Gender Reassignment Surgery

Definition

Also known as sex change surgery or sex reassignment surgery, gender reassignment surgery is a procedure that changes a person's external genital organs from those of one gender to those of the other.

Purpose

There are two reasons commonly given for altering the genital organs:

• 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 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. This condition is known as gender identity disorder ; it is thought to be more common in men than in women.

Although technical considerations in the case of babies with ambiguous genitalia would seem to favor surgical conversion to female structures rather than to male, this conclusion has been challenged in the early 2000s. William G. Reiner, a child and adolescent psychiatrist, undertook a study of 29 genetic males who had been born with defective external genitalia and reared as females following surgery. He found that over half of them identified as males by adolescence in spite of the absence of male genitalia. Dr. Reiner has concluded that psychosexual development in genetic and hormonal males is heavily influenced by exposure to androgens prior to birth, and has called for a reevaluation of the practice of routinely assigning male babies with ambiguous genitals to the female sex.

Precautions

Sexual identity is probably the most profound characteristic humans have. Assigning it must take place immediately after birth, both for the child's and the parents' comfort. Changing sexual identity may be the most significant change one can experience. It therefore should be done with every care and caution. By the time most adults come to surgery, they have lived for many years with 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 other sex.

Gender identity disorder has been officially defined by the American Psychiatric Associan in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV, as a condition in which the affected individual has "a strong and persistent cross-gender identification" combined with "persistent discomfort about one's assigned sex." Because of widespread social disapproval of surgical gender reassignment, researchers do not know the true prevalence of gender identity disorders in the general population. Early estimates were 1:37,000 males and 1:107,000 females. A recent study in the Netherlands, however, maintains that a more accurate estimation is 1:11,900 males and 1:30,400 females. In any case, the number of surgical procedures is lower than the number of patients diagnosed with gender identity disorders.

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.

Female to male surgery has achieved lesser success, due to the difficulty of building a functioning penis from the much smaller amount of erectile 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 patients 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 done quite successfully.

Orgasm, or at least a reasonable degree of erogenous sensitivity, can be experienced by patients after surgery.

Preparation

As of the early 2000s, patients requesting gender reassignment surgery must undergo a lengthy process of physical and psychological evaluation before receiving approval for surgery. The Harry Benjamin International Gender Dysphoria Association (HBIGDA), which is presently the largest worldwide professional association dealing with the treatment of gender identity disorders, has published standards of care that are followed by most surgeons who perform genital surgery for gender reassignment. HBIGDA stipulates that a patient must meet the diagnostic criteria for gender identity disorders as defined by either the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) or the International Classification of Diseases-10 (ICD-10).

Preparation for gender reassignment surgery includes a period of several years of hormonal treatment to change the body contours, vocal pitch, patterns of facial and body hair, etc. to those of the other sex. As the patient's body and voice begin to change, he or she is also asked to practice dressing and acting as a member of that sex.

There is some controversy as of the early 2000s regarding the appropriateness of performing gender reassignment surgery on adolescents, as opposed to either infants or older adults, on the grounds that teenagers are often uncertain about many aspects of their sexuality. The recent case of a thirteen-year-old girl who requested gender reassignment surgery in Australia reflects the intensity of this controversy among surgeons as well as members of the general public.

Aftercare

Social support, particularly from the family, is important for readjustment as a member of the opposite sex. If patients were socially or emotionally unstable before the operation, over 30, or had an unsuitable body build for the new sex, they tend to do poorly. Paul McHugh, the former head of the department of psychiatry at Johns Hopkins University, has reported that people who think that gender reassignment surgery will solve all their emotional and social problems are likely to be disappointed. "[These patients] had much the same problems with relationships, work, and emotions as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled."

Risks

All surgery runs the risk of infection, bleeding, and a need to return for repairs. This surgery is irreversible, so the patient must have no doubts about accepting the results.

KEY TERMS

Chromosomes— The carriers of genes, which determine sex and characteristics.

Gender identity disorder (GID)— A mental disorder in which a person strongly identifies with the other sex and feels uncomfortable with his or her biological sex. It occurs more often in males than in females.

gender reassignment surgery— The surgical alteration and reconstruction of a person's sex organs to resemble those of the other sex as closely as possible. It is sometimes called gender reassignment surgery.

The most common physical complication of the male to female surgery is narrowing of the new vagina.

There is some risk of patients developing other mental disorders associated with their new sex. Several cases of anorexia nervosa, an eating disorder that is far more common in women than in men, have been reported in males who underwent gender reassignment surgery.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., revised. Washington, DC: American Psychiatric Association, 2000.

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Psychosexual Disorders." Section 15, Chapter 192 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2002.

PERIODICALS

McHugh, Paul, MD. "Surgical Sex." First Things 147 (November 2004): 34-38.

Reiner, W. G., and J. P. Gearhart. "Discordant Sexual Identity in Some Genetic Males with Cloacal Exstrophy Assigned to Female Sex at Birth." New England Journal of Medicine 350 (January 22, 2004): 333-341.

Reiner, W. G. "Psychosexual Development in Genetic Males Assigned Female: The Cloacal Exstrophy Experience." Child and Adolescent Psychiatry Clinics of North America 13 (July 2004): 657-674.

Spriggs, M. P. "Ethics and the Proposed Treatment for a 13-Year-Old with Atypical Gender Identity." Medical Journal of Australia 181 (September 20, 2004): 319-321.

Winston, A. P., S. Acharya, S. Chaudhuri, and L. Fellowes. "Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases." International Journal of Eating Disorders 36 (July 2004): 109-113.

ORGANIZATIONS

American Board of Urology (ABU). 2216 Ivy Road, Suite 210, Charlottesville, VA 22903. (434) 979-0059. 〈http://www.abu.org〉.

American Psychiatric Association (APA). 1400 K Street, NW, Washington, DC 20005. (888) 357-7924. 〈http://www.psych.org〉.

Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA). 1300 South Second Street, Suite 180, Minneapolis, MN 55454. (612) 625-1500. 〈http://www.hbigda.org〉.

OTHER

Harry Benjamin International Gender Dysphoria Association (HBIGDA). Standards of Care for Gender Identity Disorders, 6th version. February 2001. 〈http://www.hbigda.org/socv6.html〉.