Illustration by Peter Bennett

Change/MD

Written by Amy Saunders Category: Lifestyle Issue: April 2016
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Dr. Toby Meltzer turned Scottsdale into a worldwide destination for gender reassignment surgery almost by stealth. His new partner and protégé may change that.

As a brilliant young surgeon, Dr. Toby Meltzer was capable of performing the most complex of plastic and microsurgery procedures: on hands, on nerves and blood vessels, on faces damaged by cancer or car accidents.

But those weren’t the patients he coveted. He was a gender reassignment surgeon. And because of that fact, he couldn’t find a place to operate in the entire state of Oregon.

Meltzer had already moved his growing practice away from one hospital in Portland, which at times had denied his patients a bed the day they arrived for surgery. The next hospital, initially accommodating, changed its tune when it hit financial trouble. Administrators told Meltzer they were unable to recruit physicians because of the stigma attached to his work. He wasn’t welcome there – nor was he welcome anywhere, he learned as he toured the state requesting hospital privileges. The year was 2003.

Meltzer considered shifting his focus back to the traditional plastic surgery he’d trained for years to perform. But he kept thinking of his transgender patients, and about how few other surgeons in the country could help them become the people they felt they were supposed to be. “No one asks for this. It’s not a choice they make,” he says. “It was tempting [to give up] at that time… but I wasn’t going to let my patients down.”

The fact that Meltzer was driven out of one of America’s most liberal states seems hard to imagine now that he’s spent more than 13 years quietly practicing in Scottsdale without incident.

It’s even harder to imagine now that TIME magazine has trumpeted “the transgender tipping point” on its cover. Now that Bruce is Caitlyn. Now that Meltzer, 58, has worked with more than 3,000 patients, inspiring demand for his services so great that he’s expanding his practice to include another surgeon.

One who happens to understand transgender patients better than he even could.

Photography by Madison Kirkman; Dr. Toby Meltzer in his Scottsdale officeUnexpected “Residency”
After performing his first gender reassignment surgery, Meltzer vowed never to do another.

“I have no idea what I’m doing,” he remembers thinking. “I’m going to stick to the things I know.”

Meltzer knew nothing about transgender health in 1990, when he began working for Oregon Health & Science University in Portland. Even now, no transgender surgery residencies or formal training programs exist in the United States. Doctors must learn the surgeries as Meltzer did: from surgeons willing to teach.

He was a year out of plastic surgery residency when two doctors at the Portland hospital approached him about taking over their practice. A plastic surgeon and a urologist had been teaming up for gender-reassignment surgeries, but with both retiring, they wanted someone to continue their work.

Meltzer, whose career goal had been to perform a wide variety of surgeries, accepted the challenge of learning. Because the two doctors performed gender reassignment surgery only a few times per year, Meltzer’s “residency” consisted only of observing one surgery by each doctor. He also traveled to Colorado, where Dr. Stanley Biber started the first private gender reassignment practice in 1969, to watch one more. In Meltzer’s early procedures, another doctor in Portland assisted him with urology, a specialty in which he was never formally trained.

But largely, Meltzer taught himself. In female-to-male surgery, the uterus and ovaries are removed before constructing what looks like a penis, either from a clitoris enlarged by hormone therapy or skin grafted from another part of the body. While the surgery has not been perfected, it can leave patients with the ability to stand to urinate and with sexual sensation from the clitoris. Reliable statistical studies are notoriously elusive, but several European studies do seem to indicate generally positive satisfaction rates among patients, despite significant post-surgical mechanical issues. (See sidebar.)

Male-to-female surgery involves removing the testicles and tissue from the penis, inverting skin to form a vagina and turning scrotum skin into labia. Meltzer pushed himself to improve the procedure, becoming the first in the U.S. to create a clitoris with sensation by rearranging nerves in the tip of the penis — offering patients real sexual function instead of what had essentially been an amputation.

It’s 80 percent plastic surgery, Meltzer says, and 20 percent complicated urology. Genitals not only need to be reshaped, but they need to function – and surgery requires dangerous proximity to the bladder, urethra and rectum. “It’s a challenge on almost everyone you do, and I’ve done over 3,000 of them,” he says. “You’re a millimeter or two from creating a disaster if you don’t know what you’re doing.”

Meltzer’s first procedure resulted in enough trial and error that the patient later required additional surgery. He was ready to dismiss the idea of more surgeries when the patient sent him a note, thanking him “for validating their life and helping them live the way they needed to live,” Meltzer says.

