Discuss the pros and cons of transsexual surgery
Transsexualism is one of several conditions of where gender is ambiguous. This ambiguity can be expressed as intersexuality, transgenderism and transsexuality. Gender dysphoria refers to a state of dissatisfaction that one may experience when there is gender ambiguity. Transsexuals often believe this sense of misalignment between their physical bodies and their psychosexual orientation can be rectified through sexual reassignment surgery (SRS). In recent years, however, a transgendered community has emerged that embraces multiple gender and social identities and challenges the value of SRS (Strong et al. 2002). A transgendered person might publicly live in a gender role that is other than their genetic/genital sex.
Kessler and McKenna (2000) propose that the prefix “trans” has in fact three meanings. It can imply transformation as in changing one’s body to fit the other gender as transsexuals traditionally sought to do. It can also imply movement as in transcontinental when a person goes from one gender to the other without committing permanently to either one. The third meaning goes beyond the idea of there being two genders that one must negotiate and/or choose between. As in the word transcutaneous, one goes beyond gender by living in a world in which gender markers do not exist.
Depending on available technologies as well as cultural beliefs, transgenderism has been addressed in varying ways. Amongst many traditional Native American tribes, a berdache or two spirit (physical) male lived as a female (Williams, 1986). He would cook and sew as any woman would and would typically marry a (non-berdache) male. If he chose to have children, arrangements would be made for a fully biological female to produce children for him with his husband. Upon weaning, he would assume full maternal responsibilities.
Nanda (1999) documents the life and culture of East Indian hijiras, physiological males who, beginning in their teens, take on a status that is neither culturally male nor culturally female. Hijiras dress in flamboyant female attire and sing and dance at parties. They undergo an emasculation surgery by which both penis and testicles are completely separated from the body. (A small stick is inserted to maintain the urethra opening.) The surgery and the 40 days following are experienced as a rite of passage, parallel to giving birth. Once emasculated, the hijira leaves behind the sexual desires (and capacities) of maleness and transforms into an otherworldly being.
In most of the Western world, options such as being a hijira or a berdache do not exist, despite that about 1.7 percent of all births are intersexual (Fausto-Sterling 2000). Intersexuals may physically look more male (merms) or more female (ferms) or be true-in-the-middle hermaphrodites. Intersex babies have been frequently subject to surgery to “repair” their ambiguous genitals; very much reflecting mainstream Western society’s need to fit everyone in strict male or female categories. This penchant for avoiding gender ambiguity coupled with advanced medical technology has made it possible for transsexuals to physically transform their bodies into those that look like the other sex.
Despite plastic surgeons’ increasingly levels of expertise in creating aesthetically believable and physically functional genitals, a transgendered community has emerged that questions the ultimate efficacy of SRS. The “mother of transgenderism,” Virginia Prince (1977) has suggested that surgical solutions to gender identity conflict represent confusion between biology and psychology. In her succinctly stated view, surgery is "only a painful, expensive, dangerous and misguided attempt to achieve between the legs what must eventually and inevitably be achieved between the ears."
Ultimately Prince’s observations raise considerations regarding the necessity for SRS. If a genetic male can pass well as a female (and thus fully express his female gender persona), what would surgery actually change? Is the experience of vaginal penetration (albeit with a surgically constructed vagina) important? Or is it being able to “pass” not just in clothes, but in the nude?
Again we might examine the question of gender identity. There are some SRS candidates who do not embrace the world of transgenderism. They believe that their gender identity problem can be resolved by realigning their genitals to match who they believe they are socially, emotionally and psychologically. They don’t seek to live in a transgendered netherworld; all they want is to look like how they feel.
Despite that the American Psychiatric Association no longer considers transsexualism to be a psychiatric disorder, (it’s now considered a “gender identity disorder”), many psychologically oriented therapies are available to rectify the discordance between gender identity and physiological status (Strong et al. 2002). Gender dysphoria therapy explores the origins of the discordance, considering mental disorders, confusion over sexual orientation, and a penchant for cross-dressing. Hormonal treatment in the form of estrogen or testosterone therapy can help transsexuals access the other gender.
Males who seek to become females may take estrogen-based hormones like Estradiol or Premarin. These hormones will function to enlarge the breasts and shrink the penis and testicles. Females who seek to become males would take testosterone-based hormones that would reduce breast size, increase clitoral size, and reduce hair growth on the chest and face. In addition to hormonal therapy, malefemale transsexuals often undergo electrolysis to remove the vestiges of facial and chest hair while femalemale transsexuals may undergo a mastectomy to remove the remains of their hormonally reduced breasts and a hysterectomy to terminate their menstrual cycles.
Transgendered people may engage in life-long ingestion of sex hormones with no desire to undergo genital surgery. Ultimately, the difference between a transgenderist (such as Virginia Prince) and a transsexual is that the former has little interest in altering their genitals as a means of accessing their gender of choice. Here, being pre-operative is no longer regarded as a way station on the road to surgery (Denny, 1997). She-Male sex workers fill a valued erotic niche; their economic viability would be severely compromised if they were to have such surgery.
