Time for a Change – Gender Reassignment

I still remember him plainly: middle-aged, married, paunchy around the middle. He didn’t come in to the clinic because he was sick or had a chronic medical illness. He came in because he wanted to be a woman.

Gender reassignment was not something I had learned about in medical school. It was mentioned in passing, but there were no lectures about how to correctly dose estrogen for the male-to-female transsexual. I frankly had no idea what to do. I think my surprise and confusion were apparent, as the man blushed a little and suggested that I might want to refer him to a specialist.

Chastity Bono’s recent announcement that she will be transitioning from female to male reminded me anew what a deeply personal and difficult decision gender reassignment is. Medically, it’s complicated as well. Before even embarking on the anatomically-altering regimen, a great deal of therapy is recommended, as well as a “test run” living as the desired gender. Following that, hormones are begun. The regimen for a woman becoming a man is relatively straightforward: testosterone shots once every twelve weeks. Such a regimen produces increased facial hair, body mass index, a deeper voice, and enlargement of the clitoris, sometimes to the degree that intercourse is possible without surgery. It can have adverse effects on serum triglycerides and may cause acne.

A man wanting to become a woman faces a bit more complicated hormonal regimen, as not only does estrogen need to be added, but testosterone needs to be suppressed. Surgery to remove the testicles will obviate the latter, but is not a procedure that some are willing to undergo right away. This hormonal one-two punch will result in breast growth, increased subcutaneous fat, some decrease in upper body strength, and atrophy of both the testicles and prostate. Facial hair growth and voice depth will not change appreciably, however, and usually require additional procedures to mitigate.

The ultimate step in sexual reassignment is surgery. The most common type of surgery involves the removal of sex-specific organs; beyond that is genital reconstruction, which is significantly more complicated. After the entire process is completed, only 1 to 2 percent of postsurgical transsexuals experience regret.

As for my patient, I never saw him again after I referred him to another physician. Hopefully he is now a she, and is living a happy and fulfilling life.


Benjamin H. International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, Sixth Version. February 2001.

Lawrence, A. (2003). Factors associated with satisfaction or regret following male-to-female sex reassignment surgery Archives of Sexual Behavior, 32 (4), 299-315 DOI: 10.1023/A:1024086814364

T. A. McNamee, MD

T. A. McNamee, MD, is an associate professor and internal medicine residency program director at Sanford School of Medicine of the University of South Dakota.
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