My passenger giggles and shrieks as the jeep rattles down a steep jungle pass through an afternoon storm. Her tattooed arms flex as she picks at a chip in her nail polish. The road is slick and treacherous, and it takes all my concentration to carry on our conversation while peering through the maelstrom, dodging the crazed speed-freaks and half-drunk holidaymakers who have turned the Thai resort island of Phuket into something resembling a demolition derby.
Our talk ranges over the bitchy antics of the San Francisco goth scene, high-speed runs to Tijuana to load up on female hormones, and the ineffable oddity of knowing you have just 16 hours left as a man.
When she wakes up tomorrow morning, Samantha Hellstrom - former United States Marine, bodybuilder and security guard - will be wheeled into the operating theatre of the Phuket International Hospital, given a general anaesthetic and an epidural, then during six gruelling hours will have her penis peeled apart and transformed into a passable-looking and functional approximation of a vagina.
'Nervous? Sure, I'm a bit nervous about the surgery, but not the end result,' she says, as we pull into the leafy surrounds of the hospital. We've just been for a walk along Karon Beach, a quiet spot half an hour from the hospital and just south of the sex-and-booze mayhem of Patong Beach. It will be Samantha's last real chance to stretch her legs for at least a week. 'All I want is to be as complete a woman as medical science can make me at the present time. That's all I can hope for.'
Samantha is one of a growing number of transsexuals from around the world opting to have their 'sex-reassignment surgery' performed in Thailand. She has chosen Dr Sanguan Kunaporn, an affable, gangling young doctor who is fast approaching his 400th sex-change operation and is challenging his mentor and teacher, Bangkok-based Dr Preecha Tiewtranon, 57, as the kingdom's top plastic and reconstructive surgeon. The pair operate almost exclusively on patients from overseas. They are rated among the best in the world, and certainly among the cheapest. Each will take on sex-reassignment surgery for about US$5,000 (HK$38,950), which includes up to two weeks stay in hospital. Breast augmentation is another $2,000 or so. In the West, expect to pay three or four times that, unless you are prepared to risk the cowboys. Cheap as these prices may sound to those with hard currency, however, they are well out of range of most local katoeys (ladyboys), who must make do with lesser surgeons and less-than-satisfactory results or remain in the sexual netherworld of the she-male.
Like many others, Samantha was lured by the island's promise of 'sun, surf and surgery' and by Dr Sanguan's growing reputation in the transsexual community. 'Welcome to Phuket, the most famous holiday destination in the Southeast Asian region,' gushes his Phuket Plastic Surgery website. 'Our services range from breast implants, tummy tucks, liposuction, face-lifts, eyelid surgery to sex-reassignment surgery.' Of course, the combination of sand, salt water and painfully raw and tender nether regions may not hold the same appeal for all potential patients.
'Medicine is a big business in Thailand now,' acknowledges Dr Sanguan. 'We target people to come here for plastic surgery and to stay for a holiday. Last week, I did a facelift for a 65-year-old American man, who said it was cheaper here and he got to stay in paradise. We usually offer a package. People want exact prices. So, for example, if someone comes for liposuction, they pay about $1,500 for surgery and the hospital stay, then we can organise a hotel room, anything from $15 to $100, in town or on the beach. I don't know if in the future we will be a hub for cosmetic surgery in the world, or in Asia. But I think there's a good chance.'
This surgery-by-the-sea in Phuket is part of a push which began three or four years ago, when dozens of hospitals thrown up during the boom years suddenly found themselves with world-class facilities and empty beds. The medical profession, Thai airlines and the tourism authorities got together and began marketing 'medical vacations', where holidaymakers can fit a full health check-up or a face-lift into their stay at less than a quarter of what it would cost in the US, Europe or Australia. This nip-and-tuck tourism has now become a major earner for the Land of Smiles.
Bumrungrad Hospital in Bangkok is the apotheosis of the trend, boasting vast rooms that look like hotel suites, with hot and cold running nurses, cable and internet access, and even Starbucks and McDonald's franchises in the lobby. It treated more than 160,000 foreign patients last year.
HAVING BECOME ACCUSTOMED to seeing the petite frames of Asian ladyboys after living in the region for nine years, Samantha comes as a bit of a shock. She's nudging 1.8 metres, has an inky riot of tattoos over most of both arms and her chest, and bulging, vein-bisected biceps. She's wearing a black dress and black Reeboks, matching her nail polish. Her hair is receding slightly and cut in a wavy bob, and while her face is far from unattractive, there is an undeniably masculine cast to her makeup-free features.
