind), and it is difficult to make a decision where I know I would never experience the same sensation again afterwards. The part of this that complicates my feelings more, though, is that sometimes (far less often now, it is somewhat related to how confident I am, I've noticed) I am aroused and masturbate to the fantasy of my chest being sexualized and myself being feminized/misgendered due to it. I have tried to limit my engagement with this interest of mine (I personally understand it as a kink, I know others would reject that language/its basis but I think it describes my relationship to it and its presence most succinctly), since I have noticed it does have negative effects on my self-perception and confidence if not kept in check. I'd guess that I developed this interest due to internalizing (to some extent) transphobia, specifically the idea that my masculinized, transsexual body is without value and undesirable, measuring myself to the standards of heterosexual men. This is also closely connected with the objectification of women's bodies and the beauty standards they are subjected to. I think a big reason I gravitated towards this interest is because I know that, to such standards, I am a relatively attractive person, and that all I'd need to do is to excise my transness to be superficially acceptable and desirable.

I think that the barrier to top surgery, then, is that going through with it means I would undeniably go against the grain of what is socially acceptable and desirable, instead of excising my transness I would be ridding myself of the ability to put on a costume of cis womanhood for temporary gratification (which usually ends with me feeling dysphoric, shocker). It is a stand against sexist and cisnormative standards, against transphobic rhetoric that am mutilating my "natural" female body, or whatever Abigail Shrier says.

Also, the list of negatives, sans the unlikely medical complication (which are usually minor and resolved with outpatient care, IIRC), is incredibly short compared to the massively positive impact that passively existing with a flat, masculinized chest would have on my well-being. There are three things on there, and really only one of them is meaningful to me (loss of nipple sensation), the second being that I would not be able to breastfeed if I could ever afford having a child (which isn't guaranteed to be viable anyways, and also carries mental health risks for me, so it isn't at all worth it to forgo top surgery just to have that option when I know the alternative is better), and the third being the previously discussed topic.

Thanks to anyone for reading my too-long rambling. I don't really have any other trans friends or community that I can really talk to about this that I think would get it. I know my boyfriend (who is cis) would be supportive and listen to me, but I think I would benefit a lot from connecting with other trans people, especially trans men, about this topic.

[Heather]

Hey there, ratherslowseal.

I picked this one up in part because you're feeling, thinking and saying some things that have gone through my own head about top surgery, too, so I hope maybe it's helpful to hear from someone who has had some similar feelings and conflicts. I don't think any of this is weird, by the way. Doing permanent things to change our bodies is often complex and far-reaching in its complexity, because, of course, our experience of our bodies is so far-reaching and complex, not to mention super personal.

To give you a little background about me and my body before I say more, I have large breasts I don't bind, and I have long experienced people looking at them then immediately misgendering me because in their minds, big breasts they can see must = a woman. My own body, by itself, and in the presence of people who don't gender it, doesn't usually cause me any kind of dysphoria, I only experience that when people use it to gender, and misgender, me. I'm agender, and I also don't feel or believe there is actually a "masculine" or "feminine" way bodies can look, despite understanding that many people, if not most, feel differently than I do about that. I feel like those just happen to be two arbitrary categories people have divided people and personality traits and appearances and bodies into, and as someone who is nonbinary and agender, for whom those categories feel as bonafide as say, calling the same things "red" or "blue" there just isn't such a thing as my having a body that doesn't "match" my gender both because I don't really have a gender and my body, in my mind, obviously is the right body for my gender because it's the body I am in. It probably stands to mention that I have had to have a bunch of non-elective surgeries since I was a kid, so I'm never going to be someone racing to get a surgery I don't have to, and that's before we even get to how I'd raise money for yet another.

Like you, I also experience a great deal of pleasure with my chest as it is. I also am right there with you when it comes to everything you've said about the costs and cultural expectations, though. At the same time, even though I personally resent that it's even something for me to think about given that I don't myself experience dysphoria with my chest, I have thought a lot about what it might be like not to be misgendered quite as often or as easily (I still would have a very hourglass body, and there's nothing that can be done about the rest of it as far as legible gender and people's assumptions are concerned, thus the "often"), and there are times when it sounds really, really lovely. But for me, it's still pretty clear it just isn't the right thing. It probably won't ever be, but who knows. I say that about bangs, and yet, every decade or so I find myself growing the dang things out again.

