Does sexual reassignment surgery work?

In the comments to my post “mutilating gender” last week, J. (a.k.a Mac Diva, author of two (!) notable blogs, Mac-a-ro-nies and Silver Rights) argued forcefully against sexual reassignment surgery (SRS).

I’ve researched the transsexuality issue pretty thoroughly. The main reason some reputable SRS programs shutdown is because it became increasingly clear that the surgery was not ‘curing’ many transsexuals. (It doesn’t help that the originator of the concept, Dr. John Money, is a fraud to an extent.) They continued to have profound psychological problems after the surgery, sometimes even seeking to have it reversed.

J. has repeated this point on Silver Rights arguing that SRS isn’t a “proven medical treatment” and that it “may not be an actual remedy.”

Unfortunately, J. didn’t reference the specific research she’s relying on, so it’s possible that by posting this I’ll be smearing egg on my own face. But as far as I can tell, the evidence doesn’t support J.’s claims.

First, regarding John Money, J. is mistaken to think he is “the originator of the concept.” David Cauldwell, for example, was using the term “transsexual” in the late 1940s, whereas John Money’s work didn’t begin until the 1950s.

Much more importantly, J. is mistaken about outcomes of SRS. The most comprehensive study of post-SRS outcomes is “Sex Reassignment. Thirty Years of International Follow-up Studies” by Friedemann Pf’fflin and Astrid Junge (1992 in German, English translation 1998). Pf’fflin and Junge used data from over 70 studies, in total considering the outcomes of over 2000 patients from 13 countries. They found that outcomes – measured in terms of “subjective satisfaction; mental stability; socioeconomic functioning; and partnership and sexual experience” – of SRS are generally positive. Overall, 71% of male-to-female (MTF) and 90% of female-to-male (FTM) operations had positive results. When they limited their sample only to more recent patients (who benefited from improvements in techniques and procedures over the decades), the results were positive for 87% of MTFs and 97% for FTMs.

Of course, Pf’fflin and Junge’s article is now a decade old, but I’m not aware of any study of comparable scope since then which has discredited their work. And it may be that there are problems with the data which should prevent us from drawing conclusions; Dr. Anne Lawrence, summarizing more recent studies, points out that they have a distressingly low response rate.

In the seven years since the comprehensive review by Pf’fflin and Junge, researchers have continued to publish outcome studies looking at the benefits and disadvantages of sex reassignment. Bodlund and Kullgren (1996) found that in a five-year follow-up of 10 MFs and 9 FMs, 68% of patients achieved a satisfactory outcome, defined as improvement in at last two areas of social functioning with worsening in none. Eldh et al (1997) reviewed the Stockholm experience from the period 1965-1995, involving 136 patients. Over 86% of the reassigned patients who responded to the investigators’ questionnaire were satisfied with their overall life situation, although the response rate was low. However, only 55% of the MFs and only 34% of the FMs were satisfied with their sexual lives. Landen et al (1998) found an incidence of 3.8% regrets in group of 218 Swedish transsexuals approved for SR during the years 1972-1992. Rehman et al (1999) studied 47 MF patients operated by the same surgeon between 1980 and 1994, of whom 28 returned questionnaires. All 28 reported themselves satisfied with their reassignment and surgical outcome, and none expressed regrets.

On the other hand, as Lawrence points out, even the controlled study by Mate-Kole (in which MTFs were randomly selected to either be given SRS quickly, or to be in a control group which was waiting for the surgery) found that “patients who underwent expedited SRS demonstrated improved psychosocial outcomes, compared to the still unoperated controls. They were more active socially, and had fewer neurotic symptoms.”

On the important issue of regrets, Pf’fflin and Junge found 14 documented cases of patients who regretted having gone through SRS. Some of these patience appear to have been inadequately prepared, or to have had botched or incomplete surgeries. While it’s of course regrettable that anyone feel regrets, 14 out of 2000 doesn’t strike me as a high enough rate of regrets to discredit SRS, or to suggest (as J. did) that a typical SRS patient may seek to have their surgery reversed.

The evidence is imperfect; and, since I don’t know what J.’s sources are, it’s possible that she’ll post references that blow this post away. For now, however, it seems that the evidence indicates that SRS probably is effective; for those patients who choose to go through SRS, it provides real relief and life improvement.

