One Week until SRS

[Guest vtphoenix]

Ok, so it's technically a little longer than a week. My surgery is July 2nd and I leave for Montreal on the 30th. I just had my last therapist appt before it all goes down and I'm feeling really excited. I started a topic a couple of weeks ago about SRS fears and since then things have been going really well, pretty much nothing except excitement. Until the last couple of days.

It's been a roller coaster and all kinds of thoughts are going through my mind. I compared it to checking and rechecking a difficult math problem that you can't afford to get wrong. It's not like I have "doubts" per se. I'm actually feeling pretty confident that it's the right choice. I just have an epistemological tendency toward skepticism: how is knowledge known? I mean, mistakes are sometimes borne of doubt, that's what I think most of us believe, but it's actually been my experience that more mistakes are borne of certainty. So I'm just trying to be as brutally honest with myself as I can be as this defining moment approaches.

What I've come to find is that I've been thinking of SRS as being about this big thing - giving me the body form that I desire, but it is actually easier for me to grasp when I think of it as being about a bunch of little things.

I have learned to cope with my this body and I feel like if something goes wrong with the surgery, that I'll beat myself up: why did I do this when I was getting by without surgery?

But sometimes little moments lately strike me in a particularly profound way.

Today, before my therapist appt, I went to the mall with my partner and she bought me this beautiful dress. The man running the store was really nice to us and interacted with us in a perfectly normal way. I'm trans and my partner is a GG but, in that moment, we were just a couple of normal girls shopping. I went in the fitting room to try on the dress and it was absolutely beautiful and I looked so pretty (I don't always feel that way!) and, as my eyes went from my face and shoulders to my breasts and lower, suddenly I was struck by the sight of this out of place bump and I was like "Oh... there it is..." and it sort of took me out of that wonderful moment.

I could list a ton of reasons why I'm having surgery, and being comfortable with my body is the big reason that most people, even non-trans ones can easily comprehend, but what defines this comfort? Infinite little moments where I can feel normal, beautiful even, without the painful reminders of my past.

All of us can do better than to just "get by."

~Ashley~

[Guest LizMarie]

Don't settle for "getting by", Ashley. Out thoughts and prayers go with so many of you right now. You, Nova, Lizzie, DJ... You're an angel and you're going to get your wings. Soar!

[Guest Jade T]

Ashley,

I am so happy to hear about your upcoming surgery! I hope, no, I WILL one day get SRS so I too can be like you and so many others so I no longer have to "just get by" and live my life fully as I was meant to. I hope you speedy recovery after the surgery and that you enjoy your life post surgery.

Jade

[Guest DesiB]

Skepticism is a major part of my thought process as well, Ashley. But since you're accustomed to it, I expect that it will actually help you get through the next few months of surgery and recovery. Skepticism implies patience and taking time to get to comfortable with all the experiences used for building that never complete database we like to think of as knowledge. It would be nice to just wake up after surgery and have all the bad things from the past erased as if you were born a perfect female from the start. But we don't get that option. Still, by the time you've put in so much time and effort into your transition, surgery, recovery, and have given your body time to heal and adjust hormonally, emotionally, etc., you will have so many days ahead to enjoy your life more completely than you've ever been capable up to the present. I wish you nothing but the best!

[Guest angels wings]

Wow not long now how exciting wishing u all the best Ashley (((((hugs))))))

[Guest Juniper Blue]

HUGS!! You have our love and Support!

[Guest]

Hi Ashley,

I'm always so overjoyed when someone finally makes it to thier surgery. It's such an immense undertaking and you're right there on the doorstep. Of course, we'll all be right there with you, and will be waiting to hear from you after the big day.

Like you, I've been trying to understand why this surgery is so necessary. In so many ways, I can't justify it - the expense, the pain, the risks. But there is a huge balance on the other side - mostly intangible. How I look, how I look to others, how I perceive myself, how others perceive me. It's so hard to put a value on that - it's just priceless.

Where you lead - I hope to follow. All the best to you!

Love, Megan

[Michelle 2010]

I just have an epistemological tendency toward skepticism: how is knowledge known? I mean, mistakes are sometimes borne of doubt, that's what I think most of us believe, but it's actually been my experience that more mistakes are borne of certainty.

Well. I have no doubt I have never heard Epistomology and SRS discussed in the same paragraph before!!! Of that I have absolute certainty! Very cool...

