Sexual Reassignment Surgery

Sexual reassignment surgery, also known as sex change or gender reassignment surgery, is the alteration of a person's genitals and other physical characteristics to that of the opposite gender. Transsexuals suffering from gender identity disorder often undergo sexual reassignment surgery to change their physical body to match their gender identity. Sexual reassignment surgery is also a way of assigning an infant who is born with intersex deformities to one sex or the other (Sex Reassignment Surgery 1).

Sexual reassignment surgery is an expensive procedure most of which is not covered by medical insurance. Most people have this surgery done outside of the U.S. because foreign countries offer the lowest prices. The total cost of male to female reassignment surgery including additional cosmetic surgery averages between $5,000 and $30,000. Female to male reassignment surgery is much more costly averaging at a total between $50,000 and $80,000 (Sex Reassignment Surgery 1).

A person seeking SRS must first meet all given requirements. Most medical professionals use a set of guidelines called The Standards of Care for Gender Identity Disorders that were developed by the Harry Benjamin International Gender Dysphoria Association. These standards define the criteria that determine if in fact a person is indeed transsexual and if they are emotionally and psychologically suited for sexual reassignment surgery. The requirements include testing HIV negative, having lived for at least one full year in the new gender role, having engaged in hormone therapy for at least one year, must have the recommendation of a psychologist or therapist after an appropriate series of sessions as well as a recommendation of a psychiatrist that surgery is not contrary to the mental health of the patient. In order for a person to know if they meet these requirements, they must undergo an assessment of their mental and physical health (SRS: Sex Reassignment Surgery 1).

Both MTF's and FTM's use hormones to change their physical characteristics. MTF's take estrogen in order to feminize their face and body characteristics. Estrogen redistributes the patient's body fat making a more womanly shape. It increases the size of their breasts, and decreases the amount of body hair. The penis and testicles also shrink as a result of taking Estrogen. FTM's take the hormone testosterone. Testosterone results in the growth of facial and body hair, the lowering of the voice, an increased sex drive, and the cessation of menstruation. Requirements for the use of hormone therapy require the patient to be at least 18 years old, they must understand what hormones can and cannot do as well as the social benefits and risks, and either a documented real life experience of at least three months prior to the administration of hormones or a period of psychotherapy after the initial evaluation of a duration of usually three months (The Harry Benjamin International Gender Dysphoria 1).

Patients must follow strict preoperative instructions before undergoing their SRS. These instructions include having the patient quit taking hormone pills, smoking, and taking Aspirin 2 weeks before the operation, the patient should not consume any soft drinks and should begin a soft diet 2 to 3 days before the operation, and the patient should not have anything to eat or drink 6 hours before the operation (Genital Reassignment Clinic 1). Most surgeons require several preoperative blood and laboratory tests. These tests may include having a complete blood count and platelet count, kidney function test, screening test for bleeding tendency due to liver disease, fasting blood sugar, chest x-ray, and an EKG if the patient is over 45 (How To Schedule Your Surgery).

The core procedures for a male to female surgery include a vaginoplasty and a labiaplasty. These procedures are usually done at two separate times with the vaginoplasty being performed first and the labiaplasty being done at a later time. A vaginoplasty is performed under general or spinal anesthesia. During this procedure, the surgeon removes both testicles as well as the erectile tissue of the penis. A vaginal space is then created below the urethra. In order to eliminate the need for skin grafts, the patient's penile skin is used to line the vaginal vault. The clitoris is formed from the glans of the penis. By keeping the nerves that supply the glans intact, the doctor can create a sensate clitoris. A small portion of the patient's scrotum is then used to fashion the labia. When the procedure is complete, the surgeon places a cotton stent into the vagina which is to stay in place for five to six days. After the removal of the stent, the patient is instructed to begin gently dilating their vagina at least four times a day for the first month. Dilation of the vagina is a very important part of vaginoplasty postoperative care. If the patient fails to dilate, their vagina will narrow and collapse. A urinary catheter is left in place for eight days following the surgery. Once it is removed, the patient will be able to urinate while sitting. A labiaplasty may be done as soon as three months following the vaginoplasty surgery. Although this operation is not required, some patients do prefer to have it. The purpose of a labiaplasty is to better shape the labia and other areas of the newly created vagina. A labiaplasty is an outpatient procedure and is done under local anesthesia (MTF FTM 1). Patients experience swelling in the first three to four days following the surgery, which gradually disappears over the next couple of weeks (Cosmetic Surgery Labioplasty 1). The most serious complication associated with male to female reassignment surgery is rectovagina fistula. This is when a hole develops between the colon and the vagina. Other risks and complications include infection, a short vagina, pulmonary thromboembolism, and extensive bleeding (SRS: Sex Reassignment Surgery). Many MTF's undergo additional cosmetic procedures. These procedures may include electrolysis to remove facial and body hair, breast augmentation, Adams Apple reduction, hair transplantation, liposuction, and many types of facial surgeries (Transgender Health 1).

