Sex reassignment surgery for male-to-female involves reshaping the male genitals into a form with the appearance of, and, as far as possible, the function of female genitalia. Prior to any surgeries, patients usually undergo hormone replacement therapy (HRT), and, depending on the age at which HRT begins, facial hair removal. There are associated surgeries patients may elect to, including facial feminization surgery, breast augmentation, and various other procedures.
Lili Elbe was the first known recipient of male-to-female sex reassignment surgery, in Germany in 1930. She was the subject of four surgeries: one for orchiectomy, one to transplant an ovary, one for penectomy, and one for vaginoplasty and a uterus transplant. However, she died three months after her last operation.
Christine Jørgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. She was a strong advocate for the rights of transgender people.
Another famous person to undergo male-to-female sex reassignment surgery was Renée Richards. She transitioned and had surgery in the mid-1970s, and successfully fought to have transgender people recognized in their new sex.
The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician to perform sex reassignment surgery in the United States was the late Elmer Belt, who did so until the late 1960s.
In 2017, the United StatesDefense Health Agency for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who identifies as a woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.
Main article: Vaginoplasty
When changing anatomical sex from male to female, the testicles are removed, and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951), to form a fully sensitive vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hairfollicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.
In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty).
Surgeon's requirements, procedures, and recommendations vary enormously in the days before and after, and the months following, these procedures.
Plastic surgery, since it involves skin, is never an exact procedure, and cosmetic refining to the outer vulva is sometimes required. Some surgeons prefer to do most of the crafting of the outer vulva as a second surgery, when other tissues, blood and nerve supplies have recovered from the first surgery. This relatively minor surgery, which is usually performed only under local anaesthetic, is called labiaplasty.
The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is affected by age, nutrition, physical activity and smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage.
Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. Lubrication is needed when having sex and occasional douching is advised so that bacteria do not start to grow and give off odors.
Because of the risk of vaginal stenosis (the narrowing or loss of flexibility of the vagina), any current technique of vaginoplasty requires some long-term maintenance of volume (vaginal dilation), by the patient, using medical graduated dilators to keep the vagina open. Penile-vaginal penetration with a sexual partner is not an adequate method of performing dilation. Daily dilation of the vagina for six months in order to prevent stenosis is recommended among health professionals. Over time, dilation is required less often, but it may be required indefinitely in some cases.
Regular application of estrogen into the vagina , for which there are several standard products, may help, but this must be calculated into total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually, or, in extreme cases, under anaesthetic.
With current procedures, trans women do not have ovaries or uteri. This means that they are unable to bear children or menstruate until a uterus transplant is performed, and that they will need to remain on hormone therapy after their surgery to maintain female hormonal status.
Other related procedures
Facial feminization surgery
Main article: Facial feminization surgery
Occasionally these basic procedures are complemented further with feminizing cosmetic surgeries or procedures that modify bone or cartilage structures, typically in the jaw, brow, forehead, nose and cheek areas. These are known as facial feminization surgery or FFS.
Breast augmentation is the enlargement of the breasts. Some trans women choose to undergo this procedure if hormone therapy does not yield satisfactory results. Usually, typical growth for trans women is one to two cup sizes below closely related females such as the mother or sisters. Estrogen is responsible for fat distribution to the breasts, hips and buttocks, while progesterone is responsible for developing the actual milk glands. Progesterone also rounds out the breast to an adult Tanner stage-5 shape and matures and darkens the areola.
Voice feminization surgery
See also: Voice therapy (trans) § Vocal surgeries
Some MTF individuals may elect to have voice surgery, altering the range or pitch of the person's vocal cords. However, this procedure carries the risk of impairing a trans woman's voice forever, as happened to transsexual economist and author Deirdre McCloskey. Because estrogens by themselves are not able to alter a person's voice range or pitch, some people proceed to seek treatment. Other options are available to people wishing to speak in a less masculine tone. Voice feminization lessons are available to train trans women to practice feminization of their speech.
Main article: Chondrolaryngoplasty
A tracheal shave procedure is also sometimes used to reduce the cartilage in the area of the throat and minimize the appearance of the Adam's apple, in order to conform to more feminine dimensions.
Because anatomically masculine hips and buttocks are generally smaller than those that are anatomically feminine, some MTF individuals will choose to undergo buttock augmentation. If, however, efficient hormone therapy is conducted before the patient is past puberty, the pelvis will broaden slightly, and even if the patient is past their teen years, a layer of subcutaneous fat will be distributed over the body rounding contours. Trans women usually end up with a waist to hip ratio of around 0.8, and if estrogen is administered at a young enough age "before the bone plates close", some trans women may achieve a waist to hip ratio of 0.7 or lower. The pubescent pelvis will broaden under estrogen therapy even if the skeleton is anatomically masculine.
- ^Wexler, Laura (2007). "Identity Crisis". Baltimore Style (January/February). Archived from the original on 2012-02-19. Retrieved 2009-10-12.
- ^Kube, Courtney (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News.
- ^Lynne Carroll, Lauren Mizock (2017). Clinical Issues and Affirmative Treatment with Transgender Clients, An Issue of Psychiatric Clinics of North America, E-Book. Elsevier Health Sciences. p. 111. ISBN 0323510043. Retrieved January 8, 2018.
- ^ abAbbie E. Goldberg (2016). The SAGE Encyclopedia of LGBTQ Studies. Sage Publications. p. 1281. ISBN 1483371298. Retrieved January 8, 2018.
- ^Jerry J. Bigner, Joseph L. Wetchler (2012). Handbook of LGBT-Affirmative Couple and Family Therapy. Routledge. p. 307. ISBN 1136340327. Retrieved February 29, 2016.
