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Gender reassignment surgery: an overview

This article has been updated

Abstract

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

Key Points

  • The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

  • Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

  • Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

  • Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

  • In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

  • In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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Figure 1: Male-to-female genital surgery.
Figure 2: Phalloplasty techniques in female-to-male genital surgery.
Figure 3: The Norfolk technique for glans sculpturing.

Change history

  • 26 April 2011

    In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

References

  1. Meyer, W. 3rd. et al. The Harry Benjamin International Gender Dysphoria Association's standards of care for gender identity disorders, sixth version. World Professional Association for Transgender Health [online], (2001).

    Google Scholar 

  2. Bakker, A., Van Kesteren, P., Gooren, L. & Bezemer, P. The prevalence of transsexualism in The Netherlands. Acta Psychiatr. Scand. 87, 237–238 (1993).

    CAS  Article  Google Scholar 

  3. Selvaggi, G. et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast. Reconstr. Surg. 116, 135e–145e (2005).

    Article  Google Scholar 

  4. Benjamin, H. (ed.) The Transsexual Phenomenon (Julian Press Inc., New York, 1966).

    Google Scholar 

  5. World Professional Association for Transgender Health [online], (2010).

  6. Zhou, J. N., Hofman, M. A., Gooren, L. J. & Swaab, D. F. A sex difference in the human brain and its relation to transsexuality. Nature 378, 68–70 (1995).

    CAS  Article  Google Scholar 

  7. Kruijver, F. P. et al. Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J. Clin. Endocrinol. Metab. 85, 2034–2041 (2000).

    CAS  Article  Google Scholar 

  8. Swaab, D. F., Chun, W. C., Kruijver, F. P., Hofman, M. A. & Ishuina, T. A. Sexual differentiation of the human hypothalamus. Adv. Exp. Med. Biol. 511, 75–105 (2002).

    Article  Google Scholar 

  9. Garcia-Falgueras, A. & Swaab, D. F. A sex difference in the hypothalamic uncinate nucleus: relationship to gender identity. Brain 131, 3115–3117 (2008).

    Article  Google Scholar 

  10. Cohen-Kettenis, P. & Kuiper, B. Transseksualiteit en psychotherapie [Dutch]. Tijdschr. Psychoth. 3, 153–166 (1984).

    Google Scholar 

  11. Kuiper, B. & Cohen-Kettenis, P. Sex reassignment surgery: a study of 141 Dutch transsexuals. Arch. Sex. Behav. 17, 439–457 (1988).

    CAS  Article  Google Scholar 

  12. Kanhai, R. C., Hage, J. J., Karim, R. B. & Mulder, J. W. Exceptional presenting conditions and outcome of augmentation mammoplasty in male-to female transsexuals. Ann. Plast. Surg. 43, 476–483 (1999).

    CAS  Article  Google Scholar 

  13. Kanagalingm, J. et al. Cricothyroid approximation and subluxation in 21 male-to-female transsexuals. Laryngoscope 115, 611–618 (2005).

    Article  Google Scholar 

  14. Bouman, M. Laparoscopic assisted colovaginoplasty. Presented at the 2009 biennial World Professional Association for Transgender Health meeting, Oslo.

  15. Rubin, S. O. Sex-reassignment surgery male-to-female. Review, own results and report of a new technique using the glans penis as a pseudoclitoris. Scand. J. Urol. Nephrol. Suppl. 154, 1–28 (1993).

    CAS  PubMed  Google Scholar 

  16. Fang, R. H., Chen, C. F. & Ma, S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast. Reconstr. Surg. 89, 679–682 (1992).

    CAS  Article  Google Scholar 

  17. Selvaggi, G. et al. Genital sensitivity in sex reassignment surgery. Ann. Plast. Surg. 58, 427–433 (2007).

    CAS  Article  Google Scholar 

  18. Watanayusakul, S. SRS procedures. The Suporn Clinic [online], (2010).

    Google Scholar 

  19. Melzer, T. Managing complications of male to female surgery. Presented at the 2007 World Professional Association for Transgender Health biennial meeting, Chicago.

  20. Gilleard, O., Qureshi, M., Thomas, P. & Bellringer, J. Urethral bleeding following male to female gender reassignmetn surgery. Presented at the 2009 World Professional Association for Transgender Health biennial meeting, Oslo.

  21. Beckley, I., Thomas, P. & Bellringer, J. Aetiology and management of recto-vaginal fistulas following male to female gender reassignment. Presented at 2008 EAU section of genitourinary surgeons and the EAU section of andrological urology meeting, Madrid.

  22. Monstrey, S. et al. Chest wall contouring surgery in female-to-male (FTM) transsexuals: a new algorithm. Plast. Reconstr. Surg. 121, 849–859 (2008).

    CAS  Article  Google Scholar 

  23. Mueller, A. & Gooren, L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur. J. Endocrinol. 159, 197–202 (2008).

    CAS  Article  Google Scholar 

  24. Selvaggi, G., Elander, A. & Branemark, R. Penile epithesis: preliminary study. Plast. Reconstr. Surg. 126, 265e–266e (2010).

    Article  Google Scholar 

  25. Selvaggi, G. & Elander, A. Penile reconstruction/formation. Curr. Opin. Urol. 18, 589–597 (2008).

    Article  Google Scholar 

  26. Gilbert, D. A., Jordan, G. H., Devine, C. J. Jr & Winslow, B. H. Microsurgical forearm “cricket bat-transformer” phalloplasty. Plast. Reconstr. Surg. 90, 711–716 (1992).

    CAS  Article  Google Scholar 

  27. Bettocchi, C., Ralph, D. J. & Pryor, J. P. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95, 120–124 (2005).

    Article  Google Scholar 

  28. Monstrey, S. et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast. Reconstr. Surg. 124, 510–518 (2009).

    CAS  Article  Google Scholar 

  29. Selvaggi, G. et al. Donor-site morbidity of the radial forearm free flap after 125 phalloplasties in gender identity disorder. Plast. Reconstr. Surg. 118, 1171–1177 (2006).

    CAS  Article  Google Scholar 

  30. Hoebeke, P. et al. Impact of sex reassignment surgery on lower urinary tract function. Eur. Urol. 47, 398–402 (2005).

    Article  Google Scholar 

  31. Agrawal, V. & Ralph, D. An audit of implanted penile prosteses in the UK. BJU Int. 98, 393–395 (2006).

    Article  Google Scholar 

  32. Hoebeke, P. B. et al. Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur. Urol. 57, 334–340 (2010).

    Article  Google Scholar 

  33. Vesely, J. et al. New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals. Ann. Plast. Surg. 58, 544–550 (2007).

    CAS  Article  Google Scholar 

  34. Selvaggi, G. et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast. Reconstr. Surg. 123, 1710–1718 (2009).

    CAS  Article  Google Scholar 

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G. Selvaggi and J. Bellringer contributed equally to the research, discussions, writing, reviewing, and editing of this article.

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Correspondence to James Bellringer.

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The authors declare no competing financial interests.

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Selvaggi, G., Bellringer, J. Gender reassignment surgery: an overview. Nat Rev Urol 8, 274–282 (2011). https://doi.org/10.1038/nrurol.2011.46

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