Sex change: What Is It, | Risks, Results, Options and Cost

Introduction

Transsexuality has gone through many ups and downs throughout history; accepted and standardized, to later be considered as a disease; today it is recognized as real suffering and there are many solutions to help transgender people become the person they want.

In this article, we will try to give you as much information as possible about sex reassignment or sex-change surgery.

Definitions

Before delving into the subject of sexual reassignment, it is important to clarify some definitions of the transgender realm. However, it is very difficult to find the same definition for each of these terms since they differ according to the sources consulted. We try here to summarize them with simple words :

• Sex change or sexual reassignment: Surgical intervention whose goal is to change the birth sex to make it the desired sex.
• Gender dysphoria: A medical term used by the American Psychiatric Association to express pain and suffering associated with gender nonconformity.
• Transgender: A person who does not feel comfortable with their gender assignment. We also speak of trans identity. The words “transgender” and “transsexual” are often used synonymously to refer to people who want to undergo a sex change.
• Transsexual: A transgender person who has undergone a sexual reassignment intervention to change sex.
• Cisgender: Person by the assigned gender and their biological sex.
• Intersexuality: People who are born with a malformation at the level of the sexual organs, which makes it difficult or impossible to assign them sex. Therefore, parents must choose a name and gender, not knowing how the child will develop.
• Transsexual man: A person born in a woman’s body that has begun its transformation into a man’s body.
• Transsexual woman: Person born in a man’s body that has begun its transformation into a woman’s body.
• MtF (Male to Female): Transformation from male to female
• FtM (Female to Male): Transformation from woman to man
• Non-binary people: A person who does not conform to the standards of today’s society that divides the population into two genders; men and women.

Causes of transsexuality

We still do not know with certainty what the causes of transsexuality are, because scientists do not conclude. According to The Journal of Neuroscience, transsexuality would have a biological basis. Others speak of a genetic cause or related to the brain structure. What is important to get out of here is that transgender people are not sick.

The early beginnings of transsexuality

Today everyone is talking about transsexuality as if it were a new phenomenon, however, it is the opposite! The subject began to be discussed in ancient times, and even in the Native American tribes, where transsexual women had the possibility of dressing as a woman and even having a husband. There are also known transgenders in history, such as Joan of Arc in France.

In modern history, we remember Lili Elbe, the first known person to have had sex reassignment surgery in 1930; but he died in an ovarian transplant operation. We also remember Christine Jorgensen, who is the first known transgender woman to have successfully undergone all sexual reassignment interventions. His various surgeries were performed between 1952 and 1954.

It was just at that moment that Dr. Harry Benjamin became the first physician and endocrinologist to claim that transgender people were not sick, but suffered from real suffering. Dr. Benjamin has helped many trans people throughout his career, which is why he is considered the ” founder ” of Western transsexuality, according to data collected in the thesis of Lynn Conway, from the artificial intelligence laboratory of Michigan.

In the late 1950s, French plastic surgeon Georges Bureau invented the modern penis inversion technique during an MtF transformation, which is the one used today.

Transsexuality from an early age

Transsexuality can manifest from an early age, that is, from the three years when children are mature enough to define themselves as a child. Parents need to pay attention to their children during this stage if they notice that they develop gender dysphoria. Accompany and support them. Treating gender dysphoria from an early age helps avoid further suffering in the future. In addition, the doctor may prescribe hormonal treatment for the child so that he does not continue to develop in a gender that does not correspond to him during the stage of puberty.

Which doctor to go to?

Many surgeons and physicians are involved in the sex reassignment process as we will see later.

Concerning these surgical procedures, we recommend you always visit a certified surgeon, experienced and experienced. Sex reassignment interventions are very specific so very few surgeons can carry them out.

We recommend that you first verify that your surgeon is certified. You can enter the SECPRE website to verify that it is part of its directory. You can also search for opinions online, such as in forums. Check out the before and after photos to learn more about the type of work performed by the surgeon of your choice. If you cannot find photos online, ask for them during the consultation.

Finally, we advise you to go to different surgeons to complete your transformation: choose a breast implant specialist if you are undergoing an MtF transformation or a rhinoplasty specialist for facial feminization procedures.

