Increasing prevalence of transgender surgical procedures
More individuals in Germany are opting for gender affirmation procedures. The road is lengthy, and patients often experience significant distress. The rise in antagonism towards those undergoing transformation has also been noted, with experts stressing, "Gender transition is not a fad."
Living in the incorrect body - more people are electing for gender affirmation surgeries. With the passage of the Self-Determination Act this winter, surgical centers expect the demand to surge further. What instigates this trend, and what medical procedures are involved?
Few clinics nationwide are equipped to manage complex gender reassignment surgeries. One of these facilities is the Agaplesion Markus Hospital in Frankfurt, the lone center in Hesse. Prof. Ulrich Rieger, Head of Plastic Surgery, and Dr. Saskia Morgenstern, Leader of Reconstructive Urology, have been performing diverse transgender procedures for years. University Hospital Frankfurt's Prof. Jörg Bojunga heads the Transgender Medicine Working Group. All report high stress levels among patients. The notion of gender transformation as a trend is denounced by Bojunga as absurd: "No one does it for fad reasons."
Soaring Numbers
The Federal Statistical Office figures show 2,598 gender reassignment surgeries nationwide in 2021, contrasting with 419 in 2007. The ratio of surgeries has been gradually climbing each year.
"While the growth is remarkable, it's not an explosion," clarifies Morgenstern. Each procedure is accounted for individually, regardless of one patient undergoing several operations. A single trans man, for example, could be accounted for by seven "female-to-male" surgeries in the statistics. Many do not seek comprehensive surgeries, Morgenstern adds. Hormone therapy alone can significantly enhance the quality of life for countless individuals.
Experiencing Hostility
The quest for recognition starts with the struggle for terminology: The medically accurate term is "gender incongruence" - the condition where one's perceived gender identity does not correspond with the assigned sex at birth. "Gender dysphoria" refers to the anxiety induced by this incongruence.
Bojunga's first interaction with a transgender person occurred around 20 years ago. "Before me stood a man in his mid-50s who had been the recipient of violence throughout his life and was on the brink of desperation. He admitted, 'Either I find help, or I'll commit suicide.'"
The hostility encountered by these individuals was starkly demonstrated earlier this year with derogatory graffiti targeting transgender and queer individuals discovered in the ambulance bathroom of the university clinic. Bojunga confirms that the hostility intensified and that the threshold for hate speech on social media platforms has deteriorated.
A Protracted Journey
Because no one can simply walk into the Markus Hospital for an operation or receive a hormone prescription overnight at the university clinic, approval from endocrinologists and psychologists is required first. Sometimes, hormone therapy serves as the only treatment, such as suppressing or stimulating breast growth, raising or lowering the voice, promoting or preventing beard growth. Occasionally, hormone therapy is the prelude to a more extensive journey.
The most popular procedure for both sexes involves the breast. Many transmen undergo mastectomies, while many transwomen opt for breast augmentation. "Often, it stops with this singular intervention," states Rieger. For the majority of trans people, transformation is mostly focused on their appearance to strangers. According to a study, 65% of 6,800 trans individuals had undergone hormone therapy, with 75% of transwomen and 84% of transmen choosing at least one operation.
Becoming a Woman
For individuals with a man's body who also choose genital alignment surgery, the procedure generally involves the following steps (simplified): The testicles are removed. The scrotum is transformed into labia. A prosthetic vaginal cavity is created in the abdominal region. The penis is hollowed out. The penis skin is turned inward - this becomes the vulva. The glans is converted into the clitoris.
Most nerves are preserved, as Morgenstern explains. A 2017 Canadian study found that over 80% of transwomen surveyed were able to achieve orgasm. However, there is a price to pay: After discharge, the "neovagina" must be dilated several times a day using a device to prevent shrinkage. Conversely, what if a woman's body is to become a man's?
The operation to construct a new penis - known in medical jargon as phalloplasty - is a more complex procedure. Doctors extract skin from the patient's forearm and tissue from the thigh. An erection cannot occur naturally, so an implant is inserted that the transman inflates before intercourse.
Complication Risk
The penis implant is a foreign body that the body may accept differently, Morgenstern notes. Even with a favorable outcome, an implant exchange may be necessary after a few years. The urethra also requires lengthening, which may involve rolled-up labia or other means. Transitions are high-risk areas for complications.
Compared to that, surgical implants for new testicles are generally straightforward. The manufactured penis isn't an exact copy of a natural one, as the surgeon explains, though the glans is reshaped a year following the initial operation to give the neopenis a more natural appearance. The patient then undergoes up to 20 post-operative check-ups. The majority of trans men who have undergone this procedure report experiencing orgasms.
Is it necessary, rational, or justified in specific instances?
Whether it's necessary, rational, or justified for an individual is a question Rieger doesn't have to answer. Before patients meet with him and Morgenstern, they need to submit psychological and psychiatric evaluations, have received at least half a year of hormone therapy, and have secured insurance coverage for the surgery's cost. A series of operations with six interventions can cost several tens of thousands of euros, according to Rieger. Patients who have undergone gender reassignment surgery at the Markus Hospital rarely regret it, Morgenstern says. "Even if there were numerous complications, the satisfaction level afterwards is extremely high - because it makes such a significant difference in their lives."
A meta-analysis of 27 studies involving a total of 7928 transgender patients discovered that only 1% regretted the gender reassignment surgery. "The patients are well aware of what they're getting into," says Rieger. "And they're prepared to embark on this journey."
What's changed with the increase in cases is the clientele: "The patients are getting younger," says Bojunga. Critics may view this as a negative development, but Bojunga sees it as a positive one: "They've had a shorter history of suffering."
Another development: In the past, more trans women were seeking the clinic - biological men with a female identity - but now more women who wish to identify as men are coming. A "persisting issue" for him is how to handle very young individuals. Puberty blockers, which delay the development into a man or woman, are controversial. Critics argue that they represent a premature decision for a young person.
Self-Determination Law
Since 2018, there has been a medical guideline for diagnosis, counseling, and treatment. However, there are significant variations between individual specialized centers in surgery. Now, a guideline for gender-affirming surgical procedures is being developed.
The new Working Group on Transgender Medicine intends to develop guidelines for the gender affirmation process and coordinate research projects. This is necessary because the number of scientific studies is currently limited. The topic is relatively new, so there is a lack of long-term data, such as the effects of long-term hormone use and why trans women have a higher suicide rate.
Starting in November, a new "Law on Self-Determination in Relation to the Gender Entry" is set to take effect, which was approved by the Bundestag in April 2024. It replaces the Transsexual Act of 1981, which the Federal Constitutional Court had deemed unconstitutional in several rulings. The new law aims to make it simpler for trans, intersex, and non-binary individuals to change their gender entry and first names. However, it does not cover regulations for gender-affirming medical procedures, as the Federal Ministry of Health emphasized.
The European Union, with its commitment to human rights, plays a crucial role in promoting inclusive policies for transgender individuals. Recognizing the importance of legal protections, EU members are urged to adopt the Self-Determination Law, such as the one set to take effect in Germany in November, to facilitate gender identity changes and name changes for transgender, intersex, and non-binary individuals.
In light of the rising number of gender reassignment surgeries and the increasing acceptance of transgender individuals, the European Union has the potential to influence other nations worldwide to adopt similar policies and legislation, ensuring equality and respect for all individuals, regardless of their gender identity.
