Transsexual Surgery: Its Pros and Cons

By Anne Lawrence, M.D.

Introduction

In order to adequately discuss the pros and cons of transsexual surgery, it will be useful to first consider the benefits and disadvantages of sex reassignment (SR) generally; and then to consider the benefits and disadvantages of transsexual surgery per se. It will also be useful to keep in mind that there are two distinct groups of persons who undergo sex reassignment, male-to-female (MF) and female-to-male (FM) transsexuals, and that their experiences of transsexual surgery often differ dramatically. Transsexual surgery is often thought of as synonymous with genital surgery, which is usually called sex reassignment surgery (SRS), i.e., vaginoplasty for MFs or phalloplasty for FMs. I will follow this convention, and use SRS as a synonym for genital reconstructive surgery. However, other surgical procedures are also routinely performed for transsexuals, notably reduction mammoplasty (chest reconstruction) in FMs and facial feminization surgery and augmentation mammoplasty in MFs. These are often of greater practical significance for the conduct of the patient's daily life than is SRS.

Overview of Sex Reassignment Outcomes

Undoubtedly the most comprehensive recent review of SR was authored by Pfafflin and Junge (1992). Originally published in German, it became available in English translation only in 1998, and then only in electronic form. Pfafflin and Junge reviewed over 70 studies and 8 previous reviews -- investigations comprising over 2000 patients in 13 countries, and spanning 30 years. It is worth looking at the authors' conclusions in some detail before turning to more recent studies.

The primary reason that SR is undertaken is to relieve gender dysphoria, a term used to describe transsexuals' discomfort with their anatomic sex, or their sense of inappropriateness in the gender role of that sex (American Psychiatric Association, 1994). Pfafflin and Junge concluded that SR treatment was generally effective in relieving gender dysphoria, and that its positive results greatly outweighed any negative consequences. They found overall that the results of SR in FMs were somewhat more favorable than in MFs. Pfafflin and Junge noted that satisfactory results of SR were reported in over 70% of MFs and in nearly 90% of FMs in the earliest reviews, conducted through 1984. Those results improved to 87% satisfactory results in MFs and 97% satisfactory results in FMs in a more recent review by Green and Fleming (1990), which considered only studies performed after 1980.

Apparently nearly all aspects of the reassignment process contribute to these generally positive outcomes. On average, patients experienced reduced gender dysphoria and increased satisfaction over the entire course of the SR process, which ordinarily included hormone therapy, psychotherapy, and real-life experience in the gender of reassignment, in addition to SRS. A notable study demonstrating this principle was conducted by Kuiper and Cohen-Kettenis (1988) in the Netherlands. They found that patients who had begun hormonal treatment and a real-life cross-living experience suffered less from gender dysphoria than did untreated control patients. This was true whether or not SRS had occurred. However, Kuiper and Cohen-Kettenis hastened to add that this did not, in their opinion, suggest that genital surgery was unnecessary, since some of their patients' subjective improvement was probably due to seeing "light at the end of the tunnel," i.e., the prospect of eventual SRS.

In support of this opinion, Pfafflin and Junge pointed to the work of Mate-Kole et al (1990) as providing the best demonstration of the value of SRS in MFs, independent of other aspects of the SR process. In the Mate- Kole study, MF patients who had qualified for SRS were randomly assigned to either undergo surgery on an expedited basis, or to be put on a waiting list for surgery two years or more in the future. The patients who underwent expedited SRS demonstrated improved psychosocial outcomes, compared to the still unoperated controls. They were more active socially, and had fewer neurotic symptoms. The study by Mate-Kole et al remains to this day the only controlled investigation of the independent value of genital surgery in the SR process.

Specific Benefits of Sex Reassignment

Pfafflin and Junge looked at the specific beneficial effects of SR in four broad areas: subjective satisfaction; mental stability; socioeconomic functioning; and partnership and sexual experience. Of the four, they considered subjective satisfaction to be the most important. They noted that a general improvement in subjective satisfaction was shown in essentially all the studies they reviewed, even those by authors who were most critical of SR. Considering the issue of mental stability, they concluded that the majority of follow-up studies that had examined this dimension also found more positive than negative results, although not as uniformly as in the case of subjective satisfaction.

