Sex change therapy is a medical aspect of sex transition, that is, modifying one's characteristics to better suit one's gender identity. It may consist of hormone replacement therapy (HRT) to modify secondary sex characteristics, genital change surgery to alter the characteristics of primary sex, and other procedures that alter the appearance, including the removal of the permanent hair for trans females.
In properly evaluated cases for severe gender dysphoria, genital replacement therapy is often the best when standard care is followed. There is an academic concern over the low quality of evidence supporting the efficacy of genital replacement therapy as a treatment for gender dysphoria, but stronger studies are impractical to do; also, there is broad clinical consensus, complementing academic research, which supports the effectiveness in terms of subjective improvement of genital change therapy in properly selected patients. The treatment of gender dysphoria involves no attempt to correct the gender identity of the patient, but to help the patient adapt.
Major health organizations in the US and UK have issued affirmative statements that support sex assignment therapy as comprising the necessary medical care in certain cases being evaluated appropriately.
Video Sex reassignment therapy
Feasibility
In current medical practice, a diagnosis is required for sex change therapy. In the International Classification Disease diagnosis is known as transsexualism (). The US Diagnostic and Statistical Manual of Mental Disorders (DSM) calls it gender dementia (in version 5). While the diagnosis is a requirement to determine the medical needs of sex change therapy, some people who are legally diagnosed have no desire for all or some portion of genital change therapy, especially genital and/or non-candidate surgery appropriate for such treatment.
Transsexualism
Common standards for diagnosing, as well as treating, gender dysphagia are outlined in the WPATH Treatment Standards for Transsexual, Transgender and Gender Nonconforming Health. Beginning in February 2014, the latest version of this standard is Version 7. According to the standard of care, "gender dysphoria refers to the discomfort or distress caused by the difference between a person's gender identity and the sex of the person defined at birth (and the relevant gender roles and/or the characteristics of primary and secondary sex)... Only some people who have no gender experience gender dysphoria at some point in their life Gender incompatibility is not the same as gender dementia, nonconformity, by treatment standard, is not pathological and requires no medical treatment.
Local care standards exist in many countries.
In cases of comorbid psychopathology, the standard is to first manage psychopathology and then evaluate the patient's sex dysphoria. Treatment may be appropriate and necessary in cases of significant comorbid psychopathology, since "cases have been reported in which the individual has suffered from severe co-emergent psychopathology, and is a late-onset, gynephilic, and have not experienced long-term, positive outcomes with hormonal and surgical gender transition. "
However, some transsexuals may suffer from joint psychiatric conditions unrelated to their gender dysphoria. DSM-IV itself suggests that in rare cases, gender dysphoria may co-exist with schizophrenia, and that psychiatric disorders are generally not considered contraindicated to sex therapy therapy unless they are a major cause of patient dysphoria.
Feasibility for different stages of treatment
While mental health assessment is required by standard care, psychotherapy is not an absolute requirement but is highly recommended.
Hormone replacement therapy will begin on the referral of qualified healthcare professionals. General requirements, in accordance with WPATH standards, include:
- Continuous, well-documented gender discorcisms;
- Capacity to make informed decisions fully and to approve treatment;
- The majority age in a country (however, WPATH care standards provide separate discussion of children and adolescents);
- If there is a significant medical or mental health problem, they should be controlled fairly well.
Often, at least a certain period of psychological counseling is required before the initiation of hormone replacement therapy, such as the lifetime in the desired gender role, if possible, to ensure that they can function psychologically in that role of life. On the other hand, some clinics provide hormone therapy based on informed consent alone.
Since surgery is a radical and irreversible intervention, more stringent standards are usually applied. In general, doctors who perform genital replacement surgery require patients to live as members of their target gender in all possible ways for at least a year ("cross-life"), prior to commencement of surgery, to ensure that they can psychologically function in a life role that. This period is sometimes called the Real Life Test (RLT); it is part of battery requirement. Another frequent requirement is routine psychological counseling and letters of recommendation for this operation.
