Gender-affirming surgery

Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals. It is also known as sex reassignment surgery, gender confirmation surgery, and several other names.

Professional medical organizations have established Standards of Care, which apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female, such as vaginoplasty, vulvoplasty and breast augmentation, while masculinization surgeries are those that result in anatomy that is typically gendered male, such as phalloplasty and breast reduction.

In addition to gender-affirming surgery, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Sweden became the first country in the world to allow transgender people to change their legal gender after "reassignment surgery" and provide free "reassignment" treatment in 1972.^[1] Singapore followed soon after in 1973, being the first in Asia.^[2]

Terminology

Gender-affirming surgery is known by numerous other names, including gender-affirmation surgery, sex reassignment surgery, gender reassignment surgery, and gender confirmation surgery.^[3] Top surgery and bottom surgery refer to surgeries on the chest and genitals respectively.^[4] It is sometimes called a sex change,^[5] though this term is usually considered offensive.^{[6][unreliable source?]}

Some transgender people who desire medical assistance to transition from one sex to another identify as "transsexual".^[7][8]

Trans women and others assigned male at birth may undergo one or more feminizing procedures which result in anatomy that is typically gendered female. These include genital surgeries such as penectomy (removal of the penis), orchiectomy (removal of the testicles), vaginoplasty (construction of a vagina), vulvoplasty (construction of a vulva), as well as breast augmentation, tracheal shave (reduction of the Adam's apple), facial feminization surgery, and voice feminization surgery among others.

Trans men and others assigned female at birth seeking surgery may undergo one or more masculinizing procedures, which include chest reconstruction, breast reduction, hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries). A penis can be constructed through metoidioplasty or phalloplasty, and a scrotum through scrotoplasty.^[9]

As knowledge of non-binary genders expands in the medical community, more surgeons are willing to tailor operations to individual needs. Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Gender nullification is the removal of all external genitalia except the urethral opening, typically pursued by people assigned male at birth.^{[10][medical citation needed]}

Gender-affirming surgery can also refer to operations pursued by cisgender people, such as mammaplasty, penile implant, or testicular implants following orchiectomy.^[11]

Gender-affirming surgery is often sensationalized and misrepresented by anti-trans activists through terminology such as genital-mutilation surgery.^[12]

Surgical procedures

Main articles: Gender-affirming surgery (male-to-female) and Gender-affirming surgery (female-to-male)

Genital surgery

For trans women, genital reconstruction usually involves the surgical construction of a vagina, by means of penile inversion or the sigmoid colon neovagina technique; or, more recently, non-penile inversion techniques that make use of scrotal tissue to construct the vaginal canal. For trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty.

Non-binary people often pursue genital surgeries, including the same operations as binary trans people of the same sex assignment, as well as bigenital or gender nullification surgeries. Bigenital operations include androgynoplasty, a procedure that retains the penis,^[13] or vagina-preserving phalloplasty.^[10]

Genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons.^[14]

Other surgeries

As underscored by WPATH, a medically assisted transition from one gender to another may entail any of a variety of non-genital surgical procedures which change primary and/or secondary sex characteristics, any of which are considered "gender-affirming surgery" when undertaken to affirm a person's gender identity.^[15] For trans men, these may include mastectomy (removal of the breasts) and chest reconstruction (the shaping of a male-contoured chest), or hysterectomy and bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes). For some trans women, facial feminization surgery, hair implants, and breast augmentation are also aesthetic components of their surgical treatment.^[16]

Scope and procedures

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery - or bottom surgery (the latter is named in contrast to top surgery, which is surgery to the breasts; bottom surgery does not refer to surgery on the buttocks in this context). However, the meaning of "sex reassignment surgery" has been clarified by the medical subspecialty organization, the World Professional Association for Transgender Health (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for "gender dysphoria" or "transsexualism".^{[needs update]} According to WPATH, medically necessary sex reassignment surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation ... including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient ...)... and certain facial plastic reconstruction."^[17] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.^[17]

Voice feminizing surgery is a procedure in which the overall pitch range of the patients voice is reduced.^[18]

Adam's apple reduction surgery (chondrolaryngoplasty) or tracheal shaving is a procedure in which the most prominent part of the thyroid cartilage is reduced.^[19]

There is also Adam's apple enhancement therapy, in which cartilage is used to bring out the Adam's apple in female to male patients.^{[20][better source needed]}

History

Nero had Sporus castrated,^[a] and during their marriage, Nero had Sporus appear in public as his wife wearing the regalia that was customary for Roman empresses.

