Gender Reassignment Surgery Post Op

Below is an overview of the instructions you will receive when you leave the hospital, and will answer many of your questions about post-operative care and dilation.  As ever, please contact us with any questions!

Discharge instructions:

You will be leaving Mills-Peninsula Hospital today. You should be reasonably mobile, able to walk short distances and not in a great deal of pain. About half our patients are off heavy pain medication by the time of discharge. However, you may seek to have wheelchair assistance out to your transportation. Everyone heals at a different pace, so ask for help if you need it. We want you to be confident when you are out of direct patient care. All patients are free to contact Dr. Bowers by text  or call, of course, if need be.

The DRAIN TUBE is thin but removed on your last day in the hospital just prior to discharge. There remains VAGINAL PACKING soaked with antibiotic gel (Metrogel)  inside you and a FOLEY CATHETER for urine drainage. Nursing will meet with you with an actual foley catheter to teach you the finer points of Foley catheter care for the remaining 3 days you will have the thing in your bladder. Your responsibility will be to simply empty the bag when it is full. DON’T BE AFRAID OF YOUR FOLEY–IT IS YOUR FRIEND. If it bothers you, adjust it. Sometimes the foley gets pulled down. If it pulls down, it can hurt so push it back up! The catheter is secured to your inner thigh via the “stat lock” and should be placed so that it is secure, projects forward and is not under tension.  There are 2 bags and you should go home with both–the BIG BAG for overnight and the LEG BAG for hiding it under clothing while out and about. An outing is possible (2 – 3 hours) into the city or to Half Moon Bay or Stanford or Hillsdale Malls although your activity should consist mostly of short walks, visits for food and drink, and bathroom responsibilities.

You will be given dilators, lubrication, Neosporin and pads. Apply Neosporin to each incision (on the sides and in the middle) whenever you change your pad–it shouldn’t be often, just a few times per day.  When you come back for your follow up visit (already scheduled), you will be seeing Erika or Karen, who will help you to learn all aspects of your post op dilation duties and take your questions. On Mondays, Dr. Bowers likes to see you as well. If you wish to see her more formally during this week, you may do so by scheduling an additional appointment. Dr. Bowers is often in surgery so have patience here. In general, if all is well, another visit is not mandatory. We like you to remain in the area for at least two-three nights after packing removal/dilation in case there are any issues with the initial dilating experience. You also must pee on your own–rarely, swelling of surgical tissues can make this difficult and reinsertion of a catheter would be necessary. Be certain that you are comfortable dilating prior to leaving the Bay Area!

Complications

Complications during your first week are quite rare but could include bleeding.There is also some blood noted occasionally when removing the foley catheter. In general, pressure on whatever seems to be bleeding is all it takes to stop the problem. There is naturally some oozing of old, darker blood from the incision sites as well as discharge of varying colors, mostly yellowish to blood-tinged. A gush of blood would prompt a call to Dr. Bowers  although this is rare.

Swelling takes weeks to months to go down and patience here is the rule. Undies, yoga shorts or other tight-fitting garments can help to bring the swelling down–often by the time you return for packing removal.

Bowel function usually returns sometime late in your hospital stay or over the first few days after discharge as appetite returns and effects from the anesthesia and pain medications lessen. If you have not had a bowel movement by the time of packing/dilation, please let the office know. A diet high in fruits, vegetables and fiber is recommended during the first few weeks following surgery. Meat is ok, less dairy initially is better and do limit cheese intake.

Other potential but rare complications could include fever (greater than 101 degrees), swelling or excess pain and any of these could prompt a call to the office or any of us at our contact cell numbers (see below). Texting is great, particularly while Dr. Bowers is in surgery. Wound separation remains the most common (10%) problem. You should let us know if this happens as it will require closer follow up with our office. Fortunately, this complication heals itself, normally without intervention beyond keeping the area clean and dry. It can hurt though. Most important, CONTINUE TO DILATE. Following showers, pat the area dry and consider using a hair dryer. Granulation tissue (7%) is also fairly common and often follows wound separation. It is the body trying to heal itself but hurts and bleeds when touched. It can be very frustrating. Primary doctors treat this with silver nitrate but is best excised with scissors, then treated with silver nitrate.