Wishing you all the best on this journey... And btw, I agree there have been some monumental mistakes in history borne out of absolute certainty. Maybe thats where the term "healthy skeptisism" comes from? But thats a topic for another day. We can discuss it after your surgery!

Best wishes

Michelle

[Guest vtphoenix]

Well. I have no doubt I have never heard Epistomology and SRS discussed in the same paragraph before!!! Of that I have absolute certainty!

hehe, thanks! I guess I'm just weird that way lol

[Guest CallMeKatie]

Yay, how exciting for you! I hope everything goes well with the surgery. I couldn't imagine the how excited I would be if I was in your shoes. Anyway good luck and keep us updated!

[Guest Jenny C]

Ouf... My heart is pounding.

You are there. Almost.

Thank you for our honesty. I certainly understand the notion of doubts.

Life is a oneway trip. You just bought the biggest ticket...

My heart is with you.

My words just can't justly express my empathy.

Love,

Jenny

[Drea]

I would tend to agree that questioning means one is more open that absolute certainty and thus less likely to make an error.

Someone who was absolutely certain that SRS was right for them from the days before starting to transition all the way thru without ever questioning isn't giving it due thought. Some personality types are prone to expressing this sort of thing such as narcissistic types.

Someone willing to question is more likely to stop themselves, but the key is how one deals with the questions and one could also classify questions differently than doubts. There are plenty who have had doubts, didn't feel the need for SRS, but proceeded anyway only to find out that, for them it was more work than was worth it.

[Guest vtphoenix]

Frankly, I think the subject of doubts and SRS is all semantics. I looked up the word doubt on dictionary.com and it says the following:

1. To be undecided or skeptical about: began to doubt some accepted doctrines.

2. To tend to disbelieve; distrust: doubts politicians when they make sweeping statements.

3. To regard as unlikely: I doubt that we'll arrive on time.

4. Archaic To suspect; fear.

And it lists "uncertainty" as a synonym.

So it is pretty much impossible to be a Skeptic in the philosophical sense and not entertain doubts about SRS, because a Skeptic lives constantly with the idea that there are no certainties. I think that that is just the nature of life.

Also, people have said they have "fears" not "doubts", which I sort of get, I've said the same thing myself, but isn't fear just a different type of doubt? Like not in doubt about wanting to have the right body but doubt about whether it is possible and what the cost might be. In the book, "Rules for Radicals" by Saul Alinsky, this is what he describes as the essence of a person of action - that they look at means and ends pragmatically, asking of ends only if they are achievable and of means, if they are worth the cost.

In statistics, "uncertainty" is defined as "The estimated amount or percentage by which an observed or calculated value may differ from the true value."

So one can hardly argue that the whole process from coming out, to RLT, to SRS, has a degree of inherent uncertainty. It's all probabilities - which are reassuring perhaps if they are in your favor but not so much if you "beat the odds" and have some horrific surgical complication.

What we do know is that the best predictor of SRS satisfaction is the surgical outcome itself. But obviously we can't know the outcome. So uncertainty i.e. doubt seems to me like actually the only option for a rational person. And I say this because I don't like the party line that we habitually repeat about how we're so very certain, and I've often been made to feel less legitimate if I have voiced doubts or concerns or fears or uncertainties (which are all really different words for the same things - let's be honest).

That's why I started a thread on SRS fears when I first came here, because it seemed like a taboo subject (why?) and it made me feel like something was wrong with me because yes, I am worried that I might get a fistula, or just not enough depth, or even that having a vagina might not be all it's cracked up to be. So what? I'll say it and risk people thinking that SRS might not be right for me but hey, I've discussed all this with multiple therapists and shrinks, and they think my stance is pretty balanced and reasonable on the whole thing.

There are desperate people out there and they do desperate things. There are also young people who think they're invincible and old people who have lived much longer than I have who are in an entirely different place when it comes to fear. My point is that it sucks. Lately I'm feeling like I should just keep my mouth shut. Both trans and non-trans people act the same way like "OMG well you don't have to do this!" and it just frustrates me so much because I DO want to do this. But my life is in a pretty good place, I just want to fix this thing, not inadvertently make my life worse because I have to wear a colostomy bag, am in chronic pain, or can never have an orgasm again.

So I hope writing this will help someone else who's rational enough to accept that there is actually some danger here and has some concern about it - or doubt, or fear, or uncertainty, or questions, or whatever you want to call it.

Basically, I think it's all about figuring out if you want it, then weighing the risks and guaging whether they are acceptable. I would say doubts about the surgical result itself are probably pretty normal even if people don't want to talk about them.

