Dr. Thomas Satterwhite

Maria: So how did you end up in San Francisco?
Dr. Thomas: I’ve been here since 1996 when I started college at Stanford. I was born in the Philippines — I’m half-Black, half-Filipino. My dad was in the Air Force, so I’ve lived in a lot of places. But meeting my now-husband was a huge reason for me to stay in the Bay Area.
And how did you decide you wanted to pursue a career providing gender-affirming care?
The very first plastic surgery case that I saw was with Dr. James Chang — who’s now the Chief of plastic and reconstructive surgery at Stanford. He did what was called a toe-to-thumb transfer. This 16-year-old had blown up his thumb with a firecracker, and Dr. Chang took his toe and made a new thumb. I thought it was the most amazing thing.
Which toe?
The big toe!
The big toe switches over to your thumb?! Then what’s left on your foot?
Nothing!
Nothing?!
I love how you can move things around the body, how you can affect appearance and function. Then in my second or third year of residency, Dr. Douglas Ousterhout gave a presentation on facial feminization surgery and I was just blown away.
He’s a legend. I mean, c’mon, he’s the FFS pioneer.
I adore him. He’s the quintessential craniofacial surgeon. Like, he chases women and drinks whiskey and talks about cars and shit. But when he’d talk about his work, he covered the technical aspects of it, but also why it’s so important for the patient — that was my biggest inspiration to pursue this line of work.
I see. I’m not totally surged out or anything, but from the FFS consults I’ve had, typically the surgeons are macho guys. They’re churning out beautiful women, but you have to wonder, because they’re so masculine, what’s their investment in that?
Yeah, most of the FFS surgeons are cisgender white guys and I’m also wondering why that is the case. What do they think is beautiful? It’s a funky contrast. It’s always good to make sure that people who are working with the community are doing it for the right reasons, but, honestly, I’m sure a lot of folks are doing it for the money.
Well, that’s why I feel like you get major props for accepting insurance. It’s kind of a rarity in this field. Okay, let’s back up, you mentioned meeting your husband in the Bay Area. What’s the story there?
This was around Valentine’s Day…2001. And I went out to The Stud — is The Stud still there?
It’s in a new location, but it’s still there.
Yeah, it’s been forever. So we met at The Stud. He says that he came up to me, I think I came up to him, I don’t know, but we met and hit it off.
That’s cute.
We’re very different people. He’s German — regimented, practical, utilitarian. He owns three pairs of shoes. I’ve got, like, a hundred. He’s just been a stable, you know, rock in my life. Always so supportive, so loving. He knows who I am and he allows me to be myself. And I feel the same for him. It’s been 20…we’re approaching 25 years. I was 22 and he was 36 when we met. I’ve always been attracted to older men.
I was gonna ask!
We were together for two years when I finally came out to my parents and told them I’d be bringing my boyfriend to Thanksgiving. I was telling my mom about him — his name is Harald — and my mom was, like, ‘Well, we’ve got one thing in common, we both like older men.’
You could bond with her over that.
(both laugh) He was working as a kindergarten and preschool teacher for years, and when our son was about four or five, he stopped working. Well, he’s working at home and taking care of us. And he also works part-time in my practice. He’s much more detail-oriented than I am. I tend to be more intuitive. And he makes sure we don’t miss anything.

