Finding a Path in a Broken System

Thailand is a top destination for gender confirmation surgery. Its success is a symptom of Western failure.

Mailee Osten-Tan | Longreads | June 2022 | 7,449 words (27 minutes)

 

CW: This story mentions depression, suicide, and isolation, and discusses different types of gender confirmation surgery and recovery procedures in graphic detail.

Go behind the scenes of this story in our Q&A with Mailee Osten-Tan.

As Amy (not her real name) walks toward the immigration hall in Bangkok’s Suvarnabhumi Airport, she is visibly nervous. The long glass corridors, rows of fluorescent lights reflecting off plastic face shields, and sound of crinkling white protective suits make her feel like she’s entered a science fiction film. She is presented with a small number tag and guided toward neatly spaced plastic seats where she waits for her documents to be inspected. The airport is almost completely empty: echoey, eerie.

It is July 3, 2021, and there are reports of 6,230 new cases of COVID-19 in Thailand today. But Amy’s anxiety is not the result of an 18-hour flight in the middle of a pandemic to a country — and a part of the world — she has never visited before. Being denied entry would create yet another stumbling block, another frustrating barrier, to what has already felt like a never-ending process. She is here to receive gender confirmation surgery (GCS), a procedure she has been dreaming about since childhood and for which she has been planning for six long years. Like an object on a conveyor belt, she has already passed through four different airport checkpoints — each time she scrutinizes the memory of her own documentation for one typo, one incorrectly filled form. When an immigration officer finally stamps her passport, she feels a cold wave of relief.

* Osten-Tan spoke to 15 trans women for this story. Among this group, one person had surgery in the U.K. through the NHS, two opted for surgery in the U.S., and another did not have GCS.

Amy is not alone. Since the first operation in 1975, Thailand has gained a reputation as the global expert in this niche field: Foreigners made up 90% of GCS patients between 2010 and 2012. But what is driving this thriving industry in the country goes well beyond the comparatively low cost of care. Over a period of six months, I spoke to a group of trans women* to better understand why many would rather fly halfway across the world than receive GCS at home. Coming from the U.S., the U.K., Norway, Bulgaria, Israel, Canada, and Australia, and facing different personal and social circumstances, they were united in their conviction that their home countries had not presented them with good options and that they had to take matters into their own hands.

***

I first met Amy at the end of June 2021, 22 days before her surgery. We connected on Zoom, the hot sun streaming through the windows of my Bangkok apartment, while in England, Amy sat at a desk in a dimly lit bedroom. She is not shy but I sensed an introvert, often subconsciously smoothing her long, red hair down in front of her face. She described understanding that she was transgender as a child in unvarnished terms: “How do you know you’re left-handed? You just do, don’t you?”

Her voice has a Yorkshire lilt, and she readily leans into her working-class identity. She told me of an early memory watching the soap opera Coronation Street with her parents, which featured a trans character called Hayley Cropper. That Cropper had not been assigned female at birth was something of a national sensation in the early 2000s — but not a positive one. “All the storylines about this character were basically her getting shat on and being abused by people,” she said. “And then I would hear people in my life mock her and be like, ‘Oh, it’s a bloke, it’s a bloke.’ … I think experiences like that at the time just increased my real desire to try to be a guy the best I could.”

Amy thought joining the army at 19 would “make a man of her” — instead, it added to her feelings of distress and confusion. The sheer magnitude of difficulties she imagined facing by coming out had a severe effect on her mental health. She considered accepting deployment to Afghanistan a suicide bid. “I felt so fed up and low about dealing with this that I thought it literally wouldn’t matter if I died,” she said. The pressures of working in a conflict zone provided some distraction, but when she returned home in 2012, she felt just as fraught as ever. By the time she left the army in 2014, the knowledge that she could no longer ignore her overwhelming gender dysphoria — the sense of discomfort she felt about the sex she was assigned at birth — resulted in a deep two-month depression.

***

Across the world, the levels of financial support trans people receive for gender confirmation surgery range from little or none in Bulgaria and Australia to funded fully by social healthcare systems in the U.K. and Canada. In this respect, Amy should be considered lucky; as a British citizen, she qualifies for gender confirmation surgery under the National Health Service (NHS). But despite relentless efforts, Amy tells me, she has been waiting three-and-a-half years since her first doctor’s referral. Straight-talking and methodical, Amy found this process excruciating. “I like to be on time,” she says. “I like to get things done now. For someone with my personality type, it’s just been like hell.”

The pandemic has worsened her situation; the U.K. is in the middle of a healthcare crisis. Nearly 6 million people in England are currently waiting for operations and procedures — a problem that has been compounding for more than 10 years. Trans people have been among those most severely affected. “The effect of the pandemic has been to exacerbate a problem which already existed,” said James Bellringer, an NHS and private GCS surgeon in the U.K. for over two decades, in an email. But even apart from the pandemic, he wrote, the U.K. lacks trained staff to meet the demand for surgeries. “It’s not just surgeons but the gender specialists working in the clinics. Gender has been chronically underfunded everywhere (not just the U.K.) for years, and the elastic has finally snapped.”

A photo of an elevated walkway over a street in Thailand, with a wide sign that reads "Welcome to Chonburi" in both Thai and English.

