“Spektrum.de”: You operate on people who want to adjust their bodies. How do you feel when a trans person comes to you?

Sebastian Dietrich: I have a lot of respect and admire their courage and will. Before I can help, the people have already had to do a lot and know that there is still a lot to do.

Sebastian Dietrich is a specialist in plastic and aesthetic surgery and a senior physician at the Ev. Elisabeth Clinic in Berlin.

How many surgeries take place each year?

Across Germany, it is assumed that more than 2000 people undergo gender reassignment surgery every year.

Around 400 times in 2021, patients had their bodies changed at our clinic at their own request. In 2018 there were still 200.

What are possible reasons for the increase?

Medical care has certainly improved. The crucial factor, however, is that social acceptance has increased. It is believed that more people than before dare to talk about their sexuality and then dare to undergo gender reassignment surgery.

What is certain is that the number of inpatients treated in Germany has increased 2.6 times since 2000.

A visit to a therapist or a psychologist is mandatory before you can have an operation. How so?

Above all, therapy should help those affected to cope better with the situation. They should have the certainty that they are actually trans and clarify whether the interventions make sense. Finally, there could be depression or a mental disorder that is the reason for the desire for change.

The patient must first deal with himself with professional help and be completely convinced that surgery is the best way for him.

The reports then officially confirm the condition. The letter gives surgeons the justification for the procedure. After all, as a doctor, I’m not allowed to do any harm, but I operate on organs on trans people that, strictly speaking, are healthy.

Once it has been determined that there is a high probability that the person’s condition will not change, I can begin. I discuss with the patient what is desired and what is surgically possible so that there is no disappointment afterwards.

For example?

Let’s take the change from woman to man. As a surgeon, my primary goal is for the person to be able to express their gender in a self-determined manner after the operation. This includes the fact that, in addition to the external, optical adjustment, functionality such as urination while standing or penetrative sexual intercourse is also possible.

But that doesn’t mean that this person has a penis that is biologically identical to one-to-one. Also, a surgically inserted penile prosthesis is not an equivalent substitute for a natural limb.

However, it makes no difference whether a biological male gets a penile prosthesis because he has erectile dysfunction or a trans male – both are similarly satisfied with the replacement.

How many surgeries does it take to turn a woman into a man and a man into a woman?

In our treatment plan there are seven steps for “woman to man”. In the case of “male to female” it is three.

Let’s start with “woman to man”: What are the seven steps?

We first remove the breast by performing a mastectomy. Then the uterus and ovaries are removed. This procedure is performed by gynecologists. We will then focus on the vaginal vestibule, labia and clitoris – i.e. the vulva.

It is also about preparing the penis. Among other things, we work part of the new urethra into the forearm. The penis can then be built up after six months at the earliest.

To do this, we cut out the prepared part of the urethra from the forearm, reshape it and connect it to the genital area. In addition to the soft tissues, nerves, arteries and veins must be connected so that blood can flow and the patient can feel something.

The intervention is only possible under a surgical microscope and with micro-instruments. The fifth step is followed by the testicular prostheses, implants made of silicone that – inserted under the skin – feel like real, healthy testicles.

This is followed by the penile prosthesis, thanks to which a penis can become stiff, and in the last, seventh step, the glans is formed in a foreskin plastic surgery.

That sounds very tiring and very painful.

Exhausting? Yes. In order to find themselves in the new role and to cope better with reactions from outsiders, some seek psychotherapeutic support, especially within the first year after adjustment. Because there are effective, safe medications, however, the pain is quickly overcome. Most importantly, you need time to recover from the surgeries.

Since there are at least three to six months between the individual interventions, the entire treatment takes at least two years.

What helps some to persevere is to know that patients rarely stop treatment, and 80 percent are actually happier afterwards.

Repeatedly in operating rooms for two years – how can you live everyday life at all during this time?

The majority of patients – especially those who change from woman to man – have the procedures carried out between the ages of 20 and 30 years. So most of them are in training, studying or working and have to take sick leave.

How long someone is absent after the operation depends on the job. Some take unpaid leave to relax. Still others deliberately leave more time between treatments than is theoretically necessary, so as not to be absent for too long at a time.

Trans women have it easier in this context. They said that in this case only three surgical steps are planned in the clinic. Which are they?

First of all, I would like to say that fewer steps does not mean that it is less complicated. However, the necessary changes can be bundled better. To turn a man’s body into a woman’s, I start with vaginoplasty.

This is an inversion of the penis and testicle skin. The supplying nerves and vessels remain intact, as does the urethra; it’s just shortened.

Surgeons form the neovagina between the bladder and rectum, the clitoris emerges from the glans and is positioned where it would also be found in a biological woman.

It is important that the trans woman then keeps the neovagina open with the help of a medical dildo – called a vaginal dilator – by inserting it and thereby counteracting a scarring constriction; for up to a year.

The next intervention follows after two to three months, in which we model the labia majora. Finally, we adjust the breast with the help of implants if growth is insufficient after 24 months of hormone therapy.

So it only works with hormone therapy?

Theoretically yes, but in practice it is often not even enough for cup size A. Breast surgery is therefore common. The breasts should look as natural as possible and fit the person.

Once the basic information has been discussed, we can – if the patient wishes – simulate the result three-dimensionally on the computer.

When is sex possible again? And what do you actually feel?

On average, you can have sex again six weeks after the operation. I am meticulous about preserving the nerves of both sexes during the operation. In the case of “woman to man”, for example, the clitoris is preserved and a clitoral nerve is connected to the skin nerve of the new penis so that the ability to have an orgasm is maintained and sexual stimulation is also possible via the new penis.

In “man to woman” we get the nerve of the glans. And – as surprising as it may be – after the procedure, the sexual experience is increased, the patients are happier, as various studies show.

This aligns with studies from psychology, according to which the likelihood of beneficial sex increases if you like your own body.

That’s right, everyone is like that. With trans people it just becomes particularly clear. One only has to imagine that trans men brutally bandage their breasts in order to conceal female sexual characteristics before the operation.

After the operation, I often hear that those affected are happy to finally be rid of their breasts. This is a physically noticeable pressure that can be relieved with an operation.

Not all patients want all procedures. Who stops when and why?

For some trans men, having the breast removed is enough. It is less common that they also want to have the female sex organs removed. There is an interim solution in which, after removal of the vaginal tube, uterus and ovaries, the clitoris is lengthened and slightly enlarged.

In addition, an extension of the urinary tract is achieved from the labia, so that at least a different position when urinating is possible. We speak colloquially of a Klitpen. The penis construction and the prosthesis are then not absolutely necessary, but can also be carried out later if necessary.

Overall, however, this intervention is relatively rare. The majority want full operational alignment. Since male-to-female conversion requires less intervention, most people have it all done.

what about the face

While women can take the hormone testosterone to get masculine traits, androgens and estrogens are significantly less effective in men. A pronounced forehead and the enlarged Adam’s apple can therefore only be insufficiently reduced with hormone therapy.

However, the health insurance companies decide in individual cases whether they will pay for it, which is why the number of facial feminisation procedures is manageable.

What if you can’t or don’t want to take the hormones?

Then, for example, the body hair may be thicker than desired. Or you still feel that your own voice is too high or too low for your biological gender.

While hormonal therapy works very well for trans men, it’s nearly impossible to make a male voice more feminine.

Does this require surgery on the vocal cords?

Possible, but not absolutely necessary. With a speech therapist, you can train very well to change the pitch of your voice. Both trans men and trans women.

For trans men, the goal is usually to strengthen their voice. In the case of trans women, the higher pitch and the position of the voice are crucial. There are singing and other exercises that ensure, for example, that the throat area shortens and narrows.

Phonosurgical interventions, in which the vocal cords are treated surgically, can only be offered if speech therapy does not succeed in changing the pitch of the voice.

Intensive interventions are required for gender reassignment, there is a lot of cutting, turning, and sewing. What are risks and side effects?

Wound healing disorders, secondary bleeding, wound infections and dying tissue are possible, as with any operation. Specifically, tissue loss can occur in both the new penis and the neovagina, which is serious but rare—an estimated one to two percent—and can be corrected with additional surgery in most cases.

In addition, scars can lead to a constriction in the urinary tract or the opposite: the urinary tract develops fistulas and thus connections to the skin, through which urine is then excreted.

How common is that?

Every second to third person develops these urinary tract complications in varying degrees. However, they usually heal after a long wait and regular check-ups. Only in a few cases does the problem have to be corrected operationally if it leads to significant restrictions.

And then there is a completely different side effect: the person in the mirror looks different than you have been used to for years, and the people around you also perceive the person differently.

Self-awareness changes. You may feel alienated at first and have to rediscover yourself – no matter how much you wished for the change.

A transition begins with the person themselves and usually remains a lifelong task, they say. Do you agree?

I only see the patients when they want an operation. That means they already have a diagnosis, are informed and determined to act because they are sure they can survive in everyday life with a new body.

From time to time there are patients who struggle with follow-up checks, but many who are grateful and relieved. This is also shown in studies: the quality of life increases, as does the desire for sex, one feels more than I am.

When the operation is complete, most of it is done. Mastering life afterwards is a lifelong task for everyone. It doesn’t matter if it’s cis, trans or something else.

The original of this post “Trans operations: “By the time I can help, people have already had to do a lot”” comes from Spektrum.de.