Transsexuality: Information & Doctors Specializing in Transsexuality

Transsexuality is a gender identity disorder. Those affected do not feel they belong to the gender that was socially and legally assigned to them at birth. They therefore have a strong desire to undergo gender reassignment surgery.

It can occur equally as male-to-female or female-to-male transsexuality.

The cause of transsexuality remains scientifically unproven. Transsexuality is influenced by many factors. A congenital predisposition is discussed as a possible cause of transsexuality, as are genetic or environmental factors.

Surgery for transsexuality is colloquially referred to as gender reassignment. However, the individual surgical steps should be understood more as gender-affirming procedures. A true transformation into the opposite sex is not possible, even with the most advanced surgical techniques.

Surgical procedures for transsexuality are typically performed through collaboration among various medical specialties. Depending on the patient’s gender, the surgical team consists of urologists, gynecologists, and plastic surgeons.

Not feeling aligned with the gender with which one identifies is very distressing for those affected © Good Studio | AdobeStock

In Germany, the Transsexuals Act provides the legal basis for changing one’s first name or civil status. The medical process is governed by the Standards of Care and the MDS Guidelines of May 19, 2009. Neither of these guidelines is legally binding, but they are applied as such in practice.

The diagnosis is typically confirmed by two independent psychiatric or psychological evaluations. Both evaluations must clearly establish the medical indication for gender-affirming surgery in cases of transsexuality. The evaluations also allow for cross-sex hormone therapy to begin even before the first surgical procedures.

Both reports are currently sufficient for a first name change as well as for a change in civil status. Marriage is possible thereafter.

Cross-sex hormone therapy must be continued for life, even after gender-affirming surgery. Antiandrogens are no longer necessary for male-to-female transsexuality. Likewise, during this period, the patient’s ability to cope with daily life, as assessed through accompanying psychotherapy, should be evaluated positively.

As a rule, several surgical procedures—and consequently several hospital stays—are necessary for surgical gender reassignment. Depending on the stage of the procedure, the hospital stay ranges from 4 to 20 days.

Depending on the extent of the procedure, general anesthesia is required. Only minor secondary or additional procedures can be performed under local anesthesia on an outpatient basis.

No special preparation is necessary for gender-affirming surgery for transsexuality. However, you should avoid taking pain relievers such as aspirin for at least 14 days before the surgery, as these can delay blood clotting.

The use of sleeping pills, as well as alcohol and nicotine consumption, should also be avoided as much as possible.

Various surgical methods are available for female-to-male gender-affirming surgery:

Removal of the female reproductive organs

The first step is usually the removal of the female breasts.

For small breasts, this can be done through an incision around the nipple. After the surgery, virtually no visible scars remain (subcutaneous mastectomy).

In cases of very large breast tissue and a large layer of skin and soft tissue, a breast lift and nipple reduction are usually performed at the same time.

The removal of the internal female reproductive organs—that is,

• the uterus,
• ovaries, and
• fallopian tubes

is part of gender reassignment. This procedure can be performed before the initial gender-affirming surgeries or simultaneously as part of another surgical stage.

Penile Reconstruction in Female-to-Male Transsexual Surgery

For penile reconstruction, also known as phalloplasty, two surgical methods are routinely offered. Depending on the patient’s wishes and physical conditions, phalloplasty can be performed using a groin flap or a forearm flap (radial flap). B

In certain specific cases, however, other surgical methods may also be used (circular pedicle flaps/free fibular flaps).

The inguinal flap penoid is created from a portion of the rectus abdominis muscle, covered with skin from both inguinal regions. It is a pedicled myocutaneous flap (skin and muscle tissue). In addition, a rod-shaped silicone prosthesis is implanted to achieve flexible rigidity.

Phalloplasty using autologous tissue from the forearm is significantly more technically complex. A skin flap with the underlying tissue is harvested from the non-dominant forearm.

For the free tissue transfer, the supplying blood vessels in the forearm are first exposed. The surgeon then connects them to the inguinal vessels using a surgical microscope. The same procedure is performed to connect the nerves of the former clitoris to the former cutaneous nerves of the forearm. This ensures that the graft retains sensitivity and the ability to experience orgasm.

During the same surgical session, the urethra is extended to the tip of the penoid, and the vagina is removed. In the case of an inguinal penoid, the removal of the vagina and the extension of the urethra are performed only in subsequent surgical steps.

The creation of a scrotum is performed in subsequent surgeries. The skin of the labia majora is shaped into a scrotum. The implantation of silicone testicular prostheses completes the reconstruction.

For a penoid constructed from forearm tissue, wound healing must first be fully complete. In a later surgery, an erectile pump prosthesis is implanted.

In gender-affirming surgery for male-to-female transsexuality, the following procedures are performed in detail

• removal of the testicles and scrotum (orchiectomy),
• followed, in a subsequent step, by the removal of the corpora cavernosa and the penile shaft.

The glans penis (glans) is preserved and used to reconstruct the clitoris.

The skin of the former penis is then used to line the newly formed vagina.

Immediately after gender-affirming surgery, pain medication is necessary. Compression stockings and medication help prevent blood clots and embolisms.

It takes approximately 14 to 20 days for the skin to heal and for the swelling and bruising to subside. However, complete healing is not expected until several weeks later.

Depending on the surgical procedure, further treatment of the newly formed urethra in the urology department may be necessary.

Special precautions are necessary for certain pre-existing medical conditions. These include

• vascular diseases,
• venous stasis, or
• blood clots (e.g., thrombosis or embolism).

Despite the utmost care, complications may occur in isolated cases during or after surgery. Since the surgical wounds are extensive, bruising, discharge, or bacterial infections can interfere with healing.

Significant blood loss must be compensated for with infusions or blood transfusions. For this purpose, autologous blood can be collected prior to gender reassignment surgery.

In rare cases, excessive scarring may occur in individuals with a predisposition to it. Nevertheless, the surgical scars will remain permanently visible. Sensation in the skin and lymphatic drainage recover only slowly over the course of several months and may remain reduced in scarred areas.

Thrombosis and embolism are extremely rare but can place a life-threatening strain on the heart and circulatory system.

Specific complications that may occur following penile reconstruction include

• necrosis of the flap tips or
• extensive flap necrosis.

In rare cases, these can lead to complete loss of the flap. Urethral fistulas can occur, particularly at the suture sites (anastomoses) of the urethra. However, they usually heal on their own.

Other, very rare complications include rejection reactions or intolerance to the suture material or silicone implants. Prosthetic infections are also possible.