Gender reassignment surgery, or as it is commonly known as sex change operation, is a highly complex surgery performed for patients with gender identity disorder. Gender identity disorder is a unique human condition which is classified as psychological and behavioral condition. This is a condition where patient morphologically belongs to one of the two sexes but behaviorally takes the role of that of opposite sex.
The treatment of these patients involves multidisciplinary approach, the first step being confirming the diagnosis. The patient with gender identity disorder has distress or discomfort with his or her gender. Continuous psychological evaluation is required initially. A trial of cross living is given and his or her psychological functioning is assessed for a period of 1 to 2 years. Hormone therapy may be instituted during this period and its responsible intake is evaluated. This leads to suppression of secondary sexual characters and more successful gender transformation is achieved.
The final step in this journey of gender transformation is carried out by a plastic and reconstructive surgeon.
The demand for this surgery has outpaced the number of qualified caregivers. It should be thoroughly understood that gender confirmation is a complex process and multiple surgeries are required for complete transformation. For this reason only mentally stable patients who understand the risks and benefits are brought to the operation table after thorough psychoanalysis.
Male to female Transformation
The prevalence of male to female conversion are higher than that of female to male conversions. The surgery for male to female conversion is relatively straight forward and much less complex. Our surgical goals are to create perineal-genital complex as feminine as possible, free of any fistula/stenosis, minimal scars and neuromas as possible, creation of short urethra with an ability to void with a straight stream, and minimal donor site morbidity.
The options for vaginoplasty for male to female conversion are Penile inversion vaginoplasty and bowel segment vaginoplasty.
Penile inversion vaginoplasty involves use of penile and scrotal skin for lining the neovagina whereas, in bowel segment vaginoplasty intestine is used for lining the neovagina. We prefer to perform penile inversion vaginoplasty due to its simplicity of execution and its ability to provide good results. Moreover, an abdominal surgery is avoided with above technique and there is increased risk of stenosis, fistula, colitis and Crohn’s disease in bowel segment vaginoplasty.
Clitoroplasty and Labiaplasty is also performed along with the creation of neovagina. This provides good sensitivity and sexual satisfaction to these patients. Other ancillary surgical procedures that are required in male to female transformation are breast augmentation, facial feminization surgery, rhinoplasty, mentoplasty and thyroid cartilage reduction. Voice change surgery may be required in some patients.
Female to Male Transformation
The surgeries performed for female to male confirmation are highly complex. The goal of this surgery is to create a new phallus allowing the patient to micturate in standing position and perform gratifying sexual intercourse. The conversion from female to male starts from in removal of the uterus, ovaries and both breasts. Usually this is performed in the single stage. The next stage is creation of neophallus i.e. phalloplasty. Phalloplasty is performed using tissue from forearm or thigh and in some cases from the back.
We find radial forearm flap to be the best choice for penile reconstruction as it provides adequate tissue for creation of urethra and phallus along with good sensations for neophallus.
Inflatable implants or any other material insertion for stiffness of neophallus is done in the later stage.Vaginectomy and scrotoplasty is also required in these patients. Other ancillary procedures that are done are creation of Adam’s apple, testicular implants, hair transplant and voice change surgery.