Vaginal discharge is expected following surgery although it should not turn green. If this happens, the addition of stronger or new antibiotics could be necessary until your own bacterial flora has established itself. Metrogel, used as a dab at the beginning of each dilation session could be helpful here prescribed as a new prescription.

Follow-up

Follow up at any time while you are in the Bay Area following surgery is possible. We like to see that you are doing well and are happy! Once you have returned home though, it is ideal to see your primary care doctor one month following surgery or sooner, if needed. The best doc to arrange this with is the doctor you have had an ongoing relationship with. They are the most likely doctor who will want to see you, including your surgical site. A local gynecologist or plastic surgeon are also good doctors to see, if preferred. They are also free to call Dr. Bowers if there are any concerns.

Long term follow up is also important and can include a pap smear (if sexually active with men especially) one year after surgery and then at a frequency similar to that of a natal woman who has had a hysterectomy (every 3 – 5 years). A speculum examination at one year minimum is strongly advised. This can detect granulation tissue or areas that have not fully healed, on occasion. Vaginal hair is possible but is normally minimal if present. Granulation tissue is fleshy and red and bleeds easily. If bleeding is experienced 6 months or more after surgery, see your doctor (or one of us) who can take a look. Whether present on the outside or on the inside, granulation tissue is easily treated with a combination of excision of the tissue in the office followed by local application of silver nitrate to the base. The treatment hurts but works immediately. But more often than not the results internally are as stunningly positive as they are on the outside. Mammography is recommended on an age-related basis. Prostate examination is best directed via the vagina (the prostate lies in front of the neovagina). The rectum needs examination also but not as the nearest portal to the prostate anymore! A PSA remains controversial for all male borns but can be helpful if near zero (as it should be) one year following GRS. So long as you remain on estrogen, the prostate should remain virtually non-existent and at low risk for cancer. Hormone dosing is usually less than what was recommended as a pre-op. Often this is half the pre-op dose. Our office prefers use of bioidentical hormones such as estradiol, which is the predominant estrogen normally produced in adult women. 2 mg of Estradiol daily is a typical post op dose. Progesterone is recommended for those who wish to cycle their hormones as would a premenopausal woman. Thus, progesterone (Prometrium 200 mg) is normally prescribed for two weeks on and then 2 weeks off.

Sexual activity

Sexual activity resumption is recommended for those at least 12 weeks out from surgery. Earlier friskiness is possible anecdotally although not endorsed by our office. Orgasm should be an expectation of each and every patient. Keep in mind though that the clitoris is derived from the head of the penis. This area is extremely sensitive and most find it annoyingly so. There can be numbness to the area initially but, again, the arousable areas most likely to lead to an orgasm are probably not the clitoris itself. Orgasm is a complex and complicated combination of sensory inputs and imagination that make it happen. So be inventive and open minded! Each patient of Dr. Bowers will also have the much coveted “B-spot” which is the direct counterpart of the natal female “G-spot”. The B-spot is the erectile tissue surrounding the internal urethra which now lies immediately in front of the vaginal wall just beneath the bladder, just as it is in any cis-gender female. Dilating may never be fun for some although with this “b-spot” discovery and its entirely new sensory input, you should find penetration at least interesting. Be patient and persistent! Up to one year may be necessary before rediscovering that ‘killer orgasm’ although with a female hormonal composition, we  say, “Meeeoooooow!”

Excitation and climax may result in a good amount of secretions from the connections to the prostate, seminal vesicle and cowper’s glands. These behave much like their female homologues. Actual vaginal lubrication is reported by patients but  is not as likely due to the nature of vaginal lubrication which is a result of a watery transudate across the walls of the natal vagina. Needing to use lubrication during penetration is the expectation. We recommend thicker, water-based lubricants such as Surgilube and K-Y or Wet. Let us know if you find others that work for you that we can recommend to others! The peritoneal lining grafting (available only in New York) is an exciting advance but currently experimental and utilized only for patients needing re-lining of the vagina.

Exercise

Physical activity and exercise is recommended as soon as healing has finalized, usually no sooner than 3 – 4 weeks after surgery. Start slowly though and use common sense. Lifting is limited to ten pounds or less for ten days. Driving is discouraged for the first ten days as well. Full activity such as bicycling, motorcycle, rollerblading, skydiving or horseback riding should be reserved until fully healed, usually by 12 weeks out. Hot tubs and swimming are also discouraged until 12 weeks post op.

