Sex Reassignment Surgery

(SRS)
David G. Chu
Surgery 2003
 Transgender Disclaimer
Topics of Transgender Identity and
Transgender Health are important for
physicians, but are beyond the scope of this
presentation
For more information on Transgender Identity
or Transgender Health, visit:
www.transgendercare.com
www.gayhealthchannel.com/transgender
 Transgender
An inclusive term for individuals whom
challenge traditional gender roles and the
assumption that sex determines gender.
Transvestites do so by dressing in clothing of
the opposite sex.
Transsexuals do so by actually changing their
anatomy to the opposite sex.
DDx: Gender Identity Disorder (must r/o)
 Transsexual
A person whose MTF: Male to Female
gender identity differs Breast Augmentation
from the sex assigned Sex Reassignment
at birth and who may Surgery (Vaginoplasty)
or may not pursue FTM: Female to Male
steps to change their Breast Reduction
body physically in an Sex Reassignment
attempt to make the Surgery (Phalloplasty)
two more congruent.
 Advantages to SRS for
Transgender Patients
Evidence suggests SRS early in life prevents
developmental emotional trauma of social
discrimination for being transgender
Postoperatively the Treated group:
no longer gender-dysphoric
psychologically and socially functioning quite well
nobody expressed regretted decision to undergo SRS
Nontreated group (w/o SRS):
showed some improvement
also showed more dysfunctional psychological profile
 Advantages to SRS for
Transgender Patients
Study Conclusions:
Careful diagnosis and strict criteria are necessary
and sufficient to justify hormone treatment in
adolescent transsexuals
High levels of psychopathology found in Gender
Identity Disorder adolescents justify the decision to
NOT start hormone treatment too soon or too easily
Smith YL, van Goozen SH, Cohen-Kettenis, Adolescents with gender identity disorder who were
accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child
Adolesc Psychiatry. 2001 Apr;40(4):472-81.
 Challenges to SRS for
Transgender Patients
Vast majority of studies addressing outcome have
provided convincing evidence for the benefit of
sex reassignment surgery in carefully selected
[transgender] cases
However, current legislature maintains strict age
restrictions and requirements because:
Most children with gender identity disorder do not
identify as transgender as adults
Adolescents (under 18yo) are legally dependent on
parental consent for medical treatment
Landen M, Bodlund O, Ekselius L, Hambert G, Lundstrom B., Done is done--and gone is gone. Sex reassignment is
presently the best treatment for transsexuals, Lakartidningen. 2001 Jul 25;98(30-31):3322-6. Review. Swedish.
 Sex Reassignment Surgery
Criteria for Eligibility
After at least 3 months of psychotherapy,
recommendation by a clinical behavioral
professional for hormonal sex reassignment
(hormone therapy treatment)
Endocrinologist assessment after hormone tx
Completion of at least 12 months of full-time
living in the social role of the chosen gender
2 Required Letters:
Mental Health Professional with >6 mo pt f/u
Psychiatrist or Clinical Psychologist (MD or PhD)
 Sex Reassignment Surgery
Overview M to F
Goals of Penile Skin Inversion Vaginoplasty:
Skin hooding (prepuce) over clitoris
Neoclitoris formed with sensitive skin from glans of
original penis
Good vaginal depth obtained with a skin graft from
scrotal sac at end of the skin tube harvested from
original penis
Vaginal opening with labia minora
Erogenous sensation and sexual satisfaction
Minimal donor site scars on abdomen, thighs
 Sex Reassignment Surgery
M to F - Vaginoplasty
Step 1: Skin incisions on the ventral penis
shaft and perineum
 Sex Reassignment Surgery
M to F - Vaginoplasty
Step 2: Penis degloving and optional testis
removal (orchidectomy)
 Sex Reassignment Surgery
M to F - Vaginoplasty
Step 3: Penis is amputated, mucosal flap
used to create neoclitoris and vaginal cavity
is dissected
 Sex Reassignment Surgery
M to F - Vaginoplasty
Step 4: Skin inverted with mold inside
dissected cavity, skin hooding (prepuce)
created over neoclitoris
 Sex Reassignment Surgery
M to F Additional
2 Sex Characteristic surgical procedures to
complement Sex Reassignment Surgery (1 Sex
Characteristics) include:
Breast Augmentation (mammoplasty)
Adams Apple Shaving (chondrolaryngoplasty)
Voice Surgery (cricothyroid approximation)
Face and Body Feminization
 Sex Reassignment Surgery
Overview M to F - Photos
Vaginoplasty Pre/Post-Op Photos:

