Male to Female Gender Reassıgnment Surgery

Table of Contents

Male to Female Gender Reassıgnment Surgery

After the interview with female patients at the first stage of their gender assignment surgery, the breast prosthesis is made to gain the desired opportunity to experience that life for a while. The construction of a new external genital apparatus, internal genital surgery, breast aesthetic surgery, and facial aesthetic surgeries involve many processes. With the patient’s consultation, a step-by-step identification of all the procedures is made along with a schedule and timing. All physical and mental preparation for the patient in this process that provides positive improvement signifies that the comprehensive work has been produced.

Extensive information is provided related to the patient, with a plan of all surgical and medical care that will be performed in addition to the gender reassignment surgeries. Along with a comprehensive plan, medical interventions that will be made are compiled under the patient and their family’s control. Hormonal therapies, speech therapies if necessary, mental support, and compliance with surgical procedures are combined to become a comprehensive treatment. This professional comprehensive approach is creating the traces of this process. This process is not only about the physical change, it aims to recover the person’s life from all points. Clothes for use after surgery, grooming, makeup, clothing, shoes, and accessories selection is a support that a comprehensive approach should provide.

The term “gender dysphoria” is used to define the discomfort and feeling of being trapped in a body that is not suitable for the gender in these patients who are mentally ready to undergo the process of conversion. This surgical transition process is subject to certain legal arrangements in order to be performed. During the transition process, legal and medical accompanying procedures are comprehensively performed after an official approval is obtained from an international board. This approval is obtained with a document signed by a board of specialists stating that the mental and psychological preparation of the patient is complete.

Gender reassignment surgery procedures provide patients with the opportunity to experience the gender they feel more comfortable living in. This process is becoming increasingly common in the field of plastic and aesthetic surgery. In our consultation and preoperative preparations for such cases, detailed and thorough statements are presented about this transition process to every MTF patient who will undergo surgery.

Defınıtıon and Purpose

Considering the truly irreversible nature of GRS surgery, transgender patients are carefully evaluated prior to undergoing GRS on the need for this procedure by a team of experts to ensure comprehensive care. The main prerequisites are the presence of persistent and well-documented gender identity disorder signs, age greater than 18 or post-pubertal, as well as the absence of major comorbid psychiatric and somatic disorders that would be contraindicated for undergoing the treatment.

The patient should have 12 continuous months of living in the preferred gender and have undergone continuous hormonal therapy; 12 continuous months of hormone therapy is necessary if the individual has reached the age of legal majority. The patient is considered to be eligible for surgery when all other treatments are completed and the desired anatomical features are obtained, in particular, the removal of hair from the male genitalia skin by electrolysis. Before surgery, the patient is required to provide informed consent, being informed about the potential risks and benefits, as well as the available alternatives and reconstruction complications.

Male to Female Gender Reassignment Surgery (MtF GRS) is a set of surgical procedures designed to address ongoing body dysphoria in transgender women. GRS feminizes the appearance and social roles of the patient, facilitating living and personal interactions as women. The primary goals of this surgery are to create a natural outward appearing and functionally successful female genitalia, to enable the individual an unhampered lifestyle, and to aid in enjoying normal sexual relations. GRS involves a wide range of surgeries including genital surgery, breast augmentation, liposuction, and facial surgeries.

Brıef Hıstory

The spotlight was now fixed on what had for so long been left in the shadows, and numerous advances in SRS have been made since that time. During those early years, the surgical procedures proved to be not only somewhat primitive but also quite controversial, and several medical societies condemned their application and closed this field to those pioneer doctors. The birth of modern Sex Reassignment Surgery (SRS) can be traced back to 1950, or possibly even earlier. A Danish person born as a boy committed a crime and was sentenced to spend the rest of her life in a women’s prison. It was there that she was examined by Dr. Christane Northrtrup, who advised him to have a sex reassignment. Their meeting became an unusual friendship, and as a consequence, Christine was not only successful in making the first successful sex reassignment but also the first genital reconstruction.

Surgical procedures for creating a neovagina in transgender patients were first performed in the 1930s and 1940s and consisted of elongating the urethra and elevating vaginal flaps by a technique known as the “dilation method,” which involved the use of graduated vaginal dilators of increasing diameter. These created a neovagina by tunneling through the tissues in a similar way to that of a tunnel technique, still in use today for patients who require a vaginoplasty. This was, however, associated with reduced rates of neovaginal stenosis, as a significant proportion of these patients needed to use a vaginal dilator lifelong.

