Anita Fajardo was always a favorite patient of mine. In body image, perfectionism may be a negative factor. Anita Fajardo was a perfectionist, but perfection is the enemy of good. She was sexy and beautiful. She was not fully in a “job.” She chose pleasure over pain in one of her very important decisions.
She was perfectly beautiful, more so than other male-to-female patients I had seen. In fact, it was very hard to imagine that she was ever a man. Pleasant, respectful, and beautiful. Always nice to see her name on the schedule.
I know that she had sex appeal as a female because she hooked into my personal T (testosterone). At this time I recall her well, but do not know if she ever had a job, which was one of our basic prerequisites for making the bodily rearrangement, male-to-female. I do recall her being beautiful, most beautiful, as compared to other patients. She was sexy, but not with any ostentatious mannerisms, or even anything you might identify as being purposefully feminine. It was a testament to her truly female brain. Her attitude was that she was living life as a female.
“Hi, Doctor. How are you? What a nice day. Nice to see you.”
In regard to the criteria for surgery as usually used by our gender identity committee consisting of Norman Fisk, psychiatrist, Judy van Maasdam, experienced clinical social worker, and myself: passability was 9.5 out of 10; psychologic was 7.5 out of 10. She was happy with her life as a female, but not perfectly happy, however. Economic legs: I don’t know about this aspect. Sexual: she ingeniously had sex with males in her pre-op state.
Our gender identity committee passed her for surgery after a one-year trial period. She had been on female hormones, progesterone and estrogen. Periodic testing for possible liver damage was done, and some interval history and physical examinations, were included in that “okay.”
The operation was an augmentation mammoplasty with implants containing silicone gel, removal of the penis corpora cavernosa and corpora spongeosum, and dissection of a space between the rectum and the bladder up to the peritoneal reflection.
A dressing change was made on the fifth day after surgery. The drain was kept on suction and the amount of drainage was recorded. The patient was on bed rest for seven days so that the healing skin graft would not move on the structure onto which we desired it to grow. Then the stent was temporarily removed, and hygiene and dilation were carried out with an antibiotic solution and with the stent being inflated and deflated periodically. This dilation continued for six to twelve months. If intercourse had begun sooner, dilation would not have been necessary.
“Magnificent” was the word of Dr. François Burou of Morocco, who was the inventor of the penile inversion male-to-female operation, and really the pioneer as far as gender surgery is concerned. He was present at our second international gender dysphoria syndrome meeting to present a paper and came to see my patients in clinic. I showed Fajardo off at that time. My body image increased when the father of the inversion of male genitalia for gender change examined her and made that statement. It must have impressed Burou because he immediately referred to me three cases, not for male-to-female surgery, but the other way round, for female-to-male surgery. His construction for phallus was not as generous as those he saw in my clinic. He was a gynecologist, not a plastic surgeon.
Fajardo was successful. There was no complication. She became happy, passable, and promiscuous.
Twenty years passed, 1972 to 1992. I began performing a different kind of male-to-female surgery, nicknamed “The Rolls Royce Vagina” at the professional meetings, as compared to the Volkswagen vagina of days of yore. I performed 111 cases with the skin graft technique as on Fajardo, and 38 cases with the newer rectosigmoid vaginoplasty technique. The Rolls Royce had increased vaginal depth. The patient could appreciate some vibration because I studied that with the vibration of the fiber optic scope with the camera and I reported that. The patient did have orgasms by stimulation of the nerves, which previously belonged to the prostate gland. These corresponded exactly to the so-called magical spot of Dr. Adam Ostrzenski.
Even though the function of Fajardo’s vagina was excellent and superior, she heard about this newer surgery and came to ask for that upgrade with the new technique. The idea, of course, was re-evaluation with medical history and examination and lab work, and review of her hormone therapy with adjustments as needed. An HIV test was part of her workup for the surgery, and alas, she was HIV positive, without any symptoms of AIDS.
I told her that the surgery would not be possible. She was not at all pleased. I told her that the colon mucosa of her new vagina could then be able to transmit the virus in question to the male. In my words to her, this would be manslaughter.
Surgery was cancelled, but here is where the quality of perfectionism reared its ugly head. “Perfect is the enemy of good.” Perfect rather than good was her idea; she wanted to go from 94% to 100% perfect.
She, from a sense of injustice to herself, sought a top-of-the-field trial lawyer professional consultation in San Jose, California. The letter to me from the attorney (name withheld) spelled out that I was breaking the law, the Unruh Law. His second letter quite strongly warned me of the discomfort I would suffer when I lost a major lawsuit. I responded strongly with a counter threat: “Please, consul, sue me and sue the whole university, my assistants, and my advisors. I will sue you back and string you up even if I have to go to the Supreme Court to do it.” I freely used the word “manslaughter.”
The follow-up was that there was no lawsuit. There was a happy patient. There was a happy surgeon and doctor. There was even a happy attorney; he won many subsequent other cases for sufficient money to make him happy.
In body image work in plastic surgery perfection is the enemy of good. In seeking perfection we look at the graph (see figure 1) where the difficulty of surgery is on one axis and the difficulty in achieving the unwritten agenda is on the other axis.
In the case of seeking perfection, the unwritten agenda is extremely high, and in many cases the difficulty of the physical surgery itself is also extremely high, making a danger point (point X) much more likely to occur. However, ego now plays a role because of the difficulty of achievement, the ego of the surgeon is highly tempted. The “hothouse orchid” psychological profile of the plastic surgeon is the easiest target in all of the specialties, especially when combined with praise from the patient. We know that the one of the plastic surgeon’s main objectives is to please the patient. The surgeon’s ego flourishes and the surgeon is happy, and with hot air the orchid does the same. With cold air, the orchid fades and wilts. With displeasure from the patient, the surgeon’s ego wilts and he becomes unhappy.
I thank God for the HIV test, which saved me from the anguish that loomed. And thank you to Judy van Maasdam, Mark Gorney, Norman Fisk, and all of those Jesuits and parents who programmed my decision-making before I arrived to practice the plastic surgery principles with my friends, the patients.
The request on the part of the patient had economic legs, the profit motive was at work here. Could having diagnosed the patient have economic legs? And the goal having a lot of sexual activity? I missed that hidden agenda because she was so beautifully passable. In her case the desire to have perfection in sex was linked to happiness, but this turned out to be a chink in her armor. It was irresistible for her to try to claim what she saw as the last three or four percentage points of perfection in her life.