'Come in,' she trills. Samantha, like her surgeon, is 41. She'd prefer not to mention her previous name. She was born in Chicago and raised in San Francisco's Bay area, where she still lives. She works at the Federal Reserve Bank, in the building services department, where she has toiled for 17 years, after seven years in the Marines. She previously sported a full and bushy beard and tipped the scales at 95 kilos during her serious bodybuilding days, when she often worked as a security guard at rock concerts. She still lifts weights, but these days she's down to a slinky size 12. Her breasts look to be about a B-cup. 'That's all from hormones,' she says proudly. 'I've never had implants. Some of the younger trannies worry about their breasts and Adam's apples [the surgeons can shave the cartilage for a small extra fee] but I'm pretty comfortable now with who I am, that's not so important to me.'
Samantha just got back in touch with her dad after 20 years, and says he was shocked to learn of his son's transformation and is struggling to understand. She doesn't talk to her mum much, but dotes on her two sisters. She crosses her legs and sighs. 'I've done many different things in my life. I was a very different person during my repression years. I realised I was meant to be a woman when I was still a young kid but I didn't start actually living as a woman until two and a half years ago. I started taking hormones about a year before that, and I was into the transsexual community, going around as a woman part time. It got to the point where I couldn't stand living two lives anymore. I was fed up with trying to be macho, trying to be a man. So one day I went to work looking like this, and it's been fine ever since. Of course, a lot of people were shocked, but most of them got over it.'
She says she'd love to get rid of her tattoos. 'But it's too expensive. I don't want to have my entire arms lasered. I have my facial hair lasered and that's bad enough.' But she feels, on the whole, like the woman she believes she is destined to be. 'I'm still basically developing. Even after surgery, it will take another year or so for feminisation to take its full effect. It will accelerate after surgery, when my body is not fighting the testosterone the whole time. I'm still growing and changing.'
As if to accentuate the point, she pulls out a picture of herself at 17, just after being inducted into the Marines. She looks like a recruitment poster. Dress blues and white hat, smooth olive skin, square jaw and wide-set eyes. I can't help thinking she was a much better-looking man than she is as a woman.
She gets her share of hassle but San Francisco is more tolerant than most places. 'You do get people coming on the weekends from out of town, and they're not tolerant at all. They throw things at me when I'm walking back from a club, or yell things. I've had the urge to punch people. I've Maced people. They've come up to hassle me and I've just emptied a can of Mace in their face. I know people stare a lot, because I'm fairly big and muscular compared to most transgendered people. But I'm comfortable with that.'
Samantha says she is now 'going with' a guy but the relationship is not sexual. She says there are plenty of 'straight' men who go after transsexuals for a walk on the wild side, but she's not interested in those relationships. 'They want to control you, and keep that part of their life secret. When I have my life back, when the operation's healed, I'll start worrying about things like sex.'
Why Phuket? And why Dr Sanguan? 'I know a lot of people in San Francisco's transgendered community, and many of them are from Southeast Asia. So I knew all about the surgeons in Thailand. I got the best reports from people about Sanguan, and I did a lot of research over the internet once I began my transition.'
THREE WEEKS EARLIER, I meet Dr Sanguan for the first time. He introduces me to Rebecca Steen, an erstwhile 140kg, bearded Methodist priest and father of three, who had a sex change a year ago. She's down to a trim 75kg and looks like your average suburban mum, apart from her big hands. 'I'm here to have a tummy tuck because I've lost so much weight,' she says. 'I over-ate before to run away from who I was. Now I know I am the person I was born to be.' She speaks like a woman, with none of the usual ladyboy's high-pitched whine, courtesy of larynx surgery and vocal coaching.
Dr Sanguan believes he's getting better at his work all the time, and there are no shortage of glowing testimonials on his website. He began sex-reassignment surgery more than a decade ago, under the watchful eye of Dr Preecha, before going for further training with the best in the US. He's had patients as old as 72 and as young as 19. He's done doctors, lawyers, pilots, politicians.
'There are cowboys here, but people shouldn't be worried if they come to a reputable surgeon,' he says. 'We have our own Society of Plastic and Reconstructive Surgery and a board to control the quality.' He has horror stories, however, like the butcher who preyed on naive katoeys in Pattaya about five years ago, stuffing their chests with silicone-filled condoms which became horribly infected. Dr Sanguan was called on to undo the damage on several occasions.
Now, he says almost all his patients are foreigners, usually from the US, Europe, Australia, Japan, New Zealand, Taiwan and Canada. Western transsexuals differ greatly in their physical makeup from Asians, he says. 'But it's not true to say all Westerners have bigger penises. In fact, many of them are circumcised, which makes the surgery more difficult because there is less tissue for reconstruction. It varies from individual to individual.'