A street sign in Chonburi, a province in eastern Thailand. The renowned Suporn Clinic, cited by trans patients as one of the best places for gender confirmation surgery in the world, is located in Chonburi.

In 2019, over 13,500 people were waiting for treatment at NHS England’s gender identity clinics, which provide gender dysphoria assessments, prescriptions for hormones and puberty blockers, referrals for patients seeking surgery, and other services. NHS England states that patients should be able to see a nonurgent specialist within 18 weeks. Even before the pandemic, average waiting times were closer to 18 months, and in some cases, more than three years. It is no surprise, then, that many have resorted to risk self-medicating with drugs bought on the internet or seeking private care. Amy’s military salary and tour bonus provided her with the funds she needed to begin her transition, but she didn’t have nearly enough for gender confirmation surgery. Knowing how much the surgery meant to her, her dad insisted on dipping into his pension to pay for it.

For those who want but cannot afford surgery, the longer they are made to wait, the greater their chance of developing serious mental health ramifications. These often relate to the chronic high levels of stress experienced by trans people over the course of their lives — also known as minority stress — brought on by factors such as poor social support, discrimination, rejection, abuse, and/or violence. The majority of trans women I interviewed — including Amy — wanted to remain anonymous out of fear of being doxxed, harassed, or targeted by hate speech. It is no wonder, then, that transgender people are more likely to attempt suicide than nearly any other social demographic.

She described understanding that she was transgender as a child in unvarnished terms: ‘How do you know you’re left-handed? You just do, don’t you?’

To cope with the administrative bureaucracy of the NHS, Amy approached her transition like a military operation. She kept keen records of appointments and referrals, followed up vigorously when deadlines were passed, and even volunteered as a governor for her local NHS foundation trust with the hopes of streamlining the system. But after years of continuous delays, Kafkaesque protocols, and spending close to £30,000 in private expenses on transitioning already, she found herself at a breaking point in 2020. Like countless others, she turned to the internet. Hours of research and a friend’s recommendation led her to decide on a surgeon in Thailand instead. Angered by her treatment under the NHS, she returned the medal she received for her service in Afghanistan to the government, writing in an open letter, “I am no longer proud to have served a country that cares so little for people such as myself when we need help.” NHS England declined to comment for this piece.

***

* It is customary in Thailand to refer to a doctor by their first name. Doctors are also more commonly known and recognized in this way online.

A minivan takes Amy from the airport to an upmarket hotel where she is checked into a generous room with a view of Bangkok Metropolis. Here she spends two agonizingly slow weeks in quarantine. In a room with a palette of brown and greige, she feels as if she is mentally and physically occupying a liminal space: transient, unsettled. Two days before her operation and a day earlier than she was expecting, Amy is suddenly checked out and escorted to her first consultation with Dr. Kamol Pansritum at the Kamol Cosmetic Hospital, located in a northeastern suburb of the city. One of the most popular Thai surgeons for foreigners, Dr. Kamol’s* clinic is known for its vigorous online marketing strategy. A graduate of the prestigious Chulalongkorn Faculty of Medicine in Bangkok, Dr. Kamol states on his website that he has performed over 5,000 gender confirmation surgeries since 1997. From the windows of the minivan, Amy watches the bustle of tuk-tuks, yellow taxis, and delivery drivers in green jackets on motorbikes, shuttling food and parcels across the city. Giant concrete pillars that hold up the Skytrain line the middle of the road. The minivan soon turns away from the city center; along the streets leading up to the hospital, there are numerous cosmetic clinics, their window displays advertising breast augmentation, liposuction, rhinoplasty, Botox, and fillers.

A four-image collage featuring a wide view of Bangkok, a shot of the Skytrain, the exterior of a surgery clinic, and the interior of a clinic with heart-rate monitors on a table.

Top left: A wide view of Bangkok. Top right: A shot of Bangkok’s Skytrain from below. Bottom left: The exterior of Kamol Cosmetic Hospital, where Dr. Kamol Pansritum has performed gender confirmation surgeries since 1997. Bottom right: The patient registration area and heart-rate monitors inside Dr. Kamol’s clinic.

From the early 2000s, medical tourism was increasingly encouraged by the Thai government, which recognized an economic opportunity. By 2017, Thailand was bringing in nearly $600 million per year from medical tourists, ranking it fifth in the world. While transgender surgeries remain polarizing in most countries, some suggest that Thailand’s majority Buddhist population and attitude of tolerance allowed for the industry to flourish relatively undisturbed for decades. But this does not mean that the trans community in the country is free from significant stigma. Thai transgender people cannot obtain legal documentation that reflects their gender identity, effectively barring them from access to vital services. Employers can demand for them to present according to their sex assigned at birth, and some explicitly state, with impunity, that trans people will not be considered for job vacancies. Thai trans people speak of discrimination in medical settings and unobtainable price points for surgery which often discourages them from seeking care altogether.

