Genital realignment surgery
Genital reassignment surgery (GRS) or SRS, (sex reassignment surgery) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.
According to WPATH (World Professional Association for Transgender Health), medically necessary sex reassignment surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation [...] including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient[...])[...] and certain facial plastic reconstruction." In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial electrolysis.
People who pursue sex reassignment surgery are usually referred to as transsexual; "trans" - across, through, change; "sexual" - pertaining to the sexual characteristics (not sexual actions) of a person. More recently, people pursuing SRS often identify as transgender instead of transsexual.
Sex reassignment surgery is the most common term for what may be more accurately described as "genital reconstruction surgery." The commonly used term "sex change" or "sex change operation" is considered factually inaccurate. The terms feminizing genitoplasty and masculinizing genitoplasty are used medically. Other terms for SRS/GRS include "gender confirmation surgery", "genital correction surgery" and "genital reassignment surgery".
The aforementioned terms may specifically refer to genital surgeries like vaginoplasty and phalloplasty or the multiple procedures to change the body, most notably chest/breast surgery. Contrary to popular belief, these surgeries, especially face and genital surgery, are composed of multiple procedures which take place concurrently even though popular use is to lump them into one term.
For details of surgical procedures see either:
The array of medically necessary surgeries differs for trans women (male to female) rather than trans men (female to male). In both cases, for trans women and trans men, genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy or vaginectomy. As underscored by WPATH, a medically-assisted transition from one sex to another may entail any of a variety of non-genital surgical procedures, any of which are considered "sex reassignment surgery" when performed as part of treatment for transsexualism.
For trans women, genital reconstruction usually involves the surgical construction of a vagina, clitoris, and vulva. For some trans women, facial feminization surgery and breast augmentation are also necessary components of their surgical treatment.
For trans men these may include top surgery (the removal of most of the lipid tissues of the breast, and shaping of a male contoured chest), hysterectomy and bilateral salpingo-oophorectomy. Genital reconstruction may involve either construction of a penis or metoidioplasty.
As a result of GRS, the person will have the apparent anatomical structures and function typical of the new sex. People about to undergo genital realignment surgery that also want children should consider their reproductive options beforehand. They are unable to reproduce due to the lack of actual sex glands (testes or ovaries), except through prior sperm banking or embryonic freezing, which still require a natal woman as the birth mother.
Additionally, continuing hormone replacement therapy is necessary to maintain muscle and bone integrity and characteristic form.
For trans women, medical advances may eventually make childbearing possible by using a donor uterus although there is risk of complications such as preterm delivery and birth defects due to the use of immunosuppressive drugs. The DNA in a donated ovum can be removed and replaced with the DNA of the receiver.
For trans men, gene therapy may allow the "reprogramming" of ovaries into testicular like tissue, negating the need for synthetic testosterone.
Another technology involves "3D" printed organs which can be used to create organs which replace the need for artifical hormone therapy. This option could evolve into entire reproductive tracts for either sex.
A growing number of public and commercial health insurance plans in the United States now contain defined benefits covering sex reassignment related procedures, usually including genital reconstruction surgery (for both genders), chest reconstruction (for trans men), breast augmentation (for trans women), and hysterectomy (for trans men). In June 2008, the American Medical Association House of Delegates declared that discrimination , stating that the denial to patients with Gender Identity Disorder of otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender identity disorder as recommended by the patient's physician." Other organizations have issued similar statements, including WPATH , the American Psychological Association , and the National Association of Social Workers .
It is not only financial reasons that determine whether a transsexual or transgendered person has GRS -- there are also legal, medical, or other considerations. Transsexual people who cannot or want not to have GRS and particularly genital reassignment surgery for medical, financial reasons are considered non-op, while "gender refusenik" is a slang term used among transgender people.
People with HIV or hepatitis C may have difficulty finding a surgeon able or willing to perform surgery. Many surgeons operate out of small private clinics that are not equipped to adequately treat potential complications in these populations and thus charge higher fees for HIV and hepatitis C positive patients.
Most medical professionals underscore that it is unethical to deny surgical or hormonal treatments to transsexual patients solely on the basis of their HIV or hepatitis status. In addition, universal precautions regarding body substance isolation have been part of most clinic/hospital policy to reduce the risks to the health care providers.
Other health conditions such as diabetes, abnormal blood clotting, and obesity do not usually present a problem to experienced surgeons. The conditions do increase the anesthetic risk and the rate of post-operative complications. Surgeons may require overweight patients to reduce their weight before surgery and smoking patients to refrain from smoking before and after surgery. Surgeons commonly stipulate the latter regardless of the type of operation.
For some, depression and/or anxiety is experienced after surgical procedures, at various times post operatively (immediately or months later). The longer the operation time, time higher chance of post-op anesthesia effects. Intensity can range from mild dysphoria to major depressive symptoms. Shortly after surgery, depression can be attributed to pain, a problem with anesthesia, a sense of loss or another underlying cause. There might also be uncertainty about the future, or lack of understanding on the part of individuals close to them.
