Do you know that one of the first sex reassignment operations was performed in the USSR? Before her, only four cases were described in the world. In the early 1970s, Riga surgeon Viktor Kalnberz successfully turned a woman named Inna into a man, Innocent. Although the psychiatric commission confirmed the need for such intervention for the patient and there was permission from the Latvian Minister of Health, the surgeon was subsequently reprimanded in Moscow “for carrying out a mutilation operation that does not correspond to the structure and ideology of the state.”
V. Kalnberz with Fidel Castro’s bodyguard, to whom he restored “male health”
These days, according to the Vademecum analytical center, at least 800 gender reassignment operations are performed in Russia annually. In the USA, according to statistics from the American Society of Plastic Surgeons, there are more than 3 thousand. And many times more in Thailand, which is considered a global mecca for transgender people due to more affordable prices.
Queen and finalists of the Pattaya Transgender Beauty Pageant 2015. Reuters
But in any case, these prices are rather high - from several tens to one and a half hundred thousand dollars. But the procedures themselves are difficult and painful. Anews found out what people go through when they decide to change their sex.
First prove that you are of the “other gender”
According to the standards of the World Professional Association for Transgender Health (WPATH), first of all, the patient must be examined by a psychiatrist and undergo a special commission. If a diagnosis of gender identity disorder or gender dysphoria is made, hormone replacement therapy can be started under the supervision of a doctor.
Moreover, while a person noticeably changes in appearance, he should not hide from anyone. Moreover, WPATH requires that a transgender person live openly as a member of the opposite sex for at least a year and even provide evidence to the surgeon that not only his doctors, but also other people know him as such.
For example, Kelly Maloney, the former boxing promoter and manager of Lennox Lewis, formerly known as Frank Maloney, lived as a transgender woman for a year and a half before surgery.
This is what Frank Maloney was like before his transformation
What do hormones do?
Men take the female hormone estrogen and antiandrogens. As a result, muscles decrease, the skin becomes smoother and softer, body fat is distributed “feminine-style,” and body hair decreases (but does not disappear). The appearance becomes more feminine.
Women, on the contrary, take androgens, thanks to which their voice breaks, the silhouette and structure of the body changes, the Adam's apple grows and hair begins to grow on the face and body. In principle, therapy alone can radically change the appearance of such a person, making him visually indistinguishable from an ordinary man. Take a look at New York musician Jamie Wilson before and after 2 years of testosterone therapy.
But the main task of hormones, as physician Fred Ettner explains, is to “rewire” the brain. If previously the patient suffered from a discrepancy between physical and mental gender, then after hormonal therapy he feels “right”.
Only after this long and public preparation is an operation to change the genitals scheduled. According to doctors, at most a third of patients pass through it. The reasons for indecision are different, but for many it is simply unaffordable.
Preparing for vaginoplasty
Needless to say that such an operation is very complex and should be trusted only to the most experienced hands who specialize in such cases? In addition, the rehabilitation period and compliance with all doctor’s instructions for caring for the new organ are extremely important.
A month before vaginal plastic surgery, the patient stops taking hormonal medications. They are usually admitted to the hospital within 24 hours. After general and biochemical blood tests, a general urine test, an electrocardiogram and a chest x-ray, doctors will conclude that the body is ready for surgery. The last meal is 12 hours before. Anesthesia is usually general.
Operation: from man to woman
Changing male genitals into female ones is technically easier and cheaper than vice versa. Such operations are performed much more often and their results are more successful. But according to men on thematic forums, this is still a “painful procedure.”
The operation is performed under general anesthesia and lasts about 4 hours.
The skin is removed from the penis and scrotum, these organs themselves are removed while preserving the nerve branches and blood supply, and a small sensitive area of the head is also preserved to form the clitoris. The urethra (urethra) is shortened and removed separately, located in the same place as in an ordinary woman.
The labia and vagina are formed from the skin of the scrotum and penis. Essentially, the empty “sleeve” of the penis turns inward, like a coat sleeve. To do this, an incision is made in the appropriate place and a cavity is created between the internal organs. To ensure long-term functionality of the vagina, it is usually made 15 cm deep, but the size varies depending on the size of the patient's male genital organs: the larger they are, the more skin can be used. In some vaginoplasty options, intestinal tissue is additionally taken.