In clinical terms, the standard operation involves the removal of the testicles (orchidectomy), creation of a vaginal tunnel (vaginoplasty), construction of a clitoris using the sensitive tissue from the head of the penis, which is kept attached to its main nerve (sensate clitoroplasty), construction of labia majora (limited labiaplasty), removal of the penis (penectomy) and construction of a new urethral opening (urethroplasty). Five to seven days later, a scrotal skin graft is performed inside the vaginal tunnel using skin kept refrigerated from the first operation. Most patients are up and walking within two weeks, and can have sex after two months. Many report achieving orgasm. One Hong Kong patient healed so fast she was shopping and clubbing a week after the operation, and a recent patient from England was able to go for an elephant ride in a week.
The operation sounds eye-watering but Dr Sanguan says the pain from breast augmentation is usually worse. His method, which includes the separate skin graft and entails five or six days' bed rest to allow the graft to take, has its critics. Some medics say that is too long to spend immobile because of the risk of clotting.
In March, Laura Hodges of Sheffield, England, died following sex-reassignment surgery in Neenah, Wisconsin. The death has caused an uproar in transgendered circles. Six days after Dr Eugene Schrang performed the secondary skin graft, Hodges got out of bed for the first time, collapsed and died from a massive pulmonary embolism - the so-called Economy Class Syndrome.
Dr Sanguan acknowledges the controversy, but says the risks are small if the patient is properly cared for, and the advantages of his method outweigh the risks. 'All surgery has risks,' he says. 'Fortunately in Thailand, no one has ever died during sex reassignment.'
Some US surgeons also criticise the gung-ho approach of their Thai counterparts, some of whom are happy to operate at short notice if the patient has the money, even if they have not undergone extensive counselling and psychological evaluation. 'They have to have been under female hormone therapy for at least six months before I consider them as a candidate for reassignment surgery,' says Dr Sanguan.
He says overseas patients must be referred by their therapists in their home country. Thai transsexuals, he says, are a different matter. 'In Thailand, transsexuals show themselves up in social life when they are still teenagers usually, and everyone accepts and knows they are women. They live as women, dress as women, have female friends; they never have sex with women. So we do reassignment surgery for these people without psychological examinations because we know they are good candidates. In the West it's different. People fight it, hide it, get married, have kids, divorce, marry again.'
So of course he's loaded, right? He drives a new BMW but is cagey about the rewards of his profession. 'If you have a million, then someone else has 10 million. So how do you define rich?' He says he got into sex reassignment because it changes people's lives. 'Many of them thank me, say I've given them a chance to be happy.'
IT IS 10AM ON FRIDAY and Samantha is waiting on a gurney in the operating theatre. She looks amazingly peaceful, considering the ordeal to come. 'I didn't sleep much, but then I never do,' she says. 'I'm a night person.' The anaesthetist bustles about preparing syringes, from the tiny to the truly fearsome. Then the mask comes down, Samantha goes out, and Dr Sanguan arrives, looking almost frail in his hospital greens.
An epidural is poked into Samantha's spine, a tube stuck down her throat, and the nurses drape sterile sheets over her body, concealing her face behind a kind of curtain. Her arms rest to the sides on cross-pieces, the black nail polish incongruous in the scrubbed surrounds, and her legs are hoisted into stirrups. Samantha is exceptionally well-endowed, and the nurses point and giggle as they swab her groin. The only other sound is the ummphhh-hiss of the respirator until a nurse slips Music For The Operating Theatre into the CD player: Chicago, Air Supply and other anodyne stuff.
'Have you ever watched surgery before?' asks Dr Sanguan, as I shake my head. 'Okay, you stand back here.' He puts a chair behind me. 'If you feel faint, sit down and breathe deeply.' And indeed I'm feeling curiously light-headed as the reality of what I'm about to witness sinks in. Which is, basically, every man's worst nightmare.
The doctor takes a 'before' shot with a digital camera, turns to me and says, 'You know, after the operation, some girls go out and buy a new bikini. It's the first time they can wear one without embarrassment.'
Then he pulls on his gloves ... snap, snap ... sits on a stool between Samantha's legs and with a kind of inked brush marks out his first incisions. It is just like in the movies, but he doesn't shout 'Scalpel!' The nurses have done plenty of these operations and know what he needs. Except it's not like in the movies at all, because I'm less than two metres away, and there's blood and glistening flesh and the room feels very small and my breath is coming in short gasps and now the room is spinning.
Get a grip, I tell myself. You're a professional. It wouldn't do to keel over. The doctor is slicing away, swapping scalpel for a little yellow wand called an electric cautery, which closes the cuts with a puff of smoke and a reek of singed flesh.
