Sex reassignment surgery SRS

Sex reassignment surgery (SRS), also known as gender reassignment surgery (GRS)  or transgender surgery or sex change surgery and several other names, is a surgical procedure (or procedures) by which a transgender person’s physical appearance and function of their existing sexual characteristics are altered to resemble that socially associated with their identified gender. It is part of a treatment for gender dysphoria in transgender people.

Professional medical organizations have established Standards of Care that apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female. These surgeries include vaginoplasty, feminizing augmentation mammoplasty, orchiectomy, facial feminization surgery, reduction thyrochondroplasty (tracheal shave), and voice feminization surgery among others male to female sex change surgery.

Masculinization surgeries are surgeries that result in anatomy that is typically gendered male. These surgeries include chest masculinization surgery (top surgery), metoidioplasty, phalloplasty, scrotoplasty, and hysterectomy in female to male sex change surgery.

In addition to SRS or sex change surgery, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

1. 1. Requirements for mastectomy for female-to-male patients:
      1. Single letter of referral from a qualified mental health professional and
      2. Persistent, well-documented gender dysphoriaand
      3. Capacity to make a fully informed decision and to consent for treatment; and
      4. For members below the age of majority (less than 18 years of age), completion of one year of testosterone treatment; and
      5. If significant medical or mental health concerns are present, they must be reasonably well controlled.

      Note that a trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy in adults.

   2. Requirements for gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female):
      1. Two referral letters from qualified mental health professionals, one in a purely evaluative role  and
      2. Persistent, well-documented gender dysphoriaand
      3. Capacity to make a fully informed decision and to consent for treatment; and
      4. Age of majority (18 years or older); and
      5. If significant medical or mental health concerns are present, they must be reasonably well controlled; and
      6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones)
   3. Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis in female to male; penectomy, vaginoplasty, labiaplasty, and clitoroplasty in male to female)
      1. Two referral letters from qualified mental health professionals, one in a purely evaluative role
      2. Persistent, well-documented gender dysphoria.
      3. Capacity to make a fully informed decision and to consent for treatment.
      4. Age of majority (age 18 years and older).
      5. If significant medical or mental health concerns are present, they must be reasonably well controlled.
      6. Twelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).
      7. Twelve months of living in a gender role that is congruent with their gender identity (real life experience).

   Note: Blepharoplasty, body contouring (liposuction of the waist), breast enlargement procedures such as augmentation mammoplasty and implants, face-lifting, facial bone reduction, feminization of torso, hair removal, lip enhancement, reduction thyroid chondroplasty, rhinoplasty, skin resurfacing (dermabrasion, chemical peel), and voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords), which have been used in feminization, are considered cosmetic. Similarly, chin implants, lip reduction, masculinization of torso, and nose implants, which have been used to assist masculinization, are considered cosmetic.

   Note on gender specific services for the transgender community

   Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy.  Examples include:

   1. Breast cancer screening may be medically necessary for female to male trans identified persons who have not undergone a mastectomy;
   2. Prostate cancer screening may be medically necessary for male to female trans identified persons who have retained their prostate.

   Gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria.

   Following procedures that may be performed as a component of a gender reassignment as cosmetic (not an all-inclusive list):

   • Abdominoplasty
   • Blepharoplasty
   • Brow lift
   • Calf implants
   • Cheek/malar implants
   • Chin/nose implants
   • Collagen injections
   • Construction of a clitoral hood
   • Drugs for hair loss or growth
   • Facial feminization and masculinization surgery
   • Forehead lift
   • Jaw reduction (jaw contouring)
   • Hair removal (e.g., electrolysis, laser hair removal)
   • Hair transplantation
   • Lip reduction
   • Liposuction
   • Mastopexy
   • Neck tightening
   • Nipple reconstruction
   • Nose implants
   • Pectoral implants
   • Pitch-raising surgery
   • Removal of redundant skin
   • Rhinoplasty
   • Tracheal shave
   • Voice therapy/voice lessons.

   Background

   Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

   Gender reassignment surgery is performed to change primary and/or secondary sex characteristics. For male to female gender reassignment, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty) and cosmetic surgery (breast implants, facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) . For female to male gender reassignment, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring .

   The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery.

   In addition to hormone therapy and gender reassignment surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender reassignment surgery or transgender surgery or sex change surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender reassignment surgery or transgender surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Gender dysphoria

Gender dysphoria involves a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify. People with gender dysphoria may be very uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender.

People with gender dysphoria may often experience significant distress and/or problems functioning associated with this conflict between the way they feel and think of themselves (referred to as experienced or expressed gender) and their physical or assigned gender.

The gender conflict affects people in different ways. It can change the way a person wants to express their gender and can influence behavior, dress and self-image. Some people may cross-dress, some may want to socially transition, others may want to medically transition with sex-change surgery and/or hormone treatment. Socially transitioning primarily involves transitioning into the affirmed gender’s pronouns and bathrooms.

People with gender dysphoria may allow themselves to express their true selves and may openly want to be affirmed in their gender identity. They may use clothes and hairstyles and adopt a new first name of their experienced gender. Similarly children with gender dysphoria may express the wish to be of the opposite gender and may assert they are (or will grow up to be) of the opposite gender. People with Gender dysphoria prefer, or demand, clothing, hairstyles and to be called a name of the opposite gender. (Medical transition is only relevant at and after the onset of puberty.)

Gender dysphoria is not the same as gender nonconformity, which refers to behaviors not matching the gender norms or stereotypes of the gender assigned at birth. Examples of gender nonconformity (also referred to as gender expansiveness or gender creativity) include girls behaving and dressing in ways more socially expected of boys or occasional cross-dressing in adult men. Gender nonconformity is not a mental disorder. Gender dysphoria is also not the same being gay/lesbian.

While some children express feelings and behaviors relating to gender dysphoria at 4 years old or younger, many may not express feelings and behaviors until puberty or much later. For some children, when they experience puberty, they suddenly find themselves unable to identify with their own body. Some adolescents become unable to shower or wear a bathing suit and/or undertake self-harm behaviors.