184 Gardenia Luk Monsaert

Transformations over time: Interview with plastic surgeon Stan Monstrey

| 8 June 2021
Stan Monstrey is a plastic surgeon and a world authority on transgender surgery. In conversation with Alain Platel (A) and Frank Van Laecke (F), he opens the door to his world and experiences and looks back on 'Gardenia'.

A: Stan, how did your interest in transgender surgery develop?

 S: You don't make important decisions in life, they are made for you. I was actually destined to become a civil engineer. I was good at maths, my father was a physicist and my college was a breeding ground for engineers. But at sixteen, after a serious car accident, I ended up at UZ Gent, the University Hospital of Ghent, in the plastic surgery department with Prof. Dr Matton. This experience made such an impression on me that I wondered why I wanted to become an engineer and not a plastic surgeon, or at least a doctor.

Later, I also wondered whether being homosexual played a role in that choice. It is sometimes said that a homosexual person feels more connected to a trans person, that there are similarities such as the coming out, but I think it just has more to do with who you are. And it's also like psychiatrist De Cuyper once said: "Once you're dealing with these patients and you dedicate yourself to them, you can't help but be an advocate for their cause." That's how I gradually grew into it.

A: How did you experience Gardenia, the performance that took place ten years ago? What memories do you have of it?

 S: Gardenia... I have seen it three times. When I think of the performance, it's mainly the scene to Ravel's Bolero. I have seen transitions happen so many times in my life, especially in the past when we saw the patients going through the change from the beginning. Now we see the patients more at the end, when they have already gone through the social transition. I remember a man who was small and sturdy in stature and who I thought would meet hardship in the social acceptance of his transition to a woman. But when I saw her six months after the operation, though her stature had not changed, she radiated so much femininity... No artificiality, no make-up, she was just who she was, but she had changed so much and I couldn't tell what had changed, she wasn't wearing different clothes, but she was radiant. Such a transformation is so comprehensive and that is what they radiate, I think.

So when in Gardenia, during Ravel's Bolero, I saw the transformation as in a time lapse, I thought "That's it!" I go through that on a daily basis and you were able to imagine it in ten minutes. It still gives me goose bumps. One of the most beautiful scenes...

I also have a bond with several people from that team, so that made it special for me as well. Andrea was our first patient, in 1988. That was the early stage of trans surgery in Belgium.

In the 1980s the gender team at UZ Gent consisted of three people: Dr Guido Matton was a surgeon, Dr Griet De Cuyper a psychiatrist and Dr Robert Rubens an endocrinologist, he prescribed the hormone therapy and was very committed to transgender people. I was a final-year assistant at the time, and the team wanted to expand the services. We went to see how things were done elsewhere: from Amsterdam, which was the Mecca of transgender surgery at the time, to a very experienced surgeon in Lausanne who also worked in a multidisciplinary manner. That was an eye-opener for us. I also went to America, where I learned about microsurgery and reconstructions with free vascularised flaps. Free flap surgery is a technique of transferring tissue from one place on your body to another. A penis is made of tissue from the forearm and that is then connected at the bottom to blood vessels and nerves in the groin area. This is how we started in Ghent in the early nineties. Now we do an average of two phalloplasties a week and even more breast surgery/reconstructions and vaginoplasties.

So I partly ended up in my specialisation in trans surgery haphazardly.

F: Looking back on it now, what has changed?

 S: In the past, people thought more in terms of man or woman. You had a man or a woman and you could understand that someone wanted to change from one gender to the other. A patient who used to come to us was expected to 'go all the way', you couldn't stop halfway. Now you see that within the 'gender spectrum' there is so much in between. It used to be normal for trans men, over the course of years, to first undergo a breast reduction or, more often than not, a complete removal of the breast, which was then typically followed by a removal of the uterus and a penis reconstruction. But now there are also patients who only want a breast correction and don't want to go any further, who don't need a penis to feel like a man. In the past, a transvestite was seen as something completely different, whereas now we realise that there are many more transitions and similarities in the whole male-female spectrum.

That's the beauty of Gardenia by the way - are they transgender, are they transvestites? - it is a wonderful mix.

 A: Do you feel in your practice that after their transition, people no longer want to be reminded of their past?

 S: I remember an expression of psychiatrist Griet De Cuyper: "A transition is successful to the extent that the person can also give the 'previous life' a certain place." Transgenders who want to eliminate their past completely, who can pretend it did not really exist, are sometimes convinced of their own lie. Trans women who say 'I was not born a boy' and who are totally convinced of this, may not be the ones who have the best chance of being happy. Because no matter how well the operation has gone, perfection, the real thing, is never achieved.

