In 1952 a 27-year-old, former WWII-era GI from New York named George Jorgensen traveled to Denmark, and returned to the U.S. as Christine Jorgensen. Jorgensen, who had described herself as a woman trapped in a man's body, was one of the first to transition from the male to female gender through a process involving hormone therapy and surgical procedures [source: Hadjimatheou]. In time, she became a trailblazer in seeking those gender reassignment surgeries as these procedures, now known as gender realignment (reconstruction, affirmation or confirmation) surgeries, wouldn't begin in the U.S. until 1966 [source: Wexler].
Gender identity struggles usually begin in early childhood but descriptions of feeling like a man trapped inside a woman's body, or vice versa, have been identified in and reported by people of all ages. A person living with this an internal conflict may develop anxiety and depression, and go on to be diagnosed with gender dysphoria, formally known as gender identity disorder (GID). Gender dysphoria is a mental health condition that can arise when a person lives with ongoing feelings of being physically incongruous with his or her birth sex — and medical intervention may be beneficial. Identifying as transgender, itself, is considered by scientists to be, at least in part, biological and not a mental illness [source: HRF].
Being transgender also isn't about anatomy or sexual orientation; it's about internally identifying with a gender status — which could be masculine, feminine, agender or gender fluid — that is different than the one culturally assigned to you based upon your physical characteristics. While some people may never publicly acknowledge their transgender status, others may decide to live as their desired gender — and that could mean changing how they express their gender through transitioning.
Transitioning is often two-fold: a social transition, such as new clothing, a new name and new pronouns; and a medical transition, with treatments such as hormone therapy and surgical procedures. Depending on the needs and wants of each individual, transitioning may include both social and medical transitions; just one of the two; or for those who eschew gender completely, neither.
Diagnosing Gender Dysphoria
Gender transition is a process unique to each individual, and for those who do choose to affirm their gender with a medical transition, the path often consists of counseling and a diagnosis of gender dysphoria, hormone therapy and real-life experience before genital-changing surgeries are performed. Not all transgender people need — or want — these therapies; and, not all transgender people undergo surgery. Those who do choose to medically transition may select a number of procedures, or focus on just "top," "bottom" or cosmetic surgeries. The collection of procedures are also commonly called gender reassignment or — and the process begins long before the procedures do.
It begins with psychotherapy; in addition to providing counsel, mental health professionals assess a person's readiness for hormone therapy and surgery. To become a candidate for gender reassignment surgery, a person must first be diagnosed with gender dysphoria, as defined by the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a common language and standards protocol manual for the classification of mental disorders. Gender dysphoria was previously known as gender identity disorder (GID) and broken into a handful of classifications (such as childhood and adulthood) in the DSM-4. The revision was made not only to help ensure access to care while attempting to reduce the stigma associated with gender identity struggles, but it also removed the concomitance between transgender feelings and mental illness.
Having persistent feelings — for at least six months — that a person's birth sex doesn't align with his or her gender identity isn't considered a behavioral health issue. To be diagnosed with gender dysphoria, adults and adolescents must also exhibit at least two other conditions, including [source: APA]:
- An outward expression of gender that differs from what society expects
- The desire to be a different gender
- The wish to be treated as a different gender
- The desire to get rid of the primary and secondary sex characteristics of the "wrong" gender
- The wish to have the sexual characteristics of a different gender
- The belief their gender reactions are of a different gender
The desire for gender change cannot be a symptom of another disorder or a chromosomal abnormality. Additionally, these gender identity issues must cause distress, personally, socially, professionally or in any other manner [source: APA].
After counseling, evaluation and diagnosis, patients don't immediately schedule a vaginectomy (removal of the vagina), or penectomy (removal of the penis). Those who choose gender affirmation surgery will need letters of recommendation from counselors, psychiatrists, psychologists, sexologists and/or therapists prior to major gender reconstructive surgery.