That feels German, too.
A lot of folks stereotype Germans as cold and unemotional, but Harald is very romantic, very in touch with his emotions. He’s taught me to be more open about my emotions because I didn’t grow up in a family that did that kind of thing.
Y’all flip the script a tiny bit with you being the younger partner, the doctor with his own practice, and then he’s supporting you.
When people see us together they assume he’s the sugar daddy. But, no, that’s me.
You can both be daddy. So part of gender-affirming care that’s so mind-blowing to me is that body parts can get rearranged. That’s so remarkable. It makes sense, that this toe-to-thumb operation would be a light bulb moment. With gender affirming care it’s not about physical survival per se, but it’s rearranging things to be more aligned.
For a lot of surgeons, we want immediate gratification. That’s what drives us. And so just being able to see that toe become a thumb was astounding. And it just made me realize that we can do all these crazy things because the human body has this remarkable ability to heal!
It really is crazy.
So crazy. And then for transgender/gender-diverse patients it’s like this other level…it’s transformative. It’s life-changing. The way that I view it, it’s like creating the body that that patient was meant to have. With vaginoplasty, initially, when someone’s healing, they still feel sensations of their prior genitalia. They’re, like, ‘Oh my gosh. It feels like I still have an erection.’ And then after a couple months, the brain remaps. And when you get to six months, a year down the line, the patient doesn’t remember their prior genitalia.
Whoa.
It’s almost like their brain was already primed for that vagina to be there.
FFS is more about safety and passing, as well as your own idea of what you should look like. But bottom surgery is about our most private moments. Are patients ever coming to you with particular desires for what they’ll be able to do sexually?
Sure. When I started doing vaginoplasty in, like, 2014, it was different and foreign. The year prior I’d been working on face bones, and then all of a sudden, I’m moving down the body. In the past decade, I’ve done probably a thousand procedures, but with my earlier vaginoplasties, I remember Googling pictures of vaginas — and I shouldn’t be saying this, but this was SO long ago — because I was, like, ‘What does a vagina look like? Where does a clitoris go? Does anyone know?!’ But I’ve got it down now. Early on, patients were, like, ‘You’re a gay man. What do you know about vaginas?’ And I’d reassure them, like, I can view it objectively and without emotion.
(laughs) Totally.
But it’s not just the appearance, it’s the function. And a lot of what I know about vaginas is what my patients have taught me. Like how long it takes to finally be able to orgasm: about three months. Fifty percent of patients can start to orgasm at three months, another fifty percent up until about a year.
What’s the limiting factor? Your nerves or the healing?
A combination. Inflammation can sometimes make the area a little numb. And then it’s also the change in the hormones. If you no longer have testosterone in your system, that can also affect your hormonal milieu. Sexuality and the ability to orgasm are a combination of so many things, physical and mental.
Right.
I certainly want to be honest, too…

Please, do.
There are patients who have physical characteristics that they wanna recreate. There have been patients who’ve brought in a photo of an 18-year-old’s porn vagina and I have to tell them that it’s impossible to recreate it.
Sure.
Most patients are very very realistic and understanding. And they want to have a vagina that matches their body. They wanna have the right depth so that they can have penetrative sexual intercourse. I also have to tell patients that a vagina isn’t gonna solve your problems. Years ago, a patient was like, ‘I want to have a vagina that Ryan Gosling is gonna bow down to.’ But that’s not gonna happen. Relationships are more than just genitalia. I spend a lot of time talking with folks about what having a vagina means. And understanding why they want it.
Do patients come back to you a year later and they’re like, ‘Oh my god. I just got fucked in my vagina for the first time, it was amazing?’
I used to give out my number, and patients would text me at two in the morning that they just had their first vaginal orgasm. Or some of them would do porn and ask if I wanted to watch a clip. A couple of years ago, this woman was asking me about all of these different BDSM things that she wanted to do with her vagina.
What were her concerns?
She wanted to do certain toys… No! Ginger root. She wanted to put ginger in her vagina. I was like, I don’t know, three months? In the world of surgery, it’s always three months. Another one, she was into wearing diapers. At first I thought it was more of a medical thing. I told her she could use them immediately. Honestly, diapers are great, because they’re very absorbent. And post-op you’re gonna have a lot of drainage. And she was like, ‘No, Dr. Satterwhite, I like to pee and poop in them and wear them for a VERY long time.’ And I’m like, ‘Okay!’
We’re not yucking anyone’s yum.
I just realized how vanilla I am. (laughs) But wait three months! I also want patients to be able to explore their body as soon as they can. People are so excited about having their new vagina, but please wait until it’s fully healed. Self-exploration is also important and at about one month, touching and masturbating is good. And then at three months, you can start having sexual activity, vaginally and anally.
And does that include dilation?
No. Dilation should start immediately. Start using the dilator as a sex toy at about a month. If they wanna start using a vibrator, they certainly can. Prior to that, the dilator is strictly a medical device.
I see I see. I can imagine girls getting breast augmentation, for instance, trying to be the bustiest girl on OnlyFans. Do you ever get outsized requests?
Over the years I’ve developed the reputation of being someone who does operations that are natural and proportional. But if I do have patients who want them as big as possible, I make sure they understand the physical restraints — skin can only stretch so much.

