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Trans Man Challenges Japan’s Archaic Gender Laws With Historic Legal Action

There are several reasons why a trans man might choose to have a Hysterectomy.

Satisfying a government’s archaic law shouldn’t be one of them.

Gen Suzuki, 46, has filed a request to legally change his gender without having to undergo surgery and be sterilized.

Japan implemented the Gender Identity Disorder (GID) special case law in 2004. Under the law, transgender people must meet five requirements before they can legally change gender. The individual must be at least 20 years old, not presently married, not have any underage children (under 20), must be sterilized and have genitalia that “closely resemble the physical form of an alternative gender”. In 2019, the Japanese supreme court unanimously upheld the law requiring trans people seeking to legally change their gender to be sterilized.

Reasons To Get a Hysterectomy

1. If there is a risk for cervical cancer and getting regular Pap tests isn’t possible, a Hysterectomy is recommended.

2. While there's no conclusive evidence suggesting that Testosterone causes cervical or uterine cancer, the fear of atrophic cancerous cells developing, especially if there's a family history of pelvic cancer, is often cited as a reason for having a Hysterectomy.

3. Hysterectomy is used to remove fibroid cysts (non-cancerous tumors), and as a treatment for endometriosis (the growth of the uterine lining outside of the uterus) and breakthrough bleeding, conditions that are commonly reported by trans men.

4. Abdominal pain can also suggest Hysterectomy. Testosterone causes atrophy of the uterus and vagina, which puts tension on surrounding muscles and ligaments which can cause painful cramping.

5. Another strong indication for Hysterectomy is failure to practice safe sex, risking accidental pregnancy and sexually transmitted diseases.

6. Many trans men seek out Hysterectomy to eradicate the primary source of Estrogen production, to maximize masculinization from Testosterone.

7. Another strong indication for gender-affirming Hysterectomy is to provide a feeling of wholeness and completeness. While not all trans men are bothered by having a uterus, others find its presence to be an acute source of gender dysphoria, and Hysterectomy can help align internal anatomy with external identity.

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Should You Keep One Or Both Ovaries?

Hysterectomy surgery removes the uterus, and may also include the removal of the cervix, one or both ovaries (oophorectomy, bilateral oophorectomy) as well as the fallopian tubes (bilateral salpingo).

In the past, trans men weren’t offered the option of retaining their ovaries, but it’s now common to choose to keep one or both. If you’re on the fence, here are some things to consider.

Retaining One or Both Ovaries:

Keeping one or both ovaries maintains natural hormone production, which may be helpful if you choose to not take testosterone, plan to stop taking testosterone in the future or have concerns about access to testosterone.

If there's a family history of severe osteoporosis, keeping one or both ovaries is worth considering.

If you keep one or both ovaries and stop taking testosterone, ovulation will return (for those who are pre-menopausal).

After Hysterectomy, removing ovaries and treating ovarian cysts and fibroids is more technically difficult.

Removing Both Ovaries:

Removing both ovaries lowers the risk of gynecological cancer, especially if there is a family history of the BRCA gene.

Removing both ovaries also eliminates the development of ovarian cysts and drastically reduces production of estrogen.

Removing both ovaries results in a total loss of fertility. If you wish to have your own biological children in the future, you can do egg retrieval before surgery or keep one or both ovaries and do egg retrieval at a later date.

Isn't life long HRT required if the ovaries are removed?        

"Long term HRT is not required. There is a whole population subset of patients not taking hormones. Yes, they are susceptible to osteoporosis but there are other non-hormonal medications for prevention and/or treatment. If a patient wants estrogen on board then keep the ovaries, but if estrogen causes dysphoria, then using hormone replacement therapy with preferred testosterone would be better. Testosterone helps prevent osteoporosis. I ask patients that if they were without hormones, which one would they prefer to be on. If it's testosterone then they should continue testosterone. The ovaries would not provide any benefit." — Dr. Heidi Wittenberg

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Years spent undiagnosed. Dismissed and dissed by doctors. Ineffective hormonal and surgical treatments.

