Sex reassignment surgery

from Wikipedia, the free encyclopedia

Sex reassignment operations ( GA-OP for short ) are surgical sex reassignment measures in which primary or secondary sexual characteristics are adjusted in appearance and function to the sexual sensation. These interventions are carried out on intersex and trans people. The same or similar surgical techniques are used when it comes to restoring sexual characteristics after an accident or illness.

Since the 1960s , these operations have often been performed on intersex children without medical indication and without the effective consent of their parents as early as infancy. Often no sufficient medical education was about the massive consequences of the subsequent, usually counterproductive chromosomal hormone treatment instead of, among other things, for later infertility led. Since a new regulation in Section 22 (3) of the German Civil Status Act on November 1, 2013, no gender entry has to be made in the birth register if a child cannot be assigned to either the male or female gender. In a statement from 2012, theGerman Ethics Council stated that surgical interventions to establish a certain gender affiliation were associated with massive physical and mental impairments for many adults affected. A guideline of the Society for Pediatrics and Adolescent Medicine takes this into account by now judging surgical interventions in infants with more reluctance. On May 22, 2021, a general ban on the operation of intersex children who are incapable of consent came into force in Germany.

Since a decision by the German Federal Constitutional Court on January 11, 2011, adult trans people no longer necessarily have to undergo an operative genital adjustment in order to achieve a change in civil status according to the Transsexual Act .

The interventions in detail

Surgical interventions are listed that are carried out on trans people who wish to do so, i.e. people in whom the feminine sexual characteristics appearing to be masculine are to be changed or vice versa. Interventions in intersex people or reconstructive interventions have to be adapted much more to the extremely different circumstances in individual cases.

In trans people, surgery is almost always preceded by sex hormone therapy . According to today's standards, a lifelong continuation of the hormone administration is necessary beyond the operations, since hormone deficiency symptoms can otherwise occur after the removal of one's own gonads . This hormone therapy also develops the secondary sexual characteristics of the opposite sex. However, the secondary sexual characteristics of one's own anatomical sex are largely retained, and the effect on the primary sexual characteristics is usually only slight. A genital adjustment operation cannot be used to establish fertility . In both sexes, the interventions after removal of their own gonads lead rather to sterility .

A distinction is made between genital adjustment interventions, i.e. those that take place on the primary sexual characteristics, and further interventions that affect the secondary sexual characteristics.

Trans men (woman-to-man)

Mastectomy

This refers to the removal of the female mammary gland while preserving the nipple and at least part of the skin, leaving a flat breast. There are different techniques, which are also clearly dependent on the initial situation (breast size). The aim is an aesthetic situation with the smallest possible scars. In contrast to surgery for breast cancer, the skin and nipples can be spared.

Hysterectomy with adnexectomy

This refers to the removal of the internal female organs, i.e. the uterus , ovaries and fallopian tubes . Such an intervention is recommended primarily because of the increased risk of cancer from hormone treatment. The hysterectomy is performed either through an abdominal incision or through the vagina , very rarely endoscopically . It is a standard procedure these days. The length of stay is between three and ten days.

Genital adjustment surgery

Result of a genital adjustment operation on a penis

The construction of genitals that appear male (phalloplasty) is more complicated and risky. The following techniques are common; In all of them, a scrotum is usually formed from the labia majora and filled with plastic testicular prostheses :

  • Metaidoioplasty : The clitoris , enlarged by hormone therapy, is partially cut free from its skin and a urethra is formed from the labia minora.
    The result usually looks authentic - but very small. The sensitivity is largely retained, the size is usually between 2 and 3.5 cm. With the right technique, sexual intercourse is usually possible. Metaidoioplasty is a relatively low- complication method and no tissue from other parts of the body is transplanted. The length of stay in the hospital is one to two weeks.
  • Forearm plastic : A skin flap with underlying tissue, veins and nerve cord is removed from the non-dominant forearm (mostly on the left), less often from the upper arm or the lower leg. A penoid is then formed from these . Occasionally, this technique is combined with metaidoioplasty, then the procedure is performed in two steps. The veins and the nerve cord are connected in the groin, so that the penoid gains its own blood supply and sensitivity. In this method, the urethra is usually led to the tip of the penoid.
    There is usually a scar at the removal site. Depending on the surgical method, the sensitivity is usually largely preserved. The size of the penoid is usually 10–12 cm, sometimes more. Depending on the arm thickness, the circumference is usually small. In a second operation, plastic testicular prostheses and a stiffening implant (which were developed for men with erectile problems and therefore contribute little to the size) are installed so that sexual intercourse is possible. The length of stay is two to six weeks.
  • Abdominal muscle plastic : One of the two longitudinal abdominal muscles is loosened from the costal arch, rolled up, folded down and shaped into a penis-like structure with inguinal skin flaps. The urethra is seldom led to the tip of the penoid; it usually ends at the base of the same. This is an extremely complicated method, the penis plasty often dies partially or completely.
    The sensitivity can be partially restored after a few years. The size is usually up to 12 cm, sometimes more. Sexual intercourse is possible with a stiffening implant. The length of stay is 6 to 10 weeks for the first procedure.
  • Latissimus dorsi plasty: Due to the fact that the abdominal muscle plasty has not proven itself due to its complication rate and the forearm plasty leads to considerable dissatisfaction in the patients because of the limited possibilities in terms of size, various other techniques have been used in recent years presented to the specialist congresses. The latissimus dorsi plastic from the “widest back muscle”, which can be used to construct a penis with a manageable risk and minimal functional failure , is considered expedient and has therefore now been carried out by several centers around the world . As a rule, even after the healing process has been completed, it is still of a size comparable to that of an original penis.

