A podcast with Tommy Crow, who is on Substack, Twitter (@tommyjoancrow), TikTok, and elsewhere, recorded irl after a recent EAGx conference in DC!
Topics discussed
Tommy’s awake top surgery: how it happened, why almost every doctor said it was impossible
“Fighting the tube,” post-op torture, and the liability incentives that quietly make pain a tolerated feature of US surgical care
The role of amnestic drugs like midazolam - preventing memory of suffering rather than the suffering itself - and why that’s epistemically and morally suspect
Historical precedent for getting this catastrophically wrong as evidence the current consensus deserves scrutiny
Practical self-advocacy: drafting a healthcare power of attorney with anesthesia/intubation restrictions, and why the state-default POA is worse than anything you’d write
How to find heterodox doctors
Hormones as a tightly-coupled system: Aaron’s cis TRT experience, Tommy’s trans TRT experience, and tradeoffs that get glossed over
Healthcare abundance as a policy and career direction
Shenanigans by Tommy’s insurance provider
Gay male culture as Tommy’s “classically liberal” second home
Transcript
[00:00] Aaron: Hi, this is Aaron, and in this episode of Pigeon Hour, Tommy Crow and I talk about surgery, medicine, and more. Tommy is a super cool guy who I met in person for the first time at EAGxDC a couple weeks ago. We recorded the next day after the conference in person, and we’re finally getting this out now. One thing to note is that during the recording, I committed to running the transcript through Claude in case anything is misleading or deserving of correction. There are a few things what I consider to be pretty minor, but those are in the Substack post attached to this episode, with a bit of back and forth between Claude and then Tommy or I depending on who said the thing in question. So, without further ado, me and Tommy.
[00:48] Aaron: Okay, we are now recording.
[00:50] Tommy: Okay.
[00:51] Aaron: Actually, so we’re recording on one device just in case. And because now I have a 48-gig Mac, I can do Otter as well. Okay. Tommy, I hope that’s okay — that was the name of the Google Calendar event.
[01:13] Tommy: Tommy coming. Love that. Yeah, I had a similar incident that also made me a little paranoid about losing recordings.
[01:22] Aaron: Oh wow, what happened?
[01:23] Tommy: I mean, it wasn’t like a huge deal, but I similarly tried to rig up a way to record a phone call and failed to record one side of it — I only recorded my side. And it was with this kind of gray-market surgeon I was talking to. He — I almost did my surgery with him. I actually had plane tickets to Italy booked.
[01:49] Aaron: Oh, dang.
[01:51] Tommy: And he was actually a legitimate researcher at the University of Naples, and then we just found out that he was also doing black-market plastic surgeries out of a hotel on the side.
[02:01] Aaron: That’s kind of cool. I’m —
[02:03] Tommy: Yes. Like, and I totally —
[02:05] Aaron: — not sure if I endorse it, but it’s kind of cool anyway.
[02:08] Tommy: Well, we had a whole debate. I was thinking about doing it with him because at the time I couldn’t find anyone else in the world who was willing to try it. So I thought he might be my only hope.
[02:18] Aaron: Do you want to give — wait, so for the people, do you want to give context?
[02:23] Tommy: So, okay, so as far as we know, I’m the only documented case of someone getting modern female-to-male top surgery fully awake. And before I did this, most doctors would tell you that it was medically impossible. And this was just very obviously not true. Anyone who understands this particular method of local anesthesia that was used would know that it can be done this way. It’s not hard technology to understand, but it’s very underappreciated. So a lot of doctors will just sort of dismiss it out of hand.
[02:59] Aaron: And yesterday — so we met at EA Global. Well, we met online, but then we were talking at EA Global in person, Washington, DC. By the way, this is an in-person Pigeon Hour, a special event. Yeah, welcome to the beautiful recording studio, which is a couch.
[03:10] Tommy: Happy to be here.
[03:11] Aaron: So wait, why did you even want to do the not-asleep version?
[03:23] Tommy: That’s the million-dollar question, isn’t it? So I think general anesthesia opens you up to a lot more risk of pain at multiple points throughout the procedure. And I think this happens a lot more than people are typically aware of. And it actually happens oftentimes as part of the procedure. So just one example of something that commonly happens in American hospitals is this phenomenon that they call “fighting the tube” — that’s actually the phrase that doctors and anesthesiologists use. They call it fighting the tube. And that’s basically exactly what it sounds like. It’s where they wake you up after surgery in post-op while you’re still intubated, and they wait for you to basically struggle and thrash and try to scream and gurgle against the tube because you feel like you’re getting waterboarded. And they just kind of tie you down or hold you down and let that happen for a while. And they do this because there’s a complicated mix of liabilities here. Basically they will slightly, slightly, slightly reduce your chance of dying in exchange for an almost certain chance of causing you extreme suffering and anguish, because that reduces liability for them — they face much more liability for your preventable death than they do for your preventable suffering.
[04:47] Aaron: Yeah, okay. So to not be coy about it — yes, we’re going to be talking about how you’re secretly being tortured in surgery and why this is bad. I’m always doing this — I’m always saying “um” and “uh” when I start recording. It’s terrible. I do it even off recording, to be fair. But anyway. So this is not just a top surgery thing. This is a general surgery thing. I’m not trying to cancel trans voices or anything, I promise. I’m trying to make it like — there’s a general problem here, right? Or a general phenomenon here. And then we’ll let the people of Pigeon Hour decide if it’s a problem. I think it’s a problem.
[05:32] Tommy: Well, and I will say it in my very trans voice — this is not the issue that I encountered, it just happened to be applicable in a trans surgery for me. But this is applicable in many, many, many surgeries across the entire United States, and presumably elsewhere as well, although I’m not informed about that particularly. And there are two things that I’ll say that are very general concerns or topics that I’m interested in. Number one, there is a pain management crisis in the United States that has been going on ever since the opioid epidemic, where basically there’s a whole bunch of incentives that discourage doctors from managing pain effectively and also normalize the use of anterograde amnesia–inducing drugs as a substitute for pain relief. So that’s number one. And number two, there are just better ways to do fat-based surgeries specifically. Any surgery that’s being done with fat can be done better oftentimes than it is, because this technology called tumescent local anesthesia is very underused.
[06:44] Aaron: Yeah, so wait — the amnesia thing is kind of obviously also — wait, to back up, a meta point is like, it’s a very kind of horrifying topic that I don’t especially like discussing. Do you think it’s important?
[06:55] Tommy: Yeah.
[06:55] Aaron: But we’ll try. I mean, we’ll try to strike a balance of being like — not withholding important information, but also not scaring people away from actually listening. I mean, I think it’s a genuinely hard problem. There’s some sort of curve where you maximize the impact, but if no one’s listening, you don’t maximize the impact. So you’ve got to hit the top of the curve. So the amnesia thing basically means that you don’t remember, and so that is effectively what’s going on — that you are being made to not form memories of being tortured, rather than just not being tortured in the first place. And you know way more about this than I do. This is like a big part of your researching this — it’s evidently a big part of your life. And the way it’s sort of been like the horrors of the background universe to me or something. But I do know as some context that there’s precedent in the sense of — we used to not use any anesthesia at all when operating on infants.
[07:59] Tommy: Yes.
[07:59] Aaron: And this is in Jonathan Birch’s book Edge of Sentience — sorry, we’ll cut out my pausing. And yes, that’s the proper, both philosophical and just accurate, as far as I can tell, description of what happened. And basically, it was totally standard practice to just simply cut open human babies without doing anything about — without any sort of prevention of pain or suffering. And one normie response is like, “that’s obviously bad,” and I think it probably is. But the other thing is that there’s a gigantic asymmetry. It’s like, why are you so sure? You know, if there’s only a — I mean, definitely at a 30% chance I think you can go pretty low while the moral calculus checks out as to whether you should take at least any steps, and certainly probably pretty intensive steps, to prevent suffering. Like, what are the chances that we’re wrong about infants not feeling pain, right? And I will go to bat for: knowing the subjective experience of another being is extraordinarily difficult. So like — yeah, I don’t think there’s any sort of trick going on to say that even if you think in some situations that maybe in fact there’s no suffering, like, ground truth under the surface — it’s worth considering the probability that you’re wrong, or how certain you are or whatever. That’s my pitch or ramble about — I don’t know, any takes?
