sex reassignment

Sex reassignment, sometimes colloquially called sex change, refers to the
surgical changing of a transsexual human's biological sex. A transsexual is a
person, female or male, who perceives his or her gender identity as incongruous
with the anatomical reality and actively seeks to resolve the conflict through
sex-reassignment surgery. The term transsexual is used to refer to both pre-
and postoperative men and women, though once surgery is completed the new
identity of male or female is preferred.  Sex reassignment for transsexual
humans requires various social, hormonal, legal, and surgical procedures.
Social reassignment involves living and working as a member of the sex opposite
from that which a person was born. In some cases, social reassignment suffices.
In other cases, hormonal reassignment is required, in which hormonal therapy
partially suppresses the existing phenotypic sex characteristics of the body
and allows the development and maintenance of characteristics of the opposite
sex. For male-to-female transsexuals, electrolysis of beard and body hair is
necessary because estrogen does not stop hair growth. Also, estrogen does not
elevate the pitch of the voice, although androgen lowers voice pitch in
female-to-male transsexuals. 
In the United States, a legal change of sex involves chiefly a change in the
birth certificate, but in Europe, legal reassignment is a more complex


In the female-to-male transsexual, mastectomy might, for cosmetic and
employment reasons, antedate surgery of the reproductive organs which involves
hysterectomy (removal of the uterus) and oophorectomy (removal of the ovaries).
For some female-to-male patients, subsequent phalloplasty (plastic surgery to
attach a penis) is important for their body image and self-concept.
Phalloplasty is sought by these transsexuals despite the possible imperfection
of the organ for urination and its guaranteed imperfection for copulation. Many
transsexuals use a prosthetic strap-on or glue-on penis, which can be made
lifelike by a medical sculptor.  The surgical technique for phalloplasty
involves an attempt to create a tubular structure in a progressive series of
operations in which the skin is peeled, rolled, and subsequently transplanted
from the lower abdomen or inner thigh. This rolled skin is then attached in the
position of a penis. The clitoris is left intact, embedded at the base of the
penis, to preserve erotic sensation. In one type of procedure, the new organ is
for copulation only and does not have a urinary connection, thus avoiding
possible severe complications of urinary stricture and infection.  In
male-to-female surgery, the penis and testicles are removed and a vulva and
vagina are constructed by using the skin from the penis to line a vaginal
cavity, which has been surgically opened. If the penile skin is not adequate,
an augmenting skin graft is used. Some male-to-female transsexuals also undergo
surgery to enlarge the breasts and seek other forms of feminizing cosmetic
surgery, such as rhinoplasty (nose surgery) and hip augmentation. For those
patients whose vocal cords have not become permanently habituated toward a
feminine register, surgery can be used to shorten the vocal cords in order to
elevate the pitch of the voice.  In female-to-male transsexuals, genital
surgery involves no loss of erotically sensitive areas. In fact, under the
influence of androgen, erotic sensitivity increases. In male-to-female
transsexuals, however, genital surgery involves the loss of a great deal of
erotic tissue. Whereas androgen enhances or intensifies the orgasm in the
female-to-male transsexual, estrogen is antiandrogenic and diminishes or
diffuses the orgasm as subjectively experienced in the male-to-female
transsexual.  Bodily feminization in males and virilization in females occurs
naturally in certain endocrine syndromes. In such cases, however, the affected
people do not request sex reassignment but, rather, want to get rid of what is
experienced as unsightly and abnormal.


On the basis of endocrine techniques now available, it is not possible to
demonstrate a difference in steroidal sex hormones from the gonads in
transsexual patients and normal controls. However, transsexual patients
possibly are atypical with respect to the way in which the brain's
hypothalamic-releasing hormones respond to and interact with pituitary and
gonadal hormones. If such evidence proves correct, the transsexual condition
most likely originates during prenatal or early infantile periods. No other
feasible hormonal hypothesis exists at present on the etiology of
transsexualism. Also, no feasible hypothesis of a genetic component in
transsexualism exists, although the most likely explanation is that the
condition is determined by various, sequential factors.  The developmental
biographies of transsexuals vary. One type is that of effeminate males and,
conversely, virilistic females. Such people have a history of active erotic
imagery, if not experience, with same-sex partners from a very early age. A
second type is that of a person who, even if he or she manifested no
cross-gender signs in childhood and adolescence, was always secretly obsessed
with being sex-reassigned; at puberty this person is erotically inert. A third
type is that of a person who has a history of transvestism, manifesting two
names, two wardrobes, and two personalities until middle life when, under the
pressure of a major life crisis, full-blown transsexualism emerges.  Sex
reassignment is a method of rehabilitation in selected, relatively rare cases
of severe displeasure with a person's natal gender. Before surgical means are
used, one way to evaluate the probable success of sex reassignment is to spend
2 years living, working, and becoming rehabilitated as a member of the other
sex. Hormonal reassignment can be reversed, but surgical reassignment cannot;
therefore, if all psychological and social consequences of sex reassignment are
negotiated far ahead of surgery, the chances of error are virtually eliminated.
At this moment in medical history, sex reassignment is the only effective form
of treatment for transsexualism. JOHN MONEY AND VIOLA G. LEWIS

Bibliography: Benjamin, Harry, The Transsexual Phenomenon (1966); Feinbloom,
Deborah H., Transvestites and Transsexuals (1976); Green, Richard, and Money,
John, eds., Transsexualism and Sex Reassignment (1969); Hunt, Nancy, ed.,
Mirror Image (1978); Hutchison, John B., ed., Biological Determinants of Sexual
Behavior (1978); Kando, Thomas, Sex Change (1973); Lothstein, Leslie M.,
Female-to-Male Transsexualism (1983); Mittwoch, Ursula, Genetics of Sex
Differentiation (1973); Stoller, Robert J., Sex and Gender, 2 vols. (1976). 

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