Final appearance

Final appearance should really begin to take shape approximately 12 weeks following GRS. At times, it can take longer. Certainly, swelling, firmness and numbness will lessen over the course of one year and beyond. 12 weeks tho is the big milestone. If things aren’t looking like you had hoped in any way, bring this up with our office and Dr. Bowers as this can be a time when planning a second surgery is reasonable. Secondary labiaplasty can always be helpful in lessening scars, adding symmetry, straightening urine flow or improving labia definition but are rarely necessary (1 in 18). Many surgeons perform the labiaplasty routinely but we hold ourselves to labiaplasty only as an exception to the ONE STAGE expectation.

Above all, take care of yourself. Love yourself and you will be loved. Be patient, be kind but be yourself. Let us know how you do. We really do care.

Dilation Instructions – You will receive this information while you are in the hospital.  Please familiarize yourself with these instructions before your follow up appointment, six days after surgery.

Dilation Process

At rest, the vaginal walls of all women, cis and trans, lie exposed to one another. Dilation is a necessary process for trans women who lack the constant sloughing and lubrication that accompanies a natal vagina and keeps it from annealing together when at rest. There is also a tendency of the neovaginal graft to contract. Dilation allows the depth and diameter of the neovagina to remain adequate. The frequency of dilation recommended in our office is once 3 times daily for 15 minutes at a time for 3 months, then twice daily for 9 months, then once daily thereafter. Intercourse is a suitable but imperfect replacement for dilation. Thus, regardless of sexual activity, dilation is recommended. It is also true that after one year, dilation becomes slightly less necessary and many—but not all—patients are able to go to a frequency of less than once per day without losing depth or diameter. Once you have established depth as a recent post-op, mark the dilator and use that permanent marking as a reference point. The dilators also have dots that equate to ½ inch increments up to 9 inches in length (please don’t faint–most depth averages about 6 inches). Girth of the dilators range from 1 ⅛ to 1 ½  in size from small (#1) to large (#4) . In future sessions, these dots can be used as references to assure that depth is maintained.

Dilators are medical instruments and, for that reason alone, must be handled with care and respect. Injuries have occurred with improper use. Take this process seriously as it is the absolutely most critical aspect of your postoperative care! Dilators are assigned based upon an assessment of diameter at the time of surgery by your surgeon. The sets are labeled ‘large’ and ‘small’ but these are misnomers as the sets have significant overlap. The large set (#2, 3, 4) is only a notch larger than the small (#1,2, 3). Both sets are plenty large and more than adequate for suitable dilation and/or sexual function. The neovaginal tissue can stretch and some patients are able or desire a larger diameter dilator. Similarly, if patients prefer to start with a smaller dilator, smaller sizes are available via our supplier, Soulsource Enterprises at soulsourceenterprises.com. Each dilator is tapered with a slight curve to the ends. When dilating, the curves should be directed upwards to allow the tip to glide beneath the pubic bone with pressure always away from the rectum. 

Start dilating by laying a towel on your bed. Get comfortable with pillows but lay flat on your back. You may boost your head up slightly but no more than 15 degrees elevation—-the reason for this is that lying flat allows the rectum (which is very closely approximated to the vagina, lying just in front) to fall away from the new vagina. We do NOT want to injure the rectum while dilating. A mirror may also be helpful. Use plenty of lubrication but, upon placing the first dilator, apply a small dollup of Metrogel. Metrogel is a vaginal antibiotic that helps to suppress ‘bad’ bacteria and allow a more normal (almost cis!) bacterial balance to be established. This is particularly true in the first 6-12 weeks following surgery. Metrogel is not necessary—except to treat bacterial vaginosis (bad smell due to bacterial imbalance)—once you have finished the initial tube prescribed to you at the time of surgery.

When initiating the dilation process, entering the vagina may require a slight downward direction to the tip but generally, the direction of the tip should be upwards towards the belly button as you move from outside to inside. First goal is to establish depth—do that with the smaller of the dilators but the largest you feel comfortable with. The second goal of dilation is to progressively move up in size to stretch and establish the diameter of the vagina. A slight back-and-forth twist as you advance the dilator is helpful. Re-lubing is also useful and may prevent the feeling of a suction type effect as you remove the dilator. Generally, we prefer a water-based, thick lubricant like Surgilube as opposed to watery lubricants more popular in sex. But feel free to experiment! Following dilation, wash each dilator with soap and water and return each to the original pouch.