[09:30] Tommy: Yeah. When people talk about the pain-related risks of general anesthesia, oftentimes what people are imagining is kind of the classic horror story where someone is aware during surgery, like while the doctor is cutting them open. And I actually think that there is a risk there. I mean, this has happened to people — people have woken up during surgery. I do think that’s a real risk. I will say that’s not my primary concern. My primary concern is mostly during post-op, where there are actual, you know, lots and lots of witnesses seeing this happen and whistleblowing and talking about how it’s actually part of the procedure to just expect pain. But also there is a concern about what’s happening during surgery. I don’t think general anesthesia is well understood. And I think it’s also somewhat simplistically logical to say, well, I can have a higher certainty that no pain is happening if I block that pain at the source, at the actual nerve, the nerve pathway, rather than try to do it systemically at the brain level.
[10:49] Aaron: Yeah, I mean, I don’t know if that’s — maybe that’s true. It’s not intuitive for me at all. I feel like I’m much more confident if I just nuke myself with fentanyl instead of —
[10:56] Tommy: Oh, I’m not.
[10:56] Aaron: Okay. I mean, there’s reasons not to do that, right? But also I don’t know what I’m talking about. But just at an intuitive level, blocking it at the source sounds kind of like — okay, well, why? Like, maybe. Also, I have a sense that people, at least philosophically, often talk about pain as though it is entirely localized to where some sort of injury actually happens — and that is often true that if you get a paper cut, you feel it on your finger. But the visceral sense of suffering is, at almost a philosophical level, it needn’t at least conceptually exist or needn’t be tracked consciously as located wherever. Your brain can just decide to do whatever it wants or something. I feel like this is probably not the most important point, but —
[11:51] Tommy: Well, think about it. I mean, I guess if we’re going to get into this point — think about: okay, so I was in surgery and I was just as alert and clear as I am speaking to you right now. And in fact I was narrating the entire surgery to the camera and I was watching it happen. And I was watching him — sorry, this is going to be graphic.
[12:16] Aaron: No, tell it. You can — well, we can figure out what to cut later. If anything, we don’t have to.
[12:20] Tommy: So I was watching him literally skin me alive, because he skins them first, you know, and then cuts them off. And I was just watching and talking, like just like I’m talking to you now, and I was just watching him do this and I couldn’t feel anything. And for me, when I look at that scenario, there is no big philosophical question to ask, because I was exactly the same person that I am now and I know for a fact that I was not experiencing pain or suffering. But if I was in some sort of weird anesthesia state — I’m not going to call it sleep because it’s actually very different from sleep — there are actually real philosophical questions and uncertainties about what’s going on in the brain while I’m in that sort of weird sleep state. Whereas if I’m awake and I’m just talking like I’m talking to you now, I know that there’s no pain.
[13:09] Aaron: Or at the very least, I mean, somebody could be pedantic, but I think I agree that it is overwhelmingly likely that you’re correct about your own experience. We don’t have to get into it.
[13:16] Tommy: In whatever sense I can be confident that I’m not going through torture right now, I was confident at that time.
[13:22] Aaron: Yeah. And to poke at the — oh wait, hold on, I had a thought on the people waking up during surgery, which is that — okay, I take your point that this might be the secondary issue. I think it’s important as at least evidence, or like very, very high-evidence case studies or something, because you don’t need to speculate about the ground truth of subjective experience, like, absent report or things like that. Like, these are just existence proofs — or not approximately, but very, very close to existence proofs of terrible suffering during surgery. A pet peeve to get out there is that — I’ve read about this back in, I was honestly reading about this more than a couple years ago, I think 2023. And yeah, there are these horrifying case reports — people genuinely being tortured during surgery, and then they talk about it in terms of like, “oh wow, they’re traumatized.” It’s like, that sucks, I agree it sucks that they’re traumatized, but also it sucks they’re being tortured. I think that’s actually the primary thing.
[14:30] Tommy: Completely agree with that. Completely agree with that. And oftentimes I talk about the reliance on these amnesia-inducing drugs and people say, “wow, that sounds so horrible because the body keeps the score, these people must be traumatized afterwards.” And I’m like, I don’t really give a shit if they’re traumatized afterwards. If you have seen torture — like, I’ve seen some shit in hospitals, and that is way worse. I’m sorry, to me that’s way worse than any sort of psychological trauma I’ve ever experienced.
[15:00] Aaron: You also don’t have to take a strong stand of “I don’t give a shit.” It could just be that both things are bad. But I agree, the fundamental primary issue here, probably the main one, is the experience itself.
[15:08] Tommy: Yes. To me the trauma is rough, and I’m sorry if that exists, but it’s so secondary to the actual torture.
[15:17] Aaron: I mean, there’s a general thing — I guess we’re sort of preaching to a choir while having this conversation. But like, I don’t know, sometimes the choir is just correct, right? I mean, this is like many such cases in society — we have factory farming. There’s also the neonatal anesthesia thing. There’s the fact that — I don’t know, I’m pausing the fact that they use — what is the term again, prevention of memory formation —
[15:52] Tommy: Anterograde amnesia.
[15:54] Aaron: Yes, anterograde amnesia, like amnestic drugs or whatever. That is very, very sus, right? It’s like, wait, hold on a second, why are you causing me to not form memories specifically? And wait — sometimes it comes along for the ride, right? So it’s not necessarily nefarious, but I think we should — I don’t know, it’s a big — like, literally, not literally, but figuratively a red flag.
[16:17] Tommy: Yeah. And a few things I will say on that: number one, just to give a few disclaimers, I am not claiming that doctors have nefarious motives to torture you and they’re like, “oh yeah, I love this.” That’s not the motive. And oftentimes I think there is a level of pseudo-benevolent paternalism where they just honestly don’t want you to be traumatized by something that has to happen anyway. However, I think especially after the opioid epidemic, there has been an increasing callousness about pain, and it really has seeped into the culture of anesthesiology. You hear oftentimes a very common phrase that I’ll hear anesthesiologists say, or emergency room nurses say, is “pain is not an emergency.” And I just completely disagree with this philosophy. I think that is an evil philosophy. I think pain is pretty much the worst thing that can happen to you besides death, and somehow it’s worse —
[17:17] Aaron: I mean, plausibly, quite plausibly worse than death.
[17:18] Tommy: Exactly, yeah. And similarly, midazolam is relied upon for the explicit purpose of memory prevention. I want to emphasize this very strongly. It is not relied upon for pain management. It is not a good pain management drug. It is for memory prevention. And you can Google this and look at what anesthesiologists are saying about it — they will explicitly say this is for the prevention of, quote, “unpleasant memories.” That is explicitly what it’s for.
[17:53] Aaron: Also, just as a tiny bit of added credibility, I commit to running the transcript through Claude and saying, with your consent, I guess — actually, non-consensual Claude transcript analysis, just kidding — to figure out, presumably something we say is going to be slightly off. It’s very hard to talk for an hour and never say anything wrong. But we will report that.
[18:15] Tommy: Yes, yes.
[18:17] Aaron: Yeah, seems bad. I mean, so at one level I 100% buy this, and at another, for some reason I am less mad than I feel like I should be about the fact that this has probably happened to me. And I don’t know, memory is highly integrated into the human psychology, neurology, whatever. I have gotten surgery before and I struggle — it’s very similar to like a factory farming thing — I just struggle to viscerally care enough or in proportion, or not even in proportion, but sort of to a maximally appropriate all-things-considered degree or whatever about pigs and chickens being confined their whole lives, et cetera. And I do think the amnesia thing is just doing a ton of work here. And I guess also, I do actually kind of bite the bullet — if we could causally isolate everything, that amnesia is good because of the trauma thing. Like, I’m glad that I’m not traumatized.
[19:23] Tommy: Oh yeah.
[19:23] Aaron: But it’s very hard to have people act in their self-interest when you’re preventing the mechanism by which they know to protest or something.
