Worldwide some people believe with the firmest conviction that they are not what they appear. Born into the wrong body, they feel themselves to be a boy held hostage within a girl’s body, a girl within a boy’s body. When self-perception (gender identity) and body do not match, a person must adjust either their minds to their bodies or their bodies to their minds. For many, changing their body to fit their minds, a process requiring great effort and resources, is easier to achieve than the reverse. Perhaps this says everything about the strength of our minds and the power of our self-perception.

Specifically, what is required to align the body with the mind is sex reassignment surgery (SRS), where the genitals are transformed into those of the opposite sex. More than surgery, though, is necessary to achieve and maintain the alternate gender identity. In their standards of care, the World Professional Association for Transgender Health (WPATH) recommend one year of hormone treatment before SRS. Pre-operative hormone treatments tip a patient’s internal chemical balance in favor of the gender they aspire to be and, according to WPATH, it takes about two years before a patient achieves maximum results. While less obviously dramatic than surgery, hormones are crucial to the process of gender reassignment and some people argue they may be dangerous, even beyond the fact that their physical and medical effects are unknown (there is no published data from randomized clinical trials).

Hormonal Regret?

For instance, at least one regret-filled transsexual suggests pre-surgery hormones may be overly persuasive. As the only (known) case of someone who underwent both types of SRS, Charles Kane, formerly Sam Hashimi, offers a unique perspective on gender and some surprising insights. After divorcing his wife, this businessman and father of two began a phase of so-called experimentation with forays into a nightlife scene, which included many transsexuals. Fascinated by this alternative lifestyle, he made his original decision in 1997 to change his gender and become Samantha Kane. However, after seven years of living as a glamorous blonde (including a broken engagement to a successful businessman, much like her former self), Samantha decided she was not really a woman after all and had another surgery to turn herself back into a man, now known as Charles Kane.

According to Kane, he felt Samantha, his female identity, was simply playing a part, and she would never feel like (or be accepted as) a real woman. Worse, Kane feels he made the decision hastily under the influence of the female hormones, which he feels “pushed him” into the surgery. “I don’t think there’s anyone born transsexual. Areas of their human brain get altered by female hormones,” Kane told Nightline. “It really is like brain washing someone into a way of life.”

As intriguing as Kane’s insights may be, he does not appear to be representative when viewed in light of a recent Swedish study. Looking at SRS over a 50-year period ending in 2010, the researchers found a “2.2 percent regret rate for both sexes,” according to the authors, who also noted “a significant decline of regrets over the time period.” Overall, in Sweden, a total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. and of these 89 percent, comprised of 252 female-to-male transitions (FM) and 429 male-to-female transitions (MF) underwent the procedures. If in Sweden, most transsexuals do not regret their transformation. In all likelihood, they may not feel their hormone treatments pushed them into surgery.

How Many Surgeries Are Performed Each Year?

The long-term implications of transsexual surgeries may be difficult to grasp on a global basis. One reason is it is nearly impossible to calculate the number of SRSes performed each year, since private facilities are not subject to reporting requirements. Nevertheless, the Surgery Encyclopedia estimates the number of gender reassignment procedures conducted in the United States each year at between 100 and 500, while the global number may be two to five times larger than that, and these figures include surgeries performed on children born with intersex genitalia. However, in a more recent report, Lynn Conway suggests surgeons perform between 800 and 1,000 MF operations each year — it is unclear whether Conway includes surgeries performed on intersex children — with as many or more performed on American patients overseas.

In Thailand, sometimes referred to as the gender reassignment capital of the world, SRSes allegedly cost about one-third the price of those performed in the U.S. Meanwhile, the hormones necessary for transitioning are sold, like aspirin and NyQuil, as over-the-counter medications. Many believe Thailand has one of the largest transgender populations in the world and, concurrently, one of the most accepting cultures. Unlike most Western countries, which pathologize the condition as gender identity disorder (GID), or gender dysphoria, Thailand shows tolerance for a wider range of gender identity, including the effeminate men referred to as kathoey.

However, in 2009, Thailand began to require two psychological evaluations and a one-year waiting period for patients wishing to undergo sex reassignment surgery in accordance with the guidelines issued by WPATH. In keeping with Thai culture, though, these rules often may go unenforced, especially for the medical tourists arriving from America, Europe, Japan, Australia, and the Middle East for less expensive surgeries.

One of the premier sex reassignment surgery centers in Bangkok, Preecha Aesthetic Institute (PAI) indicates on its website that it has performed 4,259 plastic and reconstructive surgery operations for MF reassignment. Worldwide, MF surgeries are more common than FM surgeries as female to male surgery is less successful for two reasons. According to the Surgery Encyclopedia, construction of a penis is not feasible less than a year after the surgery to remove the female organs, plus, it is difficult to create a functioning penis from much more limited clitoral tissue.

This YouTube video discusses the techniques of MF transition:

By comparison, this YouTube video reveals the surgeries for a transition from female to male:

While the surgery from male to female may be easier, the resulting lifestyle of those who transition may be more difficult (though not for the reasons suggested by Kane). In this article, a sociologist who has interviewed dozens of transmen (FM transsexuals) notes how many believe they are taken more seriously in their careers now that they are men. By contrast, Joan Roughgarden, a biologist who transitioned in the opposite direction, suggests the opposite effect may have occurred in her life. Judging from personal experience, she now believes “men are assumed to be competent until proven otherwise, whereas a woman is assumed to be incompetent until she proves otherwise.” Gender identity may be more fluid today due to SRS and hormones, but in many ways it remains very much a solid trait, with the power to influence our daily experience of life.