Gender Reassignment

The process of gender change, or, more accurately, Gender-Affirming Care in current medical terminology, is a multidisciplinary journey of treatment and support undertaken to resolve the incongruence between an individual’s biological sex and the gender identity they perceive and experience. This process is not limited to surgical interventions but aims to transform the individual’s mental health, social life, hormone balance, and ultimately, physical appearance to achieve full alignment with their inner gender identity.

This blog post comprehensively covers this complex and intricate process, detailing everything from fundamental concepts to the most complex surgical procedures, legal prerequisites, and long-term risk management.

Conceptual Framework and Correct Terminology

To understand gender-affirming care, we must first correctly define the basic concepts. The language used in medical literature and ethical discussions must reflect the sensitivity of the topic and modern scientific understanding.

Gender Identity and Expression

Gender Identity: The gender a person deeply and internally perceives themselves to be (woman, man, non-binary, etc.). This does not have to be the same as a person’s sexual orientation (who they are attracted to) or their assigned biological sex. Gender identity is a subjective experience, independent of the biological sex assigned at birth.

Gender Expression: The external manifestation of a person’s gender identity. It is expressed through social markers such as clothing, hairstyle, behaviors, voice tone, and body language. Gender expression may or may not be consistent with gender identity.

Transgender: Describes individuals whose gender identity differs from the biological sex assigned at birth. While the term transsexual often (though not always) refers to individuals seeking medical and/or surgical intervention, transgender is a broader umbrella term.

What is Gender Dysphoria?

The fundamental medical necessity underlying gender-affirming care is Gender Dysphoria. The ICD-11 (International Classification of Diseases), published by the World Health Organization (WHO), and the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), published by the American Psychiatric Association, formally define this condition.

DSM-5 Definition (Gender Dysphoria): A condition marked by a significant incongruence between a person’s assigned gender and the gender they experience or express, causing clinically significant distress or impairment. It is treated not as a mental disorder but as a condition requiring significant clinical attention. Dysphoria is a profound source of distress that can lead to intense anxiety, depression, and suicidal ideation.

ICD-11 Definition: The WHO, in its 2019 ICD-11 publication, removed this condition from the mental disorders chapter and moved it to the Conditions Related to Sexual Health section, renaming it Gender Incongruence. This change emphasizes that being transgender is not a pathological state, but a health condition requiring medical care.

The intensity and focus of dysphoria can vary from person to person. Some experience dysphoria only from certain parts of their body (genitals, chest), while others may experience dysphoria from their voice, facial features, or social role expectations. The goal of treatment is to alleviate this dysphoric distress and create harmony between the individual’s internal identity and external self.

Why Is It Done? Medical and Ethical Necessity

Gender-affirming care is based on medical necessity, not a choice or a cosmetic desire.

The Impact of Dysphoria on Quality of Life

Untreated Gender Dysphoria leads to a series of serious health outcomes:

• High Rates of Depression and Anxiety: Transgender individuals experience significantly higher rates of depression and anxiety disorders compared to the general population.
• Suicide Attempts and Ideation: The distress caused by gender dysphoria is, unfortunately, one of the most significant risk factors for suicidal thoughts and attempts. Providing gender-affirming care has been scientifically proven to be the most effective method for reducing suicide rates.
• Poor Quality of Life: Dysphoria has detrimental effects on work/school performance, social relationships, and overall physical health. Treatment leads to marked improvement in these areas.

WPATH Standards of Care (SOC)

The World Professional Association for Transgender Health (WPATH) is the organization that sets global standards in this field. Their Standards of Care for the Health of Transgender and Gender Diverse People (SOC) serves as a guide for the ethical, safe, and effective delivery of treatment. The SOC defines gender-affirming care as a multidisciplinary process consisting of a series of stages.

Core Principles of SOC:

1. Informed Consent: It is essential that the individual fully understands the process and proceeds with their consent.
2. Multidisciplinary Team: The process must be managed by a team consisting of mental health professionals, endocrinologists, surgeons, and primary care providers.
3. Medical Necessity: All interventions must be documented as medically necessary for the purpose of alleviating Gender Dysphoria.