I feel that viscerally. (shudders)
The requests that are often harder are with vaginoplasty, where I’ve had some patients desire a 10-inch vagina because their partner is 10 inches and he wants to go balls deep. Understandable, but maybe impossible. Even for someone born with a vagina, they probably won’t be able to accommodate a penis that large. A vagina is not this endless, capacious space.
I’ve always had the understanding — maybe this is false — that how big your penis is before surgery partially determines how deep your vagina can be.
That’s a good question, but no. It’s all about internal anatomy. The width is determined by the size of your pelvis. The depth is going to vary, anywhere from five and a half to maybe six and a half inches, which is a normal physiological depth to have meaningful, comfortable, satisfactory sex. I begin by opening up a space between the rectum and the urethra and then you reach what’s called the peritoneum, and that’s the lining of the inside of the abdomen. If you try to go any further, you’ll cut through it and hurt the intestines.
Oof.
So everyone’s different. You get to this point where it stops. And that’s it. And once I get there, I use the patient’s tissue from their phallus and scrotum to line the inside of the vagina. If that’s not enough, there are actually skin substitutes — I use one that’s made out of fish skin.
Whoa.
It’s not covered in scales or whatever. (laughs) Your body turns it into its own neovagina.
There’s a certain trade-off that I feel as a trans woman. The closer I’ve gotten to passing there’s a lot that’s gained in terms of safety. I don’t need to think about being trans every day. When I board a flight with an ID that says “F”, everything’s good. But then sometimes with sex or romance, people actually want to fetishize a trans woman for being clocky. And especially for having tits up top and a dick on the bottom. For your patients, is there ever a surprising mismatch like that?
Oh totally. I’ve seen that. I remember this one patient was involved in porn, and then she got a vaginoplasty and then all her jobs dried up. She was making more money when she had a penis. And I remember this one woman — I did everything: vaginoplasty, chest, body, face. And she was, like, ‘My sisters are jealous of me and guys just stare at my tits all day.’ It moved beyond passing to being hypersexualized, and she got stuck in this position where people are, like, competitive.
Yeah, you are definitely right, a vagina won’t fix your life.
I tell patients to give themselves grace. You are going to experience moments of depression, anxiety and doubt. Even feelings of regret. But let’s talk about it! Some patients feel crappy after surgery, but are afraid if they voice it people will think they made a mistake. There’s already so much talk about detransitioning, they don’t wanna somehow add to that conversation. But this is a normal part of the process. Any human being who goes through a stressful experience is going to have feelings.
It’s interesting that they’re afraid of being part of the detransition narrative. That’s such a big part of how the news is covering us right now. In the current climate, are you afraid for your practice? Afraid for your patients?
I’m certainly afraid, but I can’t even imagine what my patients are going through. If they can’t get the care that they need, what’s the alternative? What’s so frustrating is that when I started doing this work a decade ago people would say how cool it was and ask for more information. Now it’s, like, ‘Are you operating on children?’
Is that the first question?
I have to just bite my tongue and talk about all the positive experiences. These operations are life-saving, with a big medical team heavily involved in every step of the process. It’s not like I’m standing at a playground and saying, ‘Come over here, little Timmy, let me cut your penis off.’ No! There’s such an extreme perception of what gender-affirming care is about, which is not rooted in reality. We’re talking about people who need lifesaving medical care! That’s the bottom line. Why is that so hard to understand? It’s just about providing more education. When people ask me stupid-ass questions, I try to not get angry. People don’t respond very well to anger, I’ve realized.
You play an important role as someone who’s not trans, but is so invested in the community. People might listen to you more than me…the ideologue. (laughs) You’re an expert in this field, but you’re also really in it with us.
We all need allies! But it just sucks that people aren’t listening to you just because you’re, like, just…
Trans?
Yeah.

It’s a product of decades of no representation and then maybe a couple years of “good” representation. And now we’re way back in this stereotyped, almost villainous space, grooming children or whatever.
I think it’ll swing back.
Okay, thank you for that. We really just went all in, didn’t we? I had prepared these easy questions that I never got to, like, what are your hobbies?
Oh, that’s easy — snakes and pickleball.
Snakes and…wait, snakes?
I have snakes.
You have pet snakes?
I have five snakes.
Do they have names?
Yes. My biggest one is Debby. Debby’s 10 feet long. She’s a huge huge snake. Then my other snakes are Ruby, Cody, Toby and Becky.
And are you and your husband open? That was the other question.
We’ve been in an open relationship since the beginning. A lot of it was because I was 22. But then starting around Covid I just stopped. And the big reason, just to be honest, was because there are so many STIs out there, because no one uses condoms anymore. Everyone’s on PrEP, but then gonorrhea and chlamydia are all over.
You’re the doctor, so you know best, but DoxyPEP isn’t enough to cut the risk?
No, I mean, DoxyPEP and PrEP do work, which is amazing. But I mean, the infection rates are really high in San Francisco. For everything.
We do live in Sodom and Gomorrah.
And I just don’t have the time anymore. I’m getting old.
I mean, you already did an operation today, so yeah, you’re busy.
It’s nap time now.