Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.
Notes and references
Sex reassignment surgery
Also known as sex change or gender reassignment surgery, sex reassignment surgery is a procedure that changes genital organs from one gender to another.
There are two main reasons to alter the genital organs from one sex to another.
- Newborns with intersex deformities must early on be assigned to one sex or the other. These deformities represent intermediate stages between the primordial female genitals and the change into male genitals caused by male hormone stimulation.
- Both men and women occasionally believe they are physically a different sex than they are mentally and emotionally. This dissonance is so profound that they are willing to be surgically altered.
In both cases, technical considerations favor successful conversion to a female rather than a male. Newborns with ambiguous organs will almost always be assigned to the female gender unless the penis is at least an inch long. Whatever their chromosomes, they are much more likely to be socially well adjusted as females, even if they cannot have children.
Reliable statistics are extremely difficult to obtain. Many sexual reassignment procedures are conducted in private facilities that are not subject to reporting requirements. Sexual reassignment surgery is often conducted outside of the United States. The number of gender reassignment procedures conducted in the United States each year is estimated at between 100 and 500. The number worldwide is estimated to be two to five times larger.
Converting male to female anatomy requires removal of the penis, reshaping genital tissue to appear more female, and constructing a vagina. A vagina can be successfully formed from a skin graft or an isolated loop of intestine. Following the surgery, female hormones (estrogen) will reshape the body's contours and stimulate the growth of satisfactory breasts.
Female to male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals. Penis construction is not attempted less than a year after the preliminary surgery to remove the female organs. One study in Singapore found that a third of the persons would not undergo the surgery again. Nevertheless, they were all pleased with the change of sex. Besides the genital organs, the breasts need to be surgically altered for a more male appearance. This can be successfully accomplished.
The capacity to experience an orgasm, or at least "a reasonable degree of erogenous sensitivity," can be expected by almost all persons after gender reassignment surgery.
Gender identity is an extremely important characteristic for human beings. Assigning it must take place immediately after birth, for the mental health of both children and their parents. Changing sexual identity is among the most significant changes that a human can experience. It should therefore be undertaken with extreme care and caution. By the time most adults come to surgery, they have lived for many years with a dissonant identity. The average in one study was 29 years. Nevertheless, even then they may not be fully aware of the implications of becoming a member of the opposite gender.
In-depth psychological counseling should precede and follow any gender reassignment surgical procedure.
Sex change surgery is expensive. The cost for male to female reassignment is $7,000 to $24,000. The cost for female to male reassignment can exceed $50,000.
Social support, particularly from one's family, is important for readjustment as a member of the opposite gender. If surgical candidates are socially or emotionally unstable before the operation, over the age of 30, or have an unsuitable body build for the new gender, they tend not to fare well after gender reassignment surgery. However, in no case studied did the gender reassignment procedure diminish their ability to work.
All surgery carries the risks of infection, bleeding, and a need to return for repairs. Gender reassignment surgery is irreversible, so a candidate must have no doubts about accepting the results and outcome.
Persons undergoing gender reassignment surgery can expect to acquire the external genitalia of a member of the opposite gender. Persons having male to female gender reassignment surgery retain a prostate. Individuals undergoing female to male gender reassignment surgery undergo a hysterectomy to remove the uterus and oophorectomy to remove their ovaries. Developing the habits and mannerisms characteristic of the patient's new gender requires many months or years.
Illustration by GGS Inc.)
Morbidity and mortality rates
The risks that are associated with any surgical procedure are present in gender reassignment surgery. These include infection, postoperative pain, and dissatisfaction with anticipated results. Accurate statistics are extremely difficult to find. Intraoperative death has not been reported.
The most common complication of male to female surgery is narrowing of the new vagina. This can be corrected by dilation or using a portion of colon to form a vagina.
A relatively common complication of female to male surgery is dysfunction of the penis. Implanting a penile prosthesis is technically difficult and does not have uniformly acceptable results.
Psychiatric care may be required for many years after sex-reassignment surgery.
The number of deaths in male-to-female transsexuals was five times the number expected, due to increased numbers of suicide and death from unknown cause.
