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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.

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.

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 th

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.

There are numerous other expressions that are used to refer to this type of surgery apart from sexual reassignment surgery and gender reassignment surgery. The American Society of Plastic Surgeons (ASPS) uses the term gender confirmation surgery or GCS.[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 masculinizing genitoplasty, metoidioplasty or phalloplasty.[citation needed]

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, Dr. 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.[6]

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. An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[8] but their identity is unclear at

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 masculinizing genitoplasty, metoidioplasty or phalloplasty.[citation needed]

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, Dr. Alan L. Hart, an American tuberculosis specialist, became one of the first female-to-male transsexuals to undergo hysterectomy and In the US in 1917, Dr. 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.[6]

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. An earlier known recipient of this was Magnus Hirschfeld's housekeeper,[8] but their identity is unclear at this time.

In 1951, Dr. 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.[9] 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.[10] 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.[10] Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.[10]

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.[11]

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".[12]

As of 2017, some European countries require forced sterilization for the legal recognition of sex reassignment.[13] As of 2020, Japan also requires their forced sterilization for that.[14]

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.[15][16]

Some transgender persons present with health conditions including diabetes, asthma, and HIV, which can lead to complications with future therapy and pharmacologic management.[17] 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.[18][19] 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.[20]

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.[21]

Other health conditions such as 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.[21]

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.[18]

SRS does not refer to surgery performed on infants with differences in sex development (intersex).[22] Infants born with intersex conditions might undergo interventions at or close to birth.[23] This is controversial because of the human rights implications.[24][25]

Minors

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.[26][27]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.[26][27][28] 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.[29][30]

Standards of care

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 ...)...

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.[41]

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."[42] In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.[42]

Post-surgical considerations

India: India is offering affordable sex reassignment surgery to a growing number of medical tourists[67] and to the general population.India: India is offering affordable sex reassignment surgery to a growing number of medical tourists[67] and to the general population.[68]

Iran: The Iranian government's response to homosexuality is to endorse, and fully pay for, sex reassignment surgery.[69][69][70] The leader of Iran's Islamic Revolution, Ayatollah Ruhollah Khomeini, issued a fatwa declaring sex reassignment surgery permissible for "diagnosed transsexuals".[69] 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.[69] 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.[71]

Japan: As of 2020, Japan requires the forced sterilization of transgender people for the legal recognition of sex reassignment.[14]

Pakistan: In Pakistan, the Council of Islamic Ideology has ruled that SRS contravenes Islamic law as construed by the council.[72] 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.[71]

France: Since 2016, France no longer requires SRS as a condition for a gender change on legal documents.[73][74] 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.[75]

Malta: As late as 2010, transgender people that have undergone SRS can change their sex on legal documents.[76]

Spain: Despite a resolution from the European Parliament in 1989 suggesting advanced rights

Malta: As late as 2010, transgender people that have undergone SRS can change their sex on legal documents.[76]

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.[77][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[78][79] and inability to procreate.[80]

Ukraine: In 2015, the Administrative District Court of Kiev ruled that forced sterilization was unlawful and no longer required for legal gender change.[81][failed verificationsee discussion]

Canada: Laws regarding legal recognition of gender identity vary from province to province in Canada with most provinces requiring reassignment surgery for a sex change on legal identification.

The United States of America: Many of the surgeries mentioned in the History section of this article were developed in the United States. Before the legalization of same-sex marriage in the United States, t

The United States of America: Many of the surgeries mentioned in the History section of this article were developed in the United States. 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.[82][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.

Mexico: As of a 2014 law,[83] Mexico City no longer requires SRS for changes of sex on birth certificates, and several states have followed suit.[84]

Argentina: In 2012, Argentina began offering government subsidized total or partial SRS to all persons 18 years of age or older.[85][86][70] 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.[87] Furthermore, it is not required to undergo SRS to change sex on legal documents.[88]

Chile: In 2012, a bill was introduced that stated SRS was no longer a requirement for legal name and sex change.[89]

In 2013, Chile's public health plan was required to cover sex reassignment surgery.[89]

In 2013, Chile's public health plan was required to cover sex reassignment surgery.[89] The cost is subsidized by the government based on a patient's income.[89]