CONCEPT OF SEX AND GENDER

In the English language, the terms "sex" and "gender" were considered synonymous until around 1950. However, during the same century, the concept of sexual orientation emerged, leading to a distinction between these two terms. The fundamental difference lies in "sex" being associated with an individual's physical attributes that generally do not change across societies, while "gender" pertains to the social roles, norms, and perceptions associated with that sex, which can vary across different cultures.

Sex and gender in modern society

Numerous definitions have been elaborated by various of organizations they provide a useful starting point for the discussion. The WHO defines the sex and gender as: the term sex refers to the different biological and physiological characteristics of males and females like reproductive organs chromosomes hormones etc. While the term gender refers to the socially constructed characteristics of women and men including expectations rolls and relationships within and between group of women and men. Well, there is another institute called European institute for gender equality it defines sex and gender as: sex can be referred to the physiological and biological traits that define humans as male or female. And gender can be referred to the social characteristics along with opportunities that come with being a female or male. While women's relationships with men, girls contact with boys and men's interaction with women are all referred to as having a particular gender.

According to another study, Sex generally refers to masculine and feminine, in human interpretation, male and female. The word sex is a purely biological term it clearly refers to declaring someone male or female with the special shape of the sexual organ a person with different sex organ will be called the opposite sex. While gender is actually a social and cultural term what position a person occupies in the society with his specific attitude duties and responsibilities and what is the nature of his bilateral relations with the society.

In another study, A person's sex is related to the organs and biological factors at birth. While gender is the general theory of how an individual should behave on the basis of biological sex. How they should dress and present themselves. What their roles and responsibilities should be in society?

Sex and Gender in Islam

In Islam, the concept of gender adheres to the principle that there are two distinct and separate genders. This perspective is based on the binary understanding of gender/sex. Thus, within Islamic jurisprudence, gender and sex are two distinct concepts and hold different meanings, without gradation. This viewpoint is widely accepted among Islamic scholars. This viewpoint is supported by religious scholars in the Islamic community. They agree that there are only two genders, and these genders do not have different levels or gradations.

The Quran mentions in various verses that Allah created humans as "male and female." This means there are two distinct genders, male and female. One example is from Surah An-Najm (Chapter 53) where Allah talks about the creation of males and females. This emphasizes that there are only two genders, without any middle ground. Even though the concept of intersex might be complex, within Islamic teachings, there is no third gender. Scholars have agreed that gender is either male or female, and any confusion regarding intersex individuals typically applies during childhood and becomes clearer as they grow up. This is because, in Islam, gender is based on specific signs associated with being male or female, and these signs become more apparent as one matures.

Overall, Islamic teachings emphasize that humans are created as male and female, and there is not a third gender. This is supported by verses in the Quran like Surah An-Nisa (Chapter 4), which talks about the creation of males and females and how they complement each other in pairs. Renowned scholars, like Malik, have explained that in the Quran, Allah mentions that humans are divided into two genders: male and female. There is no separate category for intersex. Since a person is human, they will be categorized as either male or female. They further explain that intersex individuals are not considered a separate gender. Instead, they fall into one of the two categories—male or female—based on the primary characteristics they possess. There is only “male” and “female" and do not consider the gender (sexual identity) which opposes the apparent and inner body structure. The holy Quran says: And that it is He Who has created the pairs, male and female.

The American jurist Shaykh Dr. Yasir Qadhi has described that according to modern society: gender is not the same as biological sex. In biological sex one can, be bone male or female, a boy, or a girl. But to be assigned male or female modern societies say it is from culture, society. While Islam rejected this and cleared that the fact is, there is boy and girl means there is male and female. And in Islam it is affirmed that the male and female are not the same. They are different physiologically they are different from the DNA. So, the Sharia has taken these differences into account and Sharia has come with gender not just with sex. Genders, male and female are not just imaginary but there are some roles like masculine and feminine. So, it is affirmed in Islam that there are two genders and these two genders are distinct and separate.

Then the sex and gender in the viewpoint of Islam is based only on male and female. And the case of Khuntha is another, they are also in view of Islam either male or female by looking with some methods. Here is the line of Fatawa Hindia (Hanafi school): “If he reaches puberty and has intercourse with his penis, then he is a man, and likewise if he does not have intercourse with his penis but his beards come out, then he is a man, and likewise if he has a wet dream as a man has a wet dream, or he has flat breasts. And if a breast appears to him like a woman’s breast, or milk comes in his breasts, or menses, or pregnancy, or it is possible to reach it from the vulva, then he is a woman, and if one of these signs does not appear, then he is a problematic hermaphrodite” (khuntha mushkil).

