The Controversy About Gender Reassignment Surgery Will Likely Continue

Reproductive Medicine

Karel Claes , ... Stan Monstrey , in Encyclopedia of Reproduction (Second Edition), 2018

History of Transwomen Surgery

The development of modern gender reassignment surgery began in the twentieth century when, following rapid advances in the fields of endocrinology and plastic surgery after World War II, comprehensive medical and surgical treatments for transsexualism started to become available. In 1952, the Danish plastic surgeon Paul Fogh-Andersen initiated the modern era of sex reassignment surgery by using penile skin as a full thickness graft to line the neovagina of Christine Jörgenson ( Fogh-Andersen, 1956). In the United States, things began to change during the late 1950s, when several hundred transsexuals came under the care of Dr. Harry Benjamin, a compassionate endocrinologist who was the first physician to elucidate the nature of gender dysphoria (Benjamin, 1964).

For the majority of transsexuals seeking surgery, the 'Clinique du Parc' in Casablanca was the place of last resort. There, Dr. Georges Burou (1910–1987), a French gynecologist, invented and applied the anteriorly pedicled penile skin flap inversion technique in 1956 (Hage et al., 2007).

In 1966, surgeons at the Johns Hopkins Medical Center began performing a limited number of Male-to-Female (MtF) sex reassignment surgeries (SRS) at its new gender identity clinic. Shortly thereafter, hospitals at Stanford, Chicago and Colorado followed suit (Laub and Fisk, 1974; Pandya and Stuteville, 1973).

The surgeons at Johns Hopkins initially used partial thickness skin grafts to line the neovaginal cavity, but later used penile skin, applied as a full thickness skin graft, much as the technique employed in Copenhagen. The posteriorly pedicled penile skin flap inversion technique for vaginoplasty — a variation of Burou's method — was introduced by Edgerton and Bull at Johns Hopkins between 1968 and 1970 (Edgerton and Bull, 1970). Beginning in 1967, the Chicago group used the anteriorly pedicled penile skin flap to line the vagina, and scrotal skin to form the labia (Pandya and Stuteville, 1973).

In Europe, beginning in the 1970s, the University Hospital of the Free University of Amsterdam became the leading center for medical and surgical treatment of patients with severe gender dysphoria. By the end of the 20th century many centers of excellence employed a multidisciplinary approach for transsexual individuals, providing state of the art treatment, including surgical therapy, for both transwomen and transmen. With the recent increase in number of individuals seeking treatment for gender dysphoria, the quantity and the quality of the multidisciplinary teams has substantially increased worldwide with the largest number of vaginoplasties probably still being performed in Thailand.

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Transgender, gender non-conformity and transvestism

John Bancroft MD FRCP FRCPE FRCPsych , in Human Sexuality and Its Problems (Third Edition), 2009

Outcome of surgical gender reassignment

There have now been several reviews of the outcome of gender reassignment surgery ( Abramowitz 1986; Green & Fleming 1990; Pfafflin & Junge 1998; Carroll 1999) and their conclusions were summarized by Carroll (2007). Lawrence (2003) reported on 232 male-to-female surgical reassignments all carried out by one surgeon between 1994 and 2000. Using a 0–10 scale to rate happiness with result, 86% scored 8 or higher. None reported consistent regret about having the surgery, and any regret that was reported was about disappointment with the functional outcome of the genital reconstruction, rather than with the gender reassignment per se.

In spite of methodological limitations, there is overall consistency in the findings of improvement or a satisfactory outcome in 66% to 90% of cases, for both male-to-female and female-to-male reassignments. The greatest improvements were in self-satisfaction, interpersonal interaction and psychological well-being. The cosmetic results of the surgery were more variable, reflecting variability of skill among surgeons as well as improvements in relevant surgical techniques over the years. Sexual functioning is often impaired. Given the extent of overall satisfaction, this underlines the primary importance of gender identity over sexuality. Abramowitz (1986) found a poor outcome in around 8% of cases. Pfafflin & Junge (1998) reported that less than 2% regretted the surgery. In spite of the fact that the surgical possibilities for converting female genitalia to male are less than in the reverse direction, female to males showed a more positive psychosocial outcome than male to females (Pfafflin & Junge 1998). Apart from it being generally easier for female-to-males to pass effectively in their chosen gender, they also tended to have less mental health problems pre-surgery.