F: Someone told me about the transition from man to woman: you think by doing this, you will finally achieve what you want to be: you want to be a woman and be accepted by society as a woman. But it turned out that that person had never felt as much of an outcast as after the operation. I don't know whether that person was happier before or after the operation. But in the search for happiness, this transition does play a role. How have you experienced that in your work?

S: Whichever way you look at it, it is quite dramatic to realise that you were born in the wrong body, so to speak. And you are constantly confronted with this from a very young age. It can only be frustrating. Whatever we do, it is never the real thing, never.

I know a very attractive homosexual trans man, who tells me that he can count on a lot of interest from other men. But when it comes down to it, i.e. in bed, they don't go for it. He does have a beautiful penis, everything is well reconstructed, but it is not the real thing.

But still, most transgender patients are really happier after their operation and we have few people with regrets. We have had a few suicides over the years, but that is also true of the general population. We have had a total of three regrettants after just a breast operation. There was someone for whom we had performed a mastectomy - not followed by a genital operation, which already says something - and who came back afterwards to have a breast enlargement. This was someone who had been abused as a girl. She had quite large breasts and she saw that as a cause. This was an element that played a part in her decision. The expectations of such an operation are sometimes very high. People have a number of problems and think that they will all be solved with surgery. Which, of course, is not the case.

 A: Has a play like Gardenia helped change attitudes?

 S: I am convinced of that. A lot has changed in the last ten years. People sometimes tell me that the media attention surrounding transgender is a bit exaggerated, but I think it is a good thing. It should continue to be spoken and written about, to show the diversity within the community.

I remember a newspaper clipping from the 1980s that Dr Matton had received: it described transgender people as psychiatric patients for whom perhaps castration was the only remedy. The way it was written was so denigrating.

When Gardenia played in 2010, you didn't read that much about transgender people in the newspapers or magazines. When you told me about the idea of doing a performance with older transvestites and transgenders, I had my doubts: are people waiting for this? But I never heard any negative reactions, not even through the grapevine. At the time, people did not talk about it that much, but in Gardenia, the non-binary comes up in a different form. And of course, it is also about getting older, something that everyone is confronted with sooner or later.

A: How do you see the future with what is now happening in the blurring of sexual identities?

 S: In recent years we have seen a huge increase in operations, which worries us a little. Until about seven years ago, we used to do the breast and uterus surgeries together for trans boys and we would do two a day. We had one or two such operation days per month, which means that we did a maximum of four such operations per month. If I look at the last four years, I see that we are doing four a week. And this increase is worldwide. We have no idea where this increase is coming from, but we can't keep asking 'are you sure’?

F: Why can't you ask that?

S: We are allowed to, but we are moving more and more towards a situation where the patient has a say. We used to make the decisions about who was and was not allowed to do it, and how. Now that is completely gone, which is a very good thing. We listen to the patients and also make them aware of their responsibilities. This applies to medicine in general, but even more so in the case of transgender surgery. With us, you have a whole team. A patient is first guided through an assessment, which is largely completed by the group of psychologists and psychiatrists.

A: Sometimes I think: there should be another play, not only about transitions, but also about sexuality and the experience of sexuality. This was one of the things I was confronted with when working with the actors of Gardenia. How far can you go in this or how broad can you deal with it. This discussion is still insufficient.

S: Gender or identity is indeed separate from sexual preference. Half of trans women, those who were born as men but are women, have a lesbian relationship with a woman. You also have people in a heterosexual relationship who stay with their partner after their operation. Sometimes people say that this is for reasons of convenience or financial motives, but many also say: we just love each other and you continue to love that person even after the transition.

I have also been thinking about what Gardenia does not highlight about transgenderism. I was thinking about the recent development of young people. There are some who are already being monitored here as children, for whom we temporarily stop puberty, so as not to impregnate their bodies with the wrong hormones. If they continue with the trajectory, they sometimes already have a social transition at the age of sixteen (including the breast amputation for trans boys). And then there is the question of whether we will perform genital surgery on them at eighteen. Often, young people have such high expectations: that if they have the perfect breasts or penis, they will have a perfect life. Those young people are not in Gardenia, that is another discussion.

F, A: Stan, thank you so much.

S: Thank you! And I was so happy when I heard about the re-release.

Written down by Tessa Daluwein and Nele Dhaese.