Many people come to Thailand for gender reassignment because, under existing Thai law, it is not necessary to comply with the Standards of Care (SOC) as set by the Harry Benjamin International Gender Foundation. While individual surgeons may set their own standards, including full compliance with the SOC, other surgeons may accept patients based on a single psychiatric referral asserting that the patient is diagnosed as transsexual, and is competent to understand the irreversible nature of surgery.
These rules can be a major benefit for transsexuals who, for various reasons, cannot meet the rigorous standards of the SOC, and who would otherwise be condemned to live their lives without proper treatment. Common problems include lack of money to pay for therapy, living in an area where there are no qualified therapists, or dealing with a therapist who is adamant about having the patient complete the Real Life Test – living in the desired gender role, at a time when the patient is unable to make a living. Unfortunately, bypassing the SOC can lead to people who are not true transsexuals obtaining surgery, to their ultimate regret – or, in some cases, true transsexuals who discover that other factors in life may be equally important to satisfaction and survival. While the overwhelming majority of persons who undergo gender reassignment are pleased with the long term outcome, this is because the majority of cases have been well diagnosed. If the diagnosis is not correct, or if the patient is unable to adjust to life in the desired gender, the results may be tragic.
Ideally, we recommend compliance with the Standards of Care, including obtaining the recommended two letters. If this is impossible, try to manage as many of these recommendations as you can, in order to assure that the diagnosis is correct:
1 – Have at least 6 months of therapy with a therapist who is qualified to perform a differential diagnosis. If you are truly transsexual, surgery is probably indicated. If you are a transvestite, the emotional impact of orchiectomy and penectomy may be devastating.
2 – Have at least 6 months of hormone therapy. Hormones help provide a differential diagnosis which is very valuable. While true transsexuals feel better while taking the hormones of their desired gender, others feel distresses, particularly at the loss of libido and the inability to achieve an erection. Keep in mind that hormones also lead to some degree of breast enlargement that will not go away after hormones are discontinued. Hormones should be used only under medical supervision, in part to monitor for safety (hormones have been associated with increased risk of heart attack and stroke) and in part to assure that the dose is adequate. Remember also that after SRS, it will be essential to continue hormone therapy for life.
3 – Cross dress for at least a month, even if it isn’t evident. This may be a problem for some, but it’s worth doing. If your normal shirt is heavy enough to hide a brassier, then wear a bra to work. Wear panty hose every day. A bra may be exciting to wear when you don’t have to wear it all the time, but it can also be uncomfortable. Panty hose will require you to sit down to urinate. Again, these are trivial annoyances, but they can help separate the TS from the TV.
4 – If you do cross dress, examine your wardrobe and your feelings. Do you routinely wear what might be considered fetish wear and find it sexually exciting – or are you most comfortable in jeans and flats?
There are other questions to ask yourself before you apply for surgery:
1 – Can I make a living as a woman? If not, consider obtaining new skills before you apply for surgery. It may be necessary to defer your dream until you can afford to make it a reality.
2 – Will my family reject me? Could you stand it if they did?
3 – Will my friends and neighbors reject me? Do you live in an area where you can make new friends among the GLBT community?
4 – What are your expectations both socially and sexually? If you anticipate being able to find an “admirer”, remember that these men are usually stimulated by the idea of a woman with a penis, and lose interest in post-ops. Many straight men don’t consider transsexuals to be women, and feel that being with a TS is equivalent to being gay.
Being TS is not a matter of choice. If you truly are transsexual, surgery is the most effective treatment. But before you present for surgery, be sure that it’s right for you, and that you’re prepared for the consequences.
Dr. Somsak Kunachakr is a board certified plastic surgeon specialising in cosmetic surgery procedures in Kasemrad Cosmetic Surgery Center, Bangkok, Thailand. His expertise includes facelift, rhinoplasty, tummy tuck, body lift, liposuction, sex change surgery and breast enhancement procedures, such as breast augmentation, breast lift and breast reduction.