Those whose transgender emerged from a previous phase of fetishistic transvestism or autogynephilia were more likely to regret reassignment or have more negative outcomes than those whose gender identity discordance was primary. The reasons for this are not established. Predictors of a poor outcome are personality problems of various kinds and a history of depression.

In general, these more recent reviews convey a more positive picture than those cited in the previous edition of this book, which was based on much more limited evidence. This may reflect more effective selection of suitable cases by referring clinicians as well as improvements in surgical techniques.

Overall, there is strong support for gender reassignment improving the mental health and quality of life for both male-to-female and female-to-male transgendered individuals. However, surgical reassignment is only part of the reassignment process, and careful selection of those who are recommended for surgical reassignment is important and will be considered more closely in the following section.

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Case history-taking

Peter Conway Dip Phyt MNIMH MCPP Cert Ed , in The Consultation in Phytotherapy, 2011

Gender

This is usually obvious and doesn't need to be asked. However, transsexual (or transgender) people and people who have had gender reassignment surgery will usually prefer to be classed in their 'target' sex (i.e. the sex they perceive themselves as, or have undergone surgery to become, rather than the sex they were born as, which is known as the 'assigned' sex). To be respectful towards the patient and to avoid confusion, the practitioner can record the patient's target sex as their definitive sex and then in brackets show the 'assigned-to-target' sexes so that for a person who was born male but who self-identifies as a female, the note would be: Female (male-to-female). This can be alternatively written as: F (M2F).

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Reproductive Medicine

Ervin Kocjancic , Valerio Iacovelli , in Encyclopedia of Reproduction (Second Edition), 2018

Abstract

Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery.

Gender reassignment surgery represents one of many therapies for transgender individuals with gender dysphoria and it can be pivotal in allowing individuals to become their true selves. Surgical procedures for the natal female subject being affirmed as a male subject can include genital reconstruction often paired with a combination of other hormonal and surgical interventions. This paper represents an evolution of surgical techniques, as well as a framework around which surgical therapies are based to allow for these transformations. While techniques will continue to advance, an understanding of the surgical principles is fundamental to this process.

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Facial feminization surgery

Jeffrey Weinzweig , Stephen B. Baker , in Aesthetic Surgery of the Facial Skeleton, 2022

Introduction

Almost 40 years ago, Dr. Douglas Ousterhout pioneered the field of facial feminization surgery (FFS) when, in 1982, Dr. Darrell Pratt, a plastic surgeon who performed gender reassignment surgery (GRS), conveyed the request of a male-to-female transgender patient who wished to have more feminine facial features as people still reacted to her as though she were a man despite her GRS. That request opened the door to a new world in which techniques of transforming the larger, more angular male features to smaller, softer, more feminine female features evolved and progressed with the goal of matching one's external appearance with the internal perception of oneself.

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Sociocultural and Individual Differences

James N. Butcher , ... Moshe Almagor , in Comprehensive Clinical Psychology, 1998

(i) Australia

In addition to rating the adequacy of the information provided in the narrative reports, raters estimated the percentage of statements they considered to be accurate descriptions of their patients (Figure 1 ). Two-thirds (66%) of reports on Australian patients were rated as having 80–100% accuracy, while 87% were rated as having more than 60% accuracy. Only 2% were rated as having less than 20% accuracy. As noted above, a large number of patients in the study (46) were gender-dysphoric clients undergoing evaluation for possible gender reassignment surgery. It might be hypothesized that their inclusion may have lowered the overall adequacy and accuracy ratings because of possible attempts by these patients to present themselves in an overly positive manner. This was not the case. There was no significant difference between the ratings of gender-dysphoric and other patients on the symptomatic pattern (t(157) = −0.53), the interpersonal relations (t(157) = 1.14), the diagnostic considerations (t(156) = 1.79) and the treatment considerations (t(154)= 0.46) sections of the reports. With respect to the two other ratings, the reports on the gender-dysphoric patients were actually rated more positively than those of the other patients (validity considerations, t(165) = −2.84, p < 0.01; overall accuracy, t for unequal variances (110) = −2.15, p < 0.05).

