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Thursday, October 12, 2023

Terminal ballistics

From Wikipedia, the free encyclopedia
Bullet parts: 1 metal jacket, 2 lead core, 3 steel penetrator

Terminal ballistics (also known as wound ballistics) is a sub-field of ballistics concerned with the behavior and effects of a projectile when it hits and transfers its energy to a target.

Bullet design (as well as the velocity of impact) largely determines the effectiveness of penetration.

General

The concept of terminal ballistics can be applied to any projectile striking a target. Much of the topic specifically regards the effects of small arms fire striking live targets, and a projectile's ability to incapacitate or eliminate a target.

Common factors include bullet weight, composition, velocity, and shape.

Firearm projectiles

Classes of bullets

There are three basic classes of bullets:

  • Those designed to maximize accuracy at varying ranges
  • Those designed to maximize damage to a target (by penetrating as deeply as possible)
  • Those designed to avoid over-penetration of a target. This is done by deformation (to control the depth to which the bullet penetrates) which, as a by-product, causes more damage inside the wound. This class may limit penetration by either expanding or fragmenting.

Target shooting

.32 ACP full metal jacket, .32 S&W Long wadcutter, .380 ACP jacketed hollow point

For short-range target shooting, typically on ranges up to 50 meters, or 55 yards, with low-powered ammunition like a .22 long rifle, aerodynamics is relatively unimportant, and velocities are low compared to velocities attained by full-powered ammunition.

As long as a bullet's weight is balanced, it will not tumble; its shape is thus unimportant for purposes of its aerodynamics. For shooting at paper targets, bullets that will punch a perfect hole through the target —called wadcutters— are preferred. They have a very flat front, often with a relatively sharp edge along the perimeter, which punches out a hole equal to or almost equal to its diameter, thus enabling unambiguous scoring of the target. Since cutting the edge of a target ring will result in a higher score, accuracy to within fractions of an inch is desirable.

Magazine-fed pistols tend not to reliably feed wadcutters because of their angular shape. To address this, the semi-wadcutter is often used. The semi-wadcutter consists of a conical section that comes to a smaller flat point and a thin sharp shoulder at the base of the cone. The flat point punches a hole, and the shoulder opens it up cleanly. For steel targets, the concern is to provide enough force to knock over the target while minimizing the damage to the target. A soft lead bullet, or jacketed hollow-point bullet, or soft-point bullet will flatten out on impact (if the velocity at impact is sufficient to make it deform), spreading the impact over a larger area of the target, allowing more total force to be applied without damaging the steel target.

There are also specialized bullets designed for use in long-range precision target shooting with high-powered rifles. The designs vary somewhat from manufacturer to manufacturer. Research in the 1950s by the U.S. Air Force discovered that bullets are more stable in flight for longer distances and more resistant to crosswinds if the center of gravity is biased to the rear of the center of pressure. The MatchKing bullet is an open-tip match design with a tiny aperture in the jacket at the point of the bullet and a hollow air space under the point of the bullet, whereas previous conventional bullets had a lead core that went all the way up to the point.

The U.S. military now issues ammunition to snipers that use bullets of this type. In 7.62×51mm NATO, M852 Match and M118LR ammunition are issued, both of which use Sierra MatchKing bullets; in 5.56×45mm NATO, those U.S. Navy and U.S. Marine snipers who use accurized M16-type rifles are issued the Mk 262 Mod 0 cartridge developed jointly by Black Hills Ammunition and Crane Naval Surface Warfare Center.

For ultra-long-range precision target shooting with high-powered rifles and military sniping, radically designed very-low-drag (VLD) bullets are available that are generally produced out of rods of mono-metal alloys on CNC lathes. The driving force behind these projectiles is the wish to enhance the practical maximum effective range beyond normal standards. To achieve this, the bullets have to be very long and normal cartridge overall lengths often have to be exceeded. Common rifling twist rates also often have to be tightened to stabilize very long projectiles. Such commercially nonexistent cartridges are termed "wildcats". The use of a wildcat-based (ultra) long-range cartridge demands the use of a custom or customized rifle with an appropriately cut chamber and a fast-twist bore.

