From surgical expertise to post-operative care, and from complications to personal style, a great many factors go into the transsexual's choice of a surgeon. Eugene Schrang has performed almost 900 genital reassignment procedures and over 3,000 breast augmentation mammaplasties, in addition to other procedures.

Ms. Israel: Dr. Schrang, I understand that your training consists of eight years of premedical and medical school studies followed by eight years of residency training in specialized general surgical and plastic surgery programs. You have also cumulatively provided a variety of cosmetic and reconstructive procedures to a large cross-section of patients. What makes transsexual men and women interesting and unique among patients for you? And, what is the most challenging surgical case you have encountered thus far?

Dr. Schrang: I have found transgendered individuals as a group to be most interesting because the problem itself is so fascinating and occurs in such a variety of individuals. Transsexualism is found in both sexes, every race, every country, the entire spectrum of economic and social achievement and in virtually every personality type. It simply knows no bounds.

Your last question is difficult to answer since I am trying so hard to make each patient look authentic. I consider all cases of transgenderism challenging. If, however, you mean "challenging" as in the case is "difficult to perform", I would have to say that any patient who has multiple physical problems in addition to an attitude that is hard to deal with is most challenging. Fortunately, I do not see too many individuals with attitude problems but when I do, the surgery itself can be more difficult and certainly their post operative care is much harder because the nursing staff must then deal with demanding, cantankerous patients. If they only realized it, these people would recover much more quickly with a positive, happier frame of mind.

Ms. Israel: Consumers place a lot of weight into the surgery accounts of other transsexuals who have had procedures by you and other surgeons. As you have tracked long-range patient responses to genital reassignment, what have you learned and what recent advances have you incorporated?

Dr. Schrang: With the passage of time I have learned that since we are surgically transforming male anatomy to appear and function as female anatomy, the final result must:

1. Look so authentic and genuine that no one can tell the difference from the genetic female.
2. Enable the patient to function normally, that is, trouble free, effortless sexual intercourse.
3. Hopefully, enable the patient to have orgasmic capability.

The main advances have been in the area of appearance. If the final result does not possess all of the structures found in the genetic female, something is obviously missing and this becomes readily apparent to any casual observer. Most important is what I like to call the "Triad of Distinction" which is defined as follows:

1. The Clitoris
2. Well defined, delicate Labia Minora
3. Highly visible, pink, wet mucosa

Without at least these three structures, SRS has not been done artistically. I would expect that any surgeon would know how to create the Labia Majora and position the Urethra correctly but even these I very often find are poorly constructed.

One distressing problem I run into is the fact that most patients seem to disappear after they have had their Labiaplasty, which is usually the last procedure that is done, and I never get a chance to see them or their results again. By far the greater majority of those who have returned look wonderful and I am able to get long term (over one year) follow-up pictures for my slide collection. I have yet to see a long or short term follow-up patient who has not been most pleased with their results. The SRS operation in my hands continues to develop and I am now working on a red-hot idea to form a better looking and functioning hood over the clitoris. Like some of the other ideas I have had, it will take me several years to develop and evaluate the outcome but I think this will be a truly wonderful step forward in the aesthetics of SRS.

Ms. Israel: Post-operative mortality or death of a patient after surgery is of paramount concern to consumers and surgeons alike. Compared to other major surgical procedures, how much more dangerous is genital reassignment? Is it possible for a patient to suddenly start hemorrhaging on their plane ride or shortly after arriving home?

Dr. Schrang: I have never felt that SRS is dangerous in a life threatening way - certainly no more so than most other operations that we do. To be sure there are possible complications which are told to every patient before surgery; Thromboembolism and post-operative bleeding are two that are mentioned. Post-operative hemorrhage can occur immediately or while traveling home by car or plane. This is the reason that I encourage my patients to stay in town a few days after discharge for things to settle down before they make a long trip home. If someone did hemorrhage going home, I instruct them to apply ice, if available, and pressure until it stops. Should bleeding reoccur the individual should seek prompt medical attention and contact my office.

Ms. Israel: Earlier this year you had a post-operative mortality from Pulmonary Emboli, after a patient had stopped her regular anticoagulant medication shortly before undergoing surgery with you. Can you put this situation in easy to understand terms? And, what do such situations mean to future patients?

Dr. Schrang: I did have a patient die of Pulmonary Embolism early this year who had a long history of Thrombophlebitis and Pulmonary Emboli. She had been taking Anticoagulants prescribed by her physician which she stopped taking three weeks before an eight hour plane ride from England to the United States for her surgery. My colleagues and I are convinced that she began growing those emboli weeks before coming here. She could just as easily have gone home with them and had the embolic episode back in England. For prospective patients who never had Thrombophlebitis, there is very little risk because remember that thousands of operations are done every day for all kinds of problems and seldom do we see Pulmonary Embolism unless the patient is particularly high risk and even then we take precautions - cessation of hormones, use of sequential ted stockings and so on. It is essential that patients tell their surgeon that they have a history of Thrombophlebitis.

