Sex Reassignment Therapy Definition

For specialized articles on surgical procedures, see Sex reassignment surgery (male-to-female) and Sex reassignment surgery (female-to-male).

Sex reassignment surgery or SRS (also known as gender reassignment surgery, gender confirmation surgery, genital reconstruction surgery, gender-affirming surgery, or sex realignment surgery) is the surgical procedure (or procedures) by which a transgender person's physical appearance and function of their existing sexual characteristics are altered to resemble that socially associated with their identified gender. It is part of a treatment for gender dysphoria in transgender people. Related genital surgeries may also be performed on intersex people, often in infancy. A 2013 statement by the United NationsSpecial Rapporteur on Torture condemns the nonconsensual use of normalization surgery on intersex people.[1][2]

The American Society of Plastic Surgeons (ASPS) calls this procedure Gender Confirmation Surgery or GCS.[3][4] Another term for SRS includes sex reconstruction surgery, and more clinical terms, such as feminizing genitoplasty or penectomy, orchiectomy, and vaginoplasty, are used medically for trans women, with masculinizing genitoplasty, metoidioplasty or phalloplasty often similarly used for trans men.

People who pursue sex reassignment surgery are usually referred to as transsexual (derived from "trans", meaning "across", "through", or "change", and "sexual", pertaining to the sexual characteristics—but not necessarily sexual actions—of a person).

While individuals who have undergone and completed SRS are sometimes referred to as transsexed individuals,[5] the term transsexed is not to be confused with the term transsexual, which may also refer to individuals who have not undergone SRS, yet whose anatomical sex may not match their psychological sense of personal gender identity.

Sex reassignment surgery performed on unconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case, following a botched circumcision) when the individual's sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed.[6][7][8]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, assign such infants in the gender to which they will probably best adjust, and refrain from adding shame, stigma and secrecy to the issue, by assisting intersexual people to meet and associate with others of like condition. Diamond considered the intersex condition as a difference of sex development, not as a disorder.[9][10]

Scope and procedures[edit]

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."[11] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial electrolysis.

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).[12] 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."[13] Other organizations have issued similar statements, including WPATH,[14] the American Psychological Association,[15] and the National Association of Social Workers.[16]

Different SRS procedures[edit]

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 provide greater resemblance to the genitals of cisgender women. 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.

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 identity disorder. 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.

[edit]

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 transsexuals solely on the basis of their HIV or hepatitis status.[17]

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.

Potential future advances[edit]

See also: Transgender pregnancy, Uterus transplantation § Application on transgender women, and Male pregnancy § Humans

Medical advances may eventually make childbearing possible by using a donor uterus long enough to carry a child to term as anti-rejection drugs do not seem to affect the fetus.[18][19][20][21] The DNA in a donated ovum can be removed and replaced with the DNA of the receiver. Further in the future, stem cell biotechnology may also make this possible, with no need for anti-rejection drugs.

Standards of care[edit]

See also: Legal aspects of transgenderism

Sex reassignment surgery can be difficult to obtain, due to a combination of financial barriers 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 transsexualism. For many individuals, these 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 genital reconstruction or other sex reassignment surgeries are permitted.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment for transsexualism, including accessing cross-gender hormone replacement or many surgical interventions. For this and many other reasons, both the WPATH-SOC and other SOCs are 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.

Most 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, 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.[22][23]

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.[24] 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.

Quality of life and physical health[edit]

Patients of sex reassignment surgery may experience changes in their physical health and quality of life, the side effects of sex steroid treatment. Hence, transgender people should be well informed of these risks before choosing to undergo SRS.[5]

Several studies tried to measure the quality of life and self-perceive physical health using different scales. Overall, transsexual people have rated their self-perceived quality of life as ‘normal’ or ‘quite good’, however, their overall score was still lower than the control group.[25] Another study showed a similar level of quality of life in transsexual individuals and the control group.[26] Nonetheless, a study with long-term data suggested that albeit quality of life of patients 15 years after sex reassignment surgery is similar to controls, their scores in the domains of physical and personal limitations were significantly lower.[5][27] On the other hand, research has found that quality of life of transsexual patients could 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 them. Trans women who had undergone face feminization surgery have reported higher satisfaction in different aspects of their quality of life, including their general physical health.[28]

Looking specifically at transsexual’s genital sensitivities, 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 and perform the insertion of the erect penile prosthesis after phalloplasty,[29] 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[29][30] 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.[29][30]

Erogenous Sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse.[29] Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,[31][5] implying the possibilities to maintain or even enhance genital sensitivity after SRS.