Female to male surgery is much more invasive and has achieved lesser success compared to MTF. This is because it is extremely difficult to create a functioning penis from the small clitoral tissue that is available in the female genitals (Sex Reassignment Surgery 1). A mastectomy, removal or reduction of the breasts, is the most common type of female to male sexual reassignment surgery. The surgeon removes the patient's breast by making a small incision near the nipple and removing most of the tissue and fat from under the skin (Transgender Health). Risks and complications associated with a mastectomy include prominent scarring on the chest, partial or total loss of sensation in the nipple, and puckering along the scars (Risks of Bilateral Mastectomy Mastectomy FTM).

Genital reconstruction or "bottom surgery" for FTM's falls into two basic types: phalloplasty and metoidioplasty. Free tissue flap transfer is a more contemporary phalloplasty technique. This technique involves the surgeon transferring a flap of skin and muscle tissue from the patient's forearm, groin, or thigh with its existing nerves and blood vessels to the patient' groin area. The surgeon then microsurgically connects the nerves and blood vessels of the skin flap to the nerves and blood vessels of the groin. This type of phalloplasty allows the penis to have feeling, but the penis is not capable of achieving or sustaining an erection. Implants are available which would allow the patient to achieve an erection, but they have proven to be problematic in causing infections, being rejected by the patient's body, and extrusion and intrusion. The length of hospital stay following phalloplasty is about ten to fourteen days. Metoidioplasty is the alternative to phalloplasty. This technique transforms the clitoris into a more male looking structure by releasing the clitoris. In order for the clitoris to be released, the surgeon will cut the ligaments that hold it in place. The surgeon will also form a scrotum during this procedure. This is achieved by joining the labia majora and using silicone testicular implants. Metoidioplasty creates a quite small penis but it is normal in appearance and has natural glands and foreskin. (FTM Genital Reconstruction 1). Metoidoplasty surgery normally lasts about three to five hours and the recovery time consists of very limited activity for the next two to four weeks (FTM Resource Guidev ). Risks and complications associated with FTM genital reconstruction may include a less than anticipated length, torquing of the clitoris, sensation loss, tissue necrosis, localized infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening, narrowing of the urethral, urethral obstruction, and urethral fistula (Female to Male Gender Reassignment Genital Surgery 1). In addition, some FTM's may also have vaginectomies or hysterectomies, and rarely do FTM's require any additional cosmetic procedures.

Sexual reassignment surgery is the last resort in treating someone who is suffering from gender dysphoria. A person wanting to undergo this type of procedure has to go through a long process of mental and physical evaluations. It is important they understand that the procedure is quite costly and most importantly that it is irreversible.

Works Cited

Sex Reassignment Surgery. http://www.healthline.com/galecontent/sex-reassignment-surgery

SRS: Sex Reassignment Surgery. http://www.doctorsaran.com/procedure.php?cat_id=3&procedure_id=23

How To Schedule Your Surgery. http://www.chet-plasticsurgery.com/scheduling.html

Genital Reassignment Clinic. http://www.ramhospital.com/GenderDisorderClinic.htm

MTF FTM. http://www.tmeltzer.com/procedures/mtf.shtml#vaginoplasty

Cosmetic Surgery Labioplasty. http://www.cosmeticsurg.net/procedures/Labioplasty.php

FTM Genital Reconstruction. http://www.health24.com/sex/SexEtc/1253-2427-2518-2608,32556.asp

FTM Resource Guide. http://www.ftmguide.org/grs.html#meta

Female to Male Gender Reassignment Genital Surgery. http://www.srsmiami.com/FTM-female-to-male.html

Risks of Bilateral Mastectomy Mastectomy FTM. http://www.steadyhealth.com/risks_of_bilateral_mastectomy_ftm_t67728.html

Transgender Health. http://www.lgbthealthchannel.com/transgender/surgery.shtml

The Harry Benjamin International Gender Dysphoria Association Standards of Care for Gender Identity Disorders, 6th ed. http://www.wpath.org/Documents2/socv6.pdf