Sex reassignment surgery

From Wikipedia, the free encyclopedia
Part of a series on
Transgender topics
     
Gender identities
History
Health care and medicine
Rights and legal issues
Society and culture
Theory and concepts
By country
See also
Nuvola LGBT flag.svg LGBT portal
Portal Transgender.svg Transgender portal
  • v
  • t

Sex reassignment surgery (SRS), also known as gender reassignment surgery (GRS) and several other names, is a surgical procedure (or procedures) by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble those socially associated with their identified gender. It is part of a treatment for gender dysphoria in transgender people. The term is also sometimes used to describe surgical intervention for intersex people.

Professional medical organizations have established Standards of Care that 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. These surgeries include vaginoplasty, feminizing augmentation mammoplasty, orchiectomy, facial feminization surgery, reduction thyrochondroplasty (tracheal shave), and voice feminization surgery among others.

Masculinization surgeries are surgeries that result in anatomy that is typically gendered male. These surgeries include chest masculinization surgery (top surgery), metoidioplasty, phalloplasty, scrotoplasty, and hysterectomy.

In addition to SRS, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Terminology[]

There are numerous other expressions that are used to refer to this type of surgery apart from sex reassignment surgery and gender reassignment surgery. The American Society of Plastic Surgeons (ASPS) uses the term gender confirmation surgery or GCS and many transgender people prefer this terminology.[1][2] Other terms include gender-affirming surgery, sex change operation, genital reconstruction surgery, sex realignment surgery,[3] sex reconstruction surgery, and bottom surgery.

Some transgender people who desire medical assistance to transition from one sex to another identify as transsexual.[4][5] A trans woman assigned male at birth and seeking feminizing surgery may have one or more of the procedures used for trans women, which go by various names, such as feminizing genitoplasty, penectomy, orchiectomy, or vaginoplasty. A trans man assigned female at birth and seeking masculinizing surgery may undergo one or more procedures, which may include hysterectomy, oophorectomy, metoidioplasty, or phalloplasty.[6]

History[]

The goal of early transition surgeries was the removal of hormone-producing organs (such as the testicles and the ovaries) in order to reduce their masculinizing or feminizing effects. Later, as surgical technique became more complex, the goal became to produce functional sex organs from sex organs that are already present in the patient.[citation needed]

In the US in 1917, Alan L. Hart, an American tuberculosis specialist, became one of the first female-to-male transsexuals to undergo hysterectomy and gonadectomy for the relief of gender dysphoria.[7]

In Berlin in 1931, Dora Richter became the first known transgender woman to undergo the vaginoplasty[7] surgical approach.

This was followed by Lili Elbe in Dresden during 1930–1931. She started with the removal of her original sex organs, the operation supervised by Dr. Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an orchiectomy, an ovary transplant, a penectomy, and ultimately an unsuccessful uterine transplant, the rejection of which resulted in death. She had received emasculation and ovary transplant in June 1930.[8] She changed her legal gender in October 1930.

An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[9] but their identity is unclear at this time.

Dr. Elmer Belt may have been the first U.S. surgeon to perform gender affirmation surgery about 1950.[10]

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.[11] Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by Drs. Lebovic and Laub.[12] 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.[12] Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.[12]

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.[13]

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".[14]

As of 2017, some European countries require forced sterilization for the legal recognition of sex reassignment.[15] As of 2020, Japan also requires an individual to undergo sterilization for the legal recognition of their gender identity.[16]

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.[17][18]

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 pharmacologic management.[19] Typical SRS procedures involve complex medication regimens, including hormonal 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.[20][21] 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.[22]

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.[23]

Other health conditions such as diabetes, abnormal blood clotting, ostomies, and obesity do not usually present a problem to experienced surgeons. The conditions do increase the anesthetic risk and the rate of post-operative complications. Surgeons may require overweight patients to reduce their weight before surgery, any patients to refrain from hormone replacement before surgery, and smoking patients to refrain from smoking before and after surgery. Surgeons commonly stipulate the latter regardless of the type of operation.[citation needed]

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.[20]

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.[24] Preferred treatments for children include puberty blockers, which are thought to have reversible effects,[25] 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.

