introduction

The phenomenon of gender dysphoria, or the feeling that one is living in the wrong body, is not a new one. In fact, people have complained of gender dysphoria throughout history. The medical industry offered little treatment until the nineteenth century when a small number of physicians introduced hormone replacement therapy and what is now known as "sex change" surgery. Despite a number of advances to the surgical technique, a number of people, who appear to be perfect candidates for the surgery, fail as post-operative transsexuals to benefit from the surgery, leading the medical community at loss to explain why some transsexuals benefit from the surgery while some do not. As the medical community continues to debate the merits of sexual reassignment surgery as an effective treatment one thing is certain. People, who suffer from a gender identity condition and want to sexually function as members of the opposite sex, often elect to undergo this radical surgery above all other treatments to be (at least on the surface) members of the opposite sex.

modern sexual reassignment surgery

The earliest medical experiments, involving hormone replacement therapy began in Nazi German during the second world war. Doctors in the Third Reich extracted male and female hormones from animals and injected them into the inmates of the death camps to study their effects. Much of the science that went on had little to do with the war effort and more to do with junk science. At the conclusion of the war the research and evidence into hormone therapy from the death camps were lost.

By 1950 the medical community was dispensing hormone extracts from animals and offering these medications to people for a variety of medical reasons. However, transsexual women obtained these medications (often illicitly), learning that the medications allowed them to grow breasts, soften their skin and over time develop the contours of born women. Also during the 1950s, modern surgical techniques made it possible to reconstruct the genital region of the human body (male and female). A few surgeons began exploratory surgeries to construct vaginas in male-to-female transsexuals by using skin grafts taken from the different regions of the body including thighs or buttocks, drawing upon then recent techniques for constructing vaginas in intersexed girls. [Conway, Lynn, 2005]

Christine Jorgensen, a U.S. citizen, was among the first small group of male-to-female transsexuals to undergo this early version of what became known as "sex change" surgery. On December 1, 1952, the New York Daily News reported the fact that Jorgensen had undergone surgery to change sexes and Jorgensen, herself, became incorrectly known as the world's first transsexual to undergo modern "sex change" surgery, opening the doors of the imagination to male-to-female transsexuals everywhere. Unfortunately, the surgeons, who performed the surgery were not accepting any more candidates at the time and access to the surgery was an impossibility.

In the surgery Christine Jorgensen underwent (which was rapidly evolving), doctors first removed the transsexual's male organs in one or more surgeries. The patient then waited through an extended period for healing. Then, in a surgery similar to those done to create vaginas for intersexed patients, surgeons constructed the patient's vagina by using skin grafts taken from the thighs or buttocks. In fact, in 1952 Christine Jorgensen has little more than what became known as a penectomy. Christine didn't obtain vaginoplasty surgery until 1954.

Although the patients reported being "pleased" with the result, the surgical technique had a number of problems. The skin grafts were unreliable and partially failed to "take". [Lynn Conway, 2005] In effect the body rejected the new vagina. The skin grafts also left large scars in the region where the skin was removed. In addition, the patients of the first "sex change" surgery were left with little or no sensation in their surgically constructed vaginas.

In 1958 or thereabouts, Dr. Harry Benjamin, an endrochronologist, began to care for male-to-female transsexual patients, becoming the first American doctor to do so. Benjamin rejected the accepted thinking in the psychaitric community at the time that male-to-female transsexuals were by definition suffering from mental illness. Instead, he believed they were suffering from a cross-gender condition of unknown origins. He prescribed estrogens to a select group of his patients, who were pleading for medical feminization.

In 1958 or thereabouts, French plastic surgeon, George Burou, developed what is known today as the penile inversion technique—variations of which are still in wide use to this day. Dr. Burou's technique salvaged the male genitalia as source of skin and sensitive erotic tissue to create the new female genitalia, including the vagina, the labia and the clitoris. At his clinic in Casablanca, Morocco, he performed his technique on hundreds of patients including a number of female impersonators. Coccinelle and April Ashley were well-known patients who went through Burou's clinic in Casablanca. A number of wealthy males (what the community would regard as the early trans* admirers) sponsored the surgery from Burou for a number of female impersonators. They took on these trans* woman as lovers. Aristotle Onassis was perhaps the most famous of the sponsors of "sex change" surgery. [Lynn Conway, 2005]