What then might SRS surgery be elected? Benefits would include being able to move from a liminal transgendered state into a culturally recognized state of male or female. The subject might experience higher levels of safety were s/he to be arrested and/or disrobed. Moreover his/her gender identity vis-a-vis identity cards like drivers licenses would match. Some may believe that once their psychological gender matches their physical body, they’ll have an easier time attracting a life partner. A fair number of malefemale transsexuals find that the kinds of people who are erotically drawn to them as pre-ops, are not the kinds that would be drawn to a long term traditional marriage (Nakamura, 2002).
For those transsexuals who experience their gender dysphoria as a medical problem, then a surgical solution might be in order. With the popularization of the Internet there are web sites like www.transster.com where femalemale transsexuals can look at the surgery results from various plastic surgeons and decide for themselves which ones they like the best. They can also read surgery-stories to assess patient treatment including bedside manner. Images that are documented on this site include reconstructed penises and mastectomies, which to this viewer looked both believable and functional.
The web site of Sexologist and Medical Doctor Anne Lawrence (www.annela-wrence.com) offers detailed information for malefemale sexual reassignment surgery including contact information for plastic surgeons in Asia and the United States. This site notes that more favorable outcomes are associated with younger age at surgery, childhood femininity, sexual attraction to males, absence of other psychological problems and good social and family support. Certainly a malefemale transsexual would better fit into mainstream society if she found heterosexual males attractive. Such a person might have a much harder time adjusting to their new self, if they’d spent many years being sexually active with gay males. Here, their transformation might require membership in a completely different cultural world. Regrets from sexual reassignment surgery are usually associated with dysfunctional results, postoperative complications, and the patients’ dissatisfaction with the nature of preoperative psychotherapy that they’d received.
Function and aesthetics are major issues for anyone considering SRS. There is concern that the new genitalia might not function properly during sexual intercourse, that orgasm may no longer be possible, and that they won’t look natural. Surgical innovations now abound. With the “pedicled clitoroplasty” technique, tissue from the glans of the former penis is used to create a very functional clitoris. Recent innovations in vaginoplasty have focussed on creating an adequately deep and sensitive vagina. Though still a controversial technique, functional and self-lubricating neo-vaginas have been created using a segment of the colon (www.annelawrence.com). While recovery from colon surgery coupled with genital surgery can be more extensive; the results are often well appreciated
Considering the viability of surgery and the generally high rates of satisfaction, what might be the reasons this option isn’t always selected? Engaging in SRS is a major commitment which can only undertaken following at least two years of real life experience living as the other gender. Apart from the transitional benefits of hormone therapy, one needs to learn the subtleties of handling life in a body representative of the other gender. Costs may be prohibitive. Despite a transsexual’s personal conviction that surgery is a medical necessity, health insurance plans rarely offer coverage. A full transformation including pre-operative counseling by a trained professional such as a clinical sexologist and hormone therapy can run close to $50,000. A typical surgery in the U.S. including surgeon as well as hospital fees can average around $25,000. In Thailand, such surgeries cost dramatically less, running between $4,500 and $6,000.
Some transsexual candidates are not healthy enough to handle the very high doses of sex hormones that are necessary. While a full physical and psychiatric exam is usually required before prescribing these hormones, some doctors consider successful prior taking of (non-prescribed) sex hormones (e.g. borrowed from a friend) as evidence of a patients’ commitment to the process. FemaleMale transsexuals who aren’t able to take hormones may resort to padded bras or the use of silicone falsies.
Finally there are transsexuals who would be most comfortable embracing transgenderism. If they were to make a full transition, marry heterosexually, and move to suburbia they might feel fraudulent…and ultimately quite empty. What may make their lives rich and meaningful is living in a transsexual/transgender social community. Looking and behaving like any other straight man or woman may cause them to no longer feel unique. If the focus of their whole life had been trying to switch genders, actually achieving that goal may ultimately lead to a feeling of loss and purposelessness. They may have a psychological desire to be different and once they become like everyone else whose brain and body matches, it may still not feel right. And certainly with the growing respect for transgenderism not just as a way station but as a way of negotiating gender, the social and psychological necessity for SRS is now, more than ever, up for grabs.
Denny, Dallas, “Research in the Support Group Setting: Outcome of Five Cases of Transsexualism” Paper presented at the 2nd International Congress on Sex and Gender, June 19-22, 1997.
Fausto-Sterling, Anne, “The Five Sexes, Revisited,” The Sciences, July/August, 2000, 19-23.
----Sexing the Body: Gender Politics and the Construction of Sexuality. New York: Basic Books, 2000.
Kessler, Suzanne and McKenna, Wendy, “Who Put the Trans in Transgender: Gender Theory and Everyday Life,” International Journal of Transgenderism, ISSN 1434-4599, 2000
Nanda, Serena, Neither Man nor Woman: The Hijiras of India, Belmont, CA: Wadsworth, 1999
Nakamura, Mia, Personal Communication, December 2002.
Prince, Virginia, Sexual Identity versus Gender Identity: The Real Confusion, 1977
Strong, Bryan et al. Human Sexuality: Diversity in Contemporary American, 4th Edition, Boston: McGraw Hill, 1998.
Williams, Walter. The Spirit and The Flesh, Boston: Beacon Press, 1986