Zusammenfassung
1965 präsentierte das John Hopkins Hospital in Baltimore/ USA als erste Klinik ein “Gender Identy Program”. Seitdem entstanden Zentren in vielen Ländern. Ebenso wurden Transsexuellen-Gesetze erlassen, wobei bis heute nur wenige gesetzliche Vorgaben bestehen. Dennoch hat sich in Deutschland ein Vorgehen entwickelt, welches den Betroffenen als Leitfaden dienen kann. Zunächst wird im Rahmen einer psychologischen Betreuung die Diagnose Transsexualität – die dauerhafte Gewissheit, sich dem anderen als dem angeborenen Geschlecht zugehörig zu fühlen – gestellt. In einem Alltagstest lebt die betroffene Person in der angestrebten Rolle, um einzuschätzen, wie die eigenen Vorstellungen in der Realität umgesetzt werden können. Parallel wird eine gegengeschlechtliche Hormontherapie eingeleitet. In der Regel erfolgt dann die Namensänderung (TSG §§ 1–7), anschließend operative Maßnahmen der Geschlechtsangleichung (TSG §§ 8–12). Sowohl für die Namensänderung als auch für die Operation sind Gutachten erforderlich. Erst nach operativen geschlechtsangleichenden Maßnahmen, die zur dauerhaften Fortpflanzungsunfähigkeit geführt haben müssen, ist die Personenstandsänderung möglich. Während die Geschlechtsangleichung von Mann zu Frau heute nahezu standardisiert ist und zu kosmetisch wie funktionell perfekten Ergebnissen führt, ist dies bei der Operation von Frau zu Mann nur eingeschränkt der Fall. Die aktuellen Methoden werden beschrieben.

Summary
In 1965 the John Hopkins Hospital in Baltimore/USA was the first clinic which presented a gender identy program. Since then many centers all over the world were founded. Although laws with regard to transsexualism have been enacted, only a few regulatory rules exist. Thus, in Germany procedures have been developed, which could serve as a guideline. As a first step all individuals undergoe a psychological therapy during which the diagnosis of transsexualism—the continuous certainty to belong to the other than the congenital sex—is confirmed. In a real-life test the patient experiences the new gender role in everyday life to evaluate how the image of this role can be translated into reality. Concurrent cross-sex hormonal treatment is initiated. Normally the next step is the change of the first name (TSG §§ 1–7), then genital surgery is performed (TSG §§ 8–12). Both proceedings require expert opinions. Only after surgery, which must have resulted in continuous infertility, the registered gender within the certification of birth can be changed. While sex reassignment surgery from male to female is nearly standardized today and allows perfect cosmetic and functional results, female to male surgery has limited success. Current procedures of sex reassignment surgery are described.

Stichworte
Transsexualität, Transsexuellengesetz, Geschlechtsangleichung

Keywords
Transsexuality, law of transsexualism, sex reassignment surgery

Objective To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results.

Patients and methods From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds.

Results Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse.

Conclusion Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Objective To assess, in a long-term follow-up, female patients with congenital adrenal hyperplasia (CAH), with special emphasis on vaginal functional outcome and sexual activity after vaginoplasty.

Patients and methods Twenty-seven patients with CAH (aged 14–33 years; six Prader grade II, 14 grade III, six grade IV and one grade V) underwent surgery between 1972 and 1988. Three of the patients underwent clitoridectomy, 24 clitoroplasty and 25 vaginoplasty (24 with a Fortunoff flap and one a ‘pull-through’ procedure). In 20 patients the vaginoplasty was a one-stage procedure, undertaken at a mean (range) age of 3.6 (1–9) years, and in five patients a two-stage operation. The analysis was based on the patients’ history and examination; the patients also completed a questionnaire, including a psychological profile.

Results Nine of the 25 patients (36%) who underwent vaginoplasty developed intravaginal stenosis; of these nine, six were Prader grade III and three grade IV. All had undergone a single-stage procedure at a mean (range) age of 4.7 (2–9) years. Of the 16 patients who answered the questionnaire, 14 had problems with their overall body image; patients in whom vaginal stenosis was corrected were particularly anxious about sexual intercourse and had problems with orgasm.

Conclusion The main problem during the long-term follow-up was intravaginal stenosis; all the affected patients had undergone a single-stage procedure early in life to correct ambiguous genitalia. This high rate of vaginal stenosis suggests that vaginoplasty should be undertaken at the beginning of puberty, because higher oestrogen levels may prevent stenosis and, if necessary, dilatation can be performed by the patient. These data also underscore the importance of psychological support in the treatment of children with CAH.