moral ethics behind sexual reassignment surgery

Religious groups, operating in the U.S., who learned of the Jorgensen story, pressed politicians to enact legislation to prevent plastic surgeons from practicing sexual reassignment surgery on U.S. soil. The U.S. College of Psychaitrists and Psychologists entered Transsexualism in the Diagnostics and Statistics Manual (DSM) as a disorder. The medical industry uses the DSM as a standard to form the diagnosis of patients. State institutions with the aid of the families of transsexual family members, forced transsexuals (often children) into asylums to undergo treatment in the hopes of a cure. These asylums often administrated electroshock therapy to transsexual patients young and old with little effect. The people who felt gender dysphoria continued to feel dysphoria after all attempts at treating them were exhausted.

Incidence of post-operative transsexual surgeries

There are no satistics kept on the number of genital surgeries performed worldwide. However, one can estimate the total number of surgeries performed in the last twenty five years by taking the average number surgeons in practice, multiplying that number by the average number of surgeries a surgeon performs per annum, multiplying that number by the number of years (25). Obviously less surgeons performed genital surgery in the sixtiess and seventies compared with the eighties and nineties.

Dr. Brassard performs approximately 200 GRS procedures per year. Let's use that figure as the average number of surgeries a surgeon performs per year.

At any one time there are approximately twenty three surgeons worldwide, who perform genital surgery, including Pierre Brassard, Toby Meltzer, Eugene Schrang, Marci Bowers, Gary Alter, Preecha, Chettawut, Pichet, Sanguan, Ruch Wongtrungkapon, James Bellringer, Timothy Terry, Phillip Thomas, James Dalrymple, Trevor Crofts, Michael Royle, Seghers, Peter Haertsch, Simon Ceber, Harold Reed, Michael Brownstein, Peter Walker, Jorge Sáenz. Meynard no longer performs GRS.

However, there is a larger pool of surgeons today than in 1980. To compensate, let's say there are an average of twenty surgeons over the twenty five year time horizon.

Twenty surgeons, who on average perform two hundred surgeries per annum totals to four thousand per annum (4,000) multiplied by twenty five years totals to one hundred thousand surgeries. There are approximately 100,000 post operative transsexuals in the world, not counting deaths.

Dr. Brassard's technique

Dr. Brassard's GRS procedure in detail

Dr. Brassard's technique is a variation of the technique Burou practiced in his medical office in Casablanca, Morocco as early as 1958. Dr. Brassard's technique is in contrast to Suporn's technique, which is largely based on skin grafts.

Dr. Brassard begins by opening the genital area in a "V" pattern to allow him to work on the genital fully exposed. Each opening along the stem of the "V" pattern is approximate five inches in length. Dr. Brassard then opens the scrotum. Inside the scrotum, Dr. Brassard, locates the cords to the testes, severs them and removes the testes, preserving and separating the nerves that travel through the scrotum. With the scrotum open, Dr. Brassard then detaches the skin of the penis, and spreads it out on a surgical table. He has an assistant remove the bulbs of the hair follicles on the skin of the penis from the inside out using a surgical device.

"The reason he removes the skin is to allow his assistant to remove the hair follicules while he continues working. The surgical device, itself, looks like a cross between a scaper and a shaver." says Michaela, a pre-operative transsexual woman, who witnessed Dr. Brassard perform the combination of a penectomy and vaginoplasty on her partner at the hospital in Montreal, Quebec.

After his assistant plucks the hair follicles from the skin of the penis (now separated from the body) Dr. Brassard returns to work on the shape of the skin of the penis, cutting away the head of the penis. Dr. Brassard then attaches the severed head of the penis to the body to form what will ultimately be the clitoris and labia. As Dr. Brassard sculpts the clitoris and labia, he bundles all the nerves that are now separated from the penis and scrotum beneath the newly created clitoris. Simultaneously, Dr. Brassard reduces the length of the urethra to a length appropriate for that of a neo vagina.

Dr. Brassard then returns to the skin of the penis, attaches it to the newly created labia, forming a cavity outside the body sculpted or shaped by a surgical packing that resembles a small condom.

"The surgical packing is white so that Brassard can see if there are any areas that are not stitched tight or closed." Michaela says.

