Gender Confirmation Surgery "Sexual Reassignment Surgery"

Michael Brownstein, MD

Gender reassignment surgery, or, more appropriately-gender confirmation surgery-is certainly not a new field in medical care. It has, unfortunately, carried with it, under the common name of "sex change" or transsexual surgery, a connotation of inappropriate surgical management of individuals who are either psychotic or societal misfits. This is absolutely not the case. Nor is it the case that prospective surgical patients are either gay or lesbian, though some have come from those "identities" as a way of coping with an underlying conflict between their genetic sexual identification and their true gender identity. Others undergo surgery, but maintain their gay or lesbian identification in their new surgically confirmed gender.

The surgical procedures have been carried out for many years, and probably the most familiar case was that of Christine Jorgensen, who was operated upon over 50 years ago. More recent studies carried out in the fields of psychiatry, psychology, and social science indicate that 1 in 20,000 individuals may be truly transgendered; that is, they may be, in all ways but genetically, of a sexual identity other than that of their birth.

As more understanding of the nature of this phenomenon becomes known, more interest is being shown by medical professionals and the lay public in the nature of this condition of transgenderism and the various aspects of its management, including psychological evaluation, endocrine (hormonal) management and surgical alteration of both primary and secondary physical characteristics.

Prospective surgical candidates are evaluated by psychiatric and psychological professionals to determine the appropriateness of both endocrine and surgical management. The Harry Benjamin International Gender Dysphoria Association, an organization to which most qualified professionals in the field belong, has set standards of care. Prospective surgical patients must be referred by psychiatric or psychology professionals before undergoing genital surgical procedures.

Female to Male Surgery

The surgical techniques involved vary. For female to male patients, a mastectomy is performed and the male nipple and areola are reconstructed by grafting of appropriately sized portions of native areola and nipple in proper proportion and placement to create a male appearing chest. It is also possible, in the small-breasted genetic female, to achieve a male appearing chest by performing a subcutaneous mastectomy through a periareolar incision. Some type of revision surgery is usually required later to remove any residual excess skin or to size the nipple areolar complex.

The creation of a phallus may be a very complex operation and is not ideal. Complex free forearm flaps and free bone grafts along with urethral grafts to extend the urinary tract to the tip of the phallus may be used to create a neophallus, but this procedure is not universally accepted due to its cost and the prospect of serious complications and prolonged hospitalization. Classic procedures, such as tubed flaps from the abdomen are rarely performed now. They are almost never effective for sexual gratification either by penetration or sensation.

Another procedure, metaidoioplasty, utilizes the clitoris, when hypertrophied by hormonal therapy, to form a neophallus. The clitoris is freed from the labial hood and denuded on its ventral surface. A vaginal flap can be created to cover the native urethral opening and form a tubed extension to the tip of the clitoral phallus, allowing the individual to void from a standing position. This structure may or may not be of sufficient length to allow for penetration and sexual gratification, although sensation should be preserved.

Male to Female Surgery

In the male to female transgendered individuals, augmentation mammaplasty, with the use of prostheses, is the standard method of achieving a female-appearing breast. The creation of a vaginal opening is much more complex, and there are various techniques available. The use of split thickness skin grafts is avoided when possible, as these contract and narrow the introitus and shorten the cavity.

The penile inversion technique is utilized in many instances. Here, the erectile tissues of the penis are removed, save for a portion of the glans and the dorsal neurovascular structures; the urethra is shortened and a cavity is created between the rectum and the urogenital structures. The penile skin is inverted into the cavity and an opening created to bring to the surface both the urethral and portion of the glans which serves now as a neoclitoris. These patients are often able to achieve orgasm and successfully have intercourse, though dilation techniques may be required as supplemental management.

Yet another technique is the use of a segment of colon, placed to the created neovagina to serve as a lubricated vaginal segment. The urethra and glans may be used as described above, to allow for sensation and urination in the sitting position.

These procedures can be considered safe, if performed by trained and experienced surgeons who specialize in this specific area of care. Of course, any or all of these operations carry with them risks ranging from minor to very serious and may require multidisciplinary care for their management.

Where Surgery is Performed

These procedures are performed in many places around the world, in many different centers. In some European countries, the state pays for the costs of these procedures for its citizens. It would not be correct to state that San Francisco draws people from all over the world for these procedures. There are not many surgeons in the United States who perform these procedures and those who do are located in other areas of the country, as well as here. Dr. Donald Laub, of Palo Alto, California has been a pioneer in this field, and is well known for his improvements in the techniques of metaidoioplasty and the use of intestinal segments for creation of a neovagina.

San Francisco is a "gender friendly" area and so a large number of patients may choose to come here for that very reason alone-that they will not be treated as "freaks of nature" or just plain weird.

I have been doing some form of surgery in this area for over 20 years, and, for that reason, I do see patients from many areas of the country who feel confident that their surgical treatment will be of good quality, and that their feelings will be treated with empathy and respect.

Dr. Michael L. Brownstein is a Board Certified Plastic Surgeon specializing in gender related surgery. Dr. Brownstein has performed this type of surgery since the late 1970s when, with the advice and support of Paul Walker, co-founder and president of the Harry Benjamin International Gender Dysphoria Association (HBIGD)A, he received the first of his many referrals for bilateral breast reconstruction in transgendered males. He expanded his practice in this field to include other surgical procedures over the ensuing years.

Dr. Brownstein is a member of many national plastic surgery organizations and societies, which include the American Society of Plastic Surgeons (ASPS). He is also a member of HBIGDA and chairman of the ethics committee, and is a Fellow of the American College of Surgeons (FACS). He has received additional specialized training in the field of gender reassignment surgery on several occasions, in Amsterdam, Netherlands, from internationally respected surgeon, Dr. J.J. Hage.