MedPiper Technologies and JournoMed had conducted a Webinar Series to “Improve Healthcare Access for Transgender and Sexual Minorities For The Doctors and By The Doctors” with IRIA Kerala- Raksha, Shakthi, Social Wings, IMA Kerala and CARB. On Day 3, 21st July, 2022, the speaker, Dr. Sundeep Vijayaraghavan spoke about Sex Reassignment Surgery. Dr Sundeep Vijayaraghavan is a Plastic Surgeon and Clinical Professor from Amrita Hospitals, Kochi. He has been actively performing Sex reassignment and related surgeries since 2017.
Gender affirmation Surgery/ Sex Reassignment Surgery was first performed in the year 1877. Krafft Ebbing was the first person to observe cross-gender behaviour in the medical literature. In 1921, Harry Benjamin observed that there is a change in the sexuality of animals from Eugen Steinach’s experiments. The change in sexual behaviour is due to castration and implantation of sex glands. Benjamin was very interested in Steinach’s experiments and spent his life treating transgender patients. A highly publicized sex reassignment surgery was performed on Christine Jogerson in Denmark in the year 1952. The world’s first sexual reassignment surgery was performed in 1933 by Lili Elbe in Dresden, Germany. But unfortunately, due to the complications of the procedure, the patient died.
Surgery for Transwomen
Transwomen are common in India and across the globe. The surgeries performed on transwomen are top surgery, bottom surgery and facial feminization. Top surgery is a simple colloquial term for indicating breast augmentation. The bottom surgery is genital surgery. In facial feminization, the thyroid cartilage reduction procedure may be included. The surgery is performed to shape the body (abdomen, flanks and buttocks). The contouring procedures are the additional ancillary procedures that may be performed. Vocal cord surgery is not a popular surgery. A reference letter from a clinical psychiatrist is needed if one opts for the feminizing hormone treatment. The patient must be aware of preoperative, perioperative and post-operative concepts.
Harry Benjamin had started an organization named World Professional Association for Transgender Health (W PATH). W PATH maintains the standards of care which are being followed all over the World. The current standard of care is the 7th SOC (standard of care). The top surgeries are of not much importance compared to bottom surgeries. Some key points regarding sex reassignment surgery include:
- A reference letter from a mental professional is mandatory while performing any of the sex reassignment surgeries.
- The person should be a major (not a minor) in whichever country they belong to.
- The person should be psychologically and emotionally strong to undergo any sort of surgery.
- A consent must be filled which fulfils the hormonal criteria before the pre-operative procedure for the patient.
- A physical examination of the patient is necessary before preoperative surgery is performed.
- Smoking and even hormonal usage are not recommended.
Post-operative care for Transwomen
Post-operative care is recommended for transwomen after the sex reassignment surgery. Avoid strenuous activity to prevent implant migration. Breast massage should be done for at least 6 months to prevent capsular contraction. Scar massage is also beneficial in case of breast augmentation.
- Breast augmentation: Breast augmentation, a clinically and medically approved surgery recommended in transgender women which improves psychosocial and sexual well-being.
- Fat injection: The alternative method for breast augmentation is fat injection. In this technique, a small amount of fat is injected during the surgery, 30% of fat gets lost.
- Body contouring: For body contouring, many times the patients go for liposuction or fat injections. The male body structure is entirely different from that of the female. In body contouring, people prefer the shaping of hips and buttocks either with implants or with fat. When people administer estrogen pills, it is found that shape develops in the gluteofemoral region. Few shapes don’t require any surgical procedures. In females, more adipose deposition in the gluteal region marks a distinct transition on the lower back. In the male, the mid-lateral position of the buttocks tends to be flat with a distinct concavity.
- Fertility preservation: Fertility preservation is the most common technique and is highly underutilized in transgender people. The gamete (egg) or the gonad (ovary) is stored by the process of cryopreservation. Another cost-effective method is gonadal conservation (i.e. retaining an ovary) in Transmen. The testis cryopreservation and sperm banking procedure can be followed in Transwomen. These options are available in fertility centres.
Some transgender patients become parents before transitioning. It is associated with a positive effect on the quality of life. Children are not adversely impacted by having transgender or gender-diverse patients. These children are not any more likely to be transgender themselves. Having transgender parents does not affect a child’s gender identity, sexual orientation or other pediatric developmental milestones.