"فإن بلغ وجامع بذكره فهو رجل، وكذا إذا لم يجامع بذكره ولكن خرجت حليته فهو رجل، وكذا إذا احتلم كما يحتلم الرجل أو كان له ثدي مستو، ولو ظهر له ثدي كثدي المرأة أو نزل له لبن في ثدييه أو حاض أو حبل أو أمكن الوصول إليه من الفرج فهو امرأة، وإن لم تظهر إحدى هذه العلامات فهو خنثى مشكل، وكذا إذا تعارضت هذه المعالم"

Then we can say that, there is no option for a person to select the gender he likes. But one has to be satisfied with what he has given from Allah. The Quran and history both teach us that there are two genders: not only the Quran and history but also, we can understand this by logic, reasoning, history, common sense, all these tell us that mankind has been created from two genders and in two genders. Allah also said:” وبث منهما رجالا كثيرا ونساء” (and dispersed from both of them many men and women) from this two we spread forth multitudes of men and women and the Quran explicitly says:” وليس الذكر كالأنثى” The male is not like the female, and our beloved prophet Muhammed PBUH said: women are the complementary halves of men, they are not the same.In the pre-modern period there is some gender ambiguity in the society which can be seen through the figures such as Khasi, the Hijra, the Mukhannath, the Mutarajjul, the Khuntha. What do these all mean? Here is a short description about these five kinds of genders.

Types of Gender

1) Khasis: Eunuch: 

A person whose testicles have been removed to stop his sexual heat and efficacy. This is a special one that had male sex organ and developed as boys until they were castrated. However, their operation will not change them from male to female but let them in an in-between position. The absence of one or both testicles from the scrotum and their presence in the male pelvis is known as cryptorchidism. This is one of the most common birth defects affecting the male reproductive system.

2) Hijras: 

Hijras are people who were born with male sex organs and boobs but dress and look traditionally feminine, and after becoming adults, they assume a female identity. They remove their testicles and penises. many, but not all. They are known as the "third gender" (neither male nor female) in society. Hijda is a Hindustani word which is also romanized as hijira, hijda, hijada, hijara, and hijrah, and is pronounced [ˈɦɪdʒɽaː] .In 2014, it was estimated that around 3 million third gender people live in India alone.

3) Mukhannaths: 

The Mukhannath is a man whose moral or ethical movements are similar to women. And also, they wish and like to dress and act like females. Ibn Habib says: The Mukhannath is the feminine of men. The difference between the Mukhannath and the hermaphrodite (Khuntha) is that the Mukhannath has no hidden masculinity, whereas the hermaphrodite can only be determined by discerning the sign of masculinity or femininity in it. There are two types of Mukhannaths.

1. A person who was created in this way and did not bother about the manners, clothes, speech and behaviour of women, rather, he is a creature on whom Allah created him, then he would not be blamed, punished.
2. The person who is not like this by nature, but deliberately imitates women in words and actions, by his own choice, is the abominable who is cursed by the noble and authentic hadiths. The mukhannath is the man who dares to imitate women with words and actions, and he is sinful and cursed for it,

4) Mutharajjulat: 

They are women who imitate men with their words, clothing, and speech and act like them in their movements, deeds, and other things related to men.

5) Khunthas: (intersex individuals): 

Are the people who possess both male and female sex organs and genitals. There are two types of Khunthas as the Muslim jurists have distinguished them, the first group is that they have both sex organs but they are identified as either male or female they are called Al-Khuntha gair mushkil (unambiguous intersex). In the concept of Islam this group has a true gender or sex it is either male or female and it is determined with some physical signs. The second group of the Khuntha is Alkhuntha mushkil (ambiguous intersex) ; they cannot be determined as either male or female. The Khuntha mushkil is the indistinct hermaphrodite, i.e. the one whose masculinity or femininity is not clear with a mark that distinguishes him.

The lack of clarity of masculinity and femininity in the Khuntha Mushkil is due to two things: the first: the conflict of signs in a person who has the male and female both genitals, or the second is the absolute nullity of signs in a person who does not have one of the two that of a man and a woman, but only a title . Traditional Muslim scholars mostly use to identify the gender or the sex of Khunthas through some signs such as by which genitalia the Khuntha urinates. In the case in which both organs urinate then it will be considered which one urinates first. And by observing the facial hair and semen for males and the growth of breasts and blood of menstruation for females.

Signs of Trans Genders

• Vague natal genitalia
• Very small penis
• Clitoromegaly (an enlarged clitoris)
• Partial labial fusion
• Apparently undescended testes (which may turn out to be ovaries) in boys
• Labial or inguinal (groin) masses -- which may turn out to be testes -- in girls
• Hypospadias (the opening of the penis is somewhere other than at the tip; in females, the urethra (urine canal) opens into the vagina)
• Unusual appearing genitalia at birth
• Electrolyte abnormalities
• Delayed or absent puberty
• Unexpected changes at puberty.

