A rehabilitation program for gender dysphoria syndrome by surgical sex change

Breast Augmentation in Transwomen: Can We have a Formula?

Background  Breast augmentation in transwomen is a surgical challenge as there is no available guideline for preoperative assessment of breast implant size, which caters to them specifically. The aim of our study is to derive a formula for preoperative breast implant size estimation, which would remove the personal bias, help in one-to-one discussion, and better understanding, reducing operative time, cost, and revision surgery rate. Methods  This is a retrospective study conducted from October 2018 to December 2020. We maintained a routine protocol for measurements in our patients, which has been previously published. Linear multivariate regression equation was applied to derive a formula using minimum of parameters, namely, CC (chest circumference at the inframammary fold [IMF]), POMP (circumference at the point of maximum projection of breast mound), and LOWERDIFF (lower value of difference in each breast between the stretched nipple [IMF] and the nonstretched nipple [IMF distance]). Results  A total of 51 transwomen underwent surgery in this period. The mean volume of implant used was 354.51 mL. Complications consisted of pain and discomfort in six patients, delayed healing in two patients, and wound dehiscence in one. A formula for preoperative calculation of breast implant was obtained with these data. A mathematical correlation was found between complications encountered and the percentage by which the inserted implants exceeded the calculated size. Conclusion  We could estimate the breast implant size preoperatively through a simple formula that require only four anthropometric measurements. This equation is a significant advantage for the surgeon and a useful tool for patient education. Its usefulness will be established if applied in prospective studies. From our study, it appears 9% above the calculated size is better avoided.

The Fall of the Nation's First Gender-Affirming Surgery Clinic

Johns Hopkins Hospital established the first gender-affirming surgery (GAS) clinic in the United States in 1966. Operating for more than 13 years, the clinic was abruptly closed in 1979. According to the hospital, the decision was made in response to objective evidence claiming that GAS was ineffective. However, this evidence directly contradicted many contemporaneous studies and faced immediate criticism from the scientific community. Despite this resistance, it took the hospital nearly 40 years to resume performing GAS. Scientific evidence-imbued in scandal, bias, and moralism-was instrumentalized to serve broader institutional interests. The burgeoning field of plastic surgery tethered and then untethered GAS from its auspices in response to poor technical outcomes and transphobia. No longer serving surgeons' interests, the clinic was marginalized to "barely minimal facilities" in 1974, five years before GAS was formally banned. Over the next 5 years, the clinic co-inhabited space with the Department of Obstetrics and Gynecology. Simultaneously, the Department of Obstetrics and Gynecology navigated scandals related to reproductive technology (namely, the Dalkon Shield [A.H. Robins] controversy) until the clinic space was demolished in 1979. The study that informed the GAS ban was preferentially funded in keeping with the political economy of biomedical research. This article presents a spatial argument for how the closure of the nation's first GAS clinic was not based in empirical data alone but was manipulated to fuel political and institutional agendas.

Gender Dysphoria Publication Trends: A Bibliometric Analysis between 1900 and 2018

Objective Research on gender dysphoria (GD) has been growing over the last decades with increasing interest in understanding and characterizing the causal relationships between psychological, genetics, hormonal, and sociocultural factors. Changes and acceptance of this condition as non-pathologic have led to significant changes in general perspective and its management over time. Our objective is to carry out a bibliometric analysis to know the publication trends and quality of evidence related to gender dysphoria.

Methods A systematic search and critical review of the literature was carried out between January 1900 and December 2018 to perform a bibliometric analysis. Research was done in the following databases: OVID, PubMed, EMBASE, Scopus, Web of Science and Google Scholar. The medical subject headings (MeSh) terms used were: gender dysphoria; and surgery and psychology. The results were plotted using the VOSviewer version 1.6.8. Statistical analyses were performed with the IBM SPSS, Version 25.0.

Results A total of 1,239 manuscripts were identified, out of which 1,041 were selected. The average number of cited times per year per manuscript is 1.84 (interquartile range [IQR] 0-2.33). The average impact index was 47.8 (IQR 20-111.6). The median of total citations per manuscript was 3 (IQR 0-33.1), and the highest number of citations per manuscript was 484. Most publications focus on the psychological aspects of GD, and there is a significant amount of manuscripts related to social and anthropological issues. Most articles have a low level of scientific evidence.

Conclusion There is a great amount of published literature on GD; however, there is a significant level of disagreement in many respects on this topic. Regarding surgical gender-affirmation, there is a lack of information supported by high level of evidence to uphold the emerging expansion of medical practices.

ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"

Introduction

Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.

Aim

To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.

Methods

The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.

Main Outcomes Measure

The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.

Results

The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.

Conclusion

The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.

Hundred and Eleven Cases of Subfascial Breast Augmentation in Trans Women-A Single-Center Experience

Hundred and eleven patients of breast augmentation in trans women operated between January 2004 and September 2019 are presented. Two surgeons conducted the study with a slightly different antibiotic regime. Only round implants were used. Till December 2017, 72 implants used were textured. Thereafter, we switched over smooth silicone gel implants more for reasons of availability than others. It was used in 39 patients. We did not notice any difference in results. Our postoperative regimes consisted of antibiotics (usually amoxicillin + clavulanic acid) for 10 days, restricted shoulder movements for 3 weeks, use of an inner brassiere and outer sports vest for 2 months. Routes of implantation were either periareolar or inframammary, former being selected as per choice of the patient, provided the hemicircumference of the areola was 4.5 cm or more. We never used transaxillary route. The implants were always placed in a subfascial pocket. Routine irrigation of the pocket with 5% povidone iodine was done before insertion of implant. From 3 weeks postoperatively, routine massage of breasts for a period of 6 to 8 weeks were advised. Complications included delayed minor wound healing problems usually in periareolar technique requiring secondary suture under local anesthesia. This was negligible with inframammary technique. Capsular contracture was found in 12 patients. Two of these merited intervention but one of them refused operation. In one patient, implant had to be extracted due to severe suppurative infection resulting from a separate incidence of traumatic injury with hematoma formation 2 weeks post operatively. Poor scarring including one keloid were noticed in 11 patients.

Sexual Behavior, Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study

BACKGROUND

One of the most prominent etiological theories of gender incongruence in trans women proposes a paraphilic erotic target location error (ie, autogynephilia) as a causal factor in gynephilic (ie, exclusively gynephilic and bisexual) trans women. We hypothesized that a paraphilic erotic target location should manifest itself in various aspects of sexual behavior, solitary and dyadic sexual desire, and psychosexual experience.

AIM

To compare sexual behavior, sexual desire, and psychosexual experience of exclusively gynephilic and bisexual trans women with that of androphilic trans women to explore whether their sexuality differs substantially.

METHODS

Trans women diagnosed with gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders-5) were recruited at 4 transgender healthcare centers in Germany. The present study analyzed items on sexual behavior, desire, and experience of a self-report questionnaire, collected as part of a cross-sectional multicenter study.

MAIN OUTCOMES

Multiple aspects of sexuality were examined using self-constructed items. Sexual desire was measured using the Sexual Desire Inventory and psychosexual experience using the Multidimensional Sexuality Questionnaire.

RESULTS

Significantly more exclusively gynephilic than androphilic trans women reported a history of sexual arousal in relation to cross-dressing. However, little evidence was found that gynephilic and androphilic sexual desire, behavior, and psychosexual experience differ profoundly. Interestingly, a statistically non-significant trend indicated that gynephilic trans women who had not yet undergone gender affirming surgery showed the highest levels of sexual desire (solitary and dyadic), whereas the opposite was the case for androphilic trans women.

CLINICAL TRANSLATION

Data of this study indicate that sexual orientation does not appear to be a good predicator for sexual behavior, desire, and psychosexual experience in trans women.

STRENGTHS AND LIMITATIONS

We investigated sexual desire and experience using standardized and evaluated measures such as the Sexual Desire Inventory and Multidimensional Sexuality Questionnaire. Future studies with a larger sample size should investigate how different gender affirming medical intervention might have diverging influences on sexual behavior, desire, and experience.

CONCLUSION

Ultimately, this study found little evidence for the hypothesis that sexual behavior, sexual desire, and psychosexual experience differ substantially in gynephilic (exclusively gynephilic and bisexual) and androphilic trans women. Laube JS, Auer M, Biedermann SV, et al. Sexual Behavior, Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study. J Sex Med 2020;17:1182-1194.

Genital Reconstructive Surgery in Male to Female Transgender Patients: A Systematic Review of Primary Surgical Techniques, Complication Profiles, and Functional Outcomes from 1950 to Present Day

CONTEXT

Genital reconstructive surgery (GRS) is a necessary part of transitioning for many transwomen, and there is evidence of positive effects on a person's well-being and sexual function. Surgical techniques have evolved, from pursuing aesthetic outcome to now functional outcome with natal females as the standard.