Many transmen are gender dysphoric and can become pregnant. Transmen can also conceive after testosterone administration for a longer duration. Transmen can have a healthy baby too. The transmen were advised to remove their ovaries as they have a higher risk of ovarian cancer. The bilateral salpingo-oophorectomy reduces the risk of ovarian cancer.
Bottom Surgery for Transwomen
Fully informed consent needs to be signed in case of any medical concerns. The bottom surgery is highly sophisticated. It is many times aesthetically indistinguishable from a cis vagina. They can be functionally able to accommodate receptive penetrative sexual intercourse. The individual can feel an erogenous sensation while urinating. There are many methods for performing the bottom surgery. Corpus cavernosa is the erectile tissue of the male penis that needs to be discarded. The radical removal of the corpora cavernosa prevents post-operative complications such as post-operative erections, painful sexual intercourse and psychological disturbances.
Various Techniques of Bottom Surgery
There are different techniques for performing vaginoplasty
- Penile inversion vaginoplasty
- Gut-sigmoid colon vaginoplasty, ileum loop vaginoplasty
- Scrotal skin vaginoplasty
- Shape surgery- clitoroplasty, labioplasty and urethroplasty
Penile inversion vaginoplasty: The most common technique is penile inversion vaginoplasty. The cavity is created between the rectum and the urethra. The penile skin envelope is preserved as a pedicled skin flap. The scrotal skin flap and urethral mucosa are also used most of the time as a flap. The penile skin and the scrotal skin are placed in situ and fixed to the sacrospinous ligament with a non-absorbable suture.
Penile Disassembly Technique: In this technique, the penis is disassembled. The neurovascular bundle and the glans are monitored. The urethra and the corpus cavernosa are removed, decreasing the urethral size and the skin forms the new vagina. The penis is dissected into its anatomic components-corpora cavernosa, the glans cap with a neurovascular bundle, the urethra and the vascularized penile skin.
Intestinal vaginoplasty: Intestinal vaginoplasty is a surgical procedure that uses a sigmoid colon to create a neo vagina. This is usually performed as laparoscopic surgery. Laparoscopic surgery is a minimally invasive keyhole surgery where a small incision is made through the skin. The main aim of this surgical procedure is to improve sexual health and overall quality of life.
Facial Feminisation Surgery
Facial Feminisation Surgery is designed to soften and modify facial features perceived as masculine, exaggerated or non-harmonic. The structural bone modification includes the readapting overlying soft tissues to the modified bone structure. Facial Feminisation Surgery should not be mistaken as cosmetic surgery.
Surgery for Transmen
Many transmen are usually concerned with chest reconstruction. They visit OPD with a tight elastic band-aid. The band-aid is put around the chest wall because of gender dysphoria. The area appears fibrous because of pressure over there. The important thing is to discuss chest surgery with hysterectomy, oophorectomy and salpingectomy. Smoking, diabetes and hormonal therapy need to be discontinued 2 weeks before the surgery.
Female to male gender affirmation: Phalloplasty
The goal of penile construction is to create a functional and aesthetic phallus. Many times phalloplasty is performed in multiple stages and the first stage of surgery is vaginectomy and urethral lengthening. The second stage is the microsurgical transfer of the radial forearm flap and scrotoplasty. After 3-6 months, silicon implants are placed for testis.
Vaginectomy: Vaginectomy is the surgery to remove all or parts of vagina. It can be used to remove tissue with cancerous cells and also used in gender affirmation surgery.
Radial Forearm Free Flap (RFFF): RFFF is the most frequently used surgical technique for a phalloplasty. The functioning of the neourethra allows voiding from the distal end of the neophallus. The urethra generates an erogenous sensation. The radial forearm free flap allows tubularization around the neourethra. With the tube-in-tube technique, the urethra can be created in the first sitting. One can able to pass urine through the end of the phallus. Even the normal look in glans can be reconstructed.
Sex Reassignment Surgery or Gender Reassignment Surgery is a biomedical enhancement to tackle gender dysphoria. It is standardly approved upon psychiatric authorization. Sex Reassignment Surgery is performed in concordance to the transgenders individual’s demands. It is a standard practice to ensure optimal balance between availability, beneficence and possible harmfulness. The beneficial effect of sex reassignment surgery is the individual’s mental health. Many transmen and transwomen are capable of maintaining gender sensitivity successfully.