Transsexualism: A Medical Overview

Third Edition, March 1998


This booklet was written as a summary of current practice for the medical treatment of male-to-female transsexuals. It is not intended as a general introduction to the condition: for such an introduction your attention is drawn to the booklet "Transsexualism: A Primer".

This booklet was written as a general overview of current medical practice; it is not intended as a medical textbook. Much of the material was gathered from existing medical literature, supplemented by personal experiences of some of the contributors to this booklet. Contributors include transsexual women as well as a counsellor and electrologist.

Every effort has been made to ensure that this booklet is as complete and accurate as possible, but the publishers cannot accept liability for any errors or omissions.

©The Looking Glass Society, 1997/8.
This booklet may be copied unchanged in its entirety and distributed for any non-commercial purpose promoting the understanding and well-being of transsexual people. Copying outside these terms requires the Society's written permission.


1  Introduction
2  Standards of Care
3  Diagnosis
4  Counselling and Psychiatry
5  The Real Life Test
6  Electrolysis
    6.1  General
    6.2  Pain Control
    6.3  Aftercare
    6.4  Genital Electrolysis
    6.5  Laser Epilation
    6.6  Tweezer Electrolysis
    6.7  Home Electrolysis Kits
7  Speech Therapy
8  Hormone Treatment
    8.1  General
    8.2  Risks and Monitoring
    8.3  Oestrogens
        8.3.1  Oestradiol Valerate
        8.3.2  Ethinyloestradiol
        8.3.3  Conjugated Natural Oestrogens (Premarin)
        8.3.4  Other Oestrogens
    8.4  Progestogens
        8.4.1  Medroxyprogesterone Acetate
        8.4.2  Dydrogesterone
        8.4.3  Natural Progesterone USP
        8.4.4  Synthetic Progestogens
9  Antiandrogens, GnRH Agonists and Orchidectomy
    9.1  Antiandrogen Drugs
        9.1.1  Cyproterone Acetate
        9.1.2  Flutamide
        9.1.3  Spironolactone
        9.1.4  Finasteride
    9.2  GnRH Agonists
        9.2.1  Nafarelin Acetate
        9.2.2  Goserelin Acetate
        9.2.3  Leuprorelin Acetate
    9.3  Bilateral Orchidectomy
10  Gender Reassignment Surgery
    10.1  Introduction
    10.2  Techniques and Results
        10.2.1  Penile Inversion Vaginoplasty
        10.2.2  Colovaginoplasty
        10.2.3  Cosmetic GRS
        10.2.4  Clitoroplasty
11  Care of Post-Operative Patients
    11.1  Introduction
    11.2  Hormones Post-Operatively
    11.3  Post-Operative Infections and Hygiene
    11.4  Post-Surgical Complications
    11.5  Health Screening
12  Other Surgical Procedures
    12.1  Augmentation Mammoplasty (Breast Enlargement)
    12.2  Rhinoplasty (Nose Remodelling)
    12.3  Thyroid Chondroplasty (Tracheal Shave)
    12.4  Crico-Thyroid Approximation
    12.5  Other Voice-Changing Procedures
    12.6  Hair Transplantation
    12.7  Other Cosmetic Surgery
    12.8  Dermabrasion and Skin Peeling

1   Introduction

This booklet was written in response to a perceived need among General Practitioners, Counsellors and other healthcare professionals for an up-to-date summary of the medical aspects of male-to-female transsexualism.

Transsexualism is a relatively uncommon condition, and many GPs may never have encountered a transsexual ('TS') patient before. Information in many medical/psychiatric textbooks is scanty and out-of-date, especially in the light of recent research which strongly demonstrates a basis for the condition in brain anatomy [Swaab et al., 1995] .

The reader is referred to the companion booklet "Transsexualism: A Primer" for a general introduction to the condition and the terms used in connection with it, as well as a discussion of the aetiology of the condition.

2   Standards of Care

A set of 'Standards of Care' for the hormonal and surgical gender reassignment of gender dysphoric persons was laid down some years ago by a conference of medical professionals, and is widely used as a set of guidelines within the medical profession in many countries including the UK [The Harry Benjamin International Gender Dysphoria Association Inc., PO Box 1719, Sonoma CA 95476, USA] .

These standards lay down a set of 'rules' governing gender reassignment treatment. Central among these rules is a requirement for a 'real-life test' (RLT) of at least one year lived in the new gender role, along with two psychiatric referrals, before surgery is permitted. There are also guidelines regarding hormone treatment.

It must be emphasised that the Standards do not have the force of law, and are now considered overly rigid by many patients and professionals alike. In particular, the Standards call for a minimum of three months of psychotherapy before hormone treatment is initiated, but most authorities on the condition agree that this is unnecessary in the majority of patients. Likewise, the Standards call for a minimum 1 year RLT before permitting orchidectomy; many surgeons and psychiatrists in Britain recognise the value of earlier orchidectomy in appropriate patients.

There are at least two 'alternative' sets of Standards of Care, promulgated by groups with a greater input from the client group, which seek to provide adequate guidance and cover against allegations of malpractice for the professionals, while being less of an 'obstacle course' to the patient. Both are based on the principle of 'informed consent' by the patient.

3   Diagnosis

The diagnostic criteria normally used for diagnosing transsexualism (often termed 'Gender Identity Disorder' (GID) by psychiatrists) are laid down in the American Psychiatric Association's Diagnostic and Statistical Manual, 4th edition (referred to as 'DSM-IV').

In summary however, the key features of GID are:

The diagnosis is properly made by a Consultant Psychiatrist with special experience of gender problems; however a GP, Counsellor or general Psychiatrist might reach a tentative diagnosis and would then refer the patient to a suitable specialist.

Care is necessary when the patient has a separate psychiatric condition such as schizophrenia. In some cases, such conditions may mimic transsexualism. Existence of a separate psychiatric condition does not necessarily contraindicate gender reassignment provided that GID can be clearly demonstrated to exist independently of other conditions. In particular, depressive conditions are very common among transsexuals (for obvious reasons depression can be a consequence of severe gender dysphoria) and should be treated alongside the GID.

Once the diagnosis is made, the specialist will probably prescribe hormone treatment and possibly other procedures such as speech therapy. In addition, routine blood tests are required for TS patients under hormone treatment; provision of most of these services will usually be a matter for the patient's GP in consultation with the patient's Consultant Psychiatrist.

The principal Gender Identity Clinic (GIC) within the NHS is located at Charing Cross Hospital, London. There are also a few regional GICs. It appears at present (as reported by patients) that all the NHS GICs are severely overworked with long waiting lists, and struggle to provide timely treatment to patients; there is also widely reported patient dissatisfaction, particularly with Charing Cross. For these reason, many patients opt to have a private Consultant Psychiatrist perform the diagnosis and recommend treatment, some of which can be NHS provided depending on local policy.

A special comment is warranted regarding the treatment of patients with a physical intersex condition (true or pseudo hermaphroditism, Androgen Insensitivity Syndrome, Congenital Adrenal Hyperplasia, Klinefelter's Syndrome etc.): The Standards of Care state that such patients should first be treated with recognised treatments for the intersex condition; then in the event of continuing gender dysphoria should be treated as ordinary transsexuals. This is often not an ideal course: all too many examples exist of intersexed patients who have been arbitrarily assigned (by use of surgery and/or hormones) to one sex or the other shortly after birth, only for it to become painfully apparent later that the wrong choice was made. These problems are often compounded later by misguided attempts to 'reinforce' the assigned sex by surgical, hormonal or behavioural intervention. The greatest caution should be exercised in cases of gender dysphoria accompanying a physical intersex condition and the advice of a Consultant Psychiatrist experienced in gender identity issues should be sought before any intervention is considered.

4   Counselling and Psychiatry

It should be emphasised that transsexualism itself is not a psychiatric disorder, although it may be a contributory factor for other psychiatric conditions such as depressive conditions. Furthermore, some delusional conditions may mimic transsexualism, making diagnosis by a Consultant Psychiatrist experienced in gender identity issues advisable.

Transsexuals vary greatly in their need for counselling or psychiatry. At one extreme, one could see a patient who has detailed knowledge of the condition, has planned exactly how she intends to deal with it, and only requires the diagnosis to be confirmed by a Consultant Psychiatrist who will start her on the appropriate treatment.

Conversely, a patient might have a severe depressive disorder and a history of suicide attempts and might need extensive support from a counsellor and/or psychiatrist before or during their gender role changeover. They may also be uncertain as to whether they are genuinely transsexual or not.

