Specialists in the Medical & Psychological Aspects of Transgender Health Care 

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Eugene A. Schrang, M.D.

Of all the afflictions humankind must endure, Gender Dysphoria must certainly be one of the most unusual and distressing, and not because it produces great morbidity or mortality, but because the accompanying emotional conflicts can engender much unhappiness for the patient and her family with possible later problems involving her social activities and associations with colleagues at work.

The etiology of this condition is obscure but we are quite certain that the problem occurs in utero and is therefore Congenital in nature and not Genetic, that is, it is not something that is passed from generation to generation. Management and treatment are difficult since the mind’s gender is immutable. We cannot change a person’s gender no matter what we do; historically we know of no case where a mind changed spontaneously from Male to Female or vice versa. Compounding the problem are the varying degrees of severity which, from a practical point of view, simply means that Sex Reassignment Surgery is not for everyone. SRS is only for those individuals who have been diagnosed as transsexual, who have been properly screened and evaluated and who have fulfilled the basic requirements for the operation. A most important additional requirement is that burning desire - that great emotional strength to stay the course and proceed toward the final goal in spite of the many negative expressions another people. Without this deep motivation, a difficult and frustrating journey can easily become an impossible one.

It is well known that there are various methods of doing the transformation procedure as well as a variety of techniques involved with each one depending on the operating surgeon’s preferences and capabilities. Personally, I have always felt that, no matter what I am doing, the simplest method of doing things is usually the most beneficial and productive. I have never been’ impressed with complicated and unnecessarily involved operations. The less one does to accomplish the task, the better the final result, and so I have worked hard to make the SRS procedure as simple as possible. The inversion technique, which is essentially what I do, is an excellent operation and the final result is hard to surpass. In terms of ease of performance, lack of complications and patient satisfaction, penile inversion is the method of choice for most Male to Female transsexuals. Use of the Sigmoid Colon has been advocated and performed successfully by capable men, however, in my opinion the results do not justify the extensive surgery which involves another organ system and can result in such voluminous mucous flow that Kotex pads must be used almost continuously.

I have three objectives: First to bring to bear every Plastic Surgical technique which will result in a vulva which rivals the appearance of the genetic female. Unfortunately, this cannot be done with one operation since the blood supply to the area would be severely compromised. Thus, a Labiaplasty to enhance the femininity of the Perineum is done no sooner than three months after SRS in patients who desire it. On the other hand many individuals find the shape and form of the area is so pleasing that they accept it without having more surgery. During the Labiaplasty, the superior portions of the Labia Majora are brought together over the previously created clitoris utilizing a double Z-Plasty with an attempt being made to form a hood over the clitoris. If the patient feels her clitoris is too large, it can easily be revised smaller at this time. Because the clitoris is made from the same tissue as the urethra, there is an opening “connection” if you will - between the top of the urethral opening and the bottom of the neo-clitoral opening. It is this fistula that I open as part of the Labiaplasty which results in an area of very feminine looking mucous membrane rather than skin between the urethra and clitoris. Lastly, any other revision of the vulva such as reshaping the labia can be done along with ancillary operations of the face and breast.

Second, and most importantly, I want my patients to experience comfortable, effortless, trouble-free sexual intercourse. This can be accomplished only if the dimensions of the neo-vagina are adequate. If the neo-vagina is short or has strictures and stenosis making penetration uncomfortable, the operation was not successful. A number of surgical principles must be carefully adhered to if we wish the final result of the neo-vaginal construction to be one of adequate depth and accommodating size with no contractures. Obviously, the operating surgeon must make the neo-vagina sufficiently deep to satisfy the requirements for normal intercourse. The dissection is carried out within the very narrow confines between the Rectum and Prostate gland as far posteriorly as Denonvilliers’ Fascia which is virtually as far back as the intra-abdominal cavity. If this dissection is inadequate, the depth of the neo-vagina will be compromised; also, enough Levator Ani muscle must be divided for ample diameter. Assuming that all dimensions of the neo-vagina are satisfactory, the opening must now be lined with epithelium - but remember that a seven inch deep neo-vagina cannot be lined with a three inch penis and also keep in mind that it takes two inches of penile skin just to reach the opening of the neo-vagina. Obviously, if the penis is short with little skin to contribute to the job of lining the entire shaft, additional epithelium must be obtained utilizing a skin graft which is best obtained from the lower abdomen between the umbilicus and the pubic hair. Experience tells us that this is a better donor site area than the buttocks or thighs because from here the best quality grafts arc obtained, it is easier to hide the donor site scar and the grafts can be removed with greater facility than from anywhere else. Obviously, if a patient is not at all interested in future intimate relations, no graft is necessary and we simply accept whatever depth we can get which in some cases is virtually nothing.

