first british person to have gender reassignment surgery

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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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Gender-affirming care from the 1950s in britain through the lens of roberta cowell.

Roberta Elizabeth Marshall Cowell (1918-2011) was the frist known British trans woman to undergo gender-affirming surgery in 1951. Sammie Casper-Mensing looks at Roberta Cowell and what has happened since the 1950s.

Roberta Cowell in France, 1954. Source: Digital Transgender Archive, available here .

Being trans in Britain is not easy. A university student in 2018 shared that they were “laughed at, ridiculed, and became the butt of jokes that normally gender me as a woman. This has been constant since day one.” [1] Today trans people in Britain deal with social stigma and difficulty navigating and receiving gender-affirming care. But, as highlighted by the life and experiences of Roberta Cowell, the first known British trans woman to have gender-affirming surgery, being trans in the United Kingdom has never been easy. Writing in 1954, Cowell noted that “Many people were extremely kind and pleasant to me, but an equal number would go out of their way to treat me as though I were an unpleasant, perverted freak. They had no hesitation in making their attitude abundantly clear, perhaps because they considered that I had no feelings at all, perhaps because they wanted to hurt me as much as possible.” [2] Roberta Cowell transitioned more than 70 years ago, and despite her fame and improvements in the broader National Health System, trans people in Britain still experience harassment from the public and barriers to accessing gender-affirming care.

In 2018, Chaka Bachmann and Becca Gooch published the results of their survey of over 5,000 lesbian, gay, bisexual, and transgender individuals in Britain. The study produced by Stonewall, a UK-based charity that advocates for LGBTQ+ rights, aimed to assess the quality of life for LGBTQ+ British people. The Stonewall research study, which I will be referencing throughout this analysis, surveyed over 5,000 lesbian, gay, bisexual, and transgender individuals about their lives in Britain. [3]

In comparing Roberta Cowell’s life as a trans woman to the transgender individuals surveyed in the 2018 Stonewall trans report, it becomes clear that the barriers to gender-affirming care in Roberta Cowell’s life are still prevalent amongst transgender people today. These barriers transcend time and result in emotional distress for many in the trans community due to financial hurdles, social expectations, and mental health concerns.

Financial burden

One obstacle Cowell faced was the financial burden of gender-affirming care. Roberta Cowell underwent a variety of physical changes during the process of her transition, including hormone treatment, sex reassignment surgery, and plastic surgery to modify her facial features. [4] It took several years to complete these changes, and Roberta expressed her concern about the financial toll of the process, describing that “I would have to have money enough to pay for surgery and treatment, and also to start over again in a different environment when I finally made the changeover from trousers to skirts. I would also have to allow for an indefinite period during which I would be unable to work.” [5] This illustrates the financial complexity of receiving gender-affirming care as the medical treatment is only one of many factors that contribute to the cost of this process.

These financial concerns continue today, even as the majority of countries in Europe have universal healthcare. The Stonewall report found that nearly half of the trans respondents indicated that they don’t have the financial means to afford medical intervention, either because of the cost of treatment or travel expenses associated with reaching the medical facilities. [6]

Availability

The respondents of the Stonewall study also noted the difficulties that arose when attempting to find availability for gender-affirming care. Almost half of the respondents reported wanting to undergo some sort of medical intervention but were unable to because long wait times prevented them from accessing treatment. [7] One of the respondents in the Stonewall study explained “I am currently on the waiting list to start hormones and so far, my first appointment has been pushed back by nine months, added onto the nine months I have already waited. They have given me false hope and told me that my appointment would be in the next month, then continued to say the same thing month after month.” [8]

Although Roberta Cowell did not explicitly regard wait times as being an obstacle to her gender-affirming care, she did remark that she did not have an appointment for her gender-affirming surgery until nine months after she was legally registered as a woman on her birth certificate. [9] Whether this waiting period was a choice or not is hard to say, as Roberta does not reveal the purpose of this timing. The decision may have been hers or could have been the result of other obstacles, such as cost or an inability to immediately move to a new environment post-surgery.

In her memoir, Cowell admitted that she was hesitant to make the transition. She understood the social challenges this could bring to her life. There was the possibility of being labeled an outcast, or not being able to successfully present as a woman. This apprehension is apparent in her writing, as Cowell admits that “I had no desire to become a freak…There was the possibility that when it was all over I might not be socially acceptable as a woman. There was the possibility that I might become an invalid.” [10] Roberta never mentioned discrimination in her autobiography, but her fear of being labeled as a “freak” [11] illustrates the implicit doubt that loomed in her mind surrounding being accepted by society. Many of the participants in the Stonewall study faced similar concerns, although these concerns oftentimes revolved around a fear of discrimination or familial rejection. In the 2018 study, two in five trans people in Britain reported that they altered the way they dressed because they feared discrimination or harassment. [12] One of these respondents described the hostility he has faced as a trans man, sharing that “I get shouted at every single time I leave my house and threatened at least once a week. I try to closet myself from my family because I’m so close to getting kicked out. I can’t access hormone replacement therapy without going private. I’m disabled. It’s a lot to deal with and I’m crumbling under the stress but I consider myself a warrior. But really, something needs to change.” [13] Additionally, two in five trans who wanted to utilize medical interventions reported that they have not done so for fear of disrupting their family life. [14]

Though “coming out” as trans and seeking gender-affirming care has been and can be challenging, a common experience among trans folks–from Cowell to the participants of the Stonewall study–is how necessary the transition is. Cowell described her pre-transition life as an “inky-black depression” [15] and went as far as to write that if she did not seem to be getting better, “then I considered I should be justified in taking my own life.” [16] Lack of support from family and the inability to access gender-affirming care puts trans people in a difficult position regarding their mental health and well-being. According to HPCLive, transgender youth who were able to receive gender-affirming care were 73% less likely to experience suicidality in comparison to youths who did not receive gender-affirming interventions. [17] A Stonewall study respondent emphasized this point, affirming that “We need more services available for trans people, so it gets easier to get hormones and surgery. Not sure I'd even be alive right now if I hadn't transitioned.” [18] Additionally, 1 in 5 transgender and non-binary youth attempted suicide between 2021 and 2022. [19] Another participant in the Stonewall study shared his struggles with suicidal ideation, revealing that “Coming out as transgender was the hardest thing I've ever done, and having to explain it over and over again to medical professionals that were supposed to be helping me, almost made me end my life. There needs to be better support for us.” [20] Accessing gender-affirming care is not a want, but a need for transgender individuals, yet these services are still a luxury reserved for those who have the time and money to jump through the hoops of the medical care system. 

Despite the overwhelming evidence showing that gender-affirming care saves lives, anti-trans legislation and rhetoric have become commonplace in the United Kingdom. During an annual conference of the Conservative Party, U.K. Prime Minister Rishi Sunak expressed various anti-transgender ideologies. Sunak stated, “We shouldn't get bullied into believing that people can be any sex they want to be — they can't” and went on to say “A man is a man and a woman is a woman. That's just common sense.” [21] Many of these anti-trans ideas are also being translated into policies. One such policy prohibits minors and non-binary people from changing their gender in official government documents. [22] Additionally, the U.K. government has begun drafting guidelines that would require transgender students to use gendered facilities that align with their sex assigned at birth, as well as encouraging teachers to out transgender students to their parents. [23] The National Health Service also issued an advisory in September of 2023, saying that schools should not allow students to socially transition without parental consent. [24] It’s ironic that the National Health Service would advise schools to police a student's gender expression when research and survey studies clearly show that forcing trans people to present as their sex assigned at birth can lead to severe depression and suicidal ideation. This increase in public rhetoric against transgender people is certainly disheartening for many transgender folks in the U.K. One respondent from the Stonewall study acknowledged that “ Even just five years ago it was not safe for me to come out as trans, the pace of change has been amazing. Unfortunately, there now appears to be a backlash against that progress in the last year with hate from the media against trans increasing disturbingly in the last six months. This increasing transphobia is accelerating and is causing acute anxiety in my daily life.” [25] As anti-trans speech and agendas push their way back into mainstream media, transgender people in the U.K. face uncertainty about their rights being upheld and confront the additional challenge of deciding if, and when it is safe to be open about their identity.

After comparing the individuals in the Stonewall study to Roberta Cowell, it becomes clear that many of the obstacles faced by Roberta Cowell in the 1950s are still prevalent today for trans people in Britain. Barriers to gender-affirming care, including financial constraints, accessibility of care, long wait times, and fear of discrimination continue to make necessary life changes unavailable to trans people. These barriers lead to extreme mental health concerns for many transgender individuals, putting countless lives at stake. In analyzing the historical and current-day issues regarding gender-affirming care, it is clear that national legislation must be implemented to preserve and provide access to transgender healthcare. We cannot continue to be at a standstill for transgender rights, and we certainly cannot afford to go backward. Let's make this world into a place where all trans people can live as their true selves, one step at a time.

Bibliography

Bachmann, Chaka L, and Becca Gooch. “LGBT in Britain - Trans Report.” Stonewall, April 24, 2020. https://www.stonewall.org.uk/lgbt-britain-trans-report.

Cowell, Alan. “Overlooked No More: Roberta Cowell, Trans Trailblazer, Pilot and Auto Racer.” The New York Times, June 5, 2020. https://www.nytimes.com/2020/06/05/obituaries/roberta-cowell-overlooked.html.

Factora, James. “The U.K. Is One of the Worst Places in Europe to Be Trans, New Report Finds.” Them, November 2, 2023. https://www.them.us/story/uk-worst-places-in-europe-trans-new-report-finds#intcid=_them-bottom-recirc_5697e6aa-ecd3-4488-a8d2-36086042aa7c_text2vec1.

Factora, James. “U.K. Prime Minister Rishi Sunak Platforms Anti-Trans Talking Points in a Speech to Tories.” Them, October 5, 2023. https://www.them.us/story/uk-prime-minister-anti-trans-comments.

Fisher, John Hayes. Sex Changes that Made History . Academic Video Online. no. 1009, British

Broadcasting Corporation, 2015. https://bridge.primo.exlibrisgroup.com/permalink/01BRC_INST/es0tl/cdi_alexanderstreet_marcxml_AcademicVideoOnlinePremiumUnitedStatesASP3366432_marc

Grossi, Giuliana. “Suicide Risk Reduces 73% in Transgender, Nonbinary Youths with Gender-Affirming Care.” HCP Live, August 23, 2022. https://www.hcplive.com/view/suicide-risk-reduces-73-transgender-nonbinary-youths-gender-affirming-care.