Psychological and social consequences[edit]

This article or section appears to contradict itself. Please see the talk page for more information.(April 2016)

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.[32] They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction.[31] 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.[33]

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences,[34] 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.[35] These methodological limitations such as lack of double-blind randomised controls, small number of participants due to the rarity of transsexualism, high drop-out rates and low follow-up rates,[36] 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.[37] During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours.[38] The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals.[39] The hostile environment may trigger or worsen internalised transphobia, depression, anxiety and post-traumatic stress.[40]

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.[38] 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.[38]

Sexual satisfaction[edit]

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery.[5] The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.[5] 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.[5]

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation.[5] The ability to obtain orgasms is positively associated with sexual satisfaction.[31] 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,[5][41] whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS.[42] A study found that both transmen and transwomen reported that they had experienced transformation in their orgasms sensuality. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements while male-to-female individuals have been encountering longer and more gentle feelings.[5]

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.[31][5][43] 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[5] 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.[31]

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).[43] When comparing transsexuals with biological individuals of the same gender, trans women had a similar sexual satisfaction to biological women, but trans men had a lower level of sexual satisfaction to biological men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.[31]

At birth[edit]

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.[44] This is controversial because of the human rights implications.[45][46]

Society and culture[edit]

The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.[47] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".[47] 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.[47] 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.[48]

Thailand is the country that performs the most sex reassignment surgeries, followed by Iran.[48]

India is offering affordable sex reassignment surgery to a growing number of medical tourists.[49]

In 2017, the United StatesDefense 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 identifies as a 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.[50]

History[edit]

In Berlin in 1931, Dora Richter, became the first known transgender woman to undergo the vaginoplasty[51] 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 unsuccessful uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[52] but their identity is unclear at this time.

On 12 June 2003, the European Court of Human Rights ruled in favor of 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.[53]

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".[54]

As of 2017 some European countries, mostly eastern, require forced sterilisation for the legal recognition of sex reassignment.[55]

See also[edit]

References[edit]