If I’ve followed her arguments correctly, J.’s main concern is whether or not tax dollars should be used to pay for SRS. My feeling is that all necessary and effective medical treatments ought to be paid for out of tax dollars, preferably in a single-payer health care system akin to France’s. Since I think the evidence shows that SRS is an effective medical treatment, I think it should be covered.

(To read J.’s thoughts on transsexuality for yourself, read through this comments thread – if you don’t want to read the whole thing, you can find her posts with a text search for “Mac Diva.” On her blogs, read this post and also this post on Silver Rights, plus this post on Mac-a-ron-ies.)

Note: Due to this post being published as Alas was switching commenting software, the original comments to this post have been “stranded.” They can still be read here. However, please leave any new comments in the new comment system (link below).

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18 Responses to Does sexual reassignment surgery work?

  1. 1
    Mac Diva says:

    I might as well take this opportunity to clarify that my research and reportage, which included interviewing both doctors and patients in SRS clinics, was in the U.S. From what I’ve read since, the jury is still out on whether the surgery works here. I have no idea whether the foreign studies hold up to scrutiny or not.

    My main point is that I don’t believe the state should be forced to cover something this dubious. However, I need not worry about it, because the state is not going to in the foreseeable future. As for insurers, they also past the costs of medical coverage on to other people. So, the same concerns apply.

    As for radical transsexuals not liking the status quo, that is fine with me. I would be much more concerned if there was any real danger of them getting their way because each one of those expensive surgeries would deprive truly needy people of proven medical treatments.

  2. 2
    Ampersand says:

    Was your research and reportage published anywhere that you’re able to share with us? Or can you give specific references to readings that show that the jury is still out in the US?

    It seems to me that if you’re not able to share your references, then you’re not able to support your earlier statements. Which is okay – this is just a blog, there’s no rule saying you have to support all your statements – but let’s be clear that so far you haven’t been able to support your earlier claims.

    The study I referred to, while German, included results from the United States.

    In a capitalist society, “truly needy people” get the medical care they need if they have the money to purchase it (or if they have good insurance). No one will lose their insurance because a transsexual gets an SRS; and people in the US who lack decent medical care generally lack care because they lack money, not because of transsexuals.

    In other words, I think the cause-and-effect model your rhetoric suggests – “every time SRS is performed, some needy person lacks care!” is unrealistic and unwarrented.

  3. 3
    Anonymous says:

    Anonymous, insulting comment deleted by Ampersand.

  4. 4
    Nadine says:

    I thought this topic was on whether or not SRS is an effective treatment for those suffering from a disorder.
    Let me clarify before continuing that the statements I am making here require no reference because they are MY opions on the subject at hand.

    On the orignal topic: “Does sexual reassignment surgery work?”

    I strongly believe it does in the majority(if not all) of cases where proper treatment is implemented before, during, and after the procedure. Many of the failures (for lack of a better word) can be attributed to many reasons other than the surgery itself. I think if a person undeniably believes he or she is or needs something they will go to whatever lengths to obtain whatever it is they need. ie. some patients start taking hormones without ever speaking to a therapist first, some patients study the reports so that they will know how to answer the therapists questions in order to “get the greenlight”, and many more reasons I havent the time to say.

    As for “expensive surgeries would deprive truly needy people of proven medical treatments.”

    I think this is a profound statement.

    You are basically saying that a person who in their lifetime may have lived a less than healthy life (say maybe had varying levels of alcohol comsumption) and may die from something like a liver disease is worth more than a person who may have been born in the wrong physical body.
    I find it very disturbing that anyone can make this decision. At what point has humanity ceased to play an active role in society’s decisions?

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  6. 5
    Damian says:

    Why do they make transexuals jump through hoops to get a sex change? Some of my friends wonder why they have to keep an appendage they despise and that brings them so much misery.

  7. 6
    Blu says:

    You know it’s funny that people say things like this is so expensive and takes away from other needed surgeries but that’s just not true. The average surgery costs $14,000 which in pales in comparision to major medical treatments like say open heart surgery which is around $100,000 and insurance companies don’t even blink at that. For people that basically can live their lives to the fullest extent having to wait for surgery is a huge problem. In general it improves their quality of life and let’s them be whole and normal. There have been insurance studies(i wish i could reference them) that show paying for surgery and transgender care actually is a cost benefit to insurance companies. You may think something that’s thousands of dollars is an immediate no to insurance but the formulas are much more complex than that and if someone gets turned down for a life threatening surgery it’s not because it costs too much usually but because the insurance company thinks they can get away with saying no.