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Care of Transgender/Gender Nonconforming Youth

Stephen M. Rosenthal , Amy B. Wisniewski , in Sperling Pediatric Endocrinology (Fifth Edition), 2021

Outcomes and Potential Adverse Effects

Limited outcomes data are available based on current treatment models. As noted earlier, one published study has thus far evaluated mental health in transgender adolescents/young adults before and after GnRH agonist treatment, following gender-affirming sex steroid treatment, and 1 year after "gender reassignment surgery." ⁶⁴ At the completion of the observation period, GD was resolved, general psychological functioning had improved, and a sense of "wellbeing" was observed to be equal or greater to that found in age-matched controls. In addition, none of the 55 study participants regretted treatment. ⁶⁴

Potential adverse effects of pubertal suppression with GnRH agonists in transgender youth, as recently reviewed, include impaired bone mineral density (BMD) and compromised fertility. In addition, there are unclear effects on brain development, body mass index (BMI), and body composition. ⁷⁹

With respect to skeletal health, a 6-year longitudinal study (that spanned the period of pubertal suppression, gender-affirming sex hormone treatment, and gonadectomy), observed a significant decrease in lumbar spine areal BMD z-scores (relative to natal sex) in transgender females, with a similar decrease, following pubertal suppression in transgender males. ⁸⁰ Potential study limitations, as acknowledged by the authors, included a relatively small number of study participants, relatively low doses of sex hormones, and lack of information regarding other factors that can influence BMD, including vitamin D status, dietary calcium intake, and weight-bearing exercise. ⁸⁰ During pubertal suppression with GnRH agonists in early pubertal transgender adolescents, it is recommended to monitor vitamin D status and supplement if necessary, and to encourage adequate dietary calcium intake and weight-bearing exercise. ²² In a separate study, bone turnover markers and bone mineral apparent density (BMAD) z-scores decreased, following GnRH agonist treatment in younger transgender adolescents, whereas an increase in BMAD was observed after 2 years of gender-affirming sex hormone treatment, in both younger and older transgender adolescents. ⁸¹ A 22-year follow-up study of a gender dysphoric adolescent, treated initially with GnRH agonist and subsequently with gender-affirming sex hormones, found that BMD was in the normal range for both sexes when evaluated at 35 years of age. ⁸²

A discussion about implications for fertility must precede any treatment of gender dysphoric adolescents with either GnRH agonists or gender-affirming sex hormones. Transgender adolescents may wish to preserve fertility, which will likely be compromised if puberty is suppressed at an early stage, and the individual subsequently transitions with gender-affirming sex hormones. In vitro maturation of human germ cells has not yet been achieved, although some families elect to freeze a section of prepubertal gonadal tissue for potential future use. ⁸³ Cryopreservation of mature sperm or eggs is an option for late pubertal/ fully pubertal adolescents. However, recent reports indicate that even when provided with counseling regarding potential impact of sex hormone treatment on fertility and options for fertility preservation, only a small percentage of such adolescents opted to pursue fertility preservation. ^84,85 Questionnaires to assess fertility and fertility preservation attitudes in transgender youth and their parents have been recently developed. ^86,87

With respect to brain function, few studies have thus far evaluated potential adverse effects of GnRH agonists in transgender adolescents. When comparing small groups of GnRH agonist-treated versus untreated transgender adolescents (both male-to female and female-to male), there was no significant compromise of executive functioning, a developmental milestone typically achieved during puberty. ⁸⁸ A 28-month longitudinal study in one transgender adolescent, undergoing treatment with GnRH agonist, showed lack of expected variation in white matter fractional anisotropy, a measure of brain maturation thought to normally occur during puberty, as well as a 9-point drop in operational memory testing after 22 months of pubertal suppression. ⁸⁹ Given this relative lack of data, further longitudinal studies are needed to assess the impact of GnRH agonist treatment on brain development and function in transgender adolescents.

