Transsexuals and those who choose gender re-assignment surgery

With the help of modern medicine, many transsexuals throughout the country and globe are able to experience relief from the gender conflicts they experience. Becoming educated about transsexuals and the facts surrounding gender re-assignment surgery are key ingredients for tolerating and accepting this prevailing hamlet. According to the text, “medical estimates place… transgenderism at about 1 in 30,000 for MTF and 1 in 100,000 for FTM. However, many gender activists claim that these figures vastly underestimate the true prevalence and are based on statistics of the number of sex reassignment surgeries performed rather than the overall number of people who are living transgender lives… [and] prevalence may be at least 10 times higher” (Hock, p. 385). With numbers this great, and possibly greater, it is highly probable to cross paths with such a person in an educational, social or work setting, and some people may even “date, have sex with, and even marry a postoperative transsexual and be unaware of the person’s transgender status unless he or she” were to divulge the truth (Hock, p. 386). Ergo, tolerance and acceptance of transsexuals and those who choose gender re-assignment surgery is even more exigent.

The first step to achieving a complete understanding of gender re-assignment surgery is briefly educating oneself on the history of transsexuals and gender re-assignment surgery. The concept of transsexuals has been referred to in classic literature by such authors as Herodotus and Shakespeare and “[w]ell known historical examples of psychosexual inversion span the time from the Roman emperor Caligula to the famous French diplomat Chevalier d’Eon” (Edgerton, Knorr and Callison). In 1830, “German author Friedreich first called attention to this syndrome in the medical literature”; in 1870, “Westphal was the first to give a clear and complete description” of transvestism; in 1949, Cauldwell was the first to coin the term transexualism (Edgerton, Knorr and Callison).

Regarding the birth of gender re-assignment surgery, there are varying opinions. Some believe that early “examples relate to practices carried out in ancient cultures. Gender reassignment surgery (GRS) developed from reconstructive procedures for congenital abnormalities. Some surgery was disguised, techniques were not recorded, and operations were carried out in secret” (Goddard, Vickery, Terry). However, it is also argued that even though “castration has been used throughout recorded history, and penectomies have not been unknown, it is not always clear that people given these operations desired any change of sex” (Edgerton, Knorr and Callison). Therefore, the first documented case of GRS was reported in 1931 by Abraham. (Edgerton, Knorr and Callison)

During the 1950s, Sir Harold Gillies and gynecologist Dr. Georges Burou developed the first of two methods for male-to-female gender re-assignment surgery, which “used invagination of the penile skin sheath to form a vagina”(Goddard, Vickery, Terry). Howard Jones from Johns Hopkins developed the second method of this avant garde concept, which used penile and scrotal skin flaps. Both methods serve as the basis for all male-to-female gender re-assignment surgeries performed today.

While development of male-to-female GRS was in progress, Burou was also independently developing female-to-male gender re-assignment surgery in his Clinique du Parc in Casablanca. His method consisted of “the anteriorly pedicled penile skin flap inversion vaginoplasty” and this “technique was to become the gold standard of skin-lined vaginoplasty in transsexuals” (Hage, Karim, Laub).

According to the text, gender re-assignment surgery has evolved into a multi step process that requires “psychological counseling, hormone therapy, and a pre-surgical transition period” before surgery can even take place. For both transitions, there are several surgeries that have “anatomically very realistic” results. A male-to-female gender re-assignment surgery may involve any or all of the following: penectomy (removal of the penis), uroplasty (rerouting of the urethra), orchiectomy (removal of the testicles), vaginoplasty (the use of penile skin to construct labia and a vagina), breast implants, chondrolaryngoplasty (reduces the size of the Adam’s apple) and phonosurgery (raises voice pitch). A female-to-male gender re-assignment surgery may involve any or all of the following: mastectomy (removal of breasts), hysterectomy (removal of uterus, fallopian tubes and ovaries), metadioplasty (creation of small erectile phallus from the clitoris), phalloplasty (formation of a penis from tissue taken from other areas of the body and transplanted using microsurgical techniques in the genital area; requires a penile implant for erection), uroplasty, scrotoplasty (reshaping and stretching of the labia to resemble a scrotum and the insertion of silicone prosthetic testicles). If performed in the United States, such surgeries can cost anywhere from $18,000 to $50,000 while other countries such as Thailand offer GRS costing anywhere from $7,000 to $10,000.(Hock, p. 386)