The minivan pulls up to the entrance of a whitewashed building several stories high, heat-reflecting film tinting the windows green. In the car park there are three miniature temples on plinths painted gold and white — tiny houses to shelter the spirits that once lived on the land now occupied by the hospital. On a little raised table are offerings of jasmine ma-lai flower garlands, incense, and miniature bottles of red Fanta. A large portrait of King Rama V in full military uniform looms above the reception desk in a bright gold frame. The staff greet Amy with a wai, bowing their heads and pressing their hands together as if in prayer, their faces crinkling behind N95 masks. In a small office, Dr. Kamol conducts an examination to ensure that enough tissue is available for the technique Amy has opted for. She had drafted out a list of questions but the sudden release from quarantine and the language barrier cause her to hesitate. She is reassured by his professionalism, and in many ways, feels she has already passed the point of no return. Once she is approved for surgery, Amy is shown into the private room where she will stay for just over a week. It is relatively modern but sterile in both senses of the word, furnished with a single bed surrounded by gray plastic handles, a pleather chaise lounge, a TV, and curtained windows facing the whitewashed walls of the building next door. On her bedside table, she unpacks a small stack of books, a yellow Nintendo Switch, and Heidi, her stuffed-toy hedgehog. She uses the free Wi-Fi to video call her family, and the cleanliness of the room comforts her concerned mum, who is a palliative nurse back home. If she had opted for surgery in the U.K., her mum would have wanted to come with her.

A woman with red hair on a bed, holding a stuffed hedgehog toy. The woman's face is not shown.

Amy holding Heidi, her stuffed-toy hedgehog.

On the day of her operation two days later, new COVID-19 cases have almost doubled to 11,305. That morning Amy receives the first of a number of enemas to clear out her bowels; the process makes her nauseous. Unsure as to exactly what time her surgery is scheduled for, her nerves return. She tries to keep herself distracted by reading or habitually scrolling through social media. Around lunchtime, she is visited by a Thai psychiatrist. This is a requirement in Thailand in addition to a written referral from a psychiatric doctor at home. Dr. Preecha Tiewtranon, the founder of the Preecha Aesthetic Institute (PAI) in Bangkok and a surgeon often referred to as the “Grandfather of GCS in Thailand” for performing the country’s first gender confirmation surgery in the ’70s, told me that the Thai assessment was more of a formality. “Once we have the overseas approval,” he said, the chance of someone being denied the operation in Thailand is “almost zero.” As Amy informed me, “The Thai psychiatrist acknowledged it for what it was: a box-ticking exercise.”

***

The World Professional Association for Transgender Health (WPATH), which sets international standards for trans healthcare, states that although psychotherapy is not an absolute requirement for people to access medical interventions, an assessment and referral by a professional with training in transgender health is essential. This also can serve as a supportive mechanism to help patients through mental health challenges they might face as a result of social stigma. But many of the trans women I spoke to told me these evaluations reinforced the idea that being transgender is a mental illness. They felt that the weight these psychological evaluations carried in a system of doctor referrals also patronized patients by suggesting medical professionals understood them better than they understood themselves.

Sophie from South London told me she and others support a greater informed consent model of care, where the risks, liabilities, and benefits are presented to the patient who is then empowered to make their own decision. As a teenager, she remembers having to play to doctors’ expectations of gender expression in order to get puberty blockers through the NHS. “It was less about exploring presentation for my own sake and seeing what worked for me, and it being more like ‘OK, this is what a trans person is and this is how you have to perform that.’” She recalls long wait times for appointments and invasive questioning causing her significant distress. A few years later when it came to surgery, Sophie’s parents were happy to pay for her to fly out to receive private care at the renowned Suporn Clinic, located 50 miles outside of Bangkok in Chonburi province, to escape what she called “mountains of bureaucracy” in her home country and “having to provide evidence of being trans.” Her experience is echoed in a 2020 study by Mermaids, one of the leading U.K. trans charities, where over half of young people interviewed felt, or somewhat felt, that they had to dress in a particular way in order to access support from their general practitioner. Dr. Abby Barras, a researcher at Mermaids, explained, “This included exaggerating more feminine or masculine traits, conforming to cisnormative expectations, such as wearing a dress or baggier clothing, and even talking in a different pitch. … clear examples of the medical gatekeeping that trans and nonbinary people often face when needing to access healthcare which is not inclusive or affirming.”

They felt that the weight these psychological evaluations carried in a system of doctor referrals also patronized patients by suggesting medical professionals understood them better than they understood themselves.

* GCS is commonly used both to refer to “bottom surgery” (singular) and also as an umbrella term for gender confirming surgeries (plural) — including facial feminization surgery, or the range of other surgeries available.

Feeling the need to present “proof” of being trans is the legacy of a not-too-distant past where a psychological or medical diagnosis of “transexualism” was mainstream, almost always referring to someone who is seeking hormones or surgical transition. The term implies that people must fit within the male/female binary — that is to say, be either male or female — through having taken surgical action. This differs to today’s more common use of the word “transgender,” an umbrella term which acknowledges that gender self expression and gender dysphoria can be present in different ways. WPATH accordingly changed its guidelines to better recognize transition as a nonlinear path, and that some people may not want hormonal or surgical treatments. For those who do opt for the surgical route, vaginoplasty (also known as “bottom surgery”) is one of several transfeminine surgeries available, such as breast augmentation, and facial feminization. GCS* is, by its very nature, highly personal.