Reports of people seeking gender-confirming surgery (vaginoplasty) go back to the 2nd century, such as the Roman Emperor Elagabalus.^[21][22] In the Byzantine Empire "reconstructive" surgeries on intersex people were performed at least from the seventh century on, in Alexandria possibly as early as the 2nd century.^[23] Paul of Aegina (c. 625 – c. 690), quoting Leonidas (Alexandria, 2nd – 3rd centuries), describes in section LXIX (On Hermaphrodites) of his sixth book four types of intersex and how to "cure" three of them by surgically removing the "useless parts".^[23][24] In the next section (LXX, On Extirpation of the Nympha and Cauda Pudendi) he deals with clitoromegaly and how to remove the enlarged clitoris.^[25] The first modern gender-confirming surgery was performed in the 20th century.^[21]

20th century

In the US in 1917, Alan L. Hart, an American tuberculosis specialist, became one of the first trans men to undergo hysterectomy and gonadectomy as treatment of what is now called gender dysphoria.^[26]

Dora Richter is the first known trans woman to undergo complete male-to-female genital surgery. She was one of several transgender people in the care of sexologist Magnus Hirschfeld at Berlin's Institute for Sexual Research. In 1922, Richter underwent orchiectomy. In early 1931, a penectomy, followed in June by vaginoplasty.^[26][27]

Between 1930 and 1931, Lili Elbe underwent four sex reassignment surgeries, including orchiectomy, an ovarian transplant, and penectomy. In June 1931, she underwent her fourth surgery, including an experimental uterine transplant and vaginoplasty, which she hoped would allow her to give birth. However, her body rejected the transplanted uterus, and she died of post-operative complications in September, at age 48.^[28][29][30]

A previous sex reassignment surgery (SRS) patient was Magnus Hirschfeld's housekeeper,^[31] but their name has not been discovered.^{[citation needed]}

Elmer Belt may have been the first U.S. surgeon to perform gender affirmation surgery, in about 1950.^[32]

In 1951, Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male SRS, producing a technique that has become a modern standard, called phalloplasty.^[33] Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

In 1971, Roberto Farina performed Brazil's first male-to-female gender-affirming surgery.^[34]

In 1984, Jalma Jurado developed a new surgical technique, which he used in surgeries for more than 500 transgender women in Brazil and from around the world.^[35]

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by the doctors Lebovic and Laub.^[36] Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head.^[36] Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.^[36]

21st century

On 12 June 2003, the European Court of Human Rights ruled in favor of Carola van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as van Kück vs Germany.^[37]

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".^[38]

As of 2017,^[update] some European countries require forced sterilization for the legal recognition of sex reassignment.^[39] As of 2020^[update], Japan also requires an individual to undergo sterilization to change their legal sex.^[40]

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.^[41][42]

Prevalence

The prevalence of transgender-related surgeries is difficult to measure and likely underestimated. In 2015, the largest survey of transgender people in the United States reported that 25% of respondents reported having undergone such a surgery.^[43]

Prior to surgery

Medical considerations

Some transgender persons present with health conditions including diabetes, asthma, and HIV, which can lead to complications with future therapy and pharmacological management.^[44] Typical SRS procedures involve complex medication regimens, including sex hormone therapy, throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including endocrinologists, whom the surgeon may consult when determining if the patient is physically fit for surgery.^[45][46] Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.^[47]

People with HIV or hepatitis C may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.^[48]

Fertility is also a factor considered in SRS, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.^[45]

Gender dysphoric children

Sex reassignment surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it.^[49] Preferred treatments for children include puberty blockers, which are thought to have some reversible physical changes,^[50] and sex hormones, which reduce the need for future surgery. Medical protocols typically require long-term mental health counseling to verify persistent and genuine gender dysphoria before any intervention, and consent of a parent or guardian or court order is legally required in most jurisdictions.^{[citation needed]}

Intersex children and cases of trauma

Main article: Sex assignment § Assignment in cases of infants with intersex traits, or cases of trauma

Infants born with intersex conditions might undergo interventions at or close to birth.^[51] This is controversial because of the human rights implications.^[52][53]

