TGmeds Home of the “Hormones 2016” document Psychiatric Aspects of Sex Reassignment Surgery

Sex reassignment surgerySee gender-affirming surgery. is perhaps the most controversial issue in psychiatry today. Clinicians involved in the treatment of transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
have been accused of “playing God” or colluding with the patient’s psychopathology. This paper reviews the literature and argues for a systematic approach to the treatment of transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
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Table of Contents

The first medical documentation of transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
was made by Friedreich in 1830, although the condition was not considered worthy of investigation until many years later (Althorf et al, 1983). Abraham carried out the first sex reassignment surgerySee gender-affirming surgery. (SRS) in the 1920s, and a subsequent operation was done in 1952 by Paul Fogh-Anderson, a plastic surgeon in Copenhagen, having ascertained that his patient was not psychotic with bodily delusions. The patient, an American ex-army sergeant who later became famous as Christine Jorgensen, was pleased with the results of the surgery and adapted successfully to the feminineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with girls and women. role. Less publicized surgical intervention for transsexuals was carried out in Europe in the 1950s and in North Africa, in particular in Casablanca.

Cauldwell (1949) first used the term transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
and Fisk (1973) later introduced the term gender dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
to describe a sense of uneasiness about one’s own gender identity• One’s innermost concept of self as male or female or both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different than the sex assigned at birth. Individuals are conscious of this between the ages 18 months and 3 years. Most people develop a gender identity that matches their biological sex. For some, however, their gender identity is different from their biological or assigned sex. Some of these individuals choose to socially, hormonally and/or surgically change their sex to more fully match their gender identity.
• The gender to which one feels one belongs.
• Internal and psychological sense of oneself as a woman, a man, both, in between, or neither.
accompanied by depression or anxiety and sometimes by a wish or an attempt to assume the gender role• This is the set of roles, activities, expectations and behaviors assigned to females and males by society. Our culture recognises two basic gender roles: Masculine (having the qualities attributed to males) and feminine (having the qualities attributed to females). People who step out of their socially assigned gender roles are sometimes referred to as transgender. Other cultures have three or more gender roles.
• Socially constructed and culturally behavioural norms, such as communication styles, careers and family roles, that are often expected of people based on their assigned sex.
of the opposite sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy.. The estimated prevalence in Sweden is 1 in 37 000 males and 1 in 103 000 females, and in England and Wales it is estimated as 1 in 34,000 males and 1 in 108,000 females (Walinder, 1968; Hoenig and Kenna, 1974). Transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
, which is distinct from homosexuality and fetishistic crossdressing, is a problem of gender identity• One’s innermost concept of self as male or female or both or neither – how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different than the sex assigned at birth. Individuals are conscious of this between the ages 18 months and 3 years. Most people develop a gender identity that matches their biological sex. For some, however, their gender identity is different from their biological or assigned sex. Some of these individuals choose to socially, hormonally and/or surgically change their sex to more fully match their gender identity.
• The gender to which one feels one belongs.
• Internal and psychological sense of oneself as a woman, a man, both, in between, or neither.
. The patient is convinced that his/her own psychological gender• However gender is far more complicated. It is the complex interrelationship between an individual’s sex (gender biology), one’s internal sense of self as male, female, both or neither (gender identity) as well as one’s outward presentations and behaviours (gender expression) related to that perception, including their gender role. Together, the intersection of these three dimensions produces one’s authentic sense of gender, both in how people experience their own gender as well as how others perceive it.
• Gender is expressed in terms of masculinity and femininity. It is largely culturally determined and is assigned at birth based on the sex of the individual. It affects how people perceive themselves and how they expect others to behave.
• Socially and culturally constructed roles, behaviours, expressions and identities of girls, women, boys, men, and trans people.
is the opposite of his/her anatomical sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. – in other words there is an anatomical-gender discontinuity (Gagnon, 1977, cited in Roberto, 1983). The term transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. may therefore be used for persons of either sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. who display the following characteristics –

A sense of belonging to the opposite sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. and of having been born into the wrong sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy..
A sense of estrangement from one’s own body, so that any evidence of one’s own biological sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. is regarded as repugnant.
A strong desire to resemble physically the opposite sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy. and to seek treatment, including surgery, towards this.
A wish to be accepted in the community as belonging to the opposite sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy..
Persistence of these feelings and convictions, often since childhood
No evidence of biological or associated psychiatric illness, such as schizophrenia.

The transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. feels that he/she is trapped in the wrong body. MaleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals feel feminineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with girls and women. from childhood and often believe they were “girls”. This belief is typical of these patients, and it is consistent with their distaste of their own genitalia which are described as “not mine”, “not wanted” and “useless”. A lack of interest for the penis as an insignia of maleness and a source of erotic pleasure is accompanied by the wish to be rid of it and to be given a woman’s body. The same applies to the femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. who demands removal of the breasts and of the womb. These patients remember puberty as a painful confusing period, during which erections and emissions for the maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles)., and breast development and menstruation for the femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). shattered the illusion that they were to grow up in the preferred body. Crossdressing begins in early life, usually on the patient’s own initiative and without associated sexual gratification. Crossdressing produces a sense of wellbeing which cannot be obtained by any other means. Passing successfully in the opposite gender role• This is the set of roles, activities, expectations and behaviors assigned to females and males by society. Our culture recognises two basic gender roles: Masculine (having the qualities attributed to males) and feminine (having the qualities attributed to females). People who step out of their socially assigned gender roles are sometimes referred to as transgender. Other cultures have three or more gender roles.
• Socially constructed and culturally behavioural norms, such as communication styles, careers and family roles, that are often expected of people based on their assigned sex.
reinforces the belief of being trapped in the wrong body and makes imperative the request for hormonal and surgical treatment. Some transsexuals have a very limited or absent sexual life. The maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. prefers masculineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with boys and men. “straight” men. These sexual relationships are explained as “heterosexual” because the patient believes that he is femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). and he is naturally attracted to men. Heterosexual activity is accompanied by the fantasy of being a womanA human being who self-identifies as a woman, based on elements of importance to the individual, such as gender roles, behaviour, expression, identity, and/or physiology. made love to by a manA human being who self-identifies as a man, based on elements of importance to the individual, such as gender roles, behaviour, expression, identity, and/or physiology..

This fantasy is necessary in order to achieve arousal and orgasm.

Transsexualism, transvestism, and homosexuality

In clinical practice transsexuals should be differentiated from fetishistic transvestites and effeminate homosexuals• Men and women who form their primary loving relationships with people of the same gender. Many gay people prefer that the terms “gay men and lesbians” or “gay people” be used to describe homosexuals as a group rather than the term “homosexuals”.
• An outdated term that was historically used to describe people who were attracted to other people of the same gender; replaced by the more inclusive and respectful term, ‘gay’ or ‘lesbian’, which are not considered offensive by many.
, who often present with gender dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
and crossdressing behaviour and who can request treatment. The fetishistic transvestite• A person who dresses in the clothing of the opposite sex as defined by socially accepted norms. Consequently, in contemporary society, the majority of transvestites are cross-dressing men. Social transvestites cross-dress merely to feel more comfortable. The erotic transvestite cross dresses to achieve sexual gratification alone or with a partner. Transvestites normally cross dress only occasionally and do not seek hormones or surgery.
• A transvestite individual feels compelled to wear clothing normally associated with the opposite sex, but does not desire to live permanently as a member of the opposite sex.
• An outdated term that was historically used to label people who cross dressed as having a mental illness; replaced by the more inclusive and respectful term, ‘cross dresser’, which is not considered a mental illness.
differs from the transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. in that he considers himself a manA human being who self-identifies as a man, based on elements of importance to the individual, such as gender roles, behaviour, expression, identity, and/or physiology. and he is usually successful in the maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). role. Crossdressing behaviour is accompanied by sexual excitement, generally masturbation and orgasm. For the transvestite• A person who dresses in the clothing of the opposite sex as defined by socially accepted norms. Consequently, in contemporary society, the majority of transvestites are cross-dressing men. Social transvestites cross-dress merely to feel more comfortable. The erotic transvestite cross dresses to achieve sexual gratification alone or with a partner. Transvestites normally cross dress only occasionally and do not seek hormones or surgery.
• A transvestite individual feels compelled to wear clothing normally associated with the opposite sex, but does not desire to live permanently as a member of the opposite sex.
• An outdated term that was historically used to label people who cross dressed as having a mental illness; replaced by the more inclusive and respectful term, ‘cross dresser’, which is not considered a mental illness.
, the penis as a source of erotic pleasure is an essential element in his rituals, which he does not want to lose. Most transvestites are primarily heterosexual men who prefer women to men both in reality and in their sexual fantasies. It must, however, be acknowledged that transvestites may go through phases in which the pleasure and relief of anxiety obtained by crossdressing are reduced. The fetishistic excitement is substituted by a sense of feeling like a womanA human being who self-identifies as a woman, based on elements of importance to the individual, such as gender roles, behaviour, expression, identity, and/or physiology., which can take a compulsive character. They may then wish to remain full-time in the femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). role, and eventually seek treatment, e.g. hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. and occasionally surgery, to be made into a “complete woman”. This wish usually occurs at a time of crisis, when switching to the opposite gender role• This is the set of roles, activities, expectations and behaviors assigned to females and males by society. Our culture recognises two basic gender roles: Masculine (having the qualities attributed to males) and feminine (having the qualities attributed to females). People who step out of their socially assigned gender roles are sometimes referred to as transgender. Other cultures have three or more gender roles.
• Socially constructed and culturally behavioural norms, such as communication styles, careers and family roles, that are often expected of people based on their assigned sex.
seems to provide a defense against helplessness and depression. In effeminate homosexuals• Men and women who form their primary loving relationships with people of the same gender. Many gay people prefer that the terms “gay men and lesbians” or “gay people” be used to describe homosexuals as a group rather than the term “homosexuals”.
• An outdated term that was historically used to describe people who were attracted to other people of the same gender; replaced by the more inclusive and respectful term, ‘gay’ or ‘lesbian’, which are not considered offensive by many.
, transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. fantasies are common, especially in those with a strong feminineDescribes socially and culturally constructed aspects of gender (e.g. roles, behaviour, expression, identity) typically associated with girls and women. identification. Despite the pleasure they derive from acting out their aggressive identifications by caricaturing women, their sense of identity as homosexual men is far stronger than their sense of being femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus).. They are aware of their preference for men and their fascination for the penis as a source of pleasure for themselves and their partners. Only a few effeminate homosexuals• Men and women who form their primary loving relationships with people of the same gender. Many gay people prefer that the terms “gay men and lesbians” or “gay people” be used to describe homosexuals as a group rather than the term “homosexuals”.
• An outdated term that was historically used to describe people who were attracted to other people of the same gender; replaced by the more inclusive and respectful term, ‘gay’ or ‘lesbian’, which are not considered offensive by many.
request SRS, usually as a result of a crisis in their relationships and a serious loss of confidence in their being attractive and sexually desirable. They may go as far as requesting hormonesChemical substances that control and regulate the activity of certain cells or organs; see also: sex hormones. to develop breasts, but stop short of requesting surgical reassignment of their genitalia.

It has been suggested that transvestites and effeminate homosexuals• Men and women who form their primary loving relationships with people of the same gender. Many gay people prefer that the terms “gay men and lesbians” or “gay people” be used to describe homosexuals as a group rather than the term “homosexuals”.
• An outdated term that was historically used to describe people who were attracted to other people of the same gender; replaced by the more inclusive and respectful term, ‘gay’ or ‘lesbian’, which are not considered offensive by many.
who express transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. fantasies and wish for bodily modification should be classified as secondary transsexuals. In primary transsexuals the transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. impulse stems from childhood and is persistent throughout life (Person and Ovesey, 1974a,b). In secondary transsexuals it tends to appear later and the patient may go through phases of clear active transvestism or effeminate homosexuality before converting to transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
. It is, therefore, relevant to be able to recognize a transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. crisis and to avoid an early simplified diagnosis of transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
. Clinical experience suggests that a psychotherapeutic intervention can help the patient to contain the under lying acute anxiety and to return to his usual way of living. Recent studies confirm that secondary transsexuals may adjust better to life when surgery is refused than when it is granted (Lundstrom et al, 1984).

