Gender-affirming surgery

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Gender-affirming surgery is a

Professional medical organizations have established Standards of Care, which apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female, such as vaginoplasty, vulvoplasty and breast augmentation, while masculinization surgeries are those that result in anatomy that is typically gendered male, such as phalloplasty and breast reduction.

In addition to gender-affirming surgery, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Sweden became the first country in the world to allow transgender people to change their legal gender after "reassignment surgery" and provide free "reassignment" treatment in 1972.^[1] Singapore followed soon after in 1973, being the first in Asia.^[2]

Terminology

Gender-affirming surgery is known by numerous other names, including gender-affirmation surgery, sex reassignment surgery, gender reassignment surgery, and gender confirmation surgery.^[3] It is also sometimes called a sex change,^[4] though this term is usually considered offensive.^{[5][unreliable source?]} Top surgery and bottom surgery refer to surgeries on the chest and genitals respectively.^[6]

Some transgender people who desire medical assistance to

As knowledge of non-binary genders expands in the medical community, more surgeons are willing to tailor operations to individual needs. Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Gender nullification is the removal of all external genitalia except the urethral opening, typically pursued by people assigned male at birth.^{[10][medical citation needed]}

Gender-affirming surgery can also refer to operations pursued by cisgender people, such as mammaplasty, penile implant, or testicular implants following orchiectomy.^[11]

Gender-affirming surgery is often sensationalized and misrepresented by anti-trans activists through terminology such as genital-mutilation surgery.^[12]

Surgical procedures

Genital surgery

For

Non-binary people often pursue genital surgeries, including the same operations as binary trans people of the same sex assignment, as well as bigenital or gender nullification surgeries. Bigenital operations include androgynoplasty, a procedure that retains the penis,^[13] or vagina-preserving phalloplasty.^[10]

Genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons.^[14]

Other surgeries

As underscored by WPATH, a medically assisted transition from one gender to another may entail any of a variety of non-genital surgical procedures which change primary and/or secondary sex characteristics, any of which are considered "gender-affirming surgery" when undertaken to affirm a person's

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery - or bottom surgery (the latter is named in contrast to top surgery, which is surgery to the breasts; bottom surgery does not refer to surgery on the buttocks in this context). However, the meaning of "sex reassignment surgery" has been clarified by the medical subspecialty organization, the World Professional Association for Transgender Health (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for "gender dysphoria" or "transsexualism".^{[needs update]} According to WPATH, 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."^[17] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.^[17]

Voice feminizing surgery is a procedure in which the overall pitch range of the patients voice is reduced.^[18]

Adam's apple reduction surgery (chondrolaryngoplasty) or tracheal shaving is a procedure in which the most prominent part of the thyroid cartilage is reduced.^[19]

There is also Adam's apple enhancement therapy, in which cartilage is used to bring out the Adam's apple in female to male patients.

History

Nero had Sporus castrated,^[a] and during their marriage, Nero had Sporus appear in public as his wife wearing the regalia that was customary for Roman empresses.

Reports of people seeking gender-confirming surgery (vaginoplasty) go back to the 2nd century, such as the Roman Emperor Elagabalus.^[21][22] In the Byzantine Empire "reconstructive" surgeries on intersex people were performed at least from the seventh century on, in Alexandria possibly as early as the 2nd century.^[23] Paul of Aegina (c. 625 – c. 690), quoting Leonidas (Alexandria, 2nd – 3rd centuries), describes in section LXIX (On Hermaphrodites) of his sixth book four types of intersex and how to "cure" three of them by surgically removing the "useless parts".^[23][24] In the next section (LXX, On Extirpation of the Nympha and Cauda Pudendi) he deals with clitoromegaly and how to remove the enlarged clitoris.^[25] The first modern gender-confirming surgery was performed in the 20th century.^[21]

20th century

In the US in 1917,

Dora Richter is the first known trans woman to undergo complete male-to-female genital surgery. She was one of several transgender people in the care of sexologist Magnus Hirschfeld at Berlin's Institute for Sexual Research. In 1922, Richter underwent orchiectomy. In early 1931, a penectomy, followed in June by vaginoplasty.^[26][27]

Between 1930 and 1931,

A previous sex reassignment surgery (SRS) patient was Magnus Hirschfeld's housekeeper,^[31] but their name has not been discovered.^{[citation needed]}

Elmer Belt may have been the first U.S. surgeon to perform gender affirmation surgery, in about 1950.^[32]

In 1951, Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male SRS, producing a technique that has become a modern standard, called phalloplasty.^[33] Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

In 1971, Roberto Farina performed Brazil's first male-to-female gender-affirming surgery.^[34]

In 1984, Jalma Jurado developed a new surgical technique, which he used in surgeries for more than 500 transgender women in Brazil and from around the world.^[35]

