Gender change and new life: how a woman becomes a man and vice versa

From a medical point of view, desire for gender reassignment or transgenderism is a condition related to sexual health. Modern medicine offers transgender people many options for a happy existence, but gender reassignment surgery remains the height of perfection.

Mikhail Shifrin talks about who was the first patient to change sex in Russia and how the life of a surgeon who signed up for such an adventure changed in his book “100 Stories about the History of Medicine.” And we are trying to figure out why it is difficult to decide on such operations even today.

How much does it cost and what is needed for it?

The process of preparing for sex reassignment surgery can hardly be called simple. First, patients are observed by a psychiatrist, and after recognition of gender incongruity, they undergo long-term hormone replacement therapy and only after that are placed on the operating table.

“A happy life in a new body and a new sex is overshadowed by lifelong use of hormonal drugs, problems with orgasm and the race for new plastic surgeries to complete the image. There is no need to mention the bureaucratic difficulties in obtaining new documents.”

According to data from the Internet, Thailand is a Mecca for transgender people, where gender reassignment operations cost about $7-10 thousand. In America and Germany it is about $40 thousand, but in Russia it is only $1–2 thousand, apparently due to not too much trust in Russian specialists.

Gender change

First of all, people who changed their gender underwent a large amount of preliminary training. Before the procedures, the patient must undergo hormonal therapy under the supervision of a physician. Hormone therapy lasts approximately one year. For some countries, it is not possible to change gender until a diagnosis of transsexualism is made. Without this diagnosis, no action will be taken.

Several areas of plastic surgery are involved in gender reassignment: • Mammoplasty • Phalloplasty • Vaginectomy • Scrotoplasty • Colpocleisis • Hysterectomy • Metoidioplasty • Salpingo-oophorectomy • Ovariectomy

Reasons and indications

The very first sex reassignment operations began to be performed back in the late 20s of the 20th century in Europe. In 1926, the first operation to remove the breasts of a transgender woman was performed here, and in 1930, a penectomy, an operation to remove the penis, was performed. At the beginning of the 20th century, the most popular punishment for transgender people was a diagnosis of some mental illness with lifelong hospitalization in a “psychiatric hospital.”

People were looking for an alternative to a psychiatric hospital and increasingly turned to advanced doctors who could offer help. It was the harsh laws that prompted surgeons to do the impossible - sex reassignment operations. The first operation was performed in 1931 on Einar Wegener, the husband of the Danish artist Gerda Wegener.

Among the famous people who have changed their gender: Dana International (singer), the Wachowski sisters (film directors), Chaz Bono (son of singer Cher), Billy Tipton (American pianist) and many others.

Indications for surgery

Installation of an intraocular lens (abbreviated as IOL) is necessary for eye diseases accompanied by clouding of the lens (cataract), loss of the ability to focus vision at close distances (age-related farsightedness or presbyopia), eye trauma and other pathological processes. Unconditional indications for surgery include:

• cataracts, in which age-related clouding of the lens and degeneration of its tissue occurs;
• high degree of age-related farsightedness (over +6 diopters);
• congenital or age-related high myopia (over -6 diopters);
• astigmatism, in which the problem is caused by a lens that does not focus light beams;
• congenital, traumatic or postoperative absence of the lens;
• dislocation of the lens with destruction of its body.

Such an intervention can be carried out at any stage of the disease, including complete loss of vision. The only obstacles to lens replacement may be infection of the eye, extensive retinal atrophy and optic nerve dystrophy. In this case, the installation of a lens will be impractical, since other structures of the eye responsible for the perception of visual images remain non-functional.

First successful operation in Russia

For the first time in our country, such an operation was performed in 1972 by surgeon Viktor Kalnberz, who was subsequently punished for a “mutilating” operation that was contrary to the ideology of the Soviet state. And such operations were punishable by law for another 17 years.

Victor Kalnberz. Andrejs Strokins for “Medusa”

This is how it happened. A girl, Inna, came to the then famous experimental biologist Professor Demikhov with a request to help her transform and become a man. Demikhov could not help, and therefore turned for help to his friend from Riga, the director of the Riga Research Institute of Traumatology and Orthopedics, Viktor Kalnberz:

“A nice woman with a higher engineering education came. She wants to change her gender, become a man. You are successfully practicing plastic surgery. If you can, help." Then there was a long examination of the patient, the first unsuccessful attempt at surgery (it simply did not take place), and the girl herself was seen preparing for her fourth suicide attempt. As a result, it all ended with the fact that on April 5, 1927, Victor Kalnberz performed a successful sex change operation on Inna, who became Innocent.