Across the North Sea from Sophie, Yui’s home country of Norway has only one authorized provider of tax-funded healthcare for trans people — the National Treatment Centre for Transsexualism (NBTS) — which, as the very name of the institution suggests, continues to use diagnostic terminology and approaches. Every year, the NBTS rejects all but a quarter of referrals. After many months of waiting, Yui says, she was told by an NBTS specialist to come back in another year when she had made more “progress” with her transition, like wearing makeup and dressing more femininely. She was also quizzed at length about her sexual preferences. “They asked what my sexuality was and if I had had sex, how many times, how I felt having sex,” she told me. Later, she learned that the questions were optional and for research purposes but this had not been made clear to her at the time. She had thought her answers would determine whether she qualified for medical treatment which, if true, would have been an irrelevant line of questioning. Gender identity has nothing to do with sexuality; not all trans women will categorically hate having a penis or will only want to engage in sexual relations with men. Assessing gender dysphoria through the lens of sexual activity also recalls a time when being trans was erroneously considered a form of sexual deviancy. Yui eventually resorted to seeing a private doctor to start hormone treatment. “The NBTS are insanely gatekeeping. It’s only cis people that will pass their standards for trans, so a lot of people will lie to get through the initial meeting,” she told me. Visually impaired and relying on government welfare, Yui had to take out significant loans to cover her gender confirmation surgery in Thailand instead.

A four-image collage of various interior shots in a hotel room, including a woman looking in the mirror in the bathroom as she fixes her hair, a photo of the woman gazing out the window, a photo of a pillow on her hair next to the window, and a photo of the woman as she sits next to a man (her father).

Yui, from Norway, traveled to Thailand for GCS. Top left: Yui looking in the bathroom mirror in her hotel room. Top right: Yui looking out the window of her hotel room. Bottom left: A shot of Yui’s donut pillow and a peek-a-boo view of Chonburi, a province in eastern Thailand. Bottom right: Yui and her father, who came to Thailand to support her through GCS.

While many of the intended beneficiaries of psychological and medical evaluations report them to be a model of policing, medical experts remain divided. Gender confirmation surgery is a major procedure resulting in permanent fertility loss, not to be taken lightly. Speaking to me from Perth, Australia, Curtin University Associate Professor Sam Winter, a leading academic in transgender health, explained, “No surgeon wants to be in a situation in which they do the surgery and a couple of years down the line are being sued. There is a reluctance on the part of surgeons to engage in the work that they do without some sort of professional reassurance. The assurances from a clinical assessment by a mental health professional gives them confidence.” Reports of people who detransition, or those who reverse their transgender identification or gender transition, don’t help. The amount of media and public attention these reports receive generates a false perception that many trans people experience post-operative regret. A recent study suggests that less than 1% of patients who have undergone transfeminine and transmasculine surgeries regret their decision. Other research reports that those who do often do not regret undergoing the procedure itself but rather the poor results they receive.

***

At 5 p.m., a nurse who cheerfully refers to Amy as “sister” takes her to the operating theater. She is rolled through the corridors in a wheelchair, reluctantly surrendering to the understanding that her life will soon be in another person’s hands. A hush falls over the operating room as she’s wheeled in; around nine operating staff in green gowns pause to greet her. There are bright lights and two sets of monitor screens, metal tables with instruments laid out in neat rows. The anesthetist makes cheerful small talk in broken English about being a Liverpool football fan. Amy doesn’t have the heart to tell him that she’s not from Liverpool. An oxygen mask is lowered over her face; within seconds, she’s gone.

A clean interior of a gender confirmation surgery clinic in Thailand, with a wall at the end of the hall that reads "Operating Theater"

A corridor inside Dr. Kamol’s clinic, leading to the operating room where Amy will have her procedure.

Penile inversion vaginoplasty has been the main method on offer across the world since the mid-20th century, and is still considered by many surgeons to be the gold standard. But the penile inversion technique felt dated to Amy. Of the handful of other techniques available, peritoneal pull-through (PPT) is newer and trendier, although not as widely tested or performed on trans women as penile inversion. PPT originated in gynecology to reconstruct cisgender women’s vaginas using tissue from the lining of the abdominal cavity, which has some moisture-producing properties. Using the peritoneum in gender confirmation surgery was popularized by Dr. Lee Zhao at New York University in recent years, and Dr. Kamol is one of the few surgeons in the world performing PPT. Amy found out about the technique online.

A large portion of this surgery is described in this video (warning: graphic content).

In PPT, small incisions are made in Amy’s belly through which the peritoneal tissue — which lines the abdominal wall and covers most of the organs in the abdomen — is released. The space between the rectum and urinary tract is dissected, and the peritoneal tissue is then pulled down into the space between the rectum and the urethra to serve as the vaginal lining. A catheter is inserted, and the testicles are removed. The penis is carefully dissected, using the shaft and scrotal skin to create the labia while the glans at the top of the penis becomes the new clitoris. The whole process takes around five to six hours.

Done well, neo-vaginas in all their variation can be almost aesthetically indistinguishable from natal ones.