The first gender re-assignment to receive media attention was the male-to-female re-assignment of Christine Jorgensen. Christine, born a man, lived as George Jorgensen until she had her gender re-assignment surgery in February of 1953. Christine grew up knowing that she was biologically a man but psychologically a woman and after her service in the military ended, she began hormone therapy consisting of the female hormone estradiol. Because of the nescience that enveloped the United States medical community concerning gender re-assignment surgery during the 1950s, Christine found it difficult to find a doctor willing to help her resolve her gender conflict and reach her goals. Eventually, a doctor in Denmark was able to perform surgery that consisted of a bilateral orchiectomy, removal of the scrotum and a penectomy. Several years after this initial surgery, Christine had cosmesis surgery to construct a vagina. As a result of the media coverage she received, Christine became “a spokesperson for transgender, gay, and lesbian causes” (Hock, p. 386).
Sexual and physical health after gender re-assignment surgery is a major concern for candidates. One study conducted by the Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium states that “[t]actile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery” (Selvaggi, Monstrey, Ceulemans, T’Sjoen, De Cuypere, Hoebeke). The study outlines “specific surgical tricks used to preserve genital and tactile sensitivity” that focus on the preservation of the clitoris, the inguinal nerve, two dorsal nerves of the clitoris for phalloplasty and preservation of the glans penis, the prepuce and the penile shaft for vaginoplasty. The study states that a “long-term sensitivity evaluation” was performed on the “27 reconstructed phalli and 30 clitorises” of the 105 total phalloplasties and 127 vaginoclitoridoplasties performed over a ten year period of time at the Ghent University Hospital. The study concludes that “all female-to-male and 85% of male-to-female patients reported orgasm” and the tactile sensitivity techniques that are practiced at the hospital are essential for achieving such results. (Selvaggi, Monstrey, Ceulemans, T’Sjoen, De Cuypere, Hoebeke)

For obvious reasons, gender re-assignment surgery is a major medical procedure. Any surgery presents the possibility of adverse health effects and urogenital surgical procedures are no different. They can include a variety of issues from urinary tract problems to sensations of phantom genitals to Lupus Erythematosus Tumidus. One study in Japan suggests that through the course of their research, “several complications occurred such as partial flap necrosis, rectovaginal fistula formation and hypersensitivity of the neoclitoris” (Namba, Sugiyama, Yamashita, Tokuyama, Hasegawa, Kimata). Every person is different and while there are factors that contribute to such problems, it is difficult to predict what adverse effects, if any, someone who elects for these types of procedures will experience.

In 2007, a research study based on the hypothesis that Lupus Erythematosus Tumidus can be induced by gender re-assignment surgery was published in the Journal of Rheumatology. The study highlights that the pathology of Lupus Erythematosus Tumidus is both intrinsic and extrinsic. It is stated that “[t]he intrinsic abnormalities are complicated, with diverse genetic polymorphisms described in different ethnic groups, strongly suggesting that the actual pathology underlying the immunologic disarray might not be the same for each patient” (Zandman-Goddard, Solomon, Barzilai, Shoenfeld). Extrinsic factors are outlined in the same study as the exposure to “drugs capable of modulating immune responses such as exogenous estrogens.” The study indicates that it is presenting information about “the first reported case of sex reassignment surgery and the subsequent development of cutaneous lupus” and that the purpose of the report is to “emphasize that environmental triggers including high doses of estrogens as part of sex reassignment surgery may lead to the development of lupus in a nonpredisposed individual.”

One study published in Archives of Sexual Behavior , the official publication of the International Academy of Sex Research, observed “preoperative preparations, complications and physical and functional outcomes of male-to-female sex reassignment surgery” on 232 patients. Each patient had penile-inversion vaginoplasty and sensate clitoroplasty which was performed by the same surgeon using the same technique on each patient. It is reported that almost all the patients stopped hormone therapy and received electrolysis to remove genital hair prior to the gender re-assignment surgery. While none of the patients “reported rectal-vaginal fistula or deep-vein thrombosis”, at least a third of the patients “reported urinary stream problems.” (Lawrence)

Another problem linked with gender re-assignment surgery is reported episdoes of phantom genitals which is comparable to the phantom limb phenomenon. First described by Weir Mitchell in 1871, phantom limb is the “vivid sensation of still having a limb although it has been amputated” (Ramachandran, McGeoch). Since these episodes are not restricted to people with amputated limbs, it is reported to also occur “after amputation of the penis or a breast… [and] 60% of men who have had to have their penis amputated for cancer will experience a phantom penis” (Ramachandran, McGeoch). The first documented case of “‘phantom penis’ was reported by Crone in 1951″ (Namba, Sugiyama, Yamashita, Tokuyama, Hasegawa, Kimata). Recent studies have shown that phantom sensations may be a result of “‘cross’ activation between the de-afferented cortex and surrounding areas” (Ramachandran, McGeoch). Another contributing factor to phantom limb is that “our body image is innately ‘hard-wired’ into our brains” and it is interesting to note that “congenitally limbless patients can still experience phantom sensations” (Ramachandran, McGeoch). In the aforementioned study, researchers hypothesized that “due to a dissociation during embryological development, the brains of transsexuals are ‘hard-wired’ in manner, which is opposite to that of their biological sex.” Proving or disproving this hypothesis will be essential to “showing the basis of transsexuality and provide farther evidence that we have a gender specific body image, with a strong innate component that is ‘hard-wired’ into our brains. This would furnish us with a better understanding the mechanism by which nature and nurture interact to link the brain-based internal body image with external sexual morphology” (Ramachandran, McGeoch).