“He” got into the habit of going to the hospital garage, where he became friends with the drivers. With them, “he” smoked, drank and cursed to his heart’s content, enjoying the opportunity to be in male company without male assault. He had great success with women, because he understood them and knew from himself what, for example, menstruation or high-heeled shoes were. Six months later he was already married. And he was married quite happily, except that his wife was often jealous of him.

Even after the ban was imposed, Kalnberz managed to carry out five more underground operations. We can only hope that the lives of these people have improved as much as those of Inna, who became Innokenty.

Transsexualism: etiology, sex reassignment procedures and their results

In the 1960s and early 1970s, when medical procedures for gender reassignment were first developed in the United States, approximately three out of four applicants for gender reassignment were biologically male wishing to become female. Most medical professionals believe that even today the number of men wishing to change their gender exceeds the number of women. However, we have evidence that recently this proportion has noticeably leveled off. Treating Transsexual or Transgender Individuals with Respect in Communication Situations Alexander John Goodrum has published an informative article on transsexualism and transgenderism. In this article, he provides guidelines for communicating or interacting with individuals who exhibit deviant gender identity and/or behavior. — It is very important to use the correct forms of address to transsexual or transgender individuals. If someone identifies as a man, he should be referred to as he; if a person identifies himself as a woman, she should be referred to as she. If you are in doubt, it is appropriate to ask the person what treatment is preferred or expected. Once you've figured this out, try to be consistent. If you suddenly forget and use the wrong pronoun, correct yourself. Most transgender and transgender individuals will understand your misstatement and appreciate your efforts. - Never “out” a person by telling others that he or she is transgender or transsexual without that person’s consent. Also, do not assume that other people know about a person's gender identity variations. Many transsexual and transgender individuals "act" very skillfully, and the only way to find out about their deviations in gender identity is to directly communicate this fact. Obviously, the decision whether or not to disclose one's gender status must be made by the individual. It is therefore very disrespectful to ignore this fact. — Common sense and good manners dictate that we should never ask transsexual or transgender individuals what their genital anatomy is and/or what their sexual response to other people is. - Finally, don't make assumptions about whether a person's orientation is homosexual, bisexual, or heterosexual. A person who finds it appropriate to disclose information regarding his or her sexual orientation may choose to disclose this to you. A significant amount of clinical literature is devoted to the characteristics, causes (etiology) and treatments of transsexualism. Some factors have already been established with precision. We know that most transsexuals are biologically normal individuals with healthy genitals, intact internal reproductive structures and a normal number of chromosomes (XX or XY). In addition, transsexualism is usually an independent disorder and not part of a more general psychopathological disorder such as schizophrenia or major depression. One recent study found that less than 10% of a sample of 137 transgender people had symptoms associated with mental illness. Less clear are the reasons why these individuals reject their anatomy. For many transsexuals, the feeling of inadequacy of their genital anatomy develops in early childhood. Thus, some of them recall that they experienced strong identification with characteristics of the other sex as early as five, six, or seven years of age. In some cases, such people were able to partially alleviate this discomfort by imagining themselves as representatives of the other sex. However, this often went beyond mere imagination and led to actual cross-dressing. In rarer cases, strong identification with the other sex does not arise until puberty or adulthood. Currently, there is no clear understanding among scientists of the etiology of transsexualism. Significant controversy also exists regarding the most appropriate clinical strategies to overcome this anomaly. Bearing in mind that the debate on this issue has not yet been resolved, we will try to summarize our rather fragile knowledge regarding this highly unusual deviation of gender identity. Etiology Many scientists have tried to explain the phenomenon of transsexualism. However, the data at our disposal does not allow us to come to clear conclusions. Some authors argue that biological factors may play a decisive role. One theory is that prenatal exposure to excess hormones of the other sex may cause problems with brain differentiation. This theory is partly supported by a recent study in which female-specific BST was found in six male-to-female transsexuals. Returning to the topic of brain differentiation discussed above, you may recall that the BST is a region of the hypothalamus that is normally 50% larger in heterosexual men than in heterosexual women. According to the authors of this study, the presence of an unusually small, female-like BST found in these six individuals (who were biologically male) with a female gender identity “cannot be explained by differences in sex hormones in adults.” While we await further research to confirm these intriguing findings, this finding suggests that the process of gender identity formation may be radically transformed by changes in the interactions between the developing brain and prenatal sex hormones. It has also been suggested that transsexualism may be caused by abnormal levels of sex hormones in adulthood. However, this explanation contradicts extensive evidence showing that sex hormone levels are normal in adult transsexuals. Another theory regarding the causes of transsexualism, for which there is some evidence, states that the development of this anomaly is greatly facilitated by the experience of social learning. The child may be exposed to various conditioning factors that reinforce behaviors traditionally attributed to the other sex. The child may develop a close relationship, causing a different identification, with a parent of the opposite sex. And the reactions of an adult can be a strong reinforcement of this identification. A little boy can play pretending to be a girl, and a little girl can pretend to be “daddy’s boy.” These cross-gender behaviors may be so uniquely rewarded that the child may find it difficult, if not impossible, to develop an adequate gender identity. However, as difficult as it may be for us to determine the causes of transsexualism, perhaps even more difficult is resolving the problem of opposite gender identity. As mentioned above, most transsexuals follow the heterosexual script and prefer to engage in sexual relations with people of the opposite sex. The fact that the "other sex" has genitalia similar to their own makes it much more difficult to find a partner. Most transsexuals desire intimate contact with heterosexuals. Thus, a transsexual man wants to be desired as a woman by a heterosexual man, and most transsexual women are not content with purely lesbian relationships. These romantic and sexual needs are often difficult to satisfy. As a result, both heterosexuals and homosexuals, as a rule, manage to find a reciprocating partner of the corresponding sexual orientation. However, the most desirable partners for a transsexual are likely to reject his expressions of sexual interest.