Patients with severe psychiatric problems associated with their GID should be referred to a psychiatrist experienced in transsexual issues. Other patients will probably find the services of a counsellor sufficient, again it must be emphasised that it is important to refer patients to a counsellor experienced in transsexual issues. Attempting a psychiatric 'cure' on a genuine transsexual is disastrous and must be avoided at all costs; an experienced gender counsellor will be able to help the patient explore her own issues and experiences and decide for herself whether she is indeed a genuine TS who should undergo sex reassignment, or if she is in fact a transvestite who merely requires support in learning to accept her own nature.

5   The Real Life Test

It is normal practice for any Gender Identity Clinic or private Consultant Psychiatrist to require a 'Real Life Test' (RLT) in which the patient lives and works full-time in the new gender role, before genital surgery is performed.

The patient will change her name legally at the start of the RLT, and is expected to demonstrate her ability to work (this includes voluntary work, or higher education) and function socially as a woman. The early stages of RLT can be stressful to some patients: much re-learning is required, she may experience rejection from family, friends and others, as well as numerous practical problems.

It is important that the patient receives the maximum possible support during this time; her counsellor will probably be the main focus of support, but a co-operative and sensitive attitude on the part of GPs and practice staff is also important. Once legal name-change has occurred, the patient should be referred to by her new name, and treated as female. The NHS has a policy of issuing new patient numbers to transsexual patients (and amending their records to show the new gender), and assistance with this administrative issue should be given (at the time of writing, the PPSA is the body responsible).

6   Electrolysis

6.1   General

Almost invariably, male-to-female transsexuals require electrolysis treatment to remove facial hair, prior to or shortly after their change of gender role. In rare cases this has been obtained on the NHS, the patient being referred to a Dermatologist for treatment. However, the majority of patients will find it necessary to purchase private treatment.

There are three recognised methods of electrolysis: Galvanic, Shortwave Diathermy, and Blend (a mixture of Galvanic and Diathermy). Each method has advantages and disadvantages; Galvanic is very seldom used today, but some patients find Diathermy preferable to Blend, others find the opposite. Diathermy frequently gives a quicker result, but some patients find their skin reacts too badly to it, and a patient experiencing slow progress or adverse skin reaction would be best advised to try the other method, or a different electrologist.

Patients should be advised to find an electrologist who has a recognised qualification and, more importantly, one who has proven competence in treating transsexual patients: electrolysis of facial hair, particularly in a phenotypic male, is a delicate and skilled process if the skin is not to be permanently damaged.

6.2   Pain Control

Owing to the nature of male-type facial hair, many TS patients find electrolysis an unpleasantly painful process. Protracted sessions (two hours continuous treatment is not unusual) repeated frequently over a period of years can be traumatic for many patients, especially as pain threshold has been found to decrease under hormone treatment, whilst electrolysis without hormone therapy is frequently ineffective. The problem of pain for TS patients undergoing electrolysis should not be underestimated; pain that is severe enough to make the patient flinch makes the electrologist's task very difficult and may lead to skin damage if the patient cannot avoid moving while the needle is inserted. The pain and its consequent problems can be eased by three possible methods: topical anaesthesia, analgesics and sedatives.

Topical anaesthesia is best provided by prescribing EMLA Cream 5 %for the patient; the 30g surgical pack is recommended. The cream is best applied to the area to be treated at least an hour (some patients require longer) before treatment commences, with reapplication as necessary to maintain a cover of cream until the start of treatment. An occlusive dressing can be used to reduce the amount of cream necessary but is usually inconvenient on the face.

The drawback of this method is that EMLA cream has limited penetration into the skin, thus the deeply-rooted hair follicles found early in treatment may be poorly anaesthetised. The cream works better once the original hair has been destroyed, as re-grown hair is finer and shallower. EMLA cream treatment can be supplemented with analgesics or sedatives if required. In really extreme circumstances an injected local anaesthetic (such as xylocaine) may be used, but this will of course pose the logistical problem for the patient of having a qualified person administer the injection and then travelling to the electrologist before the anaesthesia wears off.

Analgesics such as co-proxamol or dihydrocodeine can be used to supplement the effect of EMLA cream, and should generally be taken around an hour before treatment starts.

Sedatives may assist some patients when treating the most painful areas such as the upper lip, simply by improving the patient's ability to tolerate pain. Lorazepam (1--2mg) or other benzodiazepines have been found to work well in some patients. It should be stressed that sedatives should only be used when really necessary; also the patient must be warned that she will most likely be unfit to drive after taking the sedative. Lorazepam is best taken about one hour before treatment starts.

6.3   Aftercare

Any competent electrologist will provide the patient with a suitable soothing and antiseptic after-care cream, typically witch-hazel based. Some patients find a subsequent application of calamine lotion beneficial. In the majority of patients this will be all that is required, and any inflammation will be mild and transient, but a few patients experience either severe inflammation and swelling, or skin infections.

Some patients experiencing severe inflammation have found an improvement by taking an NSAID (e.g. Voltarol 50mg) and/or an antihistamine before commencing treatment. Topical antihistamines (e.g. Mepyramine Maleate cream 2 %) may prove useful after treatment. In most patients the inflammation is manageable, but in very rare cases it proves intractable, and the patient may have to switch to a different method of electrolysis.

Patients prone to skin infections after electrolysis can be given a topical antibiotic cream; Flamazine (silver sulphadiazine in a soothing cream base) has been used to good effect in many patients --- this is intended for treating burns, and electrolysis simply produces controlled, localised subcutaneous burns.

6.4   Genital Electrolysis

No discussion of electrolysis in the male-to-female transsexual would be complete without some notes on the removal of hair from genital skin prior to gender reassignment surgery (GRS).

The precise method of surgery used depends upon the surgeon performing the procedure; but all methods of GRS place potentially hair-bearing tissue from the penis and/or scrotum in locations where hair would be undesirable and problematical (inside the vagina, under the clitoral hood, and perhaps inside the labia). For this reason, patients are well advised to seek the advice of their chosen surgeon as to which parts must be depilated, and then to obtain the necessary electrolysis well in advance of surgery (to allow the skin to recover).

Genital electrolysis can be exceedingly painful, and the comments made above regarding pain control and after-care apply to genital sites as well as the face. In addition, it must be emphasised that hygiene before and after treatment is paramount, as there is a high risk of skin infections from genital electrolysis. Some patients report using Betadine liquid to good effect, before and after genital electrolysis.

Some patients have found genital electrolysis unbearably painful even with topical anaesthetic cream and analgesics/sedatives, and for this group subcutaneous local anaesthesia may be the only solution. Good results have been obtained with use of Xylocaine 2 % with Adrenaline 1 in 200 000 . The vasoconstrictor action of the adrenaline not only extends the duration of the pain block but effects a substantial reduction in the oedema which often results from electrolysis on genital tissue. It will be necessary for the patient to have the area to be treated clearly marked, so that multiple insertions of the needle can be used to ensure that the entire area is anaesthetised --- as a guide, 5--10 ml of solution will be required for the lower scrotal flap used in peno-scrotal inversion vaginoplasty, and the pain block can be expected to remain adequate for up to three hours. In many cases this is long enough for the electrologist to clear the entire area in one session. When this technique is used on scrotal tissue, a healing period of several weeks must be allowed prior to gender reassignment surgery to allow complete healing: not only does the electrolysis itself cause localised tissue damage that may take 2--3 weeks to heal, but the subcutaneous injection may result in small haematomata which, while generally harmless, must be allowed to heal prior to surgery.

6.5   Laser Epilation

Two methods of hair removal by laser have recently arrived on the market. Both are new technologies and no long-term data is yet available on their safety and efficacy. Some patients have reported good results, however 'horror stories' also abound, and these treatments must, at present, be regarded as experimental and approached with caution, and treatment provided without proper medical supervision (e.g. at certain private clinics) should be avoided under any circumstances.

The great advantages claimed for laser treatment are its speed, as each discharge of the laser can treat numerous hairs, and the lack of a needle which some patients find painful or disturbing. Some patients have claimed good results with laser epilation of the genitals prior to surgery, and some laser clinics are certainly willing to treat the genital area.

The permanency of laser epilation is uncertain at present; indeed, the US Food and Drug Administration specifically prohibits laser companies from claiming permanency. While this may not be a major problem for facial treatment (re-treatment, or treatment of subsequent regrowth by electrolysis would be possible), it is a cause for concern for genital epilation, as re-treatment of skin that post-operatively forms the interior of the vagina is clearly not possible by any method.

In the 'pure laser method', a wavelength of laser light is chosen that is strongly absorbed by melanin. The reasoning is that melanin should be very much more concentrated in hairs than in skin, so the laser light causes selective heating of the hairs, including the root, to a temperature at which protein coagulation occurs, killing the hair follicle.