The "cross-life" time period is usually known as Real-Life-Test (RLT) or Real-Life-Experience (RLE). Sometimes needed even before hormone therapy, but this is not always possible; Transsexual men often can not "pass" this period without hormones. Transsexual women may also need hormones to pass as women in society. Most trans females also require the removal of facial hair, voice training or voice surgery, and sometimes, facial feminization surgery, to be passedable as women; These treatments are usually given on request without the requirement for psychotherapy or "cross-life".
Some surgeons who perform sex change operations may require their patients to live as their target gender members in various ways over a period of time, prior to any surgery. However, some surgeons recognize that so-called real-life tests for trans men, without surgical removal of breast and/or chest reconstruction, may be difficult. Therefore, many surgeons are willing to perform some or all elements of genital replacement surgery without any real-life tests. This is very common among surgeons practicing in Asia. However, almost all surgeons practicing in North America and Europe performing genital replacement surgery require a consent letter from two psychotherapists; most Maintenance Standards recommend, and most therapists require a real-life test one year before genital rejuvenation surgery, although some therapists are willing to override this requirement for certain patients.
Requirements for chest reconstruction surgery are different for transmen and transwomen. Treatment standards require trans men to undergo 3 months of real-life test or psychological evaluation prior to surgery while transwomen are required to undergo 18-month hormone therapy. The need for trans men is due to the difficulty in presenting as men with female breasts, especially those of C cup or larger. For very large breasts it is impossible for trans men to be present as men before surgery. For trans women, extra time is needed to allow complete breast development of hormone therapy. Having breast enlargement before that point can lead to uneven breasts due to hormonal development, or removal of the implant if hormonal breast development is significant and produces larger breasts than desired.
Eligibility of minors
While WPATH care standards generally require that patients reach the age of majority, they include separate sections devoted to children and adolescents.
Although there is anecdotal evidence from cases in which a child is firmly identified as another gender from an early age, the study cited in the standard of care shows that in most cases, such identification in childhood does not continue into adulthood. However, with adolescents, persistence is much more likely, and reversible treatment by puberty can be prescribed. This treatment is controversial because the use of puberty inhibitors involves a small risk of adverse physical effects.
A 2014 study makes a long-term evaluation of the effectiveness of this approach, looking at young transgender adults who have received puberty suppression during adolescence. It was found that "After genital change, in adulthood, [gender dysphoria] is reduced and psychological functioning continues to increase," Welfare is similar to or better than young adults of the same age than the general population. "The improvement is positively correlated with subjective post-surgical well-being. there are patients who express remorse about the transition process, including puberty suppression.
"Because puberty oppression is a completely reversible medical intervention, it gives teenagers and their families time to explore their gender dis- posical feelings, and [to] make more definite decisions about the first step of genuine genital change of care at older ages , "said lead author of the study. Annelou de Vries. By delaying the onset of puberty, children who continue on gender assignment "have a lifelong advantage of a body that matches their gender identity without irreversible body changes from low voices or growth of the beard or breast, for example,".
De Vries remains cautioned that these findings need to be confirmed by further research, and added that his study did not aim to assess the side effects of pubertal oppression.
Maps Sex reassignment therapy
Psychological treatments
According to WPATH SOC v7, "Psychotherapy (individual, partner, family, or group) for purposes such as exploring gender identity, role, and expression, overcoming negative impacts of gender dysphoria and stigma on mental health, reducing internalized transphobia, increasing social support and friends peer, improve body image, or promote resilience "is a treatment option.
Hormone replacement therapy
For trans men, hormone replacement therapy (HRT) leads to the development of many secondary sexual characteristics of the sex they desire. However, many of the primary and secondary sexual characteristics that exist can not be reversed by HRT. For example, HRT can induce breast growth for trans females but can only minimize breasts for trans men. HRT can promote facial hair growth for transsexual men, but can not reduce facial hair for transsexual women. However, HRT may reverse some characteristics, such as the distribution of body fat and muscle, as well as menstruation in trans men.
Generally, easily reversible properties will return to the cessation of hormonal treatment, unless chemical or surgical castration has occurred, although for many trans men, surgery is necessary to obtain satisfactory physical characteristics. But in trans men, some hormonal changes can become irreversible in a few weeks, whereas trans women usually have to take hormones for months before irreversible changes will occur.