  8. 7
    Femme says:

    I always wonder when I see someone make a claim such as, “my research shows transex people do not benefit, over all”, as to what sort of criteria that person is using.

    There was a person who had, until it was forced down by court order, a site, which he claimed was for trans people. He himself was a crossdresser. This person made similar claims saying that he made such a study that transex people were not, over all successful after surgical support.

    This person, however, used his own ideas as to what was successful and ignored the comments from the few people he did speak with who did say they were happy. He figured if the person was not working, they were not a success. If the person did not look a certain way, they were not a success. If they were now making less money then before, they were not successful.

    When a study is done in such a subjective way, of course that person will get the result they want.

    I have yet to meet one transex person who was unhappy after their surgery, even many years later.

    We all know of stories of people who have slipped past the many gatekeepers, Alan Finch in Australia is such a person.

    He did have surgery, and is now suing the surgeon. Yet he was turned down at different GI clinics before learning what he needed to say in order to pass the gate keepers questions and tests at his third GI clinic. Is this their fault?

    Then there is the “ex” transexual who found god and now is saved and is glad he never had surgery.

    Over all the only people who say there is high non satisfaction tends to be those who, for what ever personal reason, feel some sort of fear or repulsion over the reality that some people need medical intervention in order to bring their body in line with their brain.

    Transex people work, pay taxes and are human, as such are they also entitled to having these procedures funded? Yes. Until governments and insurance stop paying for broken arms and legs caused by falling off their bikes, playing hockey etc. Until we stop paying for people who have lung cancer after years of smoking. Until we stop paying for any treatment that was needed because of something that person willfully did.

    Until such a day as that comes, then yes of course a person should receive financial support for something that the person had no choice over.

    And until such a day when the non sayers can actually bring together a real study, impartially done, showing that 50 percent plus one regret surgery, then maybe they need to allow people to live their lives as tey need.

    Why the heck is this their worry anyway?

  9. 8
    Sara says:

    I have never seen or heard someone express what I feel about this subject; so, I want to say it. As a biological female, who identifies as female I feel insulted and robbed when I am expected to accept a biological male as a woman. It feels like cultural appropration, just another way that men can steal from, degrade, and devalue women. It upsets me that a man can just say he’s a woman and voila! We’re all supposed to agree that he is. It takes 20-30 years of life as a female for an female infant to become a woman but men can do it in one breath? I respect every person’s right to live as he or she chooses, to dress, to behave, to socialize any way you want. I respect your right to alter your body any way you wish. But please recognize that living the first 20 or more years of your life as a male, you have absorbed ALL of the unconscious material of male-privilege, which is at least as powerful as white-privilege. Maybe you did not want it, maybe you wish you could give it up, but you can’t. It will always be with you, as much part of you as your mother’s hair color or your father’s chin cleft. Appropriating the identity of a woman doesn’t make you a woman. It makes you even more of a chauvanist, because you truly believe that being a woman is such a simple thing you can achieve it by just saying you have.

  10. 9
    Mandolin says:

    I think lots of people voice this viewpoint with some regularity, Sara. I’d check out some of the radfem blogs if you’re looking for peers.

    As to your POV — yeah, I think MTF transsexuals frequently have some or much male privilege. How much is going to depend on the person. Some of them were sufficiently abused for being trans that they were not always given all kinds of male privilege.

    Certainly, I think it’s important for male privilege to be something MTF and FTM transsexuals are aware of. The ones I know are aware of it.

    However, you have a kind of privilege you aren’t acknowledging — cissexual privilege. And it’s cissexual privilege that’s allowing you to look at male privilege not just as an aspect of MTF transsexuality, but the whole enchilada. If it’s male privilege to think it’s “easy” to “become” a woman, it is certainly cissexual privilege to reduce the experiences and struggles of MTF transsexuals to the phrase: easy to become a woman.

  11. 10
    Myca says:

    I’d check out some of the radfem blogs if you’re looking for peers.

    Seconded.

    There are quite a few people out there who believe that MTF transfolk are just ‘men pretending to be women’, but that doesn’t make it true.

    Kindly check your privilege, Sara.

    —Myca

  12. 11
    ChloeMtF2007 says:

    Standing ovation for Mandolin! Finally! Someone else figured it all out!

