Gender dysphoria is a complex condition where a person experiences a conflict between the gender with which they identify and their biologically determined sex and gender role.
Persons with gender dysphoria often prefer to live and be treated as a member of the opposite sex due to an enduring dissatisfaction with their birth sex. Transsexuals have a life-long and extreme form of gender dysphoria which prompts them to alter their sex using hormone treatment and surgery.
Gender reassignment surgery has been purported as an effective intervention in patients with severe gender dysphoria. This article hopes to explore further the surgical procedures involved in gender reassignment and will also briefly cover the additional interventions involved in the complete process of transitioning from one gender to another.
A form of transexualism was first described within the medical community in 1886 by a German doctor called Richard von Krafft-Ebing. He defined a condition where a homosexual person believed him or herself to be of the opposite gender without any physical transformation. He labelled this condition metamorphosis sexualis paranoia. 
The term transsexualism itself was coined by Dr. Magnus Hirschfeld in his 1923 work ‘Die intersexuelle Knonstitution.’ Hirschfeld was also the first physician to begin exploring the potential for a surgical procedure to enable a gender transition. He collaborated with Eugen Steinach, a Viennese physician who had experimented extensively with gonadal transplantation in animals. Steinach was the first to hypothesise that the gonads contained substances which influenced sex and gender. Hirschfeld went on to establish the ‘Institut fur Sexualwissenschaft’ (Institute for Sexual Research) in order to further research into sexuality and gender reassignment surgery.
Gender reassignment surgery was first pioneered by Erwin Gohrbandt in 1921 on a patient, Dӧrchen Richter (born Rudolf Richter), who was referred to him by Hirschfeld. The surgery involved a bilateral orchiectomy (castration) in order to reduce circulating testosterone levels. Richter then went on to successfully undergo a penectomy and vaginoplasty in 1931 which were performed by Felix Abraham and Ludwig Levy-Lenz at the Institute for Sexual Research. In the same year, a prominent Danish transvestite, Lili Elbe (born Einar Mogens Wegener), also underwent gender reassignment surgery performed by Abraham and Levy-Lenz. This surgery, however, was unsuccessful as Elbe succumbed to surgery-related complications during an early attempt at ovary transplantation.
Further progress and research in the field was hampered by the persecution of homosexual and transsexual persons under Nazi rule in Germany. Hirchfeld, himself a transvestite, was exiled to France while Steinach and Levy-Lenz lived precariously under Nazi surveillance. Abraham was consigned to a concentration camp where he later died. Gohrbandt, however, went on to become a general for the Luftwaffe and participated in lethal hypothermia experiments at Dachau Concentration Camp. After the war, he escaped prosecution and retired with considerable respectability and wealth.
More recently, Dr. Harry Benjamin of the John Hopkins Gender Identity Clinic is widely regarded as the first clinician to describe the symptoms and signs of a condition where a person has a severe discomfort with their biological sex which he termed ‘gender dysphoria’. He began treating his patients with hormone therapy in 1949.
Gradually, gender reassignment surgery has become more available in many countries. Britain joined the ranks in 1967 with changes in legalisation allowing the procedures to be carried out at Charing Cross Hospital. Surgeons Peter Phillip and John Randell were responsible for many of the procedures carried out regularly in the 1960s. Gender reassignment surgery gradually gained more recognition as a treatment for severe gender dysphoria with NHS funding becoming available in 1999. The estimated cost to the NHS for each gender reassignment surgery is approximately 10,000 to 40,000 pounds.
Changes in legislation have further complemented the progress in transgender surgery. An important piece of legislation which was implemented in 2004 is the Gender Recognition Act which legally recognises a trans-man as male and a trans-woman as female.
- Prevalence of M-to-F transsexualism
- Prevalence of F-to-M transsexualism
- Average age at transition
- Patient satisfaction (psychological adjustment, absence of regret and vocational adjustment)
- 1 in 30,000 
- 1 in 100,000 
- 42 
- >90% 
1. Diagnostic criteria in ICD-10 
- Transexualism (F64.0)
- The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preffered sex through surgery and hormone treatment
- The transsexual identity has been present persistently for at least two years
- The disorder is not a symptom of another mental disorder or a chromosomal abnormality
2. Diagnostic critera in DSM-IV-TR 
- Gender Identity Disorder (302.85, 302.6)
- Long-standing and strong identification with another gender
- Long-stanging disquiet about the sex assigned or sense of incongruity in the gender-assigned role of that sex
- The diagnosis is not made if the individual also has physical intersex characteristics
- Significant clinical discomfort or impairment at work, social situations, or other important life areas
Non-surgical Treatment and Indications
Although the number of GRS being performed is on the rise, the total number is still small. It is also valuable to note that only a small proportion of transsexual individuals elect for GRS. This is largely a matter of personal preference and may be due to the irreversible nature of the operation, an inability to cope reasonably with recovery and dissatisfaction with the potential surgical outcomes.