The principal problem with this method relates to pigmentation and the distribution of melanin. Some patients with very dark hair and pale skin report good destruction of hair with no skin damage; conversely there have been problems with darker-skinned patients as the melanin in their skin causes a dangerous degree of general heating of the skin, causing scars and possible destruction of sebaceous glands (leading to intractably dry skin); and pale-coloured (or grey) hair contains little or no melanin and therefore cannot be treated effectively by this method.

In the 'dye method', a light-absorbing compound is applied to the face and the surplus is then wiped off. The intention is that some of this compound will remain in the hair follicles, increasing the absorption of laser light. The main problems are that the method is indiscriminate: any pore or indentation in the skin will be filled with the compound and thus heated when the laser is discharged; severe damage to skin has been reported. Furthermore, the compound tends not to penetrate deeply into hair follicles, leading to surface heating which may scar the skin and does little to destroy the hair follicle.

6.6   Tweezer Electrolysis

A variety of variations on this theme have been marketed, and new ones appear each year, accompanied by a great deal of marketing 'hype'. The intention is that current is passed down the hair itself from a tweezer-like electrode, and no needle is used. It can readily be demonstrated from electrical theory and some simple bio-electrical measurements, that it is quite impossible to transfer enough energy into the follicle by this method to destroy it, even at the maximum voltage permitted by law. Clinical trials have supported this conclusion, finding that tweezer electrolysis quite simply amounts to nothing more than plucking the hairs, and is a waste of the patient's money.

6.7   Home Electrolysis Kits

These items are widely available on the retail market, and are generally very simple, low-powered, galvanic electrolysis units. In practice the power levels developed are quite insufficient to treat male-type hair, and again these products are quite useless in the treatment of transsexuals.

It should be stressed once again that destroying male-type facial hair without causing skin damage is a skilled and delicate process which should only be entrusted to a reputable electrologist with proper equipment and prior experience of treating transsexual clients.

7   Speech Therapy

The majority of male-to-female transsexuals will have male-sounding voices which have broken normally at puberty. Neither hormone treatment nor genital surgery will affect the voice, so the patient must learn to produce an acceptable 'female' voice if she is to integrate into normal society. Some individuals are able to adapt their voices quite readily, many require professional help, a few may have very little success even with professional tuition.

Speech therapy has provided great benefits to many transsexual patients, and a number of speech therapists have at least some experience in treating either transsexuals, or women with androphonia.

The availability of speech therapy on the NHS appears to be variable. Fundholding GPs can purchase the service directly and will no doubt have an existing contract with a hospital trust that can provide speech therapy. Non-fundholders will be dependent upon the Health Authority agreeing to fund a referral to a speech therapist. Speech therapy is a very necessary treatment for many transsexuals, and while it is of course available privately, many patients will be unable to afford it.

In some cases, a written request from the patient's Consultant Psychiatrist might influence a decision on funding. If speech therapy proves to be unobtainable, there are some 'self-help' resources available to patients in the form of tapes or written material, including a brief document on "Feminine Speech Techniques" published by the Looking Glass Society.

8   Hormone Treatment

8.1   General

Once the patient has been diagnosed as transsexual, the Consultant Psychiatrist will normally decide to initiate hormone treatment. This involves administering large doses of female sex steroids (oestrogens, usually accompanied with progestogens) to induce the development of female secondary sexual characteristics. In a pre-operative subject this will normally be accompanied by some form of anti-androgen treatment to reduce the effect of the patient's endogenous male sex hormones.

The effects of feminising hormones vary greatly from patient to patient. Younger patients generally obtain better and more rapid feminisation, although genetic factors are also highly significant.

With appropriate dosage, most patients experience noticeable changes within 2--3 months, with irreversible effects after as little as 6 months. Feminisation continues at a decreasing rate for a period of two years or more, often with a 'spurt' of breast growth and other feminisation when the testes are removed by orchidectomy or GRS.

The main effects of feminising hormones are as follows:

Hormones are most commonly administered orally; however, depot injections or skin patches are sometimes used, especially in patients with liver problems, as they avoid the 'first pass' through the liver after absorption in the digestive tract. Typical dosages listed are for oral administration.

There has been debate in recent years over whether to administer a constant dosage of hormones every day, or whether to mimic a natural menstrual cycle by reducing or stopping oestrogen for 7--10 days per 28 and adding or increasing a progestogen during that period. No advantage has been found to the cyclic method; its principal effect seems to be to induce extreme mood swings similar to PMS. There is some evidence that the non-cyclic approach produces slightly more rapid feminisation, and so a non-cyclic regime is widely regarded as preferable today.

8.2   Risks and Monitoring

There are also some risk factors associated with hormone therapy, the most serious of which is a risk of deep-vein thrombosis (DVT) or pulmonary embolism (PE), which can be life-threatening. The risks appear to be much higher if the patient is over 40 years old, overweight, or a smoker. Transsexual patients who smoke should be strongly encouraged to quit.

Hormone treatment must be discontinued for some time (typically 3--6 weeks) prior to any form of major surgery due to the risk of thromboembolic events. Likewise if the patient suffers an injury resulting in immobilisation, hormones should be withdrawn. In cases of minor surgery it may be safe to continue hormone treatment, but in all cases the advice of the surgeon and anaesthetist should be sought.

The manufacturer's safety data for the hormone(s) chosen should be consulted for full information; but it must be noted that the drugs companies do not acknowledge the use of these drugs in transsexual subjects and clinical data specific to TS patients is scarce.

Fluid retention and/or hypertension may result from hormone treatment. A change in the hormone regime often helps; for example several patients have experienced water retention or hypertension when taking the progestogen levonorgestrel, but have returned to normal when this was replaced by an alternative progestogen such as medroxyprogesterone acetate ('Provera').

If a particular hormone appears to be producing poor results or side-effects then a change in regime is probably wise: hormone therapy for transsexual patients is still somewhat 'hit-and-miss' although a consensus does appear to be emerging; much good research has been published by Prof. Gooren of Amsterdam. If no feminisation whatsoever is seen (not even the tender nipples that precede breast growth) after 2--3 months, or if feminisation is very limited over a longer period, then it may be beneficial to refer the patient for a serum androgen level test (testosterone and DHEAS), as some patients overproduce androgens to the extent that feminising hormones have little effect, and perhaps also refer the patient to an endocrinologist experienced in the treatment of male-to-female transsexuals.

Certain blood tests are advisable on a routine basis for patients undergoing hormonal sex reassignment. Opinions differ as to which checks are required and how often, but as guide, liver function, serum lipids and blood pressure should be checked annually at a minimum. It is advisable to check more frequently if the patient is preoperative (pre-ops require higher dosages, and hence are at greater risk of adverse effects), is also taking antiandrogens, or has any other factor predisposing her to side-effects such as being overweight, being a smoker, being over 40 years old, or having any relevant medical history (e.g. hypertension, liver problems etc).

Some practitioners also advise the checking of fasting glucose (high dose hormone/antiandrogen treatment may affect carbohydrate metabolism), thyroid function, blood clotting time and prolactin. The necessity or otherwise of checking serum prolactin has been debated recently --- some elevation of prolactin is to be expected under aggressive oestrogen treatment and would not necessarily indicate a problem, conversely there have been reports of pituitary prolactinoma in a few TS patients, which would be detectable by an excessively high serum prolactin level that fails to drop when oestrogens are temporarily discontinued.

Some practitioners also recommend monitoring the levels of sex hormones in the blood, particularly testosterone for pre-op male-to-female subjects. It is debatable whether this is necessary if the patient reports satisfactory physical development, however if the hormone treatment is producing poor results and it is proposed to prescribe an unusually high dosage of hormones or antiandrogens, then such a test might be indicated. Likewise, if prescribing antiandrogens to an agonadal subject (post-op or post-orchidectomy) is contemplated, such a test is indicated --- it is normally considered unwise to administer antiandrogens to a post-op subject.

When sex hormone levels are measured, it must be borne in mind that antiandrogens that work as receptor antagonists may skew the results, since the body's response to a given serum androgen level will be depressed relative to a normal subject, even though the measured androgen level may not be much below normal. Normal testosterone levels are typically considered to be 300--1000 ng/dl for a male, 5--85 ng/dl for a female.

It should also be borne in mind that serum oestrogen levels may be misleading. With an effective dose of oestrogen being administered, there is little reason to perform this test; and the normal test for serum oestradiol is insensitive to ethinyloestradiol and certain other forms of oestrogen anyway, which may cause misleading results.