Outcome of SRS

SRS has evoked controversy and has been viewed as both a panacea and a collusion with the patient’s psychopathology. The results of SRS have been described in a number of clinical follow-up reports. Pauly (1968) concluded that a group of maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals who underwent SRS were 10 times more likely to have a satisfactory outcome in terms of emotional and social adjustment than a group who did not. Randell (1969) reported that of 29 maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals who underwent SRS, two thirds showed marked improvement in social and psychological adjustment. Only two showed a worsening of the condition and both of these were psychopathic. Laub and Fisk (1974), in a 6-year follow-up of postoperative transsexuals found that the most significant factor which led to a satisfactory outcome was a successful preoperative adjustment in the gender role• This is the set of roles, activities, expectations and behaviors assigned to females and males by society. Our culture recognises two basic gender roles: Masculine (having the qualities attributed to males) and feminine (having the qualities attributed to females). People who step out of their socially assigned gender roles are sometimes referred to as transgender. Other cultures have three or more gender roles.
• Socially constructed and culturally behavioural norms, such as communication styles, careers and family roles, that are often expected of people based on their assigned sex.
of choice during a 1-3 year trial period. Walinder and Thuwe (1974) concluded that the outcome of surgery was favourable in approximately 80% of cases. They further argued: “…when we consider the suffering and many difficulties experienced by untreated transsexuals in many fields of life, the treatment programme appears to be fully justified, both medically and ethically.” Walinder et al (1978) suggested that psychosis, unstable personality, inadequacy in self-support, mental retardation, alcoholism, drug abuse and criminality are all negative prognostic factors and that active intervention should be discouraged if they are present. Lothstein (1984) in his critical review of psychological studies reported that there was evidence of severe psychopathology in maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals at the preoperative stage, and that at postoperative assessment transsexuals were shown to have a higher level of psychological adjustment. Lundstrom et al (1984), in a comprehensive review of postoperative follow-up studies, suggested that the majority of findings showed an improvement of psychological functioning and general psychopathology following SRS. They noted that 10-15% of SRS ended in failure. They argued that primary transsexuals have a better postoperative outcome than secondary transsexuals, and that for secondary transsexuals the outcome is equal or better when surgery is refused. Blanchard et al (1985) reported improvement in psychological functioning following SRS in selected cases of maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals. A more recent study by Mate-Kole et al (1987) suggested that SRS reduced psychiatric morbidity in a group of 50 maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals when compared with a group of patients on a waiting list for surgery and a group undergoing assessment.

Against this body of favourable evidence there are a number of studies which express reservations. Hoenig et al (1971) argued that SRS helped a majority of patients both subjectively and objectively but the operation could in no sense be regarded as a cure. Newman and Stoller (1971) reported that although surgery produces a change in a person’s secondary sexual characteristics, inner maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). and femaleA sex, usually assigned at birth, and based on chromosomes (e.g. XX), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. vagina, uterus). identity remains untouched. Sturup (1976) found that all his patients had psychological problems, including family rejection, difficulty at work, sexual adjustment, depressive ideation, suicidal behaviour and reactive psychosis. Nevertheless, all the patients were satisfied with the surgical outcome. A more recent study by Beatrice (1985) assessed the psychological functioning of four groups each of 10 subjects (heterosexual males, transvestites, preoperative maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals and postoperative maleA sex, usually assigned at birth, and based on chromosomes (e.g. XY), gene expression, hormone levels and function, and reproductive/sexual anatomy (e.g. penis, testicles). transsexuals) using the Minnesota Multiphasic Personality Inventory and the Tennessee Self-Concept Scale. He reported that both preoperative and postoperative patients showed evidence of psychotic functioning which surgery did not relieve.

Criteria for SRS

Once a diagnosis of transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
has been made, recommendation for SRS should be based on strict criteria as laid down by The Harry Benjamin International Gender Dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
Association (1985) as follows:

The patient should show evidence of stable transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. orientation.
The patient should show insight into his/her condition and should not suffer from any serious psychiatric disorder.
The patient should be able to pass successfully as a member of the opposite sexBiological attributes and legal categories used to classify humans as male, female, intersex or other categories, primarily associated with physical and physiological features including chromosomes, genetic expression, hormone levels and function, and reproductive/sexual anatomy., and there should be clear evidence of cross-gender functioning.
Improvement in personal and social functioning should be predicted for the individual prior to and after surgery.

Evidence from the majority of studies to date suggests that SRS is followed by an improvement in psychological status. Lundstrom et al (1984) in a general review of the literature reported as follows:

Satisfactory outcome to some degree is dependent upon good cosmetic outcome and functional results of surgery, but other variables can affect the patient’s perception of overall satisfaction.
Personal and social instability are correlated with unsatisfactory results and this is an indication that the transsexualThis is typically used to describe people who identify as transgender who are transitioning toward the gender with which they identify. This may include socially presenting (e.g., clothing, hair, mannerisms, overall gender expression) as the gender with which they identify, or it may include more extensive changes like taking hormones and/or surgical procedures to modify their body. should be supported both preoperatively and postoperatively if SRS is to be considered.
There is an inverse relationship between increasing age at the time of request for surgery and favourable outcome.
Not only do secondary transsexuals have a higher frequency of unsatisfactory outcome, but it is indicated that when such patients are refused surgery they manage their lives reasonably well and tend to give up their pursuit of SRS.

SRS is the treatment of choice for carefully selected genuine primary transsexuals only. Caution should be paid to patients with unstable backgrounds and diagnostic criteria should be consistent. There is no doubt that transsexualism• This term is used to describe a person who has “transitioned”, or is in the process of “transitioning”, or intends to transition from male to female or female to male. For a transsexual person, the process of “transitioning”, may involve a variety of treatments including: hormone therapy, surgery and hair removal. People who have transitioned do not necessarily identify as trans any longer; they may identify as simply a man or a woman. Some transsexual people may not transition due to family or other social constraints.
• When people complete their transition, they may no longer regard themselves as part of the trans umbrella. They might consider having been transsexual to just be an aspect of their medical history which has now been resolved and so is no longer an issue in their life. In such cases, they simply describe themselves as men or as women and it is most disrespectful to insist on calling them trans, transgender or transsexual against their wishes.
is an extreme form of gender dysphoria• An anxiety, uncertainty or persistently uncomfortable feelings experienced by an individual about their assigned gender which is in conflict with their internal gender identity.
• Gender dysphoria is a medical condition in which a person has been assigned one gender at birth but identifies as another gender, or does not conform to the gender role society ascribes to them. Gender dysphoria is not related to sexual orientation. Gender dysphoria has replaced gender identity disorder as the word disorder is seen as stigmatising.
• A person with gender dysphoria can experience anxiety, uncertainty or persistently uncomfortable feelings about their gender assigned at birth. This dysphoria may lead to a fear of expressing their feelings or of rejection and in some cases deep anxiety or chronic depression. It is effectively treated using methods such as counselling, hormone replacement therapy, surgery or simply social transition.
• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
. However, whether SRS is the treatment of choice is equivocal. Therefore, future studies should adopt a multidisciplinary approach ranging from psychiatric and neuropsychological evaluation to sociological and physiological investigations to improve the definition of indications and predictors for SRS.

We are deeply indebted to Dr Ashley Robin, Honorary Consulting Psychiatrist, Charing Cross Hospital, for reading this paper and for his invaluable comments.

References

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• The gender to which one feels one belongs.
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• Distress resulting from a difference between a person’s gender and the person’s assigned sex, associated gender role, and/or primary and secondary sex characteristics.
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• Gender is expressed in terms of masculinity and femininity. It is largely culturally determined and is assigned at birth based on the sex of the individual. It affects how people perceive themselves and how they expect others to behave.
• Socially and culturally constructed roles, behaviours, expressions and identities of girls, women, boys, men, and trans people.
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TGmeds Home of the “Hormones 2016” document Psychiatric Aspects of Sex Reassignment Surgery

Transsexualism, transvestism, and homosexuality

Outcome of SRS

Criteria for SRS

References

Further reading

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