There is a lot of discussion about trans people. They fascinate and irritate. And they take away our certainty that a man is a man and a woman is a woman. But how does “gender reassignment” work? A sober medical look at an emotional issue.
Is it a girl or a boy? This is usually the first question new parents are asked. Even before the name. This shows the great importance of gender. But what if the biological gender does not match the perceived gender? When the girl or boy feels they are in the wrong body and does everything they can to get rid of the body they hate?
In this case, experts speak of gender dysphoria, gender identity disorder or transsexuality. While the first term expresses dissatisfaction and suffering with biological sex, the second assumes a misguided gender identity. The third term, oddly enough, emphasizes sexuality, even though the issue of trans is primarily about identity: do I feel like a man or a woman – or am I not able to answer this question unequivocally?
Given the great linguistic confusion, it is not surprising that feeling-in-the-wrong-body was considered an illness until 2021. In the meantime, it is described as a non-judgemental variant in the diagnosis manual of the World Health Organization. Even if this removes the discriminatory stamp of the disease, gender dysphoria still has the potential to cause disease. Because many of those affected suffer so much from the feeling of being in the wrong body that they become depressed and, in the worst case, kill themselves.
Hormones and surgeries for the desired sex
Gender reassignment therapies can offer a way out of this impasse. According to the international treatment guidelines of transgender medicine, however, these should only be used when the gender dysphoria is clear and persistent. This must be confirmed by a specialist.
“Careful psychological and psychiatric evaluation and assessment is very important to us,” says Barbara Mijuskovic. She is a plastic-reconstructive surgeon at the University Hospital Basel and performs gender reassignment surgery on trans people. “The last thing I want as a surgeon is to operate on someone whose diagnosis is wrong,” she says.
Barbara Mijuskovic is a specialist in plastic and reconstructive surgery at the University Hospital Basel.
Mijuskovic estimates that around 200 “sex reassignments” are carried out in Switzerland every year. There are no exact figures because there is no uniform registration of the interventions. These are carried out in a handful of public and private hospitals. In addition, one would first have to define what is meant by gender reassignment. Is a breast augmentation in a biological man sufficient for this? Or is an operation on the genitals necessary?
But before the surgeon can be used, most trans people who want it are given hormones first. This raises the important question: Is the desire for gender reassignment expressed before or only after puberty? In the first case, puberty can be blocked with medication in a child who feels that it belongs to the opposite sex.
More time to think with puberty blockers
“Puberty blockers are also used in Switzerland,” says Mijuskovic. This gives the child and their parents time to deal with the difficult topic and to plan the next steps. “Puberty blockers have great advantages for boys who feel like girls,” explains the doctor. Because after male puberty has gone through, some physical characteristics such as the deep voice or the growth of the beard cannot be corrected or only with great effort.
So-called GnRH drugs are used as puberty blockers. They are copied from the gonadotropin-releasing hormone (GnRH) in the brain. In therapeutic doses, this lowers the blood level of sex hormones by blocking hormones in the pituitary gland. Puberty blockers are also used in children who start puberty several years too early. If the medication is stopped, normal puberty occurs.
With or without puberty blockers, trans people who want to get closer to their desired gender have to take sex hormones. In men who want to become women (trans women), that is estrogen. Testosterone is given to women who want to become men (trans men). The medication can be administered as a tablet, gel, patch or injection. Estrogen therapy can also be combined with a testosterone-blocking drug.
According to international recommendations, such sex reassignment hormone therapy should not be started before the age of 16. Like any medical therapy, it must also be checked for its effectiveness and side effects with regular doctor checks and blood tests. This is all the more important as the treatment has not been evaluated in large clinical studies. The previous investigations are mostly based on small case series, which, however, do not give any indication of serious complications and metabolic disorders.
Changes are visible after a few months
Hormone therapy triggers many signs of male or female puberty in trans people. Changes such as breast growth in trans women are visible after just a few months. However, it can take a year or two for hormone therapy to take full effect. A trans woman must take this into account if she wants breast augmentation with implants. Such an intervention should only be carried out when the estrogen therapy has developed its full effectiveness.
Hormone therapy is enough for some trans people to lead a contented life in the desired gender. “But most trans women want a gender reassignment surgery,” says surgeon Mijuskovic. This is the most common operation in these people.
The situation is different for trans men. “Most of them want a breast removal,” says Mijuskovic. This is the most important intervention for this group of patients. The female breasts are so annoying for trans men that they often bandage them tightly for years before the procedure. The breast removal is also the only transgender operation that can be carried out before the age of majority according to the international treatment guidelines; all other procedures should only be offered from the age of 18.
According to Mijuskovic, only a minority of trans men have genital surgery performed on them. Because the creation of a new penis is still the most complicated and complicated procedure in all of transgender surgery, says the specialist.
So, surgically, it’s easier to turn a man into a woman than a woman into a man? “You can say that,” confirms Mijuskovic. “Easier” refers to technical and operational aspects as well as the results achieved. “The neo-vagina is simply closer to the biological vagina than the neo-phallus is to the biological penis,” summarizes the specialist.
Neo-vagina made from the body’s own tissue
If a trans woman decides to undergo genital sex reassignment surgery, her testicles and erectile tissue are first removed in a four to five-hour operation. After that, the surgeon forms the vagina, clitoris and labia. For a long time only the skin of the penis was used for the neo-vagina. “This technology is now outdated,” says Mijuskovic. Because it is very dependent on the length of the penis. This can be a problem for trans women who have a rather small penis due to the lack of male puberty.
Today’s standard intervention for the neo-vagina at the University Hospital Basel takes advantage of the fact that the urethra of a biological man is significantly longer than that of a biological woman. A vagina is formed from the excess urethral tissue – together with the skin of the penis. “This method almost always works,” says the surgeon.
Alternatively, the neo-vagina can also be made from intestinal mucosa. But this requires a major abdominal operation. In addition, some of the trans women treated in this way complain about an unpleasant odor from the neo-vagina. Or the mucus production is so strong that the trans woman has to change the panty liner again and again. “That can be very disruptive in everyday life,” says Mijuskovic.
For a good result, the neo-vagina must be regularly expanded after the operation. It takes three to six months for the wound to heal completely. In addition to the usual surgical complications such as bleeding and infections, fistulas can rarely develop. These are connections between the neo-vagina and the rectum or urethra. Also feared are narrowing of the urethral opening with difficulty urinating. “Such problems can usually be solved with corrective surgery,” says Mijuskovic.
“Klipping” and big penis construction for trans men
If a trans man decides to have his genitals surgically adjusted, this usually requires several surgical steps. The uterus, ovaries and vagina are removed. With the new penis, a distinction is made between “small” and “large” structures. In the first case, the clitoris, enlarged by the testosterone effect, is mobilized so that it is mobile. Then the urethra, previously lengthened with material from the labia minora, is pulled up to the tip of the clitoris. The result is called a klippen. It allows many trans men to urinate standing up.
In the “big construction” a penis is constructed with skin and subcutaneous tissue from the forearm or thigh. The arteries, veins and nerves of the tissue are connected to blood vessels and nerves in the groin area under the operating microscope. According to Mijuskovic, the patient should then have a feeling in the penis after nine to twelve months.
Another operation is required for penetrative sex. An erection prosthesis is built into the surgically formed penis. There are semi-rigid prostheses that can be bent by hand and hydraulic penile implants that stiffen at the push of a button. Saline water runs into the implants via a pump.
Can trans men and trans women who have had genital surgery orgasm during sex? “This is possible in 80 to 90 percent of cases,” says Mijuskovic. Because during the interventions, the biological clitoris or part of the biological glans of the penis is integrated into the new genitalia. This should preserve the ability to have an orgasm.
Most trans people who have surgery are around 20 years old today, says Mijuskovic. The average age has fallen in the last ten years because the topic is more socially accepted today. However, she still operates on many patients between the ages of 30 and 50, some of whom are even older.
But what fascinates the doctor about gender surgery? The stories and experiences of these people, says Mijuskovic. “It’s a very interesting clientele.” But there are also exciting and complex procedures that she likes to carry out. It is also very nice to see how grateful the patients are. “I can give them something they’ve been missing.”
When she hears the sometimes dramatic stories of suffering from her patients, she has to help them, explains Mijuskovic. In society, however, she also perceives critical to negative voices. Even among doctors. “These are mostly people who don’t want to believe that there is such a thing as a trans identity.”
You occasionally hear of trans people regretting their gender reassignment. That certainly happens, says Mijuskovic: “But I myself have never seen a patient during my consultation who said I regret the procedure because I was wrong about my trans identity.” But what you have already heard: “If I had known what to expect, I don’t know if I would do the surgery again.” That is why it is so important to explain the operation and the expected results, says the doctor. So that there are no unrealistic expectations.
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