  1. ^Report of the UN Special Rapporteur on Torture, Office of the UN High Commissioner for Human Rights, February 2013.
  2. ^Center for Human Rights & Humanitarian Law; Washington College of Law; American University (2014). Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture's 2013 Thematic Report. Washington, DC: Center for Human Rights & Humanitarian Law. 
  3. ^"Gender Confirmation Surgeries". American Society of Plastic Surgeons. Retrieved 2017-08-07. 
  4. ^"About ASPS". American Society of Plastic Surgeons. Retrieved 2017-08-07. 
  5. ^ abcdefghijklDe Cuypere, G.; TSjoen, G.; Beerten, R.; Selvaggi, G.; De Sutter, P.; Hoebeke, P.; Monstrey, S.; Vansteenwegen, A.; Rubens, R. (2005). "Sexual and Physical Health After Sex Reassignment Surgery". Archives of Sexual Behavior. 34 (6): 679–690. doi:10.1007/s10508-005-7926-5. PMID 16362252. 
  6. ^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 1-9210370-7-5ISBN 9-780975-114544
  7. ^Colapinto, J. (2002). As Nature Made Him: The Boy Who Was Raised as a Girl. Sydney: Harper Collins Publishers. ISBN 0-7322-7433-8ISBN 9-780732-274337
  8. ^"Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up". Milton Diamond, Ph.D. Retrieved 1 August 2011. 
  9. ^Diamond, Milton; Sigmundson, H. Keith (October 1997). "Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia". Arch Pediatr Adolesc Med. 151 (10): 1046–50. doi:10.1001/archpedi.1997.02170470080015. PMID 9343018. Retrieved 24 April 2013. 
  10. ^Diamond, Milton; Beh, Hazel. (2008). "Changes In Management Of Children With Differences Of Sex Development". Nature Clinical Practice Endocrinology & Metabolism. 4 (1): 4–5. 
  11. ^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. 
  12. ^See discussion of insurance exclusions at: http://www.hrc.org/issues/transgender/9568.htm
  13. ^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
  14. ^See WPATH Clarification Statement
  15. ^APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination. See online at: http://www.apa.org/pi/lgbc/policy/transgender.pdf
  16. ^NASW Policy Statement on Transgender and Gender Identity Issues, revised August 2008. See www.socialworkers.org
  17. ^See WPATH Standards of Care, also WPATH Clarification. www.wpath.org
  18. ^Doctors plan uterus transplants to help women with removed, damaged wombs have babies. Associated Press.
  19. ^Fageeh, W.; Raffa, H.; Jabbad, H.; Marzouki, A. (2002). "Transplantation of the human uterus". International Journal of Gynecology & Obstetrics. 76 (3): 245–251. doi:10.1016/S0020-7292(01)00597-5. PMID 11880127. 
  20. ^Del Priore, G.; Stega, J.; Sieunarine, K.; Ungar, L.; Smith, J. R. (2007). "Human Uterus Retrieval From a Multi-Organ Donor". Obstetrics & Gynecology. 109 (1): 101–104. doi:10.1097/01.AOG.0000248535.58004.2f. PMID 17197594. 
  21. ^Nair, A.; Stega, J.; Smith, J. R.; Del Priore, G. (2008). "Uterus Transplant: Evidence and Ethics". Annals of the New York Academy of Sciences. 1127 (1): 83–91. Bibcode:2008NYASA1127...83N. doi:10.1196/annals.1434.003. PMID 18443334. 
  22. ^"Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People"(PDF). Archived from the original(PDF) on September 20, 2012. Retrieved 2013-10-31. 
  23. ^"WPATH Standards of Care". Tssurgeryguide.com. 2003-12-17. Retrieved 2014-08-11. 
  24. ^See WPATH Clarification Statement, APA Policy Statement, and NASW Policy Statement
  25. ^Gómez-Gil, Esther; Zubiaurre-Elorza, Leire; Antonio, Isabel Esteva de; Guillamon, Antonio; Salamero, Manel (2013-08-13). "Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery". Quality of Life Research. 23 (2): 669–676. doi:10.1007/s11136-013-0497-3. ISSN 0962-9343. PMID 23943260. 
  26. ^Castellano, E.; Crespi, C.; Dell’Aquila, C.; Rosato, R.; Catalano, C.; Mineccia, V.; Motta, G.; Botto, E.; Manieri, C. (2015-10-20). "Quality of life and hormones after sex reassignment surgery". Journal of Endocrinological Investigation. 38 (12): 1373–1381. doi:10.1007/s40618-015-0398-0. ISSN 1720-8386. PMID 26486135. 
  27. ^Kuhn, Annette; Bodmer, Christine; Stadlmayr, Werner; Kuhn, Peter; Mueller, Michael D.; Birkhäuser, Martin (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. 
  28. ^Ainsworth, Tiffiny A.; Spiegel, Jeffrey H. (2010-05-12). "Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery". Quality of Life Research. 19 (7): 1019–1024. doi:10.1007/s11136-010-9668-7. ISSN 0962-9343. PMID 20461468. 
  29. ^ abcdSelvaggi, G., Monstrey, S., Ceulemans, P., T'Sjoen, G., De Cuypere, G., & Hoebeke, P. (2007). "Genital sensitivity after sex reassignment surgery in transsexual patients". Annals of Plastic Surgery. 58 (4): 427–433. doi:10.1097/01.sap.0000238428.91834.be. PMID 17413887. 
  30. ^ abHage, J. J., Bouman, F. G., De Graaf, F. H., & Bloem, J. J. (1993). "Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience". The Journal of Urology. 149 (6): 1463–1468. doi:10.1016/S0022-5347(17)36416-9. PMID 8501789. 
  31. ^ abcdefWierckx, K.; Van Caenegem, E.; Elaut, E.; Dedecker, D.; Van de Peer, F.; Toye, K.; Hoebeke, P.; Monstrey, S.; De Cuypere, G.; T’Sjoen, G. (2011). "Quality of life and sexual health after sex reassignment surgery in transsexual men". The Journal of Sexual Medicine. 8 (12): 3379–3388. doi:10.1111/j.1743-6109.2011.02348.x. PMID 21699661. 
  32. ^Smith, Y. L. S.; Van Goozen, S. H. M.; Cohen-Kettenis, P. T. (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 & Adolescent Psychiatry. 40 (4): 472–481. doi:10.1097/00004583-200104000-00017. 
  33. ^Lawrence, A. A. (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. 
  34. ^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.

Sex reassignment therapy is the medical aspect of gender transitioning, that is, modifying one's characteristics to better suit one's gender identity. It can consist of hormone replacement therapy (HRT) to modify secondary sex characteristics, sex reassignment surgery to alter primary sex characteristics, and other procedures altering appearance, including permanent hair removal for trans women.