As with all medical activities, health risks are associated with hormone replacement therapy, especially when high-dose hormones are taken as usual for pre-operative or non-surgical trans patients. It is always advised that all changes in hormonal therapy therapy should be supervised by a doctor because starting, stopping or even changing the dose levels and levels can have physical and psychological health risks.
Although some trans females use herbal phytoestrogens as an alternative to pharmaceutical estrogens, little research has been done with regard to the safety or effectiveness of the product. Anecdotal evidence suggests that the results of herbal treatments are minimal and very subtle, if completely seen, when compared with conventional hormone therapy.
Some trans men can avoid the medical community's requirements for hormone therapy altogether either by obtaining hormones from black market sources, such as Internet pharmacies sent from abroad, or more rarely, by synthesizing the hormone itself.
Chest reconstruction surgery
For many reconstructions trans men chest wanted, or needed. Tying chest tissue can cause a variety of health problems including reducing lung capacity and even broken ribs if inappropriate techniques or materials are used. Mastectomy is performed, often including nipple grafting for those with B or larger cup size.
For trans females, breast enlargement is performed in a manner similar to that performed for cisgender women. Like cisgender women, there is a limit on the size of the implant that can be used, depending on the amount of breast tissue that already exists.
Genital replacement surgery
Sex change operation (SRS) refers to surgical and medical procedures performed to align the physical appearance of intersex and transsexual individual and genital anatomy with their gender identity. SRS may include any surgical procedure that will reshape the male body into a body with a female appearance or vice versa, or more specifically refers to the procedure used to make male genitals into female genitals and vice versa.
Gender reimbursement surgery is the most common term for what might be more accurately described as "genital shift surgery" or "genital reconstruction surgery." Other terms suggested for SRS include "gender confirmation operations," "gender-alignment operations," and "transsexual operations." The terms mentioned above may also refer specifically to genital surgery such as vaginoplasty and phalloplasty, although more specific terms exist to refer exclusively to genital surgery, the most common being genital change surgery (GRS). There are significant medical risks associated with SRS that should be considered before undergoing surgery.
Other procedures
Feminization facial surgery (FFS) is a form of facial reconstruction used to make masculine faces appear more feminine. The SL procedure can reshape the jaw, chin, forehead (including ridge brows), hairline, and other areas of the face that tend to be sexually dimorphic. Chondrolaryngoplasty, "shaved trachea" daily, is a reduction of cartilage surgery in the larynx to reduce the appearance of the Adam's apple.
Trans people from both sexes can practice vocal therapy. Vocal therapists can help their patients improve their tone, resonance, inflection, and volume. Another option for trans females is vocal surgery, although there is a risk of damaging the sound.
Effectiveness
The Merck Manual states, in regard to trans females, "In further research, genital surgery has helped some transsexuals lead happier and more productive lives and thus justified by highly motivated, properly assessed and treated transsexuals who have completed 1 - 2 years of real life experience in different gender roles Before surgery, transsexuals often need public help, including assistance with movement and voice modulation Participation in support groups, available in most large cities, is usually beneficial. In relation to trans men, he states, "Surgery can help certain patients [trans men] achieve greater adaptation and life satisfaction.Unlike trans women, trans men should live in men's gender roles at least 1 year before surgery. neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for trans females.Common complications, especially in procedures involving the expansion of the urethra into the neophallus. "
Kaplan and the Sadock's Comprehensive Textbook of Psychiatry stated, with regard to adults, "When patient-sex dysphoria is very severe and difficult to solve, sex change is often the best solution." Remorse tends to occur in cases of misdiagnosis, no Real Life Experience, and poor operating outcomes. Risk factors to return to genuine gender roles include a history of transvestic fetishism, psychological instability, and social isolation. In adolescents, careful diagnosis and following strict criteria can ensure good postoperative outcomes. Many preteen children with cross-gender identity do not persist with gender dysphoria. In relation to follow-up, it states that "Doctors tend to report poorly poor outcomes in their patients, thereby shifting reporting bias to positive outcomes, but some successful patients who want to blend into society as male or female do not make them available for follow-up Also, some patients who are unhappy with their reassignment may be better known to doctors as they continue clinical contact. "