Paley, Amit. “2022 National Survey on LGBTQ Youth Mental Health.” The Trevor Project, 2022. https://www.thetrevorproject.org/survey-2022/.

Roberta, Cowell E. Roberta Cowell’s Story: An Autobiography. British Book Centre, Inc., New York, 1954

Staveley-Wadham, Rose. “‘The Most Talked of Woman in England’ – Roberta Cowell in Our Newspapers.” The British Newspaper Archive Blog | Amazing finds and news from over 300 years of historical newspapers, June 13, 2022. https://blog.britishnewspaperarchive.co.uk/2022/06/13/roberta-cowell-in-our-newspapers.

[1] Taylor, qtd. in Chaka Bachmann, Becca Gooch, “LGBT in Britain - Trans Report,” Stonewall (2020), 12.

[2] Roberta Cowell, “Roberta Cowell’s Story: An Autobiography,” British Book Centre, Inc. (1954), 52.

[3] Bachmann, Gooch, “LGBT In Britain,” 5.

[4] Cowell, “Roberta Cowell’s Story.”

[5] Cowell, “Roberta Cowell’s Story,” 45.

[6] Bachmann, Gooch, “LGBT In Britain,” 16.

[7] Bachmann, Gooch, “LGBT In Britain,” 16.

[8] Jo, qtd. in Bachmann, Gooch, “LGBT In Britain,” 17.

[9] Cowell, “Roberta Cowell’s Story,” 54.

[10] Cowell, “Roberta Cowell’s Story,” 45.

[11] Cowell, “Roberta Cowell’s Story,” 44.

[12] Bachmann, Gooch, “LGBT In Britain,” 7.

[13] Stevie, qtd. In Bachmann, Gooch, “LGBT In Britain,” 14.

[14] Bachmann, Gooch, “LGBT In Britain,” 14.

[15] Cowell, “Roberta Cowell’s Story,” 59.

[16] Cowell, “Roberta Cowell’s Story,” 41.

[17] Giuliana Grossi, “Suicide Risk Reduces 73% in Transgender, Nonbinary Youths with Gender-Affirming Care,” HCP Live (2022).

[18] Sebatstain, qtd. in Bachmann, Gooch, “LGBT In Britain,” 16.

[19] Amit Paley, “2022 National Survey on LGBTQ Youth Mental Health,” The Trevor Project (2022).

[20] Henry, qtd. in Bachmann, Gooch, “LGBT In Britain,” 13.

[21] James Factora, “U.K. Prime Minister Rishi Sunak Platforms Anti-Trans Talking Points in a Speech to Tories,” Them (2023).

[22] James Factora, “The U.K. Is One of the Worst Places in Europe to Be Trans, New Report Finds.” Them (2023).

[23] Factora, “One of the Worst Places”

[24] Factora, “One of the Worst Places”

[25] Willow, qtd. in Bachmann, Gooch, “LGBT In Britain,” 22.

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Nov 12, 2018

Written By Sophie Nevrkla

The history of transgender rights in the UK

The battle over gender rights and identity has taken on huge significance in the past few years. But our understanding of transgender issues has a long and complex history, which is helping shape the present legal landscape.

In 1951, Roberta Cowell made history as the first known British trans woman to undergo gender-reassignment surgery. ‘Betty’ Cowell, formerly ‘Bob’, had previously been a racing driver and a Spitfire pilot in the Second World War, happily married with two children. After telling her wife about her plans to transition, her wife severed all contact, and Roberta’s children—Anne, six and Diana, four—grew up without any knowledge of their missing father. Roberta Cowell died in 2011 in her flat in west London, alone, with just half a dozen people at her funeral.

Since Cowell’s transition, knowledge and awareness of transgender people has grown by a significant margin. Gradually, the word ‘transsexual’ has been phased out in favour of ‘transgender’, a more inclusive term to describe someone who doesn’t identify with the gender they have been assigned at birth, but may not have had gender reassignment surgery.

Since 2000, the legal rights of trans people have begun to be entrenched more seriously in UK law. Since Caitlin Jenner came out as a woman in April 2015, an even brighter media spotlight has been placed on the trans community, particularly on trans women, and celebrity activists such as Laverne Cox and Munroe Bergdorf have worked to promote the cause and link it to wider struggles for equality happening in the UK, the US and across the world.

In 1963, fashion model April Ashley (who transitioned to become physically female in 1960) and Arthur Corbett married; by 1963, the marriage had broken down. When the marriage was eventually annulled in 1970, it was on the basis that the court considered Ashley to be male, though Corbett had been aware of Ashley’s transition at the time they wed. What came to be known as the Corbett v Corbett divorce case established the legal precedent that a person’s sex couldn’t legally be changed from that which is assigned at birth. From Corbett v Corbett onwards, members of the trans community were confined to an awkward space, unable to inhabit fully their genders and bodies in the eyes of UK law or society.

As the 20th century progressed, more and more trans people begin to take cases to court on the grounds of discrimination in the workplace and wider society. In 1986, trans man Mark Rees brought a case to the European Court of Human Rights, complaining that UK law prevented him from gaining legal status that recognised him as male. Though he didn’t win his case, the court discussed at length the legal marginalisation of the trans community—a theme that would be revisited in Goodwin v United Kingdom (2002).

The workplace, too, provided a space for discrimination. In 1996, the milestone case P v S and Cornwall County Council saw that a woman, named as P in court proceedings, had been dismissed from her workplace after informing employers that she was undergoing gender-reassignment surgery. After taking her employers to an employment tribunal, the court ruled that she was wrongfully dismissed; it became the first piece of case law to prevent discrimination in employment or vocational education on the basis of someone being trans. These subtle shifts in the 1980s and 1990s set the stage for more changes during the course of the 21st century. The early 2000s saw the slow beginnings of the legislative codification of trans rights under successive Labour governments.

In this more liberal climate, Goodwin v United Kingdom (2002) provided landmark change for the trans community. Christine Goodwin had faced sexual harassment at work during and subsequent to her gender reassignment. She complained to the court that due to her male legal status, she was forced to pay National Insurance contributions until the age of 65 rather than 60. Goodwin also stated that because her NI number must remain the same under UK law, her employer was able to find out that she had worked for the company previously under a different name and gender, which resulted in more humiliation and harassment. Further to this, the court heard that another woman, referred to as ‘I’ in court proceedings, had been refused a place on a nursing course after she refused to present her birth certificate. 

The individuals protested the lack of legal recognition of trans people, their gender and their post-operative sex, and their poor treatment with respect to employment, social security and pensions, as well as their inability to get married as either male or female. The European Court of Human Rights ruled in 2002 that UK law violated the right of transgender people to a private life, and the right to marry and start a family. Judges ruled that the UK Government should help trans people by issuing new birth certificates to reflect their gender identity, and permit their marriage to an individual of the opposite gender. Here, the Government was held directly accountable for the lack of protections for the trans community. For the first time, the lawmakers were forced to provide for the oppressed minority, recognising their gender identity and right to the same freedoms as other individuals.

This UK Government’s loss of the Goodwin case resulted in the introduction of the Gender Recognition Act in 2004, perhaps the most significant and wide-reaching piece of trans-focused legislation. Under the Act, the government awarded trans people full legal gender recognition and allowed them to acquire new birth certificates. Rather than being denied or dismissed, trans people had their personal identity recognised here for the first time in UK law. These moves towards acceptance culminated in the Equality Act of 2010, which, among other things, banned discrimination in the workplace and wider society on the basis of gender reassignment.

Despite these steps, UK law still reflects a limited understanding of the nuances that exist within transgender identity. Birth certificates and passports in the UK still only allow for the options ‘male’ or ‘female’, meaning that non-binary individuals aren’t recognised by law. Other western states are leading the way: Ontario became the first Canadian province to offer non-binary options on birth certificates in March 2018, denoted by an ‘X’. Though Gendered Intelligence was founded in the UK in 2008 to spread understanding of gender diversity, it’s only over the course of the last few years that the concerns of nonbinary individuals have been included in the wider conversation about trans rights. Perhaps enacting legislation to promote the ‘they’, rather than simply the ‘he’ or ‘she’, will be the next big shift over the following decades, as our perception of ‘gender’ changes and develops.

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Harold Delf Gillies (1882-1960)

Harold Delf Gillies performed one of the first sexual reassignment surgeries, termed gender affirmation surgeries as of 2022, on record in 1946 in London, England. He also practiced modern plastic surgery and helped distinguish it as a new branch of medicine in London, England, starting in the early 1900s. Gillies’s work focused initially on facial reconstructive surgery, particularly during both World War I and World War II. Gillies created newer and more efficient techniques that later became standard procedures for reconstructive and cosmetic surgeries. Gillies, along with two members in his practice, standardized over 11,000 techniques, and beginning in 1946, he performed one of the first successful phalloplasties on a transgender man, where he formed a new penis from the patient’s existing skin and tissue.

Gillies was born in Dunedin, New Zealand, on 17 June 1882 to Emily Street and Robert Gillies. He was the youngest of eight children and his family spent most of his childhood in rural areas where he fished and rode horses. Gillies’s father died days before his fourth birthday. Shortly after, his mother moved the family to Auckland, New Zealand. In 1888, he moved to England to attend a preparatory school for four years. He returned to Auckland briefly before attending Whanganui Collegiate School in Whanganui, New Zealand, for his secondary education from 1895 to 1900 where he competed in cricket, golf, and rowing. Selim Gebran and Arthur Nam, surgeons who wrote a biographical article about Gillies, wrote how Gillies was also an avid painter and artist and that his artistic work helped him grow as a plastic surgeon because of his eye for aesthetics.

Gillies participated in various collegiate sports and won numerous athletic awards. After he graduated from Whanganui Collegiate School in 1900, he studied at Gonville and Caius College, Cambridge University, in Cambridge, England. There, he won blue, a designation earned by university athletes for competition at the highest level, for rowing in the Boat Race 1904, an annual side-by-side rowing race between the Universities of Oxford and Cambridge along the River Thames. Gillies also won blue for golf in 1903, 1904, and 1905 and continued competing in golf at the amateur level for the first two decades of his medical career.

