Captain, My Captain has been following the story of Germaine De Larch, one of the most visible transgender representatives and activists in South Africa for over a year now.  We are honoured to have been allowed to be a part of the documentation of the top surgery process.  

As it is such a personal thing, we thought we would let Germaine speak.

Read below for a full account of what it really takes physically, emotionally and financially.


Photos: Sherene Hustler, & Joanne Olivier

My story as a transgender person is different to the popularly-known narrative in many ways.

  1. I am not a transgender woman. Trans men and masculine of centre folks are the invisible characters in the trans story.
  2. My story is one of “it’s never too late”. I’ve been on testosterone for 1 year and 10 months at the age of 40.
  3. I am non-binary. I am neither male nor female; I am outside, between and beyond the male:female binary; I am one of the many genders that exist.
  4. I do not have full access to private healthcare and have had to use a mixture of private and public healthcare.

The most well-known transgender person, Caitlyn Jenner, is one story. She doesn’t represent 95% of the transgender narratives in the world, let alone America. The landscape in South Africa is even further removed from her story. This is my story, which is one of many.

I have written and vlogged at length about the emotional aspects of this journey. This is a factual, blow-by-blow account of my story.

Medical Transition: Hormone Replacement Therapy (HRT)

When I decided to go on testosterone, I had to navigate the healthcare system and its lack of trans-competent medical practitioners. I went to one of the handful of private doctors who treated trans patients. I had to get a letter from my therapist, basically stating that I was of sound mind, had gender dysphoria and that testosterone would be an important part of alleviating that dysphoria. The doctor sent me for blood tests, which includes kidney and liver function, as well as glucose and cholesterol levels (testosterone affects these functions and levels and general health is essential before starting), along with my testosterone and estrogen levels.

A second visit to the doctor cleared me to begin testosterone (T). Based on my estrogen and testosterone levels a dosage of T from one of the two types available in South Africa was prescribed. I began with bi-weekly, self-administered injections of a low dose. It was important for me to inject myself as a symbol of taking control of this new chapter of my life. I went for blood tests 2-3 weeks after my first shot, adjusting the dose based on blood tests and the way my body reacted physically and emotionally – like HRT for cisgender (non-trans) people, it’s effectively undergoing menopause, and the adjustment takes roughly 9 months. I went for follow-up blood tests every 3 months once my hormone levels stabilised, and then every 6 months. Medical aids do not cover HRT, but those who can afford Medical Savings Accounts as part of their medical plan can use these savings.

The effects of T include the following: fat redistribution – hips, legs and arms become leaner and any excess fat moves to the abdomen; muscle gain, regardless of whether one exercises; strength gain; increased libido; increased body hair; a lowering of the voice; and clitoral growth. Bone structure also changes – jawline becomes more prominent, hands and feet grow, Adam’s Apples grow. These changes take place slowly and continue for up to 4-5 years.

These changes have significantly reduced my physical and emotional discomfort, and appearing masculine to others has changed my life completely, as the image of myself in my head finally matches what others see. It is, without a doubt, one of the best decisions I ever made.

Gender Reassignment Surgery: Top Surgery (Bilateral Mastectomy)

I could not afford private surgeon rates and had to go the public healthcare route. All private plastic surgeons train in public healthcare facilities, so the quality of surgery is as good as private.

I went to Helen Joseph Hospital in Johannesburg. I was only the second trans person to go through the process at the hospital, and the process had changed radically since the first person had his surgery. I therefore had to navigate the completely unknown process and face unexpected hurdles to have my surgery approved. I had expected that I would need letters from my therapist, psychiatrist and testosterone-prescribing doctor, but the hospital insisted that I see their psychiatrist and get the go ahead from them.

Apart from these bureaucratic requirements to prove that I was sane enough to know my own mind and was able to make my own decisions, the staff and the doctors were surprisingly sensitive about my issues and needs as a transgender person, and while levels of trans competence varied at different levels of hospital staff, I was treated well and never made to feel like a freak or an anomaly. This is not the case at multi-disciplinary public hospitals at Baragwanath and Steve Biko, where extremely invasive, unnecessary and dehumanising questions are part of the process trans people have to go through. I was asked about my sexual preferences, but given the general misunderstanding that being transgender has anything to do with sexual orientation, part of me expected this, while finding it surprising that this ignorance extended to trans healthcare.

The cost at Helen Joseph, as an unemployed person, is still unaffordable for most, including me. The dysphoria I felt about my chest had significantly increased since beginning T and my desperation to have my body aligned to my gender forced me to make the difficult decision to crowdfund my surgery. I was extremely lucky to raise the money I needed within a month.

I had my surgery on the 14th of March of this year and the sense of comfort in my body I finally feel after decades of dysphoria since puberty has significantly relieved depression and feelings of self-hatred and alienation from my own physical presence.

As a trans activist and a white transgender person, I am all too aware that my story is very different to the majority of the trans, gender variant and gender non-conforming population in South Africa. (The term “transgender” is a Western concept that has no equivalent in South African vernacular languages, and a large proportion of the community does not identify as transgender or even have access to the terminology or information that white and urban trans people have. The terms “gender variant” and “gender non-conforming” are thus important). My story, while different to those who can access private healthcare and private surgery, is one that previously disadvantaged, impoverished, rural and peri-urban members of the community cannot even conceive of. They have to access public healthcare from beginning to end, with little to no emotional or psychological support, information or access to trans competent healthcare. Many cannot even access trans healthcare due to stigma, transphobia and fear for their own lives, and those who do enter the system for gender reassignment surgery have to wait for years to undergo these surgeries.

I tell my story, I make myself visible, because I have the privilege of being able to. And it is my hope that my story will shift the understanding of trans issues in general society in order to make it an easier place for the transgender community to live in.

The Top Surgery Process at Helen Joseph

Process for top surgery at Helen Joseph, Johannesburg, South Africa #topsurgery #transgender #bilateralmastectomy


Resources: Sources of Information, NGOs, Trans-Competent Doctors and Psychosocial Support, Gender Reassignment Surgery Costs, etc.

Follow Germaine’s daily trans activism and personal progress here: