Sex reassignment therapy

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Sex reassignment therapy
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{{Transgender sidebar}}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.BOOK, George R. Brown, MD, Chapter 165 Sexuality and Sexual Disorders, 1567–1573, Robert S. Porter, MD, The Merck Manual of Diagnosis and Therapy, 19th, 20 July 2011, Merck & Co., Inc., Whitehouse Station, NJ, USA, 978-0-911910-19-3, etal, Merck Manual of Diagnosis and Therapy, {{rp|1570}}BOOK, Richard Green (sexologist), Richard M. Green, M.D., J.D., 18.3 Gender Identity Disorders, 2099–2111, Benjamin Sadock, Virginia Alcott Sadock, Pedro Ruiz (editor), Pedro Ruiz, Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Lippincott Williams & Wilkins, 9th, June 8, 2009, 978-0781768993,weblink {{dead link|date=January 2015}}{{rp|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;JOURNAL, William Byne, Susan J. Bradley, Eli Coleman, A. Evan Eyler, Richard Green (sexologist), Richard Green, Edgardo J. Menvielle, Heino F. L. Meyer-Bahlburg, Richard R. Pleak & D. Andrew Tompkins, Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder, Archives of Sexual Behavior, 41, 4, 759–796 (pages cited as pages at link), August 2012, 10.1007/s10508-012-9975-x, 22736225,weblink {{rp|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.{{rp|2–3}} Treatment of gender dysphoria does not involve attempting to correct the patient's gender identity, but to help the patient adapt.{{rp|1568}}Major health organizations in the United States and UK have issued affirmative statements supporting sex reassignment therapy as comprising medically necessary treatments in certain appropriately evaluated cases.WEB,weblink Position Statement on Access to Care for Transgender and Gender Variant Individuals, Drescher, Jack, Haller, Ellen, July 2012, American Psychiatric Association, American Psychiatric Association, 17 January 2014, WEB,weblink AMA Resolution 122, May 2008, AMA House of Delegates May 2008 Report (showing that Resolution 122 was affirmed), American Medical Association, 17 January 2014, WEB,weblink APA Policy Statement: Transgender, Gender Identity, & Gender Expression Non-Discrimination, August 2008, American Psychological Association, American Psychological Association, 17 January 2014, WEB,weblink Good practice guidelines for the assessment and treatment of adults with gender dysphoria, October 2013, Royal College of Psychiatrists, Royal College of Psychiatrists, 17 January 2014, WEB, 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,weblink WPATH, 27 August 2015, yes,weblink" title="">weblink 14 August 2015,


In current medical practice, a diagnosis is required for sex reassignment therapy. In the International Classification of Diseases the diagnosis is known as transsexualism (F64.0WEB,weblink Excerpt from ICD 10, ). The US Diagnostic and Statistical Manual of Mental Disorders (DSM) names it gender dysphoria (in version 5WEB,weblink DSM 5 gender dysphoria fact sheet, ). 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.


The general standard for diagnosing, as well as treating, gender dysphoria is outlined in the WPATH Standards 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.WEB,weblink" title="">weblink 2016-01-06,weblink Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7, yes, 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."{{rp|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.BOOK, Brown, Mildred, True selves : understanding transsexualism-- for families, friends, coworkers, and helping professionals, Jossey-Bass, San Francisco, 2003, 978-0-7879-6702-4, {{rp|108}}

Eligibility for different stages of treatment

While a mental health assessment is required by the standards of care, psychotherapy is not an absolute requirement but is highly recommended.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.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 trans men and trans women. The Standards of Care require trans men to undergo either 3 months of Real-life-test or psychological evaluation before surgery whereas trans women 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

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|date=March 2016}} 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."JOURNAL, de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., Cohen-Kettenis, P. T., Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment, Pediatrics, 8 September 2014, 134, 4, 696–704, 10.1542/peds.2013-2958,weblink 27 August 2015, 25201798, No patients expressed regret about the transition process, including puberty suppression.NEWS, Mozes, Alan, Puberty Suppression Benefits Gender-Questioning Teens: Study,weblink 27 August 2015, HealthDay, U.S. News & World Report, 10 September 2014, "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,".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.

Psychological treatment

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; enhancingsocial and peer support; improving body image; or promoting resilience" is a treatment option.

Hormone replacement therapy

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

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

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, metoidioplasty, 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

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.WEB, Del Rey Aesthetics Center Introduces Facial Feminization Surgery Services,weblink PRWeb, 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.WEB, FFS: Trachea shave,weblink, Facial masculinization surgery (FMS) is a form of facial reconstruction used to make a feminine face appear more masculine.Trans people of both sexes may practice vocal therapy. Vocal therapists may help their patients improve their pitch, resonance, inflection, and volume.WEB, Voice and Communication Therapy for Clients Who Are Transgender,weblink, en, Another option for trans women is vocal surgery, though there is the risk of damaging the voice.WEB, Vocal Feminization: Surgery,weblink,


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."{{rp|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."{{rp|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."{{rp|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.{{rp|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."{{rp|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."JOURNAL, P. A. Sutcliffe, S. Dixon, R. L. Akehurst, A. Wilkinson, A. Shippam, S. White, R. Richards & C. M. Caddy, Evaluation of surgical procedures for sex reassignment: a systematic review, Journal of Plastic, Reconstructive & Aesthetic Surgery, 62, 3, 294–306, March 2009, 10.1016/j.bjps.2007.12.009, 18222742, 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."JOURNAL, 10.1111/j.1365-2265.2009.03625.x, Hormonal therapy and sex reassignment: A systematic review and meta-analysis of quality of life and psychosocial outcomes, 2010, Murad, Mohammad Hassan, Elamin, Mohamed B., Garcia, Magaly Zumaeta, Mullan, Rebecca J., Murad, Ayman, Erwin, Patricia J., Montori, Victor M., Clinical Endocrinology, 72, 2, 214–31, 19473181, A study evaluating quality of life in female-to-male transgender individuals found "statistically significant (p

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