As in any surgical procedure the patient bleeds profusely. Dr. Brassard counters any bleed using a laser to cauterize the sources of the bleeding.

"Brassard is very meticulous about that." Michaela says.

Dr. Brassard then takes the urethra and connects the end of the urethra to the inside of the exposed vaginal cavity. Dr. Brassard then stitches the skin of the penis around the surgical packing from the inside of what will be the vaginal cavity. Dr. Brassard stitches the skin onto the packing to ensure that it doesn't fall out post-operatively.

"This is the part that takes the most time." Kassandra says. Kassandra is a three-year post operative transsexual, who underwent what is known as gender reassignment surgery performed by Pierre Brassard, M.D. "Brassard can take hours just doing this one part of the procedure."

In Fact, Dr. Brassard performs over one hundred separate stitches in the course of the one GRS procedure.

When the neo vagina is completely formed, Dr. Brassard makes a vertical incision between two muscle groups where the scrotum and penis used to be attached to. Dr. Brassard, then, inserts the exposed vaginal cavity into the catheter by hand.

"He doubles checks it to make sure there is not an area that looks like its good, but isn't good." Michaela says.

Dr. Brassard and his assistants require approximately forty five minutes to prepare the patient for what is known as a Gender Reassignment surgical procedure. Dr. Brassard requires no more than two hours to perform a GRS.

"Dr. Brassard was constantly asked me if I was Okay during the surgery and at a break and whether I was going to faint." Michaela says. "I was amazed at how meticulous Dr. Brassard is."

risk to sexual function

If you undergo GRS, and you value sexual function, you are literally placing your faith in the hands of your surgeon. Dr. Brassard's staff have you sign legal documents waiving Dr. Brassard from any liability. Although Dr. Brassard does not publish the success rates of his patients, who report being able to regain orgasmic function, Dr. Brassard's staff explicitly tell you that there is a "very good chance" from undergoing GRS, that you (or anyone) will fail to regain orgasmic function.

"Dr. Menard's wife, who is one of the head nurses at the residence, in fact takes you aside and tells you there is a chance that you may never climax. They make it clear to that you may never function after the surgery. They tell you to [in effect] prepare yourself for the chance you may never sexually function moving forward." Kassie says.

However, the sign of any good surgeon is whether people would otherwise engage his services. In the case of GRS, Dr. Brassard's skill is arguably in high demand. He sees over two hundred patients for GRS per year. There is little doubt that Dr. Brassard patients come to him with their complete trust. They are steadfast undetered by all warnings to the contrary that they may fail to ever regain orgasmic function after surgery, if that is indeed important to them. In a recent published follow-up study (Radman, Lazer, Benet, Schaefer & Melman, 1999) involving a three year follow-up of 47 male to female post operative transsexuals, where only 28 patients were in fact contacted, of those only 11 were contacted directly. Three are known to have died; one in a motor vehicle accident (the details of which are not disclosed), one from AIDS; and one from suicide in jail. Of the survivors, "all 28 expressed that they felt better from surgery." However, of those who said that orgasm was "very important for sexual satisfaction", four (29%) now report that they are unable to orgasm.

"He has a stack of endorsements from transsexual women, who write 'I want to thank you for 'saving' my life.'" Kassie says.

"Would I have Dr. Brassard do my work? Absolutely." Michaela says, after witnessing him work firsthand.

However, Brassard's technique is like all penil inversion techniques in that it has limitations.

"He [Brassard] told me he would be able to give me a life-looking vaginal area. [including] a labia, a clitoris and a hood." Kassandra says.

post surgerical care

After GRS, Dr. Brassard's patients will be at the hospital for approximately four days and nights. On the fifth day or thereabouts, Dr. Brassard's patients return to the residence. On the eighth day or thereabout, Dr. Brassard (or another staff member) remove the surgical packing.

When they are convalescing at the residence, the patients can make telephone calls and access the Internet and back in the swing of things, figuratively. The nurses encourage Dr. Brassard's patients to talk brief walks on the island of the residence.

"Even on the first walk, the nurses tell you not to go over the the bridge." Michael says. The residence is physically on a private island on the outskirts of Montreal, Quebec. "They tell you to stay on the island. Some of the girls walk vigorously [after the surgery]. We call it the 'Montreal shuffle'. We had a laugh. We said, "if it walks like a duck and it quacks like a duck, it could be a transsexual.' The one girl from Montreal, Anne, [who convalesced at the residence at the same time as Susan, Michaela's partner], was doing the 'duck'. she was over enunciating the walk and purposely being funny about it."