OBJECTIVE

To systematically review the evidence, identifying the surgical techniques used in primary GRS, their complications, functional outcomes, and the tools used to assess them.

EVIDENCE ACQUISITION

The clinical question was designed using the standard PICOS format. The search complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 statement and was performed by two independent reviewers.

EVIDENCE SYNTHESIS

Europe, USA, and Thailand favour the penoscrotal technique for vaginoplasty, whereas in the UK, the penile inversion (PI) technique predominates. Primary vaginoplasty using a segment of bowel is less common, and all three techniques have comparable rates of intraoperative rectal injury. The incidence of rectovaginal fistula is reportedly higher in the PI technique. Wound haematoma and vaginal prolapse rates are comparable. Higher rates of clitoral necrosis, urethral meatal stenosis, and wound infection are reported in PI. However, the ability to orgasm, ability to have penetrative sexual intercourse, and satisfaction with aesthetic result are better with PI.

CONCLUSIONS

The evidence for GRS complications and functional outcomes is of low level. Standardised nomenclature reporting of adverse events and robust patient-reported outcome measures (PROMs) are lacking. PROMs are a powerful assessment tool, and standardised definitions of adverse events and functional outcomes should be a priority of future research.

PATIENT SUMMARY

We looked at all studies published on genital reconstructive surgery from 1950 to the present day. We assessed each surgical technique and their associated complication rates, sexual and urinary function outcomes, and how they were reported. We found the evidence to be low and weak. We suggest more robust ways of reporting complications, and the impact on patients' quality of life should be investigated.

The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health

The notion of gender dysphoria is central to transgender health care but is inconsistently used in the clinical literature. Clinicians who work in transgender health must understand the difference between the diagnosis of Gender Dysphoria as defined and described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the notion of this term as used to assess eligibility for transition-related interventions such as hormone-replacement therapy and surgery. Unnecessary diagnoses due to the belief that a diagnosis is clinically required to access transition-related care can contribute to stigma and discrimination toward trans individuals.

Male Prison Inmates With Gender Dysphoria: When Is Sex Reassignment Surgery Appropriate?

Gender dysphoria (GD), a feeling of persistent discomfort with one's biologic sex or assigned gender, is estimated to be more prevalent in male prison inmates than in nonincarcerated males; there may be 3000-4000 male inmates with GD in prisons in the United States. An increasing number of U.S. prison systems now offer gender dysphoric inmates diagnostic evaluation, psychotherapy, cross-sex hormone therapy, and opportunities, albeit limited, to enact their preferred gender role. Sex reassignment surgery (SRS), however, has not been offered to inmates except in response to litigation. In the first case of its kind, the California Department of Corrections and Rehabilitation recently agreed to provide SRS to an inmate and developed policy guidelines for its future provision. In other recent cases, U.S. courts have ruled that male inmates with GD are entitled to SRS when it is medically necessary. Although these decisions may facilitate the provision of SRS to inmates in the future, many U.S. prison systems will probably remain reluctant to offer SRS unless legally compelled to do so. In this review, we address the medical necessity of SRS for male inmates with GD. We also discuss eligibility criteria and the practical considerations involved in providing SRS to inmates. We conclude by offering recommendations for physicians, mental health professionals, and prison administrators, designed to facilitate provision of SRS to inmates with GD in a manner that provides humane treatment, maximizes the likelihood of successful outcomes, minimizes risk of regret, and generates data that can help inform future decisions.

The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study

Various vaginoplasty methods in male-to-female transsexuals have been described, but none is ideal. The use of cultured autologous oral epithelium to cover the neovagina walls is presented. Six patients were operated on. Complications encountered were one case of low-located rectovaginal fistula that was treated conservatively; one case of partial glans necrosis resulting in a scarred but sensitive clitoris; one case of large labia majora requiring reduction; and one case of short vagina requiring surgical revision with autologous cultured oral cells that was successful. All patients had adequate vagina, experienced sexual intercourse, and were satisfied with results. Autologous cultured oral epithelium transplantation is feasible, safe, and advantageous. Satisfactory neovaginas were provided; the procedure is relatively easy to perform and provides a thin, mucosa-lined neovagina with a sufficient amount of secretion.

