Sex reassignment surgery

Last updated

Sex reassignment surgery or SRS (also known as gender reassignment surgery and by numerous other names) is a 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.

Transgender State of ones gender identity or expression not matching ones assigned sex. (Use with P21)

Transgender people have a gender identity or gender expression that differs from their assigned sex. Some transgender people identify as transsexual if they desire medical assistance to transition from one sex to another. Transgender – often shortened as trans – is also an umbrella term: in addition to including people whose gender identity is the opposite of their assigned sex, it may include people who are not exclusively masculine or feminine. Other definitions of transgender also include people who belong to a third gender, or else conceptualize transgender people as a third gender. Infrequently, the term transgender is defined very broadly to include cross-dressers, regardless of their gender identity.

Sexual characteristics are physical or behavioral traits of an organism which are indicative of its biological sex. These can include sex organs used for reproduction and secondary sex characteristics which distinguish the sexes of a species, but which are not directly part of the reproductive system.

Gender Characteristics distinguishing between masculinity and femininity

Gender is the range of characteristics pertaining to, and differentiating between, masculinity and femininity. Depending on the context, these characteristics may include biological sex, sex-based social structures, or gender identity. Traditionally, people who identify as men or women or use masculine or feminine gender pronouns are using a system of gender binary whereas those who exist outside these groups fall under the umbrella terms non-binary or genderqueer. Some cultures have specific gender roles that are distinct from "man" and "woman," such as the hijras of South Asia. These are often referred to as third genders.


Professional medical organizations have established Standards of Care that apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female. These surgeries include vaginoplasty, feminizing augmentation mammoplasty, orchiectomy, facial feminization surgery, reduction thyrochondroplasty (tracheal shave), and voice feminization surgery among others.

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses in order to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It will correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

Orchiectomy surgical procedure

Orchiectomy is a surgical procedure in which one or both testicles are removed. The surgery is typically performed as treatment for testicular cancer, in some cases of testicular torsion, and is sometimes used in the management of advanced prostate cancer.

Facial feminization surgery (FFS) is a set of cosmetic surgical procedures that alter typically male facial features to bring them closer in shape and size to typical female facial features. FFS can include various bony and soft tissue procedures such as brow lift, rhinoplasty, cheek implantation, and lip augmentation.

Masculinization surgeries are surgeries that result in anatomy that is typically gendered male. These surgeries include chest masculinization surgery (top surgery), metoidioplasty, phalloplasty, scrotoplasty, and hysterectomy.

Sex reassignment surgery for female-to-male transgender people includes a variety of surgical procedures that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.

Metoidioplasty or metaoidioplasty is a female-to-male sex reassignment surgery.

Phalloplasty is the construction or reconstruction of a penis, or the artificial modification of the penis by surgery. The term phalloplasty is also occasionally used to refer to penis enlargement.

In addition to SRS, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Transgender hormone therapy of the female-to-male (FTM) type, also known as masculinizing hormone therapy, is a form of hormone therapy and sex reassignment therapy which is used to change the secondary sexual characteristics of transgender people from feminine to masculine. It is one of two types of transgender hormone therapy, and is predominantly used to treat transgender men and other transmasculine individuals. Some intersex people also receive this form of therapy, either starting in childhood to confirm the assigned sex or later if the assignment proves to be incorrect.

Transgender hormone therapy of the male-to-female (MTF) type, also known as feminizing hormone therapy, is hormone therapy and sex reassignment therapy to change the secondary sexual characteristics of transgender people from masculine to feminine. It is one of two types of transgender hormone therapy and is predominantly used to treat transgender women and other transfeminine individuals. Some intersex people also take this form of therapy, according to their personal needs and preferences.


