Sex reassignment surgery (SRS), also referred to as gender confirmation (Hage et al. 1997) or “reconfirmation” surgery (Laub 1987), is generally considered the “icing on the cake” for gender-dysphoric persons who have navigated the other elements of treatment and have generally integrated into society, on some level, as the anatomically other sex. Most patients will fantasize about SRS, but only a minority will obtain this irreversible major surgery. A variety of factors account for this:

1. SRS is not appropriate for all patients with GID.
2. SRS referral requires a maturational process wherein “readiness” for the procedure (psychologically, socially, and medically) must be considered (Levine et al. 1998).
3. In countries where SRS is not paid for by the government or by insurance companies (e.g., the United States), many patients who require the procedure cannot afford it.
4. Many patients with GID choose nonsurgical treatments alone.
5. Lack of medical and surgical resources in many areas.
6. Unwillingness, or inability, to follow the Standards of Care (Levine et al. 1998), resulting in lack of referrals for SRS (although SRS “on demand” is available in some countries on a cash-in-advance basis outside of the accepted Standards of Care).

The state of the art for neophallus construction and metaidoioplasty for FTM patients was reviewed earlier. (Additional information on this topic may be found in Hage 1996 and 1997; Hage and Karim 1998; Hage et al. 1993a, 1993b, 1994, 1996, and 1997; Huang 1995; and Khouri et al. 1998.) This is an evolving area involving microsurgical techniques as well as plastic surgery and urological surgery (Khouri et al. 1998; Laub and Laub 1989; Wilson et al. 1999). Patients considering these treatments should therefore seek the most current information available and consider interviewing with the few surgeons adept at this highly specialized multistage procedure (e.g., Fang et al. 1998).

SRS for MTF patients has reached a higher level of sophistication in terms of both cosmetic appearance and urological and sexual functioning. It is not unusual for postoperative patients to have a neovagina and external genitalia that appear indistinguishable from women born with female genitals. Patients are therefore faced with the decision of whether or not to discuss their past anatomical histories with potential sexual partners or mates. This is a critical decision that should be explored in the psychotherapeutic relationship and is only one of many reasons why postoperative psychotherapy can be extremely valuable (Ettner 1999; Levine et al. 1998).

Once a patient has met readiness criteria for referral as outlined in the Standards of Care, she must decide on the surgical technique and surgeon. Several options exist for the creation of a neovagina including a group of related procedures utilizing invaginated penile skin (Glenn 1979; Schaefer and Wheeler 1995) and those utilizing a blind pouch fashioned from the mesocolon (Laub and Laub 1989). A variety of skin graft donor sites are often employed in the former (Hage and Karim 1998). The two groups of techniques are compared in a general way in

Table 70-12.

Other specific differences also exist, some of which are based on individual surgeons’ techniques, and these should be carefully explored by patients contemplating this treatment step. Psychiatrists should emphasize the essentially irreversible nature of SRS, regardless of the technique used, given that bilateral orchiectomy and loss of most, or all, of the penis are components of treatment. Although cases are rare, some patients have sought to “reverse” their SRS to approximate their original anatomy (Landen et al. 1998a). Most experts in the field believe that this outcome can largely be eliminated by following the Standards of Care (Levine et al. 1998) and utilizing appropriate clinical judgment well-grounded in experience with gender-dysphoric patients.

Although suggested guidelines have been published to assist the psychiatrist in the process of selection of gender-dysphoric patients for referral for SRS (e.g., Brown 1990a), there are no widely accepted criteria for selection (Petersen and Dickey 1995). The Standards of Care discuss both “eligibility” and “readiness,” but no list of specific criteria are provided. This is consistent with the stated approach of publishing “minimum standards of care” in this document (Levine et al. 1998), but it does not provide much assistance to the evaluating psychiatrist.

Table 70-13 provides some guidelines based on the clinical experience of the author as well as on a review of the English-speaking literature through late 1999.

These prognosticators continue to evolve as additional outcome studies or detailed case reports become available (e.g., Brown 1999 [addressing DID and GID]). This table should be utilized only after the minimum standards of care for eligibility and readiness have been met. The absence of some of the “referral” characteristics or the presence of some of the “reassessment or delay” criteria should not be viewed as automatically selecting for, or against, SRS referral. They should be taken into account as elements of a highly complex, dynamic clinical picture at a given point in time. Some individual elements are controversial among experts in this field. For example, it could be argued that minor genital self-harm is associated with the desperateness of severe gender dysphoria that may respond well to somatic interventions. Likewise, patients desirous of referral may “talk the talk” regarding their adaptation, expectations, and follow-up plans but then have major psychiatric difficulties postoperatively based on only a superficial exploration of these important aspects of reality.