Perovic SV, Stanojevic DS, Djordjevic ML., Vaginoplasty in male transsexuals

using penile skin and a urethral flap. BJU Int. 2000 Nov;86(7):843-50.
 Sex Reassignment Surgery
Overview M to F - Photos
Vaginoplasty Pre/Post-Op Photos:

Perovic SV, Stanojevic DS, Djordjevic ML., Vaginoplasty in male transsexuals

using penile skin and a urethral flap. BJU Int. 2000 Nov;86(7):843-50.
 Sex Reassignment Surgery
Overview M to F
Diagrams from the John's Hopkins early MtoF Sex
Reassignment Surgery Procedure

Howard W. Jones, Jr., M.D., Transsexualism and Sex Reassignment, Richard Green, M.D. and
John Money, Ph.D., Editors; Chapter 22; Johns-Hopkins Press, 1969.
 Sex Reassignment Surgery
Overview M to F
Diagrams from the John's Hopkins early MtoF
SRS Procedure (1969)

Howard W. Jones, Jr., M.D., Transsexualism and Sex Reassignment, Richard Green, M.D. and
John Money, Ph.D., Editors; Chapter 22; Johns-Hopkins Press, 1969.
 Sex Reassignment Surgery
Overview M to F
Diagrams from the John's Hopkins early MtoF
SRS Procedure

Howard W. Jones, Jr., M.D., Transsexualism and Sex Reassignment, Richard Green, M.D. and
John Money, Ph.D., Editors; Chapter 22; Johns-Hopkins Press, 1969.
 Sex Reassignment Surgery
Overview M to F
Diagrams from the John's Hopkins early MtoF
SRS Procedure

Howard W. Jones, Jr., M.D., Transsexualism and Sex Reassignment, Richard Green, M.D. and
John Money, Ph.D., Editors; Chapter 22; Johns-Hopkins Press, 1969.
 Sex Reassignment Surgery
Overview F to M
Chest Masculinization (mastectomy)
Hysterectomy and Oophorectomy (optional)
Pts who do not include either procedure are still at
risk for uterine/ovarian ca later in life
Metaidoioplasty w/ or w/o Clitoris Release
Phalloplasty
 Sex Reassignment Surgery
F to M Chest Masculinization

Trombetta C, Liguori G, Pascone M, Bucci S, Guaschino S, Papa G, Belgrano E.,Total sex-

reassignment surgery in female-to-male transsexuals: a one-stage technique. BJU Int. 2002
Nov;90(7):754-7.
 Sex Reassignment Surgery
F to M - Metaidoioplasty
Goals:
Ability to urinate while standing
Preservation of sensation to clitoris
Removal of vaginal cavity
Creation of a scrotal sac
Approx OR time: 3-4 hours
Procedure: Clitoris release to elongate phallus,
create neourethra with labia minora and vaginal
mucosa, create neoscrotum with labia majora,
insert testicular implants.
 Sex Reassignment Surgery
F to M - Phalloplasty
Step 1: Forearm skin is harvested along
with sensory nerves and vasculature
 Sex Reassignment Surgery
F to M - Phalloplasty
Step 2: Vaginal cavity is obstructed, create
neoscrotum with labia majora, construction
of neopenis around catheter
 Sex Reassignment Surgery
F to M - Phalloplasty
Step 3: Attachment of neopenis and
anastomosis of urethra, nerves and
vasculature
Patients often retain
capacity to orgasm
after phalloplasty,
however ejaculation is
not possible
 Sex Reassignment Surgery
Overview F to M - Photos
Phalloplasty Pre/Post-Op Photos:
 References
Rakic, Z., Starcevic, V., Maric, J., and Kelin, K. (1996). The Outcome of
sex reassignment surgery in Belgrade: 32 patients of both sexes.
Archives of Sexual Behavior, Vol. 25: 515-525
Cohen-Kettenis, P.T. and Van Goozen, S.H.M. (1997). Sex reassignment
of adolescent transsexuals: a follow-up study. J. of Am. Acad. Child.
Adolesc. Psychiatry, 36:2 263-271

Gender Reassignment Surgery in Montreal, Dr. Menard, Brassard

(www.grsmontreal.com)
Health and Medical Online Library FTM Australia
(library.ftmaustralia.org/health/02/0925.html)
The Cleveland Clinic Health Information Center
(www.clevelandclinic.org/health/health-info/docs/2500/2584.asp?index=9145)