Gillies studied medicine at Cambridge University, starting in 1901 and graduating in 1904. He then completed his clinical training at St Bartholomew's Hospital in London, England. Once Gillies completed his training, he received his medical degree and became a practicing physician. Andrew Bamji, a consultant physician and archivist of Queen Mary’s Hospital in London, England, notes that Gillies was recognized as the best surgeon who worked regularly at St Bartholomew’s Hospital in his time. By 1910, Gillies became a Fellow of the Royal Colleges of Surgeons, or FRCS, a professional qualification to practice as a senior surgeon in Ireland and the UK. Gillies worked as an assistant to an ears, nose, and throat surgeon, Milsom Rees, at St Bartholomew’s Hospital. On 9 November 1911 Gillies married Kathleen Margaret Jackson. The couple had four children together between 1912 and 1920.

When the World War I began in 1914, Gillies was still working alongside Rees, but by 1915, he volunteered and served with the Royal Army Medical Corps, RAMC. He was stationed in Wimereux, France, as a Surgeon General, the highest rank for a military medical officer and the most senior uniformed medical officer in the British Armed Forces. As part of the Army Medical Services, the RAMC coordinated large-scale solutions in response to the varied and numerous traumatic injuries. While posted to Wimereux, France, Gillies met Auguste Charles Valadier, a dentist of French and American origin who pioneered maxillofacial surgery, which includes operating on teeth, jawbones, and soft tissues of the face. Gillies then visited Paris, France, to meet Hippolyte Morestin, a surgeon treating injuries of the face and jaw in France. While Gillies watched, assisted, and worked alongside Valadier and Morestin, he learned surgical techniques that he later implemented in reconstructing facial structures on patients who sustained facial injuries in trench warfare. During his time in France, Gillies noted there was no available treatment specialized enough to help the wounded soldiers seen by Valadier and Morestin, something that changed when he returned to England in the following years.

In 1915, Gillies moved, under orders, to England where he continually petitioned the War Office to have a specialized unit for reconstructive surgery. On 11 January 1916, at the Cambridge Military Hospital, Aldershot, England, he began commanding one of the first plastic surgical units. After the first day of the major battle of the Somme, 1 July 1916, it was clear that the units at the hospital did not have enough room nor beds to treat the soldiers in need. Gillies lobbied and gained support from the head of army surgery for a much larger facility to treat all facial injuries. According to Bamji, Gillies argued that if they could consolidate the treatment of these types of wounds and had specialized surgeons to treat them, they would be able to make scientific advances and treat patients more effectively because of the experience and knowledge they would gain from collaborating.

In June 1917, Gillies's vision came to life when The Queen’s Hospital, called Queen Mary’s Hospital as of 2022, opened with over a thousand beds available on-site and dozens of surgeons devoted to improving the techniques of reconstructive surgical practices. Gillies worked closely with two anesthetists, or physicians who administer anesthetic drugs that induce insensitivity to pain, who assisted in surgeries as well as recovery to make the process less painful for the patients. One of them, Rubens Wade, primarily worked with patients who needed to be seated during the operation, usually if there was injury to the base of the head or back of neck. The other, Ivan Magill, pioneered endotracheal anesthesia, where the insertion of a plastic tube into the trachea creates an artificial extension through which the patient can breathe and the physician can administer anesthetics. This kept the equipment used to anesthetize the patients clear of the operating table and did not interfere with surgeons' aseptic techniques.

In 1920, two years after the war ended, Gillies became a Commander of the British Empire, a British order of chivalry, rewarding contributions to the arts and sciences nationally or regionally. In the same year, Gillies also published his first book, Plastic Surgery of the Face , a training manual for surgeons wishing to specialize in the area. The book illustrates techniques he employed, such as skin grafts, body tubes, and prosthetics. It also reminds the reader that the intensive surgeries were only possible because of antiseptic practices and anesthesia. Gillies included successful results as well as his results that were not immediate or varied in success. Doing so provided the progression of the techniques he tested and showed why he abandoned some while others became a standard procedure. He explained that the treatment timelines could range from six months to three years and some patients sustained permanent disabilities. Gillies’s first book also includes contributions from many colleagues including Wade, one of his anesthetists from The Queen’s Hospital, who wrote a passage regarding anesthetics and anesthesiology.

During and after the World War I, between 1917 and 1925, Gillies and his fellow surgeons at the hospital performed over 11,000 surgeries on around 5,000 patients. In 2015, Cheka R. Spencer wrote about how Gillies saw the importance of addressing both functional and cosmetic aspects of these treatments. A soldier who regained the ability to eat on his own and speak while having the least number of missing features or scars was able to reenter society more easily. Therefore, Gillies placed a great emphasis on rehabilitation of the injured men and ensured that by creating activities and classes, akin to modern physical therapy. Gillies checked on his patients regularly and took photographs with most of his patients for them to keep as mementos. After the World War I, Gillies exclusively practiced plastic surgery, one of the first surgeons to do so. He continued to work in the units he built until they closed in early 1929. The hospital then underwent renovations to become a general hospital named Queen Mary’s Hospital that opened the following year.

In early 1930, Gillies returned to St Bartholomew’s and became the sole plastic surgeon handling any ear, nose, and throat cases that required his specialty. David Napier Matthews, a contemporary of Gillies and fellow plastic surgeon practicing in London, England, remarks in his article, "Gillies: Mastermind of Modern Plastic Surgery," that as Gillies practiced, some physicians and journalists criticized him for performing purely cosmetic surgeries and named him a charlatan, or someone who was a fraud and swindled others out of their money. Matthews writes how Gillies, along with some of his associates, continuously argued back that purely cosmetic surgeries required craft and skill and that they were taking their patients’ worries about their appearance seriously. Throughout that time, Gillies continued to travel, assist in hospitals without plastic surgery units, and train surgeons in the UK.

In 1930, King George V knighted Gillies, boosting his status when dealing with other leaders in hospitals and government. He continued in private practice with three colleagues who were also specialists in plastic surgery. Gillies spent his time between World War I and World War II traveling to other countries as a consultant and instructor. He gave lectures at universities and hospitals and traveled to perform surgeries, particularly where local surgeons and staff saw a case that needed additional assistance.

In 1939, at the outbreak of World War II, Gillies and his colleagues were again called into action and stationed at four of the largest plastic surgery units, training, and leading teams to treat the wounded soldiers. Gillies organized numerous trainings for him and his colleagues to teach other surgeons and nurses the necessary skills. He continued his own work at Rooksdown House, part of the Park Prewett Hospital in Basingstoke, England, where he expanded his scope because of the vast number of injuries and the small number surgeons who had the necessary expertise to carry out the specialized techniques. Gillies led and assisted with surgeries on the pubic region and primarily saw blast wounds resulting in the need of reconstruction of penises.

In 1944, Gillies suggested forming a British Association of Plastic Surgeons, which would bring together the plastic surgeons of Great Britain so they could share results of new techniques used to better serve the public. Though it took years to create, it held its first meeting after World War II on 20 November 1946, and Gillies acted as chairman. The Association became affiliated with the Royal College of Surgeons of England and in 1948, it began to publish its own journal, British Journal of Plastic Surgery .

In 1946, Gillies used the knowledge he gained while operating on the genitalia of wounded soldiers and began the four-year process of one of the first sexual reassignment surgeries, called gender affirmation surgery as of 2022. He completed the phalloplasty by constructing an entirely new penis from skin and tissue with grafts. A graft is a piece of tissue a physician takes from elsewhere on a patient’s body to attach somewhere else, either to reconstruct an area with damage or create a new tissue structure. The phalloplasty included thirteen surgeries that took place in five stages. Gillies started the process by creating an extension to the existing urethra with a tube of tissue, which he then surrounded by a pedicle. Gillies was one of the first surgeons to use pedicles, a skin graft that surgeons leave, often temporarily, attached to its original site on the body to keep the existing blood flow connected so that the graft tissue does not undergo damage from lack of blood flow. For his first phalloplasty, he used skin from the pelvic area and along the groin. Once Gillies wrapped the pedicle around the urethral extension, he connected the adjacent blood vessels to fully attach the new urethra to the natural urethral opening. After adjusting the base flap of the pedicle and removing the excess tissue, Gillies shaped the constructed penis to better resemble a typical penis.

The patient, Laurence Michael Dillon, was a transgender British doctor, and the procedure that Gillies performed has not changed significantly as of 2022. Dillon is considered one of the first transsexuals, called a transgender person as of 2022, who elected to have sexual reassignment surgery or gender affirmation surgery. A transgender person is someone whose gender identity differs from the sex they were assigned at birth. In 1939, Dillon sought out medical treatment from George Foss, a doctor who had been experimenting with testosterone, a male hormone, to aid in heavy menstrual bleeding. Eventually, the testosterone had changed Dillon’s body to a point where those who met him assumed that he was male.

In the early 1940s, Dillon passed out from low blood sugar and, while recovering in the Bristol Royal Infirmary in Bristol, England, he met a plastic surgeon who was able to perform a double mastectomy, the removal of all breast tissue, on Dillon. He also gave Dillon a doctor’s note that allowed him to change his birth certificate and legal name. The surgeon then put Dillon in contact with Gillies. The two met in Basingstoke, England, in 1943, but Gillies was unable to perform the phalloplasty surgery immediately, as he was busy with treating soldiers from World War II. However, Brandy Schillace, a historian of medicine, wrote in Scientific American that Gillies took on the case with enthusiasm. Gillies gave Dillon a diagnosis of hypospadias, misplacement of the urethral opening, to cover up why Dillon was seeing him and to give a reason for recovery times. Gillies performed the phalloplasty on Dillon through multiple surgeries stretching from 1946 to 1949.

In 1957, Gillies published two books, The Principles and Art of Plastic Surgery, volumes I and II , in collaboration with David Ralph Millard, Jr., a plastic surgeon from the United States who studied under him. The book was an exploration of Gillies’s life and time as a plastic surgeon, ranging from his beginnings to the two World Wars he worked through, and what techniques he learned, created, and taught. Other chapters of the book include approaches to and techniques used in hand surgery, as well as treatments for lymphedema, a condition where extra lymph fluid builds up in tissues and causes swelling, congenital deformities, skin tumors and genital lesions. A review of the volumes in the Journal of the American Medical Association explains that Gillies’s books may be called textbooks but that they are engaging like fairytales when reading, while still being of historical and practical importance to the field of plastic surgery.