Some patients are drawn to PPT because it provides surgeons with more material to put toward vaginal depth, though penile inversion vaginoplasty does provide patients with depth akin to that of a natal vagina. Losing depth due to scar tissue development or prolapse (the weakening of the vaginal walls leading to a gradual drop) is also a common concern among trans patients, but surgeons I spoke to assured me that this wasn’t a problem with regular dilation. After the operation, Amy will need to use dilators for at least the first year to keep the vaginal canal open, with most patients needing to dilate once or twice a month for the rest of their lives. Dr. Min Jun, a surgeon in Northern California who works primarily with the robotic peritoneal flap vaginoplasty technique, told me that the peritoneal tissue also helps provide stability since it can be attached to the surrounding tissue — something that is much more difficult to do in penile inversion. But PPT can lead both to additional recovery time and time spent under anesthesia. Jun felt that the peritoneal tissue’s lubricating properties were somewhat overplayed online since the peritoneum does not respond to sexual stimuli and fluid production diminishes with time.

A two-image collage: the left photo shows a clear dilator in a person's hand, the right photo peeks inside a bag with various items to help with dilation, including cotton swabs and small boxes of medicine.

Left: A collection of dilators, which Yui shares during a hotel room visit. Right: A peek at Amy’s dilation kit.

“There’s probably 10 different ways to do gender confirming surgery,” said Dr. Christine McGinn, a GCS surgeon who founded the Papillon Gender Wellness Center in 2006 in Bucks County, Pennsylvania, and who is a trans woman herself. “With peritoneal pull-through, it has to be tested. It has to be peer reviewed. The thing with trends like these is it’s a chance for patients to feel more powerful and self-confident in their choice.” Like Amy, some patients’ suspicions around penile inversion stems from a conviction that this field has seen a lack of innovation since the ’60s, and the belief that the advancement of transgender surgery is not something the healthcare industry at large considers important. While the robotic peritoneal flap vaginoplasty method Jun is working on is arguably one of the most innovative the field has seen in years, the process uses a machine that costs upward of $1 million making it much more expensive. The decision on which technique works best for each patient ultimately depends on what is feasible in terms of available tissue, age and preexisting health conditions, cost, and individual preference. Done well, neo-vaginas in all their variation can be almost aesthetically indistinguishable from natal ones.

Innovation is the least of some patients’ concerns. Even the tried-and-tested penile inversion technique comes with risks, heightened by the fact that the success of the surgery still relies almost entirely on the skill and experience of the individual surgeon. Doctors must be able to painstakingly dissect tissue with sensitive nerve endings to provide patients with a vagina that not only looks but functions like a natal vagina. One of the priorities of modern gender confirmation surgery is the ability for post-operative patients to enjoy physical intimacy. Since the highly sensitive glans found at the tip of the penis is refashioned as the clitoris, research suggests that the majority of successful operations result in trans women being able to reach orgasm.


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* In a 2018 open letter to WPATH, 192 post-operative patients also raised concerns that surgeons were offering “free or low-cost surgeries to under-resourced patients in order to gain operating experience in procedures for which they have incomplete professional training.”

Despite the high stakes, in the U.S., surgeons are not required to have extensive specialist training or certifications in gender confirmation surgery. Insurance coverage for transgender surgeries increased after the Affordable Care Act made discrimination based on gender identity unlawful in 2010. Though insurance policies for GCS still vary widely depending on the state and insurance provider, coverage became more common, and hospitals and surgeons saw an opportunity. Surgeries increased fourfold between 2000 and 2014. “There is a very ugly underbelly to trans medicine,” said McGinn. “Some surgeons have rose-colored glasses on because all of a sudden they’re realizing how much money they can make.” There are few to no standardized rules — WPATH guidelines state a requirement for surgeons to be “qualified” but that term is loosely defined. McGinn told me that while some engage in longer apprenticeships with established surgeons, training in GCS can be as short as a week of mere observation. Dr. Curtis Crane, a GCS surgeon in Austin, Texas, who opened his practice in 2012, added, “GCS is all the rage now and so we see surgeons getting into an area they weren’t trained in. … I see results from surgeons that weren’t, in my opinion, trained as well as they should have been and that are experimenting and just hoping that they get a good result.”* Policies in the U.S. often limit patients to consulting surgeons within their state, effectively closing off other options.

When surgery is handled by an inexperienced or incompetent surgeon, the outcome can be disastrous. In 2020, Jezebel reported shocking surgical results at the hands of Dr. Kathy Rumer, a U.S. surgeon. I spoke to one of her former patients, Hannah Simpson, who developed early signs of necrosis — the death or decay of body tissue due to limited blood flow — which began about a week after surgery. She says Rumer dismissed her concerns, initially insisting that there was nothing wrong. Hannah ended up having another surgery with a new doctor to try to fix the damage, but it only made things worse. Her clitoris necrosed. Since 2015, Hannah says she’s had consultations with dozens of doctors in 10 different countries to figure out how to reconnect the nerve endings she lost through the procedure. In the months after I talked to her, she went through the first stage of a revision surgery. It’s currently unclear to what extent it will help. “I am left with a Picasso interpretation of a vagina that is missing constituent elements,” she said. “I’m a sexual person who wants to desire in sexuality and who is missing the pieces her body needs.” Unfortunately, Hannah is one of many. Despite multiple allegations of medical misconduct from different patients over recent years, Rumer has yet to face any significant legal consequences. In light of these allegations, Rumer declined to comment to Jezebel.

Despite the high stakes, in the U.S., surgeons are not required to have extensive specialist training or certifications in gender confirmation surgery.