[Drea]

What we do know is that the best predictor of SRS satisfaction is the surgical outcome itself.

We do know this? I have to say it is the first I have heard that. I would say the biggest predictor of satisfaction has more to do with what\ one's expectations fr what SRS is Both concious and subconcious expecations. I seen more than a few harbor some subconcious expections that it will somehow sole their passing or employment problems.

I feel realistic expections for surgical outcome is important as well as not expecting it to solve social problems. To go into it seeking nothing more than personal comfort with ones body is the healthiest way to view it.

This of course is easy for me to say because I am not the one with plans for surgery.

[Guest vtphoenix]

I'm looking for the studies that back that up right now, Drea. There isn't a lot of data on this subject. I was saying that in another thread - we need more. I do believe very strongly that surgical outcome is the most important factor though. For one thing, even in studies that don't explicitly look at the surgical outcomes, the regret percentages roughly match the percentages of the worst-case surgical results: 2-3 percent. I can tell you that it's at least true in my case anyway. If I have a good surgical result, I am pretty convinced I will be happier. On the other hand, it would be hard not to "regret" SRS if I had a terrible surgical result.

[Drea]

I am glad you didn't take my differing point of view personally.

Evidently surgical result is important to you. I do not know what you consider a good surgical result verses bad. There are many ways such can be defined after all. Is a good result one that is cosmetically pleasing, or is it ability to orgasm? or is it depth? or is it mearly not having a complication? You don't need to answer that. I am just illustrating that "good" is a subjective definition that is rooted in one's expectations.

I mention expectations as the key predictor as expectations will determine if it meets one, well to be blunt, expectations. Which in turn also will affect if one thinks it is good or not. It isn't just a matter of semantics, it is stepping back one level.

Interestingly, recently there was a post of a study on the surgical outcomes. An actual study of cases involving more than 100 surgeries (I think it was closer to 200 or 300 SRS surgeries). Not some article paraphrasing study results and putting its own spin. If I read the study corrrectly it suggested there were complications in somthing like 40% of surgeries. That seemed high to me. It was a german study as I recall and only looked at local surgeons.

Certainly a complication will tend to increase one's dissatisfaction, but I would hope that only be a short term thing rather than a long term outcome.

[Guest vtphoenix]

Ok here is one: http://www.tsroadmap.com/info/lawrence-vaginoplasty.html

Here is one pertinent section:

"No participants reported consistent Regret, and only 15 participants (6%) were sometimes regretful. All regretful participants provided explanatory comments. Eight regretful participants cited disappointing physical or functional outcomes of surgery as the reason for their regret (e.g., "After losing my clitoris, I entered a deep depression. Feeling is severely diminished."), while five others cited familial or social problems (e.g., "I miss my family and children. I am an outcast in my family."). Only two participants (1%) reported reversion to living as a man after SRS. Both these individuals lived part-time as men but most of their lives as women; in both cases their reversions were minor and infrequent (one presented as a male only to play golf; the other was retiring from a professional career and sometimes presented as a male when seeing clients). One of these two participants was sometimes regretful."

And this:

"Happiness With Result

No preoperative variables related to transsexual typology showed significant correlations with Happiness with Result. Two variables associated with compliance with accepted treatment regimens showed significant correlations: duration of real-life experience, which was positively associated with happiness, and the dichotomized variable preoperative psychotherapy ∗12 hr, which was negatively associated with Happiness with Result. However, the continuous variable from which the latter was derived, amount of preoperative psychotherapy, did not show a significant correlation. Among postoperative variables, amount of postoperative psychotherapy was significantly and negatively associated with Happiness with Result. Number of significant surgical complications and Functional Index both showed moderate-to-large correlations with Happiness with Result, in the expected directions.

Effect sizes were small for significant preoperative predictor variables. For duration of real-life experience, arguably the most meaningful of these, the amount of variance accounted for (r _s²) was 2.3%. By contrast, for the postoperative variable Functional Index the amount of variance accounted for was 24%"

This is actually probably also useful for that other discussion: SRS without RLT. Here you have some actual number. RLT did make a difference, a 2.4% difference. As I had stated in that thread, it is my belief that if RLT doesn't cost us anything, then any non-zero increase in the likelihood of post-op satisfaction makes it positive Expected Value. But still, 24% is TEN TIMES higher. So yes, I stand by surgical result as the best predictor.

