Time for a Change – Gender Reassignment

I still remember him plainly: middle-aged, married, paunchy around the middle. He didn’t come in to the clinic because he was sick or had a chronic medical illness. He came in because he wanted to be a woman.

Gender reassignment was not something I had learned about in medical school. It was mentioned in passing, but there were no lectures about how to correctly dose estrogen for the male-to-female transsexual. I frankly had no idea what to do. I think my surprise and confusion were apparent, as the man blushed a little and suggested that I might want to refer him to a specialist.

Chastity Bono’s recent announcement that she will be transitioning from female to male reminded me anew what a deeply personal and difficult decision gender reassignment is. Medically, it’s complicated as well. Before even embarking on the anatomically-altering regimen, a great deal of therapy is recommended, as well as a “test run” living as the desired gender. Following that, hormones are begun. The regimen for a woman becoming a man is relatively straightforward: testosterone shots once every twelve weeks. Such a regimen produces increased facial hair, body mass index, a deeper voice, and enlargement of the clitoris, sometimes to the degree that intercourse is possible without surgery. It can have adverse effects on serum triglycerides and may cause acne.

A man wanting to become a woman faces a bit more complicated hormonal regimen, as not only does estrogen need to be added, but testosterone needs to be suppressed. Surgery to remove the testicles will obviate the latter, but is not a procedure that some are willing to undergo right away. This hormonal one-two punch will result in breast growth, increased subcutaneous fat, some decrease in upper body strength, and atrophy of both the testicles and prostate. Facial hair growth and voice depth will not change appreciably, however, and usually require additional procedures to mitigate.

The ultimate step in sexual reassignment is surgery. The most common type of surgery involves the removal of sex-specific organs; beyond that is genital reconstruction, which is significantly more complicated. After the entire process is completed, only 1 to 2 percent of postsurgical transsexuals experience regret.

As for my patient, I never saw him again after I referred him to another physician. Hopefully he is now a she, and is living a happy and fulfilling life.


Benjamin H. International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery Archives of Sexual Behavior, 32 (4), 299-315 DOI: 10.1023/A:1024086814364

  • J

    I’ve always been curious about this subject. Is there an exact cause to this desire to change genders? With the potential outcasting by societies it seems very risky but there are people that go through it. Seems like a very minority of people but what causes them to think it and go through with it? I hate to use the term “chemical imbalance,” especially in this case, since wouldn’t the brain tell the body what gender you are, hence the estrogen/testosterone shots/surgery?

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  • dramacritic

    Playwright Larry Myers pioneers new subject matter for the stage in his
    “Bigfoot Dates Cher”
    a drama abou t transmen superstars & mythic monsters
    staged in Hollywood recently
    composed 9 yrs ago but never produced
    poetic prophetic eerie illuminating unique spellbinding as a Cher cabaret turn or a tell all AND
    done with taste & skill

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  • See for example Brain Gender Identity – a presentation by Dr Sidney Ecker, MD FACS
    That’s from the recent APA annual conference, and the seminar on the subject “The Neurobiological Evidence for Transgenderism.

    It’s a gross over-simplification, but the soundbyte “male brain in female body” is more accurate than not. A Trans person’s hard-wired instincts, emotional response, and body image is cross-gendered compared to the appearance and social role. While most of what we call “gendered behaviour” is a social construct, differing between societies and times, much is not.

    The discomfort this causes, having to constantly pretend, to over-ride instinct, never to relax, not to mention having the wrong body shape, that is intense, and can actually be worse than the societal odium and persecution that trans people face just for attempting to seek treatment.

    The situation is worsened by two factors in the medical profession – the lack of training in Intersex conditions, and the fact that many medical professionals see this as a moral issue. More UK GPs are in favour of providing heroin to addicts than to give any treatment to trans people for their congenital condition.

    The good GPs will realise their lack of expertise, and refer the patient to a specialist. Unfortunately, there are many who won’t in the UK – about 1 in 4.

  • I consider myself open-minded; however, having surgical procedures and hormone therapy to change one’s gender should be considered malpractice. It is certainly damaging to one’s health and who knows the long term damage that this might cause. Thanks for your contribution to Take Charge of Your Health Care Carnival.

  • J.J.

    It is certainly damaging to one’s health and who knows the long term damage that this might cause.

    For most being in the wrong body is so damaging and distressing, that a gender change is less damaging than to continue being “WRONG”. I don’t think you realize how much this matters. It’s like being in a kind of skin-tight mobile cell 24/7, only worse. There are entirely too many transsexuals who commit suicide because of the horrors of such a life.

  • The standarts of care are not cited correct. After a phase of three month of psychotherapyy hormones can be administered. The real life experience is only a criteria for the gender reassignment surgery.
    And the surgery itself is described equally false:
    The surgeon does not amputate everything an then tries to create something new. Its just a rearengment.. In case of the Chonburi flap its actually very natural afterwards, because all tissue and nerveends are finally where they would have landed without a SRY gene sequence.
    Secondly your article speaks of man who want to become women and vice versa. This would not work. Transsexual are the brainsex all the time, its just what everyone else sees thats different, and most of the times TS People first try do act to those expactations. So its not only false to speak of Chaz Bono as a she – its very disrispectfull.

T. A. McNamee, MD

T. A. McNamee, MD, is an associate professor and internal medicine residency program director at Sanford School of Medicine of the University of South Dakota.

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