With an understanding that this phenomenon plagues a greater pool of people than once assumed, researchers from the Department of Plastic and Reconstructive Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan observed and documented the sensations of phantom erectile penis in 14 male-to-female patients that they performed vaginoplasty surgery on during an almost seven year period. Their conclusions state that just after their gender re-assignment surgery “some patients feel that their penises still exist, but by several weeks postoperatively, this sensation has disappeared” but that there was one case where the “sensation of a phantom erectile penis persisted for much longer” (Namba, Sugiyama, Yamashita, Tokuyama, Hasegawa, Kimata). One 52 year old patient who underwent male-to-female re-assignment during this study reported “the feeling of a phantom erectile penis… for over six months and was enhanced when the patient was standing.” After a second surgery, the phantom sensation disappeared.

Since transsexuals seeking gender re-assignment surgery are trying to reach a goal that includes lifestyle satisfaction, research has been conducted to find out if gender re-assignment surgery will actually help transsexuals reach this goal. While there are possible adverse physical effects to gender re-assignment surgery, one study says that “[n]o single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation” (Lawrence). Another study also reported on by Lawrence “examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on ”over a six year period of time. A vast majority of the patients who participated in this study reported “that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret.” While one may feel dissonance as a transsexual, gender re-assignment surgery patients have been proven to be “better adjusted in life” than those who continue their struggle “trapped” in the wrong body. (Hock, p. 386)

A few issues rarely traversed in the medical field that are pertinent to the understanding and tolerance of transsexuals and gender re-assignment surgery are recommended for further study and observation. For example, there is limited research or published studies concerning transsexuals who have undergone GRS and their adjustment to society, or furthermore, society’s adjustment to them. It would be intriguing to learn if transsexuals feel as though society accepts them more before or after their surgery. Another issue that would be intriguing, is to learn about patients’ postoperative relationships. The text says that a transsexuals new genitals are so anatomically real that it is possible to meet, date, have sex with or even marry such a person without even realizing it. This deserves further study.

While a transsexual manages their gender dissonance, gender re-assignment surgery has proven to be a feasible solution. With references in classic literature and well known historical figures, transexualism has been around for hundreds of years. Study and development of gender re-assignment surgeries are relatively new, but the field has many pioneers who are striving to help improve the quality of life for transsexuals across the globe. As with any surgery, gender re-assignment surgery poses several risks, most of them postoperative. Since gender re-assignment surgery is both physically serious and irreversible, and has possible adverse affects such as Lupus, urinary tract issues or even phantom genitalia, the decision to have such procedures is a long process. Beginning with intense psychological preparation, hormone therapy and a period of transition, gender re-assignment surgery can not be completed until all these steps are completed successfully. On a promising note, studies conducted on overall satisfaction of patients who receive GRS overwhelmingly show that patients now feel a greater quality of life and are satisfied with their decision of gender re-assignment.

References
Bullough, 1975. Transexualism in History, Archives of Sexual Behavior, 4(5). January 18, 2009.

Edgerton, Knorr, Callison, 1970. The Surgical Treatment of Transsexual Patients, Plastic and Reconstructive Surgery, 45(1). January 18, 2009.

Goddard, Vickery, Terry, 2007. Development of Feminizing Genitoplasty for Gender Dysphoria, Journal of Sexual Medicine, 4(4). January 19, 2009.

Hage, Karim, Laub, 2007. On the Origin of Pedicled Skin Inversion Vaginoplasty: Life and Work of Dr. Georges Burou of Casablanca, Annals of Plastic Surgery, 59(6). January 18, 2009.

Lawrence, 2003. Factors Associated with Satisfaction or Regret Following Male-to-Female Sex Reassignment Surgery, Archives of Sexual Behavior, 32(4). January 19, 2009.

Lawrence, 2006. Patient-Reported Complications and Functional Outcomes of Male-to-Female Sex Reassignment Surgery, Archives of Sexual Behavior. January 18, 2009.

Namba, Sugiyama, Yamashita, Tokuyama, Hasegawa, Kimata, 2008. Phantom erectile penis after sex reassignment surgery, Acta Medica Okayama, 62(3). January 18, 2009.

Ramachandran, McGeoch, 2007. Occurrence of phantom genitalia after gender reassignment surgery, Medical Hypotheses, 69(5). January 18, 2009.

Selvaggi, Monstrey, Ceulemans, T’Sjoen, De Cuypere, Hoebeke, 2007. Genital Sensitivity after sex reassignment surgery in transsexual patients, Annals of Plastic Surgery, 58(4). January 18, 2009.

Zandman-Goddard, Solomon, Barzilai, Shoenfeld, 2007. Lupus Erythematosus Tumidus Induced by Sex Reassignment Surgery, The Journal of Rheumatology, 34(9). January 19, 2009.

Hock, 2007. Human Sexuality, Gender: Expectations, Roles, and Behaviors, 373-374 385-386. Upper Saddle River, New Jersey: Prentice Hall.

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