A systematic review of 2009 observing individual surgical procedures found that "[t] evidence of genital change operations has some limitations in terms of: (a) lack of controlled studies; (b) evidence has not prospectively collected data; (c) high loss to follow-up and ( d) lack of validated assessment measures Some satisfactory results are reported, but the magnitude of benefits and dangers for individual surgical procedures can not be accurately estimated using current evidence. "
A follow-up meta-analysis 2010 study reported "Cross-pooling studies showed that after gender reassignment, 80% of individuals with GID reported significant increases in gender dementia (95% CI = 68-89%; 8 studies; I2 = 82 %), 78% reported a significant increase in psychological symptoms (95% CI = 56-94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies, I2 = 78%), and 72% reported significant increases in sexual function (95% CI = 60-81%; 15 studies; I2 = 78%). "The study concluded" Very low quality evidence suggests that assignment repeat sexes that include hormonal intervention in individuals with GID might improve gender dysphoria, psychological function and comorbidity, sexual function and overall quality of life. "
A study that evaluated the quality of life in transgender individual women found a statistically significant "quality of life" (p & lt; 0.01) among transgender participants in FTM compared with US male and female populations, particularly in terms of mental health, transgender participants receiving testosterone (67%) reported higher quality of life scores were statistically significant (p <0.01) than those who did not receive hormone therapy. "
A recent Swedish study (2010) found that "almost all patients were satisfied with genital change at 5 years, and 86% were assessed by physicians in follow-up as stable or enhanced in global function." A prospective study in the Netherlands who looked at the function psychological and sexual problems of 162 mature applicants from adult sex job applicants before and after hormonal and surgical treatment found, "After group treatment was no longer a dysphoric gender, most functioned quite well psychologically, socially and sexually.2 Two non-homosexual male-to-transsexuals - the woman expressed regret. "
A long-term follow-up study conducted in Sweden over a long period of time (1973-2003) found that morbidity, suicide, and death in post-operative transient men were much higher than in the general population, suggesting that sex therapy assignments were inadequate to treat gender dysphoria, highlighting the need for improved health care after genital change surgery. 10 controls selected for each post-operative trance, matched with birth year and gender; two control groups were used: one matched gender at birth, another matching matching sex. The study states that "no conclusions can be drawn [from this study] on the effectiveness of sex assignment as a treatment for transsexualism," citing studies showing the effectiveness of genital change therapy, despite noting their poor quality. The authors note that the results show that those who received genital change surgeries before 1989 had a worse mortality, suicide, and crime rate than those who received surgery on or after 1989: mortality, suicide, and crime rates for the 1989 group -2003 is not statistically significant compared to healthy controls (although psychiatric morbidity); it is unclear whether this is because these negative factors tended to increase a decade after surgery or because in the 1990s and then improving treatment and social attitudes may have led to better results.
The abstract from the American Psychiatric Association Task Force on the 2012 GID report states, "The quality of evidence relating to most aspects of treatment in all subgroups is set to be low; however, a large area of ​​clinical consensus has been identified and considered sufficient to support recommendations for treatment all subgroups. "The APA Task Force states, with regard to the quality of research," For some important aspects of transgender care, it is unlikely or unwise to engage in stronger study designs due to ethical issues and the lack of volunteer registration.For example, it would be problematic to include 'long-term placebo-controlled arm' in RCT efficacy hormone therapy among adult sexes who wish to use hormonal treatment. "The Royal College of Psychiatrists agreed with SRS in trans females, stating," There is no level 1 or 2 evidence (Oxford level) yes ng supports feminine use of vaginoplasty in women but this is expected since randomized controlled studies for this. scenarios are not possible. "
Following the APA Task Force report, APA issued a statement stating that APA acknowledges that in "properly evaluated" cases, hormonal and surgical interventions may be medically necessary and oppose the "categorical exclusion" of such treatment by a paying third party. The American Medical Association's Resolution 122 states, "An established medical research body demonstrates the effectiveness and medical needs of mental health care, hormone therapy and genital replacement surgery as a form of therapeutic treatment for many people diagnosed with GID".