Gillies made many contributions to the field of plastic surgery, particularly in facial reconstructive surgery and what is called gender affirmation surgery as of 2022. His books became required reading at universities and medical programs globally, and the techniques he discovered and practiced during World War I and World War II have set the standard for many procedures in the discipline. The Danish and Norwegian governments decorated Gillies for his aid in both wars, and he became an Honorary Fellow of the Royal Australasian College of Surgeons, the American College of Surgeons, and the Royal Society of Medicine, London. In 2005, the association of plastic surgeons, which Gillies built, changed its name to the British Association of Plastic, Reconstructive and Aesthetic Surgeons, or BAPRAS. The renaming of the association brought with it an understanding that the discipline had grown and changed, continuing to advance education but adding a second emphasis on understanding the modern practice.

Gillies’s wife died on 14 May 1957, and in the same year, he married Marjorie Ethel Clayton, who he had known for many years as his surgical assistant in London, England.

Gillies died at The London Clinic in London, England, on 10 September 1960 after suffering a mild stroke while performing a major operation on a damaged leg the previous month.

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Remembering Dora Richter, One of the First Women to Receive Gender-Affirming Surgery

By Samantha Riedel

To celebrate Women’s History Month, we’re telling the stories of transgender women who reshaped history. Below, we recount the life of Dora Richter, one of the first people to receive gender confirmation surgery, and whose life was cut brutally short during the Nazi uprising.

When people discuss milestone moments in transgender history, they often point to the first known sexual “reassignment” surgeries. Some will talk about Christine Jorgensen , who became the first trans celebrity in the West to receive a vaginoplasty in the 1950s, or dive earlier back to discuss Lili Elbe’s fatal womb transplant in 1932. (The latter was the subject of the now-infamous, heavily falsified drama The Danish Girl , starring Eddie Redmayne).

But in reality, neither of these famous names were truly the first to receive gender-affirming surgery. That distinction likely belongs to another woman, whose name might have been lost to time if her murderers had their wish. And the reason she’s not a household name is the same reason trans people are still under attack by the far right today.

Dora Richter was born in 1891 on a farm somewhere in the Ore Mountains, or Erzgebirge, on the border of what’s now Germany and the Czech Republic. Little is known about her childhood except that her dysphoria seems to have been intense and began early; she was so insistent on her femininity that her parents allowed her to live as a girl and, according to surviving medical records, she attempted to remove her penis with a tourniquet at least once when she was six.

Upon reaching adulthood, Richter — who by then had begun going by the name Dӧrchen, or “Dora” for short — left her rural home and traveled more than 200 kilometers north to Berlin, where she took up seasonal work as a “male” waiter in various upper-class hotels, living as herself in the off-season. This double life was not without peril, however, even in the permissive Weimar Republic era ; Dora was repeatedly arrested for wearing dresses in public and made to serve her time in male prisons.

Finally, after one such arrest around 1920, a more understanding judge released Richter into the care of Dr. Magnus Hirschfeld, who promised her employment at his Institut fur Sexualwissenchaft , or Insitute for Sexual Science — the first modern research institute for queer and transgender health, nestled in Berlin’s idyllic Tiergarten park. Hirschfeld, himself a gay Jewish man, had in the previous two decades established himself as one of the leading researchers of gay and transgender identities, pioneering research alongside surgeons and psychologists like Eugen Steinach and Arthur Kronfeld, many of whom came to work as residents or visiting fellows after the Institute’s founding.

At the Institute, Dora — now granted an official pass to present as a woman in public — worked as a housemaid while the medical team assessed her needs, the most immediate being an orchiectomy, which she obtained via a surgeon named Dr. Erwin Gohrbandt in 1922. Steinach’s work during the 1910s on testicles and testosterone , which helped identify how hormones influence sexuality and the human body (and to which Hirschfeld referred some of his own patients), helped Hirschfeld build on his theories about how a lack of testosterone might alter a “male” body’s fat distribution; Dora’s surgery provided a chance to study the effects. Sure enough, as the Institute’s forensic sexologist Felix Abraham later wrote, in the years after her first surgery, Dora’s “body became fuller, the growth of beard diminished, breast growth became noticeable and also the fat pad of the pelvis... took on more feminine forms.”

Over the next decade, Hirschfeld’s surgical team refined their theories and techniques, while Dora established herself as part of the team of trans women who made up the essential housekeeping staff; they included women like painter Toni Ebel and her longtime lover Charlotte Charlaque, who worked as the Institute’s receptionist. Together, they were human test subjects for the first trial runs of modern vaginoplasty surgery, brave and desperate enough to give their bodies to science for a chance at a new life. By the dawn of the 1930s, the women’s patience bore fruit, and the first full reassignment surgeries began. Although the timeline remains unclear on when each procedure took place, it’s believed that Dora received one of the Institute’s first full reassignments in 1931, when she was 40 years old.

The penile inversion technique used today was still decades away from being developed, and Dora’s surgery was a rudimentary two-part affair: a penectomy performer by Dr. Levy-Lenz, followed by the construction of a neovagina by Dr. Gohrbandt. Still, Richter’s vaginoplasty and those of her friends and fellow workers at the Institute were an extraordinary success, and attracted other European trans women to Berlin, including Lili Elbe.

1931 was also the year that Magnus Hirschfeld left the Institute on a lecture tour of Asia and North America, never to return to Germany. In the decade Dora had waited for her new life to begin, the Nazi cancer had metastasized within the Weimar Republic, and Hitler’s official rise to power in the 1932 Reichstag elections marked the Institute’s death knell; Hirschfeld himself had been labeled “the most dangerous Jew in Germany” by the new führer and attacked several times on the street. The work of a gay Socialist Jew could never be suffered to survive — much less the degenerates he enabled.

On May 6, 1933 , Nazi storm troopers and gangs of nationalist students descended on the Tiergarten and laid waste to the Institute, dragging the building’s inhabitants into the street to be shot and destroying the books and files within. (Toni and Charlotte escaped to Czechoslovakia, but that’s another story.) It’s not clear precisely what happened to Dora — whether she was murdered on the spot, or sent to a camp and killed later. Perhaps, a few days later, she bore witness to Joseph Goebbels’ speech as the fascists set ablaze more of the Institute’s research along with heaps of Jewish and Communist literature. Whatever the truth, all historical traces of Dora’s life end with the Institute’s death.

The assault on the Institute was a twofold slaughter — the Nazis killed not only the people who called it home, but the physical evidence that showed that they’d lived, and how; notes from Abraham’s lectures and the case files of Levy-Lenz, photos of Dora and her surgeries and her smile, anything that could have been valuable to the next queer generation — any proof that there’d been a place for trans women to live and heal in peace — was snuffed out. After all, the goal was to make sure this was the last queer generation.

Jennifer Culp

Abby Monteil

Samantha Allen

Kazuma Hashimoto

Naturally, there are still queer and trans people, because we have always existed throughout history and always will. Hirschfeld and several of his contemporaries lived on in exile, passing on their knowledge as best they could. Their insights eventually led to other breakthroughs in trans surgical science, like Harry Benjamin’s pioneering surgical procedures in the U.S. in the ‘40s, ‘50s and ‘60s. But these small blessings are shadows of what might have been if not for the right-wing violence that killed so many people and hid their stories from the world for decades.

Unlike Lili Elbe, whose diary survived her, little firsthand information remains of Dora beyond what her doctors wrote about her in medical journals. A 1999 German dramedy about Hirschfeld’s life, The Einstein of Sex, heavily edits details of Richter’s life for the sake of plot convenience; there are no blockbusters bearing her name. Through decades of work of LGBTQ+ historians, we can presume to understand the arc of her life, but we don’t know Dora, because a few people didn’t want her to live and tell her story. They found Dora, and everyone like her, monstrous, her joy a blight, and her desires poisonous to the general public.

That base hatred, and its bigoted conception of trans people writ large, is what drives anti-trans attacks today — from Greg Abbott’s witch hunt against parents of trans kids in Texas to LGBTQ+ book bans and Marjorie Taylor Green saying that trans people must be “ beat[en] into the ground ” on InfoWars . It’s familiar rhetoric, one that echoed on the streets of Berlin a century ago; today, we are all the most dangerous transsexuals in America.

After receiving surgery that helped relieve the intense dysphoria she’d faced since childhood, Dora Richter was cut down just as her life was beginning to blossom. In essence, that’s what right-wing ideologues and politicians want when they criminalize hormone therapy and surgeries: the end of trans people in public life. More than a hundred years after Dora first walked through the threshold of what would be her final home, trans people in the U.S. and around the world are facing down another wave of fascist violence from people who think if they crush enough trans people, they can kill the whole idea of being trans forever.

But in the end, nobody could truly kill the memory of little Dӧrchen, the mountain girl whose dream of a better life helped those of so many others come true. So what hope do they have against all of us?

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By Orion Rummler, the 19th

By Mathew Rodriguez

By Amanda Becker, The 19th

A Pioneering Approach to Gender Affirming Surgery From a World Leader in the Field

Miroslav Djordjevic, MD, PhD, an internationally renowned surgeon and a leading authority on surgery for transgender individuals, is developing a procedure to match two patients undergoing transgender surgery—one male-to-female, the other female-to-male—and transfer the genitalia between these live donors in a one-stage procedure instead of discarding them as is done now.

For years, the main challenge associated with sex reassignment surgery (SRS) has been the ability to provide patients with genitalia that is not only fully functional but also aesthetically acceptable. Miroslav Djordjevic, MD, PhD , an internationally renowned surgeon and a leading authority on surgery for transgender individuals, believes he has the answer.

His idea is matching two patients undergoing transgender surgery—one male-to-female, the other female-to-male—and transferring the genitalia between these live donors in a one-stage procedure instead of discarding them as is done now.

