PROTOCOLS Suporn Clinic

 

Surgery Protocols

 

General

As a general rule, we tend only to schedule patients for surgery where they require sufficient surgical procedures to warrant a full hospital operation under general anesthetic. This may be either SRS, a full FFS surgery, or by combining minor FFS procedures (decided on a patient-by-patient basis) at the same time as the patient is undertaking SRS and/or AM. Because of the time that would be needed under general anesthetic and consequent risk to the patient Dr Suporn will not perform full FFS on a patient in the same operation as SRS. In this context, "full FFS" means undertaking more than one of the 4 main group surgical packages outlined under "ffs procedures".

For a guideline to the time required for the surgery, and the recovery time spent in hospital please see our scheduling table

Due to the long duration under which patients are under general anesthesia, all patients are advised to have a full medical check-up to confirm that they are physically fit, of healthy weight, and are strong enough to be under general anesthesia for a period upwards of about 5-1/2 hours for SRS. In our experience, Dr Suporn's patients require about twice the duration of total recovery period (3 to 4 months) compared with having SRS elsewhere. All SRS patients must stay at least 24 days and preferably 30 days in Thailand to ensure proper recovery under the care of the Clinic staff.

 

Minimum Psychosocial requirements for Patients Scheduling SRS:

It is not Dr. Suporn's policy to deny SRS surgery to any patient he believes to be medically and psychologically fit to undergo it. As far as is considered reasonable, The Suporn Clinic follows the guidelines of the Harry Benjamin Gender Identity Disorder Standards of Care (HBGIDSOC). Additionally, we always comply with the Medical standards of Thailand. We require patients to provide written evidence that they meet the following criteria:

SRS Patients

With effect from 29 November 2009, new regulations issued by the Thai Medical Council regarding SRS patients come into force.

ALL patients undergoing SRS MUST provide an original, signed document from a qualified psychiatrist or psychosexual specialist, confirming as a minimum that:

  1. They have been diagnosed with Gender Identity Dysphoria.

  2. SRS is indicated in their case, and is the recommended treatment.

  3. Ideally, the referral should also confirm that:

  4. They have been living full time as a woman for at least 12 months prior to surgery or - if not - gives an explanation as to why that has not been possible in their case. It is accepted that RLT is not a practical possibility in some countries.

  5. They have been undertaking a course of female hormone replacement therapy (HRT) unless there are medical reasons (to be indicated) that such a course is not advised in their case.

The letter must show the name, address and telephone number of the signee, for possible verification

In order to ensure that there are no difficulties with the documentation that you have, please make sure that you scan the letter and send it to me as an email attachment for review, to make sure it meets the necessary requirements. It is essential that you bring the original with you when you come for surgery (or that the original is sent to us direct). It will not be possible to go ahead with the SRS operation without such a suitable letter.

There are no exceptions to this requirement. Any patient who arrives without this evidence will not be permitted to undergo surgery. If you have difficulty with providing such evidence, please contact the Suporn Clinic, so we can discuss possible ways of meeting this requirement.

Additionally, if the referral letter from the psychosexual specialist does not specify as in items (3) and (4) above, we require you separately to provide evidence that you:

  • have had treatment with feminizing hormones (HRT) and/or anti-androgens for a minimum period of 12 months, unless there is a medical reason why to do so would not be advised in your case.

  • have lived full time in your acquired gender for a period of at least 12 months, evidenced by at least 2 original documents ( ** ), unless there are clearly given and acceptable reasons why this is not possible, or not practical in your case. Some easement of this requirement might be permitted, subject to the contents of the referral letter.

( ** ) Documentary evidence needs only to be sufficient to show the patient's acquired (female) name, and bear a date at least 12 months prior to surgery. Suitable examples would be - but are not restricted to - passport, driver's licence, official ID card, household utility bill, bank statement...etc.

SRS Referral Letter

There is no specific format for a SRS Referral letter. Dr Suporn does not expect a long report or detailed diagnosis, but he does expect it to contain certain minimum criteria. We would expect the doctor to mention how many times he has seen the patient, and since when. The doctor or practitioner does not have to specifically recommend that the patient should undergo SRS, nor do they have to specifically refer the patient to Dr Suporn ( a qualifying referral previously addressed to another surgeon is acceptable ). However, we would expect to see that the doctor or therapist considers that the patient:

  • has been diagnosed with gender dysphoria as  the conclusion of a number of personal communication sessions. Confirmation of diagnosis in accordance to DSM IV Code 302.85 and/or ICD10 code F64.0 (or as otherwise appropriate) must be mentioned.

  • shows no evidence of co-morbidity or substance abuse.

  • is demonstrably living full time as a woman for at least 12 months, or shows evidence of commitment to do so, or has satisfactory reasons as to why she is not yet doing so. There might, for example, be legal reasons in any particular country preventing this.

  • is not suffering from any psychological or psychiatric disorders (****) that might be adversely influencing her decision or desire to undergo SRS.

  • has been taking female hormones (for a specified period - usually a minimum of 6 months), unless it is considered medically unsafe to do so.

  • is fully adjusted to living in society as a woman or – if not yet living as a woman – must have a satisfactory explanation as to why this is the case.

  • is fully aware of the consequences, cost, details, complications and surgical and non-surgical options available to treat her gender dysphoria.

  • is aware that SRS is irreversible.