In appropriately evaluated cases of severe gender dysphoria, sex reassignment therapy is often the best when standards of care are followed.[1]:1570[2]:2108 There is academic concern over the low quality of the evidence supporting the efficacy of sex reassignment therapy as treatment for gender dysphoria, but more robust studies are impractical to carry out;[3]:22 as well, there exists a broad clinical consensus, supplementing the academic research, that supports the effectiveness in terms of subjective improvement of sex reassignment therapy in appropriately selected patients.[3]:2–3 Treatment of gender dysphoria does not involve attempting to correct the patient's gender identity, but to help the patient adapt.[1]:1568

Major health organizations in the U.S.A. and UK have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases.[4][5][6][7][8]

Eligibility[edit]

In current medical practice, a diagnosis is required for sex reassignment therapy. In the International Classification of Diseases the diagnosis is known as transsexualism ([9]). The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5[10]). While the diagnosis is a requirement for determining medical necessity of sex reassignment therapy, some people who are validly diagnosed have no desire for all or some parts of sex reassignment therapy, particularly genital reassignment surgery, and/or are not appropriate candidates for such treatment.

Transsexualism[edit]

The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATHStandards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. As of February 2014, the most recent version of the standards is Version 7.[11] According to the standards of care, "gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)... Only some gender-nonconforming people experience gender dysphoria at some point in their lives". Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.

Local standards of care exist in many countries.

In cases of comorbid psychopathology, the standards are to first manage the psychopathology and then evaluate the patient's gender dysphoria. Treatment may still be appropriate and necessary in cases of significant comorbid psychopathology, as "cases have been reported in which the individual was both suffering from severe co-occurring psychopathology, and was a 'late-onset, gynephilic' trans woman, and yet experienced a long-term, positive outcome with hormonal and surgical gender transition."[3]:22

However, some transsexual people may suffer from co-morbid psychiatric conditions unrelated to their gender dysphoria. The DSM-IV itself states that in rare instances, gender dysphoria may co-exist with schizophrenia, and that psychiatric disorders are generally not considered contraindications to sex reassignment therapy unless they are the primary cause of the patient's gender dysphoria.[12]:108

Eligibility for different stages of treatment[edit]

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended.[11]

Hormone replacement therapy is to be initiated on referral from a qualified health professional. The general requirements, according to the WPATH standards, include:

  1. Persistent, well-documented gender dysphoria;
  2. Capacity to make a fully informed decision and to consent for treatment;
  3. Age of majority in a given country (however, the WPATH standards of care provide separate discussion of children and adolescents);
  4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

Often, at least a certain period of psychological counseling is required before initiating hormone replacement therapy, as is a period of living in the desired gender role, if possible, to ensure that they can psychologically function in that life-role. On the other hand, some clinics provide hormone therapy based on informed consent alone.[11]

As surgery is a radical and irreversible intervention, more stringent standards are usually applied. Generally speaking, physicians who perform sex-reassignment surgery require the patient to live as the members of their target gender in all possible ways for at least a year ("cross-live"), prior to the start of surgery, in order to assure that they can psychologically function in that life-role. This period is sometimes called the Real Life Test (RLT); it is part of a battery of requirements. Other frequent requirements are regular psychological counseling and letters of recommendation for this surgery.

The time period of "cross-living" is usually known as the Real-Life-Test (RLT) or Real-Life-Experience (RLE). It is sometimes required even before hormone therapy, but this is not always possible; transsexual men frequently cannot "pass" this period without hormones. Transsexual women may also require hormones to pass as women in society. Most trans women also require facial hair removal, voice training or voice surgery, and sometimes, facial feminization surgery, to be passable as females; these treatments are usually provided upon request with no requirements for psychotherapy or "cross-living".

Some surgeons who perform sex reassignment surgeries may require their patients to live as members of their target gender in as many ways as possible for a specified period of time, prior to any surgery. However, some surgeons recognize that this so-called real-life test for trans men, without breast removal and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of sex reassignment surgery without a real-life test. This is especially common amongst surgeons who practice in Asia. However, almost all surgeons practicing in North America and Europe who perform genital reassignment surgery require letters of approval from two psychotherapists; most Standards of Care recommend, and most therapists require, a one-year real-life test prior to genital reassignment surgery, though some therapists are willing to waive this requirement for certain patients.

The requirements for chest reconstruction surgery are different for transmen and transwomen. The Standards of Care require trans men to undergo either 3 months of Real-life-test or psychological evaluation before surgery whereas transwomen are required to undergo 18 months of hormone therapy. The requirement for trans men is due to the difficulty in presenting as male with female breasts, especially those of a C cup or larger. For very large breasts it can be impossible for the trans man to present as male before surgery. For trans women, the extra time is required to allow for complete breast development from hormone therapy. Having breast augmentation before that point can result in uneven breasts due to hormonal development, or removal of the implant if hormonal breast development is significant and results in larger breasts than desired.