Problems can also crop up in the recovery period which are not expected. A study of surgical patients shown that using an epidural anesthesia reduced complications across the board, sometimes by half or more.
Treatment is usually of issues as result of severe depression, such as malnourishment and dehydration. In severe cases, antidepressant medications may be prescribed on a short term basis.
Standards of care
Sex reassignment surgery can be difficult to obtain, due to a combination of financial barriers and lack of providers, among other issues. An increasing number of surgeons are now training to perform such surgeries. In many countries or areas, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for Gender Identity Disorders (SOC). This most widespread SOC in this field is published and frequently revised by the World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the United States and other countries now recognize the WPATH Standards of Care for the treatment of transsexualism. For many individuals these may require a minimum duration of psychological evaluation and living as a member of the target gender full time, sometimes called the real life experience (RLE) (sometimes mistakenly referred to as the real life test (RLT)) before genital reconstruction or other sex reassignment surgeries are permitted.
Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment for transsexualism, including accessing cross-gender hormone replacement or many surgical interventions. For this and many other reasons, both the WPATH-SOC and other SOCs are highly controversial and often maligned documents among transgender patients seeking surgery. Some alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH-SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH-SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.
Many medical professionals and numerous professional associations have stated that surgical interventions should not be required in order for transsexual individuals to change sex designation on identity documents. However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some cases, such statutes may specify that genital surgery has been completed. (see also: Legal aspects of transsexualism)
The earliest identifiable recipient of Male to Female Sex Reassignment Surgery was 'Rudolf ("Dora R-'),, "He took the first step towards changing his sex in 1921, when he had himself castrated, As a result his sexual instinct was enfeebled, but the homosexual tendency, as well as his own feelings, remained the same. This step, however, was not sufficient for him, and he tried to obtain a still greater degree of femininity in his sexual parts. Finally, in 1930, the operation which he himself had attempted at the age of six was performed upon him, viz., the removal of his penis, and six months afterwards the transformation was completed by the grafting of an artificial vagina [sic]."
This was followed by Lili Elbe in Berlin, in 1930-1931. This was started with the removal of the male sex organs and was supervised by Dr. Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an unsuccessful uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld's housekeeper, but her identity is unclear at this time.
Filmmaker Tanaz Eshaghian discovered that the Iranian government's "solution" for homosexuality is to endorse, and fully pay for, sex reassignment surgery. The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals." Eshaghian's documentary, Be Like Others, chronicles a number of stories of Iranian gay men who feel transitioning is the only way to avoid further persecution, jail and/or execution. The head of Iran's main transsexual organization, Maryam Khatoon Molkara—who convinced Khomeini to issue the fatwa on transsexuality—confirmed that some people who undergo operations are gay rather than transsexual.
- see WPATH "Clarification on Medical Necessity of Treatment, sex Reassignment, and Insurance Coverage in the U.S." available at: http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf
- World’s first successful uterus transplant recipient is pregnant via in vitro fertilization - Agence France-Presse
- Fageeh W, Raffa H et al. (March 2002). "Transplantation of the human uterus". International Journal of Gynaecology and Obstetrics 76 (3): 245–51. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127.
- Del Priore G, Stega J et al. (January 2007). "Human uterus retrieval from a multi-organ donor". Obstetrics and Gynecology 109 (1): 101–4. PMID 17197594.
- Nair A, Stega J et al. (April 2008). "Uterus Transplant: Evidence and Ethics". Annals of the New York Academy of Sciences 1127: 83–91. doi:10.1196/annals.1434.003. PMID 18443334.
- http://www.sciencedirect.com/science/article/pii/S0142961212013312 Engineered multilayer ovarian tissue that secretes sex steroids and peptide hormones in response to gonadotropins
- See discussion of insurance exclusions at: http://www.hrc.org/issues/transgender/9568.htm
- AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf
- See WPATH Clarification Statement
- APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf
- NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
- See WPATH Standards of Care, also WPATH Clarification. www.wpath.org
- Post Op Depression - It could happen to you. by Anne Barlow (blog)
- Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials by Anthony Rodgers, Natalie Walker, S Schug, A McKee, H Kehlet, A van Zundert, D Sage, M Futter, G Saville, T Clark and S MacMahon (British Medical Journal, BMJ 2000;321(7275):1493 (16 December), doi:10.1136/bmj.321.7275.1493)
- Depression and Other Medical Conditions Regents of the University of Michigan
- See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
- Encyclopaedia of Sexual Knowledge by Norman Haire (1930), Encyclopaedic Press, London.First Sex Change
- Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
- Iran's gay plan, Matthew Hays, Canadian Broadcasting Corporation, August 26, 2008; accessed September 20, 2008.
- Sex change funding undermines no gays claim, Robert Tait, The Guardian, September 26, 2007; accessed September 20, 2008.
Lists of GRS surgeons
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