Scars after surgery are not visible: they are either hidden in folds of skin or hidden under pubic hair left after hormonal therapy. They say that if the operation is successful, even a gynecologist would not be able to distinguish a transsexual from an ordinary woman.
At the age of 22, Bosnian model Andrej Pejic, who successfully participated in both men's and women's shows, underwent gender reassignment surgery.
Before surgery
And this is what Andreja Pejic’s full-fledged girlfriend looks like now.
However, the reconstructed vagina does not have the sensitivity of the natural one and does not lubricate, at least not in sufficient quantities. When a transsexual woman is very aroused, a little pre-ejaculate may be released - male lubricant, since the male Cooper's glands are not removed from the body.
In the first six months to a year after surgery, a new woman needs to regularly use dilators - dilators for the vaginal opening, which otherwise will simply close. Subsequently, with regular sex, the need for this disappears. And if there is no sexual intercourse, then you must use a dilator at least once a week.
About orgasm
Many former men find it very difficult or impossible to achieve orgasm after gender reassignment surgery. Some manage to “learn” this after many attempts, while others take advantage of the preserved male characteristics.
New York transsexual singer Nomi Ruiz, who had the operation in 2011, told Vogue magazine that at first she felt nothing during sex and began to panic, thinking that after the operation she had completely lost sensitivity. But it turned out that everything depended on the technique and personal skills of the partner.
Nomi Ruiz
Another transgender woman named Jessica told the Truth Speak Project that she has learned to experience orgasms even more intensely than before: now it is female pleasure “with the whole body,” and not just the genitals, and male pleasure thanks to prostate stimulation. It, like the Cooper's glands, is not removed, but it greatly decreases in size due to hormones.
Well, now there is no sperm during orgasms, since after the removal of the scrotum its production stops.
Additional operations
Even before genital surgery, most transgender women get breast implants. Some people do two operations at the same time, but, according to reviews, they experience hellish pain afterwards. In addition, former men often undergo additional surgery on their vocal cords to make their voices higher, remove their Adam’s apple, and do facial plastic surgery.
Gender reassignment - objectively about the main thing, plastic surgeon Anastasia Borisenko
Today, people suffering from transsexuality can be helped to find mental and psychological peace of mind in two ways. The conservative method includes wearing clothes of the gender with which a person identifies himself, a haircut corresponding to the gender, copying behavior patterns, changing gait, etc. In modern society, there is a high percentage of tolerance for belonging to different cultures, religions, as well as the way people prefer to look , what clothes to wear, what music to listen to, how to express thoughts, etc. In this regard, the mentioned method turns out to be life-saving for many people with similar problems. However, in some cases, only gender reassignment surgery can resolve deep internal contradictions. The famous plastic surgeon Anastasia Sergeevna Borisenko answers the questions of the Infoplasty portal.
Anastasia Sergeevna, please tell us briefly what sex reassignment surgery involves?
Anastasia Borisenko: Let's start with what “transsexualism” is - it is a disease that has its own code in the international classification of diseases F 64.0 and manifests itself in the denial of one’s passport gender and the desire to change one’s biological sex. There are female and male forms of transsexualism, and sex change operations are F/M and M/F transformation. Moreover, any surgical stage can be final if it leads to the patient’s social adaptation.
What examinations should the patient undergo before surgery? Is a psychiatrist's report required for a diagnosis of transsexualism?
Anastasia Borisenko: Regardless of the operation and the form of transsexualism, in order to perform an organ-removing operation, the conclusion of a specialized commission is necessary , which establishes a diagnosis of “Transsexualism” and recommends surgical gender reassignment. Otherwise, the surgeon simply does not have the right to perform such operations.
Gender reassignment is not a single operation. How long does reincarnation usually last and how many operations will the patient have to undergo?