Cori Smith was assigned the female sex at birth but says he always felt like he was in the wrong body. The 27-year-old Rochester, NY-native, and transgender man says living life with endometriosis while facing ignorance, hatred, and stigma from his peers and caretakers alike, because of his transition, has compounded his suffering from the disease.

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Vaginectomy: Critical Info for Trans Men

In the context of gender-affirming surgery, Vaginectomy is a Colpectomy plus a Colpocleisis.

Colpectomy involves removal of the vaginal lining, or epithelium;

Colpocleisis is the fusion of the vaginal walls, which creates support for pelvic organs.

The vagina itself isn’t removed though that is done in cancer surgery. In that context, a partial Vaginectomy removes part of the vagina (upper or lower vagina) while a total Vaginecomy removes all of the vagina.

There are several reasons why trans men and non-binary individuals opt to have a Vaginectomy, including:

The desire to have the vagina removed and have a male perineum.

To eliminate the secretions produced by vaginal mucosa.

To eliminate pain from a gynecological condition.

To eliminate the need for speculum exams or Pap tests.

For many years, Vaginectomy endured a reputation for being a very risky procedure—so risky, that many surgeons refused to perform it and even discouraged trans men from seeking it out, citing major intraoperative bleeding and bladder perforation as high risks.

Recent reports from surgeons experienced with the procedure indicate that with modern techniques Vaginectomy may not be as risky as previously thought, and can reduce complications associated with urethral extension. By eliminating vaginal secretions and improving blood flow to the urethra by fusing the vaginal walls, the surgical sites—especially the critical urethral junction—heal better.

A 2018 journal study confirms that Vaginectomy decreases the rate of urethral fistulas.

"A urethral fistula developed in 111 of the 232 patients (48%)  without Vaginectomy and in 13 of the 62 (21%) who underwent primary  Vaginectomy. Secondary Vaginectomy resulted in 100% fistula closure  when performed in 17 patients with recurrent urethral fistula."

Because of this, many--but not all--surgeons now require a Vaginectomy for patients undergoing Metoidioplasty or Phalloplasty IF Urethral Lengthening is being performed.

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How a Routine Hysterectomy Lead to the Death of a Trans Man

When Rowan Feldhaus passed away from complications following a hysterectomy in May 2017, many were asking, "How could this happen with such a routine surgery?" There are more than 600,000 Hysterectomies performed each year in the United States, making it a very common procedure. While serious complications can occur with any surgery, the death rate from a hysterectomy is very low—less than 1%—so what happened in Feldhaus' case?

The Augusta, Georgia news station that broke the story of Feldhaus' condition reported that he went into septic shock a few days after surgery, lost oxygen to his brain, and went into a coma before passing away. Septic shock is a life-threatening condition that causes organ failure and dangerously low blood pressure brought on by a severe infection that has spread through the bloodstream. While not all details are known, it's possible that Feldhaus developed an infection after surgery that went undetected until it was too late. He was just 25 years old.

A 2010 study reported that the risk of infection following Hysterectomy is about 8%. A 2013 study further described infection risks by Hysterectomy technique:

Infectious complications after hysterectomy are most common, ranging from 10.5% for abdominal hysterectomy to 13.0% for vaginal hysterectomy and 9.0% for laparoscopic hysterectomy.

Safety of Hysterectomy

What kind of complications can occur after a Hysterectomy and how common are they? Infection, bleeding and needing a transfusion, injury to other structures like the bowel, bladder or ureter, possibly resulting in more surgery and/or a longer hospitalization. Thankfully, the equipment used now is very advanced and helps make surgical problems very rare.

How do the risks compare between each of the common Hysterectomy techniques? Hysterectomy is most often performed with a large incision in the lower abdomen and can also be done vaginally or laparoscopically. The complication rates are about the same with each technique with the main difference being a faster recovery with the last two approaches.

How dangerous are these complications? An injury to the intestines or bleeding need to be diagnosed quickly or else serious complications, including death, can occur.

Are there ways that I can lower the risk of complications with my Hysterectomy? The most important aspect to lowering the risks is to pick a gynecologist with more than 10 years experience to perform your Hysterectomy, preferably a transgender specialist.