[19:34] Tommy: Right. And for a surgery that you have to have — if you know that you’re going to get it anyway and it has to be painful for some reason, then it does seem like a very useful tool to just prevent memory formation of that.
[19:48] Aaron: Yeah, I guess also — one dynamic is that often the condition of surgery is not that you’re in a position to be making much of a decision. I actually think this is maybe the most actionable thing — for a highly anticipated voluntary surgery. Often you’re not in a position to be making much of a decision. Maybe this sounds unagentic or something — I think in a literal sense it is, but, you know, some shit happens, you’re in a bad car accident, or I’m just imagining I’m in a bad car accident, in the hospital, vaguely know about these concerns. Realistically, I feel like I’m probably signing the consent papers anyway because, oh no, okay. Well —
[20:28] Tommy: Go for it, and remind yourself.
[20:29] Aaron: Well look, I’m not sure that I would at this moment, and second of all, I’m very — especially I think maybe I should think through, what are my actual asks? I should have a note in my phone in case this happens. What are my actual asks here? Because I probably don’t want to die because I refused surgery, all things considered. At the same time, I guess the one saving grace here — sorry, I’m rambling — is that if you explicitly refuse consent for something in the US, my sense is that in general they don’t secretly do it.
[21:02] Tommy: I think that’s mostly true.
[21:04] Aaron: Mostly. Oh, great. Wonderful.
[21:07] Tommy: Yeah. There are many, many exceptions to that.
[21:09] Aaron: I mean, there’s also a lot of gray area in the sense of — if you’re handed a 50-page document for the benevolent doctor to make you not die, generally you say yes without doing a whole analysis. I mean, maybe LLMs are something to be used here.
[21:25] Tommy: Yeah.
[21:26] Aaron: Yeah.
[21:26] Tommy: I do carry around my healthcare power of attorney.
[21:30] Aaron: Oh wait — I mean, like, if you’re comfortable showing it. So this is embarrassing, but I don’t actually know what physical item you’re going to produce.
[21:42] Tommy: It’s a piece of paper.
[21:43] Aaron: Okay. I mean, I feel like maybe you should have it on Google Drive also. I’m guessing you do.
[21:48] Tommy: Well, yeah, doctors can be weird about that, though.
[21:50] Aaron: Yeah, no, I know. Doctors hate Google Drive. They actually give you more — they give you, like, pain-causing medication during surgery if you try to send them a Google Drive link.
[22:01] Tommy: They give you a pain-causing medication, just like inject you with water.
[22:08] Aaron: Cool. Oh, this is based. Okay, I should do this. How do I do this? Seriously.
[22:12] Tommy: It’s really, really easy. So it depends on your state — it’s on the state level. I recommend every single person does this. This is one of my big tips that I tell to everyone.
[22:19] Aaron: Should we take a picture? Is it okay if we take — I mean, we can decide whether to add it, like take a picture and then maybe add it or link it or something.
[22:25] Tommy: This is just the Wisconsin —
[22:27] Aaron: Just so people have an idea of the kind of thing they’re looking for.
[22:29] Tommy: Yeah, so basically — it’s on the state level. Just Google your state name and then “healthcare power of attorney” and read through it. And then oftentimes you’ll have to take it to a notary and have it signed by like two people. But then the important part is that you can usually, depending on the state, attach an addendum to it.
[22:49] Aaron: Oh, that’s cool.
[22:50] Tommy: So mine just says — I only have like three items on it. It says, quote, “general anesthesia,” and quote, “deep sedation,” and similar states of medically induced unconsciousness should not be used unless absolutely necessary to preserve life. That’s number one. I have those two things, general anesthesia and deep sedation, in quotation marks because those are kind of like umbrella terms.
[23:13] Aaron: Do you want to take a picture of it?
[23:14] Tommy: You can take a picture and then we’ll discuss after. Let me think about it.
[23:19] Aaron: Okay, because I’m interested in the specific wording. But like, yeah, tell me to delete it later, obviously I will.
[23:25] Tommy: And then basically, no intubation unless it’s to save my life. And then a statement about who I want to make decisions for me.
[23:34] Aaron: Oh, that’s a good one. I’m not sure if I trust the people that I actually trust with most things to make good decisions on this front.
[23:40] Tommy: Yeah, so an important thing to keep in mind is that you already have a healthcare power of attorney. It’s given to you automatically by the state. So if you haven’t made one, you’re basically just outsourcing that to the state. And presumably the state is only going to make equal or worse decisions about your healthcare than you.
[24:01] Aaron: Wait, hold on, I feel like — what does power of attorney even mean?
[24:05] Tommy: Your healthcare power of attorney is a person who makes decisions for you.
[24:10] Aaron: Right, okay, that makes sense. Wait, so I feel like — isn’t it usually like next of kin or something? I guess it’s for inheritance stuff. But usually they ask your parents or something. They don’t just call up a bureaucrat.
[24:25] Tommy: Right, right, right. And that’s why my third amendment says “not my parents.”
[24:29] Aaron: Oh, interesting. Okay, wow. My parents are not going to like this — luckily they don’t listen to this.
[24:36] Tommy: Yeah, I mean, and if your parents are your choice, then that’s great. But —
[24:40] Aaron: No, I love my parents. I actually have them excluded from my will because I don’t think they donate the money well. I have somebody who I trust to donate. I don’t have a gigantic amount of money — oh, sorry, to be clear, they are comfortable. It’s not like they’re — yes, the expected direction of money flow goes the other way. I’m very confident they’re not going to need my dinky little savings.
[25:04] Tommy: Yeah, yeah, yeah.
[25:06] Aaron: Dang. Wow.
[25:08] Tommy: But basically anything you can bring up quickly should be equal to or better than whatever the state automatically gives you.
[25:14] Aaron: Yeah, maybe I’ll try to put — this is like a post-podcast-recording project — but what I would want is a checklist of things to follow or something. Obviously some things are approximately irreducibly your decision. But I don’t want to spend 100 hours of research figuring out what to do. I want somebody who’s done the research and has an appropriate and accurate understanding of the stakes here to make reasonable recommendations that I then approve or decide on. So maybe I’ll try to put together a website where this exists. One thing I can do is vibe-code websites.
[25:55] Tommy: We could work on that together.
[25:58] Aaron: Yo. Wow. Wild.
[26:02] Tommy: Can I give my other pitch while we’re here?
[26:03] Aaron: Yeah, yeah, yeah.
[26:05] Tommy: There’s two things that I tell people to do. One is to have the healthcare power of attorney, and the other one is, if you have a stash of leftover pain medication — opiates or whatever — keep one of those in your wallet all the time.
[26:22] Aaron: Okay, yeah. No, I think Pigeon Hour is based and therefore not going to cut this for legal reasons. Cool. Although I have — so maybe I might cut this part — I don’t currently have any opioids in this house, for example. I think if it was up to me, sort of without any legal risk, I would. So it just — maybe out of sort of — it’s never been a priority of mine because I never think that I’m — luckily I’m not in chronic bad suffering, which is a great privilege to be in, you know, to not be in. So there’s a question of, like, should I in fact just seriously take seriously, and probably I think I’ll be able to acquire opioids, and if so, literally which ones? I mean, presumably pharma, not like — yeah.
[27:12] Tommy: Yeah, you know, that’s actually a great question, and I have no idea. I feel like they all work way better than ibuprofen or Tylenol, so whatever you can get your hands on, I think. I’m not actually informed about whether you should go for oxy versus hydromorphone.
[27:27] Aaron: Yeah, I’m guessing it’s mostly a question — if you have enough of any of them, it kind of works. That’s my very vague sense.
[27:36] Tommy: Yeah. The difference between zero and one is way, way bigger than the difference between one and two.
[27:42] Aaron: I’m just going to make a note on my phone.
[27:48] Tommy: Yeah, it’s a good question — literally which one — because there must be, I’m sure there are differences, I’m just totally —
[27:55] Aaron: I mean, frankly, it’s like — man, it would be really — I feel like no one’s going to buy it if I say like, “yes, officer, I’m importing X, Y, and Z, but listen to my podcast episode, bro.” Although —
[28:10] Tommy: “Tommy got me into it.” Go take Tommy to jail.