“This will result in a huge improvement over what we currently offer patients,” says Dr. Djordjevic, who joined Mount Sinai Health System in June 2019 as a Professor of Urology at the Icahn School of Medicine at Mount Sinai and a urogenital reconstructive surgeon at the Mount Sinai Center for Transgender Medicine and Surgery . “We are striving to find a way to use all genital organs that are planned for removal in transition surgery to improve the lives of others who request this surgery and enable them to lead a normal life.”

Dr. Djordjevic says he is ready to proceed with transplantation now that he has developed the necessary special surgical techniques.

His confidence in this new approach is the result of nearly three decades of expertise and innovation in SRS and urogenital reconstructive surgery, which includes 600 male-to-female vaginoplasties, 900 female-to-male metoidioplasties, 300 female-to-male phalloplasties, and the co-development of a penile disassembly technique for epispadias repair. He also performed his first uterus transplant in 2017 and the second-ever testicular transplant in December 2019 at the Belgrade Center for Genital Reconstructive Surgery. Dr. Djordjevic is also a Professor of Urology and Surgery at the School of Medicine at the University of Belgrade in Serbia.

“Through the procedures I have done, I have demonstrated to the world that it is possible to successfully perform uterine and penile transplantation,” says Dr. Djordjevic, who joined Mount Sinai from the Belgrade Center for Genital Reconstructive Surgery in Serbia, where he was one of the few urologists in the world whose scope of expertise encompassed treatment of all anomalies of the genital system regardless of sex or age.

Dr. Djordjevic joined Mount Sinai to develop his procedures, which would include finding the right pairing of donor and candidate and leading surgeons in performing concurrent transplant surgeries.

Although there have been five successful penile transplantations performed since the introduction of the procedure in 2006, Dr. Djordjevic notes that these cases involved trauma or removal of the penis due to oncological reasons. In all cases, patients had retained the corpora cavernosa and some degree of tissue, which facilitated transplantation.

His approach is novel in that it will not only involve transplantation of the entire penis with the corpora cavernosa and their crura but also determining the best position for fixation. He also expects to transplant a penis from a male to a female body.

“We are striving to find a way to use all genital organs that are planned for removal in transition surgery to improve the lives of others who request this surgery and enable them to lead a normal life.” -Miroslav Djordjevic, MD, PhD

“This is a far more complex procedure,” he explains. “I am continuing to refine my technique through cadaveric and micrometric study, and I plan to publish papers that detail the approach so that other surgeons can offer it to their patients.” For example, he plans to publish a cadaveric study in 2021 on penile transplantation.

If his technique proves successful, Dr. Djordjevic believes it will offer considerable advantages over existing modalities for creating male genitals, such as metoidioplasty or a full phalloplasty involving musculocutaneous latissimus dorsi (MLD). For one, penile transplantation with the corpora cavernosa would result in improved sexual function and sensation, and it would reduce the 50 percent risk of complications among patients who have undergone creation of the urethra from oral mucosa or surrounding material.

“Current surgical treatments do not enable us to provide a urethra with surrounding spongiosa as is present in normal penile anatomy,” Dr. Djordjevic says. “A penile transplant would enable the usage of existing urethra and corpora cavernosa, which promises an almost ideal solution for patients looking for male genitalia because there is a good channel for voiding and good erectile tissue for normal sexual function.”

Dr. Djordjevic says advances in therapeutics could address the risks involved in transplantation of reproductive organs, specifically the effects of postoperative immunosuppressant therapy among patients. But he has also developed strategies for mitigating risk in the meantime.

For example, he notes that the first successful organ transplantation was made possible by the fact that the patients involved were monozygotic twins. The testicular transplant he performed also involved monozygotic twins, and no immunosuppressive therapy was required.

Three decades of experience

male-to-female vaginoplasties performed

female-to-male metoidioplasties performed

female-to-male phalloplasties performed

“What I will be looking for is a possible genetic match between two candidates that would minimize the need to administer immunosuppressants, or a candidate who has undergone transplant surgery and is doing well on immunosuppressant therapy because the risk of rejection will be much lower,” he says.

To facilitate identification of candidates who match these criteria, Dr. Djordjevic envisions a worldwide network or registry of patients seeking SRS. In the meantime, he continues to develop his technique, optimistic that transplantation of genitalia will eventually become standard of care in the same way that hand and face transplants are becoming routine.

“Ultimately, I would like to see us reach the point where a patient is able to conceive and deliver a baby after transplantation of a uterus and ovaries, or has a functioning, anatomically acceptable penis with normal erection and voiding,” he says. “By pioneering these procedures, we are one step closer to enabling people to live the lives they want to live.”

Miroslav Djordjevic, MD, PhD

Professor of Urology and a urogenital reconstructive surgeon at the Mount Sinai Center for Transgender Medicine and Surgery

New Hampshire teen one of the youngest to have gender reassignment surgery

by Kenneth Craig

A high school student in New Hampshire is being called a 'pioneer' after becoming one of the youngest people to undergo gender reassignment surgery. But her long and challenging journey began when she was just a child.

At 17 years old, Emily Tressa finally feels fully herself. Last month, she became one of the youngest patients in the country to undergo gender reassignment surgery. Emily says, "For me, it feels almost like I'm finally fully complete now."

Emily was born a boy, but says she always knew she was a girl. "I used to look in the mirror and be like, is it only me? Am I the only one that feels like this? That I'm trapped in the wrong body?"

As a young child, she changed her name and started dressing as a girl. First at home and later at school. With her parents support, and under the care of doctors and psychologists, Emily eventually started taking hormone blockers to prevent male puberty and then estrogen to develop a female body.

Dr. Jess Ting is director of surgery at Mount Sinai Center for Transgender Medicine and Surgery. He says, "Emily is a pioneer because she is at the forefront of this new generation of young kids, adolescents who are realizing what they are much earlier in life and are able to transition even before puberty."

Dr. Ting performed Emily’s reassignment surgery at Mount Sinai Hospital in New York. He created female anatomy that is fully functional.

His team has completed 12-hundred various operations. Dr. Ting considers it a life saving surgery, given the alarming rates of attempted suicide among transgender youth.

Emily's mother, Linda, says her only fear is what would happen if she tried to hold Emily back. “We saw the unhappy boy and we saw the happy girl. And we knew the statistics and we knew we'd much rather have an alive daughter than a dead son.”

Emily has become an activist and uses social media to let others know they're not alone. She says, "I don't want people to feel like that. It's OK to be who you are and just present to the world as yourself."

Experts say there are still many barriers for transgender people when it comes to accessing appropriate care and that contributes to long-term health problems. Recently, the American College of Physicians published new guidelines for doctors to help them better understand medical issues specific to this population.

• Coffee House

The grim reality of gender reassignment

• 13 November 2021, 7:00am

Madeleine Kearns

Lisa Littman, a doctor and researcher, recently surveyed ‘detransitioners’ — people who thought they were transgender then changed their minds. The majority, 55 per cent, ‘felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition.’ Sadly, it seems, their identity issues were more complicated than simply being trans. Many of these individuals are now living with the consequences of medical treatments that failed to help their gender issues and may have caused permanent physical and psychological damage.

There is no objective diagnosis for transgenderism, and the evidence supporting hormonal and surgical ‘reassignment’ as an effective remedy for gender dysphoria (the feeling of being at odds with one’s sex) can be sketchy. Meanwhile, there is plenty — not least the risk of infertility and loss of sexual function — to suggest that so-called gender reassignment is very often a bad idea.

In the mid 20th century, sexologists and surgeons began to experiment with ‘sex change’ interventions for a tiny number of (mostly male) patients who, for complicated psychological reasons, wanted to live as the opposite sex. Of course, no one can literally change their sex. For humans, sex is determined at conception; it is evident even in fossilised bones discovered thousands of years after a person’s death. Still, with the help of medical technology, a patient could undergo experimental hormone treatments and surgical procedures, enabling him to more closely resemble a woman. Back then, the debate wasn’t whether ‘trans women are women’ but whether these medical interventions really helped alleviate gender-related confusion and distress.

Some reckoned they did. In 1965, Johns Hopkins University carried out sex change surgery, the first American academic institution to do so. The experiment was discontinued in 1979, under psychiatrist-in-chief Paul McHugh, who had major concerns about the treatment’s efficacy. 

‘In those days we weren’t thinking that we should do something because somebody would like us to do it,’ McHugh tells me. ‘We would be doing it because we were told that much in their life would improve.’

The evidence supporting hormonal and surgical ‘reassignment’ as an effective remedy for gender dysphoria can be sketchy

But when researchers at Hopkins followed up with the patients who had had the surgery, the evidence of improvement was not always clear cut. The researchers decided to stop until someone could show conclusively that the surgeries were beneficial to the patients. 

Transgender activists focus on the treatments’ satisfaction rates, insisting that regret is rare. According to data collected by the World Professional Association for Transgender Health (WPATH), that would appear to be true. However, focusing on patient satisfaction risks losing sight of the bigger picture of long-term outcomes.

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The burden of proof, after all, ought to be on those wishing to conduct an experiment. So far, results here don’t impress. In 2004, the Guardian commissioned research from Birmingham University which looked at more than 100 follow-up studies of post-operative transsexuals. Researchers found no conclusive evidence that gender reassignment is beneficial for patients. The trials were often flawed, with results skewed in favour of physical rather than therapeutic interventions. Potential complications of hormones and genital surgery, including deep vein thrombosis and incontinence, were also not always properly taken into account. Some studies failed to track patients.

A robust follow-up is a 2011 study by the Karolinska Institute in Sweden, which examined the outcomes of more than 300 patients over three decades. Its findings starkly contradict the activist narrative. Around ten years after surgery is when a post-operative transsexual person’s mental health can begin to most rapidly deteriorate.   Post-operative transsexuals also appeared to be at a higher risk of killing themselves than comparable non-transgender peers. 

As Ryan Anderson, author of When Harry Became Sally: Responding to the Transgender Moment has documented , a more recent 2014 research review conducted by Hayes Inc. gave studies of gender reassignment treatments its lowest rating for quality. It said that: ‘Evidence regarding quality of life and function in male-to-female adults was very sparse.’ In 2016, under the Obama administration,  a low evidence base was cited  as a reason not to cover sex reassignment surgeries as part of the government’s Medicare plans. It was noted that ‘many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up.’