It is thus important to familiarise oneself with the numerous sources of support and treatment available for a person with gender dysphoria which help to augment their care irrespective of whether they choose to undergo surgery. The options available vary according to the age at presentation and severity of the condition and these can be discussed thoroughly during targeted counselling sessions.
Treatment in Children
Children under the age of 18 are first referred to a specialist child and adolescent gender identity clinic where they will undergo screening for gender dysphoria. Following a full assessment of the child treatment can be arranged.
Children 16 and under (Pre-pubertal)
Endocrine treatment is not available to pre-pubertal children (Endocrine Society Guidelines) as a diagnosis of transsexualism can only be made once a child has reached puberty. 75 to 80% of pre-pubertal children diagnosed with gender dysphoria do not fulfil the criteria after puberty. 
Children 16 and under (Post-pubertal)
Endocrine treatment can be commenced if a diagnosis of transsexualism is made by a mental health professional after the onset of puberty. If recommended, gonadotrophin-releasing hormone (GnRH) analogues are administered to supress endogenous hormones. Administration is initiated when a child reaches Tanner stage two of puberty (age 11 in girls and age 12 in boys). GnRH analogues effectively supress puberty until the child reaches 16 years of age from which point hormone therapy can begin. A psychiatrist and endocrinologist must be involved in the care of a child undergoing this treatment. 
Children over 16
If a diagnosis of transsexualism persists over the age of 16 after the child has been taking GnRH analogues for several years they are offered cross-sex hormones. Cross-sex hormones alter a child’s body composition and structure such that they more closely resemble that of their gender identity. Cross-sex hormone treatment is only partially reversible and hence should be commenced with care after careful consideration. 
Treatment in Adults
After referral to a specialist gender identity clinic an adult with gender dysphoria or transsexualism is provided with various support services such as mental health support, hormone treatment, grooming advice, language and speech therapy, hair removal treatments, peer support groups and relatives’ support groups.
Hormone therapy involves taking testosterone (FTM) or oestrogen (MTF) depending on the patient’s preferred gender. Hormone therapy aims to change both the psychological and physical constitution of an individual which leads to greater ease in accepting and adapting to a preferred gender.
Oestrogen has several effects on the body such as decrease in size of the sexual organs (penis and testes), decreased muscle bulk, increased fat composition, breast enlargement and reduced facial and body hair growth. Attainment of an erection and orgasm may be more difficult whilst taking oestrogen supplements. 
Testosterone causes increased facial and body hair growth, increased muscle bulk, enlargement of the clitoris, cessation of the menstrual periods and increased libido. In some cases testosterone may also cause baldness, acne and deepening of the voice. 
Once hormone treatment is initiated a patient can be referred for gender confirmation surgery if required. In order to undergo procedures which contribute to a gender transition a potential candidate needs to first live in their preferred gender identity for a minimum of one year. During this time the patient aims to live full time and find employment in the new sex. The patient may also change their name and discuss their transsexualism with friends and family. This period is known as real life experience (RLE) and suggests whether or not surgery is an appropriate undertaking. 
Eligibility Criteria 
- Cessation of smoking to reduce the incidence of wound healing complications. 
- Cessation of cross-sex hormone therapy 2-4 weeks peri-operatively to reduce thromboembolic risk and promote wound healing. 
- Certain NSAIDs, aspirin, tricyclic antidepressants and other medication need to be avoided. 
Core Genital Surgical Procedures (MTF)
When the eligibility criteria for surgery have been fulfilled an individual may proceed onto having a number of procedures in order to consolidate their assumed gender identity and biological sex. The number of procedures undertaken and the extent of the gender transformation are guided by personal preference.
There are multiple approaches available for creation of the neoclitoris with the sensate pedicled clitoroplasty having a superior outcome. This approach involves the utilization of a segment of the glans penis that remains attached to its dorsal nerve and blood vessels. This technique has satisfactory aesthetic and functional outcomes and relatively fewer complications. [11,12,13]
The urethral spongiform tissue can also be utilised to form the neoclitoris. 
The testes are sometimes removed prior to vaginoplasty in order to reduce the levels of endogenous testosterone thus reducing the required dose of cross-hormone therapy. A lower dose of oestrogen lowers the risks and side effects associated with its administration. [9,10,11]
In some cases, the orchidectomy and vaginoplasty are performed sequentially in the same session in order to ensure preservation of scrotal skin without shrinkage or necrosis. This has the added benefit of reducing anaesthetic complications. 