 

cost

For people, who live in Ontario, electing to undergo GRS by Dr. Brassard is cost economical. Dr. Brassard is considerably less expensive than comparable U.S surgeons, including Dr. Eugene Schrang, Toby Meltzer and Marci Bowers, who now charges over US$15,000. Dr. Brassard only charges CDN$16,800 dollars for the GRS procedure, which includes post-surgical care for up to fourteen days at the residence. If one attends a consultation that is deducted from the fourteen post-surgical days of care.

The expense to travel to Thailand to undergo GRS from Suporn are considerable. If you elect to undergo GRS with Suporn you need to budget one month of post-surgical care, which is not included in Suporn's fees. The Hotel expense will run approximately US$1,000. The airfare to Thailand is approximately 1,200 dollars. At the time of this writing Dr. Suporn was charging approximately US$12,000.

Dr. Brassard takes on a considerable number of patients, who are otherwise not satisfied with undergoing GRS from a third party surgeon. Dr. Brassard tends to these clients later in the work week, after he performs his scheduled load of GRS.

motivations underlying sexual reassignment surgery

Prior to any discussion of whether the surgery is right for you, you must first understand how gender serves as a motivating factor towards the urge to undergo genital surgery and how sex (or sexual interests) serves as a motivating factor towards the urge to undergo genital sugery.

A gender identity condition is a persistent discomfort with one's gender / gender role in society and a preference to live out another gender / gender role. The discomfort of having a gender identity condition is largely satisfied when one socially functions as a member of the opposite gender.

Males and females, who are young, can function as members of the opposite gender relatively quickly and with little medical intervention. Usually the introduction of hormones (hormone replacement therapy) is sufficient to allow a young male or female to socially appear and function as a member of the opposite gender. Male-to-female transsexuals and female-to-male transsexuals (even ones who are young) cannot actually arrive at being members of the opposite sex due to limitations in medical science. Transsexuals can sexually function as member of the opposite sex in society only through surgical means. A gender identity condition in isolation is not powerful enough to motive a transsexual to elect to undergo genital surgery.

The underlying motivations a person has towards undergoing genital surgery varies by sexual orientation. Heterosexual males, who have an irrepressible urge to undergo genital surgery, largely have a sexual arousal to being or turning into a woman. Homosexual males, who have an irrepressible urge to undergo genital surgery, largely have a sexual arousal to sexually functioning as a woman with another otherwise anatomical male.

In the case of the self-identifying straight (androphillic) male-to-female transsexual, the urge or motivation in having a penectomy and vaginoplasty largely comes from the desire to sexually function as a member of the opposite sex. Having a surgically constructed vagina allows the androphillic male-to-female transsexual, to engage in intercourse with a member of the same anatomical sex (or in this case another male). The presence of a vagina alone is a shallow construct for socially functioning as a member of the opposite gender in society (or a woman in this case). However, few self-identifying straight male-to-female transsexuals ever explicitly state regret or revert to socially functioning as males in society (see exceptions to the rule below).

In case of the self-identifying straight (gynaphillic) female-to-male transsexual the urge or motivation in having a surgically constructed penis is largely the same. The urge comes from the desire to sexually function as a member of the opposite sex (in this case male). Medical science offers little to satisfy this desire outside of cosmetic appearance. However, few gynaphillic female-to-male transsexuals ever explicitly state regret or revert to socially functioning as females in society.

In the case of the self-identifying lesbian, or bi-sexual, male-to-female transsexual, the urge or motivation in having a penectomy and vaginoplasty largely comes from paraphilic tendency to become sexually aroused by the thought of being or functioning as a member of the opposite sex. Blanchard refers to this sexual condition as autogynaphilia and males that have this sexual predisposition as autogynaphiles.  Autogynaphiles largely do not have a gender identity condition. It only appears that way on the surface. A substantial number of gynaphillic male-to-female transsexuals, explicitly state regret or revert to socially functioning as males (or at times butch dykes) or demonstrate complete gender apathy (see exceptions to the rule below). A handful of masterbation thoughts during adolescence is all that is necessary to drive an autogynaphile to the operating table.