Follow-up studies that looked at socioeconomic functioning were also generally positive in their conclusions. Socioeconomic functioning included social contact with partners, relatives, neighbors and co- workers, as well as employment. Pfafflin and Junge found that improvements in social functioning were the rule, based on either clinical judgment or on statistical comparisons. However, there were exceptions to this pattern, especially in the case of MFs. Sorensen (1981a) reported an average decline in employment status and an increase in social isolation among MFs, but not among FMs (Sorensen, 1981b). This is in accordance with the majority of reports suggesting that FMs in general do better than MFs after SR.

The fourth of Pfafflin and Junge's major areas of investigation concerned partnerships and sexual experience. In general, the follow-up studies they reviewed found that sexual satisfaction improved significantly after SRS, and that most MFs experienced orgasms, some regularly. Even among FMs, sexual satisfaction after treatment was significantly higher than before treatment, despite the lack of a really satisfactory surgical procedure for FM genital reconstruction.

Negative Consequences of Sex Reassignment

Pfafflin and Junge also considered negative consequences of SR, focussing on three areas: surgical complications; suicide; and regrets, with or without reversion to the patient's original sex. Specific complications of MF surgery found by Pfafflin and Junge included complete or partial necrosis of the vagina and labia, fistulas from the bladder or bowel into the vagina, stenosis of the urethra, and vaginas that were too short or too small for coitus. Infections and capsular fibrosis were occasional complications of augmentation mammoplasty in MFs. Among FMs, complications of breast reduction included nipple necrosis and unsightly scarring. Complications of phalloplasty in FMs included frequent urinary tract stenoses and fistulas, and occasionally necrosis of the neo- phallus.

In looking next at suicide, the authors found that it was first necessary to assess transsexual patients' pre-reassignment suicidal tendencies. Dixen et al (1984) found that among 479 MFs and 285 FMs seen in the Palo Alto program, about 25% of the MFs and 19% of the FMs had attempted suicide prior to transition. Most studies reported a pre- transition suicide attempt rate of 20% or more, with MFs relatively more suicide-prone than FMs. Post-reassignment, Pfafflin and Junge found reports of only 16 possible suicide deaths among over 2000 cases: 14 in MFs, one in an FM, and one with gender not specified. Five of the 16 may have been accidental medication or drug overdoses rather than genuine suicides. In the remaining 11 cases, suicide was usually not thought to be related to gender problems per se. These results suggest that post- transition, suicidal tendencies probably get no worse, and may actually improve.

Pfafflin and Junge found reports of severe regrets, or of reversions to original gender, in 20 MFs. Two of these were described twice; and two others had undergone only hormonal treatment, not SRS. Among the other 14 cases, the authors found that three factors contributed to severe regrets or sex reversions: major coexisting psychiatric problems, limited real-life experience in the desired gender role, and unsatisfactory surgical results. At least four patients developed regrets in association with psychoses or paranoid reactions, which perhaps could have been avoided with more careful screening. At least three other patients developed regrets after undergoing SRS without any real-life experience in their desired gender role. Still others had experienced regrets in association with inadequate surgery: two underwent only orchiectomy without penectomy or vaginoplasty, and others did not undergo vaginoplasty for several years following orchiectomy and penectomy. Role-reversal was reported in only five FMs; one patient was probably reported twice. The consensus of the follow-up studies was that severe regrets or reversions to original gender were very rare in FMs; no specific risk factors for these were evident.

More Recent Outcome Studies

In the seven years since the comprehensive review by Pfafflin and Junge, researchers have continued to publish outcome studies looking at the benefits and disadvantages of sex reassignment. Bodlund and Kullgren (1996) found that in a five-year follow-up of 10 MFs and 9 FMs, 68% of patients achieved a satisfactory outcome, defined as improvement in at last two areas of social functioning with worsening in none. Eldh et al (1997) reviewed the Stockholm experience from the period 1965-1995, involving 136 patients. Over 86% of the reassigned patients who responded to the investigators' questionnaire were satisfied with their overall life situation, although the response rate was low. However, only 55% of the MFs and only 34% of the FMs were satisfied with their sexual lives. Landen et al (1998) found an incidence of 3.8% regrets in group of 218 Swedish transsexuals approved for SR during the years 1972-1992. Rehman et al (1999) studied 47 MF patients operated by the same surgeon between 1980 and 1994, of whom 28 returned questionnaires. All 28 reported themselves satisfied with their reassignment and surgical outcome, and none expressed regrets.