Psychologıcal and Medıcal Evaluatıon

If the applicant has not taken hormones, the letters must include the mental health professional’s assessment of why hormones have been withheld. All candidates must have been evaluated by a qualified mental health professional on the basis of DSM-IV-TR criteria before being eligible for surgery. Candidates meeting criteria for “gender identity disorder” or “transsexualism (MTF)” should have the presence of persistent discomfort with their anatomical characteristics or a wish to have reconstructive surgery or other procedures to feminize the appearance of any sex characteristics. It is imperative that a candidate has been treated according to the Harry Benjamin International Standards of Care and has satisfied all preoperative criteria before surgery is considered.

This includes a detailed evaluation of the patient’s mental health, not just concerning their Gender Identity Disorder, but in general, for other emotional/psychological disorders that must be addressed before surgery is considered.

All patients seeking MTF gender reassignment surgery should be counseled by qualified gender clinicians well in advance of the surgery. All MTF surgery candidates should have continuously spent at least 18 months in the female gender role and should have one or both of the following: a letter from a qualified mental health professional attesting to the patient’s gender dysphoria and psychological appropriateness for TG surgery, and two letters from two different qualified mental health professionals that are based on a minimum of three months of psychotherapy, including assessment of the patient’s capacity to make a fully informed decision and to give informed consent. Continuous documentation of gender dysphoria for a minimum of 12 months is mandatory.

Mental Health Assessment

They are expected to be aware of the risks, side effects, possible complications of vaginoplasty, and the postoperative rehabilitation process, including the necessary ongoing dilatation and the possibility of vaginal stenosis. They should have realistic expectations of the anticipated outcomes of vaginoplasty in attaining congruence with their gender identity and its psychosexual advantages. Also, the impact of hormone therapy for those patients taking estrogen on the decision between the penile-preserving technique and penile inversion technique, and the need for lifelong commitment to postoperative medical and pelvic healthcare are important to note.

All patients seeking MTF vaginoplasty should undergo a mental health assessment by a clinical psychologist or psychiatrist. The mental health professional should document the patient’s stable gender identity, the absence of psychiatric comorbidity of a nature or severity that may compromise capacity to provide informed consent or tolerance of surgery, and the presence of the ability to establish and maintain a therapeutic examination and treatment relationship with the surgical team, consistent with the WPATH Standards of Care. Specifically, patients requesting vaginoplasty are expected to understand the elective, non-regenerative, and irreversible nature of the surgical procedure.

Physıcal Health Evaluatıon

All surgeons require the World Professional Association for Transgender Health (WPATH) standards of care as the current minimum criteria to approve patients for surgery. The WPATH is the leading authority on the regulations, requirements, and standards of care for people seeking to undergo male-to-female or female-to-male gender reassignment surgery.

The WPATH is an international interdisciplinary professional organization that includes clinicians and professionals from multiple relevant disciplines such as surgeons, endocrinologists, urologists, primary care providers, mental health professionals, and other notable figures in the healthcare landscape. Individuals seeking to pursue surgery should also seek and initiate dialogue with any surgeons identified in the geographical area in which they prefer to have the surgery. Surgeons will be able to guide individuals regarding specific personal assessment protocols.

Healthcare professionals will be focused on maintaining and improving the overall health so that physicians can allow patients to undergo feminization. Patients may be required to undergo a variety of laboratory tests, such as a lipid profile, CBC (complete blood count), comprehensive metabolic panel, and hormonal levels. Patients will also require the letters of recommendation from their mental health professionals. Any specific personal assessments required will be directly communicated.

Hormone Therapy

It typically takes 2-3 weeks for the body to adjust to the hormones and up to 6 months before significant physical changes can be seen. Maximum changes can take 2-5 years depending on age, genetics, weight, and physique. Physical changes produced by estrogen and anti-androgens are extensive and many: a decrease in muscle mass, fat redistribution, and breast development, decrease in body hair, changes in skin texture, a decrease in libido, reduction in the size of the penis and testicles, and changes to the shape and appearance of the genitals, and softer and slightly higher voice. Fertility may be reduced by hormone therapy with potential infertility after a year. While hormone therapy does reduce the number of sperm-producing and hormone-producing cells in the testicles, estrogen helps maintain the integrity of the genital tissue and is essential for future vaginoplasty.