If all this great effort is expended to create a functioning vagina but the patient does not experience warmth, excitement and orgasmic feeling in the operated area, I do not believe that we have achieved all that we could from the procedure; it is this sense of sexual fulfillment that is my third objective. The mind is truly the most important sexual organ but without proper nerve and blood supply to the reconstructed site, no amount of stimulation will arouse an area devoid of nerve supply. For this reason I make every effort to preserve all possible nerve tissue. The nerve of sex is the External Pudendal Nerve which caves the lower spinal cord and eventually passes through Alcock’s Canal where it branches out to supply the entire genital and peri-anal areas. By making sure that this nerve’s integrity is maintained and as many branches of the nerve are kept intact as possible, we can feel quite certain that the equipment necessary for orgasm is present and will function to the patient’s satisfaction. This brings us to the basic surgical principle which dictates that as much tissue as possible be preserved. The longer I do surgery - surgery of any kind - the less tissue I am inclined to sacrifice. At one time I removed most all of the Corpora cavernosa; this I no longer do because I have found that by saving enough Corpora to construct the neo-clitoris, we produce yet another source of pleasurable sensations. During sexual arousal, all erectile tissue in the genital area becomes engorged with blood, and it is this engorgement which causes some of the intense excitement experienced during intercourse. For this reason I construct the clitoris from the Corpora cavernosa rather than utilizing - as some surgeons have proposed - a small part of the glans penis, either as a skin graft or as an island Rap, preserved on a long neuro-vascular pedicle which usually does not survive anyway. I believe that the entire intact head of the penis serves a better function inside of the neo-vagina. At the conclusion of the operation, if all has gone technically well, we should have two - possibly three - potential sources of orgasmic sensation: the intravaginally positioned head of the penis, the Crus of the Corpora cavernosa on either side of the urethra and the clitoris constructed from the penile Corpora cavernosa and Corpus spongiosum.

So, to excel in the areas of aesthetics, function and pleasure is my surgical goal for the Transsexual patient. As the operation has developed in my hands, I have observed with great satisfaction the ability to routinely reproduce these objectives. Of course it is impossible to attain the same degree of success in everyone but only in those individuals who have anatomical, physiological (such as Diabetes) or psychological problems do we fail to realize the full potential of the procedure. Also to be considered are the expectations of the patient - in those whose expectations arc so high that they are unattainable, the outcome, as far as the patient is concerned, will be disappointing. My suggestion to anyone contemplating surgery of any kind would be to keep your expectations within reason - only then will you most likely find that your surgeon could do more for you than you ever thought possible.

Do things always go well? No, this world is too imperfect for that. Problems and complications do occur from time to time but fortunately not very often. Genetic males who take female hormones do run the risk of forming thrombotic emboli which could be fatal. By discontinuing the use of hormones three weeks prior to surgery and by assisting blood flow in the lower extremities with intermittent pressure stockings during the bed rest period after surgery, the likelihood of this dreaded eventuality is greatly reduced. The most feared intra-operative complication is, of course, the inadvertent entry into the Rectum while dissecting the neo-vagina. This could result in a Recto-vaginal fistula necessitating a colostomy with an eventual attempt made to repair the damage that was done. Should this happen, the neo-vagina is invariably lost to scar. Severe postoperative bleeding requiring blood transfusions or Gastro-intestinal ileus calling for the use of a naso-gastric tube to remove air from the stomach may occasionally be seen which requires our immediate attention. And certainly, less significant problems can arise to bedevil us. As healing progresses, contractures of the neo-vagina can occur and are usually due to lack of diligent neo-vaginal dilation the part of the patient. It is difficult to understand why anyone would neglect to dilate on a regular basis when it is so vital to the outcome of their surgery, especially after they have come so far, but it does happen. Substandard craftsmanship can result in a less than ideal cosmetic and functional outcome. I have examined and re-operated patients done elsewhere who have had objectionable swelling in the neo-urethral area from retained Bulbospongiosus and Ischiocavernosus muscles which should have been removed. Once this excessive muscle is excised, the area becomes comfortable with improvement in appearance as well. This retained muscle can also affect the urethra’s normal function. Patients will complain of the “sprinkling can’t effect which, incidentally, can also be caused by scar that is present around the neo-urethral orifice; scar and urethral deformity occur because the opening was not sutured properly to begin with. Great care must be utilized when suturing the urethral mucosa to the neourethral opening because it must be sutured internally - not externally. Attention to detail can make the difference between a superb result or one which will make a patient unhappy for the rest of her life.

The future for SRS is exciting. I see on the horizon a great deal of evolution and development - improvements in technique and the way the operations are done; for example, a great step forward will be a method to line the neo-vagina without the necessity for a skin graft. Clever and talented surgeons will come upon the scene and they will make sensational things happen.

The sources for genuine human happiness are many and diverse - it is my sincere hope that SRS in my hands has been, and will continue to be, a source of happiness for all who come to me as patients; and as far as l am concerned personally, the development of the SRS procedure is a never ending search for excellence which has been both an adventure and a great source of satisfaction.

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