Sex reassignment surgery female to male includes a variety of surgical procedures for transgender people that alter female anatomical traits to provide physical traits more appropriate to the trans man's male identity and functioning.
Many trans men considering the option do not opt for genital reassignment surgery; more frequent surgical options include bilateral mastectomy (removal of the breasts) and chest contouring (providing a more typically male chest shape), and hysterectomy (the removal of internal sex organs).
Sex reassignment surgery is usually preceded by beginning hormone treatment with testosterone.
Many trans men seek bilateral mastectomy, also called "top surgery", the removal of the breasts and the shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola doesn't need to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return. See Male Chest Reconstruction.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in women is sometimes erroneously referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs. A 'partial hysterectomy' is actually when the uterus is removed, but the cervix is left intact. If the cervix is removed, it is called a 'total hysterectomy.'
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer. (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men. The risk will probably never be known since the overall population of transgender men is very small;[improper synthesis?] even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.[improper synthesis?]
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a woman and may herald the development of a gynecologic cancer.
Further information: Metoidioplasty and Phalloplasty
Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or stomach and an erectile prosthetic (phalloplasty). In either case, the urethra can be rerouted through the phallus to allow urination through the newly constructed penis. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted.
Notes and references
Gender-confirmation surgeries—the name given to procedures that change the physical appearance and function of sexual characteristics—increased by 20 percent from 2015 to 2016 in the U.S., with more than 3,000 such operations performed last year. Rates are also increasing worldwide. Now, at least one surgeon is reporting a trend of regret.
Urologist Miroslav Djordjevic, who specializes in gender reassignment surgery, has seen an increase in “reversal” surgeries among transgender women who want their male genitalia back. In the past five years, Djordjevic performed seven reversals in his clinic in Belgrade, Serbia. The urologist explains to The Telegraph that those who want the reversal display high levels of depression, and in some instances, suicidal thoughts. Other researchers also report hearing about such regrets.
Related: Transgender teen repeatedly stabbed in genitals; LGBT advocates battling for hate crime classification
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“It can be a real disaster to hear these stories,” Djordjevic told The Telegraph.
Charles Kane, who identified as Sam Hashimi after male-to-female reassignment surgery, opted to become a man again after experiencing “hormonal regret.” In the BBC documentary One Life: Make Me a Man Again, Kane explained he originally wanted to become a woman after a nervous breakdown.
“When I was in the psychiatric hospital, there was a man on one side of me who thought he was King George and another guy on the other side who thought he was Jesus Christ. I decided I was Sam,” Kane said.
Postsurgery, Kane believed his female identity would never be liked or accepted as a real woman. He also blamed the influence of female hormones as responsible for making him seek the surgery. “I don’t think there’s anyone born transsexual. Areas of their human brain get altered by female hormones,” Kane told Nightline.
Kane’s insight may not be applicable to all transgender patients seeking reversal surgery. Djordjevic expresses concern about the psychiatric evaluation and counseling that take place prior to the gender reassignment surgery. He recalls patients telling him that when they inquired about the procedure at other clinics, they receive minimal information before being asked for proof that they could pay for the operation.
In Djordjevic’s practice, patients undergo a minimum of one to two years of psychiatric evaluation, accompanied by hormonal evaluation and therapy. Prior to the surgery, he asks patients for two professional letters of recommendation. After the procedure, he strives to remain in contact—he talks with 80 percent of his former patients, The Telegraph reports.
Related: What’s the cultural impact of transgender characters on TV?
A 2011 study found that after sex reassignment surgery, more than 300 Swedish transsexuals faced a higher risk for mortality, suicide ideation, and psychiatric issues compared to the rest of the population. The researchers concluded, “Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”
In male-to-female reassignment surgery, doctors will reshape the male genitals in the form of a vagina. The surgery also includes removing the testicles and an inversion of the penis. In female-to-male procedures, doctors remove the breasts, uterus and ovaries and extend the urethra so a transgender man can urinate standing up. Male-to-female reassignments are more common because they are considered less expensive and more successful.
Gender reassignment surgeries are expensive. Male-to-female procedures cost between $7,000 and $24,000, and the cost of female-to-male procedures can reach $50,000. The complications and the expense warrant extra care from doctors performing these reassignments. “Ethically, we have to help any person,” says Djordjevic, “in the best possible way.”