UNDERSTANDING SEX REASSIGNMENT SURGERY

Sex reassignment surgery is an invasive surgical process where a surgeon operates on a person to change his or her gender. It involves a series of surgeries to change the primary and secondary sexual characteristics of a person to that of the gender that he/she aspires to be(desire). That will be the form of male to female or female to male (MTF or FTM) The term "sex change" refers to the process by which a person or animal changes sex identity. This occurs naturally in some animal species, but the term is more commonly used to refer to sex reassignment surgery.

Thanks to significant technological improvement, modern advanced surgical techniques, including sex reassignment surgery, are now accessible. This surgery has spread considerably across the countries. Sex Reassignment Surgery is a surgical process which is a kind of removal of sexual organs from the body of a man or woman. It is also known as gender reassignment surgery or sex change surgery or genital reconstruction surgery, which is a surgical procedure that changes a person’s sexual structure, in appearance and function, from man to woman, or woman to man. Depending on the original and intended gender, it is also known as "feminizing" or "masculinizing," "genitoplasty, penectomy or "vaginoplasty," "orchiectomy, metoidioplasty, or "phalloplasty." The definitions of the words mentioned will be written down in the following side headings.

The term can refer to male sexual characteristics being substituted for female sexual characteristics or vice versa. Male-to-female substitution is far more common because it is the easier of the two. Intersexual people may undergo some form of sex change, usually as children, in order to take on a clearly defined gender identity. Transsexual people are more likely to go through the process as adults. When a person's brain identifies with one gender (either male or female), but his or her body anatomy displays the sexual characteristics of the opposite gender, this is referred to as "transsexuality." This is known as gender identity disorder, and one way to treat it is to undergo the gender change process.

This is a very large and complex topic, and also a very controversial subject. Despite all these controversies, it is becoming more and more accepted that gender identity disorder is a medical birth condition that leads to confusion, depression, and frustration in individuals who are born with it.Using therapy or medical procedures to bring the body and brain back into agreement with each other often allows these individuals to lead fuller, happier lives. The researcher hopes that at the end of this research you have a fuller understanding of this topic, and a broader knowledge base on which to build your own opinions.

HISTORICAL DEVELOPMENT

Modern gender reassignment surgery first emerged in the 20th century, after rapid developments in endocrinology and plastic surgery following World War II made full medical and surgical therapies for transsexualism more widely accessible.

SRS in Non-Islamic Countries

The contemporary era of sex reassignment surgery began in 1952 when Paul Fogh-Andersen, a Danish plastic surgeon, lined Christine Jörgenson's neovagina with full thickness grafts made from penile skin. Christine Jorgenson was the first man who had been completely transformed into a woman. He had sex-change hormonal therapy and surgery in 1952 to convert from a man to a female.

When discussing transgender history, the first known sexual "reassignment" surgeries are frequently mentioned. Some will discuss Christine Jorgensen, the first trans celebrity in the West to receive a vaginoplasty in the 1950s, while others will go further back in time to discuss Lili Elbe's fatal womb transplant in 1932.

However, neither of these well-known figures were the first to undergo gender-affirming surgery. That honour is most likely held by another woman, whose name is known as Dora Richter, who was born in 1891 on a farm in the Erzgebirge, known as the Ore Mountains, at the boundary between Germany and the Czech Republic. There is no more information about her childhood except her dysphoria. Her parents eventually agreed to let her live as a girl because she insisted on her parents acting and behaving like females with her. When she was six years old, she tried to remove her penis with a tourniquet.(a thing which tighten sth)

Dora was 40 years old when she decided to have sex reassignments in 1931. The modern penile inversion procedure wasn't yet created, thus Dora's surgery was a simple and crude two-part procedure that started with a penectomy performed by Dr. Levy-Lenz and ended with the creation of a neovagina by Dr. Gohrbandt. The amazing success of Richter's vaginoplasty, as well as those of her colleagues and fellow workers at the Institute, brought other transgender people from around Europe to Berlin, including Lili Elbe. According to another research study, the researcher found that, in 1931, Abraham was the first to describe an intentional sex change operation in a transsexual patient; however, this was far from the first use of surgery to alleviate the agony of people suffering from irreversible gender dysphoria. (Edgerton 1974; Abraham 1931).