There is removal of the penis and creation of a new urethral opening for micturition. A small vaginal dimple is created during the procedure. This vaginal dimple can be further enlarged using dilators, the result of which may facilitate sufficient penetration. This may be augmented with a labiaplasty and redirection of the urethra. [9,10,11]
If the patient intends to have a vaginoplasty this procedure is carried out in conjunction with the penectomy in order to incorporate penile tissue into the construction of the neovagina.
Vaginoplasty results in the creation of a vagina from pre-existing male genitalia. The outcome requirements and primary goals of a vaginoplasty include  :
- Creation of a sensate and aesthetically acceptable vaginal introitus, labia minora and majora and vulva with clitoris.
- Creation of a patent shortened urethra which allows an adequate urinary stream.
- A stable, sensate neovagina which is ideally lined with hairless, moist and elastic epithelium which is of a large enough diameter and depth to facilitate penetrative sexual intercourse.
- Elimination of erectile tissue to avoid diminishment of the introitus during coitus.
- Ideally, there should be a preservation of the ability to orgasm.
If a vaginoplasty is performed this is usually carried out in the same operative session as a bilateral orchidectomy, penile dissection, labiaplasty and clitroplasty. The operations can also be undertaken in two stages with the labiaplasty and clitoroplasty being performed after the patient heals from the initial vaginoplasty and penile dissection. A three stage operation is also discussed below.
In MTF gender reassignment surgery the neovagina is most commonly formed by penile inversion. Most of the skin from the shaft is used to line the walls. The skin is preserved along with its nerves and blood supply but the spongiform erectile tissue of the penis is removed. Additional skin grafts from the buttocks, hip, abdomen or scrotum can be used if the penile skin is insufficient. [12,13]
In the Wilson Method, the penile inversion occurs in three stages with skin from the buttocks being harvested a week after the creation of the neovagina to line the vaginal vault. The penile skin is used instead to create the labia minora, clitoral hooding and frenulum. [12,13]
Alternatively, full-thickness skin grafts from either groin are sutured together and a condom-covered foam stent is placed into the neovagina. During recovery a condom-covered pliable dilator/stent is introduced into the neovagina. The graft is thus unlikely to constrict. 
A segment of pedicled bowel, usually the sigmoid colon, can also be manoeuvred to create the cavity of the neovagina in a bowel vaginoplasty. This is regarded as one of the best methods of reconstruction but is only recommended if no other alternative is available due to the risks such as diversion colitis. 
Generally, the dimensions of the vagina are limited by the rectoprostatic fascia and bulk of the Levator ani muscle.
Additional MTF procedures
Breast Augmentation (Augmentation Mammoplasty)
A breast augmentation is suggested if a patient is unsatisfied with breast growth after 18 months of cross-sex hormone therapy. The procedure involves the insertion of saline or silicone gel breast prostheses. Saline implants are the most common and are placed below the pectoral muscle via a periareolar, axillary or inframammary incision. The choice of incision site depends on the nipple circumference and size of implant being inserted along with patient preference. [11,12]
Tissue expansion may be employed prior to implantation in order to improve outcomes in MTF patients whose often underdeveloped breast tissue tends to be denser and less fatty. The size of implants is largely decided by the patient and can be guided by the breast size of near female relatives. 
Facial Feminisation Surgery
This describes a group of procedures which help to modify the bony and cartilage structures of the face in such a way as to achieve a more feminine appearance. Voice Feminisation can further help to alter the pitch, tone and range of a person’s vocal cords such that they sound more female. [11,12]
- Cheek implantation
- Lip augmentation
- Brow lift
Core Genital Surgical Procedures (FTM)
This section details the core procedures required for a female to male transformation (FTM).
The neophallus is created using a variety of complex surgical methods. Dissatisfaction with the functionality and appearance of the neophallus is a distinct possibility. The main outcomes desired from a phalloplasty are :
- An aesthetically acceptable penis with intact sensation
- A length and bulk which enables penetrative coitus with the aid of penile implants
- Retention of the capacity to orgasm
- A functional extended urethra which allows voiding while standing
- Preservation of function without disfigurement and excessive scarring
The neophallus is created from a roll of hair-free skin and adipose tissue harvested from the forearm which is then lined with additional epithelium to create a conduit for urine. It is important to monitor the new conduit carefully as up to 45% of extended urethras can form fistulas with urine output occurring at sites other than the urethral opening [12,13].
Preservation of sensation is an important consideration. For this purpose, the clitoris is de-epithelialized and transposed to form the base of the neophallus. The neophallus is allowed to stabilise and heal for approximately one year after which an erectile prosthesis/penile implant can be inserted if desired.