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Why Trans Men Tend To Have An Easier Hysterectomy Recovery Than Women

What you read online about Hysterectomy recovery may not be accurate as it relates to you because most of the available information has been created for and is based on the experiences of cis gender women. Trans men typically have easier recoveries from Hysterectomy due to a number of factors.

1. Age: Trans men are typically younger than the average woman having Hysterectomy and therefore may have an easier recovery.

2. Reason for surgery: Trans men are often thrilled at the prospect of Hysterectomy, while women commonly suffer from deep sense of loss. Science has proven that a positive attitude during recovery can ease recovery. 

3. Supplementary hormones: Most trans men already on HRT by the time they have a Hysterectomy, reducing—and even eliminating—surgical menopausal symptoms.

4. Strong abdominal wall: In addition to being younger, many trans men seeking Hysterectomy have not carried and birthed a child so the abdominal wall is strong, which eases post-op mobility and also makes it easier to rebuild lost abdominal muscles after surgery.

In a 2010 study, recovery time for transgender men after Hysterectomy ranged from less than one week to more than eight weeks with a mean of approximately four weeks. Respondents were less likely to experience bladder problems following laparoscopically-assisted Hysterectomies (less than 1%) than following abdominal procedures (24%.) They also had a more rapid recovery and were able to more quickly return to work and daily activities.

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Will My Sex Drive Be Affected By Hysterectomy?

Many trans men are rightfully concerned that having a Hysterectomy will cause irreversible changes in sex drive. Here's what a 2010 study revealed:

About half of 118 individuals (56%) who answered the question of whether or not their orgasms had changed since surgery said that there was no change.

About one-quarter (25%) said that sexual response was better.

About 6% said that sexual response was worse.

The remaining 11% said that it was “different” and reported more complicated experiences.

An open question invited individuals to describe changes:

One respondent who reported more intense sexual responses described those changes as “bigger,” with “more build up” and that orgasms were “longer lasting.” Another respondent who reported less-intense sexual responses following surgery described his post-surgical orgasm experience as “short, not deep” and “boring” compared to before surgery, which he described as “body-shaking, deep, and long-lasting.” Some respondents ascribed the different experience in their orgasm to increased comfort with their body.

"Not surprisingly, since surgery is often part of the process of identity affirmation, many trans men have reported improvements in sexual pleasure after [hysterectomy].” (O’Hanlan, 2007).

These results are not unlike those found for cis gender women. A 1999 study looked at the experience of 1,101 women prior to and after hysterectomy. They found that “sexual functioning improved overall after hysterectomy. The frequency of sexual activity increased and problems with sexual functioning decreased” (Rhodes et al., 1999, p. 1934).

If you've had a hysterectomy, have you noticed any changes in sexual response since your surgery?

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Hysterectomy Pain Management Tip

If you’re having Hysterectomy surgery done in the USA, you will most likely be prescribed Percoset or Vicodin for post-operative pain management once you leave the surgery facility.

It has been said that any surgeon prescribing Percoset or Vicodin for hysterectomy patients has probably never had a Hysterectomy themself!

This is because Percoset and Vicodin cause constipation which can cause a lot of pain immediately after Hysterectomy, and can also put stress on the healing wounds, resulting in further complications.

If constipation has already set in, it can be remedied by diet and/or stool softeners or stimulant laxatives, but it can also be largely avoided with one simple request of your surgeon: ask for Tramadol instead of Percoset or Vicodin.

Tramadol, aka Ultram, is a synthetic opiate. It is considered a relatively weak opiate but it is prescribed to treat moderately severe pain.

What’s the benefit?

Constipation is less common with Tramadol and less pronounced than with other opioids.

Tramadol appears to produce less constipation and dependence than equianalgesic doses of strong opioids.

Being in pain during Hysterectomy recovery makes healing more difficult so staying on top of pain management is important, but if you’d like to avoid the all too common problem of post-hysto constipation, talk to your surgeon about whether or not Tramadol would be a good option for you.