Ms. Israel: As a result of the preceding situation there have been a lot of questions as to what the appropriate time for a person to recover from surgery before becoming ambulatory. Can you shed some light on this subject, and how your policies differ from that of other surgeons? How important are these differences in ambulation?

Dr. Schrang: Early ambulation is important for the aftercare of any patient. I keep my patients at bed rest with sequential teds in place for six days (which is not considered prolonged bed rest) because it takes this long for a skin graft and flap to obtain its blood supply. If a patient is moved too soon there is risk that the graft and flap will be lost and I have seen this happen. Burns, for example, are kept in bed for many weeks until they are ready to graft and more weeks until the grafts take and they can then ambulate safely. I see many patients who come from other surgeons who have very little depth to their neovaginas. This is due either to lack of diligent dilating on their part or ambulation before the graft has had a chance to get sufficient blood supply to survive.

Ms. Israel: From preparatory cessation of hormones (except Spironolactone) to the individualized medical recommendations you give patients, a variety of pre-surgical warnings have developed to protect individuals. Recently, even international airlines have also been developing healthcare warnings to help long-distance travelers from developing Deep Vein Thrombosis (DVT) and other "coach-class syndrome" symptoms. These recommendations vary from wearing knee-high compression stockings to abstaining from alcohol and caffeine. Also, included are recommendations to move around during flight or use inflatable exercise foot pads. Given recent deaths associated with air travel what are your thoughts on the subject of airline travel, including those traveling to surgery?

Dr. Schrang: Air travel has its hazards but travelers who are healthy have little to fear. Once, while on a long flight to Europe, I was called to assist a patient who had developed difficulty breathing. I called for oxygen but everyone around me was smoking so you can imagine the trouble I had treating the patient and at the same time trying to get people to stop smoking. The close quarters in an airplane with air that is recirculated over and over again can distribute bacteria and especially the cold viruses. Also the circulation of blood tends to decrease especially in overweight and unhealthy individuals so it is important for them to ambulate often. When traveling, people are usually on vacation and tend to relax; when they do, they drink alcohol which in turn dehydrates the body and increases the propensity for embolism formation. I would tell people who anticipate traveling by air before their surgery, to be as healthy as possible prior to their trip. If overweight, lose as much excess weight as possible. Ambulate often on the trip and wear compression type stockings. Do not drink any alcohol before and during the flight. Drink plenty of water to stay hydrated and that means do not take any diuretics during the trip which tend to dry out the body. I would also eat lightly until the destination is reached so as to stay less lethargic.

Ms. Israel: You have been a man of science and medicine for 48 years. What do you consider to be the most important advance in general medicine that you have seen in your life time? And, what advances do you believe may occur in genital reassignment over the next 50 years?

Dr. Schrang: There have been so many advances in medicine and surgery that it is hard to pinpoint the one that is most important. Certainly the pharmaceutical area of medicine has contributed greatly and surgical techniques have improved immensely. Just the explosion of medical knowledge in general is most impressive. Stem cell research holds great promise for things to come since it will revolutionize our ability to grow tissues needed for treating a broad-range of conditions. I do not know what the next 50 years will bring for Sex Reassignment Surgery but certainly the operations we do will improve greatly and hopefully those surgeons, who do them only occasionally getting poor to ghastly results, will stop doing them or at least learn an accepted surgical procedure. The greatest theoretical advance that I can think of would be a method - probably pharmaceutical - that would put the mind in harmony with the body rather than having to surgically put the body in harmony with the mind as we do now.

Ms. Israel: That later concept is fascinating. I can imagine it may bring about 'right to choose' issues, much like in the abortion struggle, as transsexuals strive to keep control over their minds and bodies. For some, a pharmaceutical intervention would be a welcome relief, however others may continue to want transition and genital reassignment.

Turning our focus to your practice, I have heard repeated compliments of your post-operative medical care, of your office staff, and people's attitudes in Neenah toward transsexuals. Drs. Menard and Brassard characterize their surgical experience as door-to-door comfort and surgical excellence; Dr. Sanguan Kunaporn characterizes his experience as medically necessary for transsexuals in a Palm Beach-like setting. With all those thoughts in mind, how would you characterize the Neenah experience?

Dr. Schrang: The Neenah experience is where a patient will obtain the most sophisticated and technically advanced Male to Female Sex Reassignment surgery found anywhere on the planet Earth and in a most safe, understanding and congenial atmosphere. Ten years from the time a patient gets her surgery, she will not remember how many palm trees were outside her window but she will certainly remember the results she got - she will be living with them day after day. Her life will be wonderful if the results are great, but if not, we can safely say that the bitter taste of poor surgical quality will last long after the sweet taste of good price, whether or not there are palm trees outside the window and the Doctor's bedside manner are forgotten.

Ms. Israel: Recently I was contacted by several clients who expressed concerns that several activists have mischaracterized recent genital reassignment mortalities in an inappropriate fashion. What is the appropriate method for investigation of these fatalities and for professional/public inquiry? Also, if people have questions of your past surgical results, are they allowed to contact you?