8.3   Oestrogens

Oestrogens are responsible for the development of female secondary sex characteristics, so the main component of any hormone regime for a TS patient will be some form of oestrogen. Typically this is obtained either from combined oral contraceptives or oestrogen tablets intended for HRT in postmenopausal women.

The principal natural oestrogen produced by the ovaries in a natural-born premenopausal female is 17 beta-oestradiol. Numerous derivatives and metabolites exist and play specific roles in the female body. While some of the metabolites (e.g. oestrone, oestriol) may be used successfully in treating menopause symptoms in postmenopausal women, they are not suitable for transsexual patients; it is necessary to supply 17 beta-oestradiol or a synthetic replacement for it.

Oestrogen therapy must be continued for life in a post-operative subject, otherwise numerous problems can occur. In particular, several very severe cases of osteoporosis have been reported in post-ops who have discontinued their oestrogen treatment. 'Menopause-like' symptoms also occur if oestrogen is discontinued.

8.3.1   Oestradiol Valerate

This drug is equivalent to natural 17 beta-oestradiol. It is generally well-tolerated, and clinical data from postmenopausal women suggest it is safer than ethinyloestradiol for long-term use, with less risk of breast cancer, thromboembolic events or liver problems. It is not certain whether this improved safety applies in the high doses necessary for pre-op transsexuals.

This is widely regarded as the oestrogen of choice for long-term maintenance in post-op TS patients due to its good safety record; typical post-op dose would be 1--2mg daily, ideally divided into two doses.

Oestradiol valerate appears to be less effective at inducing feminisation in pre-op subjects than ethinyloestradiol, probably due to its short serum half-life --- particularly, it appears to fare poorly when 'in competition' with endogenous male hormones; adequate results have been obtained with oestradiol valerate combined with an effective antiandrogen. Typical pre-op dose would be 4--6mg daily in divided doses (1 or 2mg per dose); if 'menopause-type' symptoms appear (hot flushes, night sweats etc) this can often be a sign that the dose is not sufficient to overcome the endogenous male hormones and a switch to ethinyloestradiol would probably be advisable.

8.3.2   Ethinyloestradiol

This drug is a synthetically-produced modification of natural 17 beta-oestradiol. The modified molecule is eliminated only slowly by the liver, giving it a far greater potency and much longer half-life than other oestrogens. It is generally well-tolerated, but appears to be less safe in very long-term use than oestradiol valerate.

Ethinyloestradiol is widely regarded as the oestrogen of choice in pre-operative subjects. A dose of 100 µg daily (in two doses) is typical; this can be increased to 150 µg if necessary. Its long half-life and high potency give it excellent feminising effects.

In post-op patients, this drug may still be used, especially for patients whose feminisation has not completed by the time they have GRS. For short-term post-op use, the full pre-op dose of 100 µg may be used, this is normally reduced to 50 µg after 6--12 months. For long-term post-op use, oestradiol valerate is probably preferable.

It should be noted here that oestrogen overdosage may paradoxically cause vasomotor symptoms similar to those produced by insufficient oestrogen dosage. This is sometimes seen in post-op patients who are still on pre-op dosage, and if this effect is suspected then the oestrogen dosage should immediately be reduced to a typical post-op level. This effect is more likely with ethinyloestradiol than with other oestrogens due to its high potency, and consideration may be given to an early switch to oestradiol valerate if the problem persists.

8.3.3   Conjugated Natural Oestrogens (Premarin)

This drug is a mixture of various oestrogenic substances extracted from the urine of pregnant mares. It lacks the potency of ethinyloestradiol, and there is no evidence that it has any advantages over oestradiol valerate. Many patients dislike this drug because of ethical concerns over the manner in which it is produced. It is increasingly regarded as an outmoded treatment for TS patients. It is also more expensive than the synthetically-manufactured drugs.

A typical pre-op dose would be 5--7.5mg daily in divided doses, reducing to 1--2.5mg daily post-op.

8.3.4   Other Oestrogens

A number of other oestrogenic drugs exist, many of which have been tried in the past in TS patients. It has already been mentioned that metabolites such as oestrone and oestriol are not suitable for use in TS patients; other oestrogen derivatives exist but have no advantages over the three oestrogens listed above. Diethylstilboestrol has been used in the past, and while it certainly produces worthwhile feminising effects, its safety record contraindicates its use in TS subjects: many serious problems, including fatalities, have been reported.

8.4   Progestogens

Progestogens administered alone do not produce feminisation in a phenotypic male. However, progestogens are generally quite antiandrogenic and will often provide a useful degree of testosterone suppression in a pre-op patient, and more importantly when administered in conjunction with oestrogen, improve the feminisation attained compared to oestrogen-only therapy, particularly in terms of breast weight and texture.

One UK endocrinologist has claimed that progestogens have no effect in transsexual patients, however numerous studies both in the UK and elsewhere have demonstrated that this claim is false. Progestogens are now very widely used in conjunction with oestrogens in the treatment of male-to-female transsexualism.

Progestogens may also lessen the risk of cancer associated with long-term oestrogen treatment, according to some studies in natural-born females. In addition, some patients report that progestogens affect them psychologically, particularly in terms of maintaining the libido. For all these reasons, it may well be desirable to continue with a low dose of progestogen post-operatively, even though there is no absolute need for it.

No reliable data exists regarding the incidence of breast cancer in transsexuals. Many are lost to followup and conceal their transsexual past after completing their treatment, and any instances of breast cancer in this group are likely to be recorded as occurring in normal women rather than transsexuals. One researcher has claimed to find a significant excess of breast cancers among certain chromosomally-intersexed patients who have been reassigned to female.

A few patients experience androgenic effects from some progestogens, possibly including an increase in body hair. If this occurs, a different progrestogen should be tried. Similarly, if fluid retention occurs, a switch to an alternative drug will probably resolve it.

8.4.1   Medroxyprogesterone Acetate

This progestogen (trade name Provera) is normally used for treating irregular menstrual bleeding or endometriosis, and its safety record is good.

It is widely regarded as the preferred progestogen, at least when the patient is not using combined contraceptive pills as a low-cost source of oestrogen and progestogens. Some patients, however, report slight virilising effects including, occasionally, a return of some degree of male sexual function even in post-orchidectomy subjects, which can be found disturbing; it appears that a proportion of the drug may be metabolised into testosterone in some patients. Medroxyprogesterone acetate is generally less virilising than the testosterone-derived synthetic progestogens (e.g. norethisterone and levonorgestrel), but more virilising than dydrogesterone. If a patient experiences virilising effects with medroxyprogesterone acetate then a switch to dydrogesterone should be considered.

A typical pre-op (or early post-op) dose (to maximise feminisation) would be 10mg in two doses; post-op, 5mg or even 2.5mg may be sufficient to maintain the patient's libido.

8.4.2   Dydrogesterone

This progestogen (trade name Duphaston) may be used as an alternative to medroxyprogesterone acetate. It is not metabolised into testosterone within the body, and is therefore free of the virilising effects which some patients experience from other progesterones. Conversely it may be less effective in maintaining libido than medroxyprogesterone acetate.

Dydrogesterone is regarded as the progestogen of choice when patients have experienced virilising effects from other progestogens.

A typical pre-op (or early post-op) dose would be 20mg in two doses, reducing to a single dose of 10mg daily post-op.

8.4.3   Natural Progesterone USP

This drug, which is probably unavailable in the UK, has a small but vocal group of transsexual adherents in the USA, who claim that it is superior to other progestogens. The present authors have been unable to find any clinical data to support this claim; while it appears to be free of virilising effects, first-pass effects are liable to make it relatively ineffective relative to dydrogesterone, which is also non-virilising.

The main problem with 'Natural Progesterone' is that it is largely destroyed by the digestive tract and liver upon ingestion, so very large doses (hundreds of milligrams) are used. Since the precise percentage of the drug metabolised in this way is variable and unknown, the actual serum levels obtained are unpredictable.

8.4.4   Synthetic Progestogens

This heading covers substances such as levonorgestrel and norethisterone, which are usually found in combined contraceptive tablets, usually with ethinyloestradiol.

Contraceptive pills provide a useful low-cost source of feminising hormones for patients who have to pay for their own medications, but of course the patient is limited to the combinations of substances available, and cannot 'mix and match' as one can with separate oestrogen and progestogen drugs.

Care should be taken with some preparations (for example, Brevinor) as they contain too high a ratio of progestogen to oestrogen, so that taking enough tablets to obtain a suitable dose of oestrogen would result in a dangerously high intake of progestogen.