Maximum penetration

For use against armored targets, or large, tough game animals, penetration is the most important consideration. Focusing the largest amount of kinetic energy and projectile mass on the smallest possible area of the target provides the greatest penetration. Bullets for maximum penetration are designed to resist deformation on impact and usually are made of lead that is covered in a copper, brass, or mild steel jacket (some are even solid copper or bronze alloy). The jacket completely covers the front of the bullet, although often the rear is left with exposed lead (this is a manufacturing consideration: the jacket is formed first, and the lead is swaged in from the rear).

For penetrating substances significantly harder than jacketed lead, the lead core is supplemented with or replaced with a harder material, such as hardened steel. Military armor-piercing small arms ammunition is made from a copper-jacketed steel core; the steel resists deformation better than the usual soft lead core leading to greater penetration. The current NATO 5.56mm SS109 (M855) bullet uses a steel-tipped lead core to improve penetration, the steel tip providing resistance to deformation for armor piercing, and the heavier lead core (25% heavier than the previous bullet, the M193) providing increased sectional density for better penetration in soft targets. For larger, higher-velocity calibers, such as tank guns, hardness is of secondary importance to density, and are normally sub-caliber projectiles made from tungsten carbide, tungsten hard alloy, or depleted uranium fired in a light aluminum or magnesium alloy (or carbon fiber in some cases) sabot.

Many modern tank guns are smoothbore, not rifled because practical rifling twists can only stabilize projectiles, such as an Armour-Piercing Capped Ballistic Cap (APCBC), with a length-to-diameter ratio of up to about 5:1 and also because the rifling adds friction, reducing the velocity and thus total force it is possible to achieve. To get the maximum force on the smallest area, modern anti-tank rounds have aspect ratios of 10:1 or more. Since these cannot be stabilized by rifling, they are built instead like large darts, with fins providing the stabilizing force instead of rifling. These subcaliber rounds, called Armor-Piercing Fin-Stabilized Discarding Sabot (APFSDS) are held in place in the bore by sabots. The sabot is a light material that transfers the pressure of the charge to the penetrator, then is discarded when the round leaves the barrel.

Controlled penetration

The final category of bullets is that intended to control penetration so as not to harm anything behind the target. Such bullets are used primarily for hunting and civilian antipersonnel use; they are not generally used by the military, since the use of expanding bullets in international conflicts is prohibited by the Hague Convention and because these bullets have less chance of penetrating modern body armor. These bullets are designed to increase their surface area on impact, thus creating greater drag and limiting the travel through the target. A desirable side effect is that the expanded bullet makes a larger hole, increasing tissue damage and speeding up incapacitation.

While a bullet that penetrates through-and-through tends to cause more profuse bleeding, allowing a game animal to be blood trailed more easily, in some applications, preventing exit from the rear of the target is more desirable. A perforating bullet can continue on (likely not coaxial to the original trajectory due to target deflection) and might cause unintended damage or injury.

Flat point

The simplest maximum disruption bullet is one with a wide, flat tip. This increases the effective surface area, as rounded bullets can allow tissues to "flow" around the edges. Flat points also increase drag during flight, which decreases the depth to which the bullet penetrates. Flat-point bullets, with fronts of up to 90% of the overall bullet diameter, are usually designed for use against large or dangerous games. They are often made of unusually hard alloys, are longer and heavier than normal for their caliber, and even include exotic materials such as tungsten to increase their sectional density.

These bullets are designed to penetrate deeply through muscle and bone while causing a wound channel of nearly the full diameter of the bullet. These bullets are designed to penetrate deeply enough to reach vital organs from any shooting angle and at a far enough range. One of the hunting applications of the flat point bullet is large game such as bear hunting with a handgun in a .44 Magnum or larger caliber. More common than hunting is its use in a defensive "bear gun" carried by outdoorsmen. The disadvantage of flat point bullets is the reduction in aerodynamic performance; the flat point induces much drag, leading to significantly reduced velocities at long range.