    As a MtF TS (Male to Female Transexual) myself, I need to tell you the honest truth. I am a tax-payer, and I work a dead-end job 40 hrs a week, making just a bit more than the new hires. I have medical insurance through this company I work for. So far, they have been good about covering the extensive psychotherapy and blood work that I have undergone… (my psychiatrist bills for one year are in excess of $1500 and the blood work was $1200/insurance covered all of the psychiatrist sessions, save for the $20 copay, and they have covered 100% of my blood work to find out what my testosterone/estrogen levels were) so, as you can see, so far I haven’t paid much… maybe around $300 for everything thus far. I live in an apartment I can barely afford, and I am continuously “raped” by the utility company over my gas bill every month to the point where I have to starve myself for a couple days at a time just to spread out what little pocket change I have left. I have NO way of saving money for electrolysis (which IS a necessity because makeup can only cover so much); NO way to save up for SRS (sex reassignment surgery), and there is NO insurance coverage for either of the two surgeries because they are considered “elective”, or “cosmetic”. HRT (Hormone Replacement Therapy) is not covered by insurance either (except for the first Spironolactone prescription, but that was merely my endocrinologist helping me out by saying that I have a “hormonal imbalance”), so I pay for my own hormones, the legal way.

    Now, let me explain my reasons for transitioning:

    I have KNOWN (notice I didn’t say “thought”) that I was FEMALE since I was 4 years old. This isn’t some “spur-of-the-moment” decision that I made, and I’m not acting on a “whim”. There is no way I can prove this is the real deal to anyone, unless they were in fact transexual themselves. So, what I am suffering from is really an invisible handicap. I didn’t just wake up one morning and say, “I think I want to be a woman!”. It doesn’t work that way, and nobody CREATES a transexual. Transexuals are born transexual. We know who we are; we know what we are. The two are not congruent with one another.

    I have suffered severe bouts with debilitating depression, and have had painful anxiety attacks, night after night. It got to the point where I had to leave work because I just couldn’t function. It also got to the point where I wanted to die. I wanted the earth to open up and swallow me whole; I wanted to disappear. I would rather die than pretend to be a “man” for the rest of my life. Over 50% of non-operative and pre-operative transexuals commit suicide, many of them before they reach the young age of 20 years old. The suicide rate for post-op transexuals drops quite significantly to the general populus norm of less than 1%. I would say that is an indication that SRS is pretty darned effective. Now that I have been going through therapy for the past 6 months, and hormone treatment for the past 3 months, I am happy to say that I am healthier, happier, and I am enjoying life (other than the financial snag, but we all hate that!). I no longer want to die, I merely want out of this male body.

    Social gender (i.e.: male and female) is just that: Socially constructed gender. Gender however, is not binary (male and female) like most people assume. Gender is a spectrum. Many people are gender-variant to some degree without even realizing it. I didn’t choose to be physically male. I didn’t choose to be psychologically female. I definitely did not choose to be transexual. I have lost my family due to prejudice; I have lost friends due to ignorance, and I was in jeopardy of losing my job, my home… EVERYTHING. I hardly chose to have any of these things happen to me. Simply because of these infernal social labels, I am called every homosexual slur in the book, and I’m ASEXUAL!!! I am tormented, ridiculed, harassed, and treated like I am the worst piece of filth anyone has ever laid eyes upon.

    And I never even did anything to those people. I was simply honest with myself. After 30 years of SERIOUS soul-searching, I finally found out how to escape from this prison, and the first sign of help that is offered by the medical community, or an insurance company, and some people decide to go off on the entire trans community. To treat MtF transexuals as if they have NO idea what it’s like to be a woman.

    To which I say: What did I do TO YOU?

    Would it be better for me to have killed myself when I was 14, knelt next to my bed, my face covered in tears, praying to the Good Lord above that He would either take these thoughts and feelings away from me, or that He would make me wake up as a girl? Or would it be better for insurance companies to provide help for those that have a serious medical condition (which Dr. Harry Benjamin calls neurological intersexism) and that DESERVE proper medical treatment?

    You decide, but if you think I should have just killed myself, you might want to rethink your own sense of humanity.

    So, to say that it’s easy to be a woman… that’s just plain ignorance. It’s hard to be a woman, but it’s even HARDER to be a transexual woman. The only thing anyone else has to go off of is a transexual’s own heartfelt conviction that we are in fact members of the opposite sex we were assigned at birth.