The bloody swabs pile up, and the two nurses perched on stools either side of Samantha are working as hard as the doctor. Chris Isaak is wailing about a wicked game as the first testicle is cut free and plopped unceremoniously into a kidney-shaped steel dish. It's soon joined by its mate, and I can't help but feel an uncomfortable tingle. Later, when they are joined by other raw and bloodied excess flesh, a nurse will scoop the lot into a jar labelled 'Samantha' and place it in a box with eight other jars, also labelled with patients' names. It's an ignominious end for organs treasured so highly by most men.
Dr Sanguan starts hollowing out the vaginal canal. By this time, Samantha's groin is splayed open and resembles roadkill. It's hard to watch, but by this point I'm fascinated. It occurs to me this is about as close as you can get to playing God, transmuting man to woman - short, perhaps, of neurosurgery or genetic tomfoolery.
He makes hundreds of tiny sutures with a minute needle. His hands are a blur and it's clear the doctor is in the zone, hearing that fine, high sound artists hear when the creative process is peaking. By 11.30am, we're onto a collection of dirge-like Thai love songs. Scalpels and forceps are put into the autoclave which pops and crackles, adding a weird, syncopated beat.
Time flies, then crawls. By 1pm, we're way past the point of no return. All that remains of the penis is a kind of mangled pulp. Blood, cautery, suture, snip. It's hypnotic. One of the nurses looms up from the next room with a pair of surgical scissors. 'Snip snip,' she laughs as I shrink back.
Towards the end of the procedure, after at least five hours, there's a tense moment. A slight slip by a nurse and a jet of blood misses the unprotected eye of her opposite number by centimetres. She looks furious, but doesn't miss a beat, calling for another colleague to wipe her face. Earlier, the doctor had told me it was up to the patients to get Aids tests, but that he treats all patients as potentially infected.
Suddenly, after five hours, it all starts to come together. The doctor still hasn't missed a beat or had a rest, and he's still stitching furiously. At 4.15pm, he's finished. He snaps off his gloves and takes a long look at his handiwork, which looks pretty close to the real article.
'Keep breathing, keep breathing,' shouts the anaesthetist, as Samantha chokes and gurgles and comes out of her slumber. She is stabilised and wheeled off to the Intensive Care Unit. When the pain starts to kick in, she'll be pumped full of morphine. She won't be making much sense for days.
Dr Sanguan heads for the coffee room and sticks a plate of fried rice in the microwave oven. 'My God, you must be exhausted,' I stammer, still in a kind of tongue-numbed shock. 'Was it a success?'
'Yes, a very normal case. No complications,' he says. In 15 minutes, he's due back in theatre to make some adjustments to a breast job gone awry.
LATER THAT NIGHT, WE venture into the heart of Phuket's darkness. Bangkla Road, which bisects Patong Beach, is a monument to sin in all its shapes and forms; a lurid carnival of beer, lust and neon that makes Bangkok's Patpong Road look like the Avenue of the Americas.
About halfway along and off to the left as you head away from the beach is the infamous Soi Katoey (Ladyboy Street). A few years ago it was one bar with a handful of dubious-looking she-males who made a killing when the navy came to town; sailors too drunk or naive to realise or care they weren't being dragged off for sex - and probably to be robbed - by natural- born women.
Now the ladyboys are thick on the ground. They've taken over at least six bars and number in their hundreds. The flash of strobes on sequins and silver lame can cause permanent eye damage. They take turns gyrating on a raised stage, gazing out over the audience with vacant, amphetamine stares. Here, for 100 baht (HK$17), or for nothing if they think you're rich or cute, katoeys will flash you a glimpse of Dr Sanguan's handiwork.
The crowd is equal parts bemused tourists - goggle-eyed European couples and red-faced, red-shouldered mums and dads who have put the kids to bed and sneaked out for a peek at the wildlife - and genuinely sleazy types who have a taste for this kind of thing.
We buy Singha beers for Nancy, who looks sad, pouts convincingly and has perfectly conical breasts. 'I had my operation five years ago,' she says, lifting her skirt. 'Do you want to see?' We demur, and ask who the surgeon was. 'Dr Sanguan. He wasn't so expensive before.' Does she feel like a woman? She pouts. 'Eighty per cent I feel I'm a woman. I get sad sometimes. It's boring coming down here, but what else can I do? Sometimes the guys are nice. Others jump on you like monkeys.'
She smiles, but not with her eyes. 'But you know the worst thing? Every night I dream that I'm pregnant. That I'm going to have a baby. And I wake up and cry because I never will.'