Sex-reassignment surgery male-to-female. Review, own results and report of a new technique using the glans penis as a pseudoclitoris

Sexually deviant humans have been mentioned since antiquity and presumably have existed at all times. Opinions on the subject have varied throughout recorded history. Nowadays we distinguish between different forms of sexual abnormality, a.o. transvestites, homosexuals and transsexuals. The estimated prevalence of transsexualism varies in different societies and cultures among men between 1/100.000 and 1/2.900. The etiology of transsexualism is unknown. There have been proposed from psychological conditioning in childhood or an unusual paranoic state to genetic disturbances. Current investigations indicate that mutations in the SRY-gene might be a cause. Surgical sex-reassignment of male transsexuals began in the 1930s, but the ideal method has not yet been found. The aim of surgical intervention is primarily social and psychologic rehabilitation of the patient, as psychiatric therapy invariably fails to "cure" a true transsexual, i.e. a person that from early childhood has an absolute and unalterable conception of himself as belonging to the opposite sex. In 1978-87 the author performed sex-reassignment on 13 transsexual biologic males, using a modified technique in which the urethra and glans penis were preserved and the glans transposed to a position at the introitus of the neovagina to serve as a "pseudoclitoris". In six cases this procedure was successful. The advantage of the technique over previous operations is that the glans penis with its sensitive mucosa is saved at the neovaginal introitus. The disadvantages are that the glans will necrotize if the blood flow through the corpus spongiosum is strangulated and that a second-step operation is required to resect and trim the glans after it is well healed. Complications and results were similar to those in earlier case series. Factors important for success of sex-reassignment operations include patient age less than 30 years old at operation and ability of the patient to handle a vaginal dilator correctly after the surgical conversion. Orchiectomy should be performed as soon as the diagnosis is confirmed, after which the estrogen dosage can be reduced.