Fulfilling sexual relations for those who desire it is arguably a human right; it is therefore understandable that many trans women feel more comfortable in the care of someone who has completed hundreds of successful GCS surgeries. Thailand’s long medical history specializing in gender confirmation surgery remains one of the main reasons attracting foreign patients from across the world. Dr. Preecha went on to train many of the surgeons who are still practicing today, including Dr. Chettawut Tulayaphanich, Dr. Suporn Watanyusakul, and Amy’s surgeon, Dr. Kamol. Yet despite Thailand’s popularity — and as with surgeons all over the world — there is never a 100-percent guarantee of success. Maria Creveling, better known as Remilia, was a professional U.S. Twitch streamer who received gender confirmation surgery from an unnamed Thai surgeon in 2018. The procedure left her with nerve damage in her pelvic area and excruciating pain. In December 2019, aged 24, she was reported to have died in her sleep — although the official cause of her death is still unknown.

A two-image collage. The left is a close-up portrait of Dr. Preecha, a Thai surgeon with glasses. The right is a framed illustration in a doctor's office of a man with glasses smoking a pipe. Text above his head reads "God Father of Plastic Surgery."

Left: Dr. Preecha, the founder of the PAI Institute in Bangkok. Right: Framed memorabilia in Dr. Preecha’s office.

Nevertheless, in August 2021, I spoke to New Yorker Justine Wiles, who called me from her hotel room in central Bangkok while recovering from surgery with Dr. Chettawut at the Chettawut Plastic Surgery Center. She had worked several jobs, including one at Starbucks, to cover the cost and had chosen Thailand after being inspired by transgender activist Janet Mock’s own journey through gender confirmation surgery. “When I went to Dr. Chettawut’s office for my surgery, I saw his degrees and all of his certifications displayed on his walls from 1997 — when I was born — and that gave me comfort.” Justine had to convince her family at first to let her go. They were concerned that the quality of care she would receive abroad would not be as high as that in the U.S., which is a common misconception given TV shows like Botched. Using state-of-the-art hospital facilities that rival Western options, Thailand’s top surgeons attracting foreign patients are known for their exemplary skill and expertise. “Thai surgeons are amazing,” said Crane in Texas. “You know, they’ve been doing it for a long time and there’s such a huge healthcare community there.”

Some patients are especially drawn to Dr. Suporn and his protégé Dr. Chayamote “Bank” Chyangsu for their reputation as perfectionists. The Suporn Clinic was repeatedly cited to me by trans patients as one of — if not the — best place for gender confirmation surgery in the world. “This is your one body,” said Rae, a trans woman from Canada who asked to use a pseudonym. She decided to opt out of GCS under publicly funded healthcare in favor of surgery with Dr. Suporn over a year ago. “I understand a lot of people don’t have the funding. … But for me, I don’t buy knock-off laptops or knock-off iPhones. I buy the iPhone. I want the number one.” The Suporn Clinic also offers free “cosmetic improvements” or revisions. This provides patients with a sense that their doctor takes pride in the quality of their work over financial gain — a welcome departure from the economic motivators driving the U.S. healthcare system. Including flights, surgery at the Suporn Clinic can however reach $25,000, which likely makes Dr. Suporn’s the most expensive GCS option in Thailand. Despite shying away from self-promotion and the media, spots for surgery at the Suporn Clinic often fill up within hours of availability.

The Suporn Clinic was repeatedly cited to me by trans patients as one of — if not the — best place for gender confirmation surgery in the world.

Although cost is not the most important motivator behind Thailand’s popularity, it is certainly one of them. In November 2021, I visit Penny Gold in her apartment on Roosevelt Island in New York City. She offers me tea, pulling out several boxes and tins with a flourish, spilling a jumble of tea bags of different brands and flavors onto the kitchen countertop. When she instructs her Google Home to “turn on the colorful lamp,” the room is bathed in purple light. From a built-in wardrobe, Penny shows me a variety of outfits she had tailored when she was in Bangkok: a purple floral tea dress, a two-piece periwinkle suit, a double-breasted purple-checkered suit, and a shift minidress in the colors of the transgender flag. It has matching earrings. “I always tell people that when I went to Thailand, I got designer suits, a designer tattoo, and a designer vagina,” she says facetiously. Penny has a large tattoo of peonies on her upper thigh.

A woman in a short pink and blue dress injects a needle with estrogen into her upper right thigh

Penny, who lives in New York City, went to Thailand for GCS and was the first patient at the PAI Clinic to receive surgery under pandemic conditions. Wearing a transgender flag-colored minidress, she injects herself with estrogen.

Penny grew up in an ultra-Orthodox Jewish community in Israel in a sect that closed itself off from wider society. This was a world of binaries “both literally and figuratively,” she explains, “because the uniform I wore every day from the age of 13 was black and white.” Stifled by the lack of freedom to explore herself within the narrow parameters of her community’s beliefs, Penny decided to break away at the age of 20. A few years later, and now living in New York, she came to understand that she was trans, and that surgery was the right decision for her.

As a freelancer, Penny didn’t have insurance through an employer. She calculated that on a private insurance plan she could be paying $5,000 before she met the deductible, on top of at least a few hundred dollars per month for the insurance plan itself, bringing the costs up to around $10,000 per year before she would even qualify for insurance coverage benefits. “The only way for me to have gotten surgery in the USA is if I had either (A) won the lottery or married a millionaire, or (B) gotten a job that offers a good health insurance plan, but I didn’t see either one of those options realistically happening in my future,” she says.