There are numerous other expressions that are used or have been used to refer to sexual reassignment surgery, including sex change operation, gender reassignment surgery, gender confirmation surgery, genital reconstruction surgery, gender-affirming surgery, and sex realignment surgery. [1]

The American Society of Plastic Surgeons (ASPS) calls this procedure Gender Confirmation Surgery or GCS. [2] [3] Another term for SRS includes sex reconstruction surgery.

People who pursue sex reassignment surgery are usually referred to as transsexual.[ citation needed ] A trans woman assigned male at birth and seeking feminizing surgery may have one or more of the procedures used for trans women, which go by various names, such as feminizing genitoplasty, penectomy, orchiectomy, or vaginoplasty . A trans man assigned female at birth and seeking masculinizing surgery may undergo one or more procedures, which may include masculinizing genitoplasty, metoidioplasty or phalloplasty .[ citation needed ]


In the US in 1917, Dr Alan L. Hart, an American TB specialist, becomes one of the first female-to-male transsexuals to undergo hysterectomy and gonadectomy for the relief of gender dysphoria. [4]

In Berlin in 1931, Dora Richter, became the first known transgender woman to undergo the vaginoplasty [5] 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, [6] 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. [7]

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". [8]

As of 2017, some European countries require forced sterilization for the legal recognition of sex reassignment. [9]

Prior to surgery

Medical considerations

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 transgender people solely on the basis of their HIV or hepatitis status. [10]

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.[ citation needed ]

Ethical considerations

At birth

SRS does not refer to surgery performed on infants with differences in sex development (intersex). [11] Infants born with intersex conditions might undergo interventions at or close to birth. [12] This is controversial because of the human rights implications. [13] [14]


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. [15] [16] [17] 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 and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder. [18] [19]

Standards of care

Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, 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 transgender individuals. Some treatment 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 sex reassignment surgeries are covered by insurance.[ citation needed ]

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be 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.[ citation needed ]

Many 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. [20] [21]

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. [22] 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.[ citation needed ]


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). [23] 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." [24] Other organizations have issued similar statements, including WPATH, [25] the American Psychological Association, [26] and the National Association of Social Workers. [27]

In 2017, the United States Defense 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. [28]

Surgical procedures

Bottom surgery

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 make use of scrotal tissue to construct the vaginal canal. 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. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons. [29]

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 dysphoria. 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.[ citation needed ]

Scope and procedures

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." [30] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial electrolysis.[ citation needed ]

Post-surgical considerations

Quality of life and physical health

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. [31]

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. [32] Another study showed a similar level of quality of life in transsexual individuals and the control group. [33] 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. [31] [34] 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. [35]

Psychological and social consequences

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. [36] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. [37] 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. [38]

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences, [39] 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. [40] These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates and low follow-up rates, [41] 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. [42] Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, having not suffered from gender identity disorders during childhood, and expressing dissatisfaction with the results of surgery. [43] During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours. [44] The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. [45] The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress. [46]

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. [44] 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. [44]


Looking specifically at transsexual people'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, [47] 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. [47] [48] 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. [47] [48]

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse. [47] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities, [37] [31] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery. [31] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics. [31] 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. [31]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation. [31] The ability to obtain orgasms is positively associated with sexual satisfaction. [37] 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, [31] [49] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS. [50] A study found that both transmen and transwomen reported qualitative change in their experience of orgasm. 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. [31]

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. [37] [31] [51] 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 [31] 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. [37]

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). [51] When comparing transsexuals with biological individuals of the same gender, trans women had a similar sexual satisfaction to non-trans women, but trans men had a lower level of sexual satisfaction to non-trans men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women. [37]



In 2012, Argentina began offering government subsidized total or partial SRS to all persons 18 years of age or older. [52] [53] [54] Private insurance companies are prohibited from increasing the cost of SRS for their clients. At the same time, the Argentinian government repealed a law that banned SRS without authorization from a judge. [55]


In 2012, a bill was introduced that stated SRS was no longer a requirement for legal name and sex change. [56]