There can be negative outcomes (including PTSD and suicide) that occur when the surgically assigned gender does not match the individual's gender identity, which will only be realized by the individual later in life.^{[54][55][56][citation needed]} Milton Diamond at the John A. Burns School of Medicine, University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.^[57][58]

Standards of care

See also: Transgender rights

Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack of providers. An increasing number of surgeons are now training to perform such surgeries. In many regions, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for the Health of Transgender and Gender Diverse People (SOC). The most widespread SOC in this field is published and frequently revised by the World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the United States and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of psychological evaluation and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly referred to as the real life test (RLT)) before sex reassignment surgeries are covered by insurance.^{[citation needed]}

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.^{[citation needed]}

Many surgeons require two letters of recommendation for sex reassignment surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.^{[59][60][needs update]}

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents.^[17][61][62] However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.^[63]

Insurance

A growing number of public and commercial health insurance plans in the United States now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and hysterectomy (FTM).^[64] For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:

• a written initial assessment by a qualified licensed mental health professional
• persistent, well-documented gender dysphoria
• months of prior physician-supervised hormone therapy

In June 2008, the American Medical Association (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician."^[65] Other organizations have issued similar statements, including WPATH,^[17] the American Psychological Association,^[61] and the National Association of Social Workers.^[62]

In 2017, the United States Defense 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 is a transgender woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.^[66]

Post-procedural considerations

Quality of life and physical health

Several studies have measured quality of life and self-perceived physical health using different scales. Castellano et al. (2015) found similar quality of life compared to a control group for 60 SRS patients two years after surgery.^[67] Kuhn et al. (2008), assessing 52 trans women and 3 trans men 15 years after surgery, found quality of life lower than control in domains of health and limitations.^[68] De Cuypere et al. (2005), assessing 32 trans women and 23 trans men after surgery, concluded that patients' emotional and social needs were met, but less so their physical and sexual needs.^[69] Ainsworth and Spiegel (2010), in a study of 247 trans women, find improvements in mental health after genital reassignment surgery or face feminization surgery.^[70]

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision.^[71]

Psychological and social consequences

A 2009 review in the International Journal of Transgenderism found that from 1998 onward,^[72] studies have shown that "the whole process of gender reassignment is effective in relieving gender dysphoria and that its positive results greatly outweighed any negative consequences", but noted methodological issues in many studies, particularly older ones.^[73] A 2010 meta-analysis in Clinical Endocrinology noted the lack of randomization and control groups and reliance of self-reporting in the studies it reviewed, reaching the conclusion "Very low quality evidence suggests that hormonal therapies given to individuals with GID as a part of sex reassignment are likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."^[74]

Smith et al. (2001) found that among 20 patients, anxiety, depression and hostility levels were lower after sex reassignment surgery.^[75] Wierckx et al. (2011), in a study of 49 trans men, found them in good self-perceived physical and mental health.^[76] Dhejne et al. (2011), in a study following 324 transgender people who received sex reassignment surgery from 1973 to 2003, found that they "have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population", concluding that "sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism".^[77] Lawrence (2003), in a study of 232 trans women who underwent surgery between 1994 and 2000, found "None reported outright regret and only a few expressed even occasional regret."^[78]

Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery.^{[79][better source needed]} During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours.^[80] The rejection faced by transgender people is much more severe than what is experienced by lesbian, gay, and bisexual individuals.^[81] The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.^[82]

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.^{[80][better source needed]}

Sexuality

Looking specifically at transsexual people's genital sensitivities, both trans men and trans women are capable of maintaining their genital sensitivities after SRS. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexual individuals to avoid unnecessary harm or injuries to the genitals, allowing trans men to obtain an erection by inserting a penile implant after phalloplasty,^[83] the ability for transsexual people to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS.^[83][84] Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasms after phalloplasty is to preserve both the clitoris hood and the clitoris underneath the reconstructed phallus.^[83][84]

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.^[83] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,^[76][69] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery.^[69] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.^[69] Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.^[69]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.^[69] The ability to obtain orgasms is positively associated with sexual satisfaction.^[76] Frequency and intensity of orgasms are substantially different among trans men and trans women. Almost all female-to-male individuals have revealed an increase in sexual excitement and are capable of achieving orgasms through sexual activity with a partner or via masturbation,^[69][76] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.^[85] A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female individuals have been encountering longer and more gentle feelings.^[69]