Things began to change in the United States in the late 1950s, when hundreds of transsexual people came under the care of Dr. Harry Benjamin, who was a compassionate endocrinologist, and was the first physician to explain the nature of gender dysphoria. Gender dysphoria is a feeling of unease or difficulty experienced by people whose gender identity differs from the sex to which they were born, indicating a mismatch between their biological sex and their gender identity. Hopkins Hospital was the first academic institution in the United States to perform sex reassignment surgeries in 1965. The procedures, now known as genital reconstruction surgery and sex realignment surgery. Hopkins became the model for other institutions as the first place in the country where doctors and researchers could learn about sex reassignment surgery. However, Hopkins stopped performing the surgeries in 1979 and never resumed them.

At the Johns Hopkins Medical Center's new gender identity clinic, surgeons began performing a very limited number of Male-to-Female (MTF) sex reassignment surgeries (SRS) in 1966. Shortly after, Stanford, Chicago, and Colorado hospitals followed suit. In the 1970s, the University Hospital of the Free University of Amsterdam rose to prominence as the premier facility in Europe for the medical and surgical treatment of patients with serious gender dysphoria. By the end of the 20th century, lots of centres of excellence were using a multidisciplinary strategy to treat transsexual people by offering cutting-edge treatments, including surgical treatments, for both transwomen and transmen. With the recent increase in the number of people seeking treatment for gender dysphoria, the number and quality of multidisciplinary teams have increased significantly around the world, with Thailand likely still performing the most vaginoplasties.

SRS in Germany

The very famous trans woman known as Lili Elbe is also another case from Germany. Lili Elbe was born as Einar Wegener in 1886 and was initially identified as a male. Her birth name was Einar Wegener, and she spent the majority of her life as a man. She was a successful artist as a man, but she gave up her career after undergoing sex reassignment surgery. Elbe travelled to Germany for sex reassignment surgery while living as Lili Elbe with her wife and lifelong companion Gerda Wegener, and had surgery and full-time transition in early 1930.

Lili Elbe underwent male to female sexual reassignment surgery for the first time in 1930. Unfortunately, she had problems during her transition, and after her fifth procedure, she passed away. Another two well-known patients who underwent this procedure were Christine Jorgensen and Renée Richards. Both women transitioned successfully and went on to become ardent supporters of transgender rights. Sexual reassignment therapy patients first receive hormone replacement medication before having any surgery.

• Alan L. Hart

Alan was born Alberta Lucille Hart in October of 1890 to parents, Edna and Albert Hart in Kansas. His father died in 1892 due to a typhoid outbreak. After the death of Alan's father, his mother emigrated with the two of them to Oregon, where her family lived. Alan was not interested in girlish things whether in acting, behaving or wearing attire like female whatsoever. He was strictly hating to do domestic homework like girls. Also he was preferring to play Civil War games. He was curious about sports such as football, rowing, hunting animals, tennis, and hiking. He always wished to be a male.

Alan's grandfather was a role model for him from a young age, and he would follow him around and listen to him talk about agriculture and politics. According to historian Peter Boag in the introduction to his book, Re-dressing America's Frontier, Alan L. Hart "always regarded herself as a boy, she early claimed that she would be one if only her family would permit her to cut her hair and wear trousers". During his medical studies, he began personal research into his own sexual and gender identity. He sought the legal advice of a physician named Allen Gilbert. Alan L. Hart seriously began his transition into living life entirely as a man, both physically and aesthetically, with Gilbert's assistance and help. Gilbert had removed Alan’s uterus in 1917.

At that time hysterectomy was considered as a full-sex change in history, which speaks to how gender was perceived medically. Alan was declared medically male after the removal of his female genital reproductive organs. Also, he changed his name from Hart to Alan, and for all time he changed his past identity, allowing him to pass as male full-time. On the contrary, Hart's history as a woman carried on to generate fear and discomfort in him and present challenges throughout his life and work.

SRS In Thailand

The first male-to-female sex reassignment surgery was carried out in Thailand in 1975 at the Chulalongkorn University Hospital (CUH) in Bangkok by doctors Preecha Tiewtranon and Prakob Thongpeaw. However, sex reassignment surgery is gaining a reputation for success, both domestically and internationally. In fact, as Thailand's medical tourism industry expands more and more, and lots of foreigners come to the country to undergo sex change operations. For the past 20 years, the Thai people have witnessed this medical tourism. Thailand is a well-liked medical tourism destination for sex reassignment surgeries. In Thailand sex reassignment surgery is typically performed on patients in their twenties, and at this age, the majority of patients have been on hormonal therapy for at least 5 years. Today, Thailand performs at least 2 or 3 operations on foreign patients each day.

SRS in Islamic Countries

As we know that SRS is a practice performed in this contemporary society firstly raised in the western country. Similarly, this practice emerged in the Islamic country. As firstly it was practiced in 1979 in the Iran, which is todays also considered one of the most Muslim populated countries.