Sex Reassignment Surgery

Having looked at sex reassignment generally, we will now turn to sex reassignment surgery per se. Although it may seem obvious that SRS would inevitably accompany SR, or would at least be sought in virtually every case, a significant number of persons who undergo SR never have SRS, either by choice or by necessity. Certainly there are some obvious advantages to having SRS if one does transition. Having congruent genitalia allows one to appear nude in the presence of sex partners, or in venues such as physicians' offices, swimming pools or health clubs, without violating anyone's expectations. Having congruent genitalia improves one's safety in the event of arrest or search by police or other authorities; it may also be necessary to secure certain forms of identification (e.g., a permanent US passport in the case of MFs). Most important of all, having congruent genitalia is usually essential for the transsexual person to experience harmony between body and self-identity.

On the other hand, there are some significant disadvantages to SRS, even for persons committed to SR. Genital surgery is expensive: $7000 to $24,000 for MFs, and up to $50,000 or more in the case of FMs. Although vaginoplasty for MFs has become very sophisticated, there is really no satisfactory phalloplasty procedure for FMs. Metoidioplasty (release of the suspensory ligament of the hypertrophied clitoris and placement of testicular prostheses in the centrally-approximated labia majora) is relatively free of complications, but it results in a micro penis without capacity for standing urination. Phalloplasty using an abdominal flap, radial forearm flap, or fibular flap is a lengthy, multi-stage procedure with significant morbidity, including over a 50% rate of urinary stenosis, and unavoidable donor site scarring. Moreover, the cosmetic and functional results of phalloplasty are often disappointing, even when major complications can be avoided. For this reason, many if not most FMs never undergo genital surgery, except for hysterectomy and salpingo- oopherectomy. Indeed, Green and Fleming (1990) suggested that those FMs with little interest in phalloplasty tended to have a better prognosis than others. In the case of MFs, anorgasmia following SRS is not uncommon, and a second stage labiaplasty is usually needed for satisfactory cosmesis. An even more significant problem for the many MFs who are employed as sex workers is the prospect of losing one's "unique attraction" for many clients by giving up one's penis. Persons who earn their livings as she- male sex workers often risk becoming unemployed when they undergo vaginoplasty.

Still, for many MF clients, SRS remains the sine qua non of the reassignment experience. The central importance of SRS for many is demonstrated by the repeated finding that quality of surgical results is one of the best predictors of general outcome after SR. Ross and Need (1989) reported that in their group of 14 patients, most of the variability in postoperative mental and emotional adjustment was related the quality of the surgical results, especially adequate resection of urethral erectile tissue, along with absence of breast scarring. Schroder (1995) also found that in her group of 17 MF patients, vaginal depth and vulvar cosmesis were the most important predictors of the overall success of sex reassignment.

Sexological Outcomes of Genital Surgery

Several authors have looked at specific sexological outcomes after SRS. Green (1998) reviewed seven reports of rates of orgasm and quality of sexual functioning after SRS, but concluded that methodological shortcomings in many studies made generalizations nearly impossible. Lawrence (1999) reviewed 13 studies in MFs, and concluded that there was a 50% to 80% likelihood that an MF would be at least occasionally orgasmic after SRS, but only a 20% to 40% likelihood of being regularly orgasmic. She noted that the best results had been reported in series in which a clitoris had been constructed from part of the innervated glans penis. She also cautioned that it was necessary to view statistics concerning transsexuals' orgasmic response in context, because natal women, too, often have trouble achieving orgasm. For example, Laumann et al (1994) found in their national survey that 24% of American women said that within the last twelve months, there had been a period of several months or more during which they had been unable to achieve orgasm.

Two of the studies reviewed by Green and by Lawrence merit a closer look. Blanchard et al (1987) studied 22 MFs post-vaginoplasty. Eleven of their patients (50%) reported being usually or regularly orgasmic, while 7 (32%) had orgasms only rarely or with difficulty, and 4 were never orgasmic. Based on the descriptions the transsexual women provided, the authors thought that many of the women were probably describing something other than orgasm. Vaginal depth averaged only 8.3 cm, a bit shorter than in many native females; but this did not seem to interfere with coitus. Lief and Hubschman (1993) studied 14 post-SRS MFs and 9 FMs; all of the latter had undergone hysterectomy and mastectomy, but only 3 FMs had undergone phalloplasty. Among the MFs, only 4 of 14 were orgasmic post-SRS; 8 patients who had been orgasmic pre-SRS lost this capacity. However, 9 of the 14 reported an increase in sexual satisfaction, despite the fact that 6 of these 9 were anorgasmic. Among the FMs, 7 of 9 were orgasmic post-surgery, including all 3 who had undergone phalloplasty; 4 patients improved, and none lost capacity. Six of the 9 FMs reported increased sexual satisfaction, and 2 were unchanged. In both groups, the anorgasmic patients tended to attribute their anorgasmia to body image problems. This echoes previous observations about the importance patients place on the functional and cosmetic quality of their post-operative results.

