Pseudomales and Pseudofemales



General Surgery Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Main Subjects



Pseudomales and Pseudofemales



Raouf Sallam


          For centuries after centuries the newly born baby was designated to be either a male or female according to the features of its external genitalia. Now we know that such features are a reflection of its chromosomes which are double X in the female and XY in the male. Very rarely the external genitalia is a mixture of both or somehow deformed. This will need surgical correction to conform with the anatomy of the dominating features which reflects the chromosomes of the baby.

        We were created to be attracted to the other sex. So we are considered heterosexual. That is how the human race is maintained. If a person is attracted emotionally and sexually to a person or persons of the same sex he is considered homosexual.

        But in the last five decades things began to change, the word sex of the individual disappeared, we are now speaking of gender rather than sex. In the context of the type of the individual this change is of paramount importance, since sex implies choosing one of two choices while gender means choosing one of two or more choices.

       Another move was through the WHO. The WHO has a list of diseases, it contains all the diseases and illnesses that affect the human. In the past this list did not include homosexuality which then it was not considered a disease but an abnormal behavior. But the gender lobby group succeeded in getting the WHO to add homosexuality to the list. That meant that homosexuality is not a crime as it was considered in some countries and not a contemptible behavior either, it is a disease.

        But this was not enough for the homosexuals. So they again pressured the WHO to remove homosexuality from the list of diseases simply because, by then, it should be considered a normal behavior, a personal choice and a human right.

        In fact by then the word homosexual disappeared, a female homosexual is lesbian and a male homosexual is gay, and who does not want to be gay..?

        But of course the slippery slope does not stop except at the bottom. Some homosexuals, males and females would like to be heterosexuals sometimes, so a new group, the bisexuals, was created. Those who were helped to change their sex, unfortunately by members of the medical profession, form a group of their own, the transsexuals. But there is still yet another group, those who do not know what to do with their sexuality, the queers. As if the other groups are not queers. And to keep the door open for yet other groups they added + to their logo LGTBQ+. Significantly they chose the rainbow as their symbol.

        Recently they claimed that sexual orientation is a continuum with the male at one end and the female at the other end, with all other sexual preferences in the middle. I think putting the straight male and the straight female at the ends of the continuum and not at the center is deliberate as if they are the extremes.

       As a surgeon what is troubling me most are the interventions surgeons do to help a male be converted physically to a female and a female to be converted to a male. As soon as an adult male, or even an adolescent, with fully developed secondary sex characters says he feels like he is a female, he will find, in many countries of the world, surgeons who will convince him that he should be what he feels and it is possible surgically. He will be subjected to the following surgical operations: bilateral orchidectomy, amputation of the penis, keeping part of the dorsal skin to use it to form a clitoris and part of the ventral skin to be added to the skin of the scrotum to form a neovagina. Female hormones are given from the beginning liberally and continuously.

        The patient will be told that his neovagina will be short and non lubricated so he will have to use dilators and lubricants all the time. Some will find it easier to use anal sex. The patient is also consulted about the shape of the vulva he prefers. In case of the adult he is offered the option to save his sperms, before the orchidectomy, in case he wants to have children in the future.

        But what about the harsh male voice ? problem..a special laryngoplasty has been developed to narrow the vocal aperture and produce a more feminine voice. Now they have changed the external appearance....have they changed the chromosomes...of course no. Such a person is externally a deformed female while internally he is a male in every cell of his body camouflaged by female hormones.

        A pragmatist May say forget about the ethnics and indications, tell me about the results of gender affirming surgeries. Here what is known about the results:

= The long term results are not known, probably not studied yet.

= Gender dysphoria, which is the main indication for these surgeries, persist after the surgeries in most of the patients.

= There are about 50% complications, especially after laryngoplasty.

= A good number of patients regret and wish they can reverse what has been done, but of course what was done is irreversible.

= Among patients who completed the conversion there is a high rate of brutality and suicide.

        For female conversion to male, comparable operations are done, including mastectomies, oophorectomies, hysterectomies and phaloplasty. An adult female is offered the choice of freezing part of her removed ovaries for future use in case she wants to have children. Many of the patients are adolescents, the consent is obtained from the parents. The overall results and fate are similar to those of male conversion to female.

        We may think that the surgeons practicing this kind of surgery are working in the dark, but no they have now a big association with branches in USA, Australia, Canada and few other countries. They call their society and the surgeries they perform, gender affirming surgery, when obviously it is a sex deforming surgery. The person they have converted from a male to a female can pass as a female only in Halloween party, but in real life he remains a male ,a deformed male may be, simply because he is a male in every cell -remember the chromosomes. You cannot beat the biological sex.

What about the human rights of the person asking to change his sex?

       Individual rights of a human should be balanced against the rights of humanity itself.

We should remember the rights of the children, biological or adopted, of a transgender father or mother, also the rights of close relatives that will be affected by this change of sex

       We recognize that a person of certain biological sex may feel that he belongs to the other sex. This is an age long problem. But we know that feelings not supported by anatomical and/or physiological findings are just feelings that belong to the scope of psychiatry. In fact psychiatrists do deal with such patients with notable success.

        Surgery is an invasive intervention with definite side effects and potential complications. It is performed only when it will offer the patient a health benefit much greater than the expected side effects and there is no other means for achieving this. It is not done just because it can be done, and it is not done on the request of the patient unless this request is on the advise and recommendation of a surgeon. The approval of the patient is necessary. The consent of the parents on behalf of their child is controversial, many believe that it is only valid if the surgery cannot be delayed until the child is old enough to consent for himself, but many accept the consent of the parents for any kind of indicated procedure.

       One may ask why the numbers of persons requesting transgender surgery are increasing in the last few years? Few reasons are obvious, the activity of a very strong international lobby group for reasons not clear. Also creating what is offered as a solution, sex affirming surgery, plays on market principles which says if you create the service, the service will create the market. One very important medical reason, usually over looked, is the documented fact that gender dysphoria is contagious, adolescents are fond of imitation and experimentation and following the trend.

        Sex affirming surgery is not needed and not even remotely indicated. It transforms a purely psychological problem into a complex irreversible psychosomatic problem. It would rather be called a sex deforming intervention.

        Surgical societies all over the world should denounce such societies and boycott them and declare that what they are doing is not surgery. This should be done now before we are confronted in few decades with millions of pseudo males and pseudofemals with unwelcome and unnatural impact on their community and on the society as a whole.



Raouf Sallam FRCS

Professor of Surgery