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Sex reassignment surgery (initialized as SRS; also known as gender reassignment surgery (GRS), genital reconstruction surgery, sex realignment surgery, or, colloquially, a sex change) is the surgical procedure (or procedures) by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble that of their identified gender. It is part of a treatment for gender dysphoria in transgender people. Related genital surgeries may also be performed on intersex people, often in infancy. A 2013 statement by the United Nations Special Rapporteur on Torture condemns the nonconsensual use of normalization surgery on intersex people. ^[1]^[2]

Another term for SRS includes sex reconstruction surgery, and more clinical terms, such as feminizing genitoplasty or penectomy , orchiectomy, and vaginoplasty, are used medically for trans women, with masculinizing genitoplasty, metoidioplasty or phalloplasty often similarly used for trans men.

People who pursue sex reassignment surgery are usually referred to as transsexual; "trans"—across, through, change; "sexual"—pertaining to the sexual characteristics (not sexual actions) of a person. More recently, people pursuing SRS may identify as transgender as well as transsexual.^{[citation needed]}

While individuals who have undergone and completed SRS are sometimes referred to as transsexed individuals,^[3] the term transsexed is not to be confused with the term transsexual, which may also refer to individuals who have not undergone SRS, yet whose anatomical sex may not match their psychological sense of personal gender identity.

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, somewhat confusingly, 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."^[4] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial electrolysis.

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).^[5] 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."^[6] Other organizations have issued similar statements, including WPATH,^[7] the American Psychological Association,^[8] and the National Association of Social Workers.^[9]

Differences between trans women and trans men SRS

The array of medically necessary 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 Neo Vagina technique or more recently non-penile inversion techniques that provide greater resemblance to the genitals of genetic women, whereas in the case of trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty. In both cases, for trans women and trans men, genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy.

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 transsexualism. 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.

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 transsexuals solely on the basis of their HIV or hepatitis status.^[10]

Other health conditions such as diabetes, abnormal blood clotting, 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.

Potential future advances

Medical advances may eventually make childbearing possible by using a donor uterus long enough to carry a child to term as anti-rejection drugs do not seem to affect the fetus.^[11]^[12]^[13]^[14] The DNA in a donated ovum can be removed and replaced with the DNA of the receiver. Further in the future, stem cell biotechnology may also make this possible, with no need for anti-rejection drugs.

Standards of care

Sex reassignment surgery can be difficult to obtain, due to a combination of financial barriers 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 transsexualism. For many individuals, these 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 genital reconstruction or other sex reassignment surgeries are permitted.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment for transsexualism, including accessing cross-gender hormone replacement or many surgical interventions. For this and many other reasons, both the WPATH-SOC and other SOCs are 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.

Most 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.^[15]^[16]

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.^[17] 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 other instances legal gender change is prohibited even after genital or other surgery or treatment without recourse, while in other cases, such statutes may specify that genital surgery has been completed.

Physical consequences

A cross-sectional study compared the self-perceived health scores between trans men, Dutch-speaking, community-dwelling men and women. ^[18] In the long-term, trans men still had a comparable self-perceived general physical health with men. Trans men even obtained a higher self-perceived health score than women. It might be explained by the higher level of testosterone in trans men after sex reassignment surgery. Another study showed that transsexual individuals had a similar level of quality of life with the Italian control group.^[19] Another variable, such as face feminization surgery, could affect trans women’s quality of life. Research showed that trans women who had face feminization surgery had a higher satisfaction with different aspects of their quality of life, including their general physical health.^[20]

In the long-term, the sexual health of trans women and trans men were found to be different.^[21] The sex satisfaction was positively related to the satisfaction of new primary sex characteristics. The rate of masturbation also changes after sex reassignment surgery for both trans women and trans men. The trans men group masturbated significantly more often than the trans women group.^[18] 78% of the whole group were able to reach orgasm by masturbation. The feeling of orgasm changed for both groups, trans men reported having a shorter but more powerful orgasm, while trans women reported having a more intense, longer orgasm. When comparing transexuals’ expectations for different aspects of their life, the sexual level has the lowest level of satisfaction among all other levels (physical, emotional and social).^[19] Comparing transsexual and biological individuals of the same gender, trans women had a similar sexual satisfaction with biological women, while trans men had a lower level of sexual satisfaction with biological men. For the sex satisfaction differences between trans men and trans women, trans men had a lower satisfaction in their sexual life than that of trans women.