Anastasia Borisenko: Not always. According to statistics in Russia, with F/M transfiguration, 30% of patients, after performing the first stage of gender reassignment - mastectomy (removal of the mammary glands), having received a conclusion from a surgical institution and changing their passport at the registry office, adapt perfectly socially and no longer seek other more complex and traumatic operations for F/M transformation. With M/F transformation, there is also a fairly high proportion of patients who, having undergone vaginoplasty and being on lifelong hormonal therapy, also no longer apply: the mammary glands increase to size A-B, and adipose tissue is redistributed in typical female places: hips, tummy. Of course, there are also perfectionists who go through all stages of transformation. So, with F/M transformation - the most complex type of transsexualism in the surgical aspect, patients undergo mastectomy (removal of the mammary glands), hysterectomy (removal of the uterus with appendages), phalloplasty (creation of the penis using one’s own tissues), urethroplasty (creation of the urethra, allowing perform male-type urination in a standing position), scrotoplasty (formation of a neoscrotum), as well as the creation of the “head” of the penis, masculinizing operations on the face (chin prosthesis), body liposuction, etc. With M/F transformation, the main stages are vaginoplasty and mammoplasty (enlargement of the mammary glands), in addition, they often seek corrective operations such as chondrolaryngoplasty (removal of the Adam's apple and plastic surgery of the vocal cords), feminizing operations on the face and body (rhinoplasty, mentoplasty, buttock and thigh augmentation). Between operations there are 4 to 6 months. Very often, at the request of patients and provided there are no contraindications, as well as similar postoperative periods, the stages are combined.
What types of transsexualism exist, and do they affect the treatment plan?
Anastasia Borisenko: They distinguish the nuclear type - this is an acute form, when patients cannot exist in their own sex and are ready to do anything to get rid of their external sexual characteristics, otherwise they are ready for suicide. When a diagnosis of “Transsexualism, nuclear type” is made, surgical gender reassignment is indicated. With the latent type, patients can live their whole lives like this, and if possible they are ready to change their sex.
Have you had to dissuade patients from such a complex operation?
Anastasia Borisenko: These patients are not afraid of anything, they are ready for any difficulties just to get closer to their goal.
What age limits are accepted for gender reassignment in our country? Do they differ greatly from the criteria in other countries?
Anastasia Borisenko: There are no such clear restrictions. Often young patients come, starting from 18 years old, but we also met 56-year-olds. There was even a joke in our department: “Be careful, no one is safe from the transsexualism virus.”
Who more often turns to a surgeon with a desire to correct their gender - men or women?
Anastasia Borisenko: In this matter, there is European statistics of 3:1 (female form to male form) , and in Asian countries it’s the other way around. Those. in our country there are many more female patients who strive to become men.
Do you have any technical secrets that allow you to perform the operation as sparingly as possible?
Anastasia Borisenko: The department where I worked and defended my dissertation on gender reassignment developed standards and principles for surgical gender reassignment. One of them is the principle of “minimum necessary sufficiency” . All operations are performed in stages and have their own order, which eliminates unnecessary trauma and reduces the percentage of complications.
It is known that it is impossible to change a person’s obstetric or chromosomal sex, so surgical correction cannot be considered a complete sex change. To what extent does a man become a woman after surgery and vice versa? Are any additional medical procedures prescribed for a long term or for life required?
Anastasia Borisenko: I had to observe these patients for many years, and every year, when they came for the next surgical stage, they looked more and more like people of the desired gender. Sometimes they even made fun of new residents: “Look, be careful, you might confuse transsexuals.” They were so natural and plausible that one could even doubt them. In addition, of course, they are on lifelong hormone replacement therapy: their voice, skin, and figure change dramatically. In my memory, there were even couples, very pleasant, when the bride’s parents had no idea that their son-in-law was a transsexual, an ex-girlfriend, and they doted on him. I remember how a beautiful girl, a young man who had not yet been operated on, was brought by “her” young man for an operation. As a rule, these people dream so much about their reincarnations and get used to their new social gender role that they always find their soul mates and friends. These are the best family men.
How long does the rehabilitation period last, and what are its main features?