Hormone therapy is part of the process of transition for many transgender individuals. As a MTF, hormone therapy can significantly change one’s body shape, physical appearance, and result in a more feminine figure. Before hormones, transgender individuals typically spend several months with a gender therapist who can provide a letter of recommendation for hormone therapy. The therapy consists of estrogen and anti-androgens or androgen blockers. Estrogen is the primary hormone used in transgender women and produces the physical changes of transition. The anti-androgens or androgen blockers will counteract the effects of testosterone. Many transgender women also use progesterone in a separate cycle in addition to estrogen.

Purpose and Effects

Careful patient assessment (psychotherapy, endocrinological evaluation, vocational and financial counseling, and Real Life Experience, or RLE), as well as thoughtful diagnosis and preoperative preparation in collaboration with social workers and endocrinologists, have reduced but not totally eliminated requests for MTF surgery from inappropriate candidates or from persons who are not diagnosed as GID. Once male-to-female GRS (also known as MTF vaginoplasty, MTF genital reconstruction surgery, sex reassignment surgery, or SRS) is performed, most patients are satisfied with the evident result.

Satisfaction rates derived from applied or mailed questionnaires sent to patients after “sex change” surgery consistently approach 100%. Many patients are so pleased with the appearance and function of the neogenitalia that MTF GRS is considered to convey the most life-changing event and to result in the highest satisfaction rate of all elective or even essential surgical procedures. Patients believe they rejoin the opposite sex. They find genital appearance and function satisfactory. Problems of penetration, climax, and impaired “authenticity” (recognition) contribute to psychosocial adaptation after MTF GRS. Satisfaction is high regardless of sexual orientation after MTF GRS, if lingering gender identity issues have been fully resolved. In other words, an MTF who chooses to become a sexual partner to men is as satisfied, on average, as an MTF who maintains or changes her relationship with a woman.

Surgical techniques have become so refined that the genitalia created are often indistinguishable from natal female genitalia. Though much work remains to be done in urogenital biological sciences to further improve the techniques and the outcomes, there are sufficient data regarding anatomy, appearance, and function of neovaginas and clitorises to make this elective, medically unnecessary, so-called “sex change” surgery a reasonable option for those few male-to-female transsexuals troubled by their male genitalia.

Regımen and Monıtorıng

The other main regimen is that of the oral estrogen preparation of smaller dosage. The most noted of the estrogen being estradiol, which is 2 to 4 mg of estrogen per day. This is taken in smaller divided doses. The toxicity that comes along with this is in the liver, and so it gives much positive feedback to the hypothalamus in decreasing luteinizing hormone production. When estrogen is taken by mouth, the entero-hepatic circulation of estrogen allows the possibility of oxosteroids being reduced to 17 or 17 ketosteroids. 

This makes estrogen less important than some of the less androgenic derivatives. Most physicians should monitor the estradiol, estrone, or estrone, LH and in HCG in both the urine or serum levels by adding those doses of the two to four weeks. Reasons for the tests need to be taken in the morning and before dosing of estrogen. A regimen for both types of M2F transsexuals can be found quite simply.

The M2F without any prior androgen use is not a radically thought out process. The two major regimens are preparations by injections or oral agents for the therapy. If using IM injections of estrogens, a multiple duct regimen of depot estradiol is used, which is 5 mg of estrogen a week. Patient disclosure is hard to keep on this regimen, as well as increased amount of the body’s own estrogen removal. The IM injectable form of estrogen is preferred by some and is newly and cautiously scrutinized by others. So no one is entirely sure that there are any side effects that can occur with this drug. There are a number of examples of it that is improved, as if estrone levels are increased, there has been and are not effective. The medication does not provide more negative feedback enhancement.

Surgıcal Procedures

The author preserves minimal scrotal skin during preparation so that they can remove the testicles through a separate longitudinal incision in the midline scrotal raphe. Though nowadays including the dissection in separate procedures with penectomy is mainstream, these two can be performed in a combined procedure by elevating the dorsal nerves to the penis, dorsal vein, and dorsal arteries of the penis together with the testicular and spermatic vessels at the same time.

The author also preserves as much penile or scrotal skin as possible in order to create maximal erectile tissue as long as the patient does not want a vaginal cavity. In cases where the patient has concerns including complications and matrix, a two-step type is suitable.

Penectomy

Penectomy is the surgical removal of all or part of the penis. Simple penectomy is the removal of the penis only, whereas radical penectomy also involves the removal of the scrotum and testicles, which are replaced with feminine genital tissue. Penectomy is most commonly performed in males as part of sex reassignment surgery and as part of the treatment for penile cancer.

