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Over the years, sex reassignment surgery has gained wide public interest and profound sociocultural implications. It has permeated artistic expression and large sections of the mass media, and it has played a recurring role in medical debates and in political discussions as well. Furthermore, political and social questions concerning the legal standing of transsexuals are associated in the public mind with the surgery. It is hardly surprising that a number of standard works have been written on the topic of male-to-female surgery, starting with La prostitution et la déchéance sociale from the Norwegian author Gasquet-Rosay in the 1920s. Gasquet-Rosay has been followed by works with greater scientific and surgical interest such as those from Magnus Hirschfeld, L. O. Hanfi, Harry Benjamin, and others.
Transgender is an umbrella term that is used to describe people whose gender identity and/or gender role does not match those assigned at birth. People calling themselves transgender are in different stages of the legal process after sex reassignment of change (from irreversible surgery to more reversible medical and hormonal intervention). In this thesis, the most irreversible part will be discussed in depth: male-to-female sex reassignment surgery, which is often metonymically referred to as Gender Reassignment Surgery (abbreviated as GRS, or SRS – Sex Reassignment Surgery). Despite the volubility of the subject in popular expositions, a study of the available scientific and surgical literature reveals, perhaps shockingly to non-surgeons, that there is a remarkable lack of consensus regarding the basic principles. There are few areas in surgery where the former site of pathology has been so characteristically altered; to date, no gold standard has been established. Interestingly, a further review of the surgical literature from both the plastic and urological sex also reveals a near unanimous lack of appreciation for the surgical principles developed more than fifty years ago by Hinderer. Therefore, this study briefly introduces the legal aspects of MTF SRS, the basic principles of its surgical technique, and subsequent research of the different fields of sex reassignment surgery. Throughout the thesis, the term “female” and “women” are applied to transgender individuals or individuals seeking male to female sexual reassignment.
Male-to-female sex reassignment surgery (SRS) is one of the main forms of sexual health and changing gender legally confirmation treatment used by male-to-female transgender individuals for legal recognition and to lead a life in their self-identified gender. The process after sex reassignment includes diagnosis, hormonal therapy, and sex reassigning surgery, especially genital sex reassigning surgery.
Legal aspects of MTF SRS and regulations:
The right to alter or modify one’s body to authenticate one’s self is included in the principles set forth in the Yogyakarta Principles (Principle 8) and the International Guidelines on Changing Gender Legally Recognition (Principle 2). Due to the absence of lesbian, gay, bisexual, and transgender (LGBT) rights in Bangladesh, sex reassignment surgery is made under the principle of consent from the advice of trained and experienced clinicians. Consented sex reassignment surgery is also the legal regulation and absence of proof relating to discrimination or stigma. The right to say no to sexual reassignment surgery is protected under the Constitution. In practice, the process, the subsequent counseling, and the social and family background of an individual are multi-disciplinary. The surgery is guided by the Sex Reassignment Surgery Management Committee comprising medical doctors (special treatment for transgender individuals), a psychologist, social psychologists, and researchers/anthropologists. This is not a governmental procedure and depends upon the consent of an individual.
Surgical sex reassignment procedures are performed in several stages. The first stage is orchidectomy or bilateral orchiectomy (surgical removal of the testes). If there are ambiguous genitalia, Burch or Urethral Deeper Vaginoplasty (removing the penile column at its base, then creating the vaginal entrance into the perineum) will be conducted at the same session. When the height of the protective scrotal tissue and the gathered penis skin is optimal, it is possible to use the aforementioned genital tissue to create a vagina. But if not, the scrotal flap or the gastrointestinal tract or both can be used. The vagina will be expanded using graft. Lubrication and some degree of orgasm is expected after sex reassignment surgery. But most of the sexual arousals, even after surgery in transsexual MtF and FtM, are physiologically caused without erotic thoughts.