Anastasia Borisenko: The rehabilitation period depends on the volume of the operation and lasts as always after general surgical operations. Of course, if we are talking about microsurgical phalloplasty or vaginoplasty, then the rehabilitation and restrictions are longer. After transplantation, the neophallus muscle begins to contract after 4-6 months, and, accordingly, participation in sexual intercourse becomes possible.
What postoperative complications are most common and can they always be eliminated?
Anastasia Borisenko: The most complex operations are, of course, microsurgical high-tech phalloplasties and urethroplasties. The risk of thrombosis of the transplanted autograft is high. But patients, realizing this, still come, and together we cope with all the difficulties. It is not always easy to reduce breasts from size 4-5 to 0 so that no traces of the operation remain. However, corrective operations ultimately lead to excellent results. And our patients in Russia have even higher expectations for the aesthetic results of operations compared to Europeans. If it is enough for them to go out in tight clothes, then our patients want to be unrecognized on the beach without clothes. And we strive for this.
Is the ability to achieve orgasm preserved after gender reassignment?
Anastasia Borisenko: The most favorable in this regard is considered to be the male type of transsexualism, with M/F transformation. These patients adapt in every sense and experience orgasm. This is due to the peculiarities of the surgical technique when performing vaginoplasty - the main stage in gender reassignment from male to female. With F/M transformation there is no such possibility, but these patients are still happy to have the opportunity to undergo surgery.
Anastasia Borisenko: Are there cases that after some time people become disappointed in their decision to change their sex?
No. That’s why there is a specialized commission that allows us to weed out patients with mental disorders and schizophrenia.
How does social adaptation occur after surgery?
Anastasia Borisenko: After the operation, patients receive documents stating that they underwent an irreversible organ-removing operation for F/M or M/F transformation from female to male or vice versa. Based on this document, they contact the registry office and change their passport. After which everything falls into place for them, they have no problems with employment and organizing a family. And their families are very strong, they understand each other perfectly. Very often they send me their wedding photos and boast about their successes. I know patients from completely different areas: and the head. department, and linguists, and actors - all very interesting, educated people. There is no point in discriminating against them at all: only people who are ignorant of this problem think poorly and do not understand such people.
Anastasia Sergeevna, thank you for such comprehensive and understandable answers.
Operation: from woman to man
Before changing the genitals, a separate operation is performed to remove the uterus and ovaries. The vaginal mucosa is also removed, with the exception of a small area, which will later be useful for urethroplasty (creating a new urethra). The vagina is sutured. And only then do they begin to create the “neophallus”.
Method 1. “Grow” your own penis
Oddly enough, this is possible due to the similar development of female and male genitalia during the embryonic stage. The procedure is called metoidioplasty. The penis (or, more precisely, its micro-similarity) is created from the clitoris, enlarged as a result of hormonal therapy (usually up to 4-5 cm, but occasionally up to 8-10 cm).
The surgeon separates the clitoris from the attachment site so that it retracts and secures the skin at the base so that it does not retract back. Using the remainder of the vaginal mucosa, as well as flaps of the outer wall of the vagina, the urethra is lengthened and its opening is brought to the head of the future neophallus.
The resulting organ is wrapped in a flap of skin from the labia minora. And from the labia majora a scrotum is created, into which prosthetic testicles are implanted.
A neophallus created in this way is capable of erection, since inside the female clitoris there are the same cavernous bodies as in the penis (although much smaller in size) - they ensure that the organ is filled with blood. However, the length of such a neophallus in an extended state is on average only 4.5-5 cm. This makes it incapable of penetration.
Chaz Bono, the only child of singer Cher, born a girl named Chastity, has been officially registered as a man since 2010. In 2012, he admitted to Rolling Stone magazine that he was considering metoidioplasty. However, he still remains transgender and has not decided to undergo surgery.
Cher and Chaz in 2022
Cher and Chastity in 1998
Despite the purely aesthetic disadvantage of the micro-phallus, many transsexuals choose this particular method because, firstly, it is simpler and much cheaper than the one we will discuss below, it is carried out in one stage and takes 3-5 hours. And secondly, “everything is different” here, so the operation has a much less traumatic effect and a low percentage of possible complications.