[28:14] Aaron: Yeah, no. I think — yeah, and this is actually something I have — I perpetually have a to-do list. This should probably go at least on the secondary to-do list rather than not even existing on the to-do list. It’s like, figure out at least whether this is something I want to do — like, acquire. And the system for, I mean, not literally but approximately, what did people refer to by “the system” — will tell you, oh, discard any unused medication. Like, no, bonk.
[28:43] Tommy: Absolutely not. Absolutely not.
[28:47] Aaron: Yeah. I mean, I don’t know, one thing is — this is just not the most fun conversation to have, so —
[28:58] Tommy: I’m a party killer, yeah.
[28:59] Aaron: No, but that’s an actual issue, right? It’s like — AI risk even is a little sexier. Yeah, lots of — not to mention global poverty. Nobody’s uncomfortable talking about, like, preventing malaria. Maybe they are, but —
[29:21] Tommy: Maybe I’m a freak, but I find surgery and — I mean, pain relief is a very hard topic to talk about, but I also find surgery and pain management so interesting.
[29:33] Aaron: Okay, interesting.
[29:34] Tommy: Which is probably why people hate me at parties — they’re like, “God, here comes Tommy, we’re going to talk about torture again.”
[29:40] Aaron: I actually — no, no, that does genuinely suck. Am I glad? I’m glad this is someone’s special interest, right?
[29:50] Tommy: Well, we can talk about the more fun parts of something, like —
[29:54] Aaron: I mean, well, I guess we should — I do want to make sure we don’t miss anything important. Are there any fun parts?
[30:00] Tommy: The surgery itself was literally the most fun I’ve ever had.
[30:04] Aaron: Oh wild, that’s weird. But —
[30:06] Tommy: It was so fucking fun. Not —
[30:07] Aaron: Not because you were high?
[30:09] Tommy: Not because I was high. I was not really high. I basically felt the way I’m talking to you now. But I just love surgery. It was —
[30:16] Aaron: That is — you’re so weird.
[30:19] Tommy: My sister said that to me once.
[30:20] Aaron: You’re the only person in the world. I think my sister can relate.
[30:23] Tommy: She said, “You just keep getting weirder.”
[30:26] Aaron: Yeah, this is not — I had an MRI not too long ago and it wasn’t that bad, but I don’t know, I feel like it’s approximately the ideal version of surgery — you’re aware, you’re just lying there, and it was mildly unpleasant. At least I wasn’t like, “wow, this is amazing.”
[30:44] Tommy: We were laughing because I was videotaping the whole surgery, and I kept looking at the camera and going, “wow, this is amazing,” and being like, “wow, this is so cool,” because — it’s just the most beautiful thing, actually. I mean, when you think about it, you are literally watching the triumph of man and technology over nature. And I was disabled, you know — I had fucking triple-D tits and I couldn’t run. And if you’ve ever met me, I’m like constantly running around, climbing stuff, fighting. I’m an extremely high-energy, high-motivation person. I want to work like 10 or more hours a day. And I could not sit up, be upright, for more than six or seven hours at a time without shooting nerve pain down my shoulders, and my bra straps would cut into my skin or into my rib cage. I was disabled from them.
[31:40] Aaron: So you mean you were — you had gender dysphoria as well? This is distinct? You don’t have to talk about it if you don’t want, but —
[31:48] Tommy: Well, like, I’m definitely —
[31:49] Aaron: Like also this pain that’s like not —
[31:51] Tommy: I’m definitely a man on the inside. That honestly almost feels like a coincidence, in this bizarre way.
[31:59] Aaron: Yeah, no, that’s totally plausible. You can have breast pain, whatever it’s called — sorry, I’m not well informed — and also anything else.
[32:07] Tommy: Yeah, I actually decided to get top surgery before I identified as a man.
[32:11] Aaron: Well, you can also get breast reductions, right? This is me learning a thing, whatever — I’m sure most women learn this at, like, 11. I intuitively missed this information. I’m a 26-year-old man.
[32:23] Tommy: You’re forgiven.
[32:23] Aaron: God. But it would also — there was a thing, not to do just the viral discourse, but there was like a thing on Twitter — this is like a culture-war thing — like, “oh, you should definitely get breast enlargements.” I think that’s probably a bad set of advice to give people, and quite possibly you should consider the opposite if it’s causing you distress.
[32:48] Tommy: Oh, yeah. There was, like, a Cremieux tweet, I think, or a quote that I’m not going to get exactly right, so maybe his fans are going to come flame me for this — but he said something like, “if your value is to be as hot as possible, never, ever, ever, ever —”
[33:06] Aaron: I don’t think it was Cremieux who originally said that. I —
[33:08] Tommy: Oh, really? Who was it? Maybe he retweeted —
[33:09] Aaron: I might be wrong, actually. There was a woman who wrote an article.
[33:13] Tommy: Yeah, I think I saw it because he retweeted it. You’re right. She was like, “you know, if your value is to be as hot as possible, never, ever, ever get a breast reduction no matter how much they pay” —
[33:24] Aaron: Which is also just a little bit of a silly thing to say. It’s like —
[33:27] Tommy: Well, it’s tautological in a way. Like, yes, if your value is absolutely maximizing this one thing, then yes. But also, I think someone who is good would usually not be encouraging having that value to such an extreme that it actually derails the rest of your life. I am like a philosopher — in principle I understand the concept of holding the value constant and then saying what actions would result in optimizing for that value, but it is sus.
[33:55] Aaron: Yeah, and it’s not super specific, I guess. I could read the wording — I just dissect the words because it’s not that important, I guess. This is reminding me that maybe I should use steroids — just, not wait, yeah. What else? Do you have any other “people should definitely consider not doing X or seriously consider doing X” hot takes, in the broad medicine/physiology, or anything actually, sphere — I guess anything, honestly.
[34:33] Tommy: Well, in all seriousness, I do actually think you need to be careful with testosterone. I’m not actually very well educated on this for natal males, but I do — I’m probably not educated enough to speak on this, but I do think there’s probably some evidence that taking it for a natal male can decrease your natural production, which you might not want to have happen.
[34:54] Aaron: Oh, totally. It’s actually — no, decent — I was on TRT, I’m not anymore. But that’s — I mean, maybe I’m not sure if I’ll keep it in — that’s how I got through puberty. I’ve been fucked up from that.
[35:04] Tommy: Wait, is that why you’re so short? No offense, sorry.
[35:05] Aaron: No, no, no — I was much shorter. I started college at 5’2”, not 5’7”.
[35:12] Tommy: That’s what I am, 5’2”, short kings.
[35:14] Aaron: Yeah, I mean now I’m like a standard deviation, but this is only one, right? You see 5’7” people walking around, it’s not like, oh — but, oh, 100% — my understanding is that this is just very clearly and demonstrably true, but also might be worth it.
[35:31] Tommy: Okay, yes.
[35:31] Aaron: Although I’m not sure at very low doses — I’m sure there’s like, it’s a question of like, okay, one molecule, does that sit in your entire pituitary? I don’t know the answer. I mean, so it’s a matter of degree to some extent. But yeah, I will say that I think more people should get checked, or it should be the kind of thing you check, like, once a year or whatever, because why not. It’s a bit of a bitch to deal with — and not even logistically. It’s true that it takes a few minutes, it’s slightly painful to inject yourself, but it’s not that bad. Managing the dosing and trying to emulate a sort of endogenous control cycle is just a difficult project, especially if you don’t have rapid testing — we don’t have rapid testing. So you have to maybe get tested occasionally and guess based on what’s going on. I wound up on a very specific regimen, which is 11 milligrams every other day. It was very small at this point, so that’s why it was relatively low — but if I had taken a standard dose of 150, I would have just been perpetually extremely — so I mean, at one point — this is just an aside, whatever — I started out with a much larger dose, I think a single 100-milligram injection, and I puffed up. I mean, presumably the mechanism is estradiol, but I felt like total shit and I was extremely puffy, with what I assume was water — I don’t think I was gel of some sort. Long story short, it’s a bit of a — it’s not a “oh whatever” kind of thing. Factor in the fact it’s a bit of a hassle, it’s also quite plausibly worth it for many people.