Studies assessing the impact of GnRH agonist treatment on BMI and body composition have also been carried out. Although variable results have been observed with respect to BMI, ^80,90 an increase in fat percentage and a decrease in lean body mass percentage, after 1 year of treatment with GnRH agonist, have been reported in both transgender male and female adolescents. ⁹⁰ In a separate study, significant weight gain was reported in one of 27 transgender adolescents treated with GnRH agonist, although this individual's BMI was noted to be greater than the 85^th percentile before treatment. ⁹¹

A small number of short-term studies have thus far evaluated potential adverse effects of gender-affirming sex hormones in transgender adolescents. No change in blood pressure, BMI standard deviation score, lean body mass percentage, or fat percentage were observed in a study from the Netherlands of 28 transgender females treated for 1 to 3 years, primarily with gradually increasing doses of 17 β-estradiol. ⁹² In addition, no abnormalities were observed with liver enzymes or creatinine, and there was no change in hematocrit or hemoglobin A1c. Hyperprolactinemia was observed in one individual who had received high-dose ethinyl estradiol treatment to limit statural growth. ⁹²

Two studies from the United States have assessed potential adverse effects of gender-affirming sex hormones in transgender adolescents and young adults. Following treatment with 17 β-estradiol in 44 transgender females, no abnormalities were seen in blood pressure, BMI, hemoglobin/hematocrit, lipids, renal and liver function studies, or in prolactin. ⁹³ Following treatment with testosterone in 72 transgender males, there was an increase in BMI and in hemoglobin/hematocrit (supraphysiologic hematocrit levels were seen in 4% of the individuals) and a decrease in high-density lipoprotein cholesterol levels; no abnormalities were seen in blood pressure, renal and liver function studies, or in hemoglobin A1c. ⁹³ A separate prospective study, after 21 to 31 months of treatment with gender-affirming hormones in 25 transfeminine and 34 transmasculine individuals, showed no clinically significant adverse effects in a variety of metabolic parameters. ⁹⁴

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Advances in Pediatrics

Marni E. Axelrad PhD , ... Lefkothea P. Karaviti MD, PhD , in Advances in Pediatrics, 2009

The decision to perform gender reassignment surgery has become more complex in recent years. Historically, the consensus was that ambiguous genitalia, left uncorrected, would cause the patient unnecessary psychological distress. Hence, an immediate decision was made concerning the child's sex, and surgery was performed accordingly. Today, however, genital surgery is 1 of the most controversial decisions in managing patients with DSDs [59]. Many researchers and advocate groups question the earlier approach and advocate postponing surgery until the patient can be involved in making the decision [60,61]. Numerous arguments have been posited to delay feminizing genital surgery in young children. One such argument is that many patients require further surgery in adolescence [62]; another is that ablative surgery, such as clitoroplasty and clitorectomy, may impair later sexual function [63,64]. Some activist groups also argue strongly against performing surgery, charging that cosmetic genital surgery on infants with DSDs violates their human rights and subordinates the value of sexual pleasure or notions of heterosexual normality [65], whereas others have challenged their position [66].

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Genital reconstruction for the transgendered individual

Marta R. Bizic , ... Miroslav L. Djordjevic , in Journal of Pediatric Urology, 2017

Metoidioplasty

Metoidioplasty is a technically demanding and challenging surgical procedure used in female transsexuals who want gender reassignment surgery without a complex, multistaged surgical creation, of an adult-size phallus [3,10]. The native female urethra is lengthened to reach the tip of the glans, as in males, allowing voiding while standing, and the scrotum is created from the labia majora with two inserted testicular prostheses.