What would I consider a bad surgical result? Anything that affected the long-term outcome. And of THOSE possibilities, orgasm is lowest on my list, while anything that would cause a loss of the vagina would be highest: necrosis, vaginal prolapse, uncorrectable fistula with a permanent colostomy bag to name a few.

[Guest vtphoenix]

Oh, the study you're talking about has issues, not the least of which is that it studied people who reported back within a certain timeframe. The study itself mentions this flaw in its methodology stating that people are much more likely to report back when things go wrong rather than when things go right. The 40% is not based on the total number of people who had surgery, just the number that came back later who they were able to talk to.

[Guest DesiB]

So one can hardly argue that the whole process from coming out, to RLT, to SRS, has a degree of inherent uncertainty.

I assume you meant the opposite.

Regarding research into human subjects, especially the tiny subcategory of transsexuals, there are no faultless methods. Such research is more suited to qualitative than quantitative research, meaning it is rarely generalizable. We have problems of sample bias, reliance on self-reporting, and I won't bore you with a comprehensive list of methodological issues making this entire topic of research informative, yes, but nowhere near reliable if certainty is the goal.

[Guest vtphoenix]

Desi, I had to read that sentence multiple times before I realized how I had worded it wrong lol but yes, I meant the opposite: one can hardly argue that SRS etc DOESN'T have a degree of uncertainty.

I just don't like how people link fear with not wanting something, or that something not being right for someone. My therapist can question my motives, that's what she gets paid to do, but I hate it when strangers do this without even knowing me. When people in the trans community do it, it's even worse, because it makes me feel all alone in my fears like I am abnormal even among an already small subset of people. But just like other things in my life (like being trans itself), I am learning to own my fear and not be embarrassed about it.

Yes I am afraid of pain, yes I am squeamish about blood and body fluids, yes I'm scared of staying in a hospital so long and being away from home, yes I am scared of complications and a poor surgical result, yes I'm scared of dilation (what if I don't do it right? or hurt myself?), and yes I'm even scared that after wanting this my whole life that I won't find the inner peace that everyone else finds. But I think a lot of these fears are because of one simple thing: I never thought I'd be at this place and I'm just afraid it's all too good to be true.

When the fear rears its ugly head, I just try to remind myself that I am a winner, that I've overcome a lot to be here, that I do deserve this, and I'm strong enough to take this last step, which is actually still probably not as scary as it was to take that first step (coming out).

[Guest KimberlyF]

Ok here is one: http://www.tsroadmap.com/info/lawrence-vaginoplasty.html

I like to know who publishes a study. The one you linked to was done by Anne Lawrence. TS roadmap provides info and allows you to make your own decisions.

This study may be accurate though and may have been a tool she was using to show most of us suffer from autogynephilia. Look at the numbers on that!

This is a paper by her the following year:

http://www.annelawrence.com/amputation-GID.pdf

"Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some

researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder or

transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female

(MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the

conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the

sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body

type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R.

Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location

error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies."

[Guest vtphoenix]

Kim, I'm not sure what you're trying to say...

Is that some kind of ad hominem argument against the study? Andrea James and Anne Lawrence have a... complex history. But Andrea still felt it helpful to link Anne Lawrence's work, so clearly she can see the distinction between Anne's character as a person and Anne's research.

I'm not sure how linking regrets to surgical results would support her autogynephilia theory and besides, I think her research into autogynephilia is fascinating, it's just that she and other researchers have made the classic mistake of taking a theory that works with SOME people and trying to apply it to ALL people.

But anyway, that is neither here nor there, as I've seen similar findings in other studies - I just couldn't find them right off last night and it was getting late. I actually think we should all be thankful that a) people are studying this and that there is less reported regret from SRS than there is from virtually any other major life-changing decision.

Now, I'll be the first to admit that wanting something to be true is not the same thing as something being true, but many people seem to want to believe that psychological factors more commonly lead to regret than the surgical outcome itself - and amazingly, some of these people are skeptical of RLT's impact!

But if we see ourselves as women and we want to have vaginas to put our bodies in line with this inner identity, then why would we expect someone to be happy with a surgical result that is less, especially much less, than an average vagina?

I wonder what the consequences would be if it became accepted thinking that surgical outcome is the #1 factor that will determine your post-op happiness? (I thought it already WAS accepted...) On the positive side of things, would we get higher quality surgical care? On the negative side of things, would we see less psychological screening? Should we even count that as a "negative", I mean if psychological screening is found to make little to no difference in post-op happiness? What about the hijira and other trans people who are willing to have primitive surgeries? Where do they fit in to this paradigm of surgical results being the most important? And if they don't fit in to this paradigm, how are they able to be happy with poor surgical results when many people in Western culture aren't? Is it because our culture is more demanding?