SRS in Iran

Iran is an Islamic Republic with an Islamic government based on Islamic principles. Because of the Islamic nature of the Iranian government, Muslim scholars play an important role in determining how it operates. Transsexuality is now legal in Iran as a result of Shi’a Imam Khomeini's approval following the 1979 Iranian Islamic revolution. The controversial history of sex reassignment surgery in Iran is simply traced back to the 1979 Islamic Republic of Iran revolution; however, sex reassignment surgery is not new in Iran, However, these surgeries have been performed for many years before that Doctor Khalatbari performed the first sex reassignment surgery in Iran in 1930. He changed an 18-year-old young boy into a girl by undergoing sex reassignment surgery; this surgery became a hotly debated issue.

Despite these criticisms and debates, Iran remains a leading country in the provision of gender reassignment surgery. According to a 2019 study published in The Lancet, Iran performs more gender reassignment surgeries than any other country in the world except for Thailand. The study estimated that around 40,000 gender reassignment surgeries have been performed in Iran since the 1980s. Many influential jurists and Iranian authorities have supported the validity of this medical sex reassignment surgery after Khomeini. In 1980, the Iranian government provided financial and legal support for transsexual people.

By the 1970s, there was more talk about sex change surgery. According to a Kayhan report from October 11th, 1976, two hospitals in Tehran and Shiraz performed sex reassignment surgeries. According to data, four to six people out of every 100,000 are transsexual. In Iran, between 28,000 and 48,000 people are thought to be transgender patients. Male to female procedures account for approximately 74% of all procedures, while female to male procedures account for 26%. This indicates that the male to female ratio is higher than the female to male.

SRS in Pakistan

Out of 53 Muslim countries in the world; most of them are located in Central Asia which is very close to the Europe. It’s a reality that, this proximity has led to the rapid acceptance of western culture in these countries. one of these cultures sex reassignment surgery is, and know in Pakistan its tremendously rising and being accepted according to a survey.

The interior Minister of Pakistan presented to the Senate regarding applications from the people seeking gender reassignment surgery. In which he informed the upper house that 28,723 people had requested sex change surgery. According to the interior ministry, people who wish to change their gender do so for medical reasons. In total, 16,530 males applied for gender reassignment from men to women between 2018 and 2021, while 12,154 women requested gender reassignment from women to men. Likewise, nine men sought gender reassignment surgery from men to transgender, 21 transgender sought gender reassignment surgery from transgender to men, and nine transgender sought gender reassignment surgery from transgender to women.

A bill to alter the Transgender People (Protection of Rights) Act, 2018 was recently introduced in the Pakistani Senate by the Jamaat-i-Islami (JI) party. The Islamic movement favours having a medical panel rule on gender identity changes. The proposed legislation would make "gender reassignment surgeries or any other treatment to change genital features based on any psychological disorder or gender dysphoria" illegal.

SRS in Malaysia

Malaysia is an Islamic country with one of largest Muslim population. The country has a unique history with transgender people and gender reassignment surgery. Initially, sex reassignment surgery was available in Malaysia. However, in 1982, influential Islamic scholar prompted the National Fatwa Council of Malaysia to issue a fatwa prohibiting such sex reassignment surgery, following which Malaysian doctors no longer perform the sex reassignment surgery, despite the claim that the council's fatwas have no legal authority. Malaysian people who are male to female transgenders are known locally as "Mak Nyah". An estimate from the past suggested that there were between 10,000 and 20,000 of them there, with the majority being Malay Muslims.

SRS in Turkey

The far-right Nationalist Movement Party (MHP), an ally of Turkey’s ruling Justice and Development Party (AKP), is working on legislation that bans sex reassignment surgery except when medically necessary, a party official has announced. The party’s deputy chairman, Feti Yıldız, announced on Twitter that the MHP would soon submit a bill to the parliament banning sex reassignment surgery, aiming family protection. “Family is the foundation of Turkish society,” he tweeted, saying the bill will also introduce heavier penalties for child sex offenders and a ban on LGBT propaganda in addition to sex reassignment surgeries.

According to Turkish law, permission from a court is compulsory for sex reassignment surgeries, which can be performed at the age of 18 first. Courts require expert analyses in a medical report that must include the results of a psychiatric examination of the individual, who must be an adult, single and permanently un-reproductive before surgery. Although homosexuality was decriminalized by the Ottoman Empire, the predecessor of modern Turkey, in 1858, it is widely frowned upon by large segments of the society, including President Rejeb Tayyip Erdogan’s AKP, while same-sex couples are not legal. One minister previously referred to gay people as “deranged.” Last year, the government withdrew from the Istanbul Convention on protecting women’s rights, claiming it encouraged homosexuality and threatened the traditional family structure. Furthermore, after hosting over 100,000 people for a Gay Pride march in 2014, Istanbul has now banned similar rallies, citing security concerns. People who sought to rally have faced significant limitations, including arrest.