Dilation is essential. Do not neglect this duty to your new anatomy. In time, penetrative sex can be a substitute for dilation but even then, occasional dilation is recommended to “check in”. Particularly after 18 months, a lesser frequency of dilation is possible. If you choose not to dilate altogether, consider this carefully. The area will eventually scar closed to some extent, which may require surgery to recover. The consequences of not dilating are also uncertain.

For specialized articles on surgical procedures, see Sex reassignment surgery (male-to-female) and Sex reassignment surgery (female-to-male).

Sex reassignment surgery or SRS (also known as gender reassignment surgery, gender confirmation surgery, genital reconstruction surgery, gender-affirming surgery, or sex realignment surgery) is the surgical procedure (or procedures) by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble that socially associated with their identified gender. It is part of a treatment for gender dysphoria in transgender people. Related genital surgeries may also be performed on intersex people, often in infancy. A 2013 statement by the United NationsSpecial Rapporteur on Torture condemns the nonconsensual use of normalization surgery on intersex people.[1][2]

The American Society of Plastic Surgeons (ASPS) calls this procedure Gender Confirmation Surgery or GCS.[3][4] Another term for SRS includes sex reconstruction surgery, and more clinical terms, such as feminizing genitoplasty or penectomy, orchiectomy, and vaginoplasty, are used medically for trans women, with masculinizing genitoplasty, metoidioplasty or phalloplasty often similarly used for trans men.

People who pursue sex reassignment surgery are usually referred to as transsexual (derived from "trans", meaning "across", "through", or "change", and "sexual", pertaining to the sexual characteristics—but not necessarily sexual actions—of a person).

While individuals who have undergone and completed SRS are sometimes referred to as transsexed individuals,[5] the term transsexed is not to be confused with the term transsexual, which may also refer to individuals who have not undergone SRS, yet whose anatomical sex may not match their psychological sense of personal gender identity.

Sex reassignment surgery performed on unconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case, following a botched circumcision) when the individual's sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed.[6][7][8]Milton Diamond at the John A. Burns School of Medicine, University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent, assign such infants in the gender to which they will probably best adjust, and refrain from adding shame, stigma and secrecy to the issue, by assisting intersexual people to meet and associate with others of like condition. Diamond considered the intersex condition as a difference of sex development, not as a disorder.[9][10]

Scope and procedures[edit]

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery (GRS)- 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". 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."[11] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial electrolysis.

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).[12] 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."[13] Other organizations have issued similar statements, including WPATH,[14] the American Psychological Association,[15] and the National Association of Social Workers.[16]

Different SRS procedures[edit]

The array of medically indicated surgeries differs between trans women (male to female) and trans men (female to male). For trans women, genital reconstruction usually involves the surgical construction of a vagina, by means of penile inversion or the sigmoid colon neovagina technique; or, more recently, non-penile inversion techniques that provide greater resemblance to the genitals of cisgender women. For trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty. For both trans women and trans men, genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy.

As underscored by WPATH, a medically assisted transition from one sex to another may entail any of a variety of non-genital surgical procedures, any of which are considered "sex reassignment surgery" when performed as part of treatment for gender identity disorder. For trans men, these may include mastectomy (removal of the breasts) and chest reconstruction (the shaping of a male-contoured chest), or hysterectomy and bilateral salpingo-oophorectomy (removal of ovaries and Fallopian tubes). For some trans women, facial feminization surgery, hair implants, and breast augmentation are also aesthetic components of their surgical treatment.

[edit]

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 transsexuals solely on the basis of their HIV or hepatitis status.[17]

Other health conditions such as diabetes, abnormal blood clotting, ostomies, and obesity do not usually present a problem to experienced surgeons. The conditions do increase the anesthetic risk and the rate of post-operative complications. Surgeons may require overweight patients to reduce their weight before surgery, any patients to refrain from hormone replacement before surgery, and smoking patients to refrain from smoking before and after surgery. Surgeons commonly stipulate the latter regardless of the type of operation.