The uterus is removed and is often accompanied by a bilateral salpingo-oophorectomy. This is a surgery preferred by some MTF individuals who experience a discomfort from having internal female reproductive organs. A hysterectomy may also be a requirement before official documentation recognises a trans-male as male. The patient may choose to retain their vagina and/or cervix. If they chose to have the uterus removed along with the cervix this is termed a complete hysterectomy. [8,9,13]
A vaginectomy results in the removal of part or all of the vaginal mucosa for the purposes for a phalloplasty or metoidioplasty. The vaginal tissue is surgically excised and the levator ani muscles used to obscure the vaginal cavity. The vaginal mucosa is then utilised to increase the urethral length for patients undergoing a phalloplasty. A suprapubic catheter is required until the urethra matures. [8,9,12,13]
A bilateral mastectomy enables a trans-male to have a more masculine torso and eliminates the need for chest binding. The type of mastectomy performed is largely decided by breast size. FTM men with larger breasts require a bilateral mastectomy with grafting and reconstruction of the nipple-areola complex. There are two resultant horizontal scars along the lower border of the pectorals. Complete removal and grafting of the nipple-areola complex may result in sensory loss which may not return or will take more than a year to regain. This approach enables the surgeon to correctly align and size the nipples such that they are symmetrical and well-aligned. [8,9]
In trans-men with smaller breasts (B cup or less) the mastectomy may be performed via periareolar incisions. Liposuction may also be used to remove adipose tissue from the breast. This results in less prominent scarring and retention of nipple, areolar and chest wall sensation.
The clitoris enlarges in response to long-term testosterone therapy to between 4 and 5 cm in size on average. This enlarged clitoris is released from the lateral crura and pubic bone and aligned to approximate the usual position of a penis. The urethra may then be extended and catheterised to facilitate two to three weeks of healing[9,12,13].
This procedure is often performed in conjuction with a scrotoplasty using skin from the labia minora and majora.
Metoidioplasty is often used as an alternative to phalloplasty as it involves a simpler procedure with fewer complications. The metoidioplasty is not capable of penetrative sexual intercourse due to its comparably small dimensions. However, genital orgasm is almost always retained after surgery and the patient can have a partial erection on arousal [9,13].
A bilateral salpingo-oophorectomy is the removal of both fallopian tubes and ovaries. This may be performed in conjuction with a hysterectomy to reduce oestrogen and progesterone production and augment cross-sex hormone therapy or to ease psychological distress caused by internal female reproductive organs [12,13].
The surgical creation of an aesthetically pleasing scrotum improves the overall masculinity of the genital area and is likely to improve satisfaction with the gender transformation as a whole. This is particularly important when wearing tight-fitting clothing or swimwear.
During this procedure, the labia majora are hollowed to create a space for the insertion of testicular implants.
Expected recovery times and outcome measures/milestones for recovery [8,9,12,13]:
- Hospital stays for vaginoplasty average six to eight days
- Hospital stays for phalloplasty are between 10 to 14 days
- Patient comfort increases dramatically two weeks after surgery
- Patient-controlled analgesics, antibiotics, and anticoagulants are often prescribed until mobility is achieved.
- A Foley catheter is placed prior to surgery and remains in place for 1 week post-surgery.
- Penile prosthesis can be inserted a year after recovery from phalloplasty
Post-surgical care: Vaginal dilators [9,10]:
- The initial prosthesis is in place continuously for 5 days post-operatively
- Then the prosthesis is maintained and removed daily to facilitate douching and self-care
- The prosthesis is removed for progressively longer periods of time over the following 8 weeks
- After 8 weeks only once-daily insertion is required to prevent stricture and maintain patency
Post-surgical care: Urethral stricture and urethral fistulae
- Need to assess for symptoms consistent with stricture
- May require reinsertion of a catheter
Post-surgical care: Skin necrosis and graft failure
- Need to monitor patient closely for signs of graft failure
Post-surgical care: Penile prosthesis
- Saline pump used to produce erection
- Adjustment to gender role and interpersonal challenges
Limitations of surgery
- Sensory loss
- Loss of capacity to orgasm
- Revision surgery, if possible, may be required
Gender reassignment surgery has a long history and progress in this interesting field has been buoyed by a changing moral and ethical jurisdiction.
The prerequisites for these procedures are at once protracted yet necessary. This ensures that a decision to reassign gender is well thought through and is accompanied by adequate psycho-social and medical support.
The entire transition process can take at least 3 years and depends on the real life experience, medical therapy time, number and type of surgery undertaken aswell as recovery and aftercare time. It can also be an extremely costly transition financially.
Due to the complex nature of gender reassignment, support from a well-heeled multi-disciplinary team as well as a well-prepared candidate are essential for success!
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