Radiological evaluation by magnetic resonance of the 'new anatomy' of transsexual patients undergoing male to female sex reassignment surgery

Magnetic resonance (MR) is the best way to assess the new anatomy of the pelvis after male to female (MtF) sex reassignment surgery. The aim of the study was to evaluate the radiological appearance of the small pelvis after MtF surgery and to compare it with the normal women's anatomy. Fifteen patients who underwent MtF surgery were subjected to pelvic MR at least 6 months after surgery. The anthropometric parameters of the small pelvis were measured and compared with those of ten healthy women (control group). Our personal technique (creation of the mons Veneris under the pubic skin) was performed in all patients. In patients who underwent MtF surgery, the mean neovaginal depth was slightly superior than in women (P=0.009). The length of the inferior pelvic aperture and of the inlet of pelvis was higher in the control group (P<0.005). The inclination between the axis of the neovagina and the inferior pelvis aperture, the thickness of the mons Veneris and the thickness of the rectovaginal septum were comparable between the two study groups. MR consents a detailed assessment of the new pelvic anatomy after MtF surgery. The anthropometric parameters measured in our patients were comparable with those of women.

Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

Feminizing genitoplasty in adult transsexuals: early and long-term surgical results

OBJECTIVE

To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period.

PATIENTS AND METHODS

Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction.

RESULTS

In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations.

CONCLUSION

This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.

Development of Feminizing Genitoplasty for Gender Dysphoria

INTRODUCTION

Determining the history and development of feminizing genitoplasty is fascinating and instructive but fraught with difficulty. Earliest examples relate to practices carried out in ancient cultures. Gender reassignment surgery (GRS) developed from reconstructive procedures for congenital abnormalities. Some surgery was disguised, techniques were not recorded, and operations were carried out in secret.

AIM

The aim of this article is to review the historical development of male-to-female GRS.

METHODS

Information was gleaned from Medline and general Internet searches. Further evidence was found by reviewing the references of early articles. A fascinating insight was also found in the autobiographies of GRS patients.

RESULTS

The first recorded case was by Abrahams in 1931. Techniques evolved from the early vaginal absence work of Beck and Graves. Pioneers of GRS were Sir Harold Gillies in England and Georges Burou of Casablanca. In the 1950s, they both used invagination of the penile skin sheath to form a vagina. Howard Jones, of Johns Hopkins, published the second classic technique using penile and scrotal skin flaps. These two methods form the basis of male-to-female GRS today. The history of GRS reveals a struggle to improve functionality as well as cosmesis. In particular, the neovagina but also a functioning neoclitoris, which has developed from a cosmetic swelling into an innovated organ, derived from the glans penis and harvested penile neurovascular bundle.

CONCLUSIONS

Improved function and cosmesis continue to be the aim of the gender dysphoria surgeon. However, this review suggests the future management of transwomen should address not only refinements of surgical techniques but also prospective collection of posttreatment quality-of-life issues.

Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals

LEARNING OBJECTIVES

After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.

BACKGROUND

Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.

METHODS

The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.

RESULTS

Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.

CONCLUSIONS

This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.

Impact of Sex Reassignment Surgery on Lower Urinary Tract Function

OBJECTIVE

To investigate the effects of sex reassignment surgery (SRS) on lower urinary tract function.

METHODS

A questionnaire concerning voiding habits and lower urinary tract symptoms after sex reassignment surgery, was given to 24 female-to-male transsexuals (FTM) and 31 male-to-female transsexuals (MTF), who respectively underwent phalloplasty and vaginoplasty. For this study only Dutch speaking patients were selected. Also, uro-flowmetry data from 92 FTM transsexuals were reviewed.

RESULTS

In general, no change in voiding patterns was observed. Post-void dribbling was reported by 79% of the FTM transsexuals, and 16% of the MTF group reported some form of incontinence. The uro-flowmetry examination showed a mean, non-significant decrease of 2 ml/s in Q(max) in FTM patients.

CONCLUSION

SRS can cause minor changes in urinary habits. Even if they do not result in patients seeking medical help, transsexuals should be warned about these eventual discomforts pre-operatively.