[37:13] Tommy: That’s fascinating. So I haven’t experienced any of those downsides, which is probably because I have never done that high of a dose. Because I think for natal females, there’s also quite a lot of risks to it. For one thing, it probably just shortens your lifespan. And one of the privileges I have as a natal female is that I get a couple extra years on you guys. I don’t really want to throw those away. And then also it drastically increases your risk of needing to get a hysterectomy eventually, and obviously I don’t want to have that, because I’m going to have to do that whole thing awake and it’s going to be a whole other project to find a guy to do that awake. So I keep it pretty low, and I’ve never experienced any of those bad side effects. I basically always just feel insanely good whenever I take it.
[37:59] Aaron: Wow, I’m so jealous.
[38:00] Tommy: Yeah, but I really half-ass it these days. I used to be pretty careful with it and I would keep track of my levels and make sure it was at, you know, somewhat less than a natal male would have. Nowadays I totally wing it — I just wait until I’m feeling kind of depressed and then I give myself like a random shot.
[38:19] Aaron: No, I mean, that’s — I feel like it’s okay, hopefully you don’t have to be depressed for that long, but that is almost the ideal thing. It’s like you eat when you’re hungry or whatever, and that’s a system working well.
[38:27] Tommy: Exactly. Yeah, I basically just eat when I’m hungry.
[38:30] Aaron: Nice. I’m jealous, but I’m glad for you. Oh wait, so here’s a whole other thing — so I am, again, I’ll probably just keep this in because I don’t care at this point. So I am, I think, going to be trying — unless something good happens, like some sort of positive surprise — I’m probably going to be trying to find a surgeon to do an exploratory laparoscopic surgery on me, or partially diagnostic with the potential, if they see anything, to fix it. How the fuck did you find a surgeon?
[39:03] Tommy: How did I?
[39:04] Aaron: No, it’s a totally different specialty or situation, but, like, how do you go about finding a heterodox surgeon?
[39:10] Tommy: That’s a great question. So I don’t know much about laparoscopic —
[39:16] Aaron: Oh no, no, yeah, I was being in general, like, as a general process, but not necessarily specific to anything.
[39:22] Tommy: Yeah, so literally basically my strategy was to go on Google Scholar, or Sci-Hub, and find people who clearly are passionate about doing actual research related to whatever weird niche thing it is that you want.
[39:41] Aaron: Find an autistic surgeon, okay.
[39:43] Tommy: Yeah, yeah. And then literally just email them or reach out.
[39:46] Aaron: No, interesting. I was thinking about just making a Google Doc that’s like, “does anybody know a surgeon?” That was massive. No, but yeah, I should — this is also on my to-do list. I wish I was your 10-hour-working kind of guy. I mean, I think that’s sort of endogenous to my health issues — it’s like a vicious cycle of not being able to work on my health issues because — or not being able to do things like write up Google Docs. Not that I can’t or whatever, but it scarcifies your productive time. Sorry, not like a “woe was me” situation. It’s all good.
[40:19] Tommy: I will say, I think this is one of my unwoke takes — but it sounds unwoke but actually is woke — I do think testosterone is just a general-purpose performance-enhancing drug. Obviously physically, but also mentally — just my stamina is way improved. And I think it’s important to recognize this, that females are at general disadvantages just because biology is unfair.
[40:49] Aaron: Wait, I have always wondered, I’m not sure I entirely buy this — so if you compare a cis male with very low testosterone to a woman with the same blood level of testosterone, you don’t see the same — I expect the guys to be much more depressed, fat, unmotivated, and I don’t expect the same of the woman. This is based on my general observations of looking around society. But sorry, backing up, I don’t think you can just say women are basically operating at a disadvantage corresponding to the level that they have but if they were a cis man.
[41:31] Tommy: Yes, I do not think women are the same thing as a strangely low-testosterone man.
[41:40] Aaron: Okay. That is a plausible interpretation you might have.
[41:45] Tommy: Right, and I definitely do not think that. And obviously I think there’s a lot of confounders if you try to compare a bizarrely low-T man to a woman — obviously it’s probably just worse in a million ways, and with the causal arrow going in both directions, to be a weirdly low-T man it’s probably not comparably as bad to be a woman, maybe.
[42:07] Aaron: Yeah. Although, maybe there’s something that’s similar — I’m not sure. I mean, hormones in general are just very powerful and very hard to get right. One thing that jumps to mind is — it’s a totally different hormone, but if you have hypothyroidism — I also have hypothyroidism, so that’s another thing wrong with me. But that is also like — somebody, a loved one, basically had Hashimoto’s, and was just living, I think eventually luckily living poorly enough that they went to the doctor and just got diagnosed. And basically, if you have Hashimoto’s and you take levothyroxine, you’re just normal again once you get the right dose. But yeah, they’re very depressed, very, very low energy. I feel like Huberman or something — I don’t listen to him, but I feel like I see clips and he talks like this — so I don’t know if there’s anything I was getting at with that. Just, yeah, like, try not to have bad hormones somehow.
[43:03] Tommy: Yeah. I mean, another one of the many practical reasons why I try to keep my T very low is because hormones are just a very — they’re not well understood, I think. And they’re one of these systems that’s kind of like an economy, you know, where you try to tweak one little thing and then you fuck up the whole shebang. And people are always really surprised that I did this crazy ridiculous experimental surgery, but now on the other hand I’m claiming that testosterone is dangerous, and they’re like, “what are you talking about? Every trans guy does testosterone — but you’re doing these weird surgeries.” But I actually think testosterone is a lot riskier than the type of surgery I had done.
[43:46] Aaron: Yeah, that sounds totally reasonable and probably just correct. Although, so I do want to, in the name of being good Bayesians or something, share my experience with this, which is that I did not find a monotonic relationship or anything close to that between testosterone and subjective well-being when I was injecting. I mean, I’m guessing this is true for everyone at some point, right — if you inject a literal gallon you just die — so at some point that obviously happens. But I was really hoping — I feel like I read all the stuff on Reddit about how, like, “yeah man, keep it at 900 nanograms per deciliter to feel good,” and whenever that happened to me I just in fact felt overall worse. I felt best at a moderate — so in general, like 500 to 700, which is middle of the range. I’m going to get canceled because — I don’t know, it’s almost like, I kind of wish it was the case that you could actually just testosterone-max and be superhuman, and I think some people in fact for whatever reason can, but I think I consider myself an existence proof of this not being a universal experience.
[44:46] Tommy: That totally makes sense. Totally.
[44:49] Aaron: Cool. Oh wait, do you want to — I don’t know how much time you have.
[44:54] Tommy: I have all day.
[44:55] Aaron: I don’t have anything actually to do, but I do have limited energy, but I’m good for now. So it hasn’t even been an hour, honestly. I think these podcasts where people talk for three hours — that’s insane. I could do that once, but it would be difficult or whatever. Wait, so presumably you do other things in life besides having surgery takes. Is this true?
[45:21] Tommy: Oh boy.
[45:22] Aaron: No, you don’t have to answer this — I’m just, do you want to talk about anything? We can also cut whatever. Obviously we’ll cut whatever you want.
[45:30] Tommy: I do do other stuff in life besides having surgery takes.
[45:33] Aaron: Not that that would be a bad thing, to be clear.
[45:35] Tommy: Like, to only do surgery.
[45:36] Aaron: I mean, presumably you want to, I don’t know — do other stuff, get laid.
[45:40] Tommy: Yeah, well, that is mostly the other thing. I am actually somewhat — I would say not — well, I really, really like gay male culture, like, anthropologically.
[45:54] Aaron: I did not expect this. I wasn’t going to fill in my sentence with what you just said. But keep going, sorry, sorry, keep going.