The need for treatment is emphasized by higher levels of mental health problems, including depression, anxiety, and addictions, as well as higher suicide rates among untreated transsexuals than in the general population. Many of these problems, in most cases, disappear or substantially decrease after changes in gender roles and/or physical characteristics.
Ethical, cultural, and political considerations
Gender replacement therapy is a controversial ethical subject. In particular, the Roman Catholic church, according to an unpublished Vatican document, states that changing sex is impossible and, in some cases, care may be necessary, it does not change one's gender in the eyes of the church. Some Catholic ethicists go further, stating that "sex change operations" are "mutilations" and therefore immoral.
Paul R. McHugh is a renowned opponent of sex change therapy. According to his own article, when he joined Johns Hopkins University as director of the Department of Psychiatry and Behavioral Sciences, it was part of his intention to end the sex change operation there. McHugh managed to end it at the university during his time. However, a new gender clinic at Johns Hopkins has been opened in 2017.
The opposition is also expressed by some writers who identify as feminist, most famous Janice Raymond. His paper allegedly plays a role in eliminating Medicaid and Medicare support for sex assignment therapy in the US.
Gender replacement therapy, especially surgery, tends to be expensive and not always covered by public or private health insurance. In many areas with nationalized national health care, such as some Canadian provinces and most European countries, the SRT is included in this plan. However, the requirements for obtaining SRS and other transsexual services under this plan are sometimes more stringent than the requirements set out in the WPATH Treatment Standards for Transsexual, Transgender and Genital Health Unsuitable, and in Europe, many local Care Standards exist. In other countries, like the United States, there is no national health plan and most private insurance companies do not include SRS. But the Iranian government, paying for such operations because it is believed to be legitimate based on Shias.
A significant and growing political movement exists, encouraging to redefine standards of care, affirming that they do not recognize the right of self-determination and control over one's body, and that they expect (and even in many cases require) a monolithic transsexual experience. Contrary to this movement is a group of transsexuals and caregivers who claim that SOCs are in place to protect others from "making mistakes" and cause irreversible changes to their bodies that would later regret - although some post-operative transsexuals believe that the operation sexual change is a mistake for them.
United States
From 1981 to 2014, the Medicare and Medicaid Service Centers (CMS) categorically excluded the coverage of Medicare's sex change operation in the National Coverage Determination (NCD) of 140.3 Transsexual Surgery, but the categorical exclusion was challenged by "harmed parties ". "in Acceptable NCD Complaint in 2013 and subsequently beaten the following year by the Department Complaints Council (DAB), the administrative tribunal of the US Department of Health and Human Services (HHS).In late 2013, the DAB issued a verdict that found the recorded evidence" not complete and sufficient to support the validity of NCD "and then move on to the invention to determine if the exclusion is valid CMS does not maintain its exceptions throughout the process On May 30, 2014, HHS announced that the categorical exclusion found by DAB to not apply" under ' ',' allowing Medicare coverage of sex change operations to be decided on a case-by-case basis.HHS says it will move to implement the verdict.Because Medicaid and private insurance firms often take Medicare's cues about what to cover, this may result in coverage of sex- Medicaid and per private insurance company. The evidence in this case "exceeds NCD records and suggests that transsexual operations are safe and effective and not experimental," according to the DAB in its decision in 2014.
A 2014 article published in the American Journal of Public Health calls on third-party payers to include sex assignment therapy in properly selected cases.
Approval and treatment of intersex people
In 2011, Christiane VÃÆ'¶lling won the first case brought by an intersex man against a surgeon for a non-consensual surgical intervention described by the International Commission of Law Experts as "an example of an individual subject to genital mutilation surgery without full knowledge or approval ".
In 2015, the Council of Europe acknowledged, for the first time, the right to intersex for not to undergo sex assignment treatments. In April 2015, Malta became the first country to recognize the right of body integrity and physical autonomy, and forbade non-consensual modification of sex characteristics. The law is widely accepted by civil society organizations.
See also
- List of transgender related topics
- Sex work
References
Bibliography
Source of the article : Wikipedia
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