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Interview with (recently retired)
Sex Reassignment Surgeon -
Eugene Schrang, MD
By Gianna E. Israel
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
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
And, what is the most challenging surgical case you have encountered thus
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
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"
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
With all those thoughts in mind, how would you characterize the Neenah
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
What is the appropriate method for investigation of these fatalities and for
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
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
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
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
And, how can interested patients contact you?
Dr. Schrang: It is interesting that very few patients come to me
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. 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. 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
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
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.
Dr. Schrang is now retired, and he is no longer performing any surgery.