How Gender Reassignment Works

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Introduction to How Gender Reassignment 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 more than your physiology? Some people feel that their minds and bodies don't quite match up. This feeling is commonly known as transsexualism -- a type of gender identity disorder. Transsexuals are dissatisfied with their sexual identity, body characteristics or gender role. They wish to live as the opposite gender and may transform their bodies through gender reassignment surgery -- a collection of procedures commonly known as a "sex change."

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Christine Jorgensen, formerly George Jorgensen, was an ex-GI and one of the most famous early American transsexuals.

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 transsexual woman. A biologically born woman who identifies as a man is known as transman, or transsexual man. Labels like cross-dresser, transvestite, drag queen or drag king are not interchangeable with transsexual. However, transgender is used as a general, non-medical term to describe anyone with any type of gender identity issue.

It's estimated that one in 11,900 males and one in 30,400 females are transsexual 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 American transsexuals 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 changes genders.

Diagnosis of Gender Identity Issues

The gender reassignment process begins long before surgery. There are five steps to the process: diagnostic assessment, psychotherapy, real-life experience, hormone therapy and surgery.

A transsexual begins by consulting a mental health professional who performs sessions of psychotherapy and formulates a diagnosis. To become a candidate for gender reassignment surgery, an individual must first be diagnosed with Gender Identity Disorder (GID). GIDs, including transsexualism, are considered mental disorders. The International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) consider transsexualism a GID.

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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.

The DSM-IV breaks GIDs into several types: Gender Identity Disorder of Childhood, Gender Identity Disorder of Adolescence or Adulthood and Gender Identity Disorder Not Otherwise Specified.

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

Transsexualism
Dual-role Transvestism
Gender Identity Disorder of Childhood
Other Gender Identity Disorders
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 and hormone therapy. The transsexual 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 to complete in the process:

Hormone therapy
Real-Life Experience, also known as the Real-Life Test
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.

The Price of IdentityThe entire gender reassignment process is extremely expensive. Costs vary depending on where patients have the surgery, if they choose to have additional elective surgeries and if they are covered by health insurance. Male to female gender reassignment surgery costs roughly $37,000 while female to male surgery costs about $77,000 [source: SF Gate] Choosing surgery outside of the United States sometimes means cheaper associated costs -- facilities in Thailand often charge less than $10,000 [source: Seattle Times].

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

Treatment of Gender Identity Issues

In addition to diagnosing patients and providing counsel, mental health professionals also assess an individual's eligibility and readiness for hormone therapy and surgery. Not all transsexuals need all three phases of therapy; each path to gender reassignment is tailored to the individual.

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A doctor inquires about the health of a patient from the United States following a female-to-male gender reassignment surgery in Bangkok, Thailand.

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:

Be 18 years of age
Understand what hormones can and cannot do medically and understand their social benefits and risks
Have either a minimum of three months of psychotherapy or a documented three month real-life experience
Show stable or improved mental health
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).

Hormone Therapy Side Effects

Biological males undergoing hormone treatment can expect, among other changes, breast growth, decrease in body hair, redistribution of body fat, decreased fertility and testicular size and less frequent and firm erections. Most of these changes are reversible if hormone therapy is stopped. The negative side effects include, but are not limited to: an increased risk for blood clots, weight gain, infertility, liver disease and hypertension.

Biological females undergoing hormone treatment can expect, among other changes, an increase in facial hair, body hair and male pattern baldness, weight gain, increased sexual interest, clitoral enlargement and a deepening voice. The negative side effects include, but are not limited to: infertility, acne, increased risk of cardiovascular disease and the increased potential of benign and malignant liver tumors [source: WPATH Standards of Care].

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.

Gender Reassignment Legal Issues, Social Aspects and Regrets

Legal Issues
An important part of changing genders in the U.S. is changing names. An individual 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 transsexual amends his or her Social Security card and birth certificate.

Most states' antidiscrimination laws don't do much to protect transsexuals from discrimination. Many transsexuals 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
Transsexuals face unique issues involving marriage, sex and fertility. Although most states do not allow homosexual marriages, transsexuals are able to marry legally. A satisfying sex life post-operation depends on the transsexual's 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 where 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.

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Transsexual Xinr (L) and husband Huang Kunlun relax at home in Changchun, China. Once a man, 24-year-old Xinr underwent gender reassignment surgery in 2004, becoming the first transsexual in the northern province of Jilin.

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].

Regrets
So is the therapy, the hormone treatment, the surgeries and legal work worth it? It's generally reported that transsexuals who have undergone gender reassignment surgery are happy they did so. And while there are some 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.

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How Gender Reassignment Works