In 2013, Chile's public health plan was required to cover sex reassignment surgery. [56] The cost is subsidized by the government based on a patient's income. [56]


Since 2016, France no longer requires SRS as a condition for a gender change on legal documents. [57] [58]

In 2017, a case brought earlier by three transgendered French people was decided. France was found in violation of the European Convention on Human Rights for requiring the forced sterilization of transgender people seeking to change their gender on legal documents. [59]


India is offering affordable sex reassignment surgery to a growing number of medical tourists [60] and to the general population. [61]


The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery. [62] [54]

The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals". [62] 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. [62] 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. [63]


As late as 2010, transgender people that have undergone SRS can change their sex on legal documents. [64]


Casablanca, Morocco is notable for being the home of Clinique de Parc, Dr. Georges Burou's clinic for transgender women. Dr. Burou is considered one of the pioneers of SRS. [65] A French gynecologist, Dr. Burou created the anteriorly pedicled penile skin flap inversion vaginoplasty, still considered the “gold standard” of skin-lined vaginoplasty. [66] He is credited with having performed over 3000 MtF surgeries. [65]


In Pakistan, the Council of Islamic Ideology has ruled that sex re-assignment surgery contravenes Islamic law as construed by the Council. [67] This Pakistani law prevents Hijras from becoming women.


Despite a resolution from the European Parliament in 1989 suggesting advanced rights for all European Union citizens, as of 2002 only Andalucia's public health system covers sex reassignment surgery. [68] Other states in Spain have not yet added, or like Valencia, refuse to add, this right into their health care systems. [68]


In 2010, the Swiss Federal Supreme Court struck down two laws that limited access to SRS. These included requirements of at least 2 years of psychotherapy before health insurance was obligated to cover the cost of SRS [69] [70] and inability to procreate. [71]


Thailand is the country that performs the most sex reassignment surgeries, followed by Iran. [63]


In 2015, the Administrative District Court of Kiev ruled that forced sterilization was unlawful and no longer required for legal gender change. [72]

See also

Related Research Articles

Penectomy surgical removal of penis

Penectomy is penis removal through surgery, generally for medical or personal reasons.

Gender dysphoria (GD) is the distress a person experiences as a result of the sex and gender they were assigned at birth. In this case, the assigned sex and gender do not match the person's gender identity, and the person is transgender. Evidence from studies of twins suggests that gender dysphoria not only has psychological causes, but may have biological causes as well.

The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal or surgical transition to the other sex. Clinicians' decisions regarding patients' treatment are often influenced by this standard of care (SOC).

Sex reassignment therapy is the medical aspect of gender transitioning, that is, modifying one's characteristics to better suit one's gender identity. It can consist of hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance, including permanent hair removal for trans women.

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. Before any surgery, 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.

Transitioning is the process of changing one's gender presentation and/or sex characteristics to accord with one's internal sense of gender identity – the idea of what it means to be a man or a woman, or to be genderqueer. For genderqueer people, the internal sense of gender identity is neither solely female nor male. For transgender and transsexual people, this process commonly involves reassignment therapy, with their gender identity being opposite that of their birth-assigned sex and gender. Transitioning might involve medical treatment, but it does not always involve it. Cross-dressers, drag queens, and drag kings tend not to transition, since their variant gender presentations are (usually) only adopted temporarily.

History of intersex surgery

The history of intersex surgery is intertwined with the development of the specialities of pediatric surgery, pediatric urology, and pediatric endocrinology, with our increasingly refined understanding of sexual differentiation, with the development of political advocacy groups united by a human qualified analysis, and in the last decade by doubts as to efficacy, and controversy over when and even whether some procedures should be performed.