Doctors normally recommend hormone therapy to alter secondary sex characteristics to the desired gender before surgery. Other than surgeries to reconstruct internal and external genitalia (and not counting anything considered a cosmetic procedure), most physical changes are managed with hormone therapy prescribed by an endocrinologist to suppress certain characteristics (such as distribution of body hair) or enhance certain others (such as breast growth). Hormone therapy may continue for a few years (it takes at least two years to achieve maximum results), and may be concurrent with what's known as the Real-Life Experience (RLE), a year dedicated to living openly as one's desired gender, and intended to help adjust — socially, physically and emotionally — to making these significant changes in gender expression [source: WPATH].
Gender Affirmation Surgery
It's difficult to know for certain what the actual numbers are, but the Williams Institute estimates that that about 0.3 percent of the general U.S. population identifies as transgender, although not all of those 1.5 million people will desire or undergo gender affirmation surgery [sources: Gates, Steinmetz]. Each year between 100 and 500 gender reconstruction surgical procedures are done in the U.S. to treat gender dysphoria. The United States is not a major player in gender dysphoria treatment; estimates range that up to 2,500 people worldwide affirm their gender through surgery every year — and Thailand has long been considered the premiere destination for gender surgeries [sources: Toro, Encyclopedia of Surgery].
Gender affirmation surgery is performed under the guidelines of World Professional Association for Transgender Health's (WPATH) globally accepted Standards of Care for Gender Identity Disorders (SOC). The types of surgeries to be conducted are decided by the patient's desire and comfort level, as well as finances. Not every patient will want or need the same surgeries, and the process is tailored for each individual. Certain procedures are considered medically necessary to treat gender dysphoria, while other common gender confirmation surgeries such as rhinoplasty and brow lifts are considered cosmetic; for some this new outward appearance may hold more significance than the reconstruction of internal and external genitalia.
Surgeries for trans men (or those assigned female at birth (AFAB)) include:
- Bilateral mastectomy;
- Complete hysterectomy
- Reconstruction of the genitalia with a metoidioplasty (a procedure that allows a surgeon to construct a phallus from the clitoris)
- Ring metoidioplasty (to lengthen the urethra)
- Scrotoplasty (the construction of a scrotum)
- Vaginectomy (to close of the vaginal canal)
- Phalloplasty (the construction of the penis)
A penile implant (a prosthetic otherwise used to treat erectile dysfunction) and testicular implants may also be added to the reconstructed penis and testes. Although the mean length of a reconstructed penis is roughly 2 inches (5 centimeters), 80 percent of trans men in one study reported they were able to engage in sexual intercourse, and most experienced orgasms [source: Harrison].
Trans women, or those assigned male at birth (AMAB), a group larger in number than trans men, may begin their physical transformation with breast augmentation (implants), as well as with cosmetic surgeries to feminize the face and body, such as facial feminization surgery (FFS), and gluteal, hip and thigh implants before undergoing genital reconstruction. Surgeries to create female genitalia include:
- Clitoroplasty (the construction of a clitoris)
- Labiaplasty (the creation of a labia from scrotum skin)
- Orchiectomy (testicle removal)
- Prostatectomy (the removal of prostate)
- Urethroplasty (the reconstruction of the urethra)
- Vaginoplasty (the creation of the vaginal canal, made from penile tissue or a colon graft)
- Penectomy (removal of the penis) is usually done concurrently with vaginoplasty, and a clitoral hood is typically constructed from the glans penis.
In the U.S. surgical costs in 2015 may run anywhere from about $25,000 for male-to-female transitions and upwards of $100,000 or more for female-to-male transitions, although typical costs fall between $7,000 and $50,000 [sources: Leitsinger, AP]. Transgender Brits pay about 10,000 pounds ($15,000) [source: Telegraph]. And for an extra $8,000, patients transitioning from female to male in Thailand can, for example, upgrade from a 1 inch (2.5 centimeter) penis to one with a few more inches [source: Ehrlich].