Sex reassignment process

a long medical journey awaits you if you have not yet embarked on your transformation. Here we summarize the steps that you will have to take until you reach the end of the process, as commented by Dr. María Serrano Velasco, a gynecologist specializing in sex changes :

1. Family doctor: The first step is to go to your family doctor to discuss your situation. He will refer you to the Gender Identity Unit (UIG) of your autonomous community.
2. Gender Identity Unit (UIG): Your UIG will help and guide you throughout the process thanks to trained and specialized professionals. You are going to have to go through tests and tests that last several months. Once diagnosed with ” gender identity disorder ” you can move on to the next phase. Both you and your family will be accompanied throughout the process by the professionals of the UIG.
3. Endocrinologist: This is where the hormonal treatment begins. Once possible contraindications to hormonal treatment have been ruled out through blood tests, your endocrinologist will prescribe hormones to begin the body change.
4. Real-life test: At the same time that you are taking your hormonal treatment, the psychologist who is accompanying you will ask you to submit to the real-life test. In other words, for 2 years, you will have to live with the gender with which you identify. It is quite a difficult period because you will not have completed your transformation yet, but it allows you to experience the change for yourself before undergoing irreversible cosmetic surgery.
5. Plastic surgery: Once the testing and testing process is finished, you can undergo sexual reassignment surgeries ( sex change ), although you will have to continue taking hormones for life. If you are transitioning to FtM, you can have a mastectomy by starting hormones. If instead, you are undergoing an MtF process, you will have to wait until your breast growth has stabilized to perform a breast augmentation.

What are the requirements to undergo sex reassignment surgery?

The professionals of the Barnaclínic Gender Identity Unit (UIG) give us a detailed list of the action protocol to treat a case of gender dysphoria :

• have made a consultation with a psychologist or a psychiatrist to rule out a temporary psychological alteration at the origin of the need to change sex
• possess a certificate from a psychiatrist proving the diagnosis of real transsexuality
• have undergone hormonal treatment by an endocrinologist as well as preoperative tests
• sign an informed consent detailing the complications as well as the irreversibility of the surgery.

Hormones

The hormonal treatment is the beginning of the physical transformation and lived as a liberation for patients transgender. There are different types of hormones, administered in different ways (orally, dermally, or through injections).

Transgender men are given male hormones, namely testosterone. Transsexual women instead take female hormones, ie estrogens, and androgens. Taking estrogens should be for life, while antiandrogens will no longer be necessary after sexual reassignment surgery. Testosterone intake should also be for life.

You will have to carry out controls every 6 months. Once you have undergone a sex change intervention, the controls will be annual.

The hormonal changes are more or less rapid depending on the patient and are similar to those experienced during puberty :

• FtM: the voice changes, body and facial hair increase, the clitoris changes shape and size, muscle mass and silhouette change, bones become stronger, and skin thicker. We also have physiological changes, such as increasing the frequency of heart and blood pressure changes in body odor, increased libido, and loss of menstruation.

• MtF: nipples and chest develop, testicles atrophy, erectile function, and muscle mass decrease, body fat is redistributed, face and skin are smoothed and slimmer, and baldness stops. The following changes are also observed: decreased libido, decreased heart rate, and inability to have an erection and create sperm or ejaculate.

Also, you need to know that during an MtF transformation, hormones have little or no influence on the voice. Therefore, you will have to take diction classes or consult a speech therapist to help you change your diction. The same is true for body hair; hormones do not remove it so you will have to undergo a laser hair removal process.

It is also important that you know that some effects of hormones are reversible, while sexual reassignment interventions are not. Hormones can make you sterile, so you must talk to your doctor if you want to have children in the future so that he can take the necessary measures.

MtF (Male to Female): Transformation from male to female

Next, we describe the main interventions that can be performed during an MTF transformation, that is, from male to female. Most of these procedures are performed under general anesthesia and may require several days of hospitalization.

Vaginoplasty

• Preparation for the intervention

To have vaginoplasty, you will need to have been taking estrogen for at least 1 year. We also recommend that you have undergone a laser hair removal treatment in the genital area before the procedure. As with any other surgical procedure, your doctor will ask you to stop smoking at least 1 month before the procedure and 1 month after to facilitate healing. You should also stop taking aspirin-type medications at least 15 days before. You will be hospitalized the day before surgery to perform a bowel wash.

• The intervention

The intervention lasts 4 to 5 hours. The vaginoplasty is to eliminate almost entirely the corpus cavernosum of the penis and uses the outer skin to create the internal walls of the vaginal. This means that the inside of the vagina will be made up of the outer skin of the penis. When the vaginoplasty by penile inversion is not possible, either because the penis is circumcised or because it has enough skin, the technique is used in the skin flap, as indicated by Barnaclínic professionals. The testicles are also removed. The upper part of the glans, which is a very sensitive part, is used to build the clitoris. The foreskin allows the labia minora to be created. As for the outer parts of the scrotum, they are used to create the labia majora. During the procedure, the outlet of the urethra is shortened to allow downward urination.

