Gender reassignment: More and more transgender operations | STERN.de

How does a male body become a female one and vice versa? Surgery now makes many things possible. Demand is rising rapidly – despite the risks. Because the suffering is often great.

Born in the wrong body – more and more people are opting for gender reassignment surgery. With the new Self-Determination Act coming into force in the autumn, centres that carry out such operations expect demand to continue to rise. What is behind this development – and how does it work medically?

Only about a handful of clinics nationwide are able to carry out all the necessary surgical steps. One of these is the Agaplesion Markus Hospital in Frankfurt, the only center of its kind in Hesse. Prof. Ulrich Rieger, head of plastic surgery, and Dr. Saskia Morgenstern, head of the reconstructive urology department, have been carrying out the entire range of transgender operations for years.

At the University Hospital Frankfurt, the endocrinologist Prof. Jörg Bojunga founded the Transgender Medicine Working Group. They all report a high level of suffering among those affected. Bojunga considers the idea that changing gender is a fad to be absurd: “Nobody does it because they saw a TV show.”

Increase in numbers

According to the Federal Statistical Office, there were 2,598 genital reassignment operations nationwide in 2021. In 2007, there were only 419. The number is increasing significantly from year to year.

“Yes, there is an increase, but it is not explosive,” Morgenstern clarifies. Especially since each procedure is counted individually, even if a person is affected multiple times. One and the same trans man could, for example, be included in the statistics with seven “female-to-male” operations.

“Not all transgender people want such extensive operations,” says Rieger. For quite a few, it remains just a single, relatively small operation, for example on the breast. Bojunga’s experience shows that for many, hormone therapy is enough to improve their quality of life.

Often met with hostility

The battle for recognition begins with the battle for terms: The medically correct term is “gender incongruence” – the condition in which the perceived gender identity does not match the sex assigned at birth. “Gender dysphoria” is the term used when this causes suffering.

Bojunga’s first contact with a trans person was around 20 years ago. “In front of me stood a man in his mid-50s who had been exposed to violence all his life and was completely desperate. He said: Either I find help or I kill myself.”

An incident at the university hospital at the beginning of the year showed the hostility people are exposed to. In the toilet of the outpatient clinic, someone had left a message with contemptuous insults and threats of violence against trans and queer people. Bojunga reports from his conversations that the hostility has increased and that inhibitions on social media are decreasing.

Long way

Just as no one can ring the doorbell at Markus Hospital and have an operation performed spontaneously, no one at the university hospital gets a prescription for hormone treatment at the first appointment. In addition to endocrinologists, psychologists must also agree beforehand that such therapy is necessary.

Sometimes hormones have to be taken for life. They inhibit or promote breast growth, raise or lower the voice, stimulate or prevent beard growth. But sometimes hormone therapy is just the first step on a path that goes much further.

Most common operation concerns the breast

By far the most common operation for both sexes is on the breasts. Many trans men have their breasts surgically removed, while many trans women have them augmented with implants. “Very often this is the only procedure,” says Rieger. Most trans people are primarily concerned with how they appear to other, strangers.

According to a study, 65 percent of 6,800 trans people had hormone therapy. Of these, 75 percent of trans women and 84 percent of trans men opted for at least one operation.

How does a man become a woman?

If a person who was born with a male body decides to undergo genital reassignment surgery, it goes – to put it simply – like this: The testicles are removed. The labia are formed from the scrotum. A cavity is created in the abdominal cavity. The penis is hollowed out. The skin of the penis is turned inwards – this becomes the vulva. The clitoris is formed from the glans.

Most of the nerves remain intact, as Morgenstern explains. A study from Canada in 2017 found that over 80 percent of the trans women surveyed were able to experience an orgasm.

However, this comes at a price: after discharge, the “neovagina” must be stretched several times a day with a device for the rest of your life to prevent it from closing up again.

And vice versa?

If a woman is to become a man physically, the operation is much more complex. The main procedure takes around eight hours, and various other operations are necessary before and after, as Rieger explains.

In order to reconstruct a penis – in technical jargon this is called phalloplasty – the doctors remove skin from the patient’s forearm and tissue from the thigh. An erection is not possible naturally; an implant must be inserted, which the trans man pumps up before sexual intercourse.

Complications

The penile implant is a foreign body and is accepted by the body with varying degrees of success, as Morgenstern explains. Even if it is successful, it will inevitably have to be replaced after a few years. Another problem is that the urethra has to be lengthened. For this, rolled-up labia are used, among other things. The transitions are a risk area for complications. Implants for the new testicles are comparatively unproblematic.

Visually, the new penis is far from being a perfect replica of a natural one, says the surgeon, even though the glans is reshaped one year after the primary operation to make the neopenis appear more natural. The patient then has to undergo up to 20 follow-up examinations. Almost all of the trans men who have undergone this operation are capable of orgasm.

Does it have to be that way?

Is the operation necessary, sensible and justified in the individual case? “I’m glad I don’t have to decide that,” says Rieger. Before patients come to him and Morgenstern, they have to submit psychological and psychiatric reports, have undergone at least six months of hormone therapy and ensure that their health insurance will cover the costs. According to Rieger, a series of operations with six procedures costs several tens of thousands of euros.

It is “extremely rare” for people who have undergone gender reassignment surgery at Markus Hospital to regret the procedure afterwards, says Morgenstern. “Even if there were many complications, the satisfaction level afterwards is very high – because it makes such a big difference for people.”

A meta-analysis of 27 studies with data from a total of 7,928 transgender patients found that only one percent regretted the gender reassignment surgery. “The patients know exactly what to expect,” says Rieger. “And they are willing to take this path.”

Wish always comes sooner

What has changed with the increase in cases is the clientele: “The patients are getting younger and younger,” says Bojunga. What sounds like a negative development to critics is actually a positive one, says the doctor: “They have a shorter history of suffering.”

Another development: In the past, more trans women – that is, biological men with a female identity – visited the outpatient clinic; today, more women come who want to live as men.

For him, an “unresolved problem” is the question of how to deal with very young people affected. So-called puberty blockers, which delay the development into a man or woman, are controversial. One point of criticism is that they represent a kind of pre-decision for a very young person.

Guidelines in progress

While there has been a medical guideline for diagnostics, advice and treatment since 2018, there are major differences between the individual specialist centers in surgery. However, a guideline for gender reassignment surgical procedures is now also in the works.

The new Transgender Medicine Working Group wants to develop guidelines for the process of gender reassignment and coordinate research projects. The number of scientific studies has so far been limited. Since the whole topic is relatively new, long-term data is lacking, says Bojunga – for example, what the effects of taking hormones for decades are and why trans women have a higher suicide rate.

Self-determination law

In November, a new “Law on Self-Determination with Respect to Gender Registration” is to come into force, which was passed by the Bundestag in April 2024. It replaces the Transsexual Act from 1981, which the Federal Constitutional Court had declared unconstitutional in several decisions.

The new law is intended to make it easier for transgender, intersex and non-binary people to have their gender registration and first names changed. However, the law will “not make any regulations on gender-affirming medical measures,” as the Federal Ministry of Health emphasizes.

dpa

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