»A clitoral nerve is attached to the new penis«

The next procedure follows after two to three months, in which we model the labia majora. Finally, we adjust the breast with the help of implants if growth is insufficient after 24 months of hormone therapy.

So it only works with hormone therapy?

Theoretically yes, but in practice it is often not even enough for cup size A. Breast surgery is therefore common. The breasts should look as natural as possible and fit the person. As soon as the basic information has been discussed, we can – if the patient wishes – simulate the result in three dimensions on the computer.

When is sex possible again? And what do you actually feel?

On average, you can have sex again six weeks after the operation. I am meticulous about preserving the nerves of both sexes during the operation. In the case of “woman to man”, for example, the clitoris is preserved and a clitoral nerve is connected to the skin nerve of the new penis so that the ability to have an orgasm is maintained and sexual stimulation is also possible via the new penis. In “man to woman” we get the nerve of the glans. And – as surprising as it may be – after the procedure, the sexual experience is increased, the patients are happier, as various studies show.

»After the operation, I often hear that those affected are happy to finally be rid of their breast«

This aligns with studies in psychology that show that liking your body increases your likelihood of having beneficial sex.

That’s right, everyone is like that. With trans people it just becomes particularly clear. One only has to imagine that trans men brutally bandage their breasts in order to conceal female sexual characteristics before the operation. After the operation, I often hear that those affected are happy to finally be rid of their breasts. This is a physically noticeable pressure that can be relieved with an operation.

Not all patients want all procedures. Who stops when and why?

For some trans men, having the breast removed is enough. It is less common that they also want to have the female sex organs removed. There is an interim solution in which, after removal of the vaginal tube, uterus and ovaries, the clitoris is lengthened and slightly enlarged. In addition, an extension of the urinary tract is achieved from the labia, so that at least a different position when urinating is possible. We speak colloquially of a Klitpen. The penis construction and the prosthesis are then not absolutely necessary, but can also be carried out later if necessary. Overall, however, this intervention is relatively rare. The majority want full operational alignment. Since male-to-female conversion requires less intervention, most people have it all done.

what about the face

While women can take the hormone testosterone to get masculine traits, androgens and estrogens are significantly less effective in men. A pronounced forehead and the enlarged Adam’s apple can therefore only be insufficiently reduced with hormone therapy. However, the health insurance companies decide in individual cases whether they will pay for it, which is why the number of facial feminisation procedures is manageable.

What if you can’t or don’t want to take the hormones?

Then, for example, the body hair may be thicker than desired. Or you still feel that your own voice is too high or too low for your biological gender. While hormonal therapy works very well for trans men, it’s nearly impossible to make a male voice more feminine.

Does this require surgery on the vocal cords?

Possible, but not absolutely necessary. With a speech therapist or a speech therapist, you can train very well to change the pitch of your voice. Both trans men and trans women. For trans men, the goal is usually to strengthen their voice. In the case of trans women, the higher pitch and the position of the voice are crucial. There are singing and other exercises that ensure, for example, that the throat area shortens and narrows. Phonosurgical interventions, in which the vocal cords are treated surgically, can only be offered if speech therapy does not succeed in changing the pitch of the voice.

Intensive interventions are required for gender reassignment, there is a lot of cutting, turning, and sewing. What are risks and side effects?

Wound healing disorders, secondary bleeding, wound infections and dying tissue are possible, as with any operation. Specifically, tissue loss can occur in both the new penis and the neovagina, which is serious but rare—an estimated one to two percent—and can be corrected with additional surgery in most cases.

In addition, scars can lead to a constriction in the urinary tract or the opposite: the urinary tract develops fistulas and thus connections to the skin, through which urine is then excreted.

»The quality of life increases, the desire for sex as well, you feel more than me«

How common is that?

Every second to third person develops these urinary tract complications in varying degrees. However, they usually heal after a long wait and regular check-ups. Only in a few cases does the problem have to be corrected operationally if it leads to significant restrictions.