The standard approach to the diagnosis and treatment of transsexuals recommends sex reassignment surgery (SRS) as a multistage reassignment surgery involving penectomy, orchidectomy, urethral plasty, outline of the labia, and construction of the neo-vagina. Patients who wish to undergo SRS are required to undergo hormonal therapy in collected centers of SRS. Some complications have been reported post-vaginoplasty in transsexuals. The minor expected complications include vaginal shrinkage that can be treated simply by placement of dilators, though major complications include a 33% incidence of urinary infection, urethrovaginal fistula 17%, vaginal pain 8%, dyspareunia 6%, and all of them can be treated surgically. Neovaginal prolapse is a least occurring complication. The most hazardous life-threatening complication is malignant transformation. However, the occurrence of mass suspicion in a physically constructed vagina can create a highly misleading diagnosis of neoplasia in a transsexual patient who has renal cell neoplasm. International Childhood Intersex Surgery Advocacy (ICIS) has issued guidelines according to which the surgeries involving the growth of external sexual organs should take place months or even years after the patient’s informed consent has been issued, as the patient may not be agreeing to their changing gender legally.
From the complex medical perspective, the management of legal aspects of MTF SRS gender dysphoria involves a multidisciplinary approach that includes hormonal therapy and surgical sex reassignment. Patients affected by this syndrome often present with distress linked to the conflict between an assigned sex and their gender identity, resulting in a deeply seated feeling of inappropriateness and manifold effects on their emotional lives. There are several ethical and legal aspects of MTF SRS primarily linked to the provision of accurate informed consent, particularly when the act of healing is a sex change. The level of invasiveness of male-to-female (MtF) reassignment surgery immediately appears to be very high, and the surgical wounds are highly personalized, constituting, together with facial feminization surgery, the most common intervention in gender dysphoria.
Individuals who express the desire to undergo a male-to-female process after sex reassignment are facing complex dilemmas – social, ethical, and psychological – which are breathtaking and which may arouse very strong opposition from societies that are, as a rule, less tolerant of any deviation from “average.” It is also undeniable that, as females are increasingly gaining significant fields of action in government and business, the choice is no longer prejudiced and sometimes becomes the subject of a lively debate in places where it is believed that men are trying to “obscure” worthily and impartially one changing gender legally that should always be represented with its clear limits and potential, often peculiar to human females. Ethical and scientific considerations on the management and outcome of the complete treatment of male sex change to female, i.e., physical and psychological, and on informed consent, are reported here.
Future directions and innovations in legal aspects of MTF SRS. With technological advancements, the application of robotic assistance in the surgical setting will continue to develop and result in the refinement of surgical skills and decrease the rate of complications. Moreover, with the development of 3D organ printing in clinical applications and 3D reconstruction of transvaginal scans, the creation of a neovagina in MtF SRS has the potential to be improved further. In addition, insights from research, biological and psychological, have not only led to an understanding and transforming gender incongruence in its conceptual form but have also expanded the initial protocols established for male-to-female reassignment surgery. In the future, the development and incorporation of these new standards for SRS would support the inevitable changes expected in legal and ethical paradigms in our society with consequences in human rights, identification, parenthood, and other fields. However, substantial improvements are still to be made in the prevention and treatment of associated comorbidities such as metabolic and cardiovascular consequences and psycho-social issues (guardianship of privacy in the peripubertal gender-atypical subjects) of long-term cross-gender hormonal therapies. Also, very promising are the results of recent research on organ decellularization, organogenesis, and organ regeneration in animals and human subjects. In this socio-medico-ethical scenario, penile reconstruction is contemplated as a distressing measure for detransition regret.
Improvements in social and surgical reassignment and changing gender legally reassignment are anticipated but also ethical changes in medico-surgical support and legal paradigms. Also, substantial investigative efforts have supported mainly the discovery of molecular, genetic nuclei, and brain connections related to gender dysphoria and its risk of suffering, with consequences for psycho-developmental diagnosis and therapeutic implications. This routine of development has already operated in the surgical field very much in changing gender legal reassignment (although much more is needed), with the male-to-female sex reassignment surgery set pole position in the last decade, driven by 4k not very invasive techniques to arrive at single-stage and most physiological and patient disease-based surgeries. Moreover, unbiased identification of proline-1-factor proteomic sexes is reached in more than 99% of the most exhaustive liquid-base biopsy discrimination mimetics in the case of 2% of unidentified proteome patterns and lower in DoD.
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