- ^Arlene Istar Lev (2013). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Routledge. p. 361. ISBN 113638488X. Retrieved February 29, 2016.
- ^ abLaura Erickson-Schroth (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press. p. 280. ISBN 0199325367. Retrieved February 29, 2016.
Bruce Jenner attends the 13th annual Michael Jordan Celebrity Invitational gala in Las Vegas in April. (Ethan Miller/Getty Images for Michael Jordan Celebrity Invitational)
In this excellent post, my colleague Steven Petrow advised that if you're wondering whether someone you know is transitioning from one gender to the other, it's best to "check your curiosity and hold your tongue." But we all have questions about a subject that is increasingly mainstream. Aside from the recent coverage of Bruce Jenner's apparent transition, Laverne Cox last year became the first trans person on the cover of Time magazine, and Amazon debuted “Transparent,” a show about a father who is transitioning.
[UPDATE: Bruce Jenner: ‘Call me Caitlyn’]
Here are answers to some of the questions surrounding this issue.
How many people are transgender?
The Williams Institute, a think tank at the UCLA School of Law dedicated to research on sexual orientation law and public policy, estimates that 700,000 Americans are transgender. But a good piece last year on fivethirtyeight.com noted that there are no national surveys. And if there were, there is no agreement on what "trangender" means.
How many people have sex reassignment surgery?
It's very difficult to know. The Encyclopedia of Surgery says that "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." At least one other researcher says there are many more. Marci Bowers, a transgender obstetrician and gynecologist in Burlingame, Calif., who performs the surgeries, said in an interview that she does about 200 per year herself, about three quarters of them male to female.
Fred Ettner, a physician in Evanston, Ill., who works with people going through transition, estimated that only about 25 percent to 30 percent of transgender people have any kind of surgery.
How does one begin the process of changing one's sex?
Under the standards of care adopted by the World Professional Association for Transgender Health (WPATH), the first step usually is meeting with a mental health professional for a diagnosis and psychotherapy. A diagnosis of gender identity disorder or gender dysphoria and a letter of recommendation from the therapist allows a person to begin hormone therapy with a doctor. That is usually followed by a period of living publicly as a member of the opposite sex and, finally, surgery to alter the genitalia and other body parts.
What do hormones do?
Androgens are given to women to help them develop secondary male sex characteristics such as a beard and body hair. Estrogen and anti-androgens are given to men to help change their musculature, skin and fat distribution, all of which will make them appear more feminine. Body hair also diminishes.
But Ettner said the hormones' most important contribution is to reduce the dysphoria transgender people have been struggling with all their lives. After a month or two, their bodies and brains begin aligning.
"It's very obvious to the individuals," Ettner said, adding, "Their brain finally is getting this hormone. They feel differently. They behave differently.
"The first effect is the brain effect," he said.
What is the Real-Life Experience (also known as the Real-Life Test)
Surgeons who follow the WPATH standards of care (which some patients and experts consider too strict) usually require candidates for surgery to live for as long as a year in their preferred gender role. They must work or go to school; do volunteer work; change their first names and prove to the surgeon that people other than their therapists know they are successfully living this way.
What happens during surgery?
Male to female genital surgery is easier, less expensive and generally more successful than female to male surgery. That's one reason why fewer women choose to have surgery on their genitals, Bowers said. (Another is cost.)
In male to female surgery, the testicles and most of the penis are removed and the urethra is cut shorter. Some of the skin is used to fashion a largely functional vagina. A "neoclitoris" that allows sensation can be created from parts of the penis. Men retain their prostates.
In female to male surgery, the breasts, uterus and ovaries are removed (in two separate procedures). A "neophallus" can be constructed using tissue from the forearm or other parts of the body that allows sexual sensation, an expensive procedure. Extending the urethra to allow standing urination has proved to be perhaps the most difficult part of the process, Bowers said.
What other kinds of surgery are performed?
Jeffrey H. Spiegel discusses the tracheal shave cosmetic surgery procedure to reduce the size of an Adam's apple. (Jeffrey H. Spiegel)
Women wishing to live as men often have mastectomies. Men transitioning to women can have plastic surgery to "feminize" their appearance, including work on their eyes, noses, brows, chins and hairlines. They also can have their Adam's apple shaved down so it is less prominent.
Sounds expensive. Is it covered by insurance?
Bowers and Ettner said a woman who chooses the full range of surgical procedures available would spend $75,000 or more to transition to a male. Switching from male to female might cost in the $40,000 to $50,000 range. Some people have the work done in Thailand, which is well known for the surgery and where the cost is much lower.
Insurance is just beginning to cover some of the costs. Last year, Medicare lifted a 33-year ban on coverage for gender reassignment surgery, and the surgery was performed on 74-year-old Army veteran.
Do many people regret having the surgery?
Anecdotal accounts of regret abound, but overall it appears to be rare. Bowers said that only two of the 1,300 people she has operated on have wanted to go back to their old bodies.
But that doesn't mean that surgery is a miracle cure for the difficulties of gender dysphoria. People who make the transition often lose spouses, families, friends and jobs. They may find themselves completely alone if they relocate to start new lives. Johns Hopkins University, which in the 1960s was one of the first medical institutions to perform sex reassignment surgery, halted the practice when officials concluded that it was not helping the transgendered overall.
A 2o11 study of 324 Swedish transsexuals by the Karolinska Institute showed that "after sex reassignment, [they] have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group."
The forgotten history of Bruce Jenner
Transgender etiquette 101
Transgender at 7: Tyler gets a legal name change