Trans women (man-to-woman)

Genital adjustment surgery

Result of a genital adjustment operation on a vulva
story

There were precursors to these operations as early as the 1920s. These were carried out in clinics in Berlin and Dresden . After the National Socialists came to power , these centers were closed and most of the medical records were destroyed. The predominantly Jewish doctors went into exile and continued their work and research in various countries. The documents relating to the operation carried out by the Danish painter Lili Elbe by the Dresden gynecologist Kurt Warnekros were probably destroyed during the air raids on Dresden .

Georges Burou , French gynecologist in Casablanca ( Morocco ), influenced in the 1960s fundamentally the male-to-female vaginoplasty. His patients included the French entertainer and singer Coccinelle in 1958 and April Ashley, the first English woman to undergo gender reassignment surgery in 1960 .

Penis Invagination Method

Part of the glans together with the blood vessels and nerves is detached from the penis and sewn back in at the appropriate point. This then creates the new clitoris, which later enables sexual pleasure through the preserved nerve endings. The urethra is also detached and shortened accordingly. The testicles are completely removed just like the erectile tissue on the penis shaft. But there are also techniques in which the latter are sometimes used as vaginal erectile tissue. The penis skin is used to line a created body cavity (inverted) and thus forms the vagina . Finally, the labia are formed from the scrotum . Some surgeons use this method to shape the labia minora from the inner sheet of the penis foreskin . In many cases, a second, smaller operation must be performed after a few months to make some corrections , especially if the artificially created vaginal canal has grown closed again.

The internal sexual organs with their functions such as menstruation and secretion formation cannot be reproduced.

Combined method

In the combined method, the clitoris is also formed from the glans and the associated vessels and nerves in the back of the penis. In contrast to the penis invagination method, however, the inner sheet of the penis foreskin is left on the glans and the clitoris, the clitoral cap and the labia minora are formed from it together with the penile skin . The remaining skin of the penis and the otherwise superfluous skin of the scrotum are used to create the vaginal entrance. In addition, the vagina is lined with the urethra, which is opened lengthways . Except for the large cavernous bodies, all material is used, which is not the case with the usual penis invagination method. In contrast to the penis invagination method, the combined method can achieve sufficient vaginal depth even with a less developed penis.

Breast augmentation

A breast augmentation is then perceived as necessary if the breast growth through the hormone therapy only relatively small breasts. This happens often with tall and broad-shouldered trans women.

Operation in the area of ​​the voice

There are various techniques for achieving a more feminine sounding voice, but these often lead to a noticeably reduced vocal range and, in extreme cases, to complete loss of the voice . For this reason, vocal cord operations have rarely been performed so far.

Basically there is the tightening method and the shortening method (glottoplasty).

Speech therapy supplements these interventions or is initially the method of choice for most man-to-woman trans people. Often, however, the possibilities here are limited due to the fact that the voice pitch is very far removed from the normal female range.

Reduction of the Adam's apple

This procedure may be necessary if the larynx or Adam's apple is noticeably large. It is usually a rather unproblematic procedure.