Dr. Schrang: Complications are found with every surgical procedure and Male to Female SRS is no exception. If anyone wishes to discuss any complication, they may call their surgeon directly and most surgeons will be glad to discuss it with them. This, of course, includes my patients.

It is customary for the Medical and Surgical Departments of hospitals to review and discuss all deaths. These are learning conferences to determine what might be looked for in the future in similar situations. All deaths can not be avoided but we can learn from them.

Ms. Israel: No interview with you would be complete without addressing sexual stimulation. Would you care to share some insight on your advances and of post-operative happiness?

Dr. Schrang: It would be absurd for me or any surgeon to guarantee orgasmic capability after SRS since orgasm is a very complicated physical and psychological phenomenon. Much depends on the attitude of the patient, whom she is with, immediate circumstances, etc. All I can do as a surgeon is assure the patient that I will leave the Pudendal nerves intact; the rest is up to her. Much like the big league pitcher who can place the baseball over the plate exactly where he wants it because he has the brain, eye, arm coordination to do so. Cut his arm off and he still has the brain, eye coordination but cannot throw the ball. If a surgeon cuts the Pudendal nerves, a patient may have the desire, circumstance and everything else necessary to achieve orgasm but obviously cannot because the nerves were cut. Most of my patients have explosive orgasmic capability - but not all. Keep in mind that, according to researchers, half the genetic female population do not climax and most never had surgery of any kind. Sexual happiness begins and ends in the head but in the mean time it passes through the Pudendal Nerves.

Ms. Israel: It is interesting hear your observations on the preceding subject from a psychobiological perspective. Essentially where the individual client is concerned, I have always advocated that pre-operative individuals remain 'in-touch' with the sensitivity of their genitals and ability to orgasm, no matter how much they dislike the pre-operative form, thus allowing sensitivity to stay viable. From a team perspective I know that all the pieces have come together when post-operatively the individual reports back to me that her neo-vagina and clitoris have "a life all their own!"

Now, for an unrelated question. Several years ago an unusual surgical situation was brought to my attention. This involved a surgeon intentionally relocating and implanting viable testicles in a MTF patient at her request, supposedly in order to preserve or enhance the individual's libido and sexual functioning. Yet, as clinicians we have known for some time that genetic women produce testosterone within the adrenal gland system, and occasionally minute prescription doses of testosterone have helped both genetic and transgender women gain libido when the adrenal glands fail. What are your thoughts on the implantation of testicles and the use of testosterone in MTF patients?

Dr. Schrang: I do not implant testicles in females - even when SRS is done - because it is anatomically wrong and they can be a source of cancerous degeneration later. Female libido is definitely a result of Testosterone and is best prescribed by an endocrinologist.

Ms. Israel: Of the many patients who have arrived at your office the day before surgery, where have you found patients most likely to be unprepared? Where can patients find information on this? And, how can interested patients contact you?

Dr. Schrang: It is interesting that very few patients come to me unprepared. They have done their homework and have researched the operation and the surgeons who do them. The patients who come to me have read my informational letter which contains virtually everything they need to know including pictures. In addition they have visited my website at www.drschrang.com which also has a great deal of information. Many have talked with some of my past patients who, in turn, give them support and more understanding of what the surgical transition is all about. Interested patients can easily contact me by email at: eschrang@aol.com or by simply calling me at 920-725-6661. I am readily accessible and always answer an inquiry - I return all phone calls. There is, however, one thing I wish patients would do more often and that is arrange to donate autologous blood; if they do, I always transfuse it back to them on the day of surgery and I have found that patients who do this always have a smoother and faster recovery that those who do not.

Ms. Israel: I have been aware of your expertise the past 13 years of my counseling practice. During that time I have observed that you have consistently treated your patients as equal partners in the surgical experience. Do you have any closing comments you would like to direct at your former and future patients?

Dr. Schrang: To my former patients - I wish you all well and the best that life can offer. If there is more you would like done or if you have lingering questions, do get back to me and I will do my best to clarify things for you. Also, please send me color pictures of your long-term results so that these may be included in my long-term patient educational study and slide show.

To my patients of the future - research everything and chose your surgeon carefully. You will live with the results of his craftsmanship for the rest of your life. You have only one chance for a good or even great result because once the anatomical structures have been altered or discarded, the bridges have been burned and except for some minor alterations, there is no second chance. You want to live a happy, rewarding and fulfilling life - not one of regret. The best surgeons of the world have their problems and the worst surgeons of the world once in a while get a good result. Choose wisely!

Ms. Israel: I have greatly enjoyed having an opportunity to exchange ideas and question you. In closing I would like to pass on my sentiment that when I have face-to-face contact with clients I am not allowed to recommend any one surgeon over another. That said, you have my highest respect for your continuous advocacy of transgender individuals both in the operating theater and across the community. Please accept a gracious thank you for making yourself available.