Transgender Surgery

Transgender is a term used to describe people whose gender identity does not match the sex they were assigned at birth. Gender identity is a person’s personal sense of being a man or a woman. In other words, for transgender people, the sex that they were born with and their internal gender identity are mismatched.

The term transgender, transsexual or gender diverse, are all synonymous terms used to describe these types of individuals.

History of treatment for transgender individuals

The modern history of transgender people goes back to a time when they were considered to have a serious psychological disorder. As such, treatment was firmly in the domain of the psychiatrists, who were notably unsuccessful in their attempts to heal transgender individuals.

As the years progressed, it became clear that transgender individuals are a diverse group of people with varying personalities, the only exception being that they do not feel they belong to the sex they were assigned at birth.

Modern treatment of transgender individuals

Fortunately, thanks to an environment with increased acceptance, and the advantages of modern medicine and surgery, treatment of transgender individuals has changed. Today, we can assist transgender people with both supplemental hormones and with surgery.

With surgery, we can physically alter the sexual appearance of your upper body, as well as your sexual genetalia, aligning your genital appearance with your gender identity.

There are specific upper body features that characterise a male person and others that characterise a female. These include: forehead shape, brow shape, brow position, nasal shape, nasal size, upper lip length, cheekbone height, chin prominence, Adams apple or thyroid cartilage prominence, as well as voice pitch. There are also the obvious differences of the chest and breasts, as well as with the male and female genitalia.

A lot of these characteristics can be altered with hormonal therapy, but certain characteristics cannot be altered with this type of treatment. For example, facial hair, thyroid cartilage or Adams apple prominence, voice pitch, and the size of your hands cannot be altered with hormone therapy.

Issues arise however, once puberty finishes and some of these characteristics become irreversible. Therefore, if a young person knows that they have a gender identity crisis or feels that they belong to the opposite sex, it is best to initiate this change before puberty, so that these non-reversible changes do not become established.

Under these circumstances, you can transition to full puberty and if you wish, you can undergo gender reassignment surgery after the age of 18.

What is gender transitioning?

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.

Transitioning may involve various forms of medical treatment involving hormonal therapy and psychological counselling. It can also include behavioural therapy to help align your physical characteristics with your gender identity. Affirmed gender is the term used for the gender of the transitioned individual.

What is gender dysphoria?

The medical diagnosis of someone who feels that they do not belong to their assigned birth gender is known as gender dysphoria. This is defined as the experiencing of discomfort or distress, due to a mismatch between your biological sex and your gender identity.

Many transgender individuals who wish to transition or become aligned to their correct gender are prescribed hormones by their doctor or endocrinologist, which will change the physical appearance of their body. Some transgender individuals who transition with hormones will eventually undergo surgery to complete their transition.

Not all transgender people can or will take these steps and it is important to know that transitioning need not involve any form of medical intervention.

Requirements for transgender surgery

There are strict guidelines from the WPATH Society governing what needs to happen before gender reassignment surgery can take place. These requirements are that you must have a constant and consistent desire and have lived as male or female for at least 2 years, and must undergo psychiatric assessment for at least 2 years.

You must also demonstrate that you have lived as male/female for 1 year and dressed according to your desired gender, before considering male to female or female to male gender reassignment surgery (XRS). This type of surgery is also known as gender confirmation surgery.

How is the transgender surgery performed?

Gender affirming surgeries can either be male to female surgery (M2F) or female to male surgery (F2M). Surgery to the top half of your body, which encompasses your facial appearance and the chest/breast area, can be performed before or after genital surgery, however it is more common to do this type of surgery first.

The top half surgery, in both instances, can be done in one stage or numerous stages depending on your wishes. The bottom half surgery in a male to female surgery is usually performed in one stage, but there can be numerous touch ups later, if required.

Female to male surgery is usually performed in a few stages, mainly due to the issue of lengthening of the urethra and insertion of an implant to stiffen the neo-phallus. There are usually three stages involved in female to male surgery.

Male to female (M2F) surgery

Male to female (M2F) surgery is easier to achieve than the female to male (F2M) surgery. The goals of the male to female affirming surgery are most commonly a functioning vagina and a typical female external genitalia that is cosmetically acceptable.

At the time of this operation, the testes are removed (orchiectomy), the penis is excised with preservation of the skin envelope, and a new vagina is reconstructed utilising all of the penile skin. The scrotum is used to reconstruct the labia minora and majora and a clitoroplasty is usually performed, by using a neurovascular island flap and some of the glands of the penis.

Male to female gender affirming surgery takes approximately 3 to 4 hours and requires a general anaesthetic. For the first 2 post-operative days you will need to remain on bed rest and you will have a urinary catheter and some drains as well, which will need to remain in place for up to a week.

Post-operatively, you will be prescribed analgesia (pain medications) and intravenous antibiotics, which will be changed to oral antibiotics a few days after your surgery.

You will remain in the hospital for 8 – 10 days, before being discharged.

It is important to understand that M2F gender affirming surgery will not allow a woman to have any pregnancies or be child bearing. Male to female surgery once performed is totally irreversible.

Female to male (F2M) surgery

Female to male (F2M) surgery is performed in three different stages, with the first stage being the longest. All of the three stages of F2M surgery require general anaesthesia and bladder catheterization.

First stage of F2M surgery

The first stage involves the following operations: an oophorectomy (removal or ovaries), hysterectomy (removal of the uterus) and a vaginectomy (removal of the vagina). The latter operation, a vaginectomy, can be performed at any stage, as it’s not considered to be part of gender affirming surgery.

In addition, a new phallus needs to be fashioned from tissue, which can be harvested from numerous parts of the body. However, microsurgery is often necessary when one transfers tissue from either the forearm or the arm, to the pubic region. For the new phallus, an inner and outer tube need to be fashioned with the inner tube forming the new urethra and the outer tube forming the penis or phallus. This is the first stage of the surgery and might take 4 – 6 hours.

The new urethra must be completely healed and watertight, prior to commencing the second stage of gender reassignment surgery.

Second stage of F2M surgery

In the second stage, the existing urethra (prior to surgery) is joined to the new urethra and the glands are fashioned on the penis.

Third stage of F2M surgery

The last stage of your F2M surgery is the insertion of a prosthesis to keep the phallus’ rigidity. The scrotum are fashioned from the labia and the testes are made by inserting silicone oval shaped implants.

Risks involved in transgender surgery

There are always risks involved with any type of surgery, and M2F and F2M gender reassignment surgeries are no exception.

These risks include: infection, bleeding, delayed healing, skin loss, flap loss, and hypertrophic or keloid scarring. In M2F surgery, injury to the bowel or urethra are also possible and in F2M surgery, injuries to the urethra structures are possible, as are one or more fistulas.

In addition, there is also the possibility of revision operations.

I hope this has given you some insight into transgender surgery or gender confirmation surgery.

If I can be of any more help or if you wish to schedule a consultation with me, please feel welcome to contact my office.

Your consultation can be at any stage of your transition.

 Thank you.