Some people swear by gender reassignment treatments, claiming their lives have been enriched and even saved. This is great for them, yet standards of care ought not to be based solely on subjective testimonies. Despite the increased social acceptance and availability of hormones and surgery, the transgender population has been found to be overrepresented in homelessness, suicidal ideation, unemployment, prostitution, and HIV contraction. There is very little reason to think that more hormones and surgeries will do anything to change that.

When Johns Hopkins reintroduced its gender reassignment surgeries in 2017, it was plastic surgeons who were likely to be rubbing their hands, not the psychiatrists who continued their work helping patients suffering from gender-related distress with non-surgical treatments. 

American hospitals have large financial incentives to carry out these procedures. In the United States, the sex reassignment surgery market is set to reach a market value of more than $1.5 billion (£1 billion) by 2026. Some operations cost up to $53,700 (£40,000); performing 50 of these a year brings in $2.7 million (£2 million). It’s easy to see how, with such a business model, one might prioritise customer satisfaction over long-term patient welfare. Meanwhile, in the UK, gender identity referrals are rising. In 2018, there were 2,519 referrals for young people, shooting up from 97 in 2009.

Historically, the population seeking transgender surgeries has been primarily male-to-female. However, what with the recent rise in females presenting at gender clinics, this will likely change — bringing new challenges. Removing a penis is easier than creating one. One increasingly popular method of ‘phalloplasty’ involves grafting the arm for skin, fat, nerves, arteries and veins then wrapping it round a tube to construct a pseudo-penis. If all goes to plan, this ‘neophallus’ can be used for urination and penetrative sex. An erection of sorts can then be achieved through a prosthetic pump. There’s a lot that can go wrong.

Some phalloplasty patients’ testimonies are disturbing, to put it mildly. Patients complain of pain, bleeding and tissue damage. Wounds, as well as disfigured and non-functional phalluses, are also reported. But to win a malpractice case, a patient must prove that the doctor breached informed consent or the standard of care, all while complying with a statute of limitations of as little as two years. It’s a high bar.

In order to give informed consent to gender reassignment, the information a patient is provided with has to be accurate and clear. But is that always the case? In 2020, the NHS changed its website on puberty blockers from saying that the effects were ‘considered to be fully reversible’ and ‘can usually be stopped at any time,’ to the admission that ‘little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria’ and that ‘it is not known what the psychological effects may be.’

Jazz Jennings, a trans icon and teen star of the American reality show I Am Jazz , says she has ‘no regrets’ about taking puberty blockers, cross sex hormones, and undergoing vaginoplasty surgery all before her 18th birthday. However, Jazz’s surgeon Dr Marci Bowers — the first transgender woman to perform gender surgeries — recently expressed doubts about such treatment. Bowers  told American journalist Abigail Shrier that ‘there was naïveté on the part of paediatric endocrinologists’ who advised early intervention with puberty blockers ‘thinking that just this magic can happen, that surgeons can do anything.’ The idea of blocking puberty ‘sounded good in the very beginning,’ but there are serious downsides. 

As Susie Green, CEO of Mermaids — Britain’s controversial child-sex change charity — explained about her son-turned-daughter: puberty blockers can stunt penile growth. Later on, this can make the surgical task of ‘penile inversion’ much trickier. Bowers also worries about her young patients’ ‘reproductive rights…[and] sexual health later and ability to find intimacy.’

Maybe some of these doubts help explain why the Karolinska Hospital in Sweden has ceased to prescribe puberty blockers and cross sex hormones to under 18s outside of research settings. Or why Finland’s national gender program is now  actively encouraging therapeutic treatment. Or why the UK’s high court found it unlikely that a child could give informed consent to be prescribed puberty-blocking drugs and mandated court approval in certain situations for clinicians wishing to prescribe them.

In September, the Court of Appeal overturned this decision, citing Gillick competency, from the landmark case allowing minors to independently access contraception should a clinician declare them sufficiently mature. There’s a certain logic to that. If a minor can consent to sex, why not to sex change? 

Yet, once again, there’s an overemphasis on autonomy here. And it may well be that short-term satisfaction is being focused on at the expense of objective evidence and a patient’s long-term interests. Conveniently, such an approach allows clinicians to experiment on patients without the burden of responsibility.

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High court to decide if children can consent to gender reassignment

A landmark test case to establish whether children can give informed consent to medical treatment for gender reassignment begins in the high court this week.

Lawyers acting for Susan Evans, a former psychiatric nurse at the Tavistock and Portman NHS foundation trust, which runs the UK’s only NHS gender identity development service (Gids), and “Mrs A”, the mother of an autistic 15-year-old girl who is on the Gids waiting list, will file papers to commence proceedings in a judicial review brought against the trust and NHS England.

At the heart of the case is the provision of puberty blockers and cross-sex hormones to young people who wish to transition or are considering doing so.

“We are essentially seeking to say that the provision at the Tavistock for young people up to the age of 18 is illegal because there isn’t valid consent,” said Paul Conrathe, a solicitor with Sinclairslaw, which is representing Evans and the mother.

Providing this treatment – puberty blocking and cross-sex hormones – to any young person who wants them requires, he argues, “a specific order of the court on a case-by-case basis. [The treatment] cannot be delivered as a matter of general approach”. Conrathe suggested the legal action would be “pressing the case of Gillick to its breaking point”.

In 1983, Victoria Gillick, a Roman Catholic mother of 10, challenged the right of doctors to prescribe contraception to girls under the age of 16 without their parents’ permission or even knowledge. Two years later the House of Lords affirmed the doctors’ right, ruling that “the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to fully understand what is proposed”.

But Conrathe said the “Gillick competence” test should not apply when it comes to gender reassignment: “The issue is whether the young person is of sufficient maturity and capacity to understand the consequences of their actions. We say it is a leap too far to think that Gillick as a judgment could apply to this type of scenario, where a young person is being offered a treatment with lifelong consequences when they are at a stage of emotional and mental vulnerability. It simply doesn’t compute, and therefore whatever medical professionals say is consent is not valid in law.”

He acknowledged that the case would break new ground. “I don’t think there has been any case that has tested a policy or practice in this way. There may have been the odd case that has come up but not one that has challenged a health service for making this service available.”

According to her crowdfunding page on the CrowdJustice website, Evans raised concerns about the treatment approach of the Tavistock with its clinical management team.

“The alarm bells began ringing for me when a colleague at the weekly team clinical meeting said that they had seen a young person four times and they were now recommending them for a referral to the endocrinology department to commence hormone therapy,” she writes.

Her actions triggered an internal inquiry in 2004 but Evans left the trust as she felt “nothing really changed”. Her husband, Marcus, resigned as a governor of the trust last February, accusing its management of having an “overvalued belief” in the expertise of the Gids that was “used to dismiss challenge and examination”.

On the CrowdJustice website, Mrs A, the mother of the autistic teenager, said she worried that “no one (let alone my daughter) understands the risks and therefore cannot ensure informed consent is obtained”.

NHS England said it would not comment ahead of the hearing. A spokeswoman for the Tavistock and Portman NHS trust said: “It is not appropriate for us to comment in detail in advance of any proposed legal proceedings. The Gids is one of the longest-established services of its type in the world, with an international reputation for being cautious and considered. Our clinical interventions are laid out in nationally set service specifications. NHS England monitor our service very closely. The service has a high level of reported satisfaction and was rated good by the Care Quality Commission.”

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Number of British people seeking to change their gender soars

Lgbt activists warn that increasingly long waiting times for people seeking gender reassignment can be dangerous, with trans people already reporting much higher rates of suicide and depression, article bookmarked.

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The number of people undertaking treatment to change their gender has increased dramatically in the UK, with some having to wait years for treatment as a result.

A Freedom of Information Act undertaken by The Guardian revealed that referrals to all 14 gender identity clinics (GICs) in the UK had increased, with some clinics reporting surges in patient numbers of several hundred per cent.

At Charing Cross in London, the oldest and largest adult clinic, the number of referrals has almost quadrupled in 10 years, from 498 in 2006-07 to 1,892 in 2015-16.

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Another clinic in Nottingham reported a 28-fold increase in referrals in eight years, from 30 in 2008 to 850 in 2015. It expected this to increase to more than 1,000 referrals during 2016.

The Tavistock clinic, the only centre for children and adolescents in England, has experienced referral increases of around 50 per cent each year since 2010-11, with an unprecedented increase of 100 per cent in the past year, up from 697 to 1,398 referrals.

James Barrett, a consultant psychiatrist at the Charing Cross clinic, said of the rise: “It obviously can’t continue like that forever because we’d be treating everyone in the country, but there isn’t any sign of that levelling off”.

Average waiting times for a first appointment at a gender identity clinic are said to be nine months for adults and half that for children, with one in six adults waiting more than a year for treatment.

Experts at the GIC in Leeds estimated that a patient referred to the service at the end of October 2015 could wait four years before their first consultation with a medical specialist.

In pictures: Pride in London 2016

Louie Stafford, the trans programme coordinator for the LGBT Foundation, was referred to the Leeds clinic in 2012 and waited two years for his first appointment.

Mr Stafford warns such long waiting times are dangerous for trans people, who already report much higher rates of depression, and have higher rates of suicide than the rest of the population.

He told The Guardian: “You’re referred from your GP, there is no contact with any specialists or clinicians until your first appointment at the gender identity clinic. People are completely on their own, sometimes for up to three years, dealing with issues around gender that are potentially life-threatening … It’s not surprising that people get desperate in that timeframe.”

There are just over 15,000 people who are gender identity patients in the UK – roughly 12,700 adults and 2,700 adolescents or children. Trans activists suggest there could be tens of thousands more considering medical intervention – which includes hormone treatments or surgery - leading to concerns that the NHS would struggle to meet demand.

• Read more Military removes ‘man’ from 19 job titles in aim for gender-neutrality

In 2015-16, the NHS in England put an additional £4.4m towards funding gender identity services.

Will Huxter, the chair of the NHS England gender task and finish group, said: “We’re keen to get waiting times down as quickly as we possibly can.”

Mr Huxter said part of the problem is that there isn’t a specialised training strand that sees medical professionals emerge from training ready to work in the gender identity clinics.

“We are working with Health Education England and the GMC [General Medical Council] about how we could improve that for the future,” he said.

