Sex Reassignment Surgery Definition

The case yielded five minority opinions--one concurring, two concurring with the result but not all its reasoning, and two (written or agreed to by five of the 15 judges) dissenting from the majority's holding of deductibility for genital sex reassignment surgery.

Sex-change surgery deductible medical expense

Because of this discrimination, transgender people must pay for any medical services relating to transsexualism out of their own pockets, with the result that many are never able to obtain sex reassignment surgery.

Legal and public policy issues for transgender elders

Male chromosomes do not change with either hormonal treatment or sex reassignment surgery," wrote Chief Justice Phil Hardberger of the state's Fourth Court of Appeals.

Genetics vs. love

Transsexuals are people who wish to undergo sex-change operations or sex reassignment surgery, whereas transgenders are people who live, or have a psychological urge to live, like members of the opposite sex without resorting to surgery.

Makeup, voice lessons help lighten transsexuals' lives

Sex reassignment surgery

Definition

Also known as sex change or gender reassignment surgery, sex reassignment surgery is a procedure that changes genital organs from one gender to another.


Purpose

There are two main reasons to alter the genital organs from one sex to another.

  • Newborns with intersex deformities must early on be assigned to one sex or the other. These deformities represent intermediate stages between the primordial female genitals and the change into male genitals caused by male hormone stimulation.
  • Both men and women occasionally believe they are physically a different sex than they are mentally and emotionally. This dissonance is so profound that they are willing to be surgically altered.

In both cases, technical considerations favor successful conversion to a female rather than a male. Newborns with ambiguous organs will almost always be assigned to the female gender unless the penis is at least an inch long. Whatever their chromosomes, they are much more likely to be socially well adjusted as females, even if they cannot have children.


Demographics

Reliable statistics are extremely difficult to obtain. Many sexual reassignment procedures are conducted in private facilities that are not subject to reporting requirements. Sexual reassignment surgery is often conducted outside of the United States. The number of gender reassignment procedures conducted in the United States each year is estimated at between 100 and 500. The number worldwide is estimated to be two to five times larger.

Description

Converting male to female anatomy requires removal of the penis, reshaping genital tissue to appear more female, and constructing a vagina. A vagina can be successfully formed from a skin graft or an isolated loop of intestine. Following the surgery, female hormones (estrogen) will reshape the body's contours and stimulate the growth of satisfactory breasts.

Female to male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals. Penis construction is not attempted less than a year after the preliminary surgery to remove the female organs. One study in Singapore found that a third of the persons would not undergo the surgery again. Nevertheless, they were all pleased with the change of sex. Besides the genital organs, the breasts need to be surgically altered for a more male appearance. This can be successfully accomplished.

The capacity to experience an orgasm, or at least "a reasonable degree of erogenous sensitivity," can be expected by almost all persons after gender reassignment surgery.


Diagnosis/Preparation

Gender identity is an extremely important characteristic for human beings. Assigning it must take place immediately after birth, for the mental health of both children and their parents. Changing sexual identity is among the most significant changes that a human can experience. It should therefore be undertaken with extreme care and caution. By the time most adults come to surgery, they have lived for many years with a dissonant identity. The average in one study was 29 years. Nevertheless, even then they may not be fully aware of the implications of becoming a member of the opposite gender.

In-depth psychological counseling should precede and follow any gender reassignment surgical procedure.

Sex change surgery is expensive. The cost for male to female reassignment is $7,000 to $24,000. The cost for female to male reassignment can exceed $50,000.


Aftercare

Social support, particularly from one's family, is important for readjustment as a member of the opposite gender. If surgical candidates are socially or emotionally unstable before the operation, over the age of 30, or have an unsuitable body build for the new gender, they tend not to fare well after gender reassignment surgery. However, in no case studied did the gender reassignment procedure diminish their ability to work.


Risks

All surgery carries the risks of infection, bleeding, and a need to return for repairs. Gender reassignment surgery is irreversible, so a candidate must have no doubts about accepting the results and outcome.


Normal results

Persons undergoing gender reassignment surgery can expect to acquire the external genitalia of a member of the opposite gender. Persons having male to female gender reassignment surgery retain a prostate. Individuals undergoing female to male gender reassignment surgery undergo a hysterectomy to remove the uterus and oophorectomy to remove their ovaries. Developing the habits and mannerisms characteristic of the patient's new gender requires many months or years.

To change male genitalia to female genitalia, an incision is made into the scrotum (A). The flap of skin is pulled back, and the testes are removed (B). The skin is stripped from the penis but left attached, and a shorter urethra is cut (C). All but a stump of the penis is removed (D). The excess skin is used to create the labia (external genitalia) and vagina (E). (

Illustration by GGS Inc.

