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Valdez: "As well-known as he is, he's really down to earth. I've cut his hair in the past. He's not uppity-up. He's a super-duper guy."
Each year several hundred people undergo sex-change operations in this country, Biber says. Many of them walk into his office. But before he agrees to meet them in the operating room, they must fit a set of criteria designed to weed out schizophrenics, sociopaths and those who simply aren't ready.
First, patients must pass at least two psychiatric evaluations ensuring that they're not homosexuals or transvestites or simply people seeking fame and fortune on the talk-show circuit. True transsexuals, Biber says, are not attracted to members of the same sex and do not become aroused by wearing clothes of the opposite sex. True transsexuals consciously and subconsciously believe they are members of the opposite sex, trapped in the wrong body. Scientists think one person in every 30,000 suffers from this gender dysphoria.
"It's not an uncommon thing," Biber says, "when you start to think about all the people in the world."
Next, patients must receive hormone therapy for at least a year and live in the role of the opposite sex for the same period. If the adjustment is successful and another evaluation approved, plastic surgery is recommended. Then, and only then, will they get a consultation with Biber, who makes the final call. If he senses doubt, hesitation or confusion, which he does about 5 percent of the time, he sends patients home. As a consolation, he often performs minor cosmetic surgery first, such as an Adam's-apple reduction or breast augmentation.
"After doing so many of these, you develop a gut feeling," Biber says. "A bell will go off and you'll know something is wrong, even if they came with good evaluations. You certainly don't want to make a mistake. You've got to have a feel for if they're really worried about being a transsexual or if they're just scared of the surgery. It helps me in my own mind to know I'm doing the right thing."
The actual procedure takes Biber about three hours (half the time it takes other surgeons), depending on the extent of the cosmetic surgery. "Sometimes I spend all morning doing a nose job or putting in breasts," he says.
For a male-to-female sex-change operation, the testicles are removed, as well as the spongy tissue inside the penis. The urethra is shortened and placed in a female anatomical position, and an opening about six inches deep is made in the perineum and lined with skin from the penis so that it can act as a vagina. Nerve endings remain undamaged during the procedure, allowing more than 80 percent of patients to achieve orgasm. The empty scrotum is then fashioned into labia, the Adam's apple is reduced by shaving cartilage from the larynx, and breasts are often augmented with implants. The price tag: $12,000 or more.
"I've got one patient married to a gynecologist, and he doesn't know," Biber says. "She won't tell him."
For a female-to-male sex-change operation, the breasts are reduced and the ovaries and uterus removed. A penis is crafted by cutting a flap of skin from the abdomen and shaping it into a tube. Using intricate microsurgical techniques, the clitoris and other nerve endings can be incorporated into the end of the phallus to allow some patients to achieve orgasm. Silicone implants are placed inside the labia skin to simulate a scrotum. This procedure takes several stages to complete and often costs $50,000 or more. "It's still considered experimental," Biber says, "but we're getting better all the time." Biber has performed 300 of these operations.
While plastic surgery techniques have improved, so has science's understanding of gender dysphoria. Biber believes the hypothalamus, a part of the brain that regulates many body functions, including sex, might be responsible. Research has shown a difference in the size and concentration of the gland in transsexual patients.
"No amount of psychological help can change a true transsexual," Biber says. "The longer you work with these people, the more you develop empathy. You realize how hard it really is for them. We definitely think it's a physiological or anatomical change that makes these people different. Papers are written every year. It's now well-accepted."
That wasn't always the case. Critics have argued that sex-change surgery treats the symptom of transsexualism and not the cause. Some still label the procedure as mutilating and potentially dangerous, while others claim it can lead to severe depression and suicide.
Johns Hopkins, the early leader in gender research, phased out transsexual surgery in the Seventies after a study found it did not make patients substantially happier. Biber himself was attacked in a national news magazine by psychologists who claimed he was "committing mayhem" on his transsexual patients.
"They tore me to pieces," he recalls. "They said what I was doing was outrageous, cutting off normal organs and disfiguring people. And the worst part about it was that I wasn't the only one doing it."
Although Biber says he has never been successfully sued by a transsexual patient, he did settle out of court in one case he'd rather not discuss. And with 3,500 male-to-female sex-change operations to his credit, he has performed only three reversals. The first patient, whose original operation was performed by another surgeon, proved not to be a true transsexual and developed psychological problems. The second was a renowned mathematician who succumbed to intense peer pressure. The third patient used the procedure to appear on talk shows, then decided to switch back. "Those patients are harder to spot, because they come to us with good evaluations," he says. "Sometimes they slip through."