Long-term results in patients after rectosigmoid vaginoplasty

Many methods are used for vaginoplasty, including the split-thickness skin graft, full-thickness skin graft, and inverted penile skin flap. However, these procedures are not entirely satisfactory in cases of reconstructed vaginal stenosis, inadequate vaginal length, or poor lubrication. The small intestine, ascending colon, and sigmoid colon can be used in the intestinal flap method, and the authors modified the operation first described by Baldwin in which a loop of rectosigmoid is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and then anastomosed to the perineum. Vaginoplasty using the rectosigmoid was performed in 36 patients (28 male-to-female transsexual patients, five patients with congenital vaginal atresia, and three with cervical cancer). The follow-up period ranged from 1 to 10 years. The postoperative results were analyzed through physical examination and interview regarding the patient's functional status and satisfaction during sexual intercourse. The mean depth and width of the vaginal cavity were 12.5 cm and 3.9 cm, respectively. Excessive mucosal discharge was seen in 8.3 percent, and malodor was found in 8.3 percent. All patients who had partners were able to have sexual intercourse; 2.8 percent of patients used lubricants and 5.6 percent used dilators before intercourse for more than a year postoperatively. During intercourse, 88.9 percent of the patients experienced orgasm. The cosmetic and functional results of rectosigmoid vaginoplasty were excellent. Thus, the advantages of rectosigmoid vaginoplasty are (1) rare contraction of the reconstructed vagina, (2) vaginal width and depth maintained without long-term vaginal stent, (3) spontaneous mucus production facilitating sexual intercourse, (4) avoidance of the malodor frequently accompanying skin graft, and (5) texture and appearance similar to that of the natural vagina. The authors concluded that rectosigmoid vaginoplasty is the best choice for transsexual patients who have previously undergone penectomy and orchiectomy, patients with unfavorable previous vaginoplasty, those with short vaginal length after cervical cancer surgery, and patients with congenital vaginal atresia.

The transsexual: what about the future?

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients

OBJECTIVE

To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results.

PATIENTS AND METHODS

From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds.

RESULTS

Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse.

CONCLUSION

Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Augmentation mammaplasty in male-to-female transsexuals

Hormonal therapy and gender-confirming surgery are the treatments of choice in appropriately selected male-to-female transsexuals. Penectomy and vaginoplasty are the paramount surgical requests of the male transsexual, but breast enlargement greatly increases subjective feelings of femininity. There are only limited reports on augmentation mammaplasty in male transsexuals, and hardly any attention has been paid to the differences between the female mammary anatomy and its male counterpart. The basic anatomic and surgical considerations of augmentation mammaplasty for 201 male-to-female transsexuals who were operated on from 1979 to 1997 are reviewed and discussed. They include the differences between male and female anatomy and how to feminize the male chest, the results of hormonal therapy and the proper timing of surgery, the choice of implant size and surgical approach, the results that may be expected after surgery, and the implications of all mentioned on the long-term outcome and follow-up after augmentation mammaplasty. Because the referring doctor may not check on the breasts or may not be trained to examine augmented breasts for pathologic conditions, the mammaplastic surgeon has an obligation to ensure the proper follow-up of these patients.

Transsexualism: a review of etiology, diagnosis and treatment

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

The classification and labeling of nonhomosexual gender dysphorias

This report suggests systematic strategies for the descriptive classification of nonhomosexual gender identity disorders, based on clinical observations and research findings. The classification of biological males is considered first. A review of cross-gender taxonomies shows that previous observers have identified and labeled a homosexual type far more consistently than any other category of male gender dysphoric. It is suggested that the apparent difficulty in differentiating reliably among the nonhomosexual types results from the sharing of many overlapping characteristics by the various groups. This is supported by a review of informal, mostly clinical, observations and by the findings of three studies designed to test the hypothesis that the nonhomosexual gender dysphorias, together with transvestism, constitute a family of related disorders in men. It is concluded that the main varieties of nonhomosexual gender dysphoria are more similar to each other than any of them is to the homosexual type. Two recommendations, based on the foregoing review, are offered for the classification of male gender dysphorics in research studies. When the number of subjects is small, they may be classified simply as homosexual or nonhomosexual. When the number is larger, the nonhomosexual cases may be classified as heterosexual, bisexual, or analloerotic (unattracted to male or female partners, but not necessarily devoid of sexual drive or activities).

Prediction of regrets in postoperative transsexuals

This study investigated whether heterosexual males are more likely to regret sex reassignment surgery than homosexual males or females. Subjects were 111 postoperative transsexuals who had been surgically reassigned for at least one year, representing a follow-up rate of 84.1%. Subjects' feelings about surgery were assessed with self-administered questionnaires. None of the 61 homosexual females or 36 homosexual males consciously regretted surgery, compared to 4 of the 14 heterosexual males: a significant difference. This finding suggests that heterosexual applicants for sex reassignment should be evaluated with particular caution, although a heterosexual preference is not an absolute contraindication for surgery.