Potential future advances[edit]

See also: Transgender pregnancy, Uterus transplantation § Application on transgender women, and Male pregnancy § Humans

Medical advances may eventually make childbearing possible by using a donor uterus long enough to carry a child to term as anti-rejection drugs do not seem to affect the fetus.[18][19][20][21] The DNA in a donated ovum can be removed and replaced with the DNA of the receiver. Further in the future, stem cell biotechnology may also make this possible, with no need for anti-rejection drugs.

Standards of care[edit]

See also: Legal aspects of transgenderism

Sex reassignment surgery can be difficult to obtain, due to a combination of financial barriers 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 Transsexual, Transgender, and Gender Nonconforming 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 transsexualism. For many individuals, these 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 genital reconstruction or other sex reassignment surgeries are permitted.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment for transsexualism, including accessing cross-gender hormone replacement or many surgical interventions. For this and many other reasons, both the WPATH-SOC and other SOCs are 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.

Most 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, 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.[22][23]

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required in order for transsexual individuals to change sex designation on identity documents.[24] 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.

Quality of life and physical health[edit]

Patients of sex reassignment surgery may experience changes in their physical health and quality of life, the side effects of sex steroid treatment. Hence, transgender people should be well informed of these risks before choosing to undergo SRS.[5]

Several studies tried to measure the quality of life and self-perceive physical health using different scales. Overall, transsexual people have rated their self-perceived quality of life as ‘normal’ or ‘quite good’, however, their overall score was still lower than the control group.[25] Another study showed a similar level of quality of life in transsexual individuals and the control group.[26] Nonetheless, a study with long-term data suggested that albeit quality of life of patients 15 years after sex reassignment surgery is similar to controls, their scores in the domains of physical and personal limitations were significantly lower.[5][27] On the other hand, research has found that quality of life of transsexual patients could be enhanced by other variables. For instance, trans men obtained a higher self-perceived health score than women because they had a higher level of testosterone than them. Trans women who had undergone face feminization surgery have reported higher satisfaction in different aspects of their quality of life, including their general physical health.[28]

Looking specifically at transsexual’s genital sensitivities, trans men and trans women are capable of maintaining their genital sensitivities after SRS. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexual individuals to avoid unnecessary harm or injuries to the genitals, allowing trans men to obtain an erection and perform the insertion of the erect penile prosthesis after phalloplasty,[29] the ability for transsexual to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS[29][30] Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasms after phalloplasty is to preserve both the clitoris hood and the clitoris underneath the reconstructed phallus.[29][30]

Erogenous Sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.[29] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,[31][5] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

Psychological and social consequences[edit]

This article or section appears to contradict itself. Please see the talk page for more information.(April 2016)

After sex reassignment surgery, transsexuals (people who underwent cross-sex hormone therapy and sex reassignment surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression and hostility levels were lower after sex reassignment surgery.[32] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction.[31] Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing sex reassignment surgery.[33]

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences,[34] It has been suggested that most studies investigating the outcomes of sex reassignment surgery are flawed as they have only included a small percentage of sex reassignment surgery patients in their studies.[35] These methodological limitations such as lack of double-blind randomised controls, small number of participants due to the rarity of transsexualism, high drop-out rates and low follow-up rates,[36] which would indicate need for continued study.

Persistent regret can occur after sex reassignment surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide.[37] During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours.[38] The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals.[39] The hostile environment may trigger or worsen internalised transphobia, depression, anxiety and post-traumatic stress.[40]

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.[38] Therefore, it is suggested that psychological support is crucial for patients after sex reassignment surgery, which helps them feel accepted and have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier sex reassignment surgery process.[38]

Sexual satisfaction[edit]

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery.[5] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.[5] Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were frigid and not enthusiastic about engaging in sexual activity. In consequence, transsexuals individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.[5]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.[5] The ability to obtain orgasms is positively associated with sexual satisfaction.[31] Frequency and intensity of orgasms are substantially different among transsexual men and transsexual 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,[5][41] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.[42] A study found that both transmen and transwomen reported that they had experienced transformation in their orgasms sensuality. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements while male-to-female individuals have been encountering longer and more gentle feelings.[5]

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.[31][5][43] 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[5] 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.[31]

Concerning transsexuals’ 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).[43] When comparing transsexuals with biological individuals of the same gender, trans women had a similar sexual satisfaction to biological women, but trans men had a lower level of sexual satisfaction to biological men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.[31]