Blanchard's transsexualism typology, also Blanchard autogynephilia theory and Blanchard's taxonomy, is a psychological typology of male-to-female (MtF) transsexualism created by Ray Blanchard through the 1980s and 1990s, building on the work of his colleague, Kurt Freund. Blanchard divided trans women into two groups: one is "homosexual transsexuals" who, Blanchard says, seek sex reassignment surgery because they are feminine in both behavior and appearance, and to romantically and sexually attract men; and the other is "autogynephilic transsexuals" who, according to Blanchard, are sexually aroused at the idea of having a female body. Blanchard's model is unusual in that neither group is considered "false transsexuals"; both autogynephilic and homosexual transsexuals are thought to benefit from transition. This distinction is a recurring theme in scholarly literature on transsexualism.

Toby Meltzer American surgeon

Toby R. Meltzer is an American plastic and reconstructive surgeon. Meltzer specializes in sex reassignment surgery male-to-female, sex reassignment surgery female-to-male, and facial feminization surgery. In the 1990s, Meltzer pioneered the neovaginal construction technique that increased the ability of the neoclitoris to feel sensations. According to his website, Meltzer performs 2-4 vaginoplasties a week, and that he has performed over 3000 male and female sexual reassignment (SRS) surgeries. Joan Roughgarden called Meltzer one of the leading surgeons in this specialized field. He practices in Scottsdale, Arizona.

Georges Burou (1910–1987) was a French gynecologist who managed a clinic in Casablanca, Morocco and is widely credited with innovating modern sex reassignment surgery for trans women.

Transsexual condition in which an individual identifies with a gender inconsistent or not culturally associated with their biological sex

Transsexual people experience a gender identity that is inconsistent with, or not culturally associated with, their assigned sex, and desire to permanently transition to the gender with which they identify, usually seeking medical assistance to help them align their body with their identified sex or gender.

The Baptist Medical Center sex reassignment surgery controversy occurred in 1977 in Oklahoma City, Oklahoma. Surgeons at the Baptist Medical Center, a hospital owned by the Southern Baptist Convention, were prohibited from performing sex reassignment surgery.

Paul Allen Walker was an American social psychologist and founding president of HBIGDA, the Harry Benjamin International Gender Dysphoria Association now known as WPATH, the World Professional Association for Transgender Health in 1979. He also served as director of the Janus Information Facility.

The real-life experience (RLE), sometimes called the real-life test (RLT), is a period of time in which transgender individuals live full-time in their preferred gender role. The purpose of the RLE is to confirm that a given transgender person can function successfully as a member of said gender in society, as well as to confirm that they are sure they want to live as said gender for the rest of their life. A documented RLE is a requirement of some physicians before prescribing hormone replacement therapy (HRT), and a requirement of most surgeons before performing genital reassignment surgery (GRS).

Transgender health care refers to how medical institutions, communities and individuals approach the care of transgender people. It includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as sex reassignment therapies.

Detransition is the cessation or reversal of a transgender identification or gender transition, whether by social, legal, or medical means.

Facial masculinization surgery (FMS) is a set of plastic surgery procedures that can transform the patient’s face to exhibit typical masculine morphology. Cisgender men may elect to undergo these procedures, and in the context of transgender people, FMS is a type of facial gender confirmation surgery (FGCS), which also includes facial feminization surgery (FFS) for transgender women.