In the case of all transsexuals, the urge or motivation in obtaining sexual reassignment surgery can also occur in individuals who exhibit an obsessive behaviour about becoming a member of the opposite sex and are not satisfied with simply socially functioning as a member of the opposite gender coupled with a transvestia. These individuals suffer more from an obsessive compulsive disorder and not from a gender identity condition. People, who have the combination of a gender identity condition and an obsessive/compulsive disorder, have persistent, racing thoughts about SRS and often contemplate suicide. These people regard SRS as necessary and often life-saving surgery. In the case of the transsexual, who suffers from a obsessive/compulsive disorder, SRS does little but take away the object of the obsession. SRS, indeed, allows these people to get the monkey off their respective backs. However, these individuals often grab onto other obsessions down the road (like the ability to procreate as a female), cause they never effectively deal with the underlying disorder. They treat the symptom and not the cause.

In the case of all transsexuals, the urge or motivation in obtaining sexual reassignment surgery can also occur in individuals who have a mood disorder, like depression coupled with a travestia. A common myth is that depression is embodied in a gender identity condition. Dr. Anne Vitale's work (which contributes to this myth) is irresponsible at best and incompetent at worst. In fact, a gender identity condition and depressive mood disorder are mutually exclusive. Harbouring the belief that one can stave off depression by having SRS or alternatively lift themselves out of depression by having SRS is particularly self-destructive. In fact, transsexuals, who suffer from a depressive mood disorder, are no less likely staving off an episode of depression after having SRS than not having SRS at all. Vaginoplasty in isolation does not attentuate serotonin levels in the brain.

"Anybody, who changes sex does it for sexual reason." Nancy Nangeroni says. Nangeroni is the host of the award winning radio program, Gender Talk.

The reason why a large number of female-oriented, male-to-female transsexuals fail to benefit from genital surgery is that as the real (not explicit) drivers toward transition change so do the motivations to function as members of the opposite gender. Many are not even aware of the 'vanishing floor' giving way beneath their feet. In the case of the autogynaphile, as their sex drive wanes, they revert to their fundamental gender identity, usually male. They live as men or butch dykes or they exhibit complete gender apathy. To say that there is no correlation between age, sex and sexual orientation of a transsexual and how well they progress into being well-adjusted men and women respectively in society is akin to saying there is no correlation between the sun and daylight.

Is there hope for the autogynaphile? Absolutely. If the autogynaphile can maintain a sex drive, she can prop up her otherwise weak female gender identity to function adequately as a member of the opposite sex for a considerable stretch of time. However, inevitably the floor vanishes and even once successful autogynaphiles recognize that their transition was a mistake. Renee Richards, a female-oriented post-operative transsexual woman, is on record for admitting to making a mistake in transitioning. Alternatively, the autogynaphile can learn to be comfortable with her new gender role without the help of her sex drive. Living full time as a woman then becomes a training exercise.

exceptions to the rule

There are a small number of male-oriented transsexuals, who like their female-oriented cousins exhibit auotgynaphilia, despite the disorder being largely a female-oriented disorder. These males often follow the post surgical experience of female-oriented transsexuals in that they often regress back to their fundamental gender identity when their sex drives wane.

There are also female-oriented transsexuals, who exhibit little or no sexual noise underlying transition and indeed have a gender identity condition.

implications for transsexual men and women

Whether the surgery is right for you (and the likelihood of whether you will benefit from genital surgery) is more a function of your age, sex, and sexual orientation and less a function of the quality of the technique and/or who you entrust your neo vagina or neo penis to. The regret rates in post-operative transsexual women have only marginally improved over the last forty years since the first skin grafts performed on transsexual women, dating back to 1962. The regret rates in post-operative transsexual men have been and now are virtually non-existent. In the paper, Predicting Regrets in Post Operative Transsexuals, dated 1989 Blanchard, Dickey, Clemensen, Steiner report that out of seventy eight (67) male-to-female transsexuals surveyed, only 6% (4) either explicitedly stated regret or reverted to living as men. Of the four individuals in the paper, dated 1989, who either explicitly stated regret or reverted to living as male, all had a heterosexual background prior to the surgery. Hence there is a significant correlation between one's sexual orientation and whether the person regrets the surgery. If the person regrets the surgery, it is reasonable to argue that the individual does not benefit from it as well.