One combined tablet that has been used widely in the treatment of transsexual patients is Ovran; a typical pre-op dose of two tablets daily gives 100 µg of ethinyloestradiol and 500 µg of levonorgestrel. Most patients tolerate this well, and it generally produces satisfactory feminisation, but levonorgestrel appears (anecdotally) to give more frequent problems with water retention, hypertension and weight gain than medroxyprogesterone acetate. Safety fears have also been raised in the past about levonorgestrel-based contraceptive implants.

Some patients experience virilising effects with norethisterone or levonorgestrel, which may impair the feminising effects of oestrogen. If this is suspected then an alternative progestogen should be tried.

9   Antiandrogens, GnRH Agonists and Orchidectomy

Hormone treatment in pre-operative male-to-female subjects is normally supplemented by some form of antiandrogen treatment. While oestrogens and progestogens are to some extent antiandrogenic in themselves, a number of other methods exists to suppress the effects of androgens and make the feminising hormones more effective without having to administer the latter in unreasonably high doses.

These treatments also, of course, cause a significant reduction in male sex drive (and indeed sexual function), which is generally considered highly desirable by transsexual subjects.

There are three approaches to antiandrogen treatment:

  1. Antiandrogen drugs.

  2. GnRH (Gonadotropin-releasing-hormone) agonists.

  3. Bilateral orchidectomy (castration).

These treatments are not applicable to patients who are post-operative, as their bodies will, by definition, be incapable of producing gonadal androgens. Adrenal androgens are produced in small amounts by both sexes, and no attempt should be made to suppress them unless a serum androgen test has indicated significant overproduction, as in cases of adrenal hyperplasia. In general it is considered unwise to administer antiandrogens to post-operative subjects (and indeed to severely hypogonadal subjects such as certain intersexed patients), as the small amount of adrenal androgens remaining in such subjects are necessary for normal functioning. For further information, see Section 8.2.

9.1   Antiandrogen Drugs

These drugs either inhibit gonadal androgen production, interfere with androgen receptor sites, or both. Most are likely to produce some side effects in effective doses; some patients cannot tolerate some or all antiandrogen drugs, in which case bilateral orchidectomy is likely to be a preferable treatment.

The effect of these drugs on fertility and male sexual function is reversible to an extent, however (like feminising hormones) irreversible infertility may ensue after some months of treatment.

All antiandrogen drugs, like feminising hormones, must be withdrawn prior to major surgery. This may lead to a degree of reversion towards masculinity, which may be pronounced and disturbing in some patients.

Please also refer to Section 8.2 for a discussion of risks and routine monitoring: comments applicable to hormones are generally also applicable to antiandrogens.

9.1.1   Cyproterone Acetate

This drug (brand names Androcur, Cyprostat) is widely regarded as the antiandrogen of choice by practitioners in Europe (it is not approved in the USA). It is an androgen receptor antagonist and weak gonadal androgen production inhibitor; normal dose is 50mg daily, which may be increased to 100 or in exceptional cases 150mg daily if required.

In these doses there are some risks associated with the drug, particularly a heightened risk of thromboembolic disease or liver damage. Carbohydrate metabolism changes are also reported; patients should receive regular blood tests (LFT and fasting glucose) and BP checks.

Possible side effects include severe lassitude, loss of concentration and depression, also weight gain and nausea. Anecdotal reports suggest that the side effects can be lessened by taking the drug after meals; opinions differ as to the best time of day to take a single dose to minimise the tiredness effect: patients are best advised to experiment for themselves, though after lunch or after the evening meal seem to be the usual choices.

9.1.2   Flutamide

This is a relatively new drug which has been used with success in some transsexual patients, particularly those who have experienced unacceptable side effects with cyproterone. There is relatively little clinical data available for this drug in transsexual patients.

It is a strong androgen receptor antagonist. Like cyproterone it can be hepatotoxic, it can also have significant adverse haematological effects (reduced platelet, leukocyte or erythrocyte count) or cause hypertension, and it can also produce less serious side effects such as fluid retention. Regular LFTs and blood checks are advisable when using this drug.

This drug also produces psychological side effects which can be severe in some patients. Depression, anxiety or nervousness can be extreme, and patients should be made aware of this possibility. Lassitude, insomnia and gastrointestinal disturbances have also been reported.

Typical dose is 250mg to 750mg daily (one to three 250mg tablets).

9.1.3   Spironolactone

This drug was originally developed as an antihypertensive/diuretic; it is also a weak androgen receptor antagonist. It is much less effective as an antiandrogen than cyproterone or flutamide, but can find use in patients who have hypertension or severe fluid retention, either pre-existing or as a result of hormone treatment.

Side effects may include lassitude, loss of concentration, and various gastrointestinal problems. There is a risk of potassium retention.

Doses range typically from 100 to 400mg daily.

9.1.4   Finasteride

This drug is not suitable as a general antiandrogen, but is mentioned here as it can be useful in countering male-pattern baldness in transsexual subjects. Classed as an androgen conversion inhibitor, it blocks the conversion of testosterone to DHT.

It is generally free from significant side effects, but does not appear to affect male sex drive. Typical dosage is 5mg daily.

9.2   GnRH Agonists

These drugs take a different approach to antiandrogens: they act on the pituitary, initially overstimulating it and then rapidly desensitising it to GnRH. The effect of this is that over a period of weeks, gonadal androgen production is greatly reduced.

Their principal advantages are that they are generally fully reversible in their effects, which makes them a useful treatment in adolescent subjects where it is desired to stall the changes of puberty but not desired to induce permanent feminisation until the subject is older; and that they do not carry the risks of thromboembolic disease associated with antiandrogens. This can be particularly useful when hormones/antiandrogens are withdrawn prior to surgery --- GnRH agonist treatment can be used to minimise the reversion to male biochemistry that many transsexual subjects find deeply disturbing.

GnRH agonists do carry risks of significant side effects and should be used with great caution. There is as yet relatively little clinical data on the use of these substances in transsexual subjects, particularly in long-term use.

9.2.1   Nafarelin Acetate

Normally administered as a nasal spray (typical dosage 1600 µg daily). May cause depression, insomnia, skin problems and other side effects. Being administered daily, the drug can easily be withdrawn should side effects occur.

9.2.2   Goserelin Acetate

Administered as a depot (i.e. time-release) injection (typically 3.6mg monthly). Reported adverse effects include heart failure, obstructive pulmonary disease and severe allergic reactions as well as more minor side effects such as lethargy and nausea. In view of the fact that it is a depot injection, this drug should be treated with caution as it cannot be rapidly withdrawn should problems occur.

9.2.3   Leuprorelin Acetate

Similar to Goserelin Acetate, with a typical dose of 3.75mg every 4 weeks. This drug has been used to good effect in adolescent subjects. Allergic reactions and other side effects have been reported.

9.3   Bilateral Orchidectomy

Bilateral orchidectomy is a possible alternative to antiandrogen therapy or GnRH agonists for androgen suppression in preoperative transsexual subjects. It can be cost-effective in comparison with lengthy antiandrogen treatment; privately, orchidectomy is available for under £1000 (1997).

Orchidectomy offers several advantages over antiandrogen or GnRH-agonist therapy:

There are some disadvantages to orchidectomy (aside from the obvious necessity of an additional surgical procedure), and patients should be made aware of these:

Bilateral orchidectomy normally requires a referral from a psychiatrist; some surgeons may require a second opinion from an independent psychiatrist. Orchidectomy as a precursor to GRS is now widely regarded as a useful procedure in properly selected patients.

10   Gender Reassignment Surgery

10.1   Introduction

This section is, of necessity, rather general. Techniques, precise details of post-operative care and results obtained vary enormously from surgeon to surgeon. It would be inappropriate in a booklet such as this to favour one surgeon's procedure over another; therefore this section has been kept general, and is not intended to replace the detailed pre-op preparation and post-op care guides given out by most reputable GRS surgeons.

Patients should be advised to exercise care in their choice of surgeon, as results obtained seem to vary from very poor (looking most unlike natural female genitals, and having little sensation) to excellent (indistinguishable from natural female genitals without an internal examination, and having full sexual sensation). Unfortunately, complications are not uncommon with GRS, and some surgeons have a very much better success rate than others. Patients would be well advised to choose a surgeon who has extensive experience of this type of surgery, and publishes statistics of results obtained and patient satisfaction, rather than relying on the surgeon's own claims. It is best to talk to patients who have actually had GRS performed by various surgeons, and to obtain pictures of typical results, before choosing a surgeon. Consultant Psychiatrists and Counsellors specialising in transsexual issues will usually be able to offer advice on choice of surgeon, and may have access to pictures of results; there are also relevant resources available on the Internet.