Options for Transsexuals Medicine has traditionally considered only two possible options for overcoming gender dysphoria for transsexuals: either changing one's gender identity to match one's physical body or changing one's body to match one's gender identity (Carroll, 1999). There are, however, other possibilities. Recent clinical evidence suggests that some intact transsexuals are discovering that they can achieve psychological satisfaction through behaviors such as adopting other-sex roles and wearing cross-sex clothing. However, in most cases, the best option remains to align your body with your psyche through surgical or hormonal changes to the genital anatomy and physiology of the body. However, the issue of gender reassignment with the help of medicine is not easily resolved, since it is associated with significant time and material costs. One leading authority on the treatment of transsexualism recommends careful consideration of all possible alternatives, including psychotherapy, before considering permanent sex reassignment surgery (Pauly, 1990). Of course, not every adult suffering from gender identity disorder needs psychotherapy before undergoing gender reassignment procedures. However, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) recently published revised standards for the treatment of persons suffering from gender identity disorders, prescribing psychotherapy in certain situations. Psychotherapy can provide transgender individuals with information about their options and allow them to discuss and explore options they may not have previously considered. Gender Reassignment Procedures The first stage of the gender reassignment process involves detailed diagnostic interviews, the purpose of which is to comprehensively assess an individual's motivation. For those who experience serious conflicts and uncertainty about their gender identity, surgery is not recommended. Those individuals who have a clear and real discrepancy between their gender identity and their biological sex are encouraged to lead a lifestyle that is consistent with their gender identity (including adopting appropriate clothing and behavior patterns). If, after a period of several months to a year or more, the individual can be said to have successfully adapted to a given lifestyle, the next step is hormone therapy. It is used to promote the manifestation of latent characteristics characteristic of the selected sex. Thus, men who want to become women are prescribed drugs that interfere with the production of testosterone, along with doses of estrogen, which promotes breast growth, softens the skin, inhibits the growth of facial and body hair, and also gives the body a feminine shape. This also reduces muscle strength and sexual desire. The pitch of the voice does not change. Transsexual women who want to become men are prescribed testosterone, which promotes the growth of body and facial hair, lowers the pitch of the voice and helps to slightly reduce the size of the mammary glands. Testosterone also suppresses the menstrual cycle. Most health care providers who perform gender reassignment procedures require candidates to live a lifestyle of the other gender for a year or more before undergoing surgery. At the same time, they are undergoing hormonal therapy. At any point during this period the process can be successfully reversed, although few transsexuals take advantage of this opportunity. The last stage of gender reassignment is surgery. Surgical procedures are most effective for men who want to become women. The scrotum and penis are removed and the vagina is created by reconstructing the pelvic tissues. This procedure requires special precautions to preserve the sensitive nerve endings contained in the skin of the penis. These sensitive skin tissues move inside the newly formed vagina. The operation makes sexual intercourse possible, although additional lubrication will be required. Many male-to-female transsexuals report being able to experience sexual arousal and orgasm after the surgery. Hormonal treatment can cause significant enlargement of the mammary glands, but some individuals also use implantation. Hair on the face and body, the growth of which is suppressed due to hormonal treatment, can additionally be removed using electrolysis. From a biological point of view, women who wish to become men have their breasts, uterus, and ovaries surgically removed and their vaginas sewn shut. The process of formation of the penis is much more complex than that of the vagina. Typically, the penis is constructed from abdominal tissue or tissue from the labia and perineum. This engineered organ is not capable of natural erection in response to sexual stimulation. However, there are a number of artificial devices that ensure the hardness of the penis during sexual intercourse. One method involves creating an empty skin channel on the underside of the shaft of the penis into which a solid silicone rod can be inserted. Another option is to use an implantable inflatable device, described in the chapter “Sex Therapy and Enhancing Sexual Relationships.” If erotically sensitive clitoral tissue is left at the base of the surgically constructed penis, the individual is also able to experience erotic sensations and orgasm. However, a study of 25 transsexuals who underwent surgery found that although 90% of all study participants expressed satisfaction with the results of the surgery and their post-operative sex life, the ability to achieve orgasm actually increased in individuals who changed their gender to male. For those who changed their gender to female, it decreased somewhat. Results of gender reassignment procedures The results of numerous studies of the psychosocial consequences of gender reassignment provide grounds for conclusions about the success of gender reassignment procedures. The most typical result of most of these studies is the fact that, more often than not, people who have undergone these types of procedures are significantly better adjusted to life in general. An important source is a publication that summarizes the results of three international reviews of the results of sex reassignment surgery. According to the findings of the authors of this work, approximately 9 out of 10 transsexuals who have undergone hormonal and surgical procedures consider their results to be satisfactory. According to the data obtained, such positive results are equally likely for transsexuals who change their sex from male to female, and for those who change their sex from female to male. A study report involving large samples of both groups reported that 94% of participants agreed to undergo the same operation again if they needed it again. According to the results of another, more recent study, 16 out of 17 transsexuals who changed their gender from male to female rated their gender transition as successful. Other reports also report that transsexuals who underwent the surgery were satisfied with the results. In addition, their social adaptation was much better than that of those who did not undergo sex reassignment surgery.

