Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.
Notes and references
Sex reassignment surgery for male-to-female involves reshaping the male genitals into a form with the appearance of, and, as far as possible, the function of female genitalia. Prior to any surgeries, patients usually undergo hormone replacement therapy (HRT), and, depending on the age at which HRT begins, facial hair removal. There are associated surgeries patients may elect to, including facial feminization surgery, breast augmentation, and various other procedures.
Lili Elbe was the first known recipient of male-to-female sex reassignment surgery, in Germany in 1930. She was the subject of four surgeries: one for orchiectomy, one to transplant an ovary, one for penectomy, and one for vaginoplasty and a uterus transplant. However, she died three months after her last operation.
Christine Jørgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. She was a strong advocate for the rights of transgender people.
Another famous person to undergo male-to-female sex reassignment surgery was Renée Richards. She transitioned and had surgery in the mid-1970s, and successfully fought to have transgender people recognized in their new sex.
The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center. The first physician to perform sex reassignment surgery in the United States was the late Elmer Belt, who did so until the late 1960s.
In 2017, the United StatesDefense Health Agency for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who identifies as a woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.
Main article: Vaginoplasty
When changing anatomical sex from male to female, the testicles are removed, and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951), to form a fully sensitive vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hairfollicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.
In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty).
Surgeon's requirements, procedures, and recommendations vary enormously in the days before and after, and the months following, these procedures.
Plastic surgery, since it involves skin, is never an exact procedure, and cosmetic refining to the outer vulva is sometimes required. Some surgeons prefer to do most of the crafting of the outer vulva as a second surgery, when other tissues, blood and nerve supplies have recovered from the first surgery. This relatively minor surgery, which is usually performed only under local anaesthetic, is called labiaplasty.
The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is affected by age, nutrition, physical activity and smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage.
Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. Lubrication is needed when having sex and occasional douching is advised so that bacteria do not start to grow and give off odors.
Because of the risk of vaginal stenosis (the narrowing or loss of flexibility of the vagina), any current technique of vaginoplasty requires some long-term maintenance of volume (vaginal dilation), by the patient, using medical graduated dilators to keep the vagina open. Penile-vaginal penetration with a sexual partner is not an adequate method of performing dilation. Daily dilation of the vagina for six months in order to prevent stenosis is recommended among health professionals. Over time, dilation is required less often, but it may be required indefinitely in some cases.
Regular application of estrogen into the vagina , for which there are several standard products, may help, but this must be calculated into total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually, or, in extreme cases, under anaesthetic.
With current procedures, trans women do not have ovaries or uteri. This means that they are unable to bear children or menstruate until a uterus transplant is performed, and that they will need to remain on hormone therapy after their surgery to maintain female hormonal status.
Other related procedures
Facial feminization surgery
Main article: Facial feminization surgery
Occasionally these basic procedures are complemented further with feminizing cosmetic surgeries or procedures that modify bone or cartilage structures, typically in the jaw, brow, forehead, nose and cheek areas. These are known as facial feminization surgery or FFS.
Breast augmentation is the enlargement of the breasts. Some trans women choose to undergo this procedure if hormone therapy does not yield satisfactory results. Usually, typical growth for trans women is one to two cup sizes below closely related females such as the mother or sisters. Estrogen is responsible for fat distribution to the breasts, hips and buttocks, while progesterone is responsible for developing the actual milk glands. Progesterone also rounds out the breast to an adult Tanner stage-5 shape and matures and darkens the areola.
Voice feminization surgery
See also: Voice therapy (trans) § Vocal surgeries
Some MTF individuals may elect to have voice surgery, altering the range or pitch of the person's vocal cords. However, this procedure carries the risk of impairing a trans woman's voice forever, as happened to transsexual economist and author Deirdre McCloskey. Because estrogens by themselves are not able to alter a person's voice range or pitch, some people proceed to seek treatment. Other options are available to people wishing to speak in a less masculine tone. Voice feminization lessons are available to train trans women to practice feminization of their speech.
Main article: Chondrolaryngoplasty
A tracheal shave procedure is also sometimes used to reduce the cartilage in the area of the throat and minimize the appearance of the Adam's apple, in order to conform to more feminine dimensions.
Because anatomically masculine hips and buttocks are generally smaller than those that are anatomically feminine, some MTF individuals will choose to undergo buttock augmentation. If, however, efficient hormone therapy is conducted before the patient is past puberty, the pelvis will broaden slightly, and even if the patient is past their teen years, a layer of subcutaneous fat will be distributed over the body rounding contours. Trans women usually end up with a waist to hip ratio of around 0.8, and if estrogen is administered at a young enough age "before the bone plates close", some trans women may achieve a waist to hip ratio of 0.7 or lower. The pubescent pelvis will broaden under estrogen therapy even if the skeleton is anatomically masculine.
- ^Wexler, Laura (2007). "Identity Crisis". Baltimore Style (January/February). Archived from the original on 2012-02-19. Retrieved 2009-10-12.
- ^Kube, Courtney (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News.
- ^Lynne Carroll, Lauren Mizock (2017). Clinical Issues and Affirmative Treatment with Transgender Clients, An Issue of Psychiatric Clinics of North America, E-Book. Elsevier Health Sciences. p. 111. ISBN 0323510043. Retrieved January 8, 2018.
- ^ abAbbie E. Goldberg (2016). The SAGE Encyclopedia of LGBTQ Studies. Sage Publications. p. 1281. ISBN 1483371298. Retrieved January 8, 2018.
- ^Jerry J. Bigner, Joseph L. Wetchler (2012). Handbook of LGBT-Affirmative Couple and Family Therapy. Routledge. p. 307. ISBN 1136340327. Retrieved February 29, 2016.
- ^Arlene Istar Lev (2013). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Routledge. p. 361. ISBN 113638488X. Retrieved February 29, 2016.
- ^ abLaura Erickson-Schroth (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press. p. 280. ISBN 0199325367. Retrieved February 29, 2016.