[46:01] Tommy: Someone asked me last night, “what do you do for fun?” And I started, once again, talking about all of the takes that I have that are related to what I want to do for a career. And they were like, “no, no, no, I said what do you do for fun?” And I was like, “well, you know, I like to go to the club.”
[46:22] Aaron: Wait, what the fuck is — okay, I always hear about “the club.” Florida saying “I’m at the club.” Where do I go? I need a Google Maps link, okay?
[46:33] Tommy: Have you ever been to the one club?
[46:34] Aaron: I don’t think I’ve been to any. I’m not even talking about — I don’t have any particular interest in going to a gay club, sorry, but where — what does one do to find oneself in a club?
[46:46] Tommy: Well, the one that I go to is Jackhammer in Chicago, happiest place in the world. That’s kind of like my leisure space.
[46:57] Aaron: Okay, cool. Wow.
[46:58] Tommy: I have my work stuff and then my fun stuff.
[47:02] Aaron: Do you want to tell me what your work stuff is?
[47:04] Tommy: Well, right now I’m in a career transition period. I’m trying to do healthcare abundance as a career.
[47:09] Aaron: Oh, based.
[47:10] Tommy: Used to be in finance.
[47:11] Aaron: Good luck. I think I have a tweet about that, which basically makes us — yeah, we’ve been throwing it around. I’m sure I know about as much about it as you, because I had a funny take once. Um, that was a dumb thing to say. Yeah, sorry, gay male culture.
[47:28] Tommy: Yeah, well, you asked me what I do for fun, and I guess when I’m doing takes and they’re kind of my for-fun takes rather than for-social-improvement takes, I oftentimes talk about gay male culture. That’s kind of like my little side anthropology project.
[47:52] Aaron: Oh, interesting. Okay, wild.
[47:55] Tommy: Because I really fell in love with that as my secondary home, my primary home being rationalism/EA. Because I’ve never experienced a culture that is so truly classically liberal as that one.
[48:13] Aaron: As which of the two?
[48:14] Tommy: As gay male culture.
[48:14] Aaron: Okay. I was going to say, I would have suspected that, you know, rat would be, but isn’t it?
[48:20] Tommy: It is, mostly.
[48:21] Aaron: Yeah, but isn’t gay culture kind of woke? Or no? Is that just a myth?
[48:25] Tommy: So it can be — like, this is definitely a complaint that I have about it, just because —
[48:30] Aaron: I mean, because — I’m not saying that should be a reason why you don’t do something, but for the particular claim that it’s, like, radically liberal, that, I think, is surprising to me.
[48:40] Tommy: It is, yeah. So there’s a big difference between the culture in gay men’s spaces versus queer/trans spaces.
[48:48] Aaron: Okay, wild. There’s a civil war — I’m sorry, that was offensive probably.
[48:52] Tommy: Oh yeah. Well, no, it’s kind of true, actually.
[48:55] Aaron: I just actually did not fully realize that. I mean, obviously they’re different — they’re just conceptually distinct, right? People don’t have to be part of the LGBT community. But okay, say more.
[49:10] Tommy: The spaces are truly very distinct. There is a very distinct culture that I fell in love with the first time that I went to Jackhammer, which in practice still is basically a gay male space. They will accept anyone, but in practice it is male, male-dominated, male culture. And in that culture, it is very, very direct, and it’s really a free market when it comes to sex. So you can just make trade offers, and people will accept mutually beneficial trades, and the trade offer itself is never seen as a threat or as a coercion.
[49:51] Aaron: Wow, this is so not relatable. Keep going.
[49:54] Tommy: Very low transaction costs. And like, for me as someone who — this is going to be graphic — you can cut this out.
[50:00] Aaron: No, I mean — I’m just hoping nobody in my room — my roommates aren’t around, but I think it’s okay. It’s fine. Go for it.
[50:06] Tommy: I have always wanted to be the dominant and be kind of rough, and it’s very rare that I feel like I can just directly ask for that stuff and directly initiate that stuff and trust that no one will be threatened by the trade offer itself. Just very low transaction costs. And I really fundamentally love free markets, both for money and for every other good and service imaginable. So I really fell in love with that culture, and that is exactly the opposite of queer spaces.
[50:42] Aaron: Okay, interesting. I am so not informed on this.
[50:48] Tommy: So that’s kind of my for-fun stuff.
[50:49] Aaron: No, no, interesting. I am — there’s a very crude sense in which I could be jealous, which is just around the sex itself, but I am more jealous around the directness allowed. You know what I mean?
[51:12] Tommy: Yeah. It’s hard. And some of it makes sense, right? Because it obviously makes sense that women are more threat-sensitive than men. That is not irrational.
[51:20] Aaron: Yeah, I’m not making any sort of enormous, like — I’m saying like, it’s an inconvenient reality for some people, not like I’m saying it’s anyone doing anything bad.
[51:29] Tommy: Right. Yeah, like to go back to the previous topic, nature is unfair. And it’s particularly unfair to females, I think. This is just a reality of the world that we live in.
[51:39] Aaron: Yeah. Return with a vengeance to asexual reproduction.
[51:44] Tommy: Yeah, yeah, yeah.
[51:47] Aaron: Wait, so actually I’m curious — do you mind — do you want more, have more gay culture? It’s healthcare abundance — we’ve talked about stuff. Is there a — do you want to give your pitch for, or actually not even pitch, what else besides the things we’ve talked about is in your vision of healthcare abundance?
[52:09] Tommy: Yeah, great question. Where to even start?
[52:17] Aaron: Or you can say what’s not. Is there anything that’s like — or is the answer just yes, access to anything, anything you want? Like drugs, certain diagnostics, whatever. I think that’s actually a very intuitive, plausible thing.
[52:37] Tommy: Yeah. I mean, I do have very libertarian instincts when it comes to just being able to access stuff. I do think natal males should be able to access testosterone — it’s definitely not right that I’m able to access testosterone and most of my man friends can’t.
[52:52] Aaron: Yes, or at least not easily, or it’s expensive — it’s a whole thing.
[52:56] Tommy: Yeah. One of the things I’m really concerned about lately in the healthcare abundance realm — the Niskanen Center talks about this kind of a lot — is that freestanding doctor’s offices, more and more over the years, we’re just bleeding those off because they’re getting acquired by hospitals. And this happens because of the way we’ve set up our Medicare system, where basically they reimburse doctors at much higher rates if they perform the exact same procedure in a hospital rather than in a freestanding clinic. And so what happens is that a doctor operating a freestanding clinic is very highly motivated to sell his clinic to a hospital, and he doesn’t even have to move locations — they just change the paperwork, and then he starts making like double money. But now all of a sudden he has all this hospital overhead, he’s bound by all these liability concerns, and something like my surgery, that was extremely safe and better than the standard of care, could not have happened outside of a freestanding office. It happened because my doctor cared about doing innovation, and he owned his practice so he could do innovation and take on that risk himself. And it was worth it to me to take on the risk myself. So we’re losing the spaces where innovation can happen.
[54:20] Aaron: Yeah, that sucks. I mean, I actually now recognize when you say it — correct me if I’m wrong, but I’m thinking, that’s why random doctor’s offices everywhere in this area are somehow associated with George Washington University for no obvious reason. Is that a plausible — or the same phenomenon, you think, or just something different?
[54:42] Tommy: Maybe. I’m not informed around here, but —
[54:43] Aaron: But I guess it could be, you know, the local university wherever, or Georgetown. But yeah.
[54:50] Tommy: Very possibly. I have no idea what’s going on in this city.
[54:52] Aaron: Okay. I’ll ask Claude — that’s right. Oh yeah, I actually — so I was talking earlier, I mentioned, if you explicitly do not say “I do not consent to something,” they generally abide by that. I think if you have an MD, there’s a fair amount of latitude in what you can do, right? So a lot of healthcare is ridiculously controlled, and so a ton of shit revolves around having a person with an MD, or I guess a DO in many cases, down to do the thing. I don’t know if I have any — there’s something, I don’t know if there’s more to say about that, but like, this is where the freedom lives — it’s like, within the discretion of individual doctors. And I think — I haven’t given my whole health history, which is obviously not interesting, but I think the main challenge for me is not — I’m guessing here, right, it could be that my case is intractable in terms of physical or physiological level, but my overall take is that in fact the problem is finding doctors willing to do even quite safe and not extremely expensive, not even operating — so I was talking about surgery, but a lot of this is like diagnostics. Like, please just do the diagnostic, I promise, you know. But often they just don’t, they don’t want to.
