What is gender reassignment surgery?

Indications and Procedures

Gender reassignment surgery is performed to allow an individual’s anatomic sex to conform to his or her gender identity. In cases of hermaphroditism or intersexuality, in which an individual is born with ambiguous genitalia
, the genitalia may not be altered upon birth to conform to chromosomal sexual identity. Anatomical changes at puberty, however, may conflict with the intersex teenager’s gender identity, and thus surgery may be used to correct the discrepancy. More commonly, gender reassignment surgery is performed on an adult who feels “trapped” within the body of the wrong gender, which causes severe emotional and psychological distress. Extensive psychological tests are performed on individuals seeking to change their anatomic sex.

In male-to-female surgery, the penis, testicles, and scrotum are removed and a vagina and labia may be created. Prior to surgery, the patient has taken estrogen
supplements. In the surgery itself, the surgeon removes each testicle through an incision at the base of the penis and ties off the spermatic cords. The skin and urethra are separated from the penis, and a tunnel for the vagina is created from skin at the base of the urethra. A scalpel is used to remove the base of the penis. The lower abdominal and penile skin is sutured to the pubic bone, and some of this skin is used to create a vagina. A colonic segment can also be used to create the vagina. A lubricated glass mold is inserted into the vagina to prevent shrinkage, and labia are formed from the scrotal skin.

During female-to-male surgery, breasts and hormone-secreting reproductive organs are removed and replaced with male secondary sexual characteristics. Prior to surgery, the patient undertakes a program of body-building exercises and testosterone supplements that promote body and facial hair development and suppress menstruation. Surgical procedures begin with the removal of excess breast tissue, in a procedure similar to breast reduction, and with a hysterectomy to remove the uterus, Fallopian tubes, and ovaries, along with their female sex hormones. At a later date, a penis may be constructed from abdominal-wall tissue or a skin graft, or both, and a scrotum containing plastic testicles formed from labia. An inflatable cylinder in the penis and a fluid pump within the scrotum can be used to simulate erection.

Uses and Complications

Because of the critical and irreversible nature of this type of surgery, the American Psychological Association has developed guidelines for diagnosing genuine transsexualism and for defining who should be considered for gender reassignment surgery in the United States. To be considered, transsexuals must feel a profound inappropriateness about their anatomic sex, have attempted to obtain gender reassignment surgery persistently for at least two years in spite of rejection for the procedure, have no genetic abnormalities or psychiatric disorders, and be past the age of puberty. In earlier cases, when such rigorous selection criteria were not in effect, some individuals who obtained gender reassignment surgery experienced severe social, sexual, and psychological trauma; some committed suicide.

Potential complications of male-to-female surgery include infection of incisions, closure of the urethral opening, and formation of an abnormal connection between the vagina and rectum, all of which are correctable. Long-term effects include dryness and potential shrinkage of the constructed vagina, unless the glass mold is worn the majority of the time, and an inability to achieve orgasm except through mental stimulation. Individuals may opt for breast augmentation surgery and must take female hormones for at least one year, perhaps for life, to maintain fat deposits on breasts and hips. Additional cosmetic surgery may be undertaken to achieve feminization of features.

Female-to-male surgery carries serious potential side effects from the hysterectomy, including pain, infection, and debilitation. Most individuals do not undertake penile construction and instead use a dildo or prosthetic penis. Constructed penises are usually unsatisfactory in that they are significantly shorter than the average erect penis and are incapable of transmitting sexual sensation. In some cases, pumps have become defective and required further corrective surgery. Male hormone supplements must be taken for the remainder of the individual’s life.

Perspective and Prospects

For centuries, hermaphrodites—persons born with ambiguous genitalia—were subjected to severe psychological trauma as they reached adulthood and/or developed a sexual anatomy contrary to the gender identity in which they were reared. In the mid-twentieth century, when chromosome analysis became available, those born with ambiguous genitalia could be identified as to chromosomal sex, and their outward ambiguities could be surgically altered soon after birth.

Transsexuals, too, have been ostracized and humiliated throughout history; in the latter half of the twentieth century, psychologists diagnosed transsexuals as genuinely feeling as if they had been born the wrong gender. What leads one to feel this sense of “wrongness,” whether the cause is biological or cultural, or both, is unknown. Theories such as exposure to large amounts of opposite-sex hormones during fetal gestation have been proven wrong.

Individuals who undergo gender reassignment surgery do not experience normal physical sensations in their new genitalia. They are also sterile and therefore unable to reproduce or become pregnant. Research into neurobiology may lead to future procedures allowing physical sensations, as well as to the possibility of transplanting functioning reproductive organs. Even in the current state of the procedure, individuals who are properly psychologically and physically prepared find peace and fulfillment in what is for them a normal gender identity.

Bibliography

American Psychological Association. "Answers to Your Questions About Transgender People, Gender Identity, and Gender Expression." Author, 2011.

Bockting W. “Sexual Identity Development.” In Nelson Textbook of Pediatrics, edited by R.M. Kliegman, et al. 19th ed. Philadelphia: Saunders Elsevier, 2011.

Boylan, Jennifer Finney. She’s Not There: A Life in Two Genders. New York: Broadway Books, 2003.

Ettner, Randi, Stan Monstrey, and A. Evan Eyler, eds. Principles of Transgender Medicine and Surgery. New York: Haworth Press, 2007.

National Center for Transgender Equality and the National Gay and Lesbian Task Force. “Injustice at Every Turn.” Washington, D.C.: Author, 2011.

Shrage, Laurie, ed. “You’ve Changed”: Sex Reassignment and Personal Identity. New York: Oxford University Press, 2009.

Simpson, Joe Leigh. Disorders of Sexual Differentiation: Etiology and Clinical Delineation. New York: Academic Press, 1976.