I honestly don't know the answer to these questions. Obviously, if there was more data, we could have a clearer picture of things but most of the information I possess on that subject is anecdotal. I don't know of a single person who regrets their surgery because they were "not trans enough" but I know of many who regret it because they had a worse surgical result than what they expected. I know I have just one perspective to offer but I'm not sure why the burden of proof would be on me to show otherwise. If there were more examples of post-op people with severe permanent issues who did not regret their surgeries, then I could be persuaded to believe otherwise.

But on a deeper level, it doesn't really matter, because SRS is a profoundly personal experience and my reasons for having it and for being satisfied or dissatisfied aren't necessarily going to be the same as anyone else's.

[Drea]

Ok here is one: http://www.tsroadmap...ginoplasty.html

Here is one pertinent section:

"No participants reported consistent Regret, and only 15 participants (6%) were sometimes regretful. All regretful participants provided explanatory comments. Eight regretful participants cited disappointing physical or functional outcomes of surgery as the reason for their regret (e.g., "After losing my clitoris, I entered a deep depression. Feeling is severely diminished."), while five others cited familial or social problems (e.g., "I miss my family and children. I am an outcast in my family."). Only two participants (1%) reported reversion to living as a man after SRS. Both these individuals lived part-time as men but most of their lives as women; in both cases their reversions were minor and infrequent (one presented as a male only to play golf; the other was retiring from a professional career and sometimes presented as a male when seeing clients). One of these two participants was sometimes regretful."

And this:

"Happiness With Result

No preoperative variables related to transsexual typology showed significant correlations with Happiness with Result. Two variables associated with compliance with accepted treatment regimens showed significant correlations: duration of real-life experience, which was positively associated with happiness, and the dichotomized variable preoperative psychotherapy ∗12 hr, which was negatively associated with Happiness with Result. However, the continuous variable from which the latter was derived, amount of preoperative psychotherapy, did not show a significant correlation. Among postoperative variables, amount of postoperative psychotherapy was significantly and negatively associated with Happiness with Result. Number of significant surgical complications and Functional Index both showed moderate-to-large correlations with Happiness with Result, in the expected directions.

Effect sizes were small for significant preoperative predictor variables. For duration of real-life experience, arguably the most meaningful of these, the amount of variance accounted for (r _s²) was 2.3%. By contrast, for the postoperative variable Functional Index the amount of variance accounted for was 24%"

This is actually probably also useful for that other discussion: SRS without RLT. Here you have some actual number. RLT did make a difference, a 2.4% difference. As I had stated in that thread, it is my belief that if RLT doesn't cost us anything, then any non-zero increase in the likelihood of post-op satisfaction makes it positive Expected Value. But still, 24% is TEN TIMES higher. So yes, I stand by surgical result as the best predictor.

Yes that study is interesting however, the study didn't look at pre-surgical expectations compared to satisfaction or pre-surgical expectations compared to preceived surgical outcomes. Thus, it doesn't invalidate my assertion.

The correlation to surgical complications is of course understandable, and if one were to define abscence of surgical complications as a good result I would agree.

The functional index is interesting.

They also reported their experience concerning 19 physical and functional outcome variables, all rated on 11-point Likert scales from 0 (very poor, major problem, etc.) to 10 (excellent, no problem, etc.). These 19 variables included vaginal depth, vaginal width, vaginal lubrication, vaginal discharge, vaginal hair growth, sensation to touch at the vaginal opening, sensation to touch deep in the vagina, vaginal pain with penetration, vaginal itching, vaginal prolapse, vaginal erotic sensation, clitoral touch sensation, clitoral erotic sensation, clitoral pain, clitoral itching, discharge from around the clitoris, hair on or around the clitoris, urine leakage with cough or strain, and postoperative bladder infections.

The responses here will be significantly affected by one's expectations. One who was expecting a great cosmetic result may be extremely bothered by a few hairs and report that result category poorly while someone else with different expectation might say it is not a problem. If someone is expecting enough lubrication will likely list the lubrication measure poorly while most will rate it as no problem because they weren't expecting lubrication.

The functional index is the other item that correlates with incomes and as it is the only thing that comes close to expectations, there may be truth in both our positions.

This is actually probably also useful for that other discussion: SRS without RLT. Here you have some actual number. RLT did make a difference, a 2.4% difference.