Eligibility of minors[edit]

While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents.

While there is anecdotal evidence of cases where a child firmly identified as another sex from a very early age, studies cited in the standards of care show that in the majority of cases such identification in childhood does not persist into adulthood.[citation needed] However, with adolescents, persistence is much more likely, and so reversible treatment by puberty blockers can be prescribed. This treatment is controversial as the use of puberty blockers involves a small risk of adverse physical effects.

A 2014 study made a longer-term evaluation of the effectiveness of this approach, looking at young transgender adults who had received puberty suppression during adolescence. It found that "After gender reassignment, in young adulthood, the [gender dysphoria] was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being."[13] No patients expressed regret about the transition process, including puberty suppression.[14]

"Since puberty suppression is a fully reversible medical intervention, it provides adolescents and their families with time to explore their gender dysphoric feelings, and [to] make a more definite decision regarding the first steps of actual gender reassignment treatment at a later age," said study lead author Dr. Annelou de Vries. By delaying the onset of puberty, those children who go on to gender reassignment "have the lifelong advantage of a body that matches their gender identities without the irreversible body changes of a low voice or beard growth or breasts, for example,".[14]

De Vries nevertheless cautioned that the findings need to be confirmed by further research, and added that her study didn't set out to assess the side effects of puberty suppression.[14]

Psychological treatment[edit]

According to the WPATH SOC v7, "Psychotherapy (individual, couple, family, or group) for purposes such as exploring gender identity, role, and expression; addressing the negative impact of gender dysphoria and stigma on mental health; alleviating internalized transphobia; enhancing social and peer support; improving body image; or promoting resilience" is a treatment option.[11]

Hormone replacement therapy[edit]

Main article: Hormone replacement therapy (trans)

For trans people, hormone replacement therapy (HRT) causes the development of many of the secondary sexual characteristics of their desired sex. However, many of the existing primary and secondary sexual characteristics cannot be reversed by HRT. For example, HRT can induce breast growth for trans women but can only minimally reduce breasts for trans men. HRT can prompt facial hair growth for transsexual men, but cannot regress facial hair for transsexual women. HRT may, however, reverse some characteristics, such as distribution of body fat and muscle, as well as menstruation in trans men.

Generally, those traits that are easily reversible will revert upon cessation of hormonal treatment, unless chemical or surgical castration has occurred, though for many trans people, surgery is required to obtain satisfactory physical characteristics. But in trans men, some hormonally-induced changes may become virtually irreversible within weeks, whereas trans women usually have to take hormones for many months before any irreversible changes will result.

As with all medical activities, health risks are associated with hormone replacement therapy, especially when high hormone doses are taken as is common for pre-operative or no-operative trans patients. It is always advised that all changes in therapeutic hormonal treatment should be supervised by a physician because starting, stopping or even changing dosage rates and levels can have physical and psychological health risks.

Although some trans women use herbal phytoestrogens as alternatives to pharmaceutical estrogens, little research has been performed with regards to the safety or effectiveness of such products. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if at all noticeable, when compared to conventional hormone therapy.

Some trans people are able to avoid the medical community's requirements for hormone therapy altogether by either obtaining hormones from black market sources, such as internet pharmacies which ship from overseas, or more rarely, by synthesizing hormones themselves.

Chest reconstruction surgery[edit]

Main articles: Male chest reconstruction and Breast implant

For a lot of trans men chest reconstruction is desired, or required. Binding of the chest tissue can cause a variety of health issues including reduced lung capacity and even broken ribs if improper techniques or materials are used. A mastectomy is performed, often including a nipple graft for those with a B or larger cup size.

For trans women, breast augmentation is done in a similar manner to those done for cisgender women. As with cisgender women, there is a limit on the size of implant that may be used, depending on the amount of pre-existing breast tissue.

Sex reassignment surgery[edit]

Main article: Sex reassignment surgery

Sex reassignment surgery (SRS) refers to the surgical and medical procedures undertaken to align intersex and transsexual individuals' physical appearance and genital anatomy with their gender identity. SRS may encompass any surgical procedures which will reshape a male body into a body with a female appearance or vice versa, or more specifically refer to the procedures used to make male genitals into female genitals and vice versa.

Sex reassignment surgery is the most common term for what may be more accurately described as "genital reassignment surgery" or "genital reconstruction surgery." Other proposed terms for SRS include "gender confirmation surgery," "gender realignment surgery," and "transsexual surgery." The aforementioned terms may also specifically refer to genital surgeries like vaginoplasty and phalloplasty, even though more specific terms exist to refer exclusively to genital surgery, the most common of which is genital reassignment surgery (GRS). There are significant medical risks associated with SRS that should be considered before undergoing the surgery.