• Postoperative

At the end of the procedure, a specially designed silicone prosthesis is placed inside the vagina. It allows to obtain the desired depth and width and will keep for 8 to 10 days. You will have to lie down for 24 hours and carry a urinary catheter for 1 week. Your drains will be removed a few days after surgery, and your doctor will change your dressing after 4 days. You will be hospitalized for approximately 12 days. You must follow the tips below to carry a successful postoperative :

1. maintain good intimate hygiene using a soap with a neutral PH, rinse well and gently dry the area
2. wear loose-fitting underwear and sweat pants or skirts
3. If you notice any significant change in the area (smell, fluid) notify your surgeon
4. avoid penetrative sex for the first 2 months

Vaginal dilator

You will need to use a vaginal dilator regularly to maintain the results. You must know the role of dilators in the postoperative period: they should be used for 30 to 40 minutes a day for several months, and they are getting bigger and thicker, so they allow you to obtain a satisfactory vagina size that is approaching that of a biological woman. After the postoperative period, in case you do not have sexual relations for a long period, you should also continue using a dilator 1-2 times a week to keep the width and depth of the vagina, according to what Lynn Conway tells us.

Results

The results are extraordinary. The vagina is similar in appearance to that of a biological woman and also allows for pleasure during sexual intercourse. Patients are generally very happy with the result, which allows them to fully live their sexuality and life as women, without any complexities.

Possible complications

All surgical procedures involve risks and possible complications that you should be aware of before starting the procedure. Regarding vaginoplasty we have the following risks:

1. infection
2. bleeding
3. vagino-rectal fistula
4. urinary function disorders
5. abnormalities in the direction of the urine stream

Breast augmentation

To complete the transformation from male to female, you can also undergo breast augmentation. Overall, this is the first intervention performed by transsexual women. You can use it during the hormonal treatment phase, once your breast size has stabilized. For more information about this procedure, we recommend you read this article: Breast augmentation

Feminization of the face

You will also likely need facial surgeries and aesthetic medicine treatments to complete your transformation and feminize your appearance. Among them, we highlight rhinoplasty, correction of the oval of the face such as the chin, chin, or mandibular angle (which can be performed during maxillofacial surgery or with injections of hyaluronic acid), correction of the volumes of the cheekbones ( hyaluronic acid or implants), a lip augmentation, forehead correction or walnut ablation.

Feminization of the body

The Barnaclínic experts tell us that the body can also be harmonized by performing interventions such as gluteal augmentation, liposculpture, or a tummy tuck.

FtM (Female to Male): Transformation from woman to man

Many interventions can be performed during an FtM transformation, that is, from woman to man. These procedures are performed under general anesthesia and require one to several days of hospitalization. Before surgery, your doctor will always advise you to stop smoking for at least 1 month before and 1 month after the procedure, and not to take aspirin for 2 weeks before surgery. Here we give you a summary of the main interventions that can be carried out as explained by Barnaclínic professionals.

Bilateral mastectomy

You can have this intervention as soon as you start your hormonal treatment to help you feel better in your body.

It is a delicate procedure since the thorax will be exposed in your daily life, therefore, it should look as natural as possible. The physician will remove the glandular tissue tamari or form a flat chest symmetrical that aesthetically resembles a male breast. If necessary, the surgeon may also reduce the size of the breast areolas.

Metoidioplasty

This sexual reassignment technique consists of transforming the clitoris into a kind of small penis. With the intake of male hormones, the clitoris tends to grow to an average size of 4 to 5 cm. Some patients decide to resort to metoidioplasty instead of phalloplasty if the size of their clitoris allows it because it is a simpler operation, which leaves fewer sequelae. The result of the metoidioplasty does not allow the patient to perform a penetration during sexual intercourse, but it allows you to maintain the orgasmic capacity of your clitoris.

This procedure is usually performed at the same time as a scrotoplasty (creation of the scrotum), a vaginectomy (more or less partial removal of the vagina), a hysterectomy (more or less partial removal of the uterus), and an oophorectomy (removal of the ovaries). ), if these have not been done yet.

Phalloplasty

Phalloplasty is sex reassignment surgery that allows transsexual men to obtain a penis.

• Preparation for the procedure

As we have said before, you should stop smoking before and after the intervention, as well as stop taking anti-inflammatory drugs. You will enter the hospital the day before to perform a bowel wash.

Results

It is a complicated surgery that lasts between 8 and 9 hours.

At first, the urologist will use the labia minora to reconstruct the urethra. Then from the labia major, he will build a scrotum, which will be similar to that of a biological man.

To build the penis, the surgeon uses the tissue from the forearm, which must first have been treated by laser hair removal. This flap of skin covers and gives volume to the internal canal, which serves to evacuate urine. The forearm will be covered by a scar and will be thinner after this procedure, which achieves a penis of about 12 to 13 cm, with penetration capacity, as Barnaclínic professionals tell us.

Postoperative

Such an operation requires 2.5 weeks of hospitalization and you will not be able to return to work for another 2 months. You will wear a compression bandage around the arm where the skin flap was removed. In a few days, the drains will be removed.

