The initial step of a sex change involves extensive screening interviews, during which a person’s motivations for undergoing the change are thoroughly evaluated. Individuals with real conflicts and confusion about their gender identity are not considered for surgical alteration. Individuals with an apparently genuine incongruence between their gender identity and their biological sex are then instructed to adopt a lifestyle consistent with their gender identity (i. e., dress style and behavior patterns). If, after several months to a year or longer, it appears that the individual has successfully adjusted to that lifestyle, the next step is hormone therapy, a process designed to accentuate latent traits of the desired sex. Thus males wishing to be females are given drugs that inhibit testosterone production together with doses of estrogen that induce some breast growth, soften the skin, reduce facial and body hair, and help to feminize body contours. Muscle strength diminishes, as does sexual interest, but there is no alteration of vocal pitch. Women who want to become men are treated with testosterone, which helps to increase growth of body and facial hair and produces a deepening of the voice and a slight reduction in breast size. Testosterone also suppresses menstruation. Most health professionals who provide sex-change procedures require a candidate to live for at least 1 year as a member of the other sex while undergoing hormone therapy, before surgery (Bockting et al., 2011). At any time during this phase, the process can be reversed, although few transsexuals choose this option.
The final step of a sex change is surgery (I Figure 5.6). Surgical procedures are most effective for men wishing to be women. The scrotum and penis are removed, and a vagina is created through reconstruction of pelvic tissue (see Figure 5.6a). During this surgical procedure, great care is taken to maintain the sensory nerves that serve the skin of the penis, and this sensitive skin tissue is relocated to the inside of the newly fashioned vagina. Intercourse is possible, although use of a lubricant may be necessary, and many male-to-female transsexuals report postsurgical capacity to experience sexual arousal and orgasm (Lawrence, 2005; Schroder & Carroll, 1999). Hormone treatments can produce sufficient breast development, but some individuals also receive implants. Body and facial hair, which were reduced by hormone treatments, can be further removed by electrolysis. Finally, if desired, an additional surgical procedure can be performed to raise the pitch of the voice in male-to-female transsexuals (Brown et al., 2000).
(a) (b)
A biological female who desires to be male generally undergoes surgical procedures in which the breasts, uterus, and ovaries are removed and the vagina is sealed off. Constructing a penis is much more difficult than constructing a vagina. In general, the penis is fashioned from abdominal skin or from tissue from the labia and perineum (see Figure 5.6b). This constructed organ cannot achieve a natural erection in response to sexual arousal. However, several options are available that can provide a rigid penis for intercourse. One involves fashioning a small, hollow skin tube on the underside of the penile shaft into which a rigid silicone rod can be inserted. Another option is an implanted inflatable device, which will be described in Chapter 14. If erotically sensitive tissue from the clitoris is left embedded at the base of the surgically constructed penis, erotic feelings and orgasm are sometimes possible (Lief & Hubschman, 1993).