Plastic Surgery and Sex Affirmation Surgery

Plastic surgery is very valuable to a group of people who seek surgical treatment to bring their physical body in line with their core identity.

These people have transexualism. The more medical term for this is gender dysphoria. There is a very strong and persistent feeling of mismatch between a person’s assigned legal sex and their core “brain sex”. They have a body that appears physically to be the sex opposite to that of their brain sex.

Gender dysphoria is characterized by the following:
1. A sense of belonging to the opposite sex and a feeling of being born into the wrong sex
2. A sense of estrangement from one’s own body, so that any evidence of one’s own biological sex is experienced as repugnant.
3. A strong desire to physically resemble the opposite sex and to seek treatment, including surgery, to achieve this.
4. A wish to be accepted in the community as belonging to the opposite sex.
5. Persistence of these feelings, often since childhood.
6. No evidence of psychiatric illness.

When this discomfort is strong and persistent, the man or woman wants to take steps to bring their body into re-alignment with their core gender (brain
sex) through medical means. The medical treatment involves hormone therapy and corrective surgery and results in a physical re-alignment of physical characteristics. The plastic surgery for this used to be called a sex change operation but this is not really correct: the person does not change sex, his or her body is brought into conformity with the core sexual identity of the person. Today the plastic surgery is called sex affirmation surgery.
The term sex re-assignment surgery is still being used but people with transsexualism prefer the term sex affirmation surgery.

This plastic surgery is not easy to get, nor is it cheap and it is not covered by insurance. The surgery has been around for quite awhile, the first surgery for male to female having been done in 1920 and that for female to male at Johns Hopkins in 1966.

The patient must conform to what are called standards of care and, although they vary from surgeon to surgeon and from state to state they tend to include the following. 1. The patient should show evidence of stable transsexual orientation. 2. The patient should show insight into his/her condition and should not suffer from any serious psychiatric disorder. 3. The patient should be able to “pass” successfully as a member of his/her brain sex and there should be clear evidence of cross gender functioning. 4. Improvement in personal and social functioning should be predicted for the individual prior to and after surgery. The individual must complete at least three months of psychotherapy and be cleared by at least one mental health professional, preferably a psychiatrist. There are strenuous objections to these standards and anyone getting the surgery in Thailand, for example, can get very good surgery by passing on one standard: the individual must be able to pay for the surgery.

Prior to surgery the individual will have been on hormone treatment for at least one year. If the individual has a male body, breast should have formed. If these are not satisfactory, breast augmentation is performed. Then a vaginaloplasty or vaginal reconstructive surgery is done.

The testicles are removed and the skin of the foreskin and the penis are used as a flap preserving blood and nerve supplies to form a fully sensate vagina. A clitoris fully supplied with nerve endings can be formed form part of the glans of the penis. If the patient has been circumcised or if the surgeon’s technique uses for skin in the formation of the labia minora, the pubic hair follicles are removed from some of the scrotal tissue, which is then incorporated within the vagina. Other scrotal tissue forms the labia majora.

Sometimes the surgeon prefers to do the outer vulva as a second surgery. This is a fairly minor surgery and is usually performed with a local anesthetic.

In the best cases, even a gynecologist has difficulty telling a trasnswoman from a female at birth.

The vagina must be kept open for the rest of the patient’s life using medically graduated dilators at first several times daily and eventually once a week.

Occasionally surgery is done to feminize the face in the jaw, brow, forehead, nose, or cheek. Tracheal shaves are sometimes used to reduce the cartilage making up the Adam’s apple.

Hormones don’t alter the pitch or range of the voice and so sometimes voice surgery is done, although voice lessons are far more common.

Many brain men do not have genital surgery but do undergo a double mastectomy, the removal of the breasts and the reshaping of a masculine chest. A hysterectomy is also usually done. Hormone treatment results in growth of a beard and the dropping of the voice.

There are two types of bottom surgery. The first is the metiodeoplasty. The clitoris is released from its hood and the urethra is lengthened with the labia minor to end at its tip. Hormones have increased the size of the clitoris and the surgery results in what appears to be a small penis. The labia major are united to form a scrotum where prosthetic testicles can be inserted. This surgery is much simpler than full-scale phalloplasty with much fewer complications. Surgery lasts 1-2 hours versus 8-10 hours. It is also much cheaper.

In phalloplastry tissue from the inner labia is rolled up with part of it forming the new urethra and it is grafted to its new place between the thighs. Sensation is retained in the clitoris, which is now at the base of the neo phallus. Often a large nerve in the graft is connected to nerves either from the clitoris or nearby nerves. Nerves from the graft and the tissue it has been attached to usually connect after awhile, adding sensation. This is the most common for of phalloplasty and it produces the best results and the best aesthetics.

It cannot be emphasized strongly enough that those who seek sex affirmation surgery have suffered a great deal and that surgery and hormone treatment offer great relief.

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