[56:31] Tommy: Yeah.
[56:32] Aaron: And actually, I mean, this is the kind — I think money buys you quite a lot. I got a concierge doctor but at the very, very low end of what that means. And I think this has been a bit helpful, but my overall sense is that if you’re very wealthy, then there are doctors who are willing, you know, for $400,000 a year, to help you get whatever tests you want. But most people can’t afford to spend $400,000 a year or whatever.
[56:59] Tommy: Yeah, yeah. There is a lot of medical tourism stuff that seems very promising that I’m not super well-informed about, but maybe worth — just flying outside the country. I don’t really know much.
[57:13] Aaron: I actually am considering this for something. It’s underdeveloped, so I probably don’t want to go into too much detail. That means maybe a future Pigeon Hour. But yeah, I know Mexico and Turkey — so it’s not just hair. And, especially if you care about being in the US, Puerto Rico is often a bit more expensive than Mexico but also a potential option for lots of things. I think there are many cases in which, if you need the best thing in the world, it’s in the United States; if you don’t, then the 90th percentile for 1% as much is in Mexico.
[57:52] Tommy: Yeah, so I was looking at Mexico when I was getting desperate. I thought that I might never be able to get this surgery.
[58:00] Aaron: That sucks.
[58:01] Tommy: It was just awful. So many people told me I would never be able to get this surgery.
[58:06] Aaron: I mean, I think I would have guessed that.
[58:09] Tommy: Yeah, that I would never have gotten it.
[58:11] Aaron: That you would never have gotten it awake, like you did.
[58:13] Tommy: Really?
[58:14] Aaron: Oh totally. I’m surprised that in fact you got that somebody — I mean, you know, it’s a testament in part to the state of the world, in part to your persistence, right? But it’s some function of those that determines whether in fact you get the thing.
[58:32] Tommy: Okay, I feel like — if I was sitting here before and I still had boobs and I told you that I was going to get it awake, I feel like you would have laughed.
[58:39] Aaron: No, I wouldn’t have laughed, because I wouldn’t have known. But given what I know now about this not being standard or being very uncommon, then in sort of a weird hindsight sense, I would have been surprised.
[58:49] Tommy: Okay, but I feel like — the thing is, the technology is so relatively speaking simple.
[58:55] Aaron: Yeah, that’s an update.
[58:59] Tommy: It’s like, every single doctor would say that it was impossible, but it’s actually very easy to understand.
[59:05] Aaron: I’m guessing what they mean is, it’s not standard.
[59:08] Tommy: They don’t want to do it, yeah.
[59:09] Aaron: And to be fair — I mean, I’m not that sympathetic to that concern, honestly, but I would be a little — there’s one thing that is, if someone is asking you to do something weird, that’s a Bayesian update that they’re a little weird in some way. I feel like this is true in many cases. It’s like, okay, is this person going to try to sue me with the footage somehow? Are they just going to be harassing me? Are they going to be crazy? Are they not going to pay? It does increase the likelihood that something weird happens, in a way that it’s worth recognizing, even though it’s not true in your case and I’m pretty sure it’s not true in mine either.
[59:46] Tommy: Yeah, totally, totally. I think basically the reason it worked was because, after I got super desperate, I was looking at gray-market body-mod surgeons in Mexico — you know, like the people who put reptile spines on people’s backs.
[1:00:02] Aaron: Oh god.
[1:00:03] Tommy: I was getting so desperate, and I finally just tracked down the inventor.
[1:00:09] Aaron: Oh, that’s — okay, nice. This is so smart.
[1:00:11] Tommy: Yeah, literally just the guy who invented the method of anesthesia that I knew would work. And because I thought that he would maybe care, you know, because no one else would fucking listen to me. And he’s retired, you know, so I just —
[1:00:25] Aaron: Oh wow, I did not know that. New bit just dropped.
[1:00:28] Tommy: So that’s why I didn’t think to call him previously, but I was just desperate, you know, so I just called him and I was like, “you’ve got to help me.” And he connected me to a co-inventor of his who did it.
[1:00:39] Aaron: Wait, can I ask how much this cost?
[1:00:41] Tommy: $8,000.
[1:00:42] Aaron: Oh, wow. Okay, I wouldn’t have been surprised if you’d said ten times that. He’d have a lot of leverage over you. I’m finding someone — I’m not sure what your willingness to pay was, but I’m guessing it would have been at least $9,000.
[1:00:54] Tommy: Oh yeah, way more. I would have put myself in debt for the rest of my life.
[1:00:56] Aaron: I mean, I was just curious.
[1:01:00] Tommy: I would have signed a contract to pay him $10 million over the course of the rest of my life.
[1:01:04] Aaron: I mean, I think I wouldn’t, because I’m a little bit — sure. No, I get it, I get it. Wow. Wait, that was out of pocket, I’m guessing? Like, you didn’t involve any sort of intermediary like insurance?
[1:01:18] Tommy: Correct. So I literally just read him my credit card number over the phone. He put it on a credit card. I did get it pre-approved by my insurance company after the fact — like, after I had paid, but before I got the surgery. I got it pre-approved by my insurance. The insurance approved it. Totally approved it. I gave them all the paperwork, all the codes.
[1:01:43] Aaron: “We don’t want to deal with this, guys, too.”
[1:01:44] Tommy: All the codes — they approved everything. Then I got the surgery. I asked them to reimburse me, as they had already promised to do, and then they told me that this surgery was impossible and they were not going to reimburse me because they didn’t believe that it actually happened.
[1:01:55] Aaron: Oh, sounds like a lawsuit.
[1:01:57] Tommy: Yeah, I need to sue them. It’s on my wishlist.
[1:01:58] Aaron: I mean, honestly, it’s actually a good use of your time for $8,000. In some just universe — I actually don’t think it’s crazy to not — I will honestly really want to — not in a bad way — I do want to experience seeing somebody — I’m honestly 60% joking. This is not in fact — I think in fact it would be more stressful, more expensive, more frustrating than I anticipate. But maybe I would want to observe someone like you going through it, especially for something that’s like — I imagine this is a very central case of a good reason to be able to sue someone. They tell you, they sign legal documents saying they’ll do X, they don’t do X. That is like the Assyrian 3000 BC type of situation.
[1:02:42] Tommy: Absolutely. Yes. Yes.
[1:02:47] Aaron: Probably it’s also a cool Substack article — “I sued [insert your healthcare provider].” They probably — they’re not going to go to court for $8,000.
[1:02:56] Tommy: Presumably. Yeah, although the amount of money — like, I have spent more than $8,000 worth of my time already fighting them.
[1:03:05] Aaron: Oh, oh. Okay, no, I feel like you should contact a lawyer to say, “here’s the situation.”
[1:03:11] Tommy: I should, yeah.
[1:03:12] Aaron: I mean, you know, I’m not actually sure about this, but it’s something to consider, especially because — I don’t know, I feel like they would love this case. Are you kidding me?
[1:03:20] Tommy: Yeah, yeah.
[1:03:22] Aaron: I mean, I have no idea.
[1:03:23] Tommy: It’s on my to-do list. I have a hundred things.
[1:03:25] Aaron: You should Substack your to-do list. It’s gonna — I feel like it’s gonna be very obviously redacted if you want. It’s gonna be very disparate — it’s like, “sue the healthcare provider, solve pain in America...”
[1:03:41] Tommy: My long-term goals. Go to the club.
[1:03:44] Aaron: Yeah, exactly.
What Claude flagged for review and why Tommy stands by his claims
Context (from above)
[00:17:06] Aaron: Also, just as a tiny bit of added credibility, I commit to running the transcript through Claude and saying, with your consent, I guess — actually, non-consensual Claude transcript analysis, just kidding — to figure out, presumably something we say is going to be slightly off. It’s very hard to talk for an hour and never say anything wrong. But we will report that.