A four-image collage, including three photos of a woman with glasses in her bedroom, looking in a mirror, and browsing a website on her computer monitor. A fourth image shows a row of seats inside the PAI Clinic.

Top left: Penny in her home in New York City. Top right: Penny looks into a handheld mirror. Bottom left: Penny at her desk, browsing PAI’s website. Bottom right: A detail of the seats inside the PAI Clinic.

In mid-March 2020, soon after the World Health Organization declared COVID-19 a global pandemic, Penny flew to Thailand. She was the first patient at the PAI Clinic to receive surgery under pandemic conditions. The date had first been set to fall on her birthday that year, but once she arrived, the operation was postponed for three weeks to comply with newly implemented quarantine restrictions. “I was a little disappointed, but they didn’t cancel it outright,” Penny tells me. “I had waited 30 years. I could wait another few weeks. There’s a reason I made all this effort, took out half of my savings, to fly half the world over to have major surgery in a place that I don’t know anybody, a language I don’t know. Why else would I do all of that if something didn’t really, really bother me?”

The price is, after all, still significant. Beyond the initial financial investment, patients must have the means to take at least a month off of work. But the exchange rate has meant that surgery remains cheaper than in places such as the U.S. where it might cost $50,000 in some cases. In contrast, most foreign patients for Thailand’s top surgeons might pay anywhere between $10,000-25,000, including flights. Dr. Thep Vechavisit charges as low as $2,000, cutting costs by opting for local anesthesia and sedatives instead of general anesthetic, potentially making his offering the cheapest gender confirmation surgery in the world.

***

Three days after Amy’s surgery, I call to check how she’s doing. It’s the first time she’s sitting up in bed since the operation and the nurses have propped her up on a couple of pillows. She is wearing the same tightly checkered, red-and-white hospital gown from the day of her surgery. “I look terrible,” she says, staring at herself on Zoom. Her words slur a little; someone recently administered her morphine. Her operation seems to have gone well, but she has a lot of healing to do before she can make an accurate judgment. She hasn’t seen the results yet, and is a little wary. With the stitches, bruising, and swelling, it won’t be pretty. For now, her sentiments are primarily of relief.

“When I woke up, I could feel that my anatomy was different,” she tells me. “That being said, though, it feels quite normal that it is different. Like, I don’t think I’ve had some great moment of transcendence. My body just clicked and it was like, ‘This feels how it should feel.’ I had male anatomy for 30 years, but I was lying in bed thinking to myself, So what does it feel like to have a penis? I can’t even conceptualize that now. It’s so strange.” After a few minutes her slurred speech and vacant expression become more apparent. I decide to end the call.

A blurred portrait of a woman, her face frozen in motion as her head moves from side to side

Amy in her hotel room in Bangkok.

Patients spend the days that immediately follow surgery in bed on high doses of pain medication. Few of the women I spoke to could recall much from that time, except Yui, who remembers vomiting from the anesthesia. Lily, an American patient who had her surgery with Dr. Suporn in 2018 and asked not to use her real name, described the packing being removed from the surgical site seven days after the operation as “the magic handkerchief trick. You know when a magician pulls silk out of a hat? [The nurse] pulls the packing out of you and it just keeps going and going and going.”

After a week in the hospital, Amy is discharged and transferred to a hotel affiliated with the Kamol Clinic, just 200 meters down the road. Off the beaten tourist track and with many prospective patients postponing their surgeries, the hotel is almost completely empty. Post-op patients are advised not to embark on any strenuous activity if the pain on its own is not enough of a deterrent. Still hooked to a catheter, Amy tells me with dark amusement how she spent a couple of days carrying around a little bag of her own urine. Outside on the street, there is not much of interest except a Pizza Company restaurant and a small tended garden next to the hotel. Although she fleetingly sees a couple of other patients from Asian countries, the language barrier once again stands in the way of any meaningful conversation. Twice daily she walks slowly back to the hospital for checkups and nurse-assisted dilation; her first session after the operation reduces her to tears, but with each day, the sessions become a little less painful. She finds herself crying more often than usual — coupled with hot flashes, she partially attributes this to having stopped hormone replacement therapy. Patients are instructed to discontinue their HRT treatment around three weeks prior to surgery, and not to restart again until a few weeks post-op.

When I visit Amy up in her hotel room, I get the impression that despite her introversion, she is deprived of human contact. Sat on her bed on a pile of pillows, she confides that she perhaps underestimated how much stress having the surgery under pandemic conditions would put on her. Family and friends had advised her to postpone it, but the pandemic had only hardened her conviction around her decision. “I had people saying to me, ‘Just wait until 2022 because COVID will be all gone then.’ But you don’t know that. I wasn’t going to do that because I don’t trust that anything will stay the same anymore.” The very thought of waiting any longer than she already had still fills her with indignation.

***

* Dr. McGinn’s Papillon Center is one of few in the U.S.