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[26] This is controversial because of the human rights implications.[27][28]

Catastrophic outcomes (including PTSD and suicide) can occur when the surgically assigned gender does not match the individual's gender identity, which is determined by neuroanatomical brain wiring and might only be realized by the individual later in life.[29][30][31] 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.[32][33]

One example of a suicide resulting from surgical sex reassignment performed after genital trauma is that of David Reimer. Reimer was born male, but following a botched circumcision was surgically altered and raised as a girl.

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 Transsexual, Transgender, and Gender Nonconforming 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.[34][35]

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required in order for transsexual individuals to change sex designation on identity documents.[36] 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.[37]

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).[38] In order 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."[39] Other organizations have issued similar statements, including WPATH,[40] the American Psychological Association,[41] and the National Association of Social Workers.[42]

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 November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.[43]

Surgical procedures[]

Main articles: Sex reassignment surgery (male-to-female) and Sex reassignment surgery (female-to-male)

Genital surgery[]

The array of medically indicated surgeries differs between trans women (male to female) and trans men (female to male). 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. For both trans women and trans men, 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.[44]

As underscored by WPATH, a medically assisted transition from one sex to another may entail any of a variety of non-genital surgical procedures, any of which are considered "sex reassignment surgery" when performed as part of treatment for gender dysphoria. 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.[45]

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 (GRS)- 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". 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."[46] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.[46]

Voice feminizing surgery is a procedure in which the overall pitch range of the patients voice is reduced. [47]

Adam’s Apple Reduction surgery (chondrolaryngoplasty) or tracheal shaving is a procedure in which the most prominent party of the thyroid cartilage is reduced.[48]

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.[49]

Post-procedural considerations[]

Quality of life and physical health[]

Patients of sex reassignment surgery may experience changes in their physical health and quality of life, as well as side effects of sex steroid treatment.[50]

Several studies have measured quality of life and self-perceived physical health using different scales. Overall, transsexual people have rated their quality of life as normal or quite good, although their overall score was lower than those in the control group.[51] Another study showed similar quality of life self-reporting in the transsexual and control groups.[52] One long-term study suggests that 15 years after surgery, quality of life is similar in transgender post-surgical and cisgender control groups, although scores in the domains of physical and personal limitations were still significantly lower among trans participants.[50][53] Research has also shown that quality of life of transsexual patients can be enhanced by other variables. For instance, trans men obtained a higher self-perceived health score than women because they had a higher level of testosterone than women. Trans women who had undergone face feminization surgery reported higher satisfaction in their general physical health.[54]

Psychological and social consequences[]

After sex reassignment surgery, transsexuals (people who underwent cross-sex hormone therapy and sex reassignment surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression and hostility levels were lower after sex reassignment surgery.[55] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction.[56] Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing sex reassignment surgery.[57]

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences,[58] it has been suggested that most studies investigating the outcomes of sex reassignment surgery are flawed as they have only included a small percentage of sex reassignment surgery patients in their studies.[59] These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates and low follow-up rates,[60] which would indicate need for continued study.

Persistent regret can occur after sex reassignment surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide.[61] 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.[62] During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours.[63] The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals.[64] The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.[65]

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.[63] Therefore, it is suggested that psychological support is crucial for patients after sex reassignment surgery, which helps them feel accepted and have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier sex reassignment surgery process.[63]

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,[66] the ability for transsexual to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS.[66][67] 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.[66][67]

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.[66] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,[56][50] 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.[50] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.[50] Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were frigid and not enthusiastic about engaging in sexual activity. In consequence, transsexuals individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.[50]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.[50] The ability to obtain orgasms is positively associated with sexual satisfaction.[56] Frequency and intensity of orgasms are substantially different among transsexual men and transsexual 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,[50][68] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.[69] 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.[50]