We advise you to follow the following instructions in the postoperative period :

1. protects the operated area from cold
2. sleep on your back
3. maintain excellent intimate hygiene
4. wear loose clothing and baggy briefs
5. wait several weeks before resuming mild, progressive physical activity
6. pay attention to any significant changes during your recovery period: smells, fluids … to communicate them to your surgeon as soon as possible.

Results

In general, patients are very satisfied with the results of their phalloplasty and most can urinate standing up and have orgasms. Regarding penetration, you will need to wear an erectile prosthesis, as we will see later. For an even more natural result, you can tattoo veins on the penis. Only after the healing is complete will you be able to perform a new intervention to complete your transformation.

Risks and complications

All surgical procedures carry several risks and potential complications that are important for you to be aware of. These include:

1. formation of a clot
2. infection
3. necrosis
4. hemorrhage
5. difficult healing

Testicular implants

To give a more natural look to the scrotum that was created in a previous procedure, you can fill it with testicular prostheses. These prostheses are made of silicone gel and exist in different sizes. However, you can only opt for this surgery at least 6 months after the scrotoplasty.

Erectile prosthesis

Erectile prostheses can be placed approximately 12 to 18 months after a phalloplasty, once sensation in the upper part of the penis has returned.

This prosthesis allows you to get an erection, and therefore a penetration. You can also stimulate the penis and even have an orgasm without wearing this type of device.

There are different types of prostheses, your doctor can advise you to choose the one that best suits you:

• semi-rigid or flexible prosthesis allows a simple and easy use, as well as the intervention. It is fully concealed in the body and folds easily. However, it remains rigid all the time, which can make you feel uncomfortable by giving an impression of being constantly erect. Initially, it was created for older men who can no longer get an erection.
• Flexible trans men erectile prostheses: specially designed for transsexuals, they can be activated with a simple movement.
• Hydraulic prosthesis: a small bulb is placed in the scrotum, which when pressed several times allows an erection to be obtained. It mimics the natural erection very well, but it lasts from 5 to 10 years.
• Inflatable erectile prosthesis: unlike the previous one, it contains a reservoir placed in the lower abdomen that contains the liquid that creates the erection.

Sexuality after a sex change

Trans people must relearn how to discover their body and their sexuality after a process of sexual reassignment. The hormones during the early phase of treatment, and alter the sexual desire of patients ( increase in transsexual men and decreased in women transsexuals ). After sex reassignment surgery, intimate relationships are often better experienced and therefore more satisfying. This phenomenon occurs because patients feel better in their bodies and are released, allowing them to thrive at all levels, including the sexual level. What is important for you to know is that you can always reach orgasm after your procedure. The genitals are transformed, but retain their ability to produce sensations and induce orgasm.

Frequently asked questions

• At what age can I start an MtF or FtM transformation? In Spain, the legal age to operate is 18 years old. However, knowing that transgender people discover their difference and express their discomfort around the age of 3, it is difficult to imagine such a long wait. If you have not yet reached the age of majority, or if your children are still young, it is best to start the procedure as soon as possible, if only to stop the body from developing during puberty. Consult your doctor to begin hormonal treatment.
• Will I still be fertile? Treatments that are part of the sex reassignment process often lead to infertility. However, if you want to have children, we advise you to consult with your doctor. He can propose solutions such as freezing sperm or eggs before you start to get hormones.
• Will my voice change? Yes, taking hormones affects the voice. In the case of an FtM transformation, you should bear in mind that your voice will be increasingly masculine, but it will not be 100% identifiable as such. You can go to a speech therapist to help you change the tone of your voice. In the case of an MtF transformation, hormones play a very small role in voice change, so you will also need to see a speech therapist or undergo vocal cord surgery.
• Does social security cover the sex change process? If you go to a UIG to start your transformation, you will not have to pay anything since social security assumes the cost of the procedure.
• Can I go back if I regret it? Sex reassignment surgeries are irreversible. However, Dr. Bauquis, a Swiss surgeon who is an expert in sex-change surgeries, says that he has never met a patient who has regretted their surgery, quite the contrary.
• Do transsexual women menstruate? No, sexual reassignment interventions are only intended to change the external appearance of the genitals.
• Will a future sexual partner know that I underwent a sex change intervention? The results of phalloplasty and vaginoplasty are truly extraordinary, however, your genitals will never be similar to those of a biological man or woman. Also, in the case of a transsexual woman, you will have to use a lubricant. Therefore, it is advisable to speak openly and without taboos with your sexual partners.
• Will I be able to urinate standing up after phalloplasty? The answer is yes in the vast majority of cases.
• Can I get pregnant after an MtF transformation? You will not be able to get pregnant. If you want to conceive a child, we recommend that you speak with your doctor before the transformation, to offer you alternatives.