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Sex Reassignment

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Genital sex reassignment surgery is the final step for many transsexual individuals to live successfully in their preferred gender role. 

The most important procedures to consider are removal of the gonads and genital cosmetic surgery. Cosmetic results of genital surgery have improved and neurological sensation is now typically preserved, resulting in better patient satisfaction with sexual function.

Male-to-female — In addition to gonadectomy, other procedures include penectomy, cosmetic surgery to create a clitoris, and surgical construction of a vagina, usually using the penile skin for vaginal lining and scrotal skin for the labia.

Vaginal dilators should be used on a regular basis postoperatively to maintain the vaginal length until successful and consistent sexual intercourse has been established.

Some individuals choose to have breast augmentation.

Cosmetic facial surgery is also sometimes performed to create more feminine features.

Female-to-male — For female-to-male (FTM) transsexual individuals, an oophorectomy, hysterectomy, and vaginectomy are usually performed after one to two years of androgen therapy, although practice patterns vary.

Sexual function after sex reassignment — Little attention has been given to this subject and all research has been based on self-reports. As expected, there is a correlation between sexual function and the quality of the neovagina or neophallus. While not all postoperative transsexual persons are orgasmic, many more report sexual satisfaction.

A hormonal factor to consider may be the androgen depletion of male-to-female transsexual individuals. It may be that biological women need a small amount of androgens to have normal libido, although this is not proven. By contrast, female-to-male transsexual persons receiving androgens generally note an increase in sexual interest. 

PSYCHOSOCIAL OUTCOMES OF TREATMENT — Sex reassignment that includes hormonal therapies results in significant improvements in quality of life and psychosocial outcomes. This was illustrated in a meta-analysis of 28 studies that enrolled 1833 individuals with gender identity disorder (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. In the pooled analysis, the percentage of patients reporting improvements in symptoms included:

  • Gender dysphoria – 80 percent
  • Psychological symptoms – 78 percent
  • Quality of life – 80 percent
  • Sexual function – 72 percent

SUMMARY AND RECOMMENDATIONS

  • Transsexualism is the condition in which a person with apparently normal somatic sexual differentiation of one gender is convinced that he or she is actually a member of the opposite gender. It is associated with an irresistible urge to be that gender hormonally, anatomically, and psychosocially.
  • If a child's cross-sex gender identity will not change during long-term follow-up, the individual may be treated with GnRH agonists to delay the onset of puberty until an age that a balanced and responsible decision can be made to transition to the other sex.
  • Before initiating hormonal or surgical treatment that will change a person's sex, the clinician should counsel the patient about risks and benefits of the hormonal or surgical therapy, as well as realistic expectations about outcomes.
  • In addition, before undergoing surgical reassignment, individuals are expected to undergo a social transition into the desired gender role by living full-time as a member of the desired gender that is typically initiated before or with hormone therapy.
  • For male-to-female transsexual individuals we suggest antiandrogen therapy with either spironolactone or cyproterone acetate, and transdermal estradiol or oral 17 beta-estradiol for estrogen replacement. We suggest against the use of ethinyl estradiol because of increased short- and long-term risks.
  • For female-to-male transsexual persons, we suggest either testosterone esters administered intramuscularly or transdermal preparations of testosterone. However, initially, clinical results are typically more rapid with parenteral therapy.
  • Male-to-female transsexual persons treated with estrogen should follow the same screening guidelines for breast cancer as biological women. This may apply also to female-to-male transsexual persons whose breast ablation is delayed.


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