Psychological 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.^[22] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction.^[23] Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. 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.^[24] Persistent regret is one of the signs implying dissatisfaction 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.^[25] Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Hence, 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.^[26]

Sexual satisfaction

In general, the majority of the transsexual individuals have better sex lives and improved sexual satisfaction after sexual reassignment surgery.^[27] Most of the individuals have reported that they are able to experience sexual excitement during sexual activity, including during masturbation.^[27] Comparing sexes, females-to-male individuals have revealed better capabilities to attain orgasms and an increase in sexual excitement.^[27]^[28] A possible explanation for better satisfaction among transgender people who undergo SRS surgery is that these individuals previously possessed unwanted sex organs and rejected their bodies. As a result, they were not enthusiastic about engaging in sexual activity.^[27]

The ability to obtain orgasms is positively associated with sexual satisfaction.^[28] Frequencies and intensity of orgasms differ to a great extent among transsexual men and transsexual women after SRS. Almost all female-to-male individuals can achieve orgasms through sexual activity with a partner or via masturbation,^[28] whereas about 85% of the male-to-female individuals are able to achieve orgasms after SRS.^[29] In DeCypee et al. (2005)'s study on sexual health after SRS, most of the participants suggested that they are engaging in a transformation in their sexual excitement sensation. The female-to-male transgender individuals experienced intensified and stronger excitements, while male-to-female individuals encountered longer and more gentle feelings.^[27]

An increased frequency in masturbation is exhibited in most transsexual individuals after SRS.^[27]^[28] However, it is reported in a study that female-to-male individuals masturbated more often to male to female.^[27] The possible reasons for the differences is the rise in masturbation frequency could be associated with the surge of libido, caused by the impact of the testosterone therapy, or the stopping of gender dysphoria.^[28]

At birth

Infants born with physical intersex conditions might undergo interventions at or close to birth.^[30] This is controversial because of the human rights implications.^[31]^[32]

History

In Berlin in 1931, Dora R, birth assigned name Rudolph R, became the first known transgender woman to undergo the vaginoplasty ^[33] 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,^[34] but their identity is unclear at this time.

The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.^[35] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".^[35] 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, and/or execution.^[35] 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.^[36]

Thailand is the country that performs the most sex reassignment surgeries, followed by Iran.^[36]

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.^[37]

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".^[38]

The University of Illinois at Urbana-Champaign joined a group of universities that includes sex reassignment surgery in its student health insurance. On March 6, 2014, the Board of Trustees approved to add the surgery to their student health insurance plan. According to Jodi S. Cohen, "the insurance will cover counseling, hormone therapy and surgery related to gender reassignment".^{[citation needed]}