The rates of masturbation have also changed after sex reassignment surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies exhibited in most transsexual individuals and 78% of them were able to reach orgasm by masturbation after SRS.^[76][69][86] A study showed that there were differences in masturbation frequencies between trans men and trans women, in which female-to-male individuals masturbated more often than male to female^[69] The possible reasons for the differences in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.^[76]

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels).^[86] When comparing transgender with cisgender individuals of the same gender, trans women had a similar sexual satisfaction to cis women, but trans men had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.^[76]

Legal status

Main article: Legal status of gender-affirming healthcare

See also

• Baptist Medical Center sex reassignment surgery controversy
• Femalia
• Genitoplasty
• Healthcare and the LGBT community
• Morphological freedom
• O'Donnabhain v. Commissioner
• Sexual and reproductive health
• Transgender health care
• Yogyakarta Principles

Notes

1. SUET., Nero 28,1: "Puerum Sporum exsectis testibus etiam in muliebrem naturam transfigurare conatus cum dote et flammeo per sollemnia nuptiarum celeberrimo officio deductum ad se pro uxore habuit"
   "He castrated the boy Sporus and actually tried to make a woman of him; and he married him with all the usual ceremonies, including a dowry and a bridal veil, took him to his house attended by a great throng, and treated him as his wife" – The expression exsectis testibus, literally "having the testicles removed", does not imply that the entire genitalia was removed.

