Gender confirming surgery: “Most patients report a significantly improved quality of life”

An increasing number of people want to have what today is referred to as gender confirming surgery. The methods used have been improved and the majority of patients who have undergone feminising surgery are pleased with the results. Experience from this field is now being applied to help another large patient group, namely those who have been subjected to female genital mutilation.

Hannes Sigurjónsson. Photo: Linda Forsell.

Text: Johan Sievers, first published in Swedish in Medicinsk Vetenskap no 1, 2017.

Around one person in ten thousand is living with gender dysphoria. The feeling that your body does not conform to your gender identity causes severe psychological distress, and a growing number are turning to the health services for help. In 2011, the Department of Reconstructive Plastic Surgery at Karolinska University Hospital in Solna had some 50 referrals for gender confirming surgeries and in 2016, that number was 360.

“We don’t actually know why this patient group is growing so much. But we think that it’s to do with a more open society, improved treatment and better results from the surgery,” says Hannes Sigurjónsson, specialist in reconstructive plastic surgery at Karolinska University Hospital in Solna and a researcher at the Department of Molecular Medicine and Surgery at Karolinska Institutet.

Up until recently, this type of surgery was referred to as a sex change, and it was most commonly performed on people born with male genitalia to make them more female. Today, we are much more perceptive of the patient’s experienced gender identity, which can be on a spectrum between male and female. For this reason, the surgical procedures can differ greatly. A person with a predominately male gender identity can experience gender dysphoria in regard to their breasts, but not their genitals. In that case, simply performing a mastectomy, i.e. the removal of the breasts, can be the best option for that person.

The surgeons therefore talk about feminising or masculinising surgery, both of which fall under the umbrella category of gender confirmation surgery. This includes surgery on the genitals, breasts and face. It also includes the removal of the uterus, ovaries and vagina as well as voice surgery.

When it comes to feminising genital surgery, there are well-tested techniques. The surgeons use skin from the penis, turned inside-out, to create a vagina. Part of the glans penis is moved, keeping vessels and nerve connections intact, in order to form the clitoris. Just a few years ago, this type of operation would take 3–4 hours, but the surgical technique has evolved, and now it only takes an hour and a half on average.

Creating a penis is significantly more complicated. When performing a phalloplasty, the surgeon uses tissue from the lower arm and/or thighs and then has to connect both vessels and nerves. This operation takes 6–12 hours.

In December, Hannes Sigurjónsson defended a thesis looking at complications and quality of life following feminising surgery. In his thesis, he shows that the surgery has improved in many ways: the duration of the operation and treatment has gone down, and there are fewer complications. Ten per cent of the patients experience complications such as bleeding or infection, but as a rule, they are easily treatable. Serious complications are uncommon.

86 per cent of the patients say that they are pleased with the results of their surgery and that they are able to reach orgasm.

“After one year, most of them report a significantly improved quality of life. Then it levels out and starts to decline somewhat. We don’t know why that is. It could be an expression of the deterioration in quality of life that comes with age and which, using the measuring method we have chosen, can be seen throughout the general population,” says Hannes Sigurjónsson.

His thesis also shows that it is important that people with a new vagina keep dilating it. This can be done with a device, or through an active sex life, and is necessary for the vagina to maintain its depth.

A new challenge when it comes to gender confirming surgery is linked to the early endocrinologic treatment that is becoming increasingly common in this patient group. So that a person will not be forced to enter puberty and feel their body develop into a gender they do not identify with, doctors sometimes choose to halt the onset of puberty with the help of hormones. This treatment is often effective, but when the male puberty is halted, the penis stops growing. This gives the surgeon less tissue to work with when performing a feminizing genital surgery.

“As surgeons, that means we have to adapt and find new methods. These days, we can make a vagina using tissue from the small or large intestine. We have performed this kind of surgery here at Karolinska University Hospital in Solna,” says Hannes Sigurjónsson.

For a few years now, he has also been working with women who have been subjected to genital mutilation. The National Board of Health and Welfare estimated in 2015 that there are at least 38,000 women in Sweden who have undergone female genital mutilation, which is one of the highest prevalence in Europe. Many of these women have been psychologically traumatised by war, displacement and the violation of the actual genital mutilation. In addition, many of them suffer from pain, sexual dysfunction and recurring infections in the genital area as a result of the mutilation.

Hannes Sigurjónsson’s patients are women who have been subjected to the worst form of female genital mutilation, in which the clitoris, the labia minora and parts of the labia majora have been cut off. The vaginal opening has then been sewn shut, leaving only a small opening for urine and menstruation.

“We perform defibulation surgery, remove scar tissue and cysts and in some cases reconstruct the clitoris by excavating any remaining tissue. The research has shown that the operation can reduce pain and increase the patient’s chances of reaching orgasm. Furthermore, scientific publications suggest that the operations not only improves their sexual function, it also gives them a sense of being whole again,” he says.

* Notering september 2022: Hannes Sigurjónsson är inte längre verksam vid KI som forskare.

Assessment can result in surgery

  • People seeking gender confirmation surgery must first go through a psychiatric assessment.
  • Karolinska University Hospital in Solna performs around 300 gender confirming surgeries per year. Around 50 of these are major genital operations. The others are face and breast operations. Gender confirming surgeries are also performed at Linköping University Hospital and at Sahlgrenska Hospital in Gothenburg.
  • In 2015, the National Board of Health and Welfare received 207 applications from people who also wanted to change their legal gender assignment.
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