Why undergo knee replacement surgery?

There are three main reasons to undergo a joint replacement procedure:

Osteoarthritis: This type of arthritis is age-related and is caused by wear and tear on the knee joint. This most often occurs in patients over 50 years of age, but can also occur in people under 50 years of age.

Osteoarthritis is the inflammation, destruction, and gradual and final loss of cartilage in the joints. Over time, the cartilage wears down and the bones rub against each other. To compensate, the bones often become thicker, but this results in more friction and more pain.

Rheumatoid arthritis: Also called inflammatory arthritis, the membrane around the knee joint becomes thick and inflamed. Chronic inflammation damages the cartilage, causing pain and stiffness.

Post-traumatic arthritis: This type of arthritis is caused by severe injury to the knee. When the bones around the knee break or ligaments tear, the cartilage in the knee joint will be affected.

Who may need a knee replacement?

Knee surgery may be suitable for patients who experience:

• Severe knee pain or stiffness that interferes with everyday tasks and activities, such as walking, climbing, getting in and out of a car, or getting up from a chair.
• Moderate but persistent knee pain that continues while sleeping or resting
• Chronic inflammation and swelling of the knee joint that does not improve with medication or rest
• Knee deformity where there is a noticeable arch on the inside or outside of the knee
• Depression due to the inability to live a full daily and social life
• If other available treatment options have failed, surgery may be the best option to resolve the issue.

Preparatory activities

No matter how much money the patient is willing to pay to “transform” into a girl, he will have to go through a preliminary stage:

• Observation by a psychiatrist, psychologist, sex therapist. There are several methods by which a doctor determines whether it is a reasonable decision to change gender from male to female. For at least one year, the patient lives as a representative of the opposite sex. The doctor monitors how social adaptation is progressing and gives a conclusion based on many factors.
• The plastic surgeon prescribes tests and instrumental examination to exclude contraindications for health reasons.
• No later than 9 months before the operation, the patient is prescribed hormones. The course is prescribed only by a doctor to reduce the risk of side effects. A man needs to reduce testosterone levels and increase estrogen levels. At this time, the voice changes, fat deposits are distributed differently, facial features become more attractive, and body hair partially disappears.
• Under favorable conditions, 1 month before the guy finally becomes a girl through surgery, hormones are stopped until the postoperative period.