References

1. "Sweden has been named the most LGBTQ+ friendly country for travellers". Trafalgar.com. 1 May 2009. from the original on 22 January 2022. Retrieved 12 February 2022.
2. Chan, Meng Choo (4 August 2011). "First sex reassignment surgery". eresources.nlb.gov.sg. Retrieved 17 September 2022.
3. "Gender Confirmation Surgeries". American Society of Plastic Surgeons. from the original on 12 June 2020. Retrieved 7 August 2017.
4. "Glossary of Transgender Terms". www.hopkinsmedicine.org. Retrieved 17 May 2022.
5. Harrington, L. (1 May 2016). Traversing Gender: Understanding Transgender Realities. Mystic Productions Press. p. 287. ISBN 978-1-942733-83-6. OCLC 947837700. from the original on 16 March 2020. Retrieved 15 October 2018.
6. "Definition of SEX CHANGE". www.merriam-webster.com. Retrieved 25 September 2022.
7. Bevan, Thomas E. (2014). The Psychobiology of Transsexualism and Transgenderism. Bloomsbury Publishing USA. ISBN 978-1-4408-3127-0., page 42: "The term transsexual was introduced by Cauldwell (1949) and popularized by Harry Benjamin (1966) [...]. The term transgender was coined by John Oliven (1965) and popularized by various transgender people who pioneered the concept and practice of transgenderism. It is sometimes said that Virginia Prince (1976) popularized the term, but history shows that many transgender people advocated the use of this term much more than Prince."
8. Polly, R.; Nicole, J. (January 2011). "Understanding the transsexual patient: culturally sensitive care in emergency nursing practice". Advanced Emergency Nursing Journal. 33 (1): 55–64. doi:10.1097/TME.0b013e3182080ef4. PMID 21317698. S2CID 2481961.
9. "Gender-Affirming Surgery: Masculinizing Options". www.ohsu.edu. from the original on 25 April 2022. Retrieved 8 June 2021.
10. Baum, Sarah E. (14 November 2022). "Trans People Are Seeking Nonbinary Bottom Surgeries". Vice. Retrieved 29 September 2023.
11. Schall, Theodore E.; Moses, Jacob D. (May 2023). "Gender-Affirming Care for Cisgender People". Hastings Center Report. 53 (3): 15–24. doi:10.1002/hast.1486. ISSN 0093-0334. PMID 37285414. S2CID 259110063.
12. Millman, Andrew (4 March 2021). "Fact-checking Rand Paul's comparisons of genital mutilation and gender confirmation surgery". CNN. Retrieved 10 July 2023.
13. Vincent, Ben (3 July 2019). "Breaking down barriers and binaries in trans healthcare: the validation of non-binary people". International Journal of Transgenderism. 20 (2–3): 132–137. doi:10.1080/15532739.2018.1534075. ISSN 1553-2739. PMC 6831034. PMID 32999601.
14. Gaither, T.W.; Awad, M.A.; Osterberg, E.C.; Murphy, G.P.; Romero, A.; Bowers, M.L.; Breyer, B.N. (March 2018). "Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-to-Female Transgender Patients". The Journal of Urology. 199 (3): 760–765. doi:10.1016/j.juro.2017.10.013. PMID 29032297. S2CID 42635923. from the original on 11 March 2022. Retrieved 23 May 2021.
15. Coleman, E.; Radix, A. E.; Bouman, W. P.; Brown, G. R.; de Vries, A. L. C.; Deutsch, M. B.; Ettner, R.; Fraser, L.; Goodman, M.; Green, J.; Hancock, A. B.; Johnson, T. W.; Karasic, D. H.; Knudson, G. A.; Leibowitz, S. F. (19 August 2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health. 23 (sup1): S1–S259. doi:10.1080/26895269.2022.2100644. ISSN 2689-5269. PMC 9553112. PMID 36238954.
16. "What Do I Need to Know About the Transitioning Process?". www.plannedparenthood.org. from the original on 5 May 2019. Retrieved 5 May 2019.
17. (PDF), WPATH, archived from the original (PDF) on 30 September 2011, retrieved 7 October 2011
18. "Voice feminizing therapy and surgery – Mayo Clinic". www.mayoclinic.org. from the original on 23 May 2021. Retrieved 23 May 2021.
19. Cohen, M.B.; Insalaco, L.F.; Tonn, C.R.; Spiegel, J.H. (October 2018). "Patient Satisfaction after Aesthetic Chondrolaryngoplasty". Plastic and Reconstructive Surgery. Global Open. 6 (10): e1877. doi:10.1097/GOX.0000000000001877. PMC 6250475. PMID 30534483.
20. "Facial Masculinization Surgery (FMS)". constructivesurgery.org. from the original on 23 May 2021. Retrieved 23 May 2021.
21. Smith, Shannon; Han, Justin (1 April 2019). "The trans-formation of gender confirming surgery: a brief history". The Journal of Urology. 201 (4S): e244. doi:10.1097/01.JU.0000555394.71572.8e. S2CID 149966616.