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.[56][50][70] 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[50] 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.[56]

Concerning transsexuals’ 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).[70] When comparing transsexuals with biological individuals of the same gender, trans women had a similar sexual satisfaction to non-trans women, but trans men had a lower level of sexual satisfaction to non-trans men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.[56]

By country[]

Africa[]

Morocco: Casablanca, Morocco, is notable for being the home of Clinique de Parc, Georges Burou's clinic for transgender women. Burou is considered one of the pioneers of SRS.[71] A French gynecologist, Burou created the anteriorly pedicled penile skin flap inversion vaginoplasty, still considered the "gold standard" of skin-lined vaginoplasty.[72] He is credited with having performed over 3000 MtF surgeries.[73]

Asia[]

India: India is offering affordable sex reassignment surgery to a growing number of medical tourists[74] and to the general population.[75]

Iran: The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.[76][77] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".[76] Eshaghian's documentary, Be Like Others, chronicles a number of stories of Iranian gay men who feel transitioning is the only way to avoid further persecution, jail, or execution.[76] The head of Iran's main transsexual organization, Maryam Khatoon Molkara—who convinced Khomeini to issue the fatwa on transsexuality—confirmed that some people who undergo operations are gay rather than transsexual.[78]

Japan: As of 2020, Japan requires the forced sterilization of transgender people for the legal recognition of sex reassignment.[16]

Pakistan: In Pakistan, the Council of Islamic Ideology has ruled that SRS contravenes Islamic law as construed by the council.[79] This Pakistani law prevents Hijras from receiving feminizing surgery.[citation needed]

Thailand: Thailand is the country that performs the most sex reassignment surgeries, followed by Iran.[78]

Europe[]

France: Since 2016, France no longer requires SRS as a condition for a gender change on legal documents.[80][81] In 2017, a case brought earlier by three transgender French people was decided. France was found in violation of the European Convention on Human Rights for requiring the forced sterilization of transgender people seeking to change their gender on legal documents.[82]

Malta: As late as 2010, transgender people that have undergone SRS can change their sex on legal documents.[83]

Spain: Despite a resolution from the European Parliament in 1989 suggesting advanced rights for all European Union citizens, as of 2002 only Andalusia's public health system covers sex reassignment surgery.[84][better source needed]

Switzerland: In 2010, the Swiss Federal Supreme Court struck down two laws that limited access to SRS. These included requirements of at least 2 years of psychotherapy before health insurance was obligated to cover the cost of SRS[85][86] and inability to procreate.[87]

Ukraine: In 2015, the Administrative District Court of Kiev ruled that forced sterilization was unlawful and no longer required for legal gender change.[citation needed]

North America[]

Canada: As of July 1st, 2017, all Canadian provinces and territories allow a change of sex on birth certificates without SRS requirements. [88][89][90][91][92][93][94][95][96][97][98][99]

Cuba: On June 4, 2008, MINSAP, the Cuban Ministry of Public Health, issued Resolution 126 - an act that assured complete coverage for Cubans seeking sexual reassignment surgeries, the first of any country in Latin America to do so. Consisting of 11 articles, article 5 of the resolution explains that it is the responsibility of the national commission to provide comprehensive health care to “all transsexual citizens.” This includes diagnosis, psychological and psychiatric care, the provision of necessary medications, therapy, and reassignment surgery.[100][101] Prior to being approved, it was suggested that the bill would make Cuba the most progressive nation in Latin America on gender issues.[102] The resolution was heavily pushed for by CENESEX a government-funded body dedicated to advocating LGBT rights and "sexual diversity".[103][104]

Mexico: As of a 2014 law,[105] Mexico City no longer requires SRS for changes of sex on birth certificates, and several states have followed suit.[106]

United States of America: Before the legalization of same-sex marriage in the United States, there were several notable Supreme Court cases that did not legally recognize individuals who underwent SRS by invalidating marriages of trans people.[107][irrelevant citation] Today, many states require SRS as a prerequisite for recognition of a legal sex change on official documents such as passports, birth certificates, or IDs.

