Gender reassignment surgery (GRS) formerly known as sex change surgery, has come a long way over the past several decades. The emotional pain suffered by transgender and intersex individuals who have gender dysphoria is better understood these days by the medical community and society as a whole. However, there is still a long way to go before the gender community is properly cared for. Dr. Mark Zukowski, an American, Board Certified plastic surgeon from Illinois, explains some basic background of gender reassignment surgery and describes some of the procedures of female-to-male (FTM) masculinization and male-to-female (MTF) feminization surgery.
History of Gender Reassignment Surgery
Beginning in the early 1900s, rare physicians would remove a patient’s hormone-producing organs such as ovaries, testicles, and uterus in order to relieve gender dysphoria. The removal of these organs allowed a patient to live free of many of the constraints placed on them by the sex they were assigned at birth. For example, transgender men would no longer have to go through menstrual cycles.
Rudimentary surgical developments occurred during the first half of the twentieth century. The first modern day vaginoplasty was performed in Berlin in 1931. A comprehensive set of gender confirmation surgeries were performed on Lili Elbe, a Dresden resident, in 1930. Her surgeries pioneered the use of orchiectomy and ovarian transplants. Unfortunately, a uterine transplant resulted in the rejection of the organ and Elbe’s death in 1931.
Most patients with gender dysphoria are suggested to begin hormone replacement therapy, either Estrogen, Progesterone or Testosterone, a few years before becoming ready for surgery. This is necessary for GRS. It is suggested also for breast augmentation and masculinization procedures. It is often optional for facial feminization procedures. This hormone therapy will help the patient’s body gain some of the secondary sex characteristics, including facial hair for transgender men, and breast development, and smoother and thinner facial skin in transgender females. Hormones have a big impact on a patient’s mental state.
When a patient has gender dysphoria and expresses an interest in GRS, feminization or masculinization procedures, they often first visit with a therapist to make sure that they are undergoing the surgery for the right reasons and get an ICD-10 diagnosis of F64.1, Gender Identity Disorder (GID). When they have this diagnosis, the surgery process can proceed more easily and might be covered by insurance.
Likewise, numerous professional organizations address this issue to clarify the nature of this treatment as medically necessary. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association that has established the Standards of Care for the evaluation and treatment of transgender individuals. WPATH has stated “surgery is essential and medically necessary to alleviate their gender dysphoria.” It continues to explain for these patients with severe gender dysphoria “relief from gender dysphoria cannot be achieved without modification of their primary and/or secondary sex characteristics to establish greater congruence with their gender identity.” Moreover, surgery can help patients feel more at ease in the presence of sex partnerships or in venues such as physician’s offices, swimming pools, or health clubs. In some settings, surgery might reduce risk of harm in the event of arrest or search by police and other authorities.
In addition, the American Medical Association, the Endocrine Society, the American Psychological Association, the American College of Obstetrics and Gynecology, the American Psychiatric Society and the American Public Health Association all support WPATH in adopting positions supporting the medical necessity of transition-related care including hormonal and surgical interventions, as well as expressing support for insurance coverage for these interventions.
Also noteworthy, The United States Tax Court has made rulings which clarify that medical services provided for the treatment of GID are medically necessary and are not to be considered “cosmetic.” One of these U.S. Tax Court rulings is O’Donnahbain versus Commissioner (2010) (134 T.C., No.4, Docket 6402-06). The Tax Court ruled that “GID is a well-recognized and serious mental disorder,” And upheld that “GID is a disease and sex-reassignment related surgeries treated the disease within the meaning of IRS Section 213 and were therefore not cosmetic surgery.”
The surgeon will work closely with the patient’s care team, learning about their physical and mental health. Often, gynecologists and urologists will be involved in the procedures. When the surgeon meets with the patient, they need to talk frankly about the changes they will be making to the patient’s body. Patients may have especially strong feelings about certain parts of their anatomy, making sure that these concerns are adequately addressed during surgery.
Gender reassignment or gender confirmation is often performed in a series of surgeries. Dr. Mark Zukowski explains some of these surgeries for transgender men and women.
Female-to-Male Gender Confirmation Surgery
After a period of testosterone hormone therapy, usually 9-12 months minimum, the patient often selects “top surgery” first. This surgery removes the patient’s breasts and reconstructs the chest to masculine proportions.
There are different types of chest surgery which are recommended for patients with differing breast sizes such as a C cup or bigger body types. In the experience of Dr. Zukowski, it is highly individualized, and the first surgery may need minor revisions to get the best results. People with larger bodies and breasts are generally suggested simple mastectomies with removal of the breast, nipple and areola. The areolas are “too big” for a male as are the nipples. If preserved, these can be a later focus of breast cancer.
A modified keyhole or minimal scar periareolar approach is recommended for patients with A or B cup breasts. This procedure allows the nipples to stay in place, allowing for retained sensation. This type of surgery provides less scarring than the simple mastectomy. Liposuction is combined with both. Nipples can later be reduced.
“Bottom surgery” for female-to-male candidates, as it is known, involves the removal of hormone-producing organs and the construction of male genital organs. This surgery is quite complex and requires an expert hand. During bottom surgery, the surgeon constructs a phallus using skin from the patient’s forearm or lower abdomen. This organ can sometimes be constructed in a way that allows it to have sensation.
Male-to-Female Gender Confirmation Surgery and Face, Breast, and Body Feminization Surgery
During male-to female breast augmentation, the physician makes incisions on the patient’s breast and places breast implants. These implants are either silicone or saline. This surgery is typically easier to recover from than a mastectomy. The breast is often unequal and spaced further apart. A larger implant is often needed to bring the breasts closer together. For facial procedures, patients receive a tracheal shave which reduces the size of their Adam’s apple, brow bone forehead contouring, scalp advancement, nose reshaping, a lip lift to show more fullness to the upper lip and to show some of the upper teeth with a smile. Cheek implants, fat grafting to the soft tissues, chin and jawbone reshaping, along with face and neck lifts are a few of the many common facial procedures.
Bottom surgery is a complex operation that often involves a urologist. Patients often choose different combinations of procedures, whether a one stage, two stage, colon interposition in order to give them anatomy that they are comfortable with. Many male-to-female patients have surgery to remove their hormone-producing organs, the testes first. The prostate is always left intact. Vaginoplasty helps male-to-female patients have feminine external genitals. There are several different strategies for vaginoplasty. The most common is known as penile inversion. This uses penile tissue to construct the neovagina. This allows the patient to retain sexual sensation. Rectosigmoid vaginoplasty uses tissue from the intestines to give both depth and lubrication. Depth and the ability to have sensation and an orgasm is critical to modern GRS.
Compassionate Care for Gender Confirmation
When a patient chooses a physician to help them match their external appearance to their internal sense of self, the physician must be caring and compassionate. Dr. Zukowski says that many of his patients state it was not but ten years ago that they were thrown out of a doctor’s office stating, “We do not treat your kind.” Dr. Zukowski notes that this is horrible since all doctors take a Hippocratic Oath to help all people. Not every plastic surgeon has the capability to treat male-to-female and female-to-male patients with fairness. Dr. Mark Zukowski recommends screening a variety of gender related surgeons before finding the right doctor for you. Beware of the doctors that have re-invented themselves as a gender surgeon. Beware of the ENT, dermatologist, general internist, osteopathic or gynecologist that calls themselves a plastic surgeon.