Expanding

More effective on lighter targets are the expanding bullets, the hollow-point bullet, and the soft-point bullet. These are designed to use the hydraulic pressure of muscle tissue to expand the bullet. The hollow point peels back into several connected pieces (sometimes referred to as petals due to their appearance) causing the bullet to create a larger area of permanent damage. The hollow point fills with body tissue and fluids on impact, then expands as the bullet continues to have matter pushed into it. This process is informally called mushrooming, as the ideal result is a shape that resembles a mushroom—a cylindrical base, topped with a wide surface where the tip of the bullet has peeled back to expose more area while traveling through a body. For the purposes of aerodynamic efficiency, due to the hollow-point not creating drag, the tip of the hollow-point will often be tipped with a pointed polymer 'nose' which may also aid in expansion by functioning as a piston upon impact pushing the hollow point open. A copper-plated hollow-point loaded in a .44 Magnum, for example, with an original weight of 240 grains (15.55 g) and a diameter of 0.43 inch (11 mm) might mushroom on impact to form a rough circle with a diameter of 0.70 inches (18 mm) and a final weight of 239 grains (15.48 g). This is excellent performance; almost the entire weight is retained, and the frontal surface area increased by 63%. Penetration of the hollow-point would be less than half that of a similar nonexpanding bullet, and the resulting wound or permanent cavity would be much wider.

It might seem that if the whole purpose of a maximum disruption round is to expand to a larger diameter, it would make more sense to start out with the desired diameter rather than relying on the somewhat inconsistent results of expansion on impact. While there is merit to this (there is a strong following of the .45 ACP, as compared to the .40 S&W and 0.355 in diameter 9×19mm, for just this reason) there are also significant downsides. A larger-diameter bullet is going to have significantly more drag than a smaller-diameter bullet of the same mass, which means long-range performance will be significantly degraded. A larger diameter bullet also means more space is required to store the ammunition, which means either bulkier guns or smaller magazine capacities. The common trade-off when comparing .45 ACP, .40 S&W, and 9×19mm pistols is a 7- to 14-round capacity in the .45 ACP vs. a 10- to 16-round capacity in the .40 S&W vs. a 13- to 19-round capacity in the 9×19mm. Although several .45-caliber pistols are available with high-capacity magazines (Para Ordnance being one of the first in the late 1980s) many people find the wide grip required uncomfortable and difficult to use. Especially where the military requirement of a nonexpanding round is concerned, there is fierce debate over whether it is better to have fewer, larger bullets for enhanced terminal effects, or more, smaller bullets for an increased number of potential target hits.

Fragmenting
Example photo of the over-penetration of a fragmenting projectile

This class of projectile is designed to break apart on impact whilst being of a construction more akin to that of an expanding bullet. Fragmenting bullets are usually constructed like the hollow-point projectiles described above, but with deeper and larger cavities. They may also have thinner copper jackets in order to reduce their overall integrity. These bullets are typically fired at high velocities to maximize their fragmentation upon impact. In contrast to a hollow-point which attempts to stay in one large piece retaining as much weight as possible whilst presenting the most surface area to the target, a fragmenting bullet is intended to break up into many small pieces almost instantly.

This means that all the kinetic energy from the bullet is transferred to the target in a very short period of time. The most common application of this bullet is the shooting of vermin, such as prairie dogs. The effect of these bullets is quite dramatic, often resulting in the animal being blown apart upon impact. However, in larger games fragmenting ammunition provides inadequate penetration of vital organs to ensure a clean kill; instead, a "splash wound" may result. This also limits the practical use of these rounds to supersonic (rifle) rounds, which have a high enough kinetic energy to ensure a lethal hit. The two main advantages of this ammunition are that it is very humane, as a hit almost anywhere on most small vermin will ensure an instant kill, and that the relatively low mass bullet fragments pose a very low risk of ricochet or of penetrating unintended secondary targets. Fragmenting bullets should not be confused with frangible bullets (see below).