There is no alternative to surgical reassignment to alter one's external genitalia. The majority of persons who experience gender disorder problems never surgically alter their appearance. They dress as members of the desired gender, rather than gender of birth. Many use creams or pills that contain hormones appropriate to the desired gender to alter their bodily appearance. Estrogens (female hormones) will stimulate breast development, widening of the hips, loss of facial hair and a slight increase in voice pitch. Androgens (male hormones) will stimulate the development of facial and chest hair and cause the voice to deepen. Most individuals who undergo gender reassignment surgery lead happy and productive lives.
Bostwick, John. Plastic and Reconstructive Breast Surgery, 2nd edition. St. Louis: Quality Medical Publishers, 1999.
Engler, Alan M. Body Sculpture: Plastic Surgery of the Body for Men and Women, 2nd edition. New York: Hudson, 2000.
Tanagho, Emil A. and Jack W. McAninch. Smith's General Urology, 15th Edition. New York: McGraw-Hill, 2000.
Walsh, Patrick C. and Alan B. Retik. Campbell's Urology, 8th Edition. Philadelphia: Saunders, 2002.
Wilson, Josephine F. Biological Foundations of Human Behavior. New York: Harcourt, 2002.
Asscheman, H., L. J. Gooren, and P. L. Eklund. "Mortality and Morbidity in Transsexual Patients with Cross-Gender Hormone Treatment." Metabolism 38, No. 9 (1989): 869–73.
Docter, R. F. and J. S. Fleming. "Measures of Transgender Behavior." Archives of Sexual Behavior 30, No. 3 (2001): 255–71.
Fugate, S. R., C. C. Apodaca, and M. L. Hibbert. "Gender Reassignment Surgery and the Gynecological Patient." Primary Care Update for Obstetrics and Gynecology 8, No. 1 (2001): 22–4.
Harish, D., and B. R. Sharma. "Medical Advances in Transsexualism and the Legal Implications." American Journal of Forensic Medicine and Pathology 24, No. 1 (2003): 100–05.
Jarolim, L. "Surgical Conversion of Genitalia in Transsexual Patients." British Journal of Urology International 85, No. 7 (2000): 851–56.
Monstrey, S., P. Hoebeke, M. Dhont, G. De Cuypere, R. Rubens, M. Moerman, M. Hamdi, K. Van Landuyt, and P. Blondeel. "Surgical Therapy in Transsexual Patients: A Multi-disciplinary Approach." Annals of Surgery (Belgium) 101, No. 5 (2001): 200–09.
American Medical Association. 515 N. State Street, Chicago, IL 60610, Phone: (312) 464-5000. http://www.ama-assn.org/ .
American Psychiatric Association. 1400 K Street NW, Washington, DC 20005, (888) 357-7924. Fax: (202) 682-6850. firstname.lastname@example.org.
American Psychological Association. 750 First Street NW, Washington, DC, 20002-4242. (800) 374-2721 or (202) 336-5500. http://www.apa.org/ .
American Urological Association. 1120 North Charles Street, Baltimore, MD 21201-5559. (410) 727-1100. http://www.auanet.org/index_hi.cfm .
Health A to Z [cited March 24, 2003]. http://www.healthatoz.com/healthatoz/Atoz/ency/sex_change_surgery.html .
Hendrick Health System [cited March 24, 2003]. http://www.hendrickhealth.org/healthy/001240.htm .
Intersex Society of North America [cited March 24, 2003]. http://www.isna.org/newsletter/ .
University of Missouri-Kansas City [cited March 24, 2003]. http://www.umkc.edu/sites/hsw/gendid/srs.html .
L. Fleming Fallon, Jr., MD, DrPH
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Gender reassignment surgery is performed by surgeons with specialized training in urology, gynecology, or plastic and reconstructive surgery. The surgery is performed in a hospital setting, although many procedures are completed in privately owned clinics.
QUESTIONS TO ASK THE DOCTOR
- What will my body look like afterward?
- Is the surgeon board-certified in urology, gynecology, or plastic and reconstructive surgery?
- How many gender reassignment procedures has the surgeon performed?
- How many of the type similar to the one being contemplated (i.e., male to female or female to male) has the surgeon performed?
- What is the surgeon's complication rate?