References

^ Report of the UN Special Rapporteur on Torture, Office of the UN High Commissioner for Human Rights, February 2013.
^ Center for Human Rights & Humanitarian Law; Washington College of Law; American University (2014). Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture's 2013 Thematic Report. Washington, DC: Center for Human Rights & Humanitarian Law.
^ Cuypere, Griet De; TSjoen, Guy; Beerten, Ruth; Selvaggi, Gennaro; Sutter, Petra De; Hoebeke, Piet; Monstrey, Stan; Vansteenwegen, Alfons; Rubens, Robert (2005-12-01). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. ISSN 0004-0002.
^ see WPATH "Clarification on Medical Necessity of Treatment, sex Reassignment, and Insurance Coverage in the U.S." available at: http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf
^ See discussion of insurance exclusions at: http://www.hrc.org/issues/transgender/9568.htm
^ AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf
^ See WPATH Clarification Statement
^ APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf
^ NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
^ See WPATH Standards of Care, also WPATH Clarification. www.wpath.org
^ Doctors plan uterus transplants to help women with removed, damaged wombs have babies. Associated Press.
^ Fageeh W, Raffa H, et al. (March 2002). "Transplantation of the human uterus". International Journal of Gynaecology and Obstetrics. 76 (3): 245–51. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127.
^ Del Priore G, Stega J, et al. (January 2007). "Human uterus retrieval from a multi-organ donor". Obstetrics and Gynecology. 109 (1): 101–4. doi:10.1097/01.AOG.0000248535.58004.2f. PMID 17197594.
^ Nair A, Stega J, et al. (April 2008). "Uterus Transplant: Evidence and Ethics". Annals of the New York Academy of Sciences. 1127 (1): 83–91. doi:10.1196/annals.1434.003. PMID 18443334.
^ Template:Wayback
^ "WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Retrieved 2014-08-11.
^ See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
^ ^a ^b Cuypere, Griet De; TSjoen, Guy; Beerten, Ruth; Selvaggi, Gennaro; Sutter, Petra De; Hoebeke, Piet; Monstrey, Stan; Vansteenwegen, Alfons; Rubens, Robert (2005-12-01). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior. 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. ISSN 0004-0002.
^ ^a ^b 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.
^ 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.
^ Wierckx, Katrien; Caenegem, Eva Van; Elaut, Els; Dedecker, David; Peer, Fleur Van de; Toye, Kaatje; Weyers, Steven; Hoebeke, Piet; Monstrey, Stan. "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.
^ 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. {{cite journal}}: More than one of |pages= and |page= specified (help)
^ 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. {{cite journal}}: More than one of |pages= and |page= specified (help)
^ Lawrence, A. A. (2003). "Factors associated with satisfaction or regret following male-to-female sex reassignment surgery". Archives of Sexual Behaviour. 32 (4): 299. {{cite journal}}: More than one of |pages= and |page= specified (help)
^ 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 Behaviour. 35 (4): 501. {{cite journal}}: More than one of |pages= and |page= specified (help)
^ Natasa, J-B.; Korajlija, A. L.; Tanja, J. (2014). "Psychosocial adjustment to sex reassignment surgery: a qualitative examination and personal experiences of six transsexual persons in croatia". The Scientific World Journal.
^ ^a ^b ^c ^d ^e ^f ^g De Cuypere, G., TSjoen, G., Beerten, R., Selvaggi, G., De Sutter, P., Hoebeke, P., Monstrey, S., Vansteenwegen, A. & Rubens, R. (2015). "Sexual and physical health after sex reassignment surgery". Archives of sexual behavior, 34(6), pp.679-690.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ ^a ^b ^c ^d ^e 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), pp.3379-3388.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Lawrence, A. A. (2005). "Sexuality before and after male-to-female sex reassignment surgery". Archives of sexual behavior, 34(2), pp.147-166.
^ 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–e9. ISSN 0031-4005. PMID 10617723.
^ United Nations; Office of the High Commissioner for Human Rights (2015). Free & Equal Campaign Fact Sheet: Intersex (PDF).
^ Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
^ http://www.transmediawatch.org/timeline.html
^ Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
^ ^a ^b ^c Iran's gay plan, Matthew Hays, Canadian Broadcasting Corporation, 26 August 2008; accessed 20 September 2008.
^ ^a ^b "Sex change funding undermines no gays claim", Robert Tait, The Guardian, 26 September 2007; accessed 20 September 2008.
^ The Case Van Kück vs. Germany, June 12 2003
^ International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex". Retrieved 2015-12-27.

[untorture-1] Report of the UN Special Rapporteur on Torture, Office of the UN High Commissioner for Human Rights, February 2013.

[wash-2] Center for Human Rights & Humanitarian Law; Washington College of Law; American University (2014). Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture's 2013 Thematic Report. Washington, DC: Center for Human Rights & Humanitarian Law.

[vc.bridgew.edu-3] Cuypere, Griet De; TSjoen, Guy; Beerten, Ruth; Selvaggi, Gennaro; Sutter, Petra De; Hoebeke, Piet; Monstrey, Stan; Vansteenwegen, Alfons; Rubens, Robert (2005-12-01). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. ISSN 0004-0002.

[wpath.org-4] see WPATH "Clarification on Medical Necessity of Treatment, sex Reassignment, and Insurance Coverage in the U.S." available at: http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf

[hrc.org-5] See discussion of insurance exclusions at: http://www.hrc.org/issues/transgender/9568.htm

[ama-assn.org-6] AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf

[7] See WPATH Clarification Statement

[8] APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf

[9] NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org

[10] See WPATH Standards of Care, also WPATH Clarification. www.wpath.org

[11] Doctors plan uterus transplants to help women with removed, damaged wombs have babies. Associated Press.

[Fageeh2002-12] Fageeh W, Raffa H, et al. (March 2002). "Transplantation of the human uterus". International Journal of Gynaecology and Obstetrics. 76 (3): 245–51. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127.

[Priore2007-13] Del Priore G, Stega J, et al. (January 2007). "Human uterus retrieval from a multi-organ donor". Obstetrics and Gynecology. 109 (1): 101–4. doi:10.1097/01.AOG.0000248535.58004.2f. PMID 17197594.