I've had a really long time to think about this, though, decades now, since top surgery became something that is within more people's reach. That time has also allowed me a lot of time and experience to explore how all of this feels, emotionally and physically, and do things like really put my mind through what top surgery could or couldn't do for me, or how I'd even feel about going through another surgery and all that entails. Having also gone through a bunch of new body changes with menopause, that's something else that provided a bunch of food for thought.

I say all of that because you are so young, and I can't help but wonder if time alone won't go a long way for you here. In other words, it does sound to me like a big part of where you're at is that you just need more time to really land on a decision with this that feels very right to you. Right now, you've obviously got a lot of conflict around it, and it sounds to me like making a decision either way at this stage of the game would leave you without feeling like you were deciding on something that really felt solid to you, instead of still being surrounded by questions and what ifs.

I wonder if you have had any conversations with any surgeons yet? I ask that, because consultations are usually free, and could both answer a lot of your questions and give you a different context to feel out this choice in. Just sitting in the office having a conversation about this with an actual surgeon is pretty likely to add at least some clarity to your feelings, I think.

[sesmith]

Howdy ratherslowseal, another member of the Scarleteam weighing in here! When I started thinking about top surgery for myself I was also really worried about losing sensation. Even those with the capacity to pay for procedures to restore/preserve (I didn't) don't always have success. And I do sometimes miss it, which is something that's really important to acknowledge, because a lot of people gloss over that. For me, the overall benefit of a chest that aligned more closely with my relationship to gender was worth that cost, but I also spent a lot of time thinking about it. It sounds like you're running the same calculus and leaning in the direction of top surgery, but it's a scary leap because once it's done, it's done, but I wanted to reassure you that you're not alone. (And I agree with you that there's a lot of talk about the right way to be trans, which surgeries to get, etc.)

Your experience of integrating your breasts into your sexual expression (and sometimes feeling conflicted about it) also really resonates with me and highlights how frustrating society's attitudes around gender and what bodies are supposed to look like can be. You are not a bad or wrong person for finding pleasure here and this is also not an unusual experience. I'd note that this kind of gender play can continue after top surgery in a variety of ways (including, if you wanted, sometimes wearing breast prostheses, which I know isn't the same).

As Heather noted, talking with a surgeon is a really good idea, because you can discuss your options. Depending on the size and shape of your breasts, surgical techniques are always improving, so there may be more sensation-preserving options than you're aware of. You could also explore a reduction, which might let you balance the best of both worlds. You can always get revision surgery later if you decide you want to further reduce your breast size. I also totally understand your fears about losing insurance coverage and that is something to talk about with a surgeon too. It may be possible to code the procedure differently (e.g. a reduction for medical reasons, or a surgery to reduce breast cancer risks) so your insurance will cover it. That would also mean that it wouldn't show up in your chart as gender-affirming care, if that's a concern for you.

You're on the right path with asking around to learn more about how other people have navigated this. The more trans people you talk to, here and in other communities, the more balanced and diverse the responses, which I think you will find really helpful for honestly assessing if you want to take this step, and what it wold look like.

You may find my Trans Summer School: Subtotal mastectomy (“top surgery”) article helpful too!

[ratherslowseal]

I say all of that because you are so young, and I can't help but wonder if time alone won't go a long way for you here. In other words, it does sound to me like a big part of where you're at is that you just need more time to really land on a decision with this that feels very right to you. Right now, you've obviously got a lot of conflict around it, and it sounds to me like making a decision either way at this stage of the game would leave you without feeling like you were deciding on something that really felt solid to you, instead of still being surrounded by questions and what ifs.

I have come to think similarly, but I need to clarify a couple things that I evidently did not elucidate in my original post. It's not that I am unsure if top surgery is ultimately right for me or not. I absolutely wish to passively exist with a flat chest, where I don't have to flatten my chest tissue with a binder or tape to force myself into the right shape, where I can just be as I am meant to, as is right for me. It's not an "if", it's really a "when". The thing is that it is uncertain for how much longer I will actually have a choice to "postpone" it before that choice is entirely taken away from me. Pursuing top surgery before my emotions are worked through and all that is left is need as I wait for a surgery date could have some negative emotional consequences, like I'd be taking everything at once, instead of little by little. But I feel that the regret I would carry with me over not acting on such a chance, even if an unideal one, outweighs the likelihood of some kind of temporary emotional turmoil. What if the only choice I will ever have is a premature one?