    Now, to interject some science into the mix. Please check out this study for more information on just how much transexuals feel like they are the opposite sex:

    http://jcem.endojournals.org/cgi/content/full/85/5/2034

    Thank you,
    Chloe

  13. 12
    MisterMephisto says:

    My question to Sara is this:

    When you are generalizing in this way, are you including the other side of the coin on this? Do FtM transexuals just “want in on” male-privilege, in your opinion? Should I be angry/offended that FtM transexuals are undermining my “masculinity/man-ness”? I’ve been a man for 30 years. Should I be asking them “how dare you think you’ve got what it takes to be a man?”

    Is it so unreasonable that they might just actually want/need to be the other gender, and not try to see it as a conspiracy to undermine the other side? That their operation is really NOT just part of a political agenda to take gender away from those born to it?

    Should I be so shallow as to value myself and who I am so little to think that their happiness hurts me? Or that I or they or you are nothing more than the sum of our birth-sex?

  14. 13
    SilverDark says:

    I stumbled on your blog from so many years ago and I think I have some useful thoughts for you. I’m trans and know many people that have had the surgery so here’s the deal. Surgery is something most people really want so that they feel more comfortable as themselves and in many cases so that they can function better as the gender they see themselves as.

    There are a lot of issues that trans people face from society and it’s really a pretty hard thing to go through especially when it can often be something you have to do all on your own. If you don’t know anyone who is trans then your understanding of most trans people is from the ones that stand out that you’ve met or in movies, etc. That’s too bad because trans people are just people. In fact some are so lucky to live without people knowing they’re even trans.

    As to whether surgery is effective the answer is yes assuming that someone has a good surgeon and has a good result. In most cases this is what happens and people are happy with the outcome. There will always be a very small percentage of people that make a bad decision or went to a horrible surgeon.

    The point you were making about whether surgery treats this condition the answer is yes and no. A lot of trans people do tend to stick out more than they would like which is unfortunate and will happen regardless of surgery. Hopefully society will continue to become more accepting of people that are different and be more understanding that trans people are after the same goals as anyone else and just want to live their life in normal way.

    A great thing that’s happened in the last 10-20 years is that people are coming out at a younger age and getting treatment earlier. This will help them be able to live their lives without having to deal with being trans as much. Also they will have a better outcome after surgery.

    Overall insurance should be paying be surgery and other needs because it’s a medical need. There have been studies that show paying these costs is negligible to the cost of insurance. I don’t have a way to reference these right now. Basically the reasoning is that people that can’t afford things tend to run into other issues which insurance does pay for so by treating trans people correctly in the beginning it’s a preventative measure. These people can live out their life better and actually save insurance companies and everyone else money.

  15. 14
    Transexual and bitter says:

    No it does not work why because of prejudice

  16. 15
    Susan says:

    “Does [surgery X] ‘work’?” is a difficult question to answer, because of the vagueness of the term “work.”

    Does knee replacement surgery work? (I’m picking a surgery I have had myself.) Well, it enables me to walk without pain, so in that sense it certainly works. Is it as good as never having had my knee degenerate in the first place? No. Many, if not most, surgeries are second-best, second to having not had the problem in the first place, so what.

    I’m sorry you’re having such a tough time, Transexual and bitter. I’m hoping your post was made at a low moment – we all have them – and that life is, overall, satisfying for you.

  17. 16
    Valerie Keefe says:

    @Transexual and Bitter

    You’re very right. So many of the operative trans women I’ve talked to when I ask, since it does seem that we as a group love all things TMI (I’m happily non-operative myself, more on that… everywhere…) mention as their first reason for wanting SRS being some form of discrimination that they suffer for having atypical female genitalia. (i.e. A penis, which plenty of women have, some of them cis.) I think as discrimination against trans women, and bepenised women decreases, we’ll see a smaller proportion of surgeries as a percentage of the total trans population, but much more transition. I never reduced my gender to my genitalia. I needed other cissexist standards to rely on as I lived in denial.

    I have to say though that it seems so often like discussions of surgery erase or somewhat degender non-operative trans women… So many of us DO NOT want surgery, do not need surgery, do not get any body-map benefit from it, but still suffer the cissexism that comes from being physically trans, and find the pressure to get vaginaplasty or phalloplasty, (I won’t call it SRS because that implies that somehow a woman is made on the operating table instead of being born female and assigned male.) to be palpable.

    Simply put, trans women, are women, even when we operate under the fiction that we are men, as so many of us have done.

  18. 17
    Ampersand says:

    Good point. I wrote this post back in 2003; if I were writing it today, I would definitely write it to acknowledge trans people who choose not to have surgery, among other differences.