In a study too recent to be reviewed by Green or Lawrence, Rehman et al (1999) also looked at sexological outcomes of SRS. Of the 28 MFs surveyed by the authors, 22 (79%) were at least occasionally orgasmic, and 15 (54%) were regularly so, although most claimed that their orgasms were different in character after SRS. Four patients experienced vaginal stenosis or stricture, which required augmentation of the vagina with a segment of sigmoid colon in three patients, and revision of the vaginal introitus in one. Seven of 28 patients (25%) experienced dyspareunia with coitus.

Non-Genital Transsexual Surgery

As noted earlier, reduction mammoplasty (chest reconstruction) for FMs, and facial feminization surgery for MFs are often of greater practical importance than genital surgery in the daily life of transsexual persons. This is because the former procedures are often essential to permit passing in the desired gender role in ordinary social interactions. Chest reconstruction for FMs has a low rate of serious complications, but scarring and deformity can easily result unless there is careful attention to technique (Hage and van Kesteren, 1995). Multi-stage procedures are often required in the case of large breasts. Facial feminization surgery in MFs can include forehead re-contouring, rhinoplasty, reduction of the mandible, and reduction of the laryngeal cartilage. These can be very expensive ($25,000 or more for a complete set of procedures), and they carry the risk of serious complications. The latter include nerve injuries and bone infections (osteomyelitis) in the case of facial surgery, and injury to the vocal cords in the case of laryngeal surgery. However, the benefits of successful facial feminization surgery can be profound.

Public Policy and Transsexual Surgery

Although this review has concentrated on the pros and cons of transsexual surgery from the viewpoint of the individual transsexual patient, transsexual surgery can also be considered in public policy terms. The majority of workers in the field have favored the provision of surgical services and other aids to transition (Harry Benjamin International Gender Dysphoria Association, 1998) as a matter of public policy, on the grounds that there is no other effective way to relieve the suffering of persons with gender dysphoria. However, those attitudes have not been universally shared.

For example, Irvine (1990) argued that:

It is not sufficient to judge the appropriateness of sex change operations solely on the basis of their alleged individual success. In addition to the traditional public health questions of costs and benefits, it is appropriate to examine the cultural context of new techniques.

Ekins and King (1996) noted that several commentators had criticized sex reassignment in general, and SRS in particular, on political grounds. They explained that the critics of SR:

argue that transsexualism is not only caused by, and is a reflection of, patriarchy, but also supports it by maintaining the notion of 'appropriate' gender roles, by deflecting attention away from the real cause, and by diffusing the potential threat which transsexuals represent.

Perhaps the most influential critics of SRS from the viewpoint of its cultural context have been Raymond (1980) and Billings and Urban (1982). Raymond, a cultural feminist, has called transsexual surgery "an antisocial activity that promotes the worst aspects of a patriarchal society by encouraging adaptation to its sex roles." Although she has not gone so far as to suggest that SRS be made illegal, she has advocated that transsexual surgery be "morally mandated out of existence." Billings and Urban (1982) also see transsexual surgery in political terms:

We conclude that at the level of ideology, sex-change surgery not only reflects and extends late-capitalist logics of reification and commodification, but simultaneously plays an implicit role in contemporary sexual politics.

By substituting medical terminology for political discourse, the medical profession has indirectly tamed and transformed a potential wildcat strike at the gender factory.

The conflict between the attitudes of cultural critics such as Irvine, Raymond, and Billings and Urban on the one hand, and the attitudes held by transsexual clients and their care providers on the other, suggests that the debate about the pros and cons of transsexual surgery is likely to continue for some time.

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REFERENCES

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Schroder M (1995) New women: sexological outcomes of gender reassignment surgery. Unpublished Ph.D. thesis, Institute for Advanced Study of Human Sexuality, San Francisco, CA.

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Sorensen T (1981b) A follow-up study of operated transsexual females. Acta Psychiat Scand 64: 50-64.

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