SRS in Saudi Arabia

Yasser Jamal, head of the Sex Correction Surgical Center at King Abdul-Aziz University Hospital in Saudi Arabia stated in 2018: Sharia has prohibited sex change for normal individuals; we only perform sex corrections here, and not sex change and only for people who biologically need it.

PROCESS OF REASSIGNMENT SURGERY

There are two types of medical intervention available for transsexuals depending on their desire to experience sex change: hormonal and surgical. Both hormonal and surgical are the major processes.

Hormonal Therapy

There are several types of hormone therapy for different purposes, including estrogen therapy, testosterone therapy, progesterone therapy, and combined hormone therapy. Each type of hormone therapy has its own unique benefits and risks, and is used to treat a specific set of conditions. Hormone therapy involves administering hormones to balance the levels of hormones in the body. It is used to treat a variety of medical conditions, including menopause, Hormone Replacement Therapy (HRT): A type of hormone therapy used to treat menopausal symptoms, endocrine disorders, and certain types of cancers. Hormones can be administered orally, transdermally (through the skin), or via injections.

Hormonal Therapy for Opposite Gender

Once the issue has been identified, the doctors begin hormone therapy, which involves replacing natural hormones with hormones from the opposite gender. Transsexual women will be given androgens, while men will be given oestrogen and progesterone. They play an important role in the development of secondary sex characteristics. Male secondary sex characteristics include the development of a beard, moustache, well-built muscles, and a sturdy Skelton. Female characteristics include breasts, a round figure, a smaller larynx, shorter vocal cords, the absence of facial hair, and definite anatomic features in the skeleton to aid in childbirth, among others.

Men will be given large doses of feminine hormones in order to dominate the effects of androgens. Similarly, testosterone, a male hormone, will be administered to women. Changes will be visible very quickly after this therapy begins. Neither moustaches nor the typical hair on a man's chest will grow any longer. The same effects will be seen in a female who is treated with androgens. The hair on the face will grow, and the body will take on a more masculine appearance. The size of the larynx and vocal cords cannot be changed with hormone therapy, voices of both genders will be slightly altered. A female converted to male will have a higher pitched voice than a male, and a man converted to woman will have a lower pitched voice than a woman. There are two major things to understand the sequence, those are: Primary Sex Characteristics and Secondary Sex Characteristics.

• Primary Sex Characteristics

The primary hormones are responsible for the development of secondary sexual traits. In Male and female have testosterone and estrogen, respectively. In addition to physical changes, secondary sexual characteristics such as hormone release within the body may cause changes in mental states. Also, there are two major things to understand, Primary Sex Characteristics Another one is Secondary Sex Characteristics. Despite the significant difference between primary and secondary sexual characteristics, people would not have considered it. Generally, the primary characteristics are the sexual organs, while secondary characteristics include sexual hormones and other related functions.

The Primary Sex Characteristics are defined as the reproductive organs in male or female organisms, which are typically discernible at birth. This would include the penis, scrotum, and the ability to make sperm that will contribute to the formation of a zygote in the male. This would include the uterus, vagina, fallopian tubes, clitoris, cervix, and the capacity to procreate it in a female. The primary sex organs differ from the secondary sex organs in that matter they create gametes, which are fully developed haploid germ cells that can be either male or female and combine to form zygotes during sexual reproduction.

• Secondary Sex Characteristics

In contrast to primary sex characteristics, the secondary sex characteristics are not present at birth and emerge throughout time as the subject ages and engages in sexual activity. Humans have prominent physical secondary traits such as vaginal hair, female breasts, lack of facial hair, shorter vocal cords, and in male pubic hair, facial hair, large muscle development, heavier skeleton, and deep voice. Only after puberty, do these changes occur. These traits include larger masculine muscles and larger female breasts.

SURGICAL PROCEDURES

Sex reassignment is usually preceded by a process of masculinization or feminization, which will be finalized through hormone replacement therapy. A two-year waiting period is required before undergoing gender reassignment surgery. This time range is outlined in the Standards of Care for the Health of Transsexual, Gender Nonconforming, and Transgender People or people who want to undergo sex reassignment surgery. Patients normally undergo hormone replacement therapy after going through sufficient counselling, and after living full-time in a particular gender, typically not less than 6 months.

