Dr SV Kotwal Senior Consultant Urologist
Human sexuality is indeed a very vast subject, one that has engaged biologists, doctors, jurists, sociologists and even priests and theologians since the beginnings of recorded history. Society as a whole has viewed sexuality in its many forms varyingly at different times. While ancient Greek and more particularly the Roman civilization was ‘liberal’ or ‘permissive’, there were periods of severe repression of all matters sexual whenever religious dogma prevailed. In fairly recent Victorian times it was considered prudent to clothe even piano legs so as to avoid prurient thought! Even today Taliban and its mores, and, closer at home, the puritanical attitudes of our own fundamentalists are only too well chronicled in the press to merit repetition.
In the animal world the sole purpose of the sexual act is procreation and this observation in the early times perhaps led to the strict assignment of gender roles as male and female in human society. Also, as the only purposeful sexual act in animals is heterosexual, this was considered the only appropriate sexual behaviour in humans. Man differs from his predecessors in having reasoning, intellect and imagination. Sexual intercourse is not only for procreation but for recreation too. Also, against the strictly oestrus- regulated coital occurence in the animal world, sexual activity amongst humans is very much more frequent.
There exists a very wide range of human sexual behaviour. Historically, only strictly heterosexual intercourse for procreative purposes had religious sanction and any deviation was regarded as sinful and punishable. With greater understanding, tolerance and indeed media coverage, societal attitudes have progressed from regarding such behaviour as a variant of normal rather than abnormal.
Just as the tv screen has taught us that there are many more colours than the ‘VIBGYOR’ we learnt in school, so also there are many shades of grey where sexual orientation is concerned. The true heterosexual individual stands at one end of the spectrum, the bisexual, the transvestite, the transsexual perhaps in the middle and the true homosexual at the other. Each sexual orientation is distinct, for example, the transvestite derives stimulation from the act of cross-dressing but will never think of undergoing sex change. The homosexual is a male attracted only to another male(he would never dream of changing his sex), while the transsexual individual is a male or female deeply unhappy in the body of the opposite sex and desires to be liberated from it
.It is most important to realize that these variants of sexual orientation are inborn and biological. They are not negotiable or correctible by coercion, punishment or aversion therapy.
A word about the Hijra or Kinnar clan that is widespread in our country. These are basically transsexual individuals from poor backgrounds who give up their families to join the group. Not all of them undergo castration. Castration when it is done, is performed crudely by quacks, often with opium as the only anaesthetic!. There is no counseling or hormonal treatment and no effort at genital reconstruction. These individuals band together and live by begging, dancing at functions and by prostitution.
The history of transsexualism is interesting. A German scientist, Dr Hirschfeld, himself gay, first described this entity in the 1920s. His research papers were later destroyed as they would have compromised many officials. Surgical correction for the condition was attempted sporadically but it was the synthesis of sex hormones in the 50s that made it meaningful. There is the tragic tale of a Danish painter Einar Wegenar who became the famous theatre personality Lili Elbe in the late 1930s and who died after her 5th operation which was an ovary transplant! The kindly Dr Harry Benjamin, an American endocrinologist, first coined the term transsexual in the 50s. Sex reassignment surgery was not permitted in the USA then and patients had to travel to Europe where surgeons like Dr Burou of Monaco did pioneering work. George Jorgenson became the celebrated Christine Jorgenson in 1952 and her ‘conversion’ was frontpaged by the New York Times. Much public interest followed and it is recorded that several wealthy men including the shipping magnate Aristotle Onassis sponsored deserving young men for such surgery and even kept them as mistresses thereafter. Dr Harry Benjamin’s seminal book, ‘The Transgender Phenomenon” was published in 1966 and even today is regarded as the basis of current understanding of the condition. In 1979 the Harry Benjamin International Gender Dysphoria Association laid down Standards of Care and these are followed worldwide.
The first step is to identify and diagnose Gender Dysphoria in a given individual. This is done by the psychiatrist or clinical psychologist who is really the first point of contact. Multiple sessions of assessment may be required. Parental interviews would be helpful but often these are not forthcoming. The Harry Benjamin criteria for selecting a patient for treatment are stringent and are designed to protect the interests of the patient as well as the treating team. Broadly they are as follows:
a) age of consent 18 yrs
b) mental stability
c) two separate independent psychiatric/psychological evaluations
d) real life experience of living in the gender role for at least 1 year
e) socio-economic stability
After the diagnosis is confirmed and the need for treatment established, the patient goes through a period of counseling therapy which usually takes three months. Appropriate hormonal therapy is now started under care of an endocrinologist. Concomitantly, cosmetic treatment such as laser removal of body hair etc is begun.
After a period of nearly a year and a half, the patient is finally taken up for surgery. Genital surgery in the male-to-female TS individual is usually completed in a single stage. While the earlier surgical techniques were unsatisfactory, it is now possible to get excellent cosmetic results, often indistinguishable from normal female genitalia. Of course there is no question of fertility in the patient. Further surgery is done as required to correct the chin, the nose and to augment the breasts (breast size also improves during hormonal treatment and augmentation is not always necessary). Voice training may be required and even laryngeal surgery to attain a female voice is now available. Femininity training courses are helpful. Hormonal treatment must continue though the dosage is lower.The aim is to fully rehabilitate the patient as a female in society.
Female-to-male sex reassignment surgery is much more difficult and is frequently done in stages. In the first stage breasts are removed, the uterus and ovaries are removed and the phallus is reconstructed, usually all this in one stage. There are many ways of doing the last part, all of them technically very challenging. The standard way of reconstructing the organ was by using forearm skin along with its blood and nerve supply but this is very tedious, difficult surgery requiring microsurgery and in addition there is severe disfigurement of the forearm which is difficult to conceal. Other ways are to use other forms of local flaps to construct the penis but this surgery is done in phases. The ultimate goal of functional genitalia is difficult to achieve.
The transsexual has throughout history suffered ridicule and persecution. Even as recently as half a century ago, Hitler had ordered the extermination of homosexuals, gypsies and jews, though not necessarily in that order. They have had to suffer physical torture including electro-convulsive therapy in a bid to ‘cure’ them of their ‘affliction’. In an emancipated society where everybody has a right to live according to their wishes, it time we learnt to treat them with compassion and dignity that is their due.