1. “Fighting the tube” as a deliberate liability-driven practice.
Claude (Opus 4.7)
The phenomenon and terminology are real — patients can emerge during/after extubation and react to the ETT, and anesthesiologists do talk about “bucking the tube” / “fighting the tube.” But Tommy’s framing — that they “wake you up...while you’re still intubated, and they wait for you to basically struggle and thrash...and they do this because” of a liability calculation that trades suffering for slightly lower death risk — is one strongly editorialized interpretation, not a description of standard practice. The actual goal during extubation, per the standard literature, is to have the patient “awake enough to breathe without assistance, but sedated enough not to fight the endotracheal tube.” Sometimes that goal isn’t achieved, and the patient does fight the tube, and that’s genuinely awful — but presenting it as the intended design of the procedure is going to read as conspiratorial to anyone with anesthesia training and will be the easiest thing for a critic to dismiss the whole episode on. Worth adding a caveat or rephrasing as “this happens routinely as a failure mode of how we do extubation, and the system seems remarkably tolerant of it.”
Tommy:
On the “fighting the tube” topic - I think you can see some examples of both corroboration and denialism in this random reddit thread. It is so frustrating that I have talked to tons of nurses who are trying to whistleblow about the fact that many hospitals have terrible “vent weaning”/”fighting the tube”/”awake extubation” PROCEDURES and then tons of other people - and AIs, lol - show up to be like “That is totally not part of the procedure”
2. “I’m the only documented case of someone getting modern female-to-male top surgery fully awake.”
Claude:
Maybe true for the specific procedure (double-incision mastectomy with chest contouring on a non-elderly, low-ASA patient, framed as gender-affirming), but mastectomy under tumescent local anesthesia has been in the literature since at least Worland 1996, and the Sassari, Italy group (Trignano et al.) has published a body of work doing breast surgery — including subcutaneous mastectomy, gynecomastia correction, and trans-related breast augmentation — under TLA, with cohorts in the dozens. So “most doctors would tell you it was medically impossible” overstates the consensus. More defensible phrasing: “no documented case of this specific procedure being done awake on someone like me” or “essentially absent from the US gender-affirming literature.”
Tommy:
Like yes. There is “no documented case of this specific procedure being done awake on someone like me.” That’s why I said “I’m the only documented case of someone getting modern female-to-male top surgery fully awake,” lol.
And yes, the reason I knew this was possible, the reason I stuck to my guns for years while people treated me like a conspiracy theorist, is because of breast cancer patients undergoing mastectomies! That definitely proves it’s possible – that was my whole argument! I was going around making the case that mastectomies were not relevantly different from FTM top surgeries from the perspective of the anesthesiologist (despite significant differences from the perspective of the cosmetic surgeon), because that was obviously true. And then, you know, I was being told that this was my untested theoretical argument, and that it was extremely dangerous and naïve to try to get a surgery that hadn’t been done before, on the basis of my theoretical arguments.
Obviously though, my arguments were right, and I was right to make decisions based off them. And I’ve now written about that publicly. But before I wrote about it publicly, doctors AND AIs were saying that an FTM top surgery done this way was either medically impossible or very risky / unlikely to work. I almost feel like Claude might be using the existence of MY work to say that my work wasn’t novel, lol.
What Claude is doing is just sorta building the same argument that I had to build, but framing it as a correction, which is weird and misleading. Like: “A research group in Sassari, Italy has published multiple papers on breast surgeries performed this way in dozens of patients.”
Part of the research that I relied upon heavily to make my case was a collection of diverse breast surgeries done under TLA that came out of Naples, Italy. Unfortunately for me, there were no FTM top surgeries included in that group (or any that I’ve ever been able to find documented in modern times), which was a huge problem. That’s why I kept getting rejected from every doctor – because I did not have a single documented case of it to point to, and no one wants the potential lawsuit of doing something without precedent, even if it’s clearly safe. So for two years I was going around making the case that the differences were irrelevant and that this was really super safe, and then getting told a bunch of bullshit about how unknown unknowns would come to bite me and how I couldn’t possibly know that it was safe, since I was “just theorizing” and “there’s no actual evidence” (aka no published report of this particular thing actually happening). But, you know. I eventually succeeded.
(It’s also perhaps notable that breast augmentations, which Claude mentions as a piece of evidence, ARE very relevantly different from mastectomies, and much easier. No real doctor would have ever listened to me if I tried to bring in augmentations as a main piece of my argument – they just aren’t great evidence. I think Claude just doesn’t have a deep understanding of the field here.)
3 and 4. Testosterone “just shortens your lifespan” (for natal females) and “drastically increases your risk of needing a hysterectomy”
Claude:
This is stronger than the evidence supports. The Amsterdam cohort study (de Blok et al., Lancet Diabetes Endocrinol 2021) — the biggest dataset we have — found trans men on testosterone had ~1.8x the mortality of cis women, but the excess was driven by non-natural causes (suicide etc.), not directly attributable to testosterone. Multiple cohort studies of trans men on T for 10+ years have found no increase in MI, stroke, or DVT. There are real cardiovascular risk-factor markers that worsen (hematocrit up, HDL down, LDL up), but the leap from “biomarkers move in a bad direction” to “shortens lifespan” isn’t established. Worth softening to “the long-term effects aren’t well-characterized, and the risk markers move in concerning directions.
and
Also overstated. Older WPATH guidance recommended hysterectomy after ~5 years of T, partly on theoretical endometrial-cancer grounds, but that’s been walked back. The actual data is mixed: ~60-65% of trans men on T for 5+ years have atrophic endometrium, ~20-40% have proliferative endometrium, and large-scale evidence of increased hysterectomy necessity (vs. elective gender-affirming hysterectomy) isn’t there. Endometrial cancer cases in this population are rare. “Increases the risk somewhat, and the long-term picture is uncertain” would be more defensible.
Tommy:
Way less confident on this one; I don’t know much about testosterone/hysto compared to how much I know about surgery. But I will just flag that I’m a little suspicious that Claude is overupdating on like, lack of a singular published study to back up these claims, while NOT actually modeling how these chemicals work and making reasonable extrapolations. He basically can’t do that still, as far as I’ve been able to tell.
Newer models are obviously wayyyy better, but as of last year, before I started writing publicly about having done top surgeries awake, the big models were still essentially claiming that it was impossible or highly unlikely to work. They would do this even after I begged them to think about MECHANISMS for the action of tumescent local anesthesia, and apply that reasoning to the proposed surgery. They were unable to form their own independent model of how an anesthesia style works, and then apply it to a hypothetical. Instead they were only able to tell me, like “This probably won’t work because there is no evidence [i.e. a published study] saying that it will work.” The conflation of “no evidence” with “no published paper” is one I’m always on alert for. But again, not confident on this one.
5. The insurance lawsuit framing.
Claude:
[Aaron’s] “honestly, it’s actually a good use of your time for $8,000... probably it’s also a cool Substack article” framing may oversell how winnable this is. Insurance retroactive denials after pre-approval are notoriously hard to litigate — there are ERISA preemption issues for employer-sponsored plans, mandatory arbitration clauses, and the fact that “pre-approval” often isn’t a binding payment guarantee in the fine print. Tommy might have a case, especially if he has the written pre-approval in hand, but the casual confidence (”they’re not going to go to court for $8,000”) is probably wrong — insurers very routinely fight small claims hard precisely to discourage future ones. Worth either softening or noting the legal complexity.
Aaron:
Ok fine increase the uncertainty on my claims. I will note that the fact that Tommy has hours and hours of high quality footage of the surgery would seem to be an unusual factor in his favor insofar as the claim really was “this didn’t happen.” Video gen models are a thing but we’re talking about hours and hours of real footage - not easy to generate synthetically without a ton of time and money.
Also the “insurers routinely fight small claims” thing doesn’t necessarily push in the direction of “Tommy won’t get his money.” If true it indicates that they’d take it to at least arbitration, which I think Tommy would win.