If you are a middle-aged, female-oriented transsexual woman, who values sexual function, and find yourself in a commmitted relationship, you should not pursue genital surgery. The reason is few wives of middle-aged transsexual women successfully cope with a husband's transition to their same-sex spouse. A large percentage of them leave their transsexual husbands, despite all attempts at relationship councilling and any pledges of support the wife may extend prior to the surgery.

"Can you blame them? They married a guy, who they thought were going to have babies with and help raise their kids with and grow old together. The male has now changed himself. If the wife is not at least bi-sexual, what have you become? Her friend?" Kassandra says.

In addition to the problems of retaining a relationship through the course of transition, a middle-aged, self-identifying lesbian transsexual woman, who values sexual function, has only a 71% likelihood of retaining sexual function after surgery. [Radman, Lazer, Benet, Schaefer & Melman, 1999]

If you are a self-identifying lesbian transsexual women, who values sexual function, and you find yourself single and open to a sexual relationship with a natal woman (and not another transsexual woman), you should not pursue sexual reassignment surgery. The reason is few homosexual women (particularly middle-aged, homosexual women) find transsexual women attractive. In fact, less than 1% of all homosexual women prefer a sexual relationship with a male-to-female transsexual over one with a natal woman.

"If you have had the surgery and you meet a girl and she goes down on you, she is going to say, 'you are not a woman'. Because the surgically constructed vagina is not [the same as] a genetic female's. It doesn't get as wet. There is no room for compromise on that." Kassandra says.

The self-identifying lesbian, post-operative transsexual will fail to realize her expectations involving relationships with natal women time and time again. Often, self-identifying lesbian, post-operative transsexuals (who do not otherwise exhibit gynandromorphophillia) compromise and take on other self-identifying lesbian, transsexuals as lovers. A smaller number simply commit suicide, realizing the true hardship at finding either a new full time position or new partners or a combination of the two.

If you are a self-identifying straight transsexual woman, you are much less at risk of the difficulty in finding sexual partners if you undergo genital surgery. Self-identifying straight transsexual women are more likely to benefit from genital surgery than their self-identifying lesbian sisters. The surgery allows the self-identifying straight post-operative transsexual woman to sexually function in an otherwise heterosexual relationship. In effect her post-operative vagina strengthens her chances at a relationship with men, both bisexual and heterosexual, who prefer vaginal intercourse. The self-identifying straight post-operative transsexual woman, also, feels a greater sense of validation in society. Her more natural feminine gender identity is only enhanced by genital surgery.

Even the self-identifying straight post-operative transsexual woman, who finds herself in a committed relationship with an admirer, or a male, who otherwise finds pre-operative transsexuals arousing, are more likely to survive in their relationships than their self-identifying lesbian transsexual sisters, who find themselves in committed marriages.

"If you are a [self-identifying lesbian] transsexual and you think you are going to get into a relationship with a genetic female or perserve your relationship with a genetic female, pass the pipe my way, [cause] I want try that drug. The reality is the percentage of women, who would continue in a relationship or be interested in a relationship is probably below one percent. (1%)" Kassandra says.

If you are a self-identifying lesbian transsexual woman, and have a paraphilic tendency to become aroused by the thought of being or turning into a member of the opposite sex (or have ever had this predisposition however remote, meaning you have once masterbated to the thought of functioning as women in society), you should not pursue genital surgery. You should pursue treatment for what is an otherwise sexual motivatiion (i.e., an irrepressible urge) to undergo genital surgery. The reason is few autogynaphiles benefit from genital surgery in terms of realizing life expectations. Further, few autogynaphiles are able to maintain their sex drive to prop up their otherwise weak feminine gender identities.

Dr. Anne Lawrence, and Kate Bornstein, if they, indeed, are autogynaphilic, are the exception and not the rule.

If you are a transsexual woman and have ancillary mental disorders, like obsessive compulsive disorder, bi-polar mood disorder or a personality disorder, and you have not be forthright with your health background during the screening process, you should definitely not pursue genital surgery as you do not qualify for the surgery under the standards of care as set down by the HBIGDA.

Female-to-male transsexuals (regardless of sexual orientation) rarely explicitly complain, despite the frequent complications and horrific results of the technique.