During penectomy, the neurovascular structures are ligated or transected, including the spongy corpora which are lateral to the urethra and contain the corpus spongiosum and the penile nerves. Ligation and resection of the dorsal arteries of the penis minimize blood loss, but larger vessels such as the internal pudendal arteries are usually controlled with electrocoagulation or suture ligatures.

The penile structures consist of skin, mucous membranes, and erectile tissues. In a simple penectomy, no more of these tissues are removed than the minimal necessary to allow access to the urethra. Radical penectomy requires total urethrectomy and total penile amputation, excision of the scrotum, and possibly association with an abdominoperineal resection. If this wide resection is necessary, the opportunity to excise the inguinal and iliac nodes should be considered. A prostate biopsy is also indicated in such patients.

Orchıectomy

Orchiectomy should be done through a scrotal incision. This is important for the completion of a penile inversion vaginoplasty. You will feel better, not only because the source of your testosterone is removed, but also because the procedure is a confirmation of where you want to go. You will be asked to stop taking any hormones that you are being prescribed as well as any herbal medications or other sources of estrogen, usually two weeks prior to surgery. 

This will minimize your risk during your surgery and the risk of developing blood clots during your recovery. Plan to rest for a week. Start gradual activities after two weeks. If an orchiectomy is performed earlier, the scrotum will have had some time to heal. When you feel that your energy has returned, do as much physical activity as you see fit.

Many transsexual women do not have the necessary funds to pay for a vaginoplasty, but desire to rid themselves of testosterone. These individuals can still undergo an orchiectomy, but a number of points should be made. One, the psychological benefit of having a source of testosterone removed from their body; the realization that surgery is the final destination and two, the body’s production removes the requirement of systemic transdermal delivery of estrogen, resulting in higher levels of plasma estrogen that can be achieved through subcutaneous injections.

Breast Augmentatıon

The most common method for the placement of the implant is the transaxillary or periareolar locations. When the implant is to be placed, certain qualities of the patient’s skin will be examined, including skin quality and quantity, which will be determined. The complete procedural information is explained in this guide during the initial stage of the consultation. In breast augmentation surgery, mostly cohesive-gel silicone or highly cohesive silicone gel is used.

The content of the implant can vary as determined according to the patient’s body and pocket anatomy. However, procedure completion would take a few hours. The breast size or breast implant type should be determined with a long-distance consultation by the medical team as to what is the most appropriate proportion and elasticity for women. The medical team will assist with recommendations and answers to be delivered for all potential questions of the patients.

This is the third most popular male to female surgical procedure that involves breast augmentation using breast implants. Implants give a natural feel and appearance of breasts in terms of weight, texture, and movement. Patients should also clean shave the chest to ensure the full outcome is achieved. Permanent facial hair removal utilizing laser and facial electrolysis during gender reassignment surgery can affect blood flow to the operated area due to scars. Also, breast implants can create a change in sensation. A lady’s new attractive breasts make her feel more womanly, and it can also help in improving the overall aesthetic to womanly proportions. The results are final and look beautiful.

Facıal Femınızatıon Surgery

Harmonizing the nose according to the patient’s facial features plays an important role during facial feminization. Fundamentally, all surgical techniques are the same as compared to a non-gender-affirming rhinoplasty. The tip and dorsum are most frequently treated. Different techniques like trans- or submucous septal resection, septal or septal- and rib cartilage grafts, dorsal hump reduction and osteotomies, cartilage modification and suture, or adjustment are performed according to the patient’s preoperative anatomical status. In order to augment cheeks, custom-made silicone implants, fat transfer techniques, or injectable fillers can be used.

With the fact that chin and jaw surgery play an important role in feminizing the patient’s face and in gender-confirming the patient as a woman, a big portion of patients decide to undergo these procedures. Male to female patients commonly do not demand an angled jaw since an obtuse angle is able to feminize the jaw contour. A vertical reduction of the jaw angle can be achieved by direct angular shaving, burring, or gonial excision.

Facial feminization surgery plays a huge role for the patients by refining and softening their features. The procedure goals are to transform a masculine face into a feminine face by altering some or all of the following features: the hair and forehead, the nose, the cheekbones, the lips, the Adam’s apple, the chin, the jaw angle, or the position of the ears. An aesthetic, female-appearing hairline should display an oval shape and be located 5-6 cm above the brows. A brow lift can be performed to correct its position, or when raising the hairline is not desired. As recommended by most authors, a Type-III forehead recontouring is suggested in order to make it as smooth as a female forehead.