When the hormone replacement therapy will be completed, the second phase of the treatment will be started which is called surgery. Sex reassignment surgery means all surgical procedures required on the genitals, face, and body to create a feminine or ornamental appearance. The patient has to get the certificate of two certified psychiatrists or psychologists that will certify the patient's suitability for surgery before the surgery is performed. After that, the surgeon will subject the patient to various tests, such as an HIV test, an obesity test, and an STDs (Sexually Transmitted Diseases) tests which are infections that can be passed on through sexual contact with a person who is infected. Even the surgery for sex change is not an easy task. Once a person has converted his sex genitals, he cannot return to his previous gender. Before undergoing surgery, medical experts establish the following criteria:

1. First and foremost, such a person must make contact with those who are undergoing or have completed the process of alteration. This will assist him in clarifying his thoughts regarding the outcome and expectations of hormonal and surgical treatment.
2. The patient must be at least 18 to 21 years old if the surgery results in sterilization. A person's decision to change his gender is one of the most difficult decisions he can make in life, due to the psychological, social, and legal implications it requires. Therefore, the motive for this conversion must be strong, as returning to the original gender is impossible, and the person must be determined and firm in making the decision that will change the way of his life. When such people asked about the reason for their transformation, most transgender people reveal and say that: "I am a female, but I am trapped in a male body," or "I am a male imprisoned in a female body," or "I am a male imprisoned in a female body," in other words, the mismatch between the sex assigned to him at birth and gender identity." This psychological condition is called gender identity disorder.

During this time, a person must maintain contact with his mental health specialists in order to assess the experience that occurred with him and the recommendations made to overcome the difficulties. It should be also noted that the process of sex reassignment surgery requires a psychiatric diagnosis and recommendation of the operation. Likewise, the surgery must follow the guidelines of the World Professional Association for Transgender Health (WPATH). The surgery is mainly divided into two sections:

First one is Male-to-Female conversion surgery, and second one is: Female-to-Male conversion surgery.

Male-to-Female Sex Reassignment Surgery

The male who wishes to convert to female must go through the following steps. In which the first integral step is Genital procedures: it consists of several operations like: (a)Vaginoplasty (b) Penectomy (c) Orchiectomy (d) labiaplasty (e) Clitoroplasty (f) Vulvoplasty.

These surgical procedures are usually performed concurrently and simultaneously. Some of them want to remove their testicles at first to reduce the amount of hormones they require. Some people simply remove them to see how the partial surgery goes before proceeding with the vaginoplasty. Others, on the other hand, only remove the penis and oppose vaginoplasty due to the health risks involved.

1. Vaginoplasty: it's a procedure to construct or repair the vagina. The main procedures in a vaginoplasty include an orchiectomy, penis amputation, neovaginal cavity creation, neovaginal cavity lining, rebuilding of the urethral meatus, and finally construction of the labia and clitoris.
2. Penectomy: the removal of the entire parts of the penis from the root including pelvic areas and testicles.
3. Orchiectomy: An orchiectomy is a surgical procedure to remove one or both testicles. Testacies, the male organ that produces sperm and testosterone. They are in a pouch known as the scrotum which will be removed, but the scrotal skin is not removed because it is used to make labia as well as a vaginal line. Orchiectomy can be carried out simultaneously with a vaginal reconstruction, or as a preliminary procedure before the vaginoplasty. A preliminary orchiectomy will not stop the possibility of a vaginoplast later on because the testicles can be accessible through a little incision at the raphe(chiri) that is only 5 cm long, leaving very little scar tissue.
4. labiaplasty: is also known as vulval surgery. A labiaplasty is surgery to reduce the size of the labia minora.It should not be performed on girls under the age of 18 because the labia continue to develop after puberty and into early adulthood.
5. Clitoroplasty: The goal of clitoroplasty is to reduce the size of the genital tubercle to give a feminine appearance. In the female, the genital tubercle will develop into the clitoris.
6. Vulvoplasty: The vagina is incomplete without the vulva (lips), which are made up of the labia majora (outer lips) and the labia minora (inner lips). Your vagina will appear as an unsightly opening without the vulva. If you choose to have vaginoplasty, you should also have vulvoplasty. The tissues from the penectomy and scrotum are used to construct the vulva in this procedure. After the above-mentioned internal surgeries, the stage of appearance changes. Some patients may wish to have other surgical procedures that are complementary to the operation of sex reassignment surgery such as: Breast Augmentation and Facial Feminization Surgery.

Breast Augmentation

At first, males are given oestrogen to help them grow breasts and nipples. The oestrogen can only grow the breasts in limit, but if someone wants larger breasts or to change the shape of their breasts, then the surgeon will begin by making an incision beneath the breasts, arms, and nipples, then positions the artificial breast above or below the chest muscles, and finally closes the incision. Other parts of the body, such as the face, nose, and chin will also be altered.

