German Standards for the Treatment and Diagnostic Assessment of Transsexuals

Standards for Somatic Treatment

• Standards for Hormonal Therapy
• Standards for Sex Reassignment Surgery

Requirements for Surgery
Recommendations for Female to Male Sex Reassignment Surgery
Recommendations for Male to Female Sex Reassignment Surgery

Hormonal therapy and gender reassignment surgery before the 19th birthday is only to be recommended in exceptional cases and requires special justification.
  

Standards for Hormonal Therapy

• The professional recommendation for hormonal therapy as described in section 4.1 (Recommending Hormonal Therapy) is an absolute requirement. The effects of treatments of this nature are to some extent irreversible (a permanent deepening of the voice, facial hair growth, testicular atrophy). When hormonal therapy begins too early, it can complicate diagnosis and lead to a premature, detrimental commitment.
• The hormonal therapy’s introduction and regulation (frequency of controls) should be carried out by a doctor with endocrinological experience. A physical examination should be performed at the beginning of treatment which documents the patient’s condition. This helps determine, among other things, the therapy’s effects. In judging the patient’s current risk of thrombosis, a history of personal and familial thromboembolic events should be recorded; liver anamnesis should be collated and current liver function should be determined.
• The psychological compatibility of the hormonal therapy and it’s effects should be assessed along with long-term physical compatibility.

The effects of hormonal substitution must be explained to the patient. Since damage can occur as a result of hormonal deficits, he must be informed that the hormonal treatments must be continued for the rest of his life. A signed release of understanding and consent is recommended.
  

Requirements for Surgery

• The operating surgeon must be convinced that the diagnostic assessment which lead to professional recommendation is in accordance with the Standards (see section 4.2, Recommending Gender Reassignment Surgery).
• In each individual case, the operating surgeon should establish the technical feasibility of the operation through physical examination. Pre-existing genital defects are not grounds for rejection, but need to be integrated into the plan of operation.The operation’s feasibility must be grounded in comprehensive medical criteria.
• In all cases, a signed release of understanding and consent describing the respective Male to Female or Female to Male transsexual operation must precede the operation. In the release the method of threatment, its results, and possible complications must be explained in detail. A verbal clarification describing the operation and it’s irreversibility is also necessary. This clarification must include a discussion of the effects of gonadectomy and the necessity of long-term hormonal substitution.
    

Recommendations for Female to Male Sex Reassignment Surgery

The goal of Female to Male transsexual operations are varied:

• Breast surgery: with small breasts, a subcutaneous mastectomy with mammillary reduction. With large breasts, a mastectomy with free retransplantation of the reduced mammilaries.
• Hysterectomy with extirpation of the adnexa, with removal of the vagina (colpectomy) when desired.
• Operations on external genitals have not yet resulted in standards. Techniques on penis construction and the implantation of surrogate testes are still in a phase of technical development. Hence, individual solutions are called for.
    

Recommendations for Male to Female Sex Reassignment Surgery
The goals of Male to Female transsexual operations are the amputation of the penis and testes and the construction of a vulva, clitoris, and vagina.

As opposed to the female to male transsexuals, standard methods for the sex reassignment surgery can be recommended,

• The construction of a neovagina through the implantation of inverted penile skin. Attention must be paid that the vagina reaches sufficient depth (for example, through cutting Denonvilliers’ fascia) The patient must be informed that even good operative results require regular stretching of the vagina after the operation to retain functional ability.
• The neovagina should not be lined with penoscrotal flaps, as this method leads to a hairy flaps vagina.
• Due to dissatisfying results and increased risk with free skin grafts and pedicled rectosigmoid transplants, these should be used to line the neovagina only in cases where complications have arisen (particularly cases of shrinkage or insufficient depth).
• If hormonal therapy brings insufficient gynecomastia, then augmentation mammaplasty can be professionally recommended.
• Changes in the male distribution of hair follicles is only possible through the removal of the the hair’s root (depilation). For this reason, depilation is to be recommended in many cases, and can be started during hormonal therapy.

Other operational measures (for example rhinoplasty, facelifting, laryngoplasty or shortening the vocal cords) are often desired after the gender reassignment surgery, but are not considered standard.