At birth[edit]

Main article: Sex assignment § Assignment in cases of infants with intersex traits, or cases of trauma

Infants born with intersex conditions might undergo interventions at or close to birth.[44] This is controversial because of the human rights implications.[45][46]

Society and culture[edit]

The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.[47] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".[47] Eshaghian's documentary, Be Like Others, chronicles a number of stories of Iranian gay men who feel transitioning is the only way to avoid further persecution, jail, or execution.[47] The head of Iran's main transsexual organization, Maryam Khatoon Molkara—who convinced Khomeini to issue the fatwa on transsexuality—confirmed that some people who undergo operations are gay rather than transsexual.[48]

Thailand is the country that performs the most sex reassignment surgeries, followed by Iran.[48]

India is offering affordable sex reassignment surgery to a growing number of medical tourists.[49]

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.[50]

History[edit]

In Berlin in 1931, Dora Richter, became the first known transgender woman to undergo the vaginoplasty[51] surgical approach.

This was followed by Lili Elbe in Dresden during 1930–1931. She started with the removal of her original sex organs, the operation supervised by Dr. Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an unsuccessful uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[52] but their identity is unclear at this time.

On 12 June 2003, the European Court of Human Rights ruled in favor of 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.[53]

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".[54]

As of 2017 some European countries, mostly eastern, require forced sterilisation for the legal recognition of sex reassignment.[55]

See also[edit]

References[edit]