Other procedures[edit]

Facial feminization surgery (FFS) is a form of facial reconstruction used to make a masculine face appear more feminine. FFS procedures can reshape the jaw, chin, forehead (including brow ridge), hairline, and other areas of the face that tend to be sexually dimorphic.[15] A chondrolaryngoplasty, colloquially a "tracheal shave", is a surgical reduction of the cartilage in the larynx to reduce the appearance of a visible Adam's apple.[16]

Trans people of both sexes may practice vocal therapy. Vocal therapists may help their patients improve their pitch, resonance, inflection, and volume.[17] Another option for trans women is vocal surgery, though there is the risk of damaging the voice.[18]

Effectiveness[edit]

The Merck Manual states, in regard to trans women, "In follow-up studies, genital surgery has helped some transsexual people live happier and more productive lives and so is justified in highly motivated, appropriately assessed and treated transsexual people, who have completed a 1- to 2-year real-life experience in a different gender role. Before surgery, transsexual people often need assistance with passing in public, including help with gestures and voice modulation. Participation in support groups, available in most large cities, is usually helpful."[1]:1570 With regards to trans men, it states, "Surgery may help certain [trans men] patients achieve greater adaptation and life satisfaction. Similar to trans women, trans men should live in the male gender role for at least 1 yr before surgery. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for trans women. Complications are common, especially in procedures that involve extending the urethra into the neophallus."[1]:1570

Kaplan and Sadock's Comprehensive Textbook of Psychiatry states, with regards to adults, "When patient gender dysphoria is severe and intractable, sex reassignment is often the best solution."[2]:2108 Regret tends to occur in cases of misdiagnosis, no Real Life Experience, and poor surgical results. Risk factors for return to original gender role include history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good post-operative outcomes. Many prepubescent children with cross-gender identities do not persist with gender dysphoria.[2]:2109–2110 With regards to follow-up, it states that "Clinicians are less likely to report poor outcomes in their patients, thus shifting the reporting bias to positive results. However, some successful patients who wish to blend into the community as men or women do not make themselves available for follow-up. Also, some patients who are not happy with their reassignment may be more known to clinicians as they continue clinical contact."[2]:2109

A 2009 systematic review looking at individual surgical procedures found that "[t]he evidence concerning gender reassignment surgery has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence."[19]

A 2010 meta-analysis of follow-up studies reported "Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%)." The study concluded "Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."[20]

A study evaluating quality of life in female-to-male transgender individuals found "statistically significant (p<0.01) diminished quality of life among the FTM transgender participants as compared to the US male and female population, particularly in regard to mental health. FTM transgender participants who received testosterone (67%) reported statistically significant higher quality of life scores (p<0.01) than those who had not received hormone therapy."[21]

A recent Swedish study (2010) found that “almost all patients were satisfied with sex reassignment at 5 years, and 86% were assessed by clinicians at follow-up as stable or improved in global functioning”[22] A prospective study in the Netherlands that looked at the psychological and sexual functioning of 162 adult applicants of adult sex reassignment applicants before and after hormonal and surgical treatment found, "After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets."[23]

A long-term follow-up study performed in Sweden over a long period of time (1973–2003) found that morbidity, suicidality, and mortality in post-operative trans people were still significantly higher than in the general population, suggesting that sex reassignment therapy is not enough to treat gender dysphoria, highlighting the need for improved health care following sex reassignment surgery. 10 controls were selected for each post-operative trans person, matched by birth year and sex; two control groups were used: one matching sex at birth, the other matching reassigned sex. The study states that "no inferences can be drawn [from this study] as to the effectiveness of sex reassignment as a treatment for transsexualism," citing studies showing the effectiveness of sex reassignment therapy, though noting their poor quality. The authors noted that the results suggested that those who received sex reassignment surgery before 1989 had worse mortality, suicidality, and crime rates than those who received surgery on or after 1989: mortality, suicidality, and crime rates for the 1989-2003 cohort were not statistically significant compared to healthy controls (though psychiatric morbidity was); it is not clear if this is because these negative factors tended to increase a decade after surgery or because in the 1990s and later improved treatment and social attitudes may have led to better outcomes.[24]