Further interventions

In addition to the measures mentioned, further interventions, especially plastic-surgical, facial feminization surgery (FFS), may be necessary or desirable in some cases . Especially with these interventions, the medical necessity is often controversial, without which the statutory health insurance will not cover the costs. Such operations include, for example, reducing the size of the nose, chin and forehead bulges, enlarging the cheekbones or padding the hips with appropriate inserts. Occasionally, the right and left lower ribs are also removed to narrow the waist and make the hips appear wider.

story

Early history

The early history of surgical measures to change the primary and secondary sexual characteristics, in particular with the aim of completely eliminating the sex drive z. For example, by castration , can be such as through various primitive peoples Indians up in the Ancient Egypt trace and other early cultures. For example, among the Phrygians in Asia Minor there was a fertility cult in honor of the goddess Cybele , during which sheer castration excesses took place in ecstatic rites . The Galloi , priests or temple servants of the ancient Phrygian Great Goddess Cybele or Great Mother, castrated themselves with a sharp stone after orgiastically increased frenzy during the solemn trains for the mother-goddess

The castration cult was also cultivated in the Roman Empire , among other things. in honor of the goddess Diana . Male slaves and serfs who were “emasculated” into so-called eunuchs or castrati were primarily affected . The radical measures, in which mostly the scrotum , but sometimes also the penis, were removed, often ended fatally, as they mostly took place without any anesthesia and under unsanitary conditions.

As medicine developed, so too did the risk of fatal complications. While these early "operations" were still shaped by a socially hierarchical and religious way of thinking, intended for guardians of a harem or as dishonorable punishment, a different gender image slowly developed in the course of the Renaissance . This was followed by a feminization of the male gender identity , while women experienced an increasing masculinization through increasing positions of power. The actual desire to belong to the opposite sex cannot be clearly dated historically. Baroque and Rococo certainly already showed many varieties and facets of gender assimilation in fashion and habitus . Presumably, some doctors of the 17th or 18th century already dared to perform gender reassignment operations. However, this was done less for the patient's benefit than in his own interest to expand the scientific spectrum experimentally. Many sexual hybrids are known in the area of androgyny , which were often presented as "monsters" at markets or circus events. Here, too, assistance was often given with operational means (the woman with a beard, men who sang opera arias in the highest tones with their castrato voices, etc.).

20th and 21st centuries

Sexology

The doctor and sexologist Magnus Hirschfeld provided the first serious insights into the psychological and physical problems of trans- or intersexuality at the beginning of the 20th century. It was also Hirschfeld who formulated the terms homosexuality , transvestism and transsexuality . Hirschfeld wanted to scientifically investigate people's desire for a " gender reassignment ". As early as the 1920s, with the suggestion and help of the staff at his Institute for Sexology in Berlin, Hirschfeld succeeded in having identity changes, name changes and so-called transvestite certificates issued. The first surgical "sex reassignments" were also carried out.

In 1923 he first used the word "transsexualism" in connection with transvestism, but without defining it.

Endocrinology and Surgery

The effects of sex hormones had already been discovered in endocrinology around 1900 . With the chemical isolation of sex hormones, a new era of sexual medicine began: As early as 1918, injections of testicular and ovarian extracts were reported, which corresponds to the first attempts at hormonal adjustment to the perceived gender.

The first surgical genital adjustments were carried out in the early 1920s. The surgeons were already trained in genital operations after treating the injured during the First World War . The doctors had also gained a lot of new knowledge through the failed experiments on “normalization” or “reversal of polarity” from homosexuals to heterosexuals. The Institute for Sexology in Berlin played an essential role in the psychological assessment, preparation and execution of the operations. Most patients asked for the offending testicles or ovaries to be removed.

The head of department at the Institute for Sexology Felix Abraham reported on the first complete sex reassignment operation in 1931 in the article "Gender reassignment on two male transvestites" . Abraham was responsible for advising the transvestites. In the course of the 1930s, the first plastic operations were gradually carried out. This is how Abraham described the castration or ectomy of ovaries by Levi Lenz, while he himself performed operations to shape a vagina.

In the course of the 20th century, the methods for genital adaptation to the perceived gender were refined, both in conservative therapy and in operative measures. In the 1950s, the subject matter and medical procedures were particularly common among US doctors. Surgical genital adjustments were often carried out on intersex children as early as one to two years of age. Numerous new - often questionable - measures have been developed, such as the extremely painful bougienage , in which the artificially created vagina is penetrated and widened with penis-like tools so that the newly created female body becomes "capable of copulation". On May 22, 2021, a general ban on the operation of intersex children who are incapable of consent came into force in Germany.

With modern conservative therapy, the hormone dosages today have fewer side effects than in the 1950s and 1960s . Even in the 1960s and 1970s, hormone-related hair and tooth loss as well as fungal diseases and the like were often observed. The surgical measures have also been simplified with laser technology and new methods in plastic surgery , but they still mean a radical intervention in the body.

Social law

As early as 1981 the State Social Court of Stuttgart recognized transsexualism as "an illness within the meaning of the statutory health insurance, which, if there is a medical indication, triggers the health insurance company's obligation to provide benefits for gender-changing funds and measures".