That kind of gratitude is what inspired Meltzer – along with his wife, three children and even four members of his office staff – to continue the practice in Scottsdale. Meltzer insists that any cosmetic surgeon would prefer working with his patients over the typical cosmetic surgery patients.

“They’re so much easier to deal with and so much nicer and so much more appreciative of what you do,” he says. “I get thanked every day.”

Meltzer with his protégé, Dr. Ellie Zara LeyBest in the World
In another specialty, Meltzer might be the best-known doctor in town, the kind hospitals advertise on billboards and in magazine ads.

Meltzer is “without a doubt, the best in the world,” says Dr. Burt Webb, a Scottsdale OB-GYN who assists him in female-to-male surgeries.

But Meltzer has never promoted his practice, and has rarely granted media interviews. For years, his office address wasn’t listed on his minimalistic website. It’s perhaps one reason controversy never followed him to Scottsdale, a city recommended to him by a former patient, a doctor. No one knows he’s here.

“He just wants to take care of his people,” Webb says. “That’s all he really cares about.”

Besides, the people who needed to find him always have, anyway.

In the early ‘90s, Meltzer unknowingly attracted out-of-state patients who mentioned a then-unfamiliar term: chat rooms. A former patient had shared surgery photos online at the time when the Internet was proliferating – and transgender people were discovering they weren’t alone in feeling they were born into the wrong body. Meltzer’s few gender reassignment surgeries per year turned into more than half his work by 1996, when he started a private practice.

Now, out-of-town or even out-of-country patients account for more than 85 percent of Meltzer’s caseload,
and nearly all of the procedures Meltzer performs at Greenbaum Surgical Specialty Hospital in Old Town are transgender-related. Operating Monday through Thursday, with two 12-hour days, he does at least five male-to-female and two to four female-to-male procedures a week.

The term “sex change surgery” isn’t preferred, nor is it very accurate. The “change” should be a transition to the desired gender over the course of a year or longer before surgery, according to care standards published by the World Professional Association for Transgender Health (WPATH). Another prerequisite: two referrals from mental health professionals.

The transition isn’t a one-step procedure, either. A male-to-female patient, who typically has genital surgery in two stages, may simultaneously undergo breast augmentation, facial feminization and body sculpting procedures like a chondrolaryngoplasty, colloquially known as a shaved Adam’s apple.

In a surgery prior to the main procedure performed by Meltzer, a female patient has her ovaries and uterus removed by Webb. (Female-to-male patients generally take testosterone supplements in perpetuity after their procedures.) He also performs a vaginectomy, removing tissue to support other organs, which leads to fewer complications in the next surgical stages. Webb is one of few surgeons worldwide performing the procedure for gender reassignment, thanks to Meltzer’s unique vision.

“His brain works in an artistic fashion,” Webb says. “A lot of people can paint, but there are only a few masters. And Toby is definitely a master.”

Meltzer is so well-regarded in the industry for his results that patients wait more than seven months just to meet him for the first time. Indeed, if one were to schedule a surgery with Meltzer this very afternoon, it most likely would not be performed until late 2018.

With transgender awareness and health insurance coverage both expanding, a long wait isn’t uncommon, says Jamison Green, president of WPATH. “We’ve seen an order of magnitude growth in demand because people are not so ashamed of who they are anymore,” Green says, “and also because they can possibly afford to go ahead and have the surgery.”

As recently as 1994, “transsexualism” was listed in the American Psychiatric Association’s Diagnostic and Statistic Manual of Mental Disorders as a mental illness. The definition has since shifted toward medical: After changing the term to “gender identity disorder,” the association in 2013 dropped its mention of a disorder for “gender dysphoria.” The condition, in which one’s expressed gender differs from the gender others would assign to him or her, isn’t itself a mental disorder. But because it can cause mental distress, gender reassignment surgery is listed as treatment.

Reliable statistics aren’t available, but Green says a 2006 survey suggested 1,200 surgeries were performed annually in the U.S. That number has likely jumped as the surgery recently has become far more affordable. Medicare lifted its ban on coverage for the procedures in 2014, and Green says two-thirds of Fortune 500 companies now offer coverage (although cosmetic procedures, like facial feminization, typically aren’t included).