Contrary to what has been written in some (now outdated) guides to gender reassignment, modern, sophisticated male-to-female surgery is available in Britain.

Most surgeons will issue their patients with detailed pre-op preparation instructions. The main requirement is to withdraw hormones (and antiandrogens if applicable) some weeks (typically 6--8) before surgery. Patients may also require various items to be prescribed prior to their GRS for use in the early post-op period; typical requirements include Betadine Vaginal Gel, Betadine VC (douche), and KY Jelly.

At the time of writing, availability of GRS on the NHS is very limited, and varies from region to region. Some patients have succeeded in obtaining it by vigorously challenging their Health Authority's refusal to fund, in court if need be. Courts have ruled that a blanket refusal to fund gender reassignment is unlawful and cases must be considered on their merits. In some cases patients have received useful assistance from Community Health Councils (CHCs), and the TS rights campaigning group Press for Change are also involved in the funding debate.

10.2   Techniques and Results

10.2.1   Penile Inversion Vaginoplasty

This is widely regarded as the preferred method of male-to-female GRS, is widely performed, and when performed by an accomplished surgeon, can produce very satisfactory results.

The basic method involves turning the penile skin 'inside out' and using it to line a vaginal cavity created by blunt dissection through the muscles of the perineal area. The penis and testes are removed. Many surgeons use variants of the technique: a pure penile inversion limits the size of the vagina that can be created, depending on the amount of penile skin available. In many patients it is necessary to supplement this material with scrotal skin or by means of a skin graft, often taken from the thigh or abdomen.

Early vaginoplasty techniques often used split skin grafts; these were invariably unsatisfactory and very prone to scar tissue formation and shrinkage, leading in many cases to vaginal stenosis. Some surgeons today still use free, full-thickness skin grafts to supplement the penile skin, but the disadvantages of these include visible scarring of the donor site, lack of sensation of the grafted tissue, and possible problems with obtaining enough material in very slim patients.

A more modern method involves the use of scrotal tissue, and is sometimes termed 'peno-scrotal inversion'. This is widely regarded as the preferred method. In this technique, the penile skin is usually divided, part being used to form the floor of the vulva, and part being used to form the anterior wall of the vagina, with a flap of scrotal tissue being used to form the posterior wall and apex of the vagina. This has the considerable advantage that a satisfactory vagina can usually be formed even in circumcised or mildly-intersexed patients where penile tissue may be very limited; the corresponding disadvantage is that the risk of vaginal prolapse increases with the proportion of scrotal tissue used, as scrotal tissue adheres less well to the muscles than penile tissue.

Labia are constructed from scrotal tissue, and the urethra is shortened and everted to correspond to normal female anatomy. A good surgeon will re-site the urethral meatus to an appropriate female position, and will ensure that the erectile material of the penis is removed to the maximum possible extent, so as not to leave an unsightly and possibly painful 'stump'. The remnant of the prostate gland (long-term hormone therapy causes it to atrophy and shrink) is left in place, and provides sexual sensation through the anterior wall of the vagina, analogous to the so-called 'G spot' of natural-born females.

Many patients report good sexual sensitivity both within the vagina and from the rest of the vulva, though some surgeons seem to produce much better results than others. Many surgeons now also perform clitoroplasty with vaginoplasty, as described in Section 10.2.4.

After this operation, the patient will have a pack (usually of surgical gauze) placed in the vagina, to retain the tissues in their proper locations for about five days while healing proceeds. During this time she will be on bed rest, and a clear-fluid-only diet to avoid the possibility of a bowel movement which could damage the vagina or disturb the pack. The patient will also be catheterised, typically for seven days, to allow the urethra to heal.

Post-operatively, the patient will need to 'dilate' her vagina regularly using purpose-made stents to prevent it from closing up. This may be two or more times daily at first, reducing eventually to once or twice a week, but dilation will be necessary for life --- although a sexually active patient may find that she receives sufficient dilation from sexual activity.

10.2.2   Colovaginoplasty

This method is sometimes used in patients who lack sufficient material for the penile inversion method, although recent progress with the use of scrotal tissue in the latter procedure, accompanied by the inherent risks and problems of colovaginoplasty, has led to colovaginoplasty becoming a less common method of GRS today.

In this procedure, formation of the labia, urethral meatus etc. follows the same method as for penile inversion vaginoplasty. But instead of using penile/scrotal tissue to line the vagina, a section of the sigmoid colon is isolated and used to form the vaginal lining. This is clearly much more major surgery than penile inversion, requiring an abdominal incision (leaving a large scar) as well as all the risks and complications usually associated with colon surgery. Additionally there is a very real risk in this procedure of shrinkage at the anastomosis between colonic and genital tissue, which may lead to stenosis of the vagina.

The colon graft does confer the useful property of self-lubrication upon the constructed vagina (penile inversion patients usually require some supplementary lubrication for penetrative sex), however this benefit is normally outweighed by the potential problems: in addition to those already mentioned, an unpleasant smell and constant secretion of mucus are very common problems; additionally, painful spasms of the grafted colon segment and even fistulae are often reported.

Sexual sensitivity from the outer genital area will be similar to that obtained with penile inversion, as the same method is used in its construction. The colon graft lining the vagina is unlikely to be sensitive in a manner that is found pleasant, and may even be uncomfortable. Clitoroplasty can be performed with colovaginoplasty, as described in Section 10.2.4.

For all these reasons, many transsexual support groups, support workers and medical professionals consider that colovaginoplasty be treated as a 'last resort' method only, and should not be undertaken without careful counselling.

This operation requires longer hospitalisation than penile inversion vaginoplasty, and of course a period of starvation will be required to allow the colon to heal. A vaginal pack is not necessary, nor is dilation usually required.

10.2.3   Cosmetic GRS

This technique produces a similar appearance to any other woman who has undergone GRS, but does not produce a functional vagina (i.e. one capable of penetration). This operation can be of value in patients who are medically unable to undergo vaginoplasty; it is a much less intrusive operation than either form of vaginoplasty, and is often chosen by elderly patients.

This procedure may also be chosen by patients who have insufficient material for penile inversion vaginoplasty and for whom colovaginoplasty is either undesirable or contraindicated by other conditions. As a word of caution, however, techniques very between surgeons, and what one surgeon dismisses as 'insufficient material' may be quite usable by another --- particularly if supplemented with scrotal tissue.

The operation involves the formation of labia and removal of the male organs, exactly as for vaginoplasty; a semblance of a vaginal opening can be created by using a deep suture to draw down the labial tissue at the appropriate point, but there will of course be no true vaginal opening. Much of the penile and scrotal tissue is discarded in this procedure, and patients must be warned that if they choose this procedure, it must be accepted that it is essentially impossible to create a vagina later.

The patient will probably have some sexual sensitivity from the labia, and it is normally possible to perform clitoroplasty (Section 10.2.4) with cosmetic GRS and thus for the patient to have sexual sensitivity from the clitoris.

After cosmetic GRS, there is usually no need for an extended period of bed rest, nor is there any need for a vaginal pack or for starvation. The patient will be catheterised for a few days to allow the urethra to heal. There is, of course, no need for dilation as there is no vagina.

10.2.4   Clitoroplasty

It has recently become possible to construct a clitoris that is both realistic-looking and sexually sensitive (to the point that many patients report the ability to have clitoral orgasms). Not all surgeons perform this procedure, and results vary; some surgeons use different methods of clitoral construction, with mixed results (usually less sexually sensitive).

The preferred method of clitoroplasty involves retaining a small section of the glans penis with its blood supply and nerves intact, and grafting this into an appropriate position above the urethral meatus. Since the nerves of the glans in a phenotypic male are analogous to the nerves of the clitoris in a female, the technique produces a natural, 'correctly-wired' sensitivity in the patient.

Some surgeons also construct a natural-looking labial juncture and clitoral hood. This is cosmetically desirable as well as being beneficial to the patient's comfort if a sensitive clitoris is constructed: the clitoral hood protects the clitoris just as it does in a natural-born female. Some surgeons, notably in the USA, perform a 'labiaplasty' as a second procedure some time after the original GRS, to produce the clitoral hood and labial juncture, while at least one UK surgeon performs this step integrally with the main procedure.

11   Care of Post-Operative Patients

11.1   Introduction

This section discusses special issues relating to the long-term health of post-operative male-to-female transsexuals. It does not attempt to detail the routine care required post-operatively, as this varies from surgeon to surgeon, and all reputable surgeons give their patients detailed directions on their care regime following their discharge from hospital.