Post-Operatıve Care and Recovery

One week following reassignment surgery, patients return to the operating room for a first dressing change and usually to undergo reconstructive surgery aiming at reducing the size of the retained part of the scrotal sac and achieving adequate vaginal depth. The final result is prone to reductions in volume due to scar contracture, which is why we create a cavity that is larger than the final volume that will be there.

Two different approaches are used to obtain a suitable length of the prospective vaginal cavity: full vaginal resection and split-thickness skin graft, harvested from the thigh crease. The full-thickness skin graft requires a second surgical site with additional scars, often leading to various types of postoperative complications. In accordance with these difficulties, most surgeons have chosen to utilize the penile-inversion technique for neovaginal creation with full mucosal length, where full-thickness labia minora flaps are used. The split-thickness graft is an alternative option that excludes the alternative donor site and may provide a thinner and viable neovaginal wall.

Immediate post-operative recovery and reconstructive surgery: After surgery, most patients are taken directly to the surgical intensive care unit for close observation. The length of stay in the intensive care unit can be very variable (often less than 12 hours). Once the patient is stable, they are discharged to the ward with oral antibiotics and pain medication. The early post-operative period is marked by a high degree of abdominal wall and general edema. The scrotum and inner thigh areas are particularly affected. This is expected, and the swelling will subside a great deal over the first several weeks.

Physıcal Recovery

For most transgender women, MTF SRS results in a vagina that is quite similar to that of a typical natal vaginal canal. The signs that a surgeon has done a very good job are: As with a natal vagina, the appearance of the surgery result should not change from the wetness, urine, vaginal discharge, etc.

During sleep or during daydreaming thoughts about sexual fantasies, the vaginal moisture should be present but not excessive. Within a few weeks after the second stage surgery, you should be able to experience a highly satisfying “event” and release. Most transgender women have 1 neoclitoris and some can have 2 divided neoclitorises.

As you recover from surgery, the surgeon will give you regular checkups to ensure that you are recovering properly. If your body responds abnormally, such as scar contracture, appearance of clitoromegaly, etc., then the surgeon will make revisions to improve the appearance of the vagina.

As with all surgeries, you should avoid heavy lifting, pushing, etc. for the first 12 weeks after surgery. You should avoid sitting for more than 15 minutes at a time for the first 2 weeks after surgery, and for the first 3 months after surgery, you should use a soft cushion (pillow) whenever sitting. After 6 weeks, you can start doing a rectal douche (for the small intestine, rectum) if care is taken to ensure that the douche water is at the right natural body temperature (37C or 98.6F).

Typical recovery milestones are:

  • Week 1-2: Hospitalization
  • Week 3-4: Returning home
  • Week 5-6: Resuming light activities such as washing, watching movies, short walks, reading, etc.
  • Week 8-10: Resuming moderate activities such as computer work, light housework.
  • Week 11-12: Resuming heavier activities such as cooking, heavy housework
  • Week 13-14: High energy level return to work

The typical recovery time after MTF SRS is about 1-2 months. After that, you should be able to resume light activities such as washing, walking, and watching movies. After 3 months, your energy will be returning and you should be able to resume moderate activity such as cooking, light house cleaning, and reading.

Emotıonal Support

Patients, families, and significant others should not always expect equally high levels of enthusiasm for sex reassignment surgery from each surgeon’s office. While a saving grace of many professionals working in gender reassignment is the strong belief that the options for patients are often good, honest, and logical, by necessity reality will allow the profession to be nothing less than discriminating, wary, conservative, pragmatic, and somewhat pessimistic regarding long-term content and satisfaction.

A variety of both psychological and medical reasons (e.g. body morphology problems, personal difficulties in male-female, female-male role changes and integration, or unrealistic patient expectations) often preclude a normal sexual reassignment experience and a content, realistic, and happy life.

Surgical gender reassignment takes its toll on every patient, and while the physical result may eventually be very satisfying, the emotional changes can be quite traumatic at first. Psychiatrists, counseling, and even group therapy sessions are invaluable during the early surgical period. Psychiatric follow-up is highly recommended, indeed mandatory, for 3-5 years after surgery, at least in most cases. Long-term psychotherapy following these surgeries is often necessary. Many individuals don’t find peace until the sex-role transformation occurs publicly as well as privately.