Transgender people who have undergone gender affirmation surgeries are, in almost all cases, happy they did so. In the U.K., for instance, only 2 percent of people who've undergone gender reconstructive surgeries report regretting their physical transformation, compared to 65 percent of cisgender (non-transgender) people who report regretting their plastic surgery choices [source: Tannehill]. And in the U.S. less than 1 percent of trans women regret their genital reconstruction, a percentage that's been decreasing alongside the risk of developing long-term complications [source: Tannehill]. More than 80 percent of patients report long-term satisfaction despite (treatable) complications such as vaginal hair growth (a 29 percent prevalence among trans females) and urinary problems (almost the same, at 27 percent) [source: Goddard]. The rate of regret for trans men is difficult to estimate, as they are smaller in number than trans women [sources: Jarolím, Tannehill].
Sure, there's the case of Charles Kane, who famously transitioned from a man to a woman in 1997, and then back again. After living as Samantha Kane for seven years, Charles decided he would never pass as a "real woman," neither to himself or to the public, and felt hormone therapy altered his brain into making the original decision [source: Scutti]. But, Kane is a rarity.
Author’s Note: How Gender Reassignment Works
The terminology surrounding gender identity, expression and affirmation has changed a lot since I first wrote about gender dysphoria, then called gender identity disorder, and the ins and outs of, what was then called gender reassignment surgery. The first thing I noticed 8 years later is that there is a lot more labeling. For instance: A biologically born man who identifies as a woman may be known as an 'affirmed' or 'confirmed' woman, 'transgender' woman, or you may also hear the term 'trans woman' — all in reference to the same woman. For some, 'transsexual' continues to be used. And then there's also the acronyms, such as MTF (or M2F), which stands for male-to-female, and AMAB (or DMAB), indicating 'assigned male at birth' (and 'designated male at birth'). I'm sure I'm overlooking some, too. And it's a similar list for someone assigned female at birth who identifies as a man (AFAB). What seems to be left out, though is the most obvious: male and female, just as those who are cisgender (a term used for non-trans people). (Unless, of course, we're talking about a person whose identity lies somewhere along a spectrum of gender, who may prefer to describe themselves as neither male nor female, but gender fluid.)
More Great Links
- Aetna. "Clinical Policy Bulletin: Gender Reassignment Surgery." Sept. 19, 2014. (April 12, 2015) http://www.aetna.com/cpb/medical/data/600_699/0615.html
- American Medical Student Association (AMSA). "Transgender Health Resources." (April 12, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
- American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." Excerpt from: The Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. Feb. 18, 2011. (April 12, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
- Bilefsky, Dan. "Serbia Becomes a Hub for Sex-Change Surgery." The New York Times. July 23, 2012. (April 12, 2015) http://www.nytimes.com/2012/07/24/world/europe/serbia-becomes-a-hub-for-sex-change-surgery.html
- Dewey, Caitlin. "Confused by Facebook's new gender options? Here's what they mean." The Washington Post. Feb. 14, 2014. (April 12, 2015) http://www.washingtonpost.com/blogs/style-blog/wp/2014/02/14/confused-by-facebooks-new-gender-options-heres-what-they-mean/
- Ehrlich, Richard s. "Everything you always wanted to know about sex... changes." CNN. Feb. 24, 2010. (April 12, 2015) http://travel.cnn.com/bangkok/play/everything-youve-ever-wanted-know-about-sex-changes-379486
- Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
- Goddard, Jonathan C. "Feminizing genitoplasty in adult transsexuals: early and long-term surgical results." BJU International. Vol. 100, no. 3. Pages 607-613. July 2007. (April 12, 2015) http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.07017.x/pdf