[Nair2008-14] Nair A, Stega J, et al. (April 2008). "Uterus Transplant: Evidence and Ethics". Annals of the New York Academy of Sciences. 1127 (1): 83–91. doi:10.1196/annals.1434.003. PMID 18443334.

[15] Template:Wayback

[16] "WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Retrieved 2014-08-11.

[17] See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement

[:3-18] Cuypere, Griet De; TSjoen, Guy; Beerten, Ruth; Selvaggi, Gennaro; Sutter, Petra De; Hoebeke, Piet; Monstrey, Stan; Vansteenwegen, Alfons; Rubens, Robert (2005-12-01). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior. 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. ISSN 0004-0002.

[:4-19] 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.

[20] 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.

[21] Wierckx, Katrien; Caenegem, Eva Van; Elaut, Els; Dedecker, David; Peer, Fleur Van de; Toye, Kaatje; Weyers, Steven; Hoebeke, Piet; Monstrey, Stan. "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.

[22] 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. {{cite journal}}: More than one of |pages= and |page= specified (help)

[23] 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. {{cite journal}}: More than one of |pages= and |page= specified (help)

[24] Lawrence, A. A. (2003). "Factors associated with satisfaction or regret following male-to-female sex reassignment surgery". Archives of Sexual Behaviour. 32 (4): 299. {{cite journal}}: More than one of |pages= and |page= specified (help)

[25] 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 Behaviour. 35 (4): 501. {{cite journal}}: More than one of |pages= and |page= specified (help)

[26] Natasa, J-B.; Korajlija, A. L.; Tanja, J. (2014). "Psychosocial adjustment to sex reassignment surgery: a qualitative examination and personal experiences of six transsexual persons in croatia". The Scientific World Journal.

[:0-27] ^ ^a ^b ^c ^d ^e ^f ^g De Cuypere, G., TSjoen, G., Beerten, R., Selvaggi, G., De Sutter, P., Hoebeke, P., Monstrey, S., Vansteenwegen, A. & Rubens, R. (2015). "Sexual and physical health after sex reassignment surgery". Archives of sexual behavior, 34(6), pp.679-690.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[:1-28] 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), pp.3379-3388.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[29] Lawrence, A. A. (2005). "Sexuality before and after male-to-female sex reassignment surgery". Archives of sexual behavior, 34(2), pp.147-166.

[:2-30] 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–e9. ISSN 0031-4005. PMID 10617723.

[un-fact-31] United Nations; Office of the High Commissioner for Human Rights (2015). Free & Equal Campaign Fact Sheet: Intersex (PDF).

[coe-32] Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper

[33] ttp://www.transmediawatch.org/timeline.html

[34] Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908

[SexChange-35] Iran's gay plan, Matthew Hays, Canadian Broadcasting Corporation, 26 August 2008; accessed 20 September 2008.

[Guardian-36] "Sex change funding undermines no gays claim", Robert Tait, The Guardian, 26 September 2007; accessed 20 September 2008.

[37] The Case Van Kück vs. Germany, June 12 2003

[icj2-38] International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex". Retrieved 2015-12-27.