22. Goldberg, Abbie E.; Beemyn, Genny, eds. (2021). "Ancient and Medieval Times". The SAGE Encyclopedia of Trans Studies. SAGE Publishing. p. 32. doi:10.4135/9781544393858.n188. ISBN 978-1-5443-9381-0. S2CID 242422061.
23. Lascaratos, John; Kostakopoulos, Athanasios (1997). "Operations on Hermaphrodites and Castration in Byzantine Times (324–1453 AD)". Urologia Internationalis. 58 (4): 232–235. doi:10.1159/000282990. PMID 9253124.
24. Adams, Francis, ed. (1844). "On Hermaphrodites". The Seven Books of Paulus Aegineta. Vol. 2. p. 381.
25. Adams, Francis, ed. (1844). "On Extirpation of the Nympha and Cauda Pudendi". The Seven Books of Paulus Aegineta. Vol. 2. p. 381.
26. Munro, D. . Archived from the original on 18 December 2019. Retrieved 1 November 2018.
27. Mancini, Elena (8 November 2010). Magnus Hirschfeld and the Quest for Sexual Freedom: A History of the First International Sexual Freedom Movement (1st ed.). New York: Palgrave Macmillan. ISBN 978-0-230-11439-5. OCLC 696313936.
28. Harrod, Horatia (8 December 2015). "The tragic true story behind The Danish Girl". The Telegraph. from the original on 21 April 2016. Retrieved 11 December 2015.
29. "Lili Elbe". Biography. 10 September 2015. Retrieved 25 September 2022.
30. Hoyer, Niels, ed. (1933). Man into Woman. p. 128.
31. Hirschfeld, Magnus (1908). Zeitschrift für Sexualwissenschaft.
32. Meyerowitz, Joanne (2002). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press. p. 214.
33. Roach, M. (18 March 2007). "Girls Will Be Boys". The New York Times. from the original on 5 May 2019. Retrieved 5 May 2019.
34. "'Monstro, prostituta, bichinha': como a Justiça condenou a 1ª cirurgia de mudança de sexo do Brasil". BBC News Brasil (in Brazilian Portuguese). Retrieved 25 October 2023.
35. . 22 March 2014. Archived from the original on 22 March 2014. Retrieved 22 October 2023.
36. Djordjevic, M.L.; Stanojevic, D.; Bizic, M.; Kojovic, V.; Majstorovic, M.; Vujovic, S.; et al. (May 2009). "Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience". The Journal of Sexual Medicine. 6 (5): 1306–13. doi:10.1111/j.1743-6109.2008.01065.x. PMID 19175859.
37. "European Court of Human Rights – Third Section – Case of Van Kück v. Germany" (PDF). menschenrechte.ac.at. 12 June 2003. (PDF) from the original on 9 March 2021. Retrieved 23 May 2021.
38. International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex". from the original on 7 May 2019. Retrieved 27 December 2015.
39. M.H. (1 September 2017). "Why transgender people are being sterilized in some European countries". The Economist. from the original on 1 September 2017. Retrieved 2 September 2017.
40. "A Really High Hurdle". Human Rights Watch. 19 March 2019. from the original on 22 October 2020. Retrieved 26 October 2020.
41. Edgerton, M.T.; Knorr, N.J.; Callison, J.R. (January 1970). "The surgical treatment of transsexual patients. Limitations and indications". Plastic and Reconstructive Surgery. 45 (1): 38–46. doi:10.1097/00006534-197001000-00006. PMID 4902840. S2CID 27318408.
42. Hoopes J.E.; Knorr N.J.; Wolf, S.R. (November 1968). "Transsexualism: considerations regarding sexual reassignment". The Journal of Nervous and Mental Disease. 147 (5): 510–6. doi:10.1097/00005053-196811000-00007. PMID 5726922. S2CID 22252676.
43. Nolan, Ian T.; Kuhner, Christopher J.; Dy, Geolani W. (2019). "Demographic and temporal trends in transgender identities and gender confirming surgery". Translational Andrology and Urology. 8 (3): 18490–18190. doi:10.21037/tau.2019.04.09. ISSN 2223-4691. PMC 6626314. PMID 31380225.
44. Bishop, B.M. (December 2015). "Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review". Pharmacotherapy. 35 (12): 1130–9. doi:10.1002/phar.1668. PMID 26684553. S2CID 37001563.
45. Hage, J.J. (January 1995). "Medical requirements and consequences of sex reassignment surgery". Medicine, Science, and the Law. 35 (1): 17–24. doi:10.1177/002580249503500105. PMID 7877467. S2CID 22752221.
46. Bizic, M.R.; Jeftovic, M.; Pusica, S.; Stojanovic, B.; Duisin, D.; Vujovic, S.; et al. (13 June 2018). "Gender Dysphoria: Bioethical Aspects of Medical Treatment". BioMed Research International. 2018: 9652305. doi:10.1155/2018/9652305. PMC 6020665. PMID 30009180.
47. Redfern, J.S.; Jann, M.W. (April 2019). "The Evolving Role of Pharmacists in Transgender Health Care". Transgender Health. 4 (1): 118–130. doi:10.1089/trgh.2018.0038. PMC 6608700. PMID 31289749.
48. "Standards of Care – WPATH World Professional Association for Transgender Health". www.wpath.org. (PDF) from the original on 14 August 2015. Retrieved 23 May 2021.
49. Rafferty, Jason; et al. (2018). "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents". Pediatrics. 142 (4): e20182162. doi:10.1542/peds.2018-2162. PMID 30224363. S2CID 52288840. from the original on 19 July 2019. Retrieved 23 July 2021.
50. "Gender dysphoria treatment". National Health Service. 3 October 2018. from the original on 2 November 2013. Retrieved 27 August 2021.
51. Bradley, S.J.; Oliver, G.D.; Chernick, A.B.; Zucker, K.J. (July 1998). "Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood". Pediatrics. 102 (1): e9. doi:10.1542/peds.102.1.e9. PMID 9651461. S2CID 7364636.
52. United Nations; Office of the High Commissioner for Human Rights (2015). Free & Equal Campaign Fact Sheet: Intersex (PDF). (PDF) from the original on 4 March 2016. Retrieved 14 March 2016.
53. Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper, from the original on 21 January 2022, retrieved 23 May 2021
54. Boyle, G.J. (2005). "The scandal of genital mutilation surgery on infants". In May, L. (ed.). Transgenders and Intersexuals. Bowden, South Australia: Fast Lane (imprint of East Street Publications. pp. 95–100. ISBN 978-0-9751145-4-4.
55. Colapinto, John (2002). As Nature Made Him: The Boy Who Was Raised as a Girl. Sydney: Harper Collins Publishers. ISBN 978-0-7322-7433-7.
56. Diamond, M. (6 November 2009). "Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up". hawaii.edu. from the original on 30 August 2019. Retrieved 1 August 2011.
57. Diamond, M.; Sigmundson, H.K. (October 1997). "Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia". Archives of Pediatrics & Adolescent Medicine. 151 (10): 1046–50. doi:10.1001/archpedi.1997.02170470080015. PMID 9343018.
58. Diamond, M.; Beh, H.G. (January 2008). "Changes in the management of children with intersex conditions". Nature Clinical Practice. Endocrinology & Metabolism. 4 (1): 4–5. doi:10.1038/ncpendmet0694. hdl:10125/66380. PMID 17984980. S2CID 13382948.
59. Weber-Main, Anne Marie (July 2012). Fall, Heidi (ed.). (PDF). wpath.org. World Professional Association for Transgender Health. Archived from the original (PDF) on 20 September 2012. Retrieved 31 October 2013.
60. . Tssurgeryguide.com. 17 December 2003. Archived from the original on 1 September 2014. Retrieved 11 August 2014.
61. (PDF). Archived from the original (PDF) on 11 February 2009.
62. (PDF). www.socialworkers.org. August 2008 [2006]. Archived from the original (PDF) on 15 March 2023. Retrieved 2 September 2022.
63. Wareham, Jamie. "New Report Shows Where It's Illegal To Be Transgender In 2020". Forbes. from the original on 30 April 2021. Retrieved 8 June 2021.
64. . hrc.org. 26 February 2009. Archived from the original on 26 February 2009.
65. (PDF), archived from the original (PDF) on 27 March 2009
66. Kube, C. (14 November 2017). "Pentagon to pay for surgery for transgender soldier". NBC News. from the original on 30 July 2020. Retrieved 15 November 2017.
67. Castellano, E.; Crespi, C.; Dell'Aquila, C.; Rosato, R.; Catalano, C.; Mineccia, V.; et al. (December 2015). "Quality of life and hormones after sex reassignment surgery". Journal of Endocrinological Investigation. 38 (12): 1373–81. doi:10.1007/s40618-015-0398-0. PMID 26486135. S2CID 8744533.
68. Kuhn, A.; Bodmer, C.; Stadlmayr, W.; Kuhn, P.; Mueller, M.D.; Birkhäuser, M. (November 2009). "Quality of life 15 years after sex reassignment surgery for transsexualism". Fertility and Sterility. 92 (5): 1685–1689.e3. doi:10.1016/j.fertnstert.2008.08.126. PMID 18990387.
69. De Cuypere, G.; T'Sjoen, G.; Beerten, R.; Selvaggi, G.; De Sutter, P.; Hoebeke, P.; et al. (December 2005). "Sexual and physical health after sex reassignment surgery". Archives of Sexual Behavior. 34 (6): 679–90. doi:10.1007/s10508-005-7926-5. PMID 16362252. S2CID 42916543.
70. Ainsworth, T.A.; Spiegel, J.H. (September 2010). "Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery". Quality of Life Research. 19 (7): 1019–24. doi:10.1007/s11136-010-9668-7. PMID 20461468. S2CID 601504.
71. Bustos, Valeria P.; Bustos, Samyd S.; Mascaro, Andres; Del Corral, Gabriel; Forte, Antonio J.; Ciudad, Pedro; Kim, Esther A.; Langstein, Howard N.; Manrique, Oscar J. (19 March 2021). "Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence". Plastic and Reconstructive Surgery - Global Open. 9 (3): e3477. doi:10.1097/GOX.0000000000003477. ISSN 2169-7574. PMC 8099405. PMID 33968550.
72. Pfäfflin, Freidemann; Junge, Astrid (1998). "Sex reassignment: Thirty years of international follow-up studies after sex reassignment surgery—Comprehensive review 1961–1991". Book Section. International Journal of Transgenderism, quoted in Monstrey, G.; Vercruysse, H. Jr.; De Cuypere (2009). "Is Gender Reassignment Surgery Evidence Based? Recommendation for the Seventh Version of the WPATH Standards of Care". International Journal of Transgenderism. 11 (3): 206–214. doi:10.1080/15532730903383799. S2CID 58637820.
73. Monstrey et al.
74. Murad, Mohammad Hassan; Elamin, Mohamed B.; Garcia, Magaly Zumaeta; Mullan, Rebecca J.; Murad, Ayman; Erwin, Patricia J.; Montori, Victor M. (February 2010). "Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes". Clinical Endocrinology. 72 (2): 214–231. doi:10.1111/j.1365-2265.2009.03625.x. PMID 19473181. S2CID 19590739.
75. Smith, Y.L.; Van Goozen, S.H.; Cohen-Kettenis, P.T. (April 2001). "Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study". Journal of the American Academy of Child and Adolescent Psychiatry. 40 (4): 472–81. doi:10.1097/00004583-200104000-00017. PMID 11314574.
76. Wierckx, K.; Van Caenegem, E.; Elaut, E.; Dedecker, D.; Van de Peer, F.; Toye, K.; et al. (December 2011). "Quality of life and sexual health after sex reassignment surgery in transsexual men". The Journal of Sexual Medicine. 8 (12): 3379–88. doi:10.1111/j.1743-6109.2011.02348.x. PMID 21699661.
77. Dhejne, Cecilia; Lichtenstein, Paul; Boman, Marcus; Johansson, Anna L. V.; Långström, Niklas; Landén, Mikael (22 February 2011). "Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden". PLOS ONE. 6 (2): e16885. Bibcode:2011PLoSO...616885D. doi:10.1371/journal.pone.0016885. ISSN 1932-6203. PMC 3043071. PMID 21364939.
78. Lawrence, A.A. (August 2003). "Factors associated with satisfaction or regret following male-to-female sex reassignment surgery". Archives of Sexual Behavior. 32 (4): 299–315. doi:10.1023/A:1024086814364. PMID 12856892. S2CID 9960176.
79. Karpel, L.; Cordier, B. (2013). "Postoperative regrets after sex reassignment surgery: A case report". Sexologies. 22 (2): e55–e58. doi:10.1016/j.sexol.2012.08.014.
80. Jokić-Begić, N.; Lauri Korajlija, A.; Jurin, T. (2014). "Psychosocial adjustment to sex reassignment surgery: a qualitative examination and personal experiences of six transsexual persons in croatia". TheScientificWorldJournal. 2014: 960745. doi:10.1155/2014/960745. PMC 3984784. PMID 24790589.
81. Norton, A.T.; Herek, G.M. (2013). "Heterosexuals' attitudes toward transgender people: findings from a national probability sample of U.S. adults". Sex Roles. 68 (11–12): 738–753. doi:10.1007/s11199-011-0110-6. S2CID 37723853.
82. Bockting, W. (2014). Gender Dysphoria and Disorders of Sex Development. New York, NY, U.S.: Springer. pp. 319–330.
83. Selvaggi, G.; Monstrey, S.; Ceulemans, P.; T'Sjoen, G.; De Cuypere, G.; Hoebeke, P. (April 2007). "Genital sensitivity after sex reassignment surgery in transsexual patients". Annals of Plastic Surgery. 58 (4): 427–33. doi:10.1097/01.sap.0000238428.91834.be. PMID 17413887. S2CID 46169398.
84. Hage, J.J.; Bouman, F.G.; De Graaf, F.H.; Bloem, J.J. (June 1993). "Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience". The Journal of Urology. 149 (6): 1463–8. doi:10.1016/S0022-5347(17)36416-9. PMID 8501789.
85. Lawrence, A.A. (April 2005). "Sexuality before and after male-to-female sex reassignment surgery". Archives of Sexual Behavior. 34 (2): 147–66. CiteSeerX 10.1.1.538.6381. doi:10.1007/s10508-005-1793-y. PMID 15803249. S2CID 25671520.
86. Gómez-Gil, E.; Zubiaurre-Elorza, L.; De Antonio, I.E.; Guillamon, A.; Salamero, M. (March 2014). "Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery". Quality of Life Research. 23 (2): 669–76. doi:10.1007/s11136-013-0497-3. PMID 23943260. S2CID 23051224.

External links

•   Media related to Gender-affirming surgery at Wikimedia Commons