For Meltzer, that means about 90 percent of his patients are covered by insurance and 10 percent pay out of pocket – a monumental shift from the many years when the opposite was true, and a patient needed $24,000 for a first-stage male-to-female surgery alone. But the supply of surgeons qualified to do the work hasn’t kept pace with demand. Green knows of only about 15 experienced surgeons nationwide – not that other, less qualified “specialists” aren’t operating, too.

In the absence of formal training programs and licensure, any doctor can claim to be a gender reassignment expert. Inexperienced doctors are offering patients a surgery wait time of months or weeks instead of years – and many patients who have already waited years or decades snap up the opportunity. Meltzer says less than 3 percent of his female-to-male patients and virtually none of his male-to-female patients suffer major complications, which isn’t the case for less-experienced surgeons.

“We get calls all day long from people who have bad outcomes from other places who are desperate to be fixed,” he says.

Over the years, Meltzer has declined dozens of requests from surgeons requesting his tutelage. Only last year, as he began to realize his workload was unsustainable, did he find the perfect protégé.

Dr. Burt WebbDestiny’s Doctor
Plastic surgeon Dr. Eleazar Ley considered learning gender reassignment surgery a decade ago, researching practices as far as Thailand. Like Meltzer, he had a fitting combination of skills – trained in craniofacial, hand and microsurgery – and continually sought his next challenge.

A single, seemingly innocuous moment made Ley realize that his interest in the surgery was more than professional. One day several years ago, while his wife was at work, Ley agreed to paint the fingernails of their two young daughters. To make fun of his shoddy work, he turned the polish on himself. That’s when it hit him.

Always, Ley had felt something missing in his life. His search for fulfillment motivated him to emigrate to the U.S. from Mexico; to complete medical school, residency and three fellowships; and to start a private plastic surgery practice in Tucson. But not until the nail polish moment did he recognize what was amiss: his gender.

“It just stirred something inside of me that wouldn’t stop, this force,” Ley says now. “It was relentless after that. My feminine side just completely came out.”

Ley, 42, last year became Ellie Zara, a slim woman with shoulder-length hair who wears dresses and heels to work. While the transition has brought pain and the end of her marriage, Ley says she’s never felt such peace, like she’s been female all along. And when Meltzer, after months of discussions, asked her to join his practice, “It just felt like destiny,” she says. “That this is what I was meant to be doing.”

Ley closed her Tucson practice and moved to the Valley, where she has been shadowing Meltzer’s surgeries since December. When he deems her ready, she’ll take on her own patients, and when he retires in about 12 years, she’ll take over the practice.

She has shared some details when asked, but Ley doesn’t use her transgender background as an ice-breaker with patients, no more than any doctor would begin a consultation by reciting their own personal health history. (Two other surgeons in the U.S. are openly transgender.) Ley wants patients to see her for the reason she was hired: her surgical expertise. But she hopes her experience gives her an advantage – in helping patients.

“I think I can sincerely encourage them that things are going to be OK,” she says. “There’s a reason we do this, and it’s worth it.”

Meltzer patient Donna Rose, an IT professional and avid guitar collector based in Chandler, didn't transition until her early 40s.The Confirmation
For decades, David Rose felt like an actor playing the role of a man. On his college wrestling team, in his marriage and in his IT consulting work, no one knew that a man who looked and acted so masculine had identified with women since his earliest recollections.

Rose, like many of Meltzer’s patients, didn’t find it personally and socially feasible to transition to Donna until age 40. Some wait even longer: A 70-something patient asked Meltzer to finish the surgery even if he died in the operating room. He wanted to be buried as the man he was.

Meltzer’s work, which included numerous facial procedures, has allowed Rose to achieve what she never thought possible: acceptance, from society and from herself.

“All you want to do is look in the mirror and see who you perceive yourself to be looking back. You want to go to the gym or get a job or be left alone when you go shopping,” says Rose, now 57, of Chandler. “That’s what this is all about. Just living.”

Meltzer emphasizes that surgery doesn’t turn patients into different people. Many of them were exceptionally accomplished long before meeting him. They include two Fortune 500 CEOs, three Olympians, a White House staffer and a number of high-achieving software developers, pilots and military veterans, people who were uncommonly driven to compensate for the void in their lives.

What surgery changes is their ability to fully be themselves. That’s why Ley prefers an emerging term for the surgery: not sex change, but “gender confirmation.”

“The surgery itself isn’t the thing that’s going to change that person. You’re already there, and you’re simply doing something physically to make it match,” Ley says, “to confirm who you already have been.”

TRANS/STATS