Surgical gender reassignment for male to female transsexual people
The Wessex Institute for Health Research and Development.
[Abstract] Full Text [PDF]
To evaluate the long-term risks and benefits of surgical gender reassignment for male to female transsexual people.
Type of intervention
Specific interventions included in the review
Male to female surgical gender reassignment, involving penectomy, orchidectomy, and vaginoplasty.
Participants included in the review
Participant inclusion criteria were not stated. Included studies involved patients over the age of 18 who have had male to female gender reassignment. In a single included controlled study, controls were those on the waiting list for the operation.
Outcomes assessed in the review
Outcomes included: changes in social, sexual and work activity, psychoneurotic symptoms, personality characteristics, gender dysphoria, body image, psychological functioning, social life, relationships, sexuality, work status, occupational status, physical examination (cosmesis, complications), surgery and sexual readjustment (outcome of surgery, strength of libido, sexual activity, number of partners, capacity for orgasm, object choice, partner relations, overall rating of sexual adjustment), mental health, MMPI, complication rates, attitudes to experience and management of gender assignment, self confidence, enjoyment of leisure activities, satisfaction of surgery, satisfaction with new sex status, psychopathology, additional surgery and current family reactions, subjective well being and personality characteristics.
Study designs of evaluations included in the reviews
All types of study design, except individual case reports, were included. Only studies published after 1980 were included. Length of follow-up was variable, and ranged from 0.4 years to 3.8 years in one study, to a mean of 8.2 years in another study.
What sources were searched to identify primary studies
The following electronic databases were searched: Cochrane Library (1998/issue 2), MEDLINE (1993-April 1998); Healthstar (1975-April 1998); EMBASE (1980-January 1998), Social Science Citation Index (1980-1998); PsycLIT (1980-December 1997), National Research Register (1997 prototype), GEARS (1998 edition). Primary studies were also sought through personal communications with experts and with Beaumont Trust.
Criteria on which the validity (or quality) of studies was assessed
The authors do not report a method for assessing validity. However, the methodological limitations of the included studies were described.
How were decisions on the relevance of primary studies made?
The authors do not state how the papers were selected for the review, or how many of the authors performed the selection.
How were judgements on the validity (or quality) made?
The authors do not state how the papers were assessed for validity, or how many of the authors performed the validity assessment.
How were the data extracted from primary studies?
The authors do not state how the data were extracted for the review, or how many of the authors performed the data extraction.
Number of studies included in the review
One controlled study comprising 40 participants, and 11 non-controlled studies comprising 519 participants.
How were the studies combined?
Studies were combined narratively.
How were differences between studies investigated?
Tests for heterogeneity were not performed. However, differences between studies were discussed to some extent.
Results of the review
Controlled study: After two years the operated group were significantly more active in visits to family, friends etc, eating out, sport in company and sexual interest. Non-significant outcomes included: social drinking, work record, cinema/theatre attendance, club membership, church attendance, spectator sports, reading and watching TV. The operated group had significantly reduced scores on the psychoneurotic index (which measures free-floating anxiety, phobic anxiety, obsessionality, somatic anxiety, depression and hysteria), although the clinical significance of this result was not reported. Scores on the personality characteristics scale (which consists of 60 personality characteristics defining “femininity” and “masculinity”) were not significantly different. Adverse effects were not reported in this study. Non-controlled studies: Eleven non-controlled studies were found, but only four of these collected baseline data with which to compare outcomes. The methods of these studies were only described very briefly. In some studies, the preoperative status was recorded retrospectively, creating the opportunity for recall bias. Without valid premeasures, it was impossible to determine the exact extent and direction of changes. The remaining seven studies only collected data at one point in time. The authors note that all of the non-controlled studies have serious methodological limitations and suggest that in light of these, the results of these studies should be interpreted with extreme caution. Benefits: Positive outcomes in the non-controlled studies were reported in areas such as cosmetic appearance, sexual functioning, self-esteem, body image, socieconomic adjustment, family life, social relationships, psychological status and satisfaction. The authors state that the published studies cannot be relied upon to provide valid estimates of benefit, and therefore they did not attempt to summarise the results from these studies. They argue that given a proportion of individuals will have negative consequences from surgery, the key issue may be in patient selection. Disbenefits: Postoperative complications include: haemorrhage, urethral stenosis, urinary incontinence, rectal fistula, vaginal stenosis, and erectile tissue around the urethral meatus. The incidence of events could not be ascertained with confidence due to variability between the studies, and the high rates of losses to follow-up. The thrombotic risk of oestrogen therapy should be considered when estimating the potential harms of gender reassignment interventions. Serious postoperative incidents include request for reversal, hospitalisation and suicide. There was great variation in the frequency of these events for individual studies which were reported in the appendix (e.g. attempted suicide rates range from 0% to 18%). New problems may emerge following reassignment surgery. Some individuals may need to come to terms with painful loss, including jobs, families, partners, children and friends. Many are forced to move away from their familiar environment and, despite being confident in their gender role, may have difficulty with social adaption and acceptance by others. The extent of these problems has not been recorded in the published studies.
Was any cost information reported?
Extracontractual costs for a single stage operation (penectomy, orchidectomy, and vagnioplasty) in 1998 were £9580. These costs do not include costs for psychiatric assessment and follow up. It is likely that psychiatric costs will decrese following surgery. Consultations may only be required annually (rather than 3-4 times per year), which may result in a saving of approximately £500 per patient per year. A proportion of patients will require additional surgical services such as breast enlargement and laryngoplasty. Costs may also be incurred for the correction of complications, although the frequency of these events cannot be estimated using the available evidence. Hormone requirements are reduced following surgery; the dose of premarin is reduced to 2.5mg daily and anti-androgens are discontinued. Savings may range from £210 to £450 per year depending on the pre-operative dose. These figures suggest that psychiatric and pharmacological savings may result from gender reassignment surgery. These savings may be up to £950 per patient year.
The evidence to support gender reassignment surgery is limited in that most studies are non-controlled and have not collected data prospectively. They are also hampered by losses to follow up and a lack of validated assessment measures. It is evident that a number of transexual people experience a successful outcome in terms of subjective well-being, cosmesis and sexual function. The magnitude of benefit and harm cannot be estimated accurately using current evidence. Gender reassignment surgey is a relatively cheap procedure. If successful, the need for psychiatric and hormonal treatment may be reduced, thereby resulting in savings to the NHS. Many studies have not used the rigorous criteria that are required for acceptance for surgery, and consequently, they may not reflect the current “success” rates in the UK. There is a pressing need for high quality controlled studies in this area.
Inclusion criteria were appropriate. Sufficient details of the individual studies were presented and the primary studies were summarised appropriately. A clear review question was not presented, but the aims can be inferred from the text. The search is fairly thorough, incorporating a number of databases, but it could also have involved some handsearching. A formal validity assessment was not undertaken, but the quality of individual studies were discussed in detail. Due to the lack of controlled studies and the poor quality of non-controlled studies, no formal conclusions could be drawn.
What are the implications of the review?
The authors state that high quality controlled studies are required to determine the risks and benefits of gender reassignment surgery. Potential patients should be identified using standardised selection criteria. The authors suggest that surgical gender reassignment should be available for carefully selected transsexual people. They note that surgery is not a cosmetic intervention, but one that attempts to reconcile an individual’s core identity and their physical characteristics.
Subject index terms
Subject indexing assigned by CRD: Transsexualism/su [surgery]
Citation: Published on the Internet by University of York, 2000.