  1. Harrington, Lee (1 May 2016). Traversing Gender: Understanding Transgender Realities. Mystic Productions Press. p. 287. ISBN   978-1-942733-83-6. OCLC   947837700 . Retrieved 15 October 2018.
  2. "Gender Confirmation Surgeries". American Society of Plastic Surgeons. Retrieved 2017-08-07.
  3. "About ASPS". American Society of Plastic Surgeons. Retrieved 2017-08-07.
  4. Munro, Donald. "Trans Media Watch" . Retrieved 1 November 2018.
  5. Munro, Donald. "Trans Media Watch" . Retrieved 13 June 2016.
  6. Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
  7. The Case Van Kück vs. Germany, June 12 2003
  8. International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex" . Retrieved 2015-12-27.
  9. M.H. (1 September 2017). "Why transgender people are being sterilized in some European countries". The Economist . Retrieved 2 September 2017.
  10. See WPATH Standards of Care, also WPATH Clarification.
  12. Bradley, Susan J.; Oliver, Gillian D.; Chernick, Avinoam B.; Zucker, Kenneth J. (1998-07-01). "Experiment of Nurture: Ablatio Penis at 2 Months, Sex Reassignment at 7 Months, and a Psychosexual Follow-up in Young Adulthood". Pediatrics. 102 (1): e9. doi:10.1542/peds.102.1.e9. ISSN   0031-4005. PMID   9651461.
  13. United Nations; Office of the High Commissioner for Human Rights (2015). Free & Equal Campaign Fact Sheet: Intersex (PDF).
  14. Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
  15. 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   1-9210370-7-5 ISBN   9-780975-114544
  16. Colapinto, J. (2002). As Nature Made Him: The Boy Who Was Raised as a Girl. Sydney: Harper Collins Publishers. ISBN   0-7322-7433-8 ISBN   9-780732-274337
  17. "Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up". Milton Diamond, Ph.D. Retrieved 1 August 2011.
  18. 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.
  19. Diamond, Milton; Beh, Hazel. (2008). "Changes In Management Of Children With Differences Of Sex Development". Nature Clinical Practice Endocrinology & Metabolism. 4 (1): 4–5. doi:10.1038/ncpendmet0694.
  20. "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.
  21. "WPATH Standards of Care". 2003-12-17. Retrieved 2014-08-11.
  22. See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
  23. See discussion of insurance exclusions at:
  24. AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see:
  25. See WPATH Clarification Statement
  26. APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at:
  27. NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See
  28. Kube, Courtney (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News.
  29. Gaither, Thomas W. et al. Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-to-Female Transgender Patients The Journal of Urology, Volume 199, Issue 3, 760 - 765
  30. 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.CS1 maint: Archived copy as title (link)
  31. 1 2 3 4 5 6 7 8 9 10 11 De 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.
  32. 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.
  33. 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.
  34. 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.
  35. 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.
  36. 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.
  37. 1 2 3 4 5 6 Wierckx, 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.
  38. 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.
  39. 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.
  40. Adams, Cecil (2012). "Does Gender Reassignment Surgery Lead to Happiness?".
  41. Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L. V.; Långström, Niklas; Landén, Mikael (2011). "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden". PLoS ONE. 6 (2): e16885. Bibcode:2011PLoSO...616885D. doi:10.1371/journal.pone.0016885. PMC   3043071 . PMID   21364939.
  42. Olsson, S-E.; Möller, A. (2006). "Regret after sex reassignment surgery in a male-to-female transsexual: a long-term follow-up". Archives of Sexual Behavior. 35 (4): 501–506. CiteSeerX . doi:10.1007/s10508-006-9040-8. PMID   16900416.
  43. Karpel, L.; Cordier, B. (2013). "Postoperative regrets after sex reassignment surgery: A case report". Sexologies. 22 (2): e55–e58. doi:10.1016/j.sexol.2012.08.014.
