The term “transsexual” was first introduced in 1966 by Harry Benjamin in “The Transsexual Phenomenon” [Ref. 1], in this text Benjamin proposed the following definition:
« True transsexuals feel that they belong to the other sex, they want to be and function as members of the opposite sex, not only to appear as such. For them, their sex organs, the primary as well as the secondary are disgusting deformities that must be changed by the surgeon’s knife. »
According to estimations [Ref. 5], one out of 100 000 women are currently suffering from gender dysphoria. The diagnosis is difficult because it is not based on scientific exams but only on clinical evaluation of female-to-male transsexuals patients.
Diagnosis of gender dysphoria is made by a psychiatrist according to the DSM 5 [Ref. 6] which is defined as following:
1. a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
2. a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
3. a strong desire for the primary and/or secondary sex characteristics of the other gender
4. a strong desire to be of the other gender
5. a strong desire to be treated as the other gender
6. a strong conviction that one has the typical feelings and reactions of the other gender
Once transsexualism is diagnosed, hormonal therapy is initiated and patients are followed by a multidisciplinary medical team composed of a psychiatrist, a surgeon and an endocrinologist.
During this preoperative phase, or even before getting access to hormone therapy, the patients are asked to live full time in their preferred gender role in order to demonstrate that they can function successfully as a member of the opposite gender in society.
Once all the criteria have been met and the psychiatrist gives his permission, the patients can contact to a plastic surgeon specialized in sex reassignment surgery.
Female-to-male transsexuals legislation in Switzerland
In Switzerland [Ref. 5] sex reassignment is completely covered by medical insurances if the following criteria are met: the operation is authorized by the psychiatrist, the operation will take place in a public hospital, the patient is older than 25 and has been treated for at least 2 years prior sex reassignment surgery.
The civil status and name correction will follow the phalloplasty procedure and will require a medical certificate by the surgeon responsible for the sex reassignment surgery.
Phalloplasty is an extraordinarily challenging operation and the goals are multiple and difficult to combine in a reproducible surgical technique. Ideally, penile reconstruction should be a single-stage operation that allows the construction of an aesthetically and functionally acceptable penis, including similarity of shape, skin texture and minimal scaring defects.
Functionally, the neo-phallus should enable the patient to void in a standing position, as well as allow tactile/erogenous sensation and rigidity allowing sexual intercourse.
This is probably the most demanding requirement when performing phalloplasty as there is no good substitute for the corpus cavernosus, the natural erectile tissue.
To obtain enough rigidity for penetration, two main techniques have been described. The first one uses a piece of autologous bone. The main drawbacks of this technique are the permanent erected look of the neo-phallus that could be a source of embarrassment for the patient and the risk of bone resorption, curving and fracture.
The second technique uses an inflatable prosthesis composed of 2 or 3 pieces. This technique requires the neo-phallus to be wide enough to tolerate the introduction of the inflatable cylinders. The tactile and pain sensation is also required to prevent complications as protrusion or perforation of the neo-phallus.