Legal and Socıal Consıderatıons

The most important part of the process is the initial psychotherapy that is a prerequisite for using hormones. An individual cannot undergo gender reassignment surgery unless she has been seeing a psychiatrist, psychologist, or clinical social worker specializing in gender identification for a total of one to two years. Most do some type of real-life test that is a requirement before undergoing surgery, such as using hormones and changing one’s name and sex-information changes.

There is no single rule, but this time of transition should give the individual and therapist a beneficial experience for surgical decisions. The usual requirement is one year of full-time living in the new gender before surgery. A person can apply for a driver’s license change at three months and a birth certificate change 12 months after surgery. After sex reassignment surgery, an individual should be able to live a more fulfilling life and be able to empathize with others who are undergoing the transition process.

A question often asked of MTF individuals planning to undergo sex reassignment surgery is, “How do I go about getting surgery or undergoing other transition treatments?” A sex change or gender change is typically a three- to ten-year process that may or may not include sex reassignment surgery. It is possible to change most legal documents – license, social security card, birth certificate, and passport – to reflect the individual’s new gender without necessarily having undergone sex reassignment surgery. The criteria and steps for changing these items vary from state to state and depend on current and past residency, income tax and voting records, and other factors. There is an extensive and comprehensive listing of the legal ramifications and requirements for transsexuals available in a resource guide from the TYFA Research Group.

Name and Gender Marker Change

This article, aimed primarily at MTF people who reside in the 143 counties of Texas, summarizes the requirements to request a name and/or gender change for both adults and for minors. Some advice for people in other states is also included. Although not required, obtaining a legal name and gender change can simplify the process for updating numerous other records, such as the social security and driver’s license, and the procedures to change these records will also be summarized.

A person’s name and their gender identifier (male or female) are a very personal expression of who they are and how they interact in the world. Legal changes to one’s name and marker can be an important step for many male-to-female (MTF) people. The specific laws and procedures to request a name and gender change can vary significantly from state to state and even among different cities in the same state. It is important to check the specific procedures and eligibility requirements with the appropriate local court clerk or, as in many places, with the court’s website. Different states and territories also have specific requirements and forms when requesting a name or gender change.

It should be noted that there are many terms used for transgender people. Some appropriate terms include transgender woman, transwoman, and male-to-female (MTF). Some inappropriate language is “transgendered” or offensive slang terms such as “tranny,” “she-male,” or “he-she.”
If a person decides to undergo sex reassignment surgery (to alter their physical appearance to match their inner identity) and they wish to have surgeries covered by their group insurance plan, specific requirements must be met.

The individual must meet World Professional Association for Transgender Health (WPATH) Standards of Care for Hormone Therapy, Mental Health Counseling Referral, and must have the appropriate employer group insurance plan benefit and also plan riders in place to cover the surgeries for the identified gender. It is important for the individual to check with his or her employer and plan sponsor to review the specific plan language, seek advice from other individuals that have gone through the surgery process, and review available resources.

A person’s gender is a very personal and evolving part of who they are. Gender is not just about physical appearance, but also about a person’s inner identity and individual experience. For many people, transitioning is a complex and often difficult process that involves both physical and emotional or psychological aspects.

Navıgatıng Socıal Interactıons

Many people who are considering MTF surgery think that the only thing that matters is anatomy, which is the most incorrect thought that anyone could have. When you undergo MTF, you have to understand how people are going to interact with you socially, at work, and dating-wise. Interpersonal dynamics play a huge role in how people relate to you, and the way people communicate with each other is conveyed in a variety of non-verbal ways. Makeup can do just the same, and more, to build trust in people and they will sense this. Try to minimize anything that would make people not trust in you to have a good or bad outcome.

The MTF procedure is done in 2 steps, where the first operation happens one day and a second operation three months later, as long as no surgical complications happen after the first surgery. The first operation is a four-step ancient procedure that is very surgically demanding, requires the modern skill of division of complex structures, has a radical recovery profile associated with emotional/physical ups and downs, and should only be done by the most experienced of surgeons and people desiring reliance. The second procedure is required for aesthetics and functional reasons. It could also be viewed as another step towards becoming the person you were meant to be.

Gender reassignment surgery is the most comprehensive way to become the gender that a person identifies with. Having such surgery is often necessary to gain not only the body that a person desires, but also the state of mind associated with that body.

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