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Medindia » Articles » Procedure » Gender-Reassignment Surgery: Everything You Need to Know

Gender-Reassignment Surgery: Everything You Need to Know

• Indications

Non-Surgical Procedures

• Surgical Procedures

Risks in Non-Surgical and Surgical Procedures

• Whom to consult?
• Pre-Op Considerations
• Post-Op Considerations

Impact on Mental Health

• Cost of the Surgery

Gender reassignment surgery, also known as gender-affirming surgery, is a medical procedure or series of procedures aimed at altering an individual's physical appearance and sexual characteristics to align with their gender identity.

In Simple words, it can be defined as the alteration of a person's physical sex characteristics by surgery in order to match the person’s gender identity

This transformative process is often pursued by transgender individuals, as well as some cisgender and non-binary individuals. It involves various surgical interventions to modify primary and secondary sexual characteristics, thereby affirming an individual's gender identity( 1 ✔ ✔ Trusted Source Sex Reassignment Surgery in the Female-to-Male Transsexual Go to source ).

Alternative Names for Gender-Affirming Surgery

• Gender reassignment surgery (GRS)
• Gender-affirmation surgery
• Gender confirmation surgery
• Sex reassignment surgery

Who Can Get Gender Reassignment Surgery?

Transgender individuals.

Transgender individuals are those whose gender identity differs from the sex they were assigned at birth. Many transgender individuals experience gender dysphoria, a condition characterized by distress or discomfort caused by a misalignment between their gender identity and physical body. Gender reassignment surgery is often sought by transgender individuals as part of their transition journey to alleviate gender dysphoria and align their physical appearance with their gender identity.

Trans Women: Assigned male at birth but identify and live as women. Trans women may pursue feminizing surgeries such as vaginoplasty (creation of a vagina), breast augmentation, facial feminization surgery, and voice feminization surgery to affirm their gender identity.

Trans Men: Assigned female at birth but identify and live as men. Trans men may undergo masculinizing surgeries such as chest reconstruction (removal of breast tissue), hysterectomy (removal of the uterus), and phalloplasty or metoidioplasty (creation of a penis) to align their bodies with their gender identity.

Intersex Individuals

Intersex is a term used to describe individuals who are born with variations in their biological sex characteristics (chromosomes, gonads (testes/ovaries), reproductive organs (prostate/uterus) or external genitalia (penis/clitoris)) that do not fit typical definitions of male or female..

Intersex Individuals with Gender Dysphoria: While intersex individuals can be transgender if their gender identity does not match the sex they were raised or assigned as, some intersex individuals may experience distress or discomfort, known as gender dysphoria , due to a misalignment between their gender identity and assigned sex characteristics, and seek gender-affirming surgery to align their physical appearance with their gender identity( 2 ✔ ✔ Trusted Source Gender Affirmation Surgeries Go to source ).

Drag Performers

Drag performers are individuals who utilize clothing, makeup, and performance art to explore and celebrate gender expression. They are typically associated with a gender different from their own. These performers engage in drag for various reasons, including self-expression, artistic exploration, and entertainment purposes.

While some drag performers may identify as transgender or non-binary and use drag as a form of self-expression or exploration of their gender identity, others may identify as cisgender and engage in drag purely for entertainment or artistic expression.

Drag Queens and Drag Kings : Drag queens are typically male individuals who dress in feminine attire and adopt exaggerated female personas for performance. Drag kings, on the other hand, present as male or masculine while performing. While some drag performers may identify as transgender and may ultimately pursue gender-affirming surgeries, the act of performing drag does not inherently imply a desire for surgical intervention.

Individuals with Klinefelter Syndrome

Klinefelter syndrome is a chromosomal condition in which individuals are born with an extra X chromosome (XXY), resulting in differences in sexual development and often leading to infertility and other physical characteristics such as tall stature, reduced muscle mass, and gynecomastia (enlarged breast tissue in males)( 4 ✔ ✔ Trusted Source Klinefelter syndrome Go to source ).

While not directly related to transgender identity, some individuals with Klinefelter syndrome may experience gender dysphoria and seek gender-affirming treatments, including surgery. These individuals may undergo procedures to modify their physical characteristics to better align with their gender identity and alleviate distress associated with gender dysphoria.

Non-Binary Individuals

"Non-binary" is a term used to describe individuals whose gender identity does not exclusively align with the categories of male or female. This is a deeply personal and internal sense of one's own gender. Non-binary individuals may identify as both, neither, a combination of both, or as a gender entirely different from male or female.

Bigenital Operation: Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Some non-binary individuals may opt for these surgeries to achieve a physical presentation that aligns with their gender identity while maintaining aspects of their original anatomy. These surgeries cater to the diverse spectrum of gender identities and expressions and provide options for individuals who do not fit within the traditional binary understanding of gender.

"Cisgender" is a term used to describe individuals whose gender identity aligns with the sex they were assigned at birth. In other words, someone who is cisgender identifies as the gender typically associated with the biological sex they were born with. For example, a person who was assigned female at birth and identifies as a woman is considered cisgender. The term "cisgender" is often used in contrast to "transgender," which describes individuals whose gender identity differs from the sex they were assigned at birth

While gender dysphoria is often associated with transgender individuals, cisgender people can also experience it. In some cases, cisgender individuals with severe gender dysphoria may seek gender-affirming surgeries to alleviate their distress and bring their physical appearance into alignment with their gender identity. These surgeries are typically pursued after extensive evaluation and therapy, and they can significantly improve the mental health and well-being of individuals experiencing gender dysphoria.

Is Gender Dysphoria the only Reason for Gender Reassignment Surgery?

No, not only gender dysphoric individuals seek gender reassignment surgery. While gender dysphoria is a common reason why individuals pursue gender-affirming surgeries, it's not the only factor. Some people may choose to undergo these surgeries for reasons beyond alleviating distress associated with gender dysphoria.

For example, individuals with intersex variations may seek gender-affirming surgeries to align their physical appearance with their gender identity, even if they do not experience gender dysphoria. Similarly, some non-binary individuals may opt for surgeries to achieve a physical presentation that better aligns with their gender identity, regardless of whether they experience gender dysphoria.

Furthermore, some cisgender individuals may also undergo gender-affirming surgeries for reasons related to body dysmorphia or dissatisfaction with their physical appearance, rather than gender dysphoria.

Ultimately, the decision to pursue gender reassignment surgery is deeply personal and can be influenced by a variety of factors beyond gender dysphoria alone.

Hormonal injections is the only available non-surgical procedure.It isa form of hormone replacement therapy (HRT) commonly used in transgender healthcare to induce and maintain desired physical changes consistent with an individual's gender identity.

These injections typically involve the administration of testosterone for transmasculine individuals (female-to-male, or FtM) and estrogen for transfeminine individuals (male-to-female, or MtF).

Testosterone Injections (for Transmasculine Individuals)

Purpose : Testosterone injections are administered to induce masculine changes, such as increased facial and body hair growth, deepening of the voice, muscle development, and redistribution of body fat.

Types of Testosterone : There are different formulations of testosterone available for injection, including testosterone cypionate, testosterone enanthate, and testosterone undecanoate.

Administration : Testosterone injections are typically administered intramuscularly (into the muscle) in either the gluteal (buttocks) or deltoid (upper arm) muscle.

Dosage and Frequency : The dosage and frequency of testosterone injections can vary depending on individual factors such as age, weight, hormone levels, and desired changes. Typically, injections are administered every one to two weeks to maintain stable testosterone levels in the body.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant markers is essential to ensure the safety and effectiveness of testosterone therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Estrogen Injections (for Transfeminine Individuals)

Purpose : Estrogen injections are administered to induce feminine changes, such as breastdevelopment, redistribution of body fat, softening of the skin, and reduction of muscle mass.

Types of Estrogen : The most common form of estrogen used in injections is estradiol valerate.

Administration : Estrogen injections are typically administered intramuscularly, similar to testosterone injections, in the gluteal or deltoid muscle.

Dosage and Frequency : The dosage and frequency of estrogen injections vary depending on individual factors and treatment goals. Typically, injections are administered every one to two weeks.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant parameters is crucial for ensuring the safety and effectiveness of estrogen therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Time Frame of Use of Hormonal Injections

Initiation : Hormonal injections are often initiated after a thorough evaluation by healthcare providers, including discussions about treatment goals, potential risks and benefits, and informed consent. The timing of initiation may vary depending on individual factors such as age, readiness for treatment, and presence of any underlying health conditions.

Duration : Hormonal injections are typically used as part of long-term hormone replacement therapy to maintain desired physical changes and support overall well-being. The duration of hormone therapy may vary from individual to individual and often continues indefinitely, especially for those who desire ongoing maintenance of gender-affirming changes.

Discontinuation : In some cases, individuals may choose to discontinue hormonal injections for various reasons, such as personal preference, changes in health status, or the achievement of desired physical changes. It's essential for individuals to discuss any plans to discontinue hormone therapy with their healthcare provider to ensure proper management of any potential effects or complications.

Surgical Procedures: Gender Affirming Surgery

These surgical procedures play vital roles in gender affirmation for transgender individuals, aligning their physical appearance with their gender identity( 3 ✔ ✔ Trusted Source Gender Confirmation Surgery Go to source ).

Male-to-Female (MtF) Transitions:

• Tracheal Shave: This procedure reduces the prominence of the Adam's apple, a typically male characteristic, to create a smoother, more feminine neck contour.
• Breast Augmentation: Transfeminine individuals undergo breast augmentation to develop fuller, more feminine breast contours. Breast implants are placed behind breast tissue or chest muscle to achieve the desired size and shape.
• Facial Feminization Surgery (FFS): FFS encompasses various surgical procedures aimed at feminizing facial features. Techniques may include forehead contouring, rhinoplasty , cheek augmentation, chin and jaw reshaping, tracheal shave, lip augmentation, and hairline lowering to achieve a more traditionally feminine appearance.
• Male-to-Female Genital Sex Reassignment (Vaginoplasty): This surgical procedure constructs female genitalia for transfeminine individuals seeking alignment with their gender identity. Techniques involve using penile and scrotal tissue to create the vaginal canal, labia, and clitoral hood. The procedure may also include the creation of a neurovascular neoclitoris, providing both aesthetic and functional female genitalia in one operation.

