The act of fully adopting a new or evolving gender role for the events and processes of everyday life is known as the real-life experience. The real-life experience is essential in the transition process to the gender role that conforms with personal gender identity. Since changing one’s gender role has immediate profound personal and social consequences, the decision to do so should be preceded by a full awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences which represent external reality issues that must be confronted in order to successfully assume the new gender role. These factors can be quite different from the personal happiness stemming from the new gender role that is envisioned prior to the real-life experience. When clinicians assess the quality of a person’s real-life experience in the new gender role, the following abilities are estimated:

Surgical treatment for a person with a gender identity disorder is not merely another elective procedure. Typical elective procedures traditionally involve only a private mutually consenting contract between a suffering person and a technically competent surgeon. Surgeries for GID can be undertaken only after a comprehensive evaluation by a qualified mental health professional has been conducted. Surgery may then be performed once written documentation testifies that a comprehensive evaluation has been made and that the person has met the eligibility and readiness criteria. By following this procedure the mental health professional, the physician prescribing hormones, the surgeon, and the patient all share in the responsibility of taking the decision to make irreversible changes to the body. The patient who has decided to undergo genital or breast surgery, however, tends to view the surgery as the most important and effective treatment for correcting the underlying problem. Surgical procedures may include orchiectomy, penectomy, vaginoplasty, and augmenting mammaplasty. Vaginoplasty requires both skilled surgical procedure and competent postoperative treatment. Additive mastoplasty may be performed prior to vaginoplasty if the physician prescribing hormones and the surgeon have both attested that breast enlargement after undergoing hormonal treatment for 2 years is not sufficient for comfort in the social gender role. Other surgeries that may be performed to assist in feminization include: reduction thyroid chondroplasty, suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction, facelift, and blepharoplasty. Unlike genital reconstruction therapy, these surgeries do not require letters of recommendation from mental health professionals. Patients who elect this procedure should wait until all other surgeries requiring general anesthesia with intubation are completed in order to protect their vocal cords.

A male-to-female gender surgical reconversion can be performed using several different techniques; however, all of them share a few basic common surgical steps:

At present, the most widely used surgical techniques are:

After anesthesia is induced, the patient is placed in the lithotomy position. A vertical perineal incision is made from the base of the penis to the midline of the scrotum to a point situated 1 cm above the anal verge. The incision is extended through the subcutaneous tissue in order to expose the urethral corpus spongiosum and corpora cavernosa bilaterally. A bilateral orchidectomy is performed by dissecting and suturing both spermatic cords at the level of external inguinal rings. Once this is done, the proximal ends of these structures will then retract into the inguinal canal. Once this happens, the external inguinal ring is closed bilaterally so as to avoid future weakness that can lead to inguinal hernia. The next step is the penile degloving where the penis is stretched and two circumferential incisions through the penile skin are made; one at the base of the penis and the other distally immediately under the glans. The penile skin with the glans penis is severed from the corpus spongiosum and the corpora cavernosa. The glans remains with the penile skin tube (Fig. 2.1). Through sharp dissection the penile skin is then isolated from the shaft and then reverted and placed around a silicone vaginal mold. At the tip of the mold, the penile skin is closed with a running absorbable suture. This sutured end will become the apex of the neovagina. Following this step the corpus spongiosum is separated from the corpora cavernosa. The corpora cavernosa are cut in the midline, and hemostatic sutures are placed through the proximal base under the pubic ramus.

The section of each corpus cavernosum should be made as proximal as possible, and a limited amount of tissue should remain. A running absorbable suture is routinely performed on the residual erectile tissue in order to avoid painful erection during sexual arousal. The bulbospongiosus muscle is then severed, and the corpus spongiosum is mobilized. The central tendon of the perineum is incised, and a careful, blunt dissection is performed in order to create a wide space between the rectum and prostate where the neovagina will be placed (Fig. 2.2). The Denonvilliers fascia is then identified, and the blunt dissection continues through this avascular plane, transecting the medial fibers of the levator ani muscles in order to obtain an optimal depth. The inverted penile skin tube distended with the vaginal mold is placed in the perineal neocavity. When the patient wishes to have external sensitivity with the creation of a neoclitoris, only a quarter of the glans is left uncovered in order to form the clitoris, while three-quarters are de-epithelialized and placed subcutaneously to ensure a deep internal sensitivity. The base of the penile cylinder is fixed to the periosteum of the pubis by heavy nonabsorbable traction sutures. An elliptical 1.5 cm incision is then performed on the anterior wall of the neovagina by passing the adequately shortened urethra through this incision and suturing it with 4-0 absorbable sutures to the skin. The most posterior aspect of the skin tube is sutured to the posterior aspect of the initial incision. The sutures are continued laterally and frontally in order to form the labia majora. Finally, if necessary, cosmetic refinements can be made such as the reduction of excessive skin of the labia majora and the creation of a labia minora. At the conclusion of the procedure, a Foley catheter is inserted and a compressive dressing applied. The Foley catheter is removed after 5–7 days (Glenn 1980).