South America[]

Argentina: In 2012, Argentina began offering government subsidized total or partial SRS to all persons 18 years of age or older.[108][109][77] Private insurance companies are prohibited from increasing the cost of SRS for their clients. At the same time, the Argentinian government repealed a law that banned SRS without authorization from a judge.[110] Furthermore, it is not required to undergo SRS to change sex on legal documents.[111]

Chile: In 2012, a bill was introduced that stated SRS was no longer a requirement for legal name and sex change.[112] In 2013, Chile's public health plan was required to cover sex reassignment surgery.[112] The cost is subsidized by the government based on a patient's income.[112]

See also[]

References[]

  1. ^ "Gender Confirmation Surgeries". American Society of Plastic Surgeons. Retrieved 2017-08-07.
  2. ^ Clements KC (19 December 2018). "Gender Confirmation (Formerly Reassignment) Surgery: Procedures". Healthline. Retrieved 4 December 2020.
  3. ^ Harrington L (1 May 2016). Traversing Gender: Understanding Transgender Realities. Mystic Productions Press. p. 287. ISBN 978-1-942733-83-6. OCLC 947837700. Retrieved 15 October 2018.
  4. ^ Thomas E. Bevan, The Psychobiology of Transsexualism and Transgenderism (2014, ISBN 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."
  5. ^ 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.
  6. ^ "Gender-Affirming Surgery: Masculinizing Options | OHSU". www.ohsu.edu. Retrieved 2021-06-08.
  7. ^ Jump up to: a b Munro D. "Trans Media Watch". Retrieved 1 November 2018.
  8. ^ In Hoyer, Main into Woman, 1933, page 128, She was referred as Lili Elbe, Woman's clinic, Dresden, June 1930 (after the operation).
  9. ^ Magnus Hirschfeld, Zeitschrift für Sexualwissenschaft, 1908
  10. ^ Meyerowitz, Joanne (2002). How Sex Changed: A History of Transsexuality in the United States. Harvard University Press. p. 214.
  11. ^ Roach M (2007-03-18). "Girls Will Be Boys". The New York Times.
  12. ^ Jump up to: a b c Djordjevic ML, 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.
  13. ^ "European Court of Human Rights - Third Section - Case of Van Kück v. Germany" (PDF). menschenrechte.ac.at. 2003-06-12. Retrieved 2021-05-23.
  14. ^ International Commission of Jurists. "SOGI Casebook Introduction, Chapter six: Intersex". Retrieved 2015-12-27.
  15. ^ M.H. (1 September 2017). "Why transgender people are being sterilized in some European countries". The Economist. Retrieved 2 September 2017.
  16. ^ Jump up to: a b "A Really High Hurdle". Human Rights Watch. 2019-03-19. Retrieved 2020-10-26.
  17. ^ Edgerton MT, Knorr NJ, Callison JR (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.
  18. ^ Hoopes JE, Knorr NJ, Wolf SR (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.
  19. ^ Bishop BM (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.
  20. ^ Jump up to: a b Hage JJ (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.
  21. ^ Bizic MR, Jeftovic M, Pusica S, Stojanovic B, Duisin D, Vujovic S, et al. (2018-06-13). "Gender Dysphoria: Bioethical Aspects of Medical Treatment". BioMed Research International. 2018: 9652305. doi:10.1155/2018/9652305. PMC 6020665. PMID 30009180.
  22. ^ Redfern JS, Jann MW (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.
  23. ^ "Standards of Care - WPATH World Professional Association for Transgender Health". www.wpath.org. Retrieved 2021-05-23.
  24. ^ Rafferty, Jason; COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH; COMMITTEE ON ADOLESCENCE; Section On Lesbian, GAY (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.
  25. ^ "Gender dysphoria treatment". National Health Service. Retrieved 27 August 2021.