And then there is a completely different side effect: the person in the mirror looks different than you have been used to for years, and the people around you also perceive the person differently. Self-perception changes. You may feel alienated at first and have to rediscover yourself – no matter how much you wished for change.

A transition begins with the person themselves and usually remains a lifelong task, they say. Do you agree?

I only see the patients when they want an operation. That means they already have a diagnosis, are informed and determined to act because they are sure they can survive in everyday life with a new body. From time to time there are patients who struggle with follow-up checks, but many who are grateful and relieved. This is also shown in studies: the quality of life increases, as does the desire for sex, one feels more than I am. When the operation is complete, most of it is done. Mastering life afterwards is a lifelong task for everyone. It doesn’t matter if it’s cis, trans or something else.

• How does one become a trans man or trans woman?

  Because no data is officially collected, it is difficult to quantify how many trans people live in Germany. There are clinical samples dealing with transgender, interventions and hormone therapy. Based on this, it can be estimated that around 9 out of 100,000 people consider themselves to be trans. In surveys, the value is significantly higher: when asked whether someone is ambivalent or trans, between 144 and 566 out of 100,000 people agree. Based on the changes in civil status according to the Transsexual Act, there are around 260 trans people per 100,000 people in this country. That’s about 0.35 percent of the population.

  According to current knowledge, not all of them can be operated on.

• How many trans operations are there?

  According to statistics, 2155 people had gender reassignment surgery in Germany in 2020. Two thirds of the operations are performed on trans women, i.e. women whose biological sex is male. According to the Federal Statistical Office, most surgeries were performed in the 20 to under 30 age group.

• What does the surgery require?

  According to the current Transsexual Act, psychotherapeutic care must have taken place for at least 18 months and the indication for gender reassignment surgery must be approved. Through the psychotherapy it is then possible to register a change of name and/or marital status within the framework of two expert opinions that confirm that the person is transsexual.

  Furthermore, the somatic medical indication by, for example, the attending surgeon is also necessary for the assumption of costs.

  Also helpful, but not mandatory, is hormone therapy of the opposite sex, which should take place over a period of at least six months. In contrast, proven hormone therapy over 24 months is a prerequisite for the assumption of costs for breast augmentation for trans women, provided there are no contraindications for hormone therapy.

• How much does the intervention cost?

  The costs differ depending on whether the person wants to be transformed externally from woman to man or man to woman. In addition, each surgical step varies in terms of effort and material. The price range per operation is between 4000 euros and 20 000 euros. Overall, it can be assumed that gender reassignment from woman to man costs around 60,000 euros due to the number of interventions. Men who want to have their bodies shaped like women pay around 30,000 euros.

• Who pays that?

  Both statutory and private health insurers are required by law to cover the costs of all necessary treatment measures. Various therapeutic and medical evidence must be available for this. For example, a psychological assessment, progress reports from endocrinologists, a letter from the attending surgeon are required.

  Important to know: For surgical changes in the face, a decision is made on a case-by-case basis. Health insurance companies only sometimes pay for the correction of prominent frontal bones or Adam’s apple.

• Where can you find a suitable surgeon?

  You can get first tips in internet forums. But be careful: Laypersons and experts can mix there, information is not necessarily checked and secured. It is best for those affected to find out in advance whether it is a patient-led forum or an official counseling center.

  In Germany there are experienced doctors mainly in clinics for plastic and aesthetic surgery or for urology and gynaecology. For example, the German Society for Aesthetic Plastic Surgery (DGPRÄC) provides information on how to find a suitable surgeon. It can also be worth making specific inquiries at transgender centers.

• How long does the process take?

  That is individual. Seeing a psychologist in less than a year to end up with a change in marital status is not possible. You should rather assume two to three years, but it can also take much longer. In the case of those affected by statutory health insurance, the medical service of health insurers (MdK) expects a period of 18 months of psychotherapy before agreeing to the assumption of the costs for the gender reassignment operation. Depending on the transformation, it often takes several years from the first intervention to the final healing.

For better legibility, the editors have adapted the interview in consultation with the interlocutor.