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by the doctors Lebovic and Laub.^[36] Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head.^[36] Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.^[36]

21st century

On 12 June 2003, the European Court of Human Rights ruled in favor of Carola van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as van Kück vs Germany.^[37]

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".^[38]

As of 2017,^[update] some European countries require forced sterilization for the legal recognition of sex reassignment.^[39] As of 2020^[update], Japan also requires an individual to undergo sterilization to change their legal sex.^[40]

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.^[41][42]

Prevalence

The prevalence of transgender-related surgeries is difficult to measure and likely underestimated. In 2015, the largest survey of transgender people in the United States reported that 25% of respondents reported having undergone such a surgery.^[43]

Prior to surgery

Medical considerations

Some transgender persons present with health conditions including

People with HIV or hepatitis C may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.^[48]

Fertility is also a factor considered in SRS, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.^[45]

Gender dysphoric children

Sex reassignment surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it.

Infants born with intersex conditions might undergo interventions at or close to birth.^[51] This is controversial because of the human rights implications.^[52][53]

There can be negative outcomes (including

Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack of providers. An increasing number of surgeons are now training to perform such surgeries. In many regions, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for the Health of Transgender and Gender Diverse People (SOC). The 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 recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment 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 sex reassignment surgeries are covered by insurance.^{[citation needed]}

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. 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.^{[citation needed]}

Many surgeons require two letters of recommendation for sex reassignment surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.^{[59][60][needs update]}

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents.^[17][61][62] 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 jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.^[63]

Insurance

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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 (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and hysterectomy (FTM).^[64] For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:

• a written initial assessment by a qualified licensed mental health professional
• persistent, well-documented gender dysphoria
• months of prior physician-supervised hormone therapy

In June 2008, the American Medical Association (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician."^[65] Other organizations have issued similar statements, including WPATH,^[17] the American Psychological Association,^[61] and the National Association of Social Workers.^[62]

In 2017, the United States Defense 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 is a transgender woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.^[66]

Post-procedural considerations

Quality of life and physical health

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Several studies have measured quality of life and self-perceived physical health using different scales. Castellano et al. (2015) found similar quality of life compared to a control group for 60 SRS patients two years after surgery.^[67] Kuhn et al. (2008), assessing 52 trans women and 3 trans men 15 years after surgery, found quality of life lower than control in domains of health and limitations.^[68] De Cuypere et al. (2005), assessing 32 trans women and 23 trans men after surgery, concluded that patients' emotional and social needs were met, but less so their physical and sexual needs.^[69] Ainsworth and Spiegel (2010), in a study of 247 trans women, find improvements in mental health after genital reassignment surgery or face feminization surgery.^[70]

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision.^[71]

Psychological and social consequences

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A 2009 review in the International Journal of Transgenderism found that from 1998 onward,^[72] studies have shown that "the whole process of gender reassignment is effective in relieving gender dysphoria and that its positive results greatly outweighed any negative consequences", but noted methodological issues in many studies, particularly older ones.^[73] A 2010 meta-analysis in Clinical Endocrinology noted the lack of randomization and control groups and reliance of self-reporting in the studies it reviewed, reaching the conclusion "Very low quality evidence suggests that hormonal therapies given to individuals with GID as a part of sex reassignment are likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."^[74]

Smith et al. (2001) found that among 20 patients, anxiety, depression and hostility levels were lower after sex reassignment surgery.^[75] Wierckx et al. (2011), in a study of 49 trans men, found them in good self-perceived physical and mental health.^[76] Dhejne et al. (2011), in a study following 324 transgender people who received sex reassignment surgery from 1973 to 2003, found that they "have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population", concluding that "sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism".^[77] Lawrence (2003), in a study of 232 trans women who underwent surgery between 1994 and 2000, found "None reported outright regret and only a few expressed even occasional regret."^[78]

Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery.

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.^[83] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,^[76][69] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery.^[69] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.^[69] Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.^[69]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.^[69] The ability to obtain orgasms is positively associated with sexual satisfaction.^[76] Frequency and intensity of orgasms are substantially different among trans men and trans women. Almost all female-to-male individuals have revealed an increase in sexual excitement and are capable of achieving orgasms through sexual activity with a partner or via masturbation,^[69][76] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.^[85] A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female individuals have been encountering longer and more gentle feelings.^[69]

The rates of masturbation have also changed after sex reassignment surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies exhibited in most transsexual individuals and 78% of them were able to reach orgasm by masturbation after SRS.^[76][69][86] A study showed that there were differences in masturbation frequencies between trans men and trans women, in which female-to-male individuals masturbated more often than male to female^[69] The possible reasons for the differences in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.^[76]

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels).^[86] When comparing transgender with cisgender individuals of the same gender, trans women had a similar sexual satisfaction to cis women, but trans men had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.^[76]

Legal status

See also

Notes

References