)


Morbidity and mortality rates

The risks that are associated with any surgical procedure are present in gender reassignment surgery. These include infection, postoperative pain, and dissatisfaction with anticipated results. Accurate statistics are extremely difficult to find. Intraoperative death has not been reported.

The most common complication of male to female surgery is narrowing of the new vagina. This can be corrected by dilation or using a portion of colon to form a vagina.

A relatively common complication of female to male surgery is dysfunction of the penis. Implanting a penile prosthesis is technically difficult and does not have uniformly acceptable results.

Psychiatric care may be required for many years after sex-reassignment surgery.

The number of deaths in male-to-female transsexuals was five times the number expected, due to increased numbers of suicide and death from unknown cause.


Alternatives

There is no alternative to surgical reassignment to alter one's external genitalia. The majority of persons who experience gender disorder problems never surgically alter their appearance. They dress as members of the desired gender, rather than gender of birth. Many use creams or pills that contain hormones appropriate to the desired gender to alter their bodily appearance. Estrogens (female hormones) will stimulate breast development, widening of the hips, loss of facial hair and a slight increase in voice pitch. Androgens (male hormones) will stimulate the development of facial and chest hair and cause the voice to deepen. Most individuals who undergo gender reassignment surgery lead happy and productive lives.

Resources

books

Bostwick, John. Plastic and Reconstructive Breast Surgery, 2nd edition. St. Louis: Quality Medical Publishers, 1999.

Engler, Alan M. Body Sculpture: Plastic Surgery of the Body for Men and Women, 2nd edition. New York: Hudson, 2000.

Tanagho, Emil A. and Jack W. McAninch. Smith's General Urology, 15th Edition. New York: McGraw-Hill, 2000.

Walsh, Patrick C. and Alan B. Retik. Campbell's Urology, 8th Edition. Philadelphia: Saunders, 2002.

Wilson, Josephine F. Biological Foundations of Human Behavior. New York: Harcourt, 2002.

periodicals

Asscheman, H., L. J. Gooren, and P. L. Eklund. "Mortality and Morbidity in Transsexual Patients with Cross-Gender Hormone Treatment." Metabolism 38, No. 9 (1989): 869–73.

Docter, R. F. and J. S. Fleming. "Measures of Transgender Behavior." Archives of Sexual Behavior 30, No. 3 (2001): 255–71.

Fugate, S. R., C. C. Apodaca, and M. L. Hibbert. "Gender Reassignment Surgery and the Gynecological Patient." Primary Care Update for Obstetrics and Gynecology 8, No. 1 (2001): 22–4.

Harish, D., and B. R. Sharma. "Medical Advances in Transsexualism and the Legal Implications." American Journal of Forensic Medicine and Pathology 24, No. 1 (2003): 100–05.

Jarolim, L. "Surgical Conversion of Genitalia in Transsexual Patients." British Journal of Urology International 85, No. 7 (2000): 851–56.

Monstrey, S., P. Hoebeke, M. Dhont, G. De Cuypere, R. Rubens, M. Moerman, M. Hamdi, K. Van Landuyt, and P. Blondeel. "Surgical Therapy in Transsexual Patients: A Multi-disciplinary Approach." Annals of Surgery (Belgium) 101, No. 5 (2001): 200–09.


organizations

American Medical Association. 515 N. State Street, Chicago, IL 60610, Phone: (312) 464-5000. http://www.ama-assn.org/ .

American Psychiatric Association. 1400 K Street NW, Washington, DC 20005, (888) 357-7924. Fax: (202) 682-6850. apa@psych.org.

American Psychological Association. 750 First Street NW, Washington, DC, 20002-4242. (800) 374-2721 or (202) 336-5500. http://www.apa.org/ .

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201-5559. (410) 727-1100. http://www.auanet.org/index_hi.cfm .


other

Health A to Z [cited March 24, 2003]. http://www.healthatoz.com/healthatoz/Atoz/ency/sex_change_surgery.html .

Hendrick Health System [cited March 24, 2003]. http://www.hendrickhealth.org/healthy/001240.htm .

Intersex Society of North America [cited March 24, 2003]. http://www.isna.org/newsletter/ .

University of Missouri-Kansas City [cited March 24, 2003]. http://www.umkc.edu/sites/hsw/gendid/srs.html .


L. Fleming Fallon, Jr., MD, DrPH

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Gender reassignment surgery is performed by surgeons with specialized training in urology, gynecology, or plastic and reconstructive surgery. The surgery is performed in a hospital setting, although many procedures are completed in privately owned clinics.

QUESTIONS TO ASK THE DOCTOR



  • What will my body look like afterward?
  • Is the surgeon board-certified in urology, gynecology, or plastic and reconstructive surgery?
  • How many gender reassignment procedures has the surgeon performed?
  • How many of the type similar to the one being contemplated (i.e., male to female or female to male) has the surgeon performed?
  • What is the surgeon's complication rate?

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