Text: Carole Extermann
Photo: Gilles weber

“A sex change doesn’t happen overnight”

Surgeon Olivier Bauquis specialises in gender change operations. He discusses the issues involved in these complex operations.

in vivo / What areas of the body are involved in sexual reassignment surgery?

Olivier Bauquis / Every body is different. In a transition, each person will more or less feel the need to adjust or remove physical characteristics of the gender they are leaving. The most frequent procedures focus on the breasts, with mastectomy for trans men and breast augmentation for trans women. If the use of hormones does not adequately transform the Adam’s apple, a procedure is available to reduce its size. We can also target the vocal cords surgically to change the pitch of the voice. The most complex operations concern the genitals, i.e. vaginoplasty, to construct a vagina in a trans woman, and phalloplasty, to create a penis in a trans man.

iv / What happens during these operations?

ob / This type of operation requires highly skilled technique in microsurgery, especially for phalloplasty. The challenge is to create an organ that is aesthetically appealing, with tactile and erogenous sensitivity and a functioning urethra. The penis is then constructed using the patient’s own flesh taken from the forearm or thigh. For erectile function, a hydraulic pump is built into the new genital organ. Unfortunately, this device is designed for cisgender people. So it is not exactly suitable, and that can cause problems. After the operation, the organ is the size of an ordinary penis, between 12 and 14 cm and can be used for penetration. To construct a vagina, we do the opposite and perform an inversion of penile skin. A skin graft may also be needed to complete the sex organ.

iv / Some of the people concerned by these procedures, or from activist transgender organisations, criticise the quality of operations in Switzerland and prefer to have the operation abroad. What do you think about that?

ob / The first question is about getting insurance coverage for the procedure. To my knowledge, insurance companies do not cover the cost of having surgery abroad, but in Switzerland, the operation is reimbursed by the basic national health insurance. Secondly, I’ve often heard that genital surgery on minors is common abroad. From what I hear at international conferences, I know the practice exists but is marginal. The only operations that are frequently performed on minors, both inside and outside Switzerland, are mastectomies, because they are less irreversible than genital operations.

iv / Do you think there are a lot of misconceptions about these operations?

ob / I think these operations are idealised. And that’s a problem that extends past transgender issues. There is a profound misunderstanding of what a vulva actually looks like, for example. Dissatisfaction with the result is sometimes due to this false image of female genitalia conveyed online and especially in pornography. Trans men generally accept their new penis more easily, because it is made clear from the outset that the result is not exactly equivalent to that of a cisgender man. That said, I’m sometimes asked for an organ that is much larger than average, as patients think that’s the norm. Also, operations also require a real follow-up, especially vaginoplasty. The neo-vagina requires extensive postoperative support. A sex change doesn’t happen overnight.

iv / Is it easier to perform these operations on a young body?

ob / A young person is usually in good health, and the skin often has greater elasticity than that of an older body, which makes the operation easier. However, I’ve noticed that mentally getting used to a new sex organ is easier between age 40 and 60. Even if you really want it, a sex change is still a shock. Surgery is not always the best option, especially as people can now change gender administratively, without an operation. However, it’s important to continue providing this procedure for those who feel they need it.

iv / How can we further improve the surgical treatment of transgender people in Switzerland?

ob / The doctors involved must perform these complex operations regularly. Plus, a holistic, multidisciplinary approach should be taken to patient care before and after the operation. It’s essential for me to feel supported by the organisation where I work. Performing this type of surgery is a huge responsibility. For operations on the genital organs, there’s no going back. /