  • is considered suitable by him / her to undergo SRS insofar as he/she offers no reason why you should NOT undergo SRS and that SRS is necessary for the patient’s long-term well-being.

If the letter has all (or most of) those "ingredients", and the doctor is competent to write and sign it by virtue of his / her qualifications and credentials, Dr Suporn will accept that as suitable referral.

( **** ) Although it is sometimes referred to as such, in this respect, we do not consider Gender Identity Disorder (GID), Gender Dysphoria or transsexualism to be a psychiatric or psychological condition.

SRS Under Age 20

Under Thai medical regulations, patients under the age of 20 are unable to undergo surgery without the written approval of their parents, legal guardians, a direct blood relative, or an individual who has legal Power of Attorney over your affairs. The signee must, himself or herself, be aged over 20. The signed document giving approval for you to undergo SRS must also be accompanied by an originally signed photocopy of a photo-ID which bears the same signature. If the family name of the signee is different from your own family name, copies of suitable evidence must be given to link the signee with having the authority to sign on your behalf.

If you are able to obtain this approval, Dr Suporn would be quite happy to proceed with surgery - providing you are able to meet the other criteria of our protocol, particularly in respect of having been diagnosed gender dysphoric, and having psychotherapeutic agreement to undergo the surgery. If you do not provide this approval, in original format, at the time of the operation, Dr Suporn will not proceed.

Dr Suporn is unable to undertake SRS on patients aged less than 18 years.

Patients Aged 65 and over

Dr Suporn no longer accepts patients aged 65 and over for SRS or substantial FFS operations. To amplify the meaning of "substantial", please contact the Clinic to discuss specific circumstances.

Pre-Operative Medical Requirements and Surgical Considerations

Patients will only be operated on if they are medically fit for surgery. While a full medical check-up is provided at the hospital prior to surgery, all patients with known medical conditions are strongly advised to undergo a full medical check-up by their own medical practitioner prior to confirming their surgery booking. They should obtain and submit along with other documentation a report from their medical practitioner certifying that detailing date of birth, height, weight, medical history, medical conditions, and a recommendation that the patient is physically fit to undergo major surgery under general anesthesia.

All patients are screened with an electronic questionnaire prior to scheduling for surgery.

Final medical clearance for surgery depends on satisfactory results of the medical admission tests, and consent of the anesthesiologist at Aikchol hospital

Orchiectomy

Bilateral orchiectomy is not recommended prior to SRS, but is permitted. If the scrotal sac has been removed, the applicant must seek elsewhere to undergo SRS.

Genital Electrolysis

Prior genital electrolysis is not required. Permanent genital depilation is unnecessary,  expensive and uncomfortable. All hair follicles are manually excised (cut) from the scrotal skin during surgery, and will not grow subsequently. A hair-free vaginal lining is guaranteed. Prior electrolysis of the scrotal area may result in scarring and thickening of the skin which could reduce its elasticity and vaginal depth. If desired, only the perineal region (perineum) between the anus to the scrotum should be cleared (which can also be cleared after SRS)

Blood Transfusions

For all surgery, no blood transfusions are used (no need for patients to bring their own blood supply)

Deep Vein Thrombosis (DVT) Risk Avoidance

Major surgery - particularly SRS - carries the potential risk of incurring Deep Vein Thrombosis. Dr Suporn and his team take every precaution possible to minimize the risk of DVT. However, much of the responsibility for risk avoidance of DVT rests with the patient, not with the surgeon. Patients are recommended to reduce weight to acceptable (non-obese) levels, to remain actively fit, and to take adequate exercise during any long-haul flight. In addition:

  • Hormones. All anti androgen/hormone injections must be stopped 4 weeks before traveling, and anti androgen/hormone oral tablets, gels, patches, and aspirin must be stopped 1 week before traveling to Thailand

  • Smoking and any heavy drinking must be stopped at least 1 month before traveling to Thailand.

  • Patients who fail to stop taking hormones or/and smoking before surgery will have their surgery cancelled.

Patients who smoke must make every effort not to resume until at least one month after surgery. FFS patients - in particular - should be aware of the extreme adverse effect that smoking has on post-operative recovery and results.

After surgery, hormone treatment can be resumed 2 weeks after surgery (in the case of SRS resumption of anti androgens is not necessary unless prescribed to the contrary by your medical practitioner)

HIV

Dr Suporn does not undertake elective surgery on HIV+ (positive) patients.

Patients who have any doubts about being HIV- (negative) should have the test before coming to Thailand. Patients who fail to disclose any serious medical conditions, including clinical obesity, may have their surgery cancelled upon arrival to Thailand, and forfeit all payments made for surgery.

 

Protocol for undergoing FFS

Dr Suporn considers FFS to be purely elective surgery, and as such does not expect any patient to meet any specific criteria other than being physically fit to undergo the operation. In general, however, he considers FFS likely to be unnecessary and unadvisable for any patient below 18 years of age, assuming she is following a course of feminising HRT, unless she has unusually dominant male characteristics.

There is no requirement for any patient to have started feminising HRT prior to undergoing FFS. HRT in general will have no effect on the underlying bone structure of the face, but might have some feminising benefit by altering the facial skin texture and facial fat distribution, which can have a softening effect. HRT is more likely to be effective in this respect for a younger client, than for a more mature individual.