Also used are bullets similar to hollow-point bullets or soft-point bullets whose cores and/or jackets are deliberately weakened to cause deformation or fragmentation upon impact. The Warsaw Pact 5.45×39mm M74 assault rifle round exemplifies a trend that is becoming common in the era of high velocity, small caliber military rounds. The 5.45×39mm uses a steel-jacketed bullet with a two-part core, the rear being lead and the front being steel with an air pocket foremost. Upon impact, the unsupported tip deforms, bending the bullet nose into a slight "L" shape. This causes the bullet to tumble in the tissue, thus increasing its effective frontal surface area by traveling sideways more often than not.

This does not violate the Hague Convention, as it specifically mentions bullets that expand or flatten in the body. The NATO SS109 also tends to bend at the steel/lead junction, but with its weaker jacket, it fragments into many dozens of pieces. NATO 7.62 mm balls manufactured by some countries, such as Germany and Sweden, are also known to fragment due to jacket construction.

Frangible

The last category of expanding bullets is frangible bullets. These are designed to break upon impact, which results in a huge increase in surface area. The most common of these bullets are made of small diameter lead pellets, placed in a thin copper shell, and held in place by an epoxy or similar binding agent. On impact, the epoxy shatters, and the copper shell opens up, the individual lead balls then spread out in a wide pattern, and due to their low mass-to-surface area ratio, stop very quickly. Similar bullets are made out of sintered metals, which turn to powder upon impact. These bullets are usually restricted to pistol cartridges and rifle cartridges intended for use at very short ranges, as the nonhomogenous cores tend to cause inaccuracies that, while acceptable at short ranges, are not acceptable for the long ranges at which some rifles are used.

By far the most common use of frangible ammunition is for training by shooting steel targets at close ranges, while one may be at risk of being injured by fragments of standard solid lead bullets at close ranges when shooting steel, the powder that frangible bullets disintegrate into upon impact poses a very low risk to the shooter. This becomes irrelevant when shooting at longer ranges because it is unlikely that fragments created by the impact of any type of bullet on a steel target will travel more than 50-100yds, in these long-range cases it is of more value to use bullets that fly identically to those to be used in real situations than to mitigate the possible risks of bullet fragments and ricochets so frangible bullets are typically not used. One interesting use of the sintered metal rounds is in shotguns in hostage rescue situations; the sintered metal round is used at near-contact range to shoot the lock mechanism out of doors. The resulting metal powder will immediately disperse after knocking out the door lock and cause little or no damage to the occupants of the room. Frangible rounds are also used by armed security agents on aircraft. The concern is not depressurization (a bullet hole will not depressurize an airliner), but over-penetration and damage to vital electrical or hydraulic lines, or injury to an innocent bystander by a bullet that travels through a target's body completely instead of stopping in the body.

Large caliber

The purpose of firing a large caliber projectile is not always the same. For example, one might need to create disorganization within enemy troops, create casualties within enemy troops, eliminate the functioning of an enemy tank, or destroy an enemy bunker. Different purposes of course require different projectile designs.

Many large caliber projectiles are filled with a high explosive which, when detonated, shatters the shell casing, producing thousands of high-velocity fragments and an accompanying sharply rising blast overpressure. More rarely, others are used to release chemical or biological agents, either on impact or when over the target area; designing an appropriate fuse is a difficult task that lies outside the realm of terminal ballistics.

Other large-caliber projectiles use bomblets (sub-munitions), which are released by the carrier projectile at a required height or time above their target. For US artillery ammunition, these projectiles are called Dual-Purpose Improved Conventional Munition (DPICM), a 155 mm M864 DPICM projectile for example contains a total of 72 shaped-charge fragmentation bomblets. The use of multiple bomblets over a single HE projectile allows for a denser and less wasteful fragmentation field to be produced. If a bomblet strikes an armored vehicle, there is also a chance that the shaped charge will (if used) penetrate and disable the vehicle. A negative factor in their use is that any bomblets that fail to function go on to litter the battlefield in a highly sensitive and lethal state, causing casualties long after the cessation of conflict. International conventions tend to forbid or restrict the use of this type of projectile.