Typology of male-to-female transsexualism

This study tested a prediction derived from the hypothesis that asexual and bisexual transsexualism are actually subtypes of heterosexual transsexualism. Two questionnaire scales measuring erotic attraction to males and females were administered to 163 male-to-female transsexuals. A cluster analysis of their scores divided the subjects into four groups: heterosexual, homosexual, bisexual, and asexual. Fisher Exact tests were used to compare the frequency with which subjects in the four clusters reported a history of erotic arousal in association with cross-dressing. As predicted, there were no differences among the asexual, bisexual, and heterosexual transsexuals, and all three groups included a much higher proportion of fetishistic cases than the homosexual group (p less than or equal to .0001, two-tailed). These findings support the view that male transsexuals may be divided into two basic types: heterosexual and homosexual.

Outcome of sex reassignment surgery for transsexuals

Fifteen years ago the author reviewed the world literature on male transsexualism (Pauly, 1965). Subsequently he summarized the results of sex reassignment surgery for male and female transsexuals (Pauly, 1968), and reviewed the literature on female transsexualism (Pauly, 1974). Very recently, Meyer and Reter (1979) concluded that 'sex reassignment surgery confers no objective advantage in terms of social rehabilitation' as compared with a group of individuals who sought sex reassignment but remained unoperated upon at follow-up. Both groups improved over time and led the Johns Hopkins Gender Identity Clinic to conclude that sex reassignment surgery would no longer be offered there. This report, and other non-surgical, psychotherapeutic approaches to gender dysphoric patients (Barlow et al., 1973; Barlow et al., 1979; Lothstein and Levine, 1980) call into question the justification for sex reassignment surgery. Therefore, it becomes important to update the results of sex reassignment surgery for transsexuals. Data on 283 male to female transsexuals and 83 female to male transsexuals are presented.

The postsurgical transsexual: empirical and theoretical considerations

Two groups of patients served as subjects for the study. Group I consisted of seven biological males (three whites and four blacks) who received surgery before the organization of the CWRU Gender Identity Clinic; Group II consisted of 14 postsurgical patients (eight biological males, two white, six black; and six white biological females) from the CWRU Gender Identity Clinic. A nine-page, 59-item questionnaire was constructed to collect systematic follow-up data for Group II. Data were collected up to 2 years postsurgery at varying intervals, measuring the sexual, psychological, environmental, economic, parental, family, medical, and social adjustment and functioning of each patient. While surgery provided in the context of a comprehensive Gender Identity Clinic program may lead to moderate social-sexual gains, researchers must begin to focus on the psychological problems not broached by surgery. The recommendation that psychotherapy be attempted with these patients (both pre- and postsurgery) is an important outgrowth of the study. Moreover, the need for a more systematic approach to follow-up, including the use of standardized interviews and clinical assessment tools and adequate control groups, is discussed.

One-stage operation for male transsexuals

A simplified surgical technique for a male-to-female transsexual operation has been developed and applied satisfactorily in a series of carefully selected patients. The simplicity of the technique allows relatively brief hospitalization for 1-stage sex conversion, provides satisfactory cosmetic and functional results, and has not been accompanied by any untoward complications.

Male transsexualism--a review of genital surgical reconstruction

Transsexualism is a poorly understood, uncommon, and controversial entity of recent interest to the lay public and medical profession. Important features of the condition are discussed, surgical procedures for genital conversion in male transsexuals are compared, and our experience at the University of Virginia where 53 patients have been treated surgically is presented. All patients have made satisfactory postoperative psychosocial adjustment despite a surgical complication rate approaching 50 per cent. It is concluded that alternative (better) surgical procedures for male transsexuals should be explored.

Parental relationships during childhood in homosexuality, transvestism and transsexualism

The nature of the relationships of 29 male homosexuals, 34 male transvestites and 29 male transsexuals with their parents, during childhood, was assessed on the basis of the subjects' reports, and on their responses to two tests, namely the Childhood Family Relationship test and a Semantic Differential. If the subjects' reports are valid significantly more mothers of transvestite and transsexual subjects hoped for a girl prior to the subject's birth. During childhood there was a trend for homosexual, transvestite and transsexual subjects to report that their fathers lacked interest in them or were absent from home. There was little evidence to support the view that homosexual, transvestite or transsexual subjects had pathological relationships with their mother. Intrafamilial childhood environmental factors reported by homosexuals, transvestites and transsexuals appear to be non-specific.