Gender-confirmation surgeries—the name given to procedures that change the physical appearance and function of sexual characteristics—increased by 20 percent from 2015 to 2016 in the U.S., with more than 3,000 such operations performed last year. Rates are also increasing worldwide. Now, at least one surgeon is reporting a trend of regret.
Urologist Miroslav Djordjevic, who specializes in gender reassignment surgery, has seen an increase in “reversal” surgeries among transgender women who want their male genitalia back. In the past five years, Djordjevic performed seven reversals in his clinic in Belgrade, Serbia. The urologist explains to The Telegraph that those who want the reversal display high levels of depression, and in some instances, suicidal thoughts. Other researchers also report hearing about such regrets.
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“It can be a real disaster to hear these stories,” Djordjevic told The Telegraph.
Charles Kane, who identified as Sam Hashimi after male-to-female reassignment surgery, opted to become a man again after experiencing “hormonal regret.” In the BBC documentary One Life: Make Me a Man Again, Kane explained he originally wanted to become a woman after a nervous breakdown.
“When I was in the psychiatric hospital, there was a man on one side of me who thought he was King George and another guy on the other side who thought he was Jesus Christ. I decided I was Sam,” Kane said.
Postsurgery, Kane believed his female identity would never be liked or accepted as a real woman. He also blamed the influence of female hormones as responsible for making him seek the surgery. “I don’t think there’s anyone born transsexual. Areas of their human brain get altered by female hormones,” Kane told Nightline.
Kane’s insight may not be applicable to all transgender patients seeking reversal surgery. Djordjevic expresses concern about the psychiatric evaluation and counseling that take place prior to the gender reassignment surgery. He recalls patients telling him that when they inquired about the procedure at other clinics, they receive minimal information before being asked for proof that they could pay for the operation.
In Djordjevic’s practice, patients undergo a minimum of one to two years of psychiatric evaluation, accompanied by hormonal evaluation and therapy. Prior to the surgery, he asks patients for two professional letters of recommendation. After the procedure, he strives to remain in contact—he talks with 80 percent of his former patients, The Telegraph reports.
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A 2011 study found that after sex reassignment surgery, more than 300 Swedish transsexuals faced a higher risk for mortality, suicide ideation, and psychiatric issues compared to the rest of the population. The researchers concluded, “Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”
In male-to-female reassignment surgery, doctors will reshape the male genitals in the form of a vagina. The surgery also includes removing the testicles and an inversion of the penis. In female-to-male procedures, doctors remove the breasts, uterus and ovaries and extend the urethra so a transgender man can urinate standing up. Male-to-female reassignments are more common because they are considered less expensive and more successful.
Gender reassignment surgeries are expensive. Male-to-female procedures cost between $7,000 and $24,000, and the cost of female-to-male procedures can reach $50,000. The complications and the expense warrant extra care from doctors performing these reassignments. “Ethically, we have to help any person,” says Djordjevic, “in the best possible way.”
Sex reassignment surgery for male-to-female involves reshaping the male genitals into a form with the appearance of, and, as far as possible, the function of female genitalia. Prior to any surgeries, patients usually undergo hormone replacement therapy (HRT), and, depending on the age at which HRT begins, facial hair removal. There are associated surgeries patients may elect to, including facial feminization surgery, breast augmentation, and various other procedures.
Lili Elbe was the first known recipient of male-to-female sex reassignment surgery, in Germany in 1930. She was the subject of four surgeries: one for orchiectomy, one to transplant an ovary, one for penectomy, and one for vaginoplasty and a uterus transplant. However, she died three months after her last operation.
Christine Jørgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. She was a strong advocate for the rights of transgender people.
Another famous person to undergo male-to-female sex reassignment surgery was Renée Richards. She transitioned and had surgery in the mid-1970s, and successfully fought to have transgender people recognized in their new sex.
The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician to perform sex reassignment surgery in the United States was the late Elmer Belt, who did so until the late 1960s.
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.
Main article: Vaginoplasty
When changing anatomical sex from male to female, the testicles are removed, and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951), to form a fully sensitive vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hairfollicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.
In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty).
Surgeon's requirements, procedures, and recommendations vary enormously in the days before and after, and the months following, these procedures.
Plastic surgery, since it involves skin, is never an exact procedure, and cosmetic refining to the outer vulva is sometimes required. Some surgeons prefer to do most of the crafting of the outer vulva as a second surgery, when other tissues, blood and nerve supplies have recovered from the first surgery. This relatively minor surgery, which is usually performed only under local anaesthetic, is called labiaplasty.
The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is affected by age, nutrition, physical activity and smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage.
Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. Lubrication is needed when having sex and occasional douching is advised so that bacteria do not start to grow and give off odors.
Because of the risk of vaginal stenosis (the narrowing or loss of flexibility of the vagina), any current technique of vaginoplasty requires some long-term maintenance of volume (vaginal dilation), by the patient, using medical graduated dilators to keep the vagina open. Penile-vaginal penetration with a sexual partner is not an adequate method of performing dilation. Daily dilation of the vagina for six months in order to prevent stenosis is recommended among health professionals. Over time, dilation is required less often, but it may be required indefinitely in some cases.
Regular application of estrogen into the vagina , for which there are several standard products, may help, but this must be calculated into total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually, or, in extreme cases, under anaesthetic.
With current procedures, trans women do not have ovaries or uteri. This means that they are unable to bear children or menstruate until a uterus transplant is performed, and that they will need to remain on hormone therapy after their surgery to maintain female hormonal status.
Other related procedures
Facial feminization surgery
Main article: Facial feminization surgery
Occasionally these basic procedures are complemented further with feminizing cosmetic surgeries or procedures that modify bone or cartilage structures, typically in the jaw, brow, forehead, nose and cheek areas. These are known as facial feminization surgery or FFS.
Breast augmentation is the enlargement of the breasts. Some trans women choose to undergo this procedure if hormone therapy does not yield satisfactory results. Usually, typical growth for trans women is one to two cup sizes below closely related females such as the mother or sisters. Estrogen is responsible for fat distribution to the breasts, hips and buttocks, while progesterone is responsible for developing the actual milk glands. Progesterone also rounds out the breast to an adult Tanner stage-5 shape and matures and darkens the areola.
Voice feminization surgery
See also: Voice therapy (trans) § Vocal surgeries
Some MTF individuals may elect to have voice surgery, altering the range or pitch of the person's vocal cords. However, this procedure carries the risk of impairing a trans woman's voice forever, as happened to transsexual economist and author Deirdre McCloskey. Because estrogens by themselves are not able to alter a person's voice range or pitch, some people proceed to seek treatment. Other options are available to people wishing to speak in a less masculine tone. Voice feminization lessons are available to train trans women to practice feminization of their speech.
Main article: Chondrolaryngoplasty
A tracheal shave procedure is also sometimes used to reduce the cartilage in the area of the throat and minimize the appearance of the Adam's apple, in order to conform to more feminine dimensions.
Because anatomically masculine hips and buttocks are generally smaller than those that are anatomically feminine, some MTF individuals will choose to undergo buttock augmentation. If, however, efficient hormone therapy is conducted before the patient is past puberty, the pelvis will broaden slightly, and even if the patient is past their teen years, a layer of subcutaneous fat will be distributed over the body rounding contours. Trans women usually end up with a waist to hip ratio of around 0.8, and if estrogen is administered at a young enough age "before the bone plates close", some trans women may achieve a waist to hip ratio of 0.7 or lower. The pubescent pelvis will broaden under estrogen therapy even if the skeleton is anatomically masculine.
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