Stages of the Gender Transition Process (Standard Care Model)

The gender-affirming care process generally consists of sequential stages that progress at speeds unique to the individual.

1. Psychological Evaluation and Counselling

This forms the foundation of the process and is mandatory for legal procedures in many jurisdictions, including Turkey.

• Diagnosis and Evaluation: A mental health professional (clinical psychologist, psychiatrist) assesses the person’s gender identity, and the nature and severity of their dysphoria. The goal is to determine the persistence of the trans identity and the individual’s capacity to fully understand their treatment decisions.
• Management of Comorbid Conditions: It is important to manage co-occurring psychiatric conditions (depression, anxiety, substance abuse) before or during the start of affirmative care.
• Documentation of Support and Consent: In most jurisdictions (including Turkey), official reports from mental health professional(s) are required for hormone therapy and surgery, documenting the person’s dysphoria diagnosis and informed consent for the interventions.

2. Hormone Replacement Therapy (HRT)

HRT is the primary medical intervention used to align the body’s secondary sex characteristics with the person’s identity. It is typically started before irreversible surgical steps.

Male-to-Female (MtF / AMAB) HRT

• Goal: To suppress endogenous testosterone levels and raise estrogen levels to the typical female range.
• Medications Used: Estrogens (oral, transdermal, injectable) and Anti-androgens (Testosterone blockers such as Spironolactone, Cyproterone Acetate).
• Physical Changes:
  • Redistribution of body fat (towards hips and breasts).
  • Breast development (begins before Augmentation Mammoplasty surgery).
  • Skin softening and thinning.
  • Decrease in muscle mass.
  • Decrease in body hair growth (facial hair usually requires laser/electrolysis).
  • Changes in sexual function (decreased libido, loss of erections).
• Maximum Effect Duration: The most significant changes are usually seen within 2-5 years.

Female-to-Male (FtM / AFAB) HRT

• Goal: To raise testosterone levels to the typical male range as the dominant sex hormone and stop menstruation.
• Medications Used: Testosterone (injectable, transdermal gel/patch). Estrogen blockers are usually not necessary, as high testosterone naturally suppresses estrogen production.
• Physical Changes:
  • Deepening of the voice (An irreversible change).
  • Increase in body hair (growth of beard/mustache on the face).
  • Increase in muscle mass and redistribution of body fat (towards the abdomen).
  • Cessation of menstruation (usually within the first few months).
  • Clitoral growth (clitoromegaly – an irreversible change).
  • Oily skin and acne.
• Maximum Effect Duration: Voice deepening is rapid (within the first year), but body and facial hair development may take 5 years or longer.

3. Real-Life Experience (RLE)

RLE refers to the period during which the person takes on a full-time social role consistent with their inner gender identity. This stage is an important step towards surgery and demonstrates the individual’s ability to cope with their new social identity and test their support systems.

• Duration: In the past, RLE was often mandatory for 12 months before surgery. The current SOC (WPATH) recommends moving away from mandatory RLE and viewing it as the individual’s experience of social transition. However, in the legal process in Turkey, the person living in this identity before a court decision may be considered evidentiary.
• Scope: Includes changing the legal name to the social name, completely changing clothing style, and introducing oneself to the entire social environment (work, school, family) with the new gender identity.

Surgical Procedures (Gender-Affirming Surgeries)

Gender-affirming surgeries are complex procedures that align the body with the person’s identity, from superficial features (chest/breasts) to primary sexual organs (genital area). The legal process in Turkey mandates surgical alteration of the genital organs by court order.

Male-to-Female (MtF) Surgeries

Genital Reconstruction: Vaginoplasty

This is the most fundamental and irreversible surgical procedure. The goal is to create a vaginal canal, vulva, and clitoris-like structures using the tissues of the penis and scrotum.

• Penile Inversion Technique: The most common method. The penile skin is used to line the vaginal canal.
• Scrotal Grafts: Scrotal tissue is used to construct the labia structure that covers the entrance to the vagina.
• Glans Reconstruction: A clitoris-like structure is created from the nerve-rich tip of the penis.
• Maintenance: Regular dilation is mandatory for months after surgery to maintain successful vaginal depth.

Orchiectomy (Removal of Testicles)

A less invasive surgery that involves the removal of the testicles. This stops the body’s own testosterone production and reduces the need for anti-androgen use. It can often be done concurrently with vaginoplasty or performed as a standalone procedure.

Facial Feminization Surgery (FFS)

Encompasses a series of procedures to make facial features more feminine, specifically targeting differences in bone structure:

• Forehead Contouring: Reduction of the prominence of the brow ridge.
• Rhinoplasty: Making the nose smaller and more feminine.
• Jaw and Chin Contouring: Creating a narrower, V-shaped jawline.
• Tracheal Shave (Chondrolaryngoplasty): Reduction of the Adam’s apple.

Breast Augmentation (Augmentation Mammoplasty)

While HRT usually provides some breast development, breast augmentation surgery with silicone or saline implants is often performed to achieve a satisfactory size and shape.

Female-to-Male (FtM) Surgeries

Chest Surgery (Mastectomy – Top Surgery)

This is typically the first surgical step in the FtM transition and is crucial for addressing chest dysphoria. The goal is to remove breast tissue and excess skin to achieve a flat, masculine chest appearance.

• Double Incision Technique: Used when breast size is moderate or large. Tissue is removed through horizontal incisions along a straight line, and the nipples are reduced and repositioned (free graft).
• Periareolar/Keyhole Technique: Used when breast size is small and skin elasticity is good, using incisions around the nipple to leave less visible scarring.

Internal Surgery: Hysterectomy and Oophorectomy

The removal of the uterus, ovaries, and fallopian tubes.

• Rationale: To address uterine and ovarian dysphoria, permanently stop menstruation, and eliminate the potential risk of cancer (especially endometrial cancer). This surgery is mandatory before phalloplasty in some cases.

Genital Reconstruction: Phalloplasty and Metoidioplasty

These surgeries are generally more complex and multi-staged than MtF Vaginoplasty.

• Metoidioplasty: The creation of a small penis (micropenis) by freeing and reshaping the clitoris, which has enlarged due to the effect of testosterone. It is less invasive, provides more natural sensory preservation, but is limited in size. Urethral lengthening (extending the urethra to the tip of the penis) can be done with this procedure.
• Phalloplasty: The creation of a functional penis (neophallus) using a skin flap taken from another part of the body (typically the arm or thigh). This offers size and the possibility of penetration, but requires multiple stages of surgery, a longer recovery time, and scarring at the donor site.
  • Urethroplasty: Extending the urethra into the neophallus.
  • Scrotoplasty: Creation of the scrotum and placement of testicular prostheses.
  • Erection Implants: Placement of erection prostheses (pump or malleable rods) into the neophallus to allow for sexual intercourse.

Legal Procedures and Requirements (Situation in Turkey)

Legal recognition is as critical as the medical stages of gender-affirming care for an individual’s social integration and quality of life. In Turkey, this process is regulated by Article 40 of the Turkish Civil Code (TMK) No. 4721.

Legal Requirements (TMK Article 40)

According to TMK Article 40, a person must meet the following conditions and obtain a court order to legally change their gender registry:

1. Legal Capacity: Must have completed eighteen years of age (be an adult).
2. Unmarried Status: The Turkish Civil Code does not permit married individuals to undergo gender change.
3. Transsexual Nature: Must be documented by an official medical board report obtained from a training and research hospital. This report must prove that the person is permanently oriented towards the opposite sex, that the gender change is psychologically essential, and that they are permanently deprived of the ability to procreate.
4. Permanent Deprivation of Reproductive Capacity: The court will demand that the person be surgically deprived of reproductive capacity (testicles for MtF, ovaries and uterus for FtM) before granting surgical permission. This means that surgical procedures (orchiectomy, hysterectomy/oophorectomy) must be performed before or concurrently with genital reconstruction.

Court Process

• Application: The person applies to the Civil Court of First Instance requesting permission for gender change.
• Medical Board Report: The court refers the applicant to a hospital for an official medical board report documenting the above-mentioned conditions (especially transsexual nature and necessity). This report is typically prepared by a committee consisting of a psychiatrist, endocrinologist, plastic surgeon, and gynecologist.
• Surgical Permission: When the reports are positive and other legal conditions are met, the court issues its decision granting permission for the surgical interventions (surgical alteration of the genital organs).
• Surgical Intervention: With the permission order, the person completes the surgical procedures.
• Second Report and Identity Change: After the surgical procedures (genital reconstruction and deprivation of reproductive capacity) are completed, a second medical board report is submitted to the court to confirm the situation. When the court determines that the surgical change is complete, it orders the change of the gender entry in the population registry. After this stage, the person can obtain documents like ID and passport with their new legal gender.

Risks, Complications, and Long-Term Follow-up

While gender-affirming care improves the quality of life, it carries risks like any medical intervention and requires careful management.

Risks of Hormone Therapy

HRT can pose serious risks if not carefully monitored:

• MtF HRT Risks (Estrogen and Anti-androgens):
  • Thromboembolism: The greatest risk is blood clotting (deep vein thrombosis or pulmonary embolism). This risk increases particularly in those using oral estrogen, smokers, or individuals over 40. Transdermal estrogen can reduce this risk.
  • Hypertension and Cardiovascular Risk: High-dose estrogen can affect blood pressure.
  • Hyperprolactinemia: Increase in prolactin levels.
• FtM HRT Risks (Testosterone):
  • Polycythemia (Increased Red Blood Cells): Leads to thickening of the blood, increasing the risk of clotting. Managed with regular blood tests and blood donation if necessary.
  • Liver Function Impairment: Oral testosterone forms, in particular, can be toxic to the liver; injectable or gel forms are preferred.
  • Changes in Lipid Profile: HDL (good cholesterol) levels may decrease.

Surgical Complications and Need for Revision

Genital reconstruction surgeries are complex microsurgical procedures, meaning complication rates can be higher compared to other surgeries.

• Vaginoplasty Complications:
  • Stenosis (Narrowing): Narrowing of the vaginal canal. Neglecting regular dilation increases this risk.
  • Infection and Scarring Issues:
  • Fistula Formation: Abnormal connection between the rectum or urethra and the vaginal canal.
  • Insufficient Depth: Failure to achieve the desired vaginal depth.
• Phalloplasty Complications:
  • Urethral Complications: Narrowing (stricture) or urine leakage (fistula) of the urethral extension are the most common complications and often require multiple revisions.
  • Tissue Loss/Necrosis: Tissue loss due to insufficient blood supply to the flap.
  • Sensory Loss: Failure to achieve the desired level of sensory return in the constructed penis.

Need for Revision: Gender-affirming surgeries, especially Phalloplasty and Vaginoplasty, frequently require additional revision surgeries to optimize aesthetic or functional outcomes. Patients should be aware that the process is not limited to a single operation.

Long-Term Follow-up and Care

Gender-affirming care is not a one-time procedure but requires lifelong follow-up:

• Endocrinological Follow-up: Regular monitoring of hormone levels (estrogen/testosterone) and adjustment of dosages.
• Cancer Screenings: In FtM individuals, the risk of uterine and ovarian cancer persists if Hysterectomy/Oophorectomy has not been performed. In MtF individuals, the risk of prostate cancer (because prostate tissue remains) persists, and PSA monitoring may be necessary.
• Psychosocial Support: Continuous counselling and psychological support are vital for the social difficulties and adaptation issues of the transition process.
• Bone Health: The risk of osteoporosis increases if hormone levels are not kept sufficiently high (especially in post-op MtF and FtM individuals). Bone density measurements are important.

Conclusion and Emphasis on Inclusivity

Gender-affirming care is a medically necessary treatment pathway, proven by modern medicine for individuals experiencing Gender Dysphoria. This process fundamentally improves the individual’s physical and mental health, social functioning, and overall quality of life. Gender-affirming care is a personalized, multidisciplinary journey that includes psychological counselling, hormone therapy, legal recognition, and surgical options.

Before starting this process in Turkey, individuals must fully understand the legal procedures (court permission, requirement to be unmarried, mandatory deprivation of reproductive capacity) and work with a healthcare team experienced in this field. It is vital for society and healthcare systems to adopt an inclusive, respectful, and scientifically compliant approach so that trans individuals can achieve health and their full potential.