If being transgender in a majority cisgender, heterosexual world is an isolating experience, then undergoing major reconstructive genital surgery can be even more so. Not many clinics or hospitals in the world* provide an enabling environment for trans patients to meet and socialize with one another. While Amy’s experience was marked by loneliness, others told me at length how the friendships they had made with other trans patients over breakfast during recovery had been an unexpected but welcome outcome. English-speaking Suporn patients are known to stay in contact for years afterward, even on occasion visiting each other across countries. With nowhere to go and three weeks of healing, dilation, and hospital checkups to complete, women described stopping by each other’s rooms at the Chon Inter Hotel or congregating in common spaces, with post-op patients speaking candidly with pre-op patients. For those still deciding on surgeons, the idea that they might be able to share their GCS journey with a group of other trans women is an attractive prospect.

While transgender surgeries remain polarizing in most countries, some suggest that Thailand’s majority Buddhist population and attitude of tolerance allowed for the industry to flourish relatively undisturbed for decades.

For Jenna, who asked to use a pseudonym, her time in Thailand felt, at times, profound. She received surgery at the Suporn Clinic, although going to Thailand had not been her initial choice. Surgery could have been fully covered by her insurance provider in the U.S., but the GCS technique developed by Dr. Suporn — the Chonburi flap method — is known to produce excellent aesthetic and functional results. “In fact, if it hadn’t been so common in the trans community to do so, the idea of flying to the other side of the planet to have major surgery would have terrified me,” she told me, balancing her laptop on her knees while sitting at the edge of her daughter’s bed, tucking her in for the night. “How often am I in a room full of 20 trans people? … It felt, for that month, like my experience was the normal one and being cisgender was the exception. And so that was nice because I had never felt that before. It was magical.” For Jenna, the hotel had become a unique microcosm — a few precious weeks in which she felt validated wholly by a community of women bound together by an experience few knew and understood intimately. COVID-19 has, however, slowed the otherwise steady flow of foreigners. Dr. Sutin Khobunsongserm told me that the number of patients at the PAI Clinic had dropped 80% in 2021. The Chon Inter Hotel did not survive the pandemic and closed its doors last year, with patients now staying at the more modern Rattanachol a few meters down the road.

A four-image collage featuring photos of the PAI Clinic and a surgeon who performs GCS there.

Top left: The exterior of the Preecha Aesthetic Institute (PAI) in Bangkok. Top right: The reception desk at PAI. Bottom left: A picture of Buddha, among other framed photos and certificates, greets patients at PAI. Bottom right: Dr. Sutin, a surgeon at PAI and colleague of Dr. Preecha.

Dr. Preecha told me how, back in the day of fax machines and prepaid long-distance calling cards, the Thai GCS industry’s popularity among foreigners was driven almost entirely through word-of-mouth. It is no surprise that Thai GCS has grown exponentially with the internet. Trans people’s lost faith in medical systems has led to a greater transference of trust in each other for healthcare recommendations and support. In an age of digital misinformation, the increasing reliance on photos shared on Reddit, threads on Twitter, conversations on Discord, and reviews on Facebook pages can be troublesome. But with many people advocating hard for a greater informed consent model of care, Thailand’s laissez-faire approach to GCS feels like an empowering alternative to more restrictive Western healthcare systems. For those with lived experiences of discrimination or barriers to care, going to Thailand is a reclaiming of control over one’s own body and medical trajectory. “I love Thailand,” said McGinn, the founder of the Papillon Center. “I think some of the surgeons there are fantastic.” But when anyone needs to leave their country to find quality surgery, “that’s the sign of a severely broken system.”

***

Two months later, Amy’s back in her bedroom in England. She is showing me her nails, holding her fingers up to her laptop camera, the polish a metallic green. “They change color based on temperature. I don’t know if I can warm them up,” she says, rubbing her hands together. Amy looks well. She is tired of the hours she spends dilating each day, but she also tells me her family and friends have noticed a small change in her: an aura of confidence. She’s largely happy with her results. But the systematic way in which she had approached the last six years coupled with the sheer amount of mental energy expended on surgically transitioning leads me to wonder if she might have difficulty adjusting. She had been forced to structure her life around transitioning, inevitably deprioritizing other important parts of her life: her relationship with her partner, investing in a home, moving forward with her dream of becoming a primary school teacher.

“Do I want my entire identity and narrative arc of my life to become about being trans?” she asks. “I spent most of my childhood ruminating on this issue, my entire adolescence, and now I’m in my 30s. … Do I want to be 40 and still going on about trans stuff? When does it end?” Amy has drawn a line underneath it all. She once described herself to me as Andy Dufresne from the 1994 film The Shawshank Redemption. For years, the innocent but incarcerated Dufresne scrapes away at a wall in his prison cell with quiet determination before making an intrepid bid for freedom. With the same self-effacing defiance, Amy escaped an imprisoning system. Now, she’s ready to get busy living.

***

Mailee Osten-Tan is a multimedia journalist based in Bangkok, Thailand. Her reporting has been commissioned by Al Jazeera, the United Nations, the Southeast Asia Globe, Thai Enquirer, and elsewhere. A graduate of the University of Oxford and the Salt Institute for Documentary Studies, Mailee’s photography and short film work often explores social exclusion, gender discrimination, and resilience.

Learn more about the author and the reporting of this story in our Q&A with Mailee Osten-Tan

Editor: Cheri Lucas Rowlands
Copy editor: Krista Stevens
Fact checker: Naomi Sharp