- Goldberg, Joseph. "When You Don't Feel At Home With Your Gender." WebMD. Sept. 24, 2014. (April 12, 2015) http://www.webmd.com/mental-health/gender-dysphoria
- Hadjimatheou, Chloe. "Christine Jorgensen: 60 years of sex change ops." BBC News. Nov. 30, 2012. (April 12, 2015) http://www.bbc.com/news/magazine-20544095
- Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape. May 20, 2013. (April 12, 2015) http://www.medscape.com/viewarticle/804432
- HealthResearchFunding.og (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 12, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
- International Foundation for Gender Education (IFGE). "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 12, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
- Jarolím, L. "Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks." The Journal of Sexual Medicine. Vol. 6, no. 6. Pages 1635-1644. June 2009. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/19473463
- Kourkounis, Erin. "Tampa transgender teen living life of transition." The Tampa Tribune. (April 12, 2015) http://tbo.com/news/education/tampa-transgender-teen-living-life-of-transition-20150412/
- Lallanilla, Marc. "Gender Reassignment Surgery: How Does It Work?" Huffington Post - HuffPost Healthy Living. Oct. 23, 2015. (April 12, 2015) http://www.huffingtonpost.com/2013/08/23/gender-reassignment-surgery-manning-bradley-chelsea_n_3804247.html
- Leitsinger, Miranda. "Sex Reassignment Surgery at 74: Medicare Win Opens Door for Transgender Seniors." NBC News. Jan. 3, 2015. (April 12, 2015) http://www.nbcnews.com/news/us-news/sex-reassignment-surgery-74-medicare-win-opens-door-transgender-seniors-n276986
- McGinn, Christine. "Services." Gender Wellness Center Papillon. 2010. (April 12, 2015) http://www.drchristinemcginn.com/services/
- Monstrey, Stan J. "Sex Reassignment Surgery in the Female-to-Male Transsexual." Seminars in Plastic Surgery. Vol. 25, no. 3. Pages 229-244. August 2011. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/
- Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. (April 12, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
- Scutti, Susan. "Becoming Transsexual: Getting The Facts On Sex Reassignment Surgery." Medical Daily. Nov. 6, 2014. (April 12, 2015) http://www.medicaldaily.com/becoming-transsexual-getting-facts-sex-reassignment-surgery-309584
- Selvaggi, G. "Genital sensitivity after sex reassignment surgery in transsexual patients." Annals of Plastic Surgery. Vol. 58, no. 4. Pages 427-433. April 2007. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/17413887
- Tannehill, Brynn."Myths About Transition Regrets." Huffington Post - HuffPost Gay Voices. Jan. 18, 2015. (April 12, 2015) http://www.huffingtonpost.com/brynn-tannehill/myths-about-transition-regrets_b_6160626.html
- The Classroom. "Gender Identity: Trans Keywords." (April 12, 2015) http://the-classroom.org.uk/lgbt-101/gender-identity/keywords-gender-identity/
- The Telegraph. "Number of NHS sex change operations triples." April 21, 2010. (April 12, 2015) http://www.telegraph.co.uk/news/health/news/7613567/Number-of-NHS-sex-change-operations-triples.html
- Toro, Ross. "How Gender Reassignment Surgery Works (Infographic)." LiveScience. Aug. 26, 2013. (April 12, 2015) http://www.livescience.com/39170-how-gender-reassignment-surgery-works-infographic.html
- University of California San Francisco - Center of Excellence for Transgender Health. "Transgender Health Learning Center: Surgical Options." (April 12, 2015) http://transhealth.ucsf.edu/trans?page=protocol-surgery
- University of Miami - Miller School of Medicine. "Plastic Aesthetic and Reconstructive Surgery: Transgender Reassignment." 2015. (April 12, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
- University of Michigan Health System. "Transgender Services: Gender Affirming Surgery." (April 12, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
- USA Today. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 12, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
- Wexler, Laura. "Identity Crisis." Jan. 2007. (June 29, 2015) http://www.baltimorestyle.com/index.php/style/features_article/fe_sexchange_jf07
- World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf