Christine Jorgensen, formerly George Jorgensen, was an ex-GI and one of the first Americans to undergo surgical gender reassignment.

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Introduction to How Gender Reassignment Surgery Works

As you were growing up, how did you know you were a girl or a boy? Was it because you had a vagina or a penis? Or was it something other than than what your body looked like? Some people feel that their minds and bodies don't match up. This feeling is commonly known as gender identity disorder or gender dysphoria. The medical community used to use the word "transsexuals" to describe this community. But today, "transgender" is used as a general, non-medical term to describe anyone whose gender identity is different from their physical sex at birth.

Transgender people often wish to live as a different gender than the one they were assigned when they were born. They may may transform their bodies through gender reassignment surgery, also known as gender confirmation surgery -- a collection of procedures also commonly known as a "sex change." The word "transition" describes a person's shift to living as the gender they perceive themselves to be, rather than the sex they were assigned at birth. Surgery is sometimes, but not always, part of a person's transition.

Gender identity struggles usually begin in early childhood but have been identified in people of all ages. A biologically born man who identifies as a woman is known as transwoman, or transgender woman. A biologically born woman who identifies as a man is known as transman, or transgender man. There are also people whose identity lies somewhere along a spectrum of gender who may refer to themselves as neither male nor female.

It's estimated that one in 11,900 males and one in 30,400 females are transgender adults [source: WPATH Standards of Care]. Lynn Conway, a professor emerita at the University of Michigan, estimates that one in 2,500 United States citizens has undergone male-to-female gender reassignment surgery [source: Advocate].

One of the most publicized Americans to undergo such surgery was Christine Jorgensen, who traveled to Denmark in 1952 to undergo an early gender reassignment surgery. Genital reassignment surgery wasn't performed in the U.S. until 1966. Jorgensen later worked with Dr. Harry Benjamin, the physician who coined the term "transsexual." Benjamin was one of the pioneering doctors to research and work with gender identity disorders, using the research of Magnus Hirschfeld, of the Institute for Sexual Science, and Alfred Kinsey, of the Kinsey Institute, as his springboard.

­In 1966, Benjamin published "The Transsexual Phenomenon" and went on to establish the Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA). Today HBIGDA is known as the World Professional Association for Transgender Health (WPATH), and is an international organization devoted to furthering the understanding and treatment of gender identity disorders. WPATH established and still publishes the Standards of Care (SOC) for the treatment of gender identity disorders. It also publishes ethical guidelines for professionals caring for transsexual patients.

So what are the requirements for gender reassignment surgery? Are patients fertile and able to have sex? Go to the next page to find out what happens before a person physically changes genders.

Neil Van Der Merwe of South Africa sits on a hospital bed during preparations for a sex change operation at a hospital in Bangkok, Thailand. Van Der Merwe has lived as a man for the past five years.

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Diagnosis of Gender Identity Issues

When a transgender person wishes to have gender confirmation surgery, the process begins long before the procedures do. There are five steps to the process: diagnostic assessment, psychotherapy, real-life experience, hormone therapy and surgery.

The process begins when a person consults a mental health professional, who performs sessions of psychotherapy and formulates a diagnosis. To become a candidate for gender reassignment surgery, a person must first be diagnosed with Gender Identity Disorder (GID) or gender dysphoria. The International Classification of Diseases-10 (ICD-10) lists gender identity disorder as a disorder and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V) lists gender dysphoria.

Previously, the DSM-IV broke GIDs into several types: Gender Identity Disorder of Childhood, Gender Identity Disorder of Adolescence or Adulthood and Gender Identity Disorder Not Otherwise Specified. The revision to include gender dysphoria in the DSM-V was made to help ensure access to care while also attempting to reduce the stigma associated with gender identity struggles.

­Additionally, the ICD-10 provides five diagnosis types for GIDs:

  1. Transsexualism
  2. Dual-role Transvestism
  3. Gender Identity Disorder of Childhood
  4. Other Gender Identity Disorders
  5. Unspecified Gender Identity Disorder

According to the ICD-10, transsexuals are diagnosed when they have a desire to live as and be accepted as a member of the opposite sex, along with the desire to transform their bodies with gender reassignment surgery or hormone therapy. The person's gender identity must be persistent for at least two years, and the desire for gender change cannot be a symptom of another disorder or a chromosomal abnormality.

­Patients are diagnosed with dual-role transvestism when they have no desire for a permanent change to the opposite sex. Unspecified and Other GID diagnoses are often used to describe an intersex condition -- when an individual is born with ambiguous genitalia. Ambiguous genitalia is a rare birth defect where a child's genitals are not clearly male or female either because they are unformed, deformed or include aspects of both male and female genitalia.

Prospective candidates for gender reassignment surgery must work with a mental health professional for diagnosis. However, the mental health professional additionally provides counsel about treatment options and implications as well as therapy and education for the individual, his or her family and employers.

­After a diagnosis, there are three phases left for patients undergoing surgery:

  1. Hormone therapy
  2. Real-Life Experience, also known as the Real-Life Test
  3. Surgery to change genitalia and other sex characteristics

For some transmen (biologically born females transitioning to males), the phases may begin with hormone therapy but breast augmentation surgery to remove the breasts may come before the Real-Life Experience.

Now that we know how the diagnosis of gender identity disorders works, let's find out about treatment. Look at the next page to learn about hormone therapy, the Real-Life Experience and surgery.

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Treatment of Gender Identity Issues

In addition to diagnosing patients and providing counsel, mental health professionals also assess a person's eligibility and readiness for hormone therapy and surgery. Not all transgender people need all three phases of therapy; each path to gender reassignment is tailored to the person. And, as we've noted before, not all transgender people undergo surgery.

Before a patient can begin hormone therapy or breast surgery, a mental health professional must write a letter of recommendation to the physician providing medical treatment.

In addition to the letter, the World Professional Association for Transgender Health's Standards of Care require several eligibility and readiness criteria for hormone therapy. A patient must:

  1. Be 18 years of age
  2. Understand what hormones can and cannot do medically and understand their social benefits and risks
  3. Have either a minimum of three months of psychotherapy or a documented three month real-life experience
  4. Show stable or improved mental health
  5. Demonstrate ability to take hormones in a responsible manner [source: WPATH Standards of Care].

After a patient meets these criteria and undergoes a basic physical examination, a physician will then prescribe hormones.

Androgens are given to biological females transitioning to male. Estrogen, progesterone, and testosterone-blocking agents are given to biological males transitioning to female. Hormones are taken orally, by injection or transdermally (a patch).

The Real-Life Experience immerses the individual into life as his or her preferred gender. The candidate is required to maintain full or part-time employment (or attend school full or part-time), legally change his or her first name to one that is gender appropriate and prove that people other than the therapist and doctor know his or her desired gender.

After 12 months of continuous and successful hormone therapy and Real-Life Experience, the individual is eligible for genital surgery. Two letters of recommendation, usually one from the mental health professional and one from the hormone-prescribing physician, are required for surgery. The patient chooses a surgeon -- a gynecologist, urologist, plastic surgeon or general surgeon -- to join the gender reassignment team.

Male-to-female patients may have several genital surgeries including orchiectomy, penectomy, vaginoplasty, clitoroplasty and labiaplasty. A transwoman might also choose reduction thyroid chondroplasty, suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reconstruction (which may include hairline correction, forehead recontouring, brow lift, rhinoplasty, cheek implants, lip lift, lip filling, chin recontouring, jaw recontouring or tracheal shave) and blepharoplasty. Some patients have vocal cord surgery or voice training.

Genital surgery for female-to-male patients may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, placement of testicular prostheses and phalloplasty (the creation of a neophallus or surgically constructed penis). A transman may also undergo elective surgeries like liposuction to reduce fat in hips, thighs and buttocks.

But once surgery is complete, do patients ever have regrets? What legal rights do they have as the opposite gender? Find out on the next page.

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Gender Reassignment Legal Issues, Social Aspects and Regrets

Legal Issues

An important part of changing genders in the U.S. is changing names. A person begins the legal name changing process by filing a court order. This usually requires completing paperwork, publishing a notice in a local newspaper and paying a fee. After changing names, a transgender person amends his or her Social Security card and birth certificate.

Most states' antidiscrimination laws don't do much to protect transgender people from discrimination. Many find themselves denied employment, housing, places to worship, marriage and child custody. Surgeons who see their roles as restorers of bodily function or creators of body alterations for self-image purposes sometimes feel gender reassignment surgeries do not fall into those categories and object to performing such operations [source: WPATH Standards of Care].

Social Aspects

Transgender people face unique issues involving marriage, sex and fertility. Although most states do not allow homosexual marriages, people who have transitioned are able to marry legally. For those completing sex reassignment surgery, a satisfying sex life post-operation depends on several surgical choices. In female-to-male gender reassignment surgery, an affordable, realistic and functional penis is considered a fantasy. Some female-to-male patients choose to have a metoidioplasty -- a procedure in which a clitoris enlarged through hormone therapy is repositioned at the end of a neophallus, or surgically constructed penis that is able to perceive sensation. In male to female transitions, the head of the penis becomes a neoclitoris.

Fertility issues and reproductive options need to be discussed before hormone therapy begins. Biological males might consider banking their sperm, while biological females sometimes consider cryopreserving, or freezing their eggs or fertilized embryos. In a survey reported by the International Journal of Transgenderism, 76 percent of the respondents favored that transwomen be made aware of the option to bank sperm before starting hormone therapy [source: IJT].


One question often on the minds of non-transgender (or cisgender) people is whether someone who decides to have gender confirmation surgery will wind up regretting it. It's generally reported that transgender people who have undergone these surgeries are, in almost all cases, happy they did so. And while there may be a few who regret their decision, the International Journal of Transgenderism cites a 1992 study that found postoperative regret was less than one percent in female to male transitions and between 1 to 1.5 percent in male to female transitions [source: IJT].

For more resources and additional information about reproduction, gender, gender identity disorder and gender reassignment surgery, see our list of links on the following page.

How Gender Reassignment Works: Author’s Note

During my first newsroom job, I worked with an editor who decided to undergo the transition from living as a man to living as a woman. This was my first experience with transsexualism and gender reassignment, at least that I knew of. Deciding to become the gender you feel you are despite your body looking a different way -- that's a big change. It's bold. I think what surprised me the most during this assignment was learning how extensive the process can be, depending on the therapies the individual decides to undertake -- the path to gender reassignment is a path of counseling and diagnosis, hormone therapy, real-life experience and surgeries to change the genitals and other sex characteristics. I was disappointed at the lack of statistics regarding the number of transsexuals who have undergone gender reassignment. What I was able to find is a bit dated (from the 1990s) but it's generally reported that people who take the leap do not regret they did so.

  • "Ambiguous genitalia." The Mayo Clinic Staff. Mayo Clinic. Jan 2008.
  • "Answers to Your Questions About Transgender Individuals and Gender Identity." The APA Task Force on Gender Identity, Gender Variance, and Intersex Conditions. American Psychological Association. 2008.
  • "Burden of Mental and Behavioural Disorders." World Health Organization. 2008.
  • De Sutter, P. "The Desire to have Children and the Preservation of Fertility in Transsexual Women: A Survey." The International Journal of Transgenderism. Vol. 6. 2002.
  • Diagnostic and Statistical Manual of Mental Disorders (DSM). American Psychiatric Assocation. 2008.
  • Gordon, Rachel. "S.F. Set To Add Sex Change Benefits." San Francisco Chronicle. 2001.
  • Mason, Margie. "Thailand's sex-change industry." The Seattle Times. 2006.
  • Mental Health: Gender Identity Disorder. Sexual Health Center. WebMD. 2000-2005.
  • Minter, Shannon. "Transgender Persons and Marriage: The Importance of Legal Planning." National Center for Lesbian Rights.
  • Rachlin, Katherine. "Transgender Individuals' Experiences in Psychotherapy." The International Journal of Transgenderism. Vol. 6. 2002.
  • Rachlin, Katherine. "Factors Which Influence Individual's Decisions When Considering Female-To-Male Genital Reconstructive Surgery." The International Journal of Transgenderism. Vol. 3. 1999.
  • "Sexual and gender Identity Disorders." Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. American Psychiatric Publishing, Inc.
  • WPATH Ethical Guidelines for Professionals
  • WPATH Standards of Care for Gender Identity Disorders, Version 6. 2001.

Gender Reassignment: Cheat Sheet

Stuff You Need to Know:
  • Transgender people are people who feel dissatisfied with their sexual identity, body characteristics and/or gender role. Transgender people who wish to live as the opposite gender may transform their bodies through gender reassignment surgery, commonly known as a sex change, although not every transgender person undergoes surgery.
  • Let's review a few definitions. Transwoman: A biologically born man who identifies as a woman. Transman: A biologically born woman who identifies as a man. Transgender: A general term used to describe a person with a gender identity disorder.
  • The journey of undergoing gender reassignment begins with the patient receiving a Gender Identity Disorder (GID) diagnosis. There are five types of GIDs: transsexualism, dual-role transvestism, gender identity disorder of childhood, other gender identity disorders and unspecified gender identity disorder. Once diagnosed, the patient will undergo diagnostic assessment, psychotherapy, real-life experience, hormone therapy and surgery to augment genitalia and other sex characteristics.
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