11.2   Hormones Post-Operatively

As with any agonadal subject, some form of hormone replacement must be undertaken for life, if major problems such as osteoporosis are to be avoided. A post-op TS patient will require some form of oestrogen, which may be administered orally or by skin patches (or, much less commonly, by depot injections). Topical oestrogens (such as vaginal creams) are insufficient on their own for agonadal subjects, but may be useful as an adjunct to oral HRT. Progestogens are not necessary for physical health in a post-op TS, but many post-ops find them beneficial psychologically, and if the patient is still feminising then the usual benefits of progestogen therapy (particularly in breast size and texture) will be obtained. Routine blood tests should be continued indefinitely.

Hormone therapy is discussed fully in Section 8, including details of appropriate doses for long-term maintenance.

Many penile (or peno-scrotal) inversion vaginoplasty patients report significant benefits from using a vaginal oestrogen cream (e.g. Ortho-Dienoestrol). Benefits include a moister vagina, better sensitivity, and less soreness. Nightly application should certainly suffice, and many patients require less frequent applications. Patients should be advised to douche (with plain warm water or very dilute vinegar) to remove the cream base, which is heavy and tends to remain in the vagina long after the oestrogen has been absorbed.

11.3   Post-Operative Infections and Hygiene

Extensive surgery in the genital area inevitably brings a considerable risk of post-operative infection; anecdotal reports from post-op subjects suggest that more than 50 % of patients experience at least one post-operative infection, although most are easily treated with antibiotics.

The patient should have been made aware by the surgeon of the need for scrupulous hygiene, and should also have been told of the warning signs of an infection (pain and swelling, fever, discharge from suture lines etc). When an infection is present or suspected, normal practice is treatment with antibiotics. Augmentin or ciprofloxacin are commonly-used broad-spectrum antibiotics in such cases, usually accompanied by metronidazole to eliminate the possibility of infection by anaerobes.

Patients who have undergone vaginoplasty will probably also require certain routine prescriptions either on a short-term basis or indefinitely, to enable them to maintain the proper regime of hygiene and dilation. Typical requirements include Betadine Vaginal Gel (usually short-term), Betadine VC (douche), and KY Jelly.

Conflicting advice is often heard on the subject of douching for inversion vaginoplasty patients. Frequent douching with Betadine solution (as well as using Betadine gel) is certainly advisable during the recovery period, but it is probably best to discontinue it in the longer term, unless the patient develops a vaginal infection, as prolonged use of such preparations will prevent the normal population of vaginal flora from developing. To maintain cleanliness, occasional douching with plain warm water is quite sufficient; some patients report benefit from using spirit vinegar diluted about 10:1 with warm water as this helps to maintain the correct pH in the vagina, and can bring relief from itching and discomfort.

Like any other woman, a post-op transsexual may occasionally suffer from a variety of genito-urinary infections, of which the most common seems to be candidiasis (thrush). Any such infections are treated in the same manner as for a normal female patient. Patients should be made aware that they have essentially the same risk of contracting an STD (including HIV) as any other woman, and should practise 'safer sex'.

11.4   Post-Surgical Complications

Due to the complexity of GRS, post-surgical complications are relatively frequent. The majority are relatively minor and appear immediately after surgery, and would normally be dealt with by the GRS team before the patient leaves hospital. This section discusses some of the more major complications that may arise later.

For penile (or peno-scrotal) inversion vaginoplasty, there is some risk of a partial or complete prolapse of the vaginal lining. The risk appears to rise with the proportion of scrotal tissue used to line the vagina, but is also affected by the patient's general health and particularly her age and weight: an elderly, overweight subject will be at much greater risk than a young fit person. Vaginal prolapses in TS subjects seem to occur in two distinct populations: in 'early prolapse' the prolapse generally occurs 1--3 months post-op, and is caused by the vaginal lining failing to attach itself firmly to the pelvic floor muscles as healing proceeds; once the absorbable sutures used inside the vagina break up, the lining prolapses. 'Late prolapse' is seen more often in long-term post-op subjects, typically 3 years or more post-op, and the underlying cause is less clear. Any significant prolapse will require surgical repair; the technique required is somewhat different to that used in natural-born women and the patient should be referred to a surgeon experienced with post-op transsexuals --- preferably the surgeon who originally performed the GRS.

After any form of vaginoplasty, a fistula may form, most commonly between the vagina and rectum. This would require surgical correction. Problems of the urethra may also occur; typically, excessive scar tissue formation causing difficulty in urinating. Such cases can sometimes be resolved by stretching the urethra with stents, more severe cases may require surgical revision. In general, post-GRS complications should be referred to an experienced GRS surgeon, as techniques applicable to natural-born women are frequently unsuitable for transsexuals.

A very large variety of problems have been seen in colovaginoplasty patients, and expert advice should generally be sought in such cases. One common problem for such patients is painful spasm of the grafted piece of colon during or after intercourse. Some success has been reported using loperamide in such cases, although very often the problem seems to persist.

11.5   Health Screening

In addition to the routine blood tests described in Section 8, other screening procedures are routinely offered to women of appropriate age groups, most notably checks for breast and cervical cancer.

In general, it is appropriate to treat a post-op TS in the same way as a natural-born woman of the same age group, in terms of routine health checks. Breast cancer is a risk for transsexual women, and they should be screened in the usual way and advised on self-examination. See Section 8.4 for further comments regarding breast cancer in transsexuals.

There is some debate regarding cervical screening: in general, it appears that the opinion in the UK is that it is not necessary for a post-op TS, while in the USA it is standard practice. The argument against screening is that a post-op TS does not possess normal cervical tissue, her vagina is closed at the apex by a piece of penile or scrotal material (or grafted skin) for an inversion vaginoplasty patient, or colonic tissue for a colovaginoplasty patient; and that these tissues do not exhibit the same behaviour as cervical tissue. Adherents of screening for transsexuals argue that even though the tissues are not the same, there is theoretically some risk of cancer developing, and a smear test could detect such cancers at an early stage. The present authors are not aware of any clinical data regarding the incidence of such cancers or the efficacy of a smear test in diagnosing them.

Periodic health checks which include an assessment of the patient's weight may require a little caution. A typical transsexual who developed as a phenotypic male to adulthood will usually have a 'male skeleton', a much larger bone structure than would be typical of a woman of the same height; therefore a weight that might be considered excessive on a natural-born woman may be acceptable on a transsexual woman, if such a weight would be acceptable for a male.

It would also be appropriate to mention psychological health issues. All the while the legal system and society in general continues to discriminate against transsexuals, it is inevitable that some will suffer stress-related problems, depressive disorders, etc. as a result. Such patients should be treated with understanding; because a patient presents with stress or depression after gender reassignment does not mean that she was not truly TS, or should not have been reassigned. Counselling and/or psychotherapy are generally preferable to psychoactive medications unless there is a documented physiological basis for the problem.

12   Other Surgical Procedures

This section describes a variety of surgical and related procedures which are commonly performed on male-to-female transsexuals to help them attain a more feminine appearance. This section is, of necessity, only an overview, and patients considering any of these procedures would be well advised to discuss their plans with their Counsellor and/or Consultant Psychiatrist; furthermore, patients would be well advised to use only practitioners who are experienced at performing these procedures on transsexual subjects , and as with any elective surgery, to discuss their expectations and intentions in detail with the surgeon, and if possible to meet others who have been treated by them.

12.1   Augmentation Mammoplasty (Breast Enlargement)

Almost certainly the most commonly requested procedure other than GRS, this is a well-established procedure that is capable of producing good results. Patients who request augmentation at an early stage in hormone therapy should usually be advised to wait and see how much natural breast growth occurs. If breast size is still unsatisfactory after, say, one to two years of hormone therapy then augmentation would be appropriate. Patients who undergo augmentation mammoplasty prior to orchidectomy or GRS should bear in mind that a 'growth spurt' to the breasts is often reported once the testes have been removed.

There has been much concern in recent years about the long-term safety of silicone-filled breast implants, and indeed the USA has banned them. A variety of other fillings are now available: saline is of course totally safe but may not have a very natural 'feel' (this will depend on whether the implant is placed under or over the pectoral muscles) and may also cause problems with mammography due to its radio-opacity; triglyceride filling (made from refined vegetable oil) also appears to be totally safe as the body can readily metabolise the filling should it leak, gives a more natural 'feel' and is not radio-opaque. A new synthetic gel has recently been introduced, which gives a very good 'feel', but of course there is as yet no long-term safety data available.

