sex change In humans, sex change normally refers to the surgical and legal conversion of a man to a woman or a woman to a man; these individuals are known as male and female transsexuals, respectively.

The term ‘transsexual’ was first coined — to describe the case of a woman who wanted to be a man — by Cauldwell, an American sexologist, in 1949, although transsexualism is known to have existed since antiquity. The first scientifically documented case of sex change surgery was that of Lili Elbe in the UK in 1930. However, public interest in sex change surgery was first aroused by the sensationalism of Christine Jorgenson's case in Denmark in 1953. Born as a male, it was she who popularized the notion that a man who felt like a woman could change sex. Although the first sex change operation was carried out that long ago, the controversy and emotion stirred up by the use of the procedures in the management of transsexualism are unmatched by most other psychosexual issues today.

According to Dr Harry Benjamin, the esteemed American pioneer in the field of gender disorders since the 1950s, transsexualism is generally accepted to occur independently of other mental disorders and in individuals of varying personality types. He defines transsexualism as a disturbance of gender identity in which persons anatomically of one sex have an intense and persistent desire for medical, surgical, and legal ‘change’ of sex so that they may live as members of the opposite gender. Overtly they may appear to be homosexual, a label which they vehemently deny, although their sexual attentions from the time of puberty have been directed to members of the same sex. They consider their genitalia as foreign, and their one obsession in life is to get rid of them. For these patients, surgery is the finishing touch, rather than a sudden leap into either femaleness for male transsexuals, or maleness for female transsexuals.

Transsexualism has been described as the most extreme form of gender reversal. To alter their body to match their inner self is an intense desire in every transsexual's life. Gender confusion is a dominant feature present in all transsexuals. However, gender confusion is not restricted to transsexuals alone; it may accompany patients suffering from other psychosexual disorders. It is common during the course of almost every child's development to experience some degree of gender confusion. For most, this gender confusion dissolves with the passage of time and growth. Therefore, all transsexuals suffer from gender confusion, but not all who suffer from gender confusion are true transsexuals.

Because of the nature of transsexualism and the apparent similarities it has with other psychosexual disorders, transsexuals are often confused with homosexuals, lesbians, and transvestites. The lack of definitive and easy diagnostic criteria for transsexualism has resulted in many patients with other psychosexual disorders being wrongly diagnosed as transsexuals. The ability to make a clear differential diagnosis, distinguishing patients with various psychosexual disorders from transsexuals is, therefore, an important management requisite.

Advancement of surgical techniques and plastic surgery have made sex change surgery available to both male and female transsexuals. Surgical outcomes have become more predictable, and cosmetically and functionally acceptable to patients. This has resulted in an increasing number of patients seeking sex change surgery. This increase is further enhanced by media exposure, and the establishment of gender identity clinics all over the world.

Despite more openness in discussing the subject of transsexualism and more autobiographies written by transsexuals themselves, the pain and confusion experienced by an average transsexual is not understood by the public at large. Historically, there has been much stereotyping of such patients. Many have viewed them with disdain, others have made them the butt of their jokes, and still others have seen them as sexual objects: in all, making such people feel they are the accursed minority.

Transsexualism is an emotionally crippling disease that impinges on all developmental stages. While sex change surgery has definite medical, surgical, and psychological limitations, there is strong evidence suggesting that true transsexuals have benefited from it, and it remains the treatment of choice for them. The problem is how to identify these patients. Instead of ruthless exclusion of doubtful cases and prolonged pre-surgery observation, thorough screening has led to successful results with excellent individual, social, and sexual adjustment.

The lack of a simple ‘litmus test’ to predict which patients will benefit from sex change surgery has created a tremendous ethical unease among professionals managing transsexuals. To provide guidance for this particularly difficult area of patient management, the Harry Benjamin International Gender Dysphoria Association has developed ‘standards’ that set minimal requirements of care. A team approach is recommended. The ‘standards’ require that a patient should have the gender disorder for at least two years, and that a person with this condition be known to a clinical behavioural scientist, and be his or her patient, for at least three months. Hormone therapy should be initiated only upon the recommendation of the clinical behavioural scientist. The endocrinologist of the team should be aware of the risk factors or side-effects of the hormone therapy. He needs to appraise the patient in the light of those risks. Regular monitoring of relevant blood chemistries and routine physical examinations must be included.

The management strategy can therefore be divided into six stages:(i) Initial evaluation by the psychiatrist/psychologist to diagnose the underlying cause of the patient's gender confusion and to identify true transsexuals from ‘wish-to-be’ transsexuals.(ii) To attempt psychotherapy to reverse the patient's desire for the sex change operation. To help patients with other compounding problems that may confuse them as to their real motives behind the desire for a sex change.(iii) Cross-gender hormone therapy to initiate reversible ‘changes’ of sex. To explain to patients the reasons, strategy, and possible side-effects of the hormone therapy. Female transsexuals are usually given testosterone-esters as a monthly or bi-weekly depot injection, while male transsexuals are given a combination of oestrogen/progestagen or oestrogen alone. Hormone therapy will bring about physical and perhaps psychogenic changes. A subsequent change of mind can be helped as most of the changes brought about by hormone therapy are reversible.(iv) On top of cross-gender hormone therapy, patients next go through a stage of total cross-dressing. This will provide a real-life test of the patient's intention and ability to adjust and cope in society.(v) When the patient is adequately prepared and ready, the sex change surgery is carried out.(vi) Post-surgery management includes monitoring of cross-gender hormone therapy, adjustment of hormone therapy according to the individual patient's response, and continuing to provide counselling to patients.The sex change surgery may be classed into two types, namely, genital and non-genital. Non-genital surgery includes plastic reconstruction of the nose, chin surgery, revision of thyroid cartilage, breast surgery, and revision of the buttocks. These surgical procedures are not exclusive to transsexuals seeking sex change surgery. Many females not suffering from gender confusion do seek these kinds of plastic surgery to improve their body image. For example, women who are bothered by large, pendulous and heavy breasts may seek reduction in breast size. All female transsexuals will ask for breast reduction surgery, while most male transsexuals will seek breast augmentation mammoplasty.

The sex change genital surgery for male transsexuals differs greatly from that for female transsexuals. Currently, it is performed as a one-stage procedure. The major steps include: (i) bilateral orchidectomy (castration); (ii) penectomy (amputation of the penile shaft); (iii) creation and lining of the neovagina; (iv) shifting of the urethra and; (v) fashioning of the labia.

The genital surgery for female transsexuals is carried out over several stages and it includes: (i) total radical hysterectomy (removal of womb, fallopian tubes, and ovaries); (ii) construction of an artificial penis (penoplasty); and (iii) closure of the vagina. Future advancement in the surgical procedures may include the fashioning of a scrotum to house artificial testes.

S. S. Ratnam Victor Goh Hng Hang

SEX CHANGE

Not Cut Out for the Army

In 1952 Americans were shocked by the news that George Jorgensen, a twentysix-year-old private in the U.S. Army Service Command at Fort Dix, New Jersey, had an operation to change his sex. Jorgensen was unhappy as a man and wanted to change his body to that of a woman. He went to Denmark for the surgery to make the transformation.

A Quiet History

Jorgensen's was not the first sex-change operation. In a highly publicized case, a woman in Great Britain was converted to a man by similar means in order to be able to inherit a title and land available only to a man. In fact, Jorgensen might not have been even the first American to have undergone a sex-change procedure. His notoriety was based on the fact that his case was publicized.

The Transformation

At the Rigs Hospital in Copenhagen, Jorgensen was subjected to slow changes in his hormone levels as surgical procedures were used to remove his male organs and produce female genitals. The hormonal therapy produced breasts and other necessary physical changes.

A Curious Nation Awaits News

While Jorgensen was undergoing therapy at Rigs, someone who knew him informed an American news reporter of the procedure. The reporter convinced Jorgensen's parents to divulge the story. When Jorgensen, now named Christine, arrived back in New York, she was met by a throng of reporters at the airport. They asked such questions as whether she could have a baby (only by adoption; she had no uterus). They also asked her to confirm rumors that she had been dating an American GI while in Europe. She moved into a suite at the Carlyle Hotel and started on the first chapter of her memoirs for American magazine. Privacy would never be easy for her again.

Sources:

Time (23 February 1953): 28;

Newsweek, 40 (15 December 1952): 64.