Sex reassignment surgery
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Sex reassignment surgery (initialized as SRS; also known as gender reassignment surgery (GRS), genital reconstruction surgery, sex affirmation surgery, gender confirmation 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. It may also be performed on intersex people, often in infancy and without their consent. A 2013 statement by the United Nations condemns the nonconsensual treatment of normalization surgery to treat intersexuality.
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.
While individuals who have undergone and completed SRS are sometimes referred to as transsexed individuals, 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." 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). 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." Other organizations have issued similar statements, including WPATH, the American Psychological Association, and the National Association of Social Workers.
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.
People with HIV or hepatitis C may have difficulty finding a surgeon able or willing to perform surgery. Many surgeons operate in small private clinics that cannot adequately 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.
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. 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.
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. 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.
This was followed by Lili Elbe in Berlin 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, 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. The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals". 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. 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.
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.
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".
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- 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
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- Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People at the Wayback Machine (archived September 20, 2012)
- "WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Retrieved 2014-08-11.
- See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
- Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
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- The Case Van Kück vs. Germany, June 12 2003