Facial Feminization Surgery

Facial feminization surgery refers to a variety of procedures that alter the shape of the face to make it appear more feminine. Examples include moving the hairline to create a smaller forehead, augmenting the lips and cheekbones, and reshaping and resizing the jaw and chin. The goal is to soften masculinized features and transform them into a more feminine shape. This surgery aims to feminize the face and includes a group of cosmetic surgeries Adjust the masculine facial features and make them more feminine, and this surgery can be a complement to sex reassignment surgery. This surgery has different types, including eyebrow lifting, lip augmentation, deceptive implants, jaw narrowing, larynx reduction.

Female-to-Male Sex Reassignment Surgery

The female to male SRS is a long procedure. Female-to-male (FTM) surgery is also known as "bottom surgery". This surgery is more difficult than the male to female surgery. The uterus and ovaries are removed by hysterectomy in the first stage. The clitoris is then formed, followed by the penis or phallus. The urethra, which transports urine, is also lengthened. It is accomplished through metoidioplasty. It should be noted that the small constructed penis is insufficient for sexual penetration and does not allow for urination while standing.

Surgery for a female to male may include vaginectomy, hysterectomy, subcutaneous mastectomy (SCM), reconstruction of the fixed part of the urethra (if isolated, metoidioplasty), scrotoplasty, phalloplasty, insertion of testicular prosthesis, However, SCM and phalloplasty are the two main surgical procedures in female to male SRS. If a female wishes to convert herself to male via sex reassignment surgery, she has to pass through the following surgeries:

There are mainly two kinds of surgery performed on the female genital organ:

• Metoidioplasty: 

The testosterone hormone is used in this procedure to enlarge the clitoris by four to five centimeters in order to create the penis. The penis lengthens and straightens as a result of testosterone-induced clitoral growth. To lower the clitoris into the position of the penis, the surgeon separates the enlarged clitoris from the labia minora and cuts the suspensory ligament. If urethral lengthening surgery is performed, the goal is to be able to urinate while standing. In most cases, this type of surgery does not allow for sexual intercourse (due to the absence of the glans).

• Phalloplasty: 

It is a surgical procedure to create an artificial penis for a woman. who wants to convert to the male sex or who lost his penis due to a traffic accident, cancer, or any other disease. The procedure involves removing large amounts of skin from the body. body parts such as the skin of the forearm, leg, or lower abdomen, and this skin is used in the penis is formed and positioned above the clitoris.

Also, there are other surgeries which will be performed during sex reassignment surgery from female to male. Such as:

Vaginectomy: 

Vaginectomy is a surgical procedure to remove all or part of the vagina. As part of sex reassignment surgery, some transgender men have vaginectomy. This procedure is usually performed before metoidioplasty or phalloplasty. There are three kinds of vaginectomy,

1. Partial vaginectomy, to remove the upper portion of the vagina.
2. Total vaginectomy, to remove the entire vagina.
3. Radical vaginectomy, which removes the entire vagina as well as the tissue around it.

Vulvectomy: 

it is a procedure of removing part of the vulva in which the entire vulva is removed (the inner and outer labia; sometimes the clitoris, too) as well as tissue just under the skin.

Hysterectomy: 

A hysterectomy is a surgical procedure that removes the uterus. After hysterectomy surgery, you can’t become pregnant and no longer menstruate.

Scrotoplasty: 

A scrotum surgery used in sex reassignment surgery to form new scrotums. Gender reassignment surgery often includes scrotoplasty with phalloplasty, or the creation of a penis. Transgender men may choose to get scrotoplasty as part of a gender affirmation (female-to-male) procedure.

Subcutaneous mastectomy (SCM): 

Subcutaneous mastectomy involves the removal of the entire breast with the exception of the nipple and areola. Although hormonal therapy has little effect on breast size, the first surgery performed in transmen is the creation of a male chest via SCM. This procedure enables the patient to function more comfortably in the male role.

Urethroplasty: 

Urethroplasty is a surgery on the urethra, which is part of the urinary system. The urethra is a tube that passes urine from the bladder to the outside of your body. Males and females have different urethras. It is longer in men than in women. It has a different position in both genders.

Facial Masculinization Surgery

In most aesthetic surgeries, patients want to improve their appearance while remaining true to themselves. The patient wishes to change his face to match his gender during facial masculinization surgery. For trans people, nothing is more essential than having an outward appearance that matches their insides. The male facial skeleton is larger, squarer, and more angulated, with sharp lines and a strong jaw. Facial masculinization procedures in transmen are far less common than facial feminization procedures in transwomen.

Douglas Ousterhout has published some articles on facial masculinization procedures in male patients, concluding that the areas generally to be considered in masculinization of the male face are the forehead, chin, and angle of the mandible. In addition, some other surgeries are required to give the appearance of a new gender as male. Breast, Rhinoplasty, and reduction of hair are included, along with the voice sound, buttocks, and facial surgeries. 

.    .    .

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