In the text there is this statement:

Participants who, with the recommendation of their caregivers, underwent SRS after only a few hours of psychotherapy, with less than 12 months of preoperative hormone therapy, or with less than 12 months of preoperative real-life experience in the desired gender role reported outcomes similar to participants who had fulfilled these minimum requirements.

When dealing with studies it is risky to draw a conclusion about a side result and a study to test such hypothsis is usually warranted.

This study's author published this paper "SRS Without One Year RLE: Still No Regrets" on this subject.

http://www.annelawrence.com/2001hbigda2.html

In this she states:

The importance of the Real-Life Experience is probably the closest thing to a "sacred cow" that exists in the world of transsexual care. But there is surprisingly little empirical evidence that a one year real-life experience -- or indeed that any real-life experience -- is either a necessary or a sufficient condition for achieving favorable outcomes after SRS.

and

Finally, the present study is just one more reason why our Association should consider uncoupling the decision to change the sexed body from the decision to live in a particular gender role. It is possible to undergo SRS without regret after living in role for only six months. Perhaps for some persons it is possible to undergo SRS without regret without having lived in cross-gender role at all.

The information in this paper is not scientific proof by any means, but it doesn't highlight some existing assumptions. I also note this paper, like the previous study is somewhat dated.

I would really be interested in a follow up survey of the respondants to that study because it has been 10 years and a significant number of the respondants were in the post-SRS euphoria period. After another 10 years they have had opportunity to become more settled in their lives and develop a longer perspecive on their results.

[Guest KimberlyF]

Kim, I'm not sure what you're trying to say...

Is that some kind of ad hominem argument against the study? Andrea James and Anne Lawrence have a... complex history. But Andrea still felt it helpful to link Anne Lawrence's work, so clearly she can see the distinction between Anne's character as a person and Anne's research.

I'm not sure how linking regrets to surgical results would support her autogynephilia theory and besides, I think her research into autogynephilia is fascinating, it's just that she and other researchers have made the classic mistake of taking a theory that works with SOME people and trying to apply it to ALL people.

I said the research may be accurate and it could be a tool to push her other issues. Buy making a study about something else nobody pays attention to the fact that 49% of post-ops fall into her highest 'preoperative autogynephilic arousal' catagory. Does that make half the post ops autogynephilics? It could be a conclusion someone could take looking at the data from a study that isn't even about that!

Edited June 26, 2012 by KimberlyF
Last line removed at poster's request

[Guest vtphoenix]

Drea, the differences in our thinking on this subject stem largely from our own views on what is an acceptable risk. When it comes to SRS without RLT, you believe that 2.3% is small AND IT IS! I'm not arguing that! lol What I am arguing is that from a mathematical standpoint, there is no reason not to opt for a path that will give you this 2.3% edge IF the opportunity cost of RLT is low. That does not mean I think RLT is right for everyone, for some the opportunity cost is not low. However, the general rule is that the cost IS low (as RLT is in line with what most of us who transition want anyway). Of course, I'm a professional card player and game theorist - I get paid to write articles on the subject so you'll forgive me if that kind of thinking comes into play here.

I personally don't want to take a 2.3% risk if it is unnecessary. But for some it may be necessary. I understand that.

What doesn't make sense to me is that someone whose position is that RLT is just a "sacred cow" would disagree with the importance of a surgical outcome vs. pre-operative psychological screening. I'll agree that RLT is not a perfect measure of someone's psychological readiness for surgery, however, multiple studies have at least attributed a small correlation (such as this one's 2.3%).

Also, I'm not disagreeing that one's expectations have a large impact on how one views the surgery afterwards, but what does that actually mean? We certainly shouldn't have low expectations, but it's unreasonable to have expectations that go beyond where the current state of technology is at. But isn't this exactly one of the things that pre-operative psychological screening is there for? To make sure people have realistic expectations? Let's be fair, people who go for vaginoplasty are expecting to leave with a permanent vagina, most likely to help them function in society more like any other female, which means it looks like a vagina, it feels like a vagina, and it functions similarly to any other vagina. Since this IS what any person who goes for vaginoplasty is looking for, I think it is unfair to judge their unhappiness with a surgical outcome as being purely about some sort of unreasonable expectations. Why should anyone have to feel that something is "good enough" when it's not? Feelings are not right or wrong, they are just the way people feel. I sincerely sympathize with anyone who has a poor surgical result. They, and we, deserve better.