I think it would be helpful to schedule some consultations, though those conversations would be happening in a video call rather than an office.

[ratherslowseal]

I think I may have failed to properly communicate the conflict that I am experiencing regarding the sexualization of my pre-op chest. While in the moment I may be aroused by it (and that is a very important detail), afterwards it almost always (though I don't really remember a case when it didn't?) triggers dysphoria. The conflict here is not really between two authentic pieces of my identity or presentation, but between my identity and the cultural imposition of misogynistic and objectifying beauty standards, the control of women's bodies, transphobia, and cissexism, which here culminate in pressure to detransition and to forgo elements of my transition. It is a conflict that plays out internally, except the antagonistic element, despite being foreign to my authentic self, finds an accomplice somewhere within me.

I don't mean to say that all engagement with this form of gender play is necessarily negative, or even that it is necessarily negative for me as an individual (though I have benefited from keeping a level of distance between it and myself). But, I cannot neglect that I am influenced by the society and culture in which I live, and it undeniably colors my experiences with and attitudes to my transition. It is internalized transphobia.

In response to sesmith:
I am not very familiar with people requesting different coding for gender-affirming procedures, but I imagine my success with that would depend on my insurance's requirements for whatever procedure it is coded as instead. I have a relatively small amount of breast tissue and I have no family history of breast cancer, so if any kind of medical history or other proof is required then I'd have a very difficult time with that.

Also, just to clarify, a breast reduction is absolutely off the table (as well as inferior pedicle preserving techniques, e.g. "buttonhole" and "inverted-T/anchor", since for me they leave behind an unacceptable amount of breast tissue and have a pretty poor track record of preserving sensation, somewhere around 30% of persons reported a return of erotic sensation according to one paper I read, IIRC). Obviously you have no way of knowing this, but I am certain that it would be the absolute worst of both worlds for me. At least in regards to my circumstances, I don't think it's very safe to assume that I'll continue to have financial means access to a further reduction or revision after already going through a procedure.

[ratherslowseal]

Sorry to send so many responses in such quick succession, but I've evidently not been keeping up with things quick enough, because after doing some research, reading the FEHB Carrier Letter 2025-01b Subject: Chemical and Surgical Sex-Trait Modification Services for Plan Year 2026 Proposals and my own benefit plan brochure for this year, I have found out that I am actually already too late. I believe my HRT and endocrinologist appointments are only covered because I'm "mid-treatment", but we'll see how that could change. I guess it's time to start looking into how much I'd need to finance surgery in Turkey or Thailand or something, even though through the whole process of researching surgery methods and surgeons I knew I really did not want to travel if I could help it.

And I'm not on Medicare or Medicaid, and most of the discussion around gender-affirming healthcare being covered or not was about federal plans, not really private plans for federal employees, so I guess my inability to get myself together has completely fucked me over, and I mistakenly thought I was in a better position because I have the "good" insurance. Nope!

[Heather]

It's okay, and I think I've understood all you've shared here.

Do you have a healthcare provider or team who is specifically your provider for gender-affirming care? If so, I think this is the right person or team to bring all of this to at this point, particularly given what you've learned about your insurance. You can still consult with that provider, who should be able to both help you with figuring out what your options are and potentially having the kinds of conversations both s.e. and I were suggesting with a surgeon.

It's always so shitty to be trying to make medical/surgical decisions while also navigating the whole financial nightmare that is paying for them, even when insurance does cover some of it, let alone when it won't or when you don't have insurance, period. I've been there a few times and I'm sorry it's a place you find yourself in now. <3

[sesmith]

Thank you for providing this additional context!

You can definitely consult via telehealth for an initial appointment, and the surgeon may have some thoughts on funding assistance (including, again, coding the surgery as something that IS covered by insurance—surgeons who specialize in top surgery often have creative approaches).