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 A cross-sectional study compared the self-perceived health scores between trans men, Dutch-speaking, community-dwelling men and women. <ref name=":3">{{Cite journal|last=Cuypere|first=Griet De|last2=TSjoen|first2=Guy|last3=Beerten|first3=Ruth|last4=Selvaggi|first4=Gennaro|last5=Sutter|first5=Petra De|last6=Hoebeke|first6=Piet|last7=Monstrey|first7=Stan|last8=Vansteenwegen|first8=Alfons|last9=Rubens|first9=Robert|date=2005-12-01|title=Sexual and Physical Health After Sex Reassignment Surgery|url=http://link.springer.com/article/10.1007/s10508-005-7926-5|journal=Archives of Sexual Behavior|language=en|volume=34|issue=6|pages=679–690|doi=10.1007/s10508-005-7926-5|issn=0004-0002}}</ref> In the long-term, trans men still had a comparable self-perceived general physical health with men. Trans men even obtained a higher self-perceived health score than women. It might be explained by the higher level of testosterone in trans men after sex reassignment surgery. Another study showed that transsexual individuals had a similar level of quality of life with the Italian control group.<ref name=":4">{{Cite journal|last=Castellano|first=E.|last2=Crespi|first2=C.|last3=Dell’Aquila|first3=C.|last4=Rosato|first4=R.|last5=Catalano|first5=C.|last6=Mineccia|first6=V.|last7=Motta|first7=G.|last8=Botto|first8=E.|last9=Manieri|first9=C.|date=2015-10-20|title=Quality of life and hormones after sex reassignment surgery|url=http://link.springer.com/article/10.1007/s40618-015-0398-0|journal=Journal of Endocrinological Investigation|language=en|volume=38|issue=12|pages=1373–1381|doi=10.1007/s40618-015-0398-0|issn=1720-8386}}</ref> Another variable, such as [[Facial_feminization_surgery|face feminization surgery]], could affect trans women’s quality of life. Research showed that trans women who had [[Facial_feminization_surgery|face feminization surgery]] had a higher satisfaction with different aspects of their quality of life, including their general physical health.<ref>{{Cite journal|last=Ainsworth|first=Tiffiny A.|last2=Spiegel|first2=Jeffrey H.|date=2010-05-12|title=Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery|url=http://link.springer.com/article/10.1007/s11136-010-9668-7|journal=Quality of Life Research|language=en|volume=19|issue=7|pages=1019–1024|doi=10.1007/s11136-010-9668-7|issn=0962-9343}}</ref>
-In the long-term, the sexual health of trans women and trans men were found to be different.<ref>{{Cite journal|last=Wierckx|first=Katrien|last2=Caenegem|first2=Eva Van|last3=Elaut|first3=Els|last4=Dedecker|first4=David|last5=Peer|first5=Fleur Van de|last6=Toye|first6=Kaatje|last7=Weyers|first7=Steven|last8=Hoebeke|first8=Piet|last9=Monstrey|first9=Stan|title=Quality of Life and Sexual Health after Sex Reassignment Surgery in Transsexual Men|url=http://linkinghub.elsevier.com/retrieve/pii/S1743609515333695|journal=The Journal of Sexual Medicine|volume=8|issue=12|pages=3379–3388|doi=10.1111/j.1743-6109.2011.02348.x}}</ref> The sex satisfaction was positively related to the satisfaction of new primary sex characteristics. The rate of masturbation also changes after sex reassignment surgery for both trans women and trans men. The trans men group masturbated significantly more often than the trans women group.<ref name=":3" /> 78% of the whole group were able to reach orgasm by masturbation. The feeling of orgasm changed for both groups, trans men reported having a shorter but more powerful orgasm, while trans women reported having a more intense, longer orgasm. When comparing transexuals’ expectations for different aspects of their life, the sexual level has the lowest level of satisfaction among all other levels (physical, emotional and social).<ref name=":4" /> Comparing transsexual and biological individuals of the same gender, trans women had a similar sexual satisfaction with biological women, while trans men had a lower level of sexual satisfaction with biological men. For the sex satisfaction differences between trans men and trans women, trans men had a lower satisfaction in their sexual life than that of trans women.
+In the long-term, the sexual health of trans women and trans men were found to be different.<ref>{{Cite journal|last=Wierckx|first=Katrien|last2=Caenegem|first2=Eva Van|last3=Elaut|first3=Els|last4=Dedecker|first4=David|last5=Peer|first5=Fleur Van de|last6=Toye|first6=Kaatje|last7=Weyers|first7=Steven|last8=Hoebeke|first8=Piet|last9=Monstrey|first9=Stan|title=Quality of Life and Sexual Health after Sex Reassignment Surgery in Transsexual Men|url=http://linkinghub.elsevier.com/retrieve/pii/S1743609515333695|journal=The Journal of Sexual Medicine|volume=8|issue=12|pages=3379–3388|doi=10.1111/j.1743-6109.2011.02348.x}}</ref> The sex satisfaction was positively related to the satisfaction of new primary sex characteristics. The rate of [[Masturbation|masturbation]] also changes after sex reassignment surgery for both trans women and trans men. The trans men group masturbated significantly more often than the trans women group.<ref name=":3" /> 78% of the whole group were able to reach orgasm by [[Masturbation|masturbation]]. The feeling of orgasm changed for both groups, trans men reported having a shorter but more powerful orgasm, while trans women reported having a more intense, longer orgasm. When comparing transexuals’ expectations for different aspects of their life, the sexual level has the lowest level of satisfaction among all other levels (physical, emotional and social).<ref name=":4" /> Comparing transsexual and biological individuals of the same gender, trans women had a similar sexual satisfaction with biological women, while trans men had a lower level of sexual satisfaction with biological men. For the sex satisfaction differences between trans men and trans women, trans men had a lower satisfaction in their sexual life than that of trans women.
 == Psychological consequences ==