After a course of therapy, such dramatic changes occur that more than half of transsexuals consider them sufficient and do not undergo surgery. You can see the effect of taking hormones on a person in the photo.

Recovery period

How the implantation of the artificial lens will proceed will depend on the correctness of postoperative rehabilitation. At an early stage, it is important to protect the eye from infection. To do this, within 5-7 days it is prohibited:

• wash your hair;
• wash your face in the usual way;
• touch your eyelids with bare hands that have not been pre-treated with antiseptics;
• go outside without an insulating eye patch.

In addition to this, it is necessary to instill antiseptic drops under the eyelid every day for 10 days and carefully monitor eye hygiene.

During the period from the first to the 20th day of rehabilitation, it is important to avoid any phenomena that could provoke blood flow to the face, especially to the operated eye. These include:

• bending forward;
• visits to baths and saunas;
• lifting weights over 3 kg;
• gymnastics and other types of sports activities.

To avoid accidentally injuring the operated eye

, it is advisable to sleep on your side with the healthy eye for the first week. If the intervention was bilateral, it is recommended to sleep on your back. The duration of sleep should be at least 8 hours a day, and the duration of continuous work with active involvement of vision should not be more than half an hour.

Don't forget about nutrition

which will help you recover faster after surgery. Ophthalmologists claim that it suppresses the immune system, and therefore the risk of infectious and inflammatory complications remains high for up to 3 months. To avoid them, it is recommended to include more fresh vegetables and fruits in your diet, which contain vitamins and microelements. Additionally, you can take vitamin complexes that your doctor recommends, or natural immune stimulants, for example, Eleutherococcus. You should give up alcohol, fatty and spicy foods, carbonated drinks and energy drinks for at least 3-4 months.

What is Knee Replacement

Knee replacement is a type of arthroplasty. Arthroplasty literally means “surgical joint reconstruction,” and involves the surgical reconstruction and replacement of degenerated joints using artificial body parts or prosthetics.

When the articular cartilage of the knee joint becomes damaged or worn out, it causes pain in the joint and makes the knee difficult to move. Instead of sliding against each other, the bones rub and crush together.

With a prosthesis, the patient will feel less pain and the knee will move correctly.

Types of knee replacement surgeries

Knee replacement can be total or partial

Total knee replacement : Surgery involves replacing both sides of the knee joint. This is the most common procedure.

The operation lasts from 1 to 3 hours. The individual will have less pain and better mobility, but there will be scar tissue that can make it difficult to move and bend her knees.

Partial knee replacement : A partial replacement replaces only one side of the knee joint. Less bone is removed, the skin incision is smaller, and the surgery does not take as long as a total joint replacement. Suitable for people with joint damage to only one part of the knee. Post-operative recovery is easier, there is less blood loss and a lower risk of infection and blood clots.

The hospital stay and recovery period are usually shorter, and there is a higher chance of natural joint movement with this type of surgery.

Duration of the procedure

The operation to replace the lens of the eye performed by an experienced surgeon can last from 6 minutes to 30-40 minutes

. Its duration depends on the severity of the disease, the condition of the eye, and especially on the condition of the ligamentous apparatus on which the natural lens is supported. These factors may make the operation more difficult and may require additional time. The duration also depends on the method used to remove the natural lens and replace it with an intraocular one.

Traditional classical ultrasound phacoemulsification

It takes the doctor from 5 to 40 minutes. The most time-consuming methods are considered to be outdated methods of “manual” removal of the lens, preparation of the capsule and installation of an intraocular lens using a microsurgical instrument. For complex dislocations and subluxations of the lens, the intervention can last more than an hour.

Cataract removal using phacoemulsification with femtosecond laser assistance

last a little longer. This adds a separate laser stage to the operation process. The laser destroys the natural lens and makes the necessary cuts. But the second stage in this case, phacoemulsification - the final destruction of the lens and implantation of an artificial lens - lasts much less. Since the lens is already divided into fragments, all the necessary incisions and accesses are made, which facilitates and reduces the work for the surgeon, increasing the efficiency and safety of the intervention.