  44. 1 2 3 Jokić-Begić, N.; Korajlija, A. L.; Jurin, T. (2014). "Psychosocial Adjustment to Sex Reassignment Surgery: A Qualitative Examination and Personal Experiences of Six Transsexual Persons in Croatia". The Scientific World Journal. 2014: 960745. doi:10.1155/2014/960745. PMC   3984784 . PMID   24790589.
  45. Norton, A. T.; Herek, G. M. (2013). "Heterosexuals' attitudes toward transgender people: findings from a national probability sample of u.s. adults". Sex Roles. 68 (11–12): 738–753. doi:10.1007/s11199-011-0110-6.
  46. Bockting, W. (2014). Gender Dysphoria and Disorders of Sex Development. New York, NY, U.S.A: Springer. pp. 319–330.
  47. 1 2 3 4 Selvaggi, 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/ PMID   17413887.CS1 maint: Multiple names: authors list (link)
  48. 1 2 Hage, 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.CS1 maint: Multiple names: authors list (link)
  49. Wierckx, K., Van Caenegem, E., Elaut, E., Dedecker, D., Van de Peer, F., Toye, K., Weyers, S., 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.CS1 maint: Multiple names: authors list (link)
  50. Lawrence, A. A. (2005). "Sexuality before and after male-to-female sex reassignment surgery". Archives of Sexual Behavior. 34 (2): 147–166. CiteSeerX . doi:10.1007/s10508-005-1793-y. PMID   15803249.
  51. 1 2 Gómez-Gil, E., Zubiaurre-Elorza, L., De Antonio, I. E., Guillamon, A., & Salamero, M. (2014). "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. PMID   23943260.CS1 maint: Multiple names: authors list (link)
  52. Ansari, Azadeh (February 23, 2017). "Transgender rights: These countries are ahead of the US". CNN. Retrieved December 10, 2018.
  53. brian (2012-05-13). "Argentina Has Passed the Most Progressive Gender Identity Legislation in Existence". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
  54. 1 2 Anonymous (2012-05-14). "Argentina Adopts Landmark Legislation in Recognition of Gender Identity". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
  55. "– Argentina Gender Identity Law" . Retrieved 2018-12-11.
  56. 1 2 3 brian (2012-08-13). "Chilean Paradoxes: LGBT rights in Latin America". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
  57. "French Law Removes the Surgical Requirement for Legal Gender Recognition". National Center for Transgender Equality. 2016-10-21. Retrieved 2018-12-14.
  58. Toor, Amar (2016-10-14). "Transgender people no longer required to undergo sterilization in France". The Verge. Retrieved 2018-12-14.
  59. "Why transgender people are being sterilised in some European countries". The Economist. 2017-09-01. ISSN   0013-0613 . Retrieved 2018-12-14.
  60. "Sex-change surgery: India's new line in medical tourism". The Hindu. May 7, 2016. Retrieved December 10, 2016.
  61. "WHO | Growing recognition of transgender health". Bulletin of the World Health Organization. 94 (11): 790–791. 2016. doi:10.2471/BLT.16.021116. PMC   5096349 . PMID   27821880 . Retrieved 2018-12-19.
  62. 1 2 3 Hays, Matthew. "Iran's gay plan". CBC News. Archived from the original on August 26, 2009.
  63. 1 2 "Sex change funding undermines no gays claim", Robert Tait, The Guardian , 26 September 2007; accessed 20 September 2008.
  64. Anonymous (2010-10-11). "Malta: UN Committee on the Elimination of Discrimination against Women (CEDAW)". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-18.
  65. 1 2 "Dr. Georges Burou's pioneering technigue for male-to-female surgical sex reassignment". Retrieved 2018-12-14.
  66. Perovic, Sava; Djinovic, Rados (November 2009). "Genitoplasty in male-to-female transsexuals". Current Opinion in Urology. 16 (6): 571–576. doi:10.1097/mou.0b013e3283312eb3. ISSN   0963-0643.
  67. "Islamic Ideology body okays test tube babies, terms sex-change operations 'un-Islamic'". 2013-11-05.
  68. 1 2 Anonymous (2002-06-10). "Spain: Health Care For All!". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
  69. "– Switzerland drops 2-year therapy as surgery-requirement" . Retrieved 2018-12-11.
  70. "Schlumpf v. Switzerland (European Court of Human Rights) – Gender Identity Watch" . Retrieved 2018-12-11.
  71. "Guide on Article 8 of the European Convention on Human Rights: Right to Respect for Private and Family Life, Home and Correspondence". European Court of Human Rights. August 31, 2018. Retrieved December 10, 2018.
  72. "– Administrative District Court of Kiev rules against forced surgery requirement" . Retrieved 2018-12-14.