At 22, Zohar started transitioning from female to male. First, he removed his breasts. Then, he took hormones to kick off his masculinization – the deepening voice, the five-o’clock shadow. Today, aged 30, he is waiting for a hysterectomy and after that, possibly, the construction of a penis.
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The Tel Aviv resident, who preferred not to give his last name, isn’t certain he wants to go through with phalloplasty – a risky procedure that uses skin from the arm, abdomen or thigh. But if Zohar does opt for penis construction, he will have a problem: Right now, he can’t do it in Israel.
In fact, for the past two years, Israel hasn’t had a sex-change surgeon at all. The vacuum was created when long-standing specialist Dr. Haim Kaplan left the only local hospital providing the service, Sheba Medical Center, Tel Hashomer.
American expert Dr. Marci Bowers, transgender herself, flew in to perform nine procedures, while some locals in search of sexual reassignment surgery have gone abroad for operations.
In the meantime, however, Dr. Alon Liran, a plastic surgeon who is also at Tel Hashomer, took up the mantle. He went with his wife and three children for a year of training in Belgium, on his own dime, to become Israel’s next SRS specialist. He returned to Tel Hashomer in August. He completed his first solo vaginoplasty on Monday, but for now he doesn’t have the team he needs to construct a penis.
A surgeon can construct a vagina without a specialized staff, Liran told Haaretz, but a specially trained urologist and/or a gynecologist is needed for phalloplasty. Right now, Liran is looking for a urologist willing to go abroad and receive the proper instruction. With that person in place, he says he will be able to perform the surgery, and deal with any ensuing complications. But finding the right person for this surgical niche is no mean feat.
“The field is not new, but definitely not popular, and most of all not profitable, which I guess is part of the issue,” Liran explained.
This means that despite the fact that Israel has a dedicated sex-change specialist, female-to-male transsexuals still have to travel abroad for surgery. With few options at home, such operations are subsidized by the National Health Institute. Still, the idea of being alone in a foreign country during a risky procedure is clearly not a comfortable one.
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People are frustrated by this, according to Elisha Alexander, a representative of Tel Aviv’s Gay Center and founder of Maavarim (Transitions, in Hebrew) – an activist group serving Israel's trans community. Across the world, estimates are that trans people make up 0.1 to 0.3 percent of a country's population. In Israel, that would be between 8,000 and 24,000 people.
“They waited a long time before he [Liran] was ready,” he said of the trans community, adding that there is concern over his relative inexperience. “He only just trained, and if he only does one operation a month, how long will it take him to become experienced?”
Since regulations were put in place by the Health Ministry in 1986, sex-change operations have been available only at Israeli public hospitals, not via private providers. The trans community has complained for years about discrimination and humiliation in the run-up to approval for operations, with many choosing to travel abroad and pay for surgery themselves.
The cost of transitioning is in the tens of thousands of dollars range, depending on where it is carried out. Thailand is a popular and cheap destination for male-to-female transsexuals, while Serbia is known as a good place for for those transitioning from female to male.
Along with taking hormones, transitioning involves anywhere from two to dozens of operations, Liran explains. These are mainly on the breasts and genitalia, while some people also need facial surgeries and finishing touches to their new penis or vagina. Most don’t go through with the entire genital-surgical process, and everyone goes at their own pace.
For his part, Liran says he understands the trans community's concern: “In my opinion – it’s mine, and I’m not representing any institute – once we decide to give the service, we will try to make it the best we can and not do half a job.”
The complexity of SRS procedures and the need for specialized skill and training are daunting problems not just in Israel, as Bowers told Haaretz in an email. The world has been “caught off-guard by the veracity and growth of trans communities,” she commented.
Although she foresees the lag in services continuing, after performing surgeries in Israel and working with Liran, who also observed some of those procedures, Bowers said that “Israel is ahead of the curve in many ways.” There even was a bid, albeit unsuccessful, to host locally the 2017 meeting of The World Professional Association for Transgender Health, to raise awareness of the issue within Israel.
In May, the Health Ministry amended the 1986 regulations. The minimum age for sex-change surgery was lowered to 18, and now candidates only have to prove that they have spent one year living in their new, requested gender identity – not two years, as before. Authority to approve surgery was also transferred from the sex-reassignment committees at Sheba Medical Center to a special committee including a psychologist, a psychiatrist, a urologist, an endocrinologist, a gynecologist and – for the first time – a representative of the trans community.
Meanwhile, at a recent Q&A session in Tel Aviv’s Gay Center, there was little Liran could say to reassure the trans men in the audience. “Right now we have no solution for female-to-male,” he said, explaining his ambition to build up Israeli expertise in the field in general, but adding that this will take time.
Good intentions aside, for many the situation remains unacceptable. Said Zohar, “This should be seen as a physical problem that needs a solution. They don’t understand that, for some people, this is a question of life and death.”