Informed Consent

Marilyn Jane Callaway, formerly Martin James Callaway, accepted the risk. She was about to undergo gender-affirming surgery, had dreamed of this day for nearly all of her 25 years, and had often worked double shifts to save enough money for the medical fees, which were not covered by her health insurance. But even if they had been, she wanted the renowned Dr. Jack Hall and no other, and he required advance cash payment for these procedures. In fact, though Hall was a respected figure in New York medical circles, he treated transsexuals only in his private Cuban clinic. The United States medical community would not certify his unique gender-affirming methods.

Today, in addition to genital reconstruction, Marilyn would simultaneously undergo breast augmentation, facial contouring, thyroid chondroplasty, and endoscopic suture glottoplasty to raise her vocal cord pitch. Fees were reduced by combining multiple procedures at the same time, and Marilyn would “endure” one day of surgery instead of several.

She wondered if she might chicken out at the last moment. Dr. Hall’s rules were strict, but Marilyn had been referred by a close friend who had undergone similar treatments in this same operating theater, and the results were beyond spectacular. Her feminization at the hands of Dr. Hall appeared completely natural.

Still, as Marilyn lay naked on the table, securely strapped down, her legs spread and her body covered by a sterile white sheet, she worried. The good doctor was about to ask for final authorization. She hoped for the necessary courage to go forward. Other doctors used more traditional methods, of course, but Hall’s results set the standard for sex reassignment. Marilyn expected to be indistinguishable from a natural female after she left his care.

A gowned and gloved Jack Hall began his pre-surgical declarations as Marilyn lay on the table. A single nurse—experienced and proficient—stood at the ready.

“Marilyn Jane Callaway,” said Dr. Hall, formally but gently, “we are about to begin your special day. Listen to everything and then give me a final ‘go’ or ‘no go.’ We have already discussed what to expect, and you’ve had a month to consider this moment, but now is the time for informed consent. I will not proceed without it. Do you understand?”

There was apprehension in Marilyn’s response. “Yes, Doctor.”

“I will strive for the finest and safest medical outcome, and I am not padding my ego when I say the results shall be extraordinary. My personal commitment is a standard of care for my transsexual patients. You will not only obtain a naturally feminine appearance, you will become beautiful, for I have refined and perfected every aspect of the male-to-female transformation.”

“Thank you,” said Marilyn, suppressing the urge to run.

Dr. Hall continued. “As a final summary, I’ll begin with single-stage genital reconstruction to provide a functional vagina, removing the testicles, scraping away the subcutaneous penile tissue, and inverting the skin to construct the vaginal lining. This will require piercing the pelvic wall and reshaping leftover scrotal matter to simulate the labia and clitoris.

“Next, I will transplant a small amount of abdominal fat to increase your breast size. Such augmentation is routine and should not concern you.

“Then, we’ll rehabilitate the nose, upper lip, and chin for more delicate features. This involves grinding bone surfaces and a partial face lift. Fortunately, you have excellent skin and no remaining facial hair, but it will take a couple months for the swelling and bruises to disappear. You’ve seen the results in other patients, so I expect you will be pleased.

“After that, I’ll make a small incision in your throat and shave the tracheal cartilage to eliminate any sign of an Adam’s apple.

“And finally, there’s the laser-endoscopic procedure to stitch one end of your vocal cords, shortening the folds so that speaking vibrations will increase from 120 per second to 200. This will create a permanent, distinctly feminine tone. Your breathing may be difficult during this stage, but I’ll work fast.”

Dr. Hall paused and said, “The combined surgeries—done quickly though expertly—take approximately six hours. Do you understand?”

“Yes,” replied Marilyn. “I wish…I wasn’t so terrified….”

“Of course you’re terrified!” said the good doctor. “Otherwise, you wouldn’t be mentally competent for consent. Only the most determined patients are allowed at this clinic, which helps me to ensure that they are a real woman and my work is in their best interest. And, yes, I believe that your decision to have final surgery is a good one.”

Dr. Hall continued. “So, before the nurse tightens your restraints and we proceed, you must re-confirm your commitment. There will be no stopping after the first incision.”

Marilyn held quiet but trembled under her covering.

“Out of suffering,” said Dr. Hall as though speaking from a pulpit, “woman’s anguish shall give way to joy. Therefore, as we discussed, you will have no anesthesia or pain control medication until after my last stitch. If you lose consciousness, I shall work with all possible speed, but most patients revive quickly during the operation.

“Now, my dear Miss Callaway, by your choice and by your authority in selecting me as your caregiver, shall I create a whole woman today? Or, shall we stop and send you home? I sincerely want to help, but you must concur.”

“I understand,” said Marilyn, now beginning to perspire under the sterile sheet.

“Do you freely offer your assent?”

Marilyn faltered, considering the physical torture of the next 6 hours against the emotional torture she had endured for almost 25 years, the rejections, heartache, lost family and friends, postponed hopes and dreams. She likewise considered other transsexuals, some of whom she knew personally, that had lost their lives having procedures with less-than-competent and less-than-caring doctors. Marilyn Callaway was terrified of this day but more terrified of the next 50 years without it.

The doctor spoke almost lovingly. “Take your time, dear child, as my nurse prepares the neuromuscular blocking agent. But remember, the paralytic injection will not affect your pain receptors. It simply inhibits localized muscle spasms while I’m operating.”

The nurse circled the table, securing the patient’s head, arms, ribcage, legs, and ankles with pink leather straps while Marilyn steadied her resolve, a tear rolling from her left eye.

Dr. Hall brightened the operating lights and held a gleaming scalpel for the patient to see. “I await final authorization.”

The nurse positioned her noise-reduction headgear that would blot out the worst reverberations yet allow her to understand the doctor’s commands. She slipped a surgical mask over the patient’s nose and mouth.

The room was quiet. Finally, Marilyn took a deep breath and spoke through clenched teeth. “Please proceed, doctor. Make me female.”

The nurse delivered the muscle relaxant into a vein.

After 60 seconds, the surgeon made a first incision and sliced away the testes.

Marilyn screamed at 120 cycles per second, engendering a flash in the surgeon’s eyes that revealed the secret hiding inside the good Dr. Jack Hall. Marilyn didn’t care. Hall’s skill was supreme! What did it matter if a part of his subconscious enjoyed itself? Monsters from the id? Ha! Transsexuals encountered monsters every week—at work, home, school, Wal-Mart, the DMV. The surgeries were Marilyn’s best way to fight back. And in the long run, she would win! She would win, damn it!

Without looking up, focusing on time and precision, Hall tossed the scrotal contents into the hazardous-waste bin. Then, he slashed the penis from base to tip, splaying the skin to be grafted.

The firmly secured patient inflated her surgical mask with guttural cries that sounded masculine.

Dr. Hall focused.

Cut. Clamp. Suture. Again.

The surgical maestro was better than his word, and Marilyn’s feminization resolved into a prolonged ode to joy.