Various types of shaped implants are also available. Some of these may be of particular benefit to those transsexuals with rather large upper-body proportions: most TS women have 'male-sized' rib-cages, and tend to have their natural breasts located somewhat further apart than on a natural-born woman. This tends to make the breasts look subjectively smaller and lacking a well-defined cleavage. Shaped implants can remedy this situation by adjusting the shape of the breasts to produce a subjectively larger cleavage. One model of implant takes this concept one step further, providing an 'inflatable' shaped implant that can be enlarged step-by-step by injection of saline into it, allowing greater enlargement of the bust than by a simple implant.

There are two main variables in the surgical technique: whether the incision is made from the underarm area or from the crease below the breast; and whether the implant is sited above or below the pectoralis major. There are advantages and disadvantages in each case, often depending on the patient's physique, and the advice of a reputable surgeon should be sought. In brief, placing the implants beneath the muscle may produce a more natural shape and 'feel' in patients with very small breasts, but conversely causes more pain during the recovery period (the muscles are stretched by the implant), and exercise involving strong contraction of the pectoral muscles will make the breast shape change as the muscles contract, which is likely to be noticeable if the patient is naked. Placing the implant above the muscle is less painful and avoids distortion of the implant during exercise, but in some patients with very little natural breast tissue, the outline of the implants may be discernible.

12.2   Rhinoplasty (Nose Remodelling)

Another popular procedure with a good safety record and generally good results. The aim is generally to reduce the size of the nose, as well as re-shaping it to a more typically feminine shape.

As with any facial cosmetic surgery, rhinoplasty is perhaps more of an art than a science, and much depends on the surgeon's skill and aesthetic judgment. Great care should therefore be exercised in the choice of surgeon.

12.3   Thyroid Chondroplasty (Tracheal Shave)

This procedure reduces the prominence of the 'Adams Apple', which many transsexuals find embarrassing, by making a small horizontal incision in a natural crease-line on the neck, and removing part of the thyroid cartilage.

The safety of the procedure is generally good, and it should not affect the quality of the voice, provided a surgeon experienced in treating TS patients is chosen, but there have been a few notable disasters in which excessive cartilage has been removed, leading to collapse of the vocal cords.

12.4   Crico-Thyroid Approximation

This procedure modifies the pitch of the voice by loosely suturing the cricoid and thyroid cartilages to each other, thus limiting the extent to which the vocal cords can be relaxed, and preventing the voice from dropping too low.

It must be stressed that this operation is not a panacea for transsexuals who have unfeminine voices. It will not give the patient access to any higher pitch than she is already capable of producing; it merely prevents her from lapsing into a lower register. Furthermore, much of the perceived masculinity/femininity of a voice is due to factors other than pitch. Crico-thyroid approximation is in no way a subsititute for speech therapy.

The operation is normally performed in conjunction with a thyroid chondroplasty, as the crico-thyroid approximation tends to make the thyroid cartilage more prominent.

As with any form of 'voice surgery' there is some risk of permanent damage, leading to disruption of the voice, even though the procedure is, in principle, reversible. Many practitioners are of the opinion that this operation would be ill-advised for all but a very small minority of transsexuals, and that speech therapy is the preferred approach. Speech therapy for TS patients is discussed in Section 7.

12.5   Other Voice-Changing Procedures

A number of other procedures have been tried, to modify (feminise) the voice of a transsexual subject, with very mixed results. Such surgeries must be regarded as both experimental and highly risky, and inadvisable for almost all patients.

Techniques include stiffening the vocal cords by creating scar tissue surgically or by laser, and thinning the vocal cords by laser ablation. It must be stressed that any attempt to modify the vocal cords is highly risky, and many patients have been left with far worse voices than they had before the procedure, and such modifications are totally irreversible.

12.6   Hair Transplantation

Many male-to-female transsexuals, especially those who change gender role later in life, will exhibit some degree of male pattern baldness. While hormones do generally cause some improvement to scalp hair (especially when used with minoxidil; see Section 8.1) in many cases patients may find that they require either hair transplants or a hairpiece.

All hair transplantation methods involve removing a narrow piece of scalp from the back of the head, where hair growth often remains dense, dividing it into 'grafts', and re-implanting these into the recipient site. Early methods used large grafts, and often produced unnatural-looking tufts of hair on the previously bald area. More sophisticated 'mini-graft' and 'micro-graft' techniques used today are capable of giving good results, however no present-day hair transplantation technique can produce a perfect female hairline.

The advice of a reputable trichologist should be sought, ideally one who has had prior experience of approximating a natural female hairline in transsexual patients.

There have also been attempts in the past to use synthetic hair 'implants', none of which have proved satisfactory.

12.7   Other Cosmetic Surgery

A number of other procedures have reportedly been performed on transsexual subjects, some of which are listed here. Patients should be made aware of the changes that can be expected from hormones (Section 8), and counselled against rushing into cosmetic surgery at an early stage in treatment, if the feature that they intend to change can be expected to change naturally under hormone treatment.

Jaw Remodelling , normally reduction of a prominent jawline, is occasionally performed. It can be relatively major surgery, causing significant pain with a lengthy recovery period. Good cosmetic results have been observed, although some patients have complained of permanent loss of tactile sensation in part of the surgical area.

Malar Implants are occasionally used to give the patient the semblance of higher cheekbones. This is a relatively simple procedure, leaving no external scarring. Synthetic implants are normally used, although in some cases patients have had this procedure performed simultaneously with a rhinoplasty and the surgeon has transplanted excess bone/cartilage from the nose to the cheek area.

Lip Implants are sometimes attempted. A variety of non-permanent methods (typically injections of collagen or a similar protein) have been used; these require frequent repetition of the treatment and are consequently very expensive in the longer term. More recently, permanent implants made of expanded PTFE have been used. Some patients have reported loss of tactile sensitivity to the lips with this method. It is probably fair to say that in most cases the appearance of a patient's lips can be improved just as effectively by judicious use of cosmetics as by surgery, and such surgery is therefore probably unjustified.

Brow Reduction involves removing bone from the supraorbital ridges of the skull, to reduce the 'heavy-browed' appearance common among phenotypic males. It is not a commonly performed procedure and its safety is uncertain.

Liposuction/Liposculpture : Liposuction involves the removal of excess fat via a cannula; it is a widely-used and reasonably safe procedure, although patients should be advised that liposuction is in no way a substitute for a healthy diet and exercise; indeed liposuction should really only be considered for very stubborn fat deposits that have failed to respond to a properly supervised diet and exercise regime. It is also possible to re-inject the removed fat cells into an area where greater fat deposition is desired, often the hips. It is reasonably safe but often unsuccessful: frequently much of the injected fat fails to 'take', usually due to a failure of the transplanted material to establish a satisfactory blood supply.

Rib Removal is occasionally undertaken to obtain a more pronounced waistline. It is widely regarded as inadvisable.

Shoulder Remodelling is occasionally used in an attempt to narrow the patient's shoulder; it involves breaking various bones and removing material from them. Few surgeons will attempt such a procedure, and it is widely regarded as inadvisable.

Other facial surgery such as 'face lifts' of various types, blepharoplasty etc. may be undertaken, particularly by somewhat older transsexuals. These procedures are commonly performed on people of both sexes, generally with reasonable safety, although results can vary and 'disasters' have been reported.

Tattoo removal is sometimes required, as it is quite conceivable that a transsexual may have been tattooed during her time of trying to function in male role. There are various methods depending on the location and nature of the tattoo: laser treatment can be used to bleach tattoo dyes, but some colours are resistant to bleaching and very often a 'ghost' of the tattoo remains even after many treatments. Serial excision (repeatedly cutting 'slices' of skin out, with or without the use of tissue expanders) is often used, although scarring will result. There is a limit to how much tissue can be excised, which may mean that a large tattoo cannot be fully treated.

12.8   Dermabrasion and Skin Peeling

Although these are not strictly surgery, they are included here for completeness. Both techniques remove the surface of the skin, the intention being that the skin will regenerate with a more youthful appearance, and lines and other blemishes will be reduced or removed.

These procedures are quite commonly sought by women, particularly in middle age. They may be particularly appealing to a transsexual subject who may have a very coarse skin texture from years of shaving, or may have acne scars or pitting from poorly-performed electrolysis.

Dermabrasion involves mechanical removal of skin; skin peeling is typically performed chemically, using compounds which attack proteins to etch the upper layers of skin away. Laser ablation of skin has also been introduced as an alternative to mechanical or chemical methods.

Results vary; some patients have reported excellent results, others have reported permanent skin damage. If these procedures are contemplated, a reputable and experienced practitioner should be chosen, and a small 'test area' in an unobtrusive location should be treated first to ascertain whether the patient is likely to react adversely to the treatment.

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