The abstract of the American Psychiatric Association Task Force on GID's report from 2012 states, "The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups."[3] The APA Task Force states, with regard to the quality of studies, "For some important aspects of transgender care, it would be impossible or unwise to engage in more robust study designs due to ethical concerns and lack of volunteer enrollment. For example, it would be extremely problematic to include a 'long-term placebo treated control group' in an RCT of hormone therapy efficacy among gender variant adults desiring to use hormonal treatments." [3]:22 The Royal College of Psychiatrists concurs with regards to SRS in trans women, stating, "There is no level 1 or 2 evidence (Oxford levels) supporting the use of feminising vaginoplasty in women but this is to be expected since a randomised controlled study for this scenario would be impossible to carry out."[7]

Following up on the APA Task Force's report, the APA issued a statement stating that the APA recognizes that in "appropriately evaluated" cases, hormonal and surgical interventions may be medically necessary and opposes "categorical exclusions" of such treatment by third-party payers.[4] The American Medical Association's Resolution 122 states, "An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID".[5]

The need for treatment is emphasized by the higher rate of mental health problems, including depression, anxiety, and various addictions, as well as a higher suicide rate among untreated transsexual people than in the general population. Many of these problems, in the majority of cases, disappear or decrease significantly after a change of gender role and/or physical characteristics.[25][26]

Ethical, cultural, and political considerations[edit]

Sex reassignment therapy is a controversial ethical subject. Notably, the Roman Catholic church, according to an unpublished Vatican document, holds that changing sex is not possible and, while in some cases treatment might be necessary, it does not change the person's sex in the eyes of the church.[27] Some Catholic ethicists go further, proclaiming that a "sex change operation" is "mutilation" and therefore immoral.[28]

Paul R. McHugh is a well-known opponent of sex reassignment therapy. According to his own article,[29] when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Science, it was part of his intention to end sex reassignment surgery there. McHugh succeeded in ending it at the university during his time.[30] However, a new gender clinic at Johns Hopkins has been opened in 2017.[31]

Opposition was also expressed by several writers identifying as feminist, most famously Janice Raymond. Her paper was allegedly instrumental in removing Medicaid and Medicare support for sex reassignment therapy in the US.[32]

Sex reassignment therapy, especially surgery, tends to be expensive and is not always covered by public or private health insurance. In many areas with comprehensive nationalized health care, such as some Canadian provinces and most European countries, SRT is covered under these plans. However, requirements for obtaining SRS and other transsexual services under these plans are sometimes more stringent than the requirements laid out in the WPATH Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, and in Europe, many local Standards of Care exist. In other countries, such as the United States, no national health plan exists and the majority of private insurance companies do not cover SRS. The government of Iran, however, pays for such surgery because it is believed to be valid under Shi'ite Belief.[33]

A significant and growing political movement exists, pushing to redefine the standards of care, asserting that they do not acknowledge the rights of self-determination and control over one's body, and that they expect (and even in many ways require) a monolithic transsexual experience. In opposition to this movement is a group of transsexual persons and caregivers who assert that the SOC are in place to protect others from "making a mistake" and causing irreversible changes to their bodies that will later be regretted – though few post-operative transsexuals believe that sexual reassignment surgery was a mistake for them.[34]

The United States[edit]

From 1981 until 2014, the Centers for Medicare and Medicaid Services (CMS) categorically excluded coverage of sex reassignment surgery by Medicare in its National Coverage Determination (NCD) "140.3 Transsexual Surgery," but that categorical exclusion came under challenge by an "aggrieved party" in an Acceptable NCD Complaint in 2013 and was subsequently struck down the following year by the Departmental Appeals Board (DAB), the administrative court of the U.S. Department of Health and Human Services (HHS).[35][36] In late 2013, the DAB issued a ruling finding the evidence on record was "not complete and adequate to support the validity of the NCD" and then moved on to discovery to determine if the exclusion was valid.[37] CMS did not defend its exclusion throughout the entire process. On May 30, 2014, HHS announced that the categorical exclusion was found by the DAB to not be valid "under the 'reasonableness standard,'" allowing for Medicare coverage of sex reassignment surgery to be decided on a case-by-case basis. HHS says it will move to implement the ruling. As Medicaid and private insurers often take their cues from Medicare on what to cover, this may lead to coverage of sex reassignment therapy by Medicaid and private insurers.[35][36] The evidence in the case "outweighs the NCD record and demonstrates that transsexual surgery is safe and effective and not experimental," according to the DAB in its 2014 ruling.[38]

A 2014 article published in American Journal of Public Health called on third-party payers to cover sex reassignment therapy in appropriately selected cases.[39]

Consent and the treatment of intersex people[edit]

Main article: Intersex human rights

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".[40]