A new type of genital reconstruction in female transgenders using the hormonally enlarged clitoris was first reported by Durfee and Rowland [11]. The term metoidioplasty was introduced later by Laub et al. [12] deriving from Greek words "meta" meaning "toward" and "oidion" meaning "male genitalia". They defined the procedure as a creation of a small neophallus, insufficient for penetrative sexual intercourse but with the ability of voiding while standing in the majority of subjects operated on and reported good results in the appearance of external genitalia, with a more male-like configuration. In their series, as the urethral plate remained intact, the neophallus was usually small and curved [13]. Hage [14] introduced refinements into modified metoidioplasty characterized by urethral lengthening. Urethroplasty was based on using both the labia minora and the urethral plate, which was divided at the level of the female urethral opening [14]. Since the course of dissection was from proximal to distal, there was a risk of compromising the vascularization of the mobilized urethral plate, resulting in a high complication rate in long term follow-up. Finally, he concluded that an average of 2.6 surgical procedures per patient was needed for a successful outcome of the surgery [15].

Metoidioplasty is performed as a one-stage procedure in our center together with the removal of female reproductive organs and vaginectomy, as well as urethroplasty and scrotoplasty with implantation of testicular prostheses. The first results showed a high success rate in esthetic and functional points in the majority of patients [16]. Since the main complications were related to urethral reconstruction, we continued searching for a better solution resulting in improved Belgrade metoidioplasty. The technique is based on clitoral lengthening by dissection of the clitoral ligaments dorsally and the short urethral plate ventrally. Bulbar urethral reconstruction is performed using part of the anterior vaginal wall and the proximal part of the urethral plate. To avoid the described complications following tubularized urethroplasty, a buccal mucosa graft is used as the dorsal half of the neourethra. A well-vascularized recipient site provides a good blood supply and prevents contraction of the graft. Covering of the buccal mucosa graft is performed using either a longitudinal dorsal clitoral skin flap or a flap harvested from the inner surface of the labia minora. In both approaches, well-vascularized tissue completely covers all suture lines, preventing fistula formation. A longitudinal island skin flap is harvested from dorsal clitoral skin and buttonholed ventrally, to join with the dorsal buccal mucosa. This approach is similar to the urethral reconstruction in severe hypospadias with ventral curvature, where the urethra is reconstructed using a buccal mucosa graft and island skin flap originating from dorsal penile skin [17]. This technique usually leaves the remaining clitoral skin insufficient for neophallic shaft reconstruction. Also, the length of the flap is related to the available hairless dorsal skin that could prove insufficient for complete urethral lengthening. On the other hand, the labia minora are always available for flap creation. They are hairless and elastic, with a very good blood supply. This abundant blood supply to the labia minora enables the creation of a very long, vascularized labia minora skin flap for urethral reconstruction leaving the other labia intact and useful for neophallic shaft reconstruction. Reconstruction is completed with scrotal reconstruction and insertion of testicular implants (Fig. 1). Overall satisfaction is noted in most patients, as male genitalia appearance and voiding while standing are achieved after a one-stage surgery. Urethral fistula and stricture occurred in only 7.72% and 2.89%, respectively. The length of the neophallus ranged from 4 to 10 cm, which was not adequate for penetration during sexual intercourse, and total phalloplasty could be subsequently added depending on the patient's sexual preferences [18,19].

Figure 1. Male-like appearance of genitalia is achieved one year after one-stage metoidioplasty.

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An Update on the Surgical Treatment for Transgender Patients

Britt Colebunders MD , ... Stan Monstrey MD, PhD , in Sexual Medicine Reviews, 2017

Abstract

Introduction

As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options.

Aim

To review current gender reassignment surgical techniques and update the clinician.

Methods

A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery.

Main Outcome Measures

Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap.

Results

Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures.

Conclusion

Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap.

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