  26. ^ Bradley SJ, Oliver GD, Chernick AB, Zucker KJ (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.
  27. ^ United Nations; Office of the High Commissioner for Human Rights (2015). Free & Equal Campaign Fact Sheet: Intersex (PDF).
  28. ^ Council of Europe; Commissioner for Human Rights (April 2015), Human rights and intersex people, Issue Paper
  29. ^ Boyle, G.J.(2005). The scandal of genital mutilation surgery on infants (pp. 95-100). In L. May (Ed.), Transgenders and Intersexuals, Bowden, South Australia: Fast Lane (imprint of East Street Publications). ISBN 1-9210370-7-5 ISBN 9-780975-114544
  30. ^ Colapinto, John. (2002). As Nature Made Him: The Boy Who Was Raised as a Girl. Sydney: Harper Collins Publishers. ISBN 0-7322-7433-8 ISBN 9-780732-274337
  31. ^ Diamond M (2009-11-06). "Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up". hawaii.edu. Retrieved 1 August 2011.
  32. ^ Diamond M, Sigmundson HK (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.
  33. ^ Diamond M, Beh HG (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.
  34. ^ "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (Version 7)" (PDF). wpath.org. Anne Marie Weber-Main, PhD (Technical writer); Heidi Fall (USA) (Editorial Assistance). World Professional Association for Transgender Health. July 2012. Archived from the original (PDF) on September 20, 2012. Retrieved 2013-10-31.CS1 maint: others (link)
  35. ^ "WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Archived from the original on 2014-09-01. Retrieved 2014-08-11.
  36. ^ See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
  37. ^ Wareham, Jamie. "New Report Shows Where It's Illegal To Be Transgender In 2020". Forbes. Retrieved 2021-06-08.
  38. ^ "Health Insurance Discrimination for Transgender People". hrc.org. 2009-02-26. Archived from the original on 2009-02-26.
  39. ^ AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients". see: http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf Archived 2009-03-27 at the Wayback Machine
  40. ^ See WPATH Clarification Statement
  41. ^ APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf Archived 2009-02-11 at the Wayback Machine
  42. ^ NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
  43. ^ Kube C (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News.
  44. ^ Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, Breyer BN (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.
  45. ^ "What Do I Need to Know About the Transitioning Process?". www.plannedparenthood.org. Retrieved 2019-05-05.
  46. ^ Jump up to: a b see WPATH "Clarification on Medical Necessity of Treatment, sex Reassignment, and Insurance Coverage in the U.S." available at: "Archived copy" (PDF). Archived from the original (PDF) on 2011-09-30. Retrieved 2011-10-07.CS1 maint: archived copy as title (link)
  47. ^ "Voice feminizing therapy and surgery - Mayo Clinic". www.mayoclinic.org. Retrieved 2021-05-23.
  48. ^ Cohen MB, Insalaco LF, Tonn CR, Spiegel JH (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. Lay summary.
  49. ^ "Facial Masculinization Surgery (FMS)". constructivesurgery.org. Retrieved 2021-05-23.
  50. ^ Jump up to: a b c d e f g h i j k 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.
  51. ^ Gómez-Gil E, Zubiaurre-Elorza L, de Antonio IE, 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.
  52. ^ 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.
  53. ^ Kuhn A, Bodmer C, Stadlmayr W, Kuhn P, Mueller MD, 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.
  54. ^ Ainsworth TA, Spiegel JH (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.
  55. ^ Smith YL, van Goozen SH, Cohen-Kettenis PT (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.
  56. ^ Jump up to: a b c d e f 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.
  57. ^ Lawrence AA (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.
  58. ^ Monstrey S, Vercruysse Jr H, De Cuypere G (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.
  59. ^ Adams C (2012-08-17). "Does Gender Reassignment Surgery Lead to Happiness?". washingtoncitypaper.com. Retrieved 2021-05-23.
  60. ^ Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M (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. PMC 3043071. PMID 21364939.
  61. ^ Olsson SE, Möller A (August 2006). "Regret after sex reassignment surgery in a male-to-female transsexual: a long-term follow-up". Archives of Sexual Behavior. 35 (4): 501–6. CiteSeerX 10.1.1.548.8934. doi:10.1007/s10508-006-9040-8. PMID 16900416. S2CID 23425058.
  62. ^ 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.
  63. ^ Jump up to: a b c 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.
  64. ^ Norton AT, Herek GM (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.
  65. ^ Bockting W (2014). Gender Dysphoria and Disorders of Sex Development. New York, NY, U.S.A: Springer. pp. 319–330.
  66. ^ Jump up to: a b c d 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.
  67. ^ Jump up to: a b Hage JJ, Bouman FG, de Graaf FH, Bloem JJ (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.
  68. ^ 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.
  69. ^ Lawrence AA (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.
  70. ^ Jump up to: a b Gómez-Gil E, Zubiaurre-Elorza L, de Antonio IE, 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.
  71. ^ Hage JJ, Karim RB, Laub DR (December 2007). "On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca". Annals of Plastic Surgery. 59 (6): 723–9. doi:10.1097/01.sap.0000258974.41516.bc. PMID 18046160. S2CID 25373951.
  72. ^ Perovic S, Djinovic R (November 2009). "Genitoplasty in male-to-female transsexuals". Current Opinion in Urology. 19 (6): 571–6. doi:10.1097/MOU.0b013e3283312eb3. PMID 19707142. S2CID 5424447.
  73. ^ Reed HM (May 2011). "Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty". Seminars in Plastic Surgery. 25 (2): 163–74. doi:10.1055/s-0031-1281486. PMC 3312144. PMID 22547974.
  74. ^ "Sex-change surgery: India's new line in medical tourism". The Hindu. May 7, 2016. Retrieved December 10, 2016.
  75. ^ "Growing recognition of transgender health". Bulletin of the World Health Organization. 94 (11): 790–791. November 2016. doi:10.2471/BLT.16.021116. PMC 5096349. PMID 27821880.
  76. ^ Jump up to: a b c Hays M. "Iran's gay plan". CBC News. Archived from the original on April 16, 2009. Retrieved September 23, 2008.
  77. ^ Jump up to: a b "Argentina Adopts Landmark Legislation in Recognition of Gender Identity". outrightinternational.org. 2012-05-14. Retrieved 2018-12-17.
  78. ^ Jump up to: a b "Sex change funding undermines no gays claim", Robert Tait, The Guardian, 26 September 2007; accessed 20 September 2008.
  79. ^ "Islamic Ideology body okays test tube babies, terms sex-change operations 'un-Islamic'". tribune.com.pk. 2013-11-05. Retrieved 2021-05-23.
  80. ^ "French Law Removes the Surgical Requirement for Legal Gender Recognition". National Center for Transgender Equality. 2016-10-21. Retrieved 2018-12-14.
  81. ^ Toor A (2016-10-14). "Transgender people no longer required to undergo sterilization in France". The Verge. Retrieved 2018-12-14.
  82. ^ "Why transgender people are being sterilised in some European countries". The Economist. 2017-09-01.
  83. ^ "Malta: UN Committee on the Elimination of Discrimination against Women (CEDAW)". outrightinternational.org. 2010-10-11. Retrieved 2018-12-18.
  84. ^ "Spain: Health Care For All!". outrightinternational.org. 2002-06-10. Retrieved 2018-12-17.
  85. ^ "Switzerland drops 2-year therapy as surgery-requirement". tgeu.org. 17 September 2010. Retrieved 2018-12-11.
  86. ^ "Schlumpf v. Switzerland (European Court of Human Rights)". genderidentitywatch.com. 2013-12-23. Retrieved 2018-12-11.
  87. ^ "Guide on Article 8 of the European Convention on Human Rights: Right to Respect for Private and Family Life, Home and Correspondence". European Court of Human Rights. August 31, 2018. Retrieved December 10, 2018.
  88. ^ "C.F. v. Alberta (Vital Statistics), 2014 ABQB 237 (CanLII)". canlii.org. 2014-04-22. Retrieved 2021-05-23.
  89. ^ "Application Forms - Vital Statistics Agency - Ministry of Health". gov.bc.ca. Archived from the original on 2015-03-22. Retrieved 2021-05-24.
  90. ^ "Manitoba Vital Statistics Agency | Province of Manitoba". Province of Manitoba - Manitoba Vital Statistics Agency.
  91. ^ Salerno R (28 April 2017). "New Brunswick trans-rights bills pass final reading". Xtra.
  92. ^ "Reassignment surgery not necessary to change gender markers on ID, ruling says Social Sharing". cbc.ca. 2015-12-09. Retrieved 2021-05-23.
  93. ^ Bird H (2016-06-14). "Trans activist celebrates proposed N.W.T. Vital Statistics changes". cbc.ca. Retrieved 2021-05-23.
  94. ^ "Consolidation of Vital Statistics Act - R.S.N.W.T. 1988,c.V-3" (PDF). gov.nu.ca. 2016-05-09. Archived from the original (PDF) on 2017-02-18.
  95. ^ "XY v. Ontario (Government and Consumer Services), 2012 HRTO 726 (CanLII)". canlii.org. 2012-04-11. Retrieved 2021-05-23.
  96. ^ Fraser S (2016-04-18). "P.E.I. transgender community applauds ID changes". cbc.ca. Retrieved 2021-05-23.
  97. ^ "New Legal Rights for Transgender People". educaloi.qc.ca. 2015-11-17. Archived from the original on 2019-04-02.
  98. ^ "Transgender people in Saskatchewan celebrate government ID change". cbc.ca. 2016-02-25. Retrieved 2021-05-23.
  99. ^ Salerno R (2017-04-26). "Yukon government introduces trans-rights bill". xtramagazine.com. Retrieved 2021-05-23.
  100. ^ Kirk, E. J.; Huish, R. (2018). "Transsexuals' Right to Health? A Cuban Case Study". Health and Human Rights. 20 (2): 215–222. PMC 6293354. PMID 30568415.
  101. ^ "HEALTH-CUBA: Free Sex Change Operations Approved". Inter Press Service. June 6, 2008. Archived from the original on 2010-06-12.
  102. ^ Israel, Esteban, "Castro's niece fights for new revolution" Archived 2006-08-22 at the Wayback Machine, Reuters, 2006-07-03
  103. ^ Kirk, E. J.; Huish, R. (2018). "Transsexuals' Right to Health? A Cuban Case Study". Health and Human Rights. 20 (2): 215–222. PMC 6293354. PMID 30568415.
  104. ^ Anderson, Tim. "hiv/aids in cuba: a rights-based analysis." health and human rights (2009): 93-104.
  105. ^ "Aprueban reforma a la ley de identidad de género en la Ciudad de México". SDPnoticias.com (in Spanish). 2014-11-13. Retrieved 2019-05-05.
  106. ^ "Mexico Transgender Ruling a Beacon for Change". Human Rights Watch. 2018-10-29. Retrieved 2019-05-05.
  107. ^ "Christine Denied Marriage License". Toledo Blade. April 4, 1959.
  108. ^ Ansari A (2017-02-23). "Transgender rights: These countries are ahead of the US". CNN.
  109. ^ brian (2012-05-13). "Argentina Has Passed the Most Progressive Gender Identity Legislation in Existence". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
  110. ^ "English Translation of Argentina's Gender Identity Law as approved by the Senate of Argentina on May 8, 2012". tgeu.org. 2013-09-12. Retrieved 2018-12-11.
  111. ^ "Six-year-old becomes first transgender child in Argentina to change identity - Telegraph". 2014-04-11. Archived from the original on 2014-04-11. Retrieved 2019-05-05.
  112. ^ Jump up to: a b c brian (2012-08-13). "Chilean Paradoxes: LGBT rights in Latin America". Leading Global LGBTIQ Human Rights Organization. Retrieved 2018-12-17.
Retrieved from ""