In 2015, the Council of Europe recognized, for the first time, a right for intersex persons to not undergo sex assignment treatment.[41] In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations.[42][43][44][45][46]

See also[edit]

References[edit]

  1. ^ abcdGeorge R. Brown, MD (20 July 2011). "Chapter 165 Sexuality and Sexual Disorders". In Robert S. Porter, MD; et al. The Merck Manual of Diagnosis and Therapy (19th ed.). Whitehouse Station, NJ, USA: Merck & Co., Inc. pp. 1567–1573. ISBN 978-0-911910-19-3. 
  2. ^ abcdRichard M. Green, M.D., J.D. (June 8, 2009). "18.3 Gender Identity Disorders". In Benjamin Sadock; Virginia Alcott Sadock; Pedro Ruiz. Kaplan and Sadock's Comprehensive Textbook of Psychiatry (9th ed.). Lippincott Williams & Wilkins. pp. 2099–2111. ISBN 0781768993. [dead link]
  3. ^ abcdeWilliam Byne, Susan J. Bradley, Eli Coleman, A. Evan Eyler, Richard Green, Edgardo J. Menvielle, Heino F. L. Meyer-Bahlburg, Richard R. Pleak & D. Andrew Tompkins (August 2012). "Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder"(PDF). Archives of Sexual Behavior. 41 (4): 759–796 (pages cited as pages at link). doi:10.1007/s10508-012-9975-x. PMID 22736225. 
  4. ^ abDrescher, Jack; Haller, Ellen (July 2012). "Position Statement on Access to Care for Transgender and Gender Variant Individuals"(PDF). American Psychiatric Association. American Psychiatric Association. Retrieved 17 January 2014. 
  5. ^ ab"AMA Resolution 122"(PDF). AMA House of Delegates May 2008 Report (showing that Resolution 122 was affirmed). American Medical Association. May 2008. Retrieved 17 January 2014. 
  6. ^"APA Policy Statement: Transgender, Gender Identity, & Gender Expression Non-Discrimination". American Psychological Association. American Psychological Association. August 2008. Retrieved 17 January 2014. 
  7. ^ ab"Good practice guidelines for the assessment and treatment of adults with gender dysphoria"(PDF). Royal College of Psychiatrists. Royal College of Psychiatrists. October 2013. Retrieved 17 January 2014. 
  8. ^Whittle, Stephen; Bockting, Walter; Monstrey, Stan; Brown, George; Brownstein, Michael; DeCuypere, Griet; Ettner, Randi; Fraser, Lin; Green, Jamison; Rachlin, Katherine; Robinson, Beatrice. "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide". WPATH. Retrieved 27 August 2015. 
  9. ^F64.0"Excerpt from ICD 10". 
  10. ^"DSM 5 gender dysphoria fact sheet"(PDF). 
  11. ^ abcd"Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7"(PDF). Archived from the original(PDF) on 2016-01-06. 
  12. ^Brown, Mildred (2003). True selves : understanding transsexualism-- for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. ISBN 978-0-7879-6702-4. 
  13. ^de Vries, A. L. C.; McGuire, J. K.; Steensma, T. D.; Wagenaar, E. C. F.; Doreleijers, T. A. H.; Cohen-Kettenis, P. T. (8 September 2014). "Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment". Pediatrics. 134 (4): 696–704. doi:10.1542/peds.2013-2958. PMID 25201798. Retrieved 27 August 2015. 
  14. ^ abcMozes, Alan (10 September 2014). "Puberty Suppression Benefits Gender-Questioning Teens: Study". HealthDay. U.S. News & World Report. Retrieved 27 August 2015. 
  15. ^"Del Rey Aesthetics Center Introduces Facial Feminization Surgery Services". PRWeb. 
  16. ^"FFS: Trachea shave". www.tsroadmap.com. 
  17. ^"Voice and Communication Therapy for Clients Who Are Transgender". www.asha.org. 
  18. ^"Vocal Feminization: Surgery". www.tsroadmap.com. 
  19. ^P. A. Sutcliffe, S. Dixon, R. L. Akehurst, A. Wilkinson, A. Shippam, S. White, R. Richards & C. M. Caddy (March 2009). "Evaluation of surgical procedures for sex reassignment: a systematic review". Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 62 (3): 294–306. doi:10.1016/j.bjps.2007.12.009. PMID 18222742. 
  20. ^Murad, Mohammad Hassan; Elamin, Mohamed B.; Garcia, Magaly Zumaeta; Mullan, Rebecca J.; Murad, Ayman; Erwin, Patricia J.; Montori, Victor M. (2010). "Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes".
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