  1. ^Report of the UN Special Rapporteur on Torture, Office of the UN High Commissioner for Human Rights, February 2013.
  2. ^Center for Human Rights & Humanitarian Law; Washington College of Law; American University (2014). Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture's 2013 Thematic Report. Washington, DC: Center for Human Rights & Humanitarian Law. 
  3. ^"Gender Confirmation Surgeries". American Society of Plastic Surgeons. Retrieved 2017-08-07. 
  4. ^"About ASPS". American Society of Plastic Surgeons. Retrieved 2017-08-07. 
  5. ^ abcdefghijklDe Cuypere, G.; TSjoen, G.; Beerten, R.; Selvaggi, G.; De Sutter, P.; Hoebeke, P.; Monstrey, S.; Vansteenwegen, A.; Rubens, R. (2005). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior. 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. PMID 16362252. 
  6. ^Boyle, G.J.(2005). The scandal of genital mutilation surgery on infants (pp. 95-100). In L. May (Ed.), Transgenders and Intersexuals, Bowden, South Australia: Fast Lane (imprint of East Street Publications). ISBN 1-9210370-7-5ISBN 9-780975-114544
  7. ^Colapinto, J. (2002). As Nature Made Him: The Boy Who Was Raised as a Girl. Sydney: Harper Collins Publishers. ISBN 0-7322-7433-8ISBN 9-780732-274337
  8. ^"Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up". Milton Diamond, Ph.D. Retrieved 1 August 2011. 
  9. ^Diamond, Milton; Sigmundson, H. Keith (October 1997). "Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia". Arch Pediatr Adolesc Med. 151 (10): 1046–50. doi:10.1001/archpedi.1997.02170470080015. PMID 9343018. Retrieved 24 April 2013. 
  10. ^Diamond, Milton; Beh, Hazel. (2008). "Changes In Management Of Children With Differences Of Sex Development". Nature Clinical Practice Endocrinology & Metabolism. 4 (1): 4–5. 
  11. ^see WPATH "Clarification on Medical Necessity of Treatment, sex Reassignment, and Insurance Coverage in the U.S." available at: "Archived copy"(PDF). Archived from the original(PDF) on 2011-09-30. Retrieved 2011-10-07. 
  12. ^See discussion of insurance exclusions at: http://www.hrc.org/issues/transgender/9568.htm
  13. ^AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf
  14. ^See WPATH Clarification Statement
  15. ^APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf
  16. ^NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
  17. ^See WPATH Standards of Care, also WPATH Clarification. www.wpath.org
  18. ^Doctors plan uterus transplants to help women with removed, damaged wombs have babies. Associated Press.
  19. ^Fageeh, W.; Raffa, H.; Jabbad, H.; Marzouki, A. (2002). "Transplantation of the human uterus". International Journal of Gynecology & Obstetrics. 76 (3): 245–251. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127. 
  20. ^Del Priore, G.; Stega, J.; Sieunarine, K.; Ungar, L.; Smith, J. R. (2007). "Human Uterus Retrieval From a Multi-Organ Donor". Obstetrics & Gynecology. 109 (1): 101–104. doi:10.1097/01.AOG.0000248535.58004.2f. PMID 17197594. 
  21. ^Nair, A.; Stega, J.; Smith, J. R.; Del Priore, G. (2008). "Uterus Transplant: Evidence and Ethics". Annals of the New York Academy of Sciences. 1127 (1): 83–91. Bibcode:2008NYASA1127...83N. doi:10.1196/annals.1434.003. PMID 18443334. 
  22. ^"Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People"(PDF). Archived from the original(PDF) on September 20, 2012. Retrieved 2013-10-31. 
  23. ^"WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Retrieved 2014-08-11. 
  24. ^See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
  25. ^Gómez-Gil, Esther; Zubiaurre-Elorza, Leire; Antonio, Isabel Esteva de; Guillamon, Antonio; Salamero, Manel (2013-08-13). "Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery". Quality of Life Research. 23 (2): 669–676. doi:10.1007/s11136-013-0497-3. ISSN 0962-9343. PMID 23943260. 
  26. ^Castellano, E.; Crespi, C.; Dell’Aquila, C.; Rosato, R.; Catalano, C.; Mineccia, V.; Motta, G.; Botto, E.; Manieri, C. (2015-10-20). "Quality of life and hormones after sex reassignment surgery". Journal of Endocrinological Investigation. 38 (12): 1373–1381. doi:10.1007/s40618-015-0398-0. ISSN 1720-8386. PMID 26486135. 
  27. ^Kuhn, Annette; Bodmer, Christine; Stadlmayr, Werner; Kuhn, Peter; Mueller, Michael D.; Birkhäuser, Martin (2009). "Quality of life 15 years after sex reassignment surgery for transsexualism". Fertility and Sterility. 92 (5): 1685–1689.e3. doi:10.1016/j.fertnstert.2008.08.126. PMID 18990387. 
  28. ^Ainsworth, Tiffiny A.; Spiegel, Jeffrey H. (2010-05-12). "Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery". Quality of Life Research. 19 (7): 1019–1024. doi:10.1007/s11136-010-9668-7. ISSN 0962-9343. PMID 20461468. 
  29. ^ abcdSelvaggi, G., Monstrey, S., Ceulemans, P., T'Sjoen, G., De Cuypere, G., & Hoebeke, P. (2007). "Genital sensitivity after sex reassignment surgery in transsexual patients". Annals of Plastic Surgery. 58 (4): 427–433. doi:10.1097/01.sap.0000238428.91834.be. PMID 17413887. 
  30. ^ abHage, J. J., Bouman, F. G., De Graaf, F. H., & Bloem, J. J. (1993). "Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience". The Journal of Urology. 149 (6): 1463–1468. doi:10.1016/S0022-5347(17)36416-9. PMID 8501789. 
  31. ^ abcdefWierckx, K.; Van Caenegem, E.; Elaut, E.; Dedecker, D.; Van de Peer, F.; Toye, K.; Hoebeke, P.; Monstrey, S.; De Cuypere, G.; T’Sjoen, G. (2011). "Quality of life and sexual health after sex reassignment surgery in transsexual men". The Journal of Sexual Medicine. 8 (12): 3379–3388. doi:10.1111/j.1743-6109.2011.02348.x. PMID 21699661. 
  32. ^Smith, Y. L. S.; Van Goozen, S. H. M.; Cohen-Kettenis, P. T. (2001). "Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study". Journal of the American Academy of Child & Adolescent Psychiatry. 40 (4): 472–481. doi:10.1097/00004583-200104000-00017. 
  33. ^Lawrence, A. A. (2003). "Factors associated with satisfaction or regret following male-to-female sex reassignment surgery". Archives of Sexual Behavior. 32 (4): 299–315. doi:10.1023/A:1024086814364. PMID 12856892. 
  34. ^Monstrey, S.; Vercruysse Jr., H.; De Cuypere, G. (2009). "Is Gender Reassignment Surgery Evidence Based? Recommendation for the Seventh Version of the WPATH Standards of Care". International Journal of Transgenderism. 11 (3): 206–214. doi:10.1080/15532730903383799.

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