Female-to-Male (FtM) Transitions:

• Hysterectomy and Oophorectomy: This procedure involves the removal of the uterus and ovaries, reducing the production of female hormones (estrogen and progesterone).
• Vaginectomy: Vaginectomy is the surgical removal of the vaginal canal, aligning the physical anatomy with a masculine appearance.
• Chest Reconstruction (Top Surgery): FtM individuals undergo chest reconstruction surgery to remove breast tissue and reshape the chest to achieve a more masculine contour. Techniques include subcutaneous mastectomy or double mastectomy with or without nipple reconstruction.
• Female-to-Male Genital Sex Reassignment (Phalloplasty): Phalloplasty is a surgical procedure to construct a phallus for FtM individuals seeking male genitalia. The radial forearm flap method is commonly used, involving tissue grafting from the forearm to create the phallus and urethra for standing urination. This procedure can be performed concurrently with a hysterectomy/vaginectomy to complete the transition process. A scrotum with testicular implants may be constructed in a second stage.

These surgical interventions are integral to gender affirmation for transgender individuals, helping align their physical appearance with their gender identity and alleviating gender dysphoria. Each procedure is tailored to the individual's unique needs and goals, reflecting the diversity of experiences within the transgender community.

Risks in Hormone Therapies

• Cardiovascular Risks : Hormone replacement therapy (HRT) may increase the risk of cardiovascular events such as heart attacks and strokes, especially in older individuals or those with pre-existing cardiovascular conditions.
• Thromboembolic Events : Estrogen therapy, particularly in forms like oral contraceptives, may elevate the risk of blood clots, leading to thromboembolic events such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Endocrine Disruption : Hormone therapies can disrupt the body's natural hormone balance, leading to potential complications such as metabolic disturbances, including insulin resistance and dyslipidemia.
• Breast Cancer Risk : Some studies suggest that long-term use of hormone replacement therapy, especially estrogen-only formulations, may increase the risk of breast cancer in transgender women.
• Liver Dysfunction : Hormone therapies, particularly oral estrogen formulations, may affect liver function and increase the risk of liver disease or dysfunction.

Risks in Gender Reassignment Surgeries

• Surgical Complications : As with any surgical procedure, gender reassignment surgeries carry risks such as infection, bleeding , anesthesia complications, and adverse reactions to medications.
• Scarring : Gender-affirming surgeries, especially those involving breast augmentation, chest reconstruction, or genital reconstruction, may result in visible scarring that could impact body image and self-esteem.
• Loss of Sensation : Surgeries involving genital reconstruction, such as vaginoplasty or phalloplasty, may result in loss of sensation or altered sensation in the genital region, affecting sexual function and satisfaction.
• Functional Complications : Some individuals may experience functional complications post-surgery, such as urinary incontinence , erectile dysfunction, or difficulties with sexual arousal or orgasm.
• Psychological Impact : Gender reassignment surgeries can have profound psychological effects, including adjustment difficulties, post-operative depression, and challenges related to body image and identity.

Guidance on Surgical Procedures: Whom to Consult?

When contemplating gender reassignment surgery, it's essential for individuals to consult with a team of experienced healthcare providers specializing in transgender care. Here's whom to consider consulting:

1. Gender-Affirming Surgeons

Gender-affirming surgeons specialize in performing gender reassignment surgeries and have expertise in various surgical techniques, including chest surgery (for both masculinization and feminization procedures), genital reconstruction, and facial feminization surgery. These surgeons can provide comprehensive information about the surgical options available, discuss the potential risks and benefits, and guide individuals through the decision-making process.

2. Endocrinologists

Endocrinologists play a crucial role in managing hormone therapy for transgender individuals. They can provide guidance on hormone replacement therapy (HRT), including the use of testosterone for transmasculine individuals and estrogen for transfeminine individuals. Endocrinologists can assess hormone levels, monitor any potential side effects, and adjust hormone regimens as needed to support the transition process.

3. Mental Health Professionals

Mental health professionals, such as psychologists, psychiatrists, or licensed therapists, offer invaluable support throughout the gender transition journey. They can assist individuals in exploring their gender identity, coping with gender dysphoria, and addressing any psychological concerns or challenges that may arise before, during, or after surgery. Mental health professionals also play a role in assessing readiness for surgery and providing pre- and post-operative counseling and support.

4. Primary Care Physicians

Primary care physicians are essential members of the healthcare team and can provide general medical care, coordinate referrals to specialists, and monitor overall health and well-being. They can also assist with managing any pre-existing medical conditions and ensuring that individuals are physically fit for surgery.

5. Support Groups and Advocacy Organizations

Support groups and advocacy organizations within the transgender community can offer valuable peer support, resources, and information about gender-affirming surgeries. These groups provide opportunities for individuals to connect with others who have undergone similar experiences, share insights, and seek guidance from those who have navigated the transition process.

Consulting with a multidisciplinary team of healthcare providers ensures that individuals receive comprehensive care tailored to their unique needs and goals. This collaborative approach helps individuals make informed decisions about gender reassignment surgery and supports their overall health and well-being throughout the transition process.

Pre-operative Considerations

1. Medical Considerations

Transgender individuals may have preexisting health conditions like diabetes , asthma , or HIV, which can impact their eligibility for surgery and postoperative care. Surgeons often consult with endocrinologists to assess the patient's physical fitness for surgery, especially considering the complex medication regimens involved in hormone therapy before and after surgery.

2. Fertility Concerns

Patients considering sex reassignment surgery (SRS) are informed about potential infertility, particularly if procedures like orchiectomy or oophorectomy are performed as part of the transition process. Preservation of fertility options may be discussed before surgery.

3. Age and Consent

SRS is generally not performed on children under 18, with rare exceptions made for adolescents based on healthcare provider assessments and potential benefits or risks. Consent from parents or legal guardians is required, along with long-term mental health counseling to confirm persistent gender dysphoria.

4. Intersex and Trauma Cases

Infants born with intersex traits may undergo surgical interventions at or near birth, raising ethical concerns about human rights implications. Trauma cases also require careful consideration, as surgically assigned gender may not align with the individual's gender identity, leading to negative outcomes later in life.

5. Standards of Care

Many regions follow Standards of Care for the Health of Transgender and Gender Diverse People (SOC), such as those published by the World Professional Association for Transgender Health (WPATH). These guidelines outline minimum requirements for treatment, including psychological evaluation and living as the desired gender before surgery.

6. Insurance Coverage

Obtaining insurance coverage for SRS may require documented assessments by mental health professionals, evidence of persistent gender dysphoria, and completion of physician-supervised hormone therapy for a specified duration.

Post-operative Considerations

1. Quality of Life and Physical Health

Studies assessing postoperative quality of life vary, with some reporting similar quality to control groups while others note lower quality in domains of health and limitations. Overall, many individuals report improvements in mental health, satisfaction with physical appearance, and overall well-being after surgery.

2. Psychological and Social Consequences

SRS has been shown to be effective in relieving gender dysphoria, though some studies highlight methodological limitations. Patients often report reduced anxiety, depression , and hostility levels post-surgery, with improvements in self-perceived physical and mental health.

3. Sexuality and Sexual Satisfaction

SRS can significantly impact individuals' sexual experiences and satisfaction. Most transsexual individuals report enjoying better sex lives and improved sexual satisfaction after surgery, with changes in orgasm frequency, intensity, and masturbation habits observed. However, satisfaction levels may vary between trans men and trans women, and expectations for sexual aspects of life may differ from cisgender individuals.

4. Continued Support

Comprehensive postoperative care involves ongoing psychological support, management of any complications, and assistance with adjustment to physical changes. Social support networks play a crucial role in helping individuals navigate their post-surgical experiences and integrate their gender identities into their daily lives.

The denial or limited access to gender-affirming surgeries can have severe consequences for the mental health and well-being of transgender individuals.

1. Persistent Gender Dysphoria

Without access to surgery, transgender individuals may continue to experience intense distress and discomfort due to the misalignment between their gender identity and physical characteristics. This persistent gender dysphoria can lead to heightened anxiety, depression, and a sense of hopelessness.

2. Heightened Anxiety

Living in a body that does not align with one's gender identity can contribute to persistent anxiety. The frustration of being unable to access necessary medical care and the ongoing struggle to navigate societal expectations can exacerbate feelings of stress and worry.

3. Increased Depression

Untreated gender dysphoria and the inability to undergo gender-affirming surgeries can lead to deepening feelings of depression and despair. Transgender individuals may struggle with low self-esteem, feelings of worthlessness, and a sense of isolation from not being able to live authentically.

4. Social Withdrawal

The distress caused by the incongruence between one's gender identity and physical appearance can result in social withdrawal and avoidance of social interactions. Transgender individuals may feel ashamed or uncomfortable in social settings, leading to further isolation and loneliness.

5. Suicidal Ideation

The lack of access to gender-affirming surgeries and the ongoing struggle with gender dysphoria can significantly increase the risk of suicidal thoughts and behaviors. Without the hope of being able to live authentically and alleviate their distress, transgender individuals may experience profound feelings of hopelessness and desperation.

Click here to know more about Mental health in transgender community

Affordable Surgery Options

Gender-affirming surgeries, including gender reassignment surgery (GRS), vary widely in cost globally. Affordable options exist in countries like Turkey, Brazil, Argentina, and Belgium. Turkey offers the most budget-friendly option, followed by Brazil, Argentina, and Belgium. While these countries provide competitive prices, individuals should consider factors beyond cost, such as healthcare quality and legal protections.

Click here for detailed information on the global cost of these surgeries and to find out which options are more affordable

In summary, gender reassignment surgery serves as a vital tool in validating the gender identities of transgender and intersex individuals, enabling them to harmonize their external appearance with their innate sense of self. Despite its transformative potential, many face obstacles in accessing this essential care, including financial constraints, inadequate insurance coverage, and legal hurdles.

As society progresses towards greater awareness and acceptance of transgender rights, it's imperative to prioritize equitable access to gender-affirming treatments and offer unwavering support to individuals throughout their transition journey. By dismantling these barriers and fostering inclusivity within healthcare systems, we can empower transgender individuals to live authentically and flourish in their gender identity.

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• Gender Affirmation Surgeries - (https://www.hopkinsmedicine.org/health/wellness-and-prevention/gender-affirmation-surgeries)
• Gender Confirmation Surgery - (https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery)
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