Surgical gender reassignment for male to
female transsexual people
The Wessex Institute for Health
Research and Development.
1998:1-25.
[Abstract] Full Text [PDF]
Introduction
To evaluate the long-term risks and
benefits of surgical gender reassignment for male to female transsexual
people.
Type of intervention
Treatment.
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.
Authors' conclusions
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.
CRD commentary
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.