Sex politics in the GDR

“We can make men out of women, but not fish out of men” was a popular saying among GDR swimming coaches in the 1970s and referred to doping with androgens . Many former athletes suffered permanent physical and psychological damage as a result of the intensive hormone treatments. Quite a few decided to have genital surgery after their active career or after the fall of the Berlin Wall. The legislation of the GDR was a few years ahead of the Federal Republic of Germany with the “Order of the Minister of Health on the gender reassignment of transsexualists” of February 27, 1976. The local transsexual law ( Federal Law Gazette 1980 I p. 1654) came into force on January 1, 1981.

Web links

Wikibooks: Gender and Identity  - Learning and Teaching Materials

Individual references and comments

  1. ↑ Law on the amendment of personal status regulations of May 7, 2013 (Federal Law Gazette I, p. 1122) ( Memento of August 19, 2014 in the Internet Archive )
  2. ↑ intersex . Statement of February 23, 2012 ( Memento of March 18, 2016 in the Internet Archive ; PDF) German Ethics Council; accessed on October 23, 2014.
  3. ↑ old : Guidelines of the Society for Pediatrics and Adolescent Medicine. No. 027/022: Sexual development disorders. On: uni-duesseldorf.de (creation date 2007) ( Memento from August 15, 2009 in the Internet Archive )
  4. ↑ new : German Society for Urology (DGU) eV / German Society for Pediatric Surgery (DGKCH) eV / German Society for Pediatric Endocrinology and Diabetology (DGKED) eV: S2k - Guideline 174/001: Variants in gender development. On: awmf.org from 07/2016 ; last accessed on January 19, 2021.
  5. ↑ Federal Law Gazette . Retrieved May 23, 2021 .
  6. ↑ Decision of January 11, 2011 1 BvR 3295/07 decision in full text
  7. ↑ Decision of January 11, 2011 1 BvR 3295/07 press release
  8. ^ H. Top, S. Balta: Transsexual Mastectomy: Selection of Appropriate Technique According to Breast Characteristics. In: Balkan medical journal. Volume 34, number 2, April 2017, pp. 147–155, doi: 10.4274 / balkanmedj.2016.0093 , PMID 28418342 , PMC 5394296 (free full text).
  9. ↑ Removal of the uterus . Meine-gesundheit.de; accessed on November 16, 2015.
  10. ↑ Yves Steinmetz: Gender reassignment operations in woman-to-man trans people with phalloplasty. Comparison of different surgical techniques and assessment of the surgical results . (PDF) Hamburg, University Dissertation, 2010; accessed on October 28, 2014.
  11. ↑ a b Infotext (PDF) accessed on November 16, 2015
  12. ↑ a b Information text on Chirurgie-Portal.de
  13. ↑ Latissimus dorsi plastic. Quality report 2006 St. Antonius Hospital (PDF; 4.6 MB) p. 112, 5-643 Plastic reconstruction of the penis.
  14. ↑ see Galloi # Die Selbstentmannung / Walter Burkert: Ancient Mysteries. Functions and Salary. Beck, Munich 1990, p. 93 / Walter Burkert: Cults of antiquity. Biological foundations of religion (= CH Beck cultural studies ). Beck, Munich 1998, ISBN 3-406-43355-3 , pp. 112, 204.
  15. ↑ a b Rainer Herrn (Head of the Research Center for the History of Sexology of the Magnus Hirschfeld Society ): From sex change mania to sex change. On the history of transsexuality. In: pro Familia magazine. No. 2, 1995, pp. 14-18; at the same time in: Communications from cultural studies research. (MKF). Volume 18, 1995, No. 36, Subject volume: Different sexualities. Pp. 197-207.
  16. ↑ taz Hamburg, November 19, 2001
  17. ↑ Federal Law Gazette . Retrieved May 23, 2021 .
  18. ↑ Landessozialgericht Stuttgart, judgment of November 27, 1981 - Az .: L 4 Kr 483/80.
  19. ↑ Volker Caysa : body utopias: a philosophical anthropology of sport. Campus publishing house, Frankfurt a. M. / New York 2003, ISBN 3-593-37248-7 , p. 282. Limited preview in Google book search
  20. ↑ Ulrike Klöppel: The "decree on gender reassignment of transsexualists" as reflected in the sexual policy of the GDR . "Learning from History" portal, 2014. Accessed October 29, 2014
  21. ↑ Ursula Sillge: In -Visible Women: Lesbians and their emancipation in the GDR. Links, Berlin 1991, ISBN 3-86153-012-0 , p. 68. Restricted preview in Google book search