Some anti-armor projectiles use what is known as a shaped charge to defeat their target. Shaped charges have been used ever since it was discovered that a block of high explosives with letters engraved in it created perfect impressions of those letters when detonated against a piece of metal. A shaped charge is an explosive charge with a hollow lined cavity at one end and a detonator at the other. They operate by the detonating high explosive collapsing the (often copper) liner into itself. Some of the collapsing liners go on to form a constantly stretching jet of material traveling at hypersonic speed. When detonated at the correct standoff to the armor, the jet violently forces its way through the target's armor.

Contrary to popular belief, the jet of a copper-lined shaped charge is not molten, although it is heated to about 500 °C. This misconception is due to the metal's fluid-like behavior, which is caused by the massive pressures produced during the detonation of the explosive causing the metal to flow plastically. When used in the anti-tank role, a projectile that uses a shaped-charge warhead is known by the acronym HEAT (high-explosive anti-tank).

Shaped charges can be defended against by the use of explosive reactive armor (ERA), or complex composite armor arrays. ERA uses a high explosive sandwiched between two, relatively thin, (normally) metallic plates. The explosive is detonated when struck by the shaped charge's jet, the detonating explosive sandwich forces the two plates apart, lowering the jets’ penetration by interfering with, and disrupting it. A disadvantage of using ERA is that each plate can protect against a single strike, and the resulting explosion can be extremely dangerous to nearby personnel and lightly armoured structures.

Tank fired HEAT projectiles are slowly being replaced for the attack of heavy armour by so-called "kinetic energy" penetrators. It is the most primitive (in-shape) projectiles that are hardest to defend against. A KE penetrator requires an enormous thickness of steel, or a complex armour array to protect against. They also produce a much larger diameter hole in comparison to a shaped charge and hence produce a far more extensive behind armour effect. KE penetrators are most effective when constructed of a dense tough material that is formed into a long, narrow, arrow/dart like projectile.

Tungsten and depleted uranium alloys are often used as the penetrator material. The length of the penetrator is limited by the ability of the penetrator to withstand launch forces whilst in the bore and shear forces along its length at impact.

Gender-affirming surgery

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Gender-affirming_surgery

Gender-affirming surgery
is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, however many such treatments are also pursued by cisgender and non-intersex individuals. It is also known as sex reassignment surgery, gender confirmation surgery, and several other names.

Professional medical organizations have established Standards of Care, which apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female, such as vaginoplasty and breast augmentation, whereas masculinization surgeries are those that result in anatomy that is typically gendered male, such as phalloplasty and breast reduction.

In addition to gender-affirming surgery, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Sweden became the first country in the world to allow transgender people to change their legal gender after "reassignment surgery" and provide free "reassignment" treatment in 1972. Singapore followed soon after in 1973, being the first in Asia.

Terminology

Gender-affirming surgery is known by numerous other names, including gender-affirmation surgery, sex reassignment surgery, gender reassignment surgery, and gender confirmation surgery. Top surgery and bottom surgery refer to surgeries on the chest and genitals respectively. It is sometimes called a sex change, though this term is usually considered offensive.

Some transgender people who desire medical assistance to transition from one sex to another identify as "transsexual".

Trans women and others assigned male at birth may undergo one or more feminizing procedures which result in anatomy that is typically gendered female. These include genital surgeries such as penectomy (removal of the penis), orchiectomy (removal of the testes), vaginoplasty (construction of a vagina), as well as breast augmentation, tracheal shave (reduction of the Adam's apple), facial feminization surgery, and voice feminization surgery among others.

Trans men and others assigned female at birth seeking surgery may undergo one or more masculinizing procedures, which include chest reconstruction, breast reduction, hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries). A penis can be constructed through metoidioplasty or phalloplasty, and a scrotum through scrotoplasty.

As knowledge of non-binary genders expands in the medical community, more surgeons are willing to tailor operations to individual needs. Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Gender nullification is the removal of all external genitalia except the urethral opening, typically pursued by people assigned male at birth.

Gender-affirming surgery can also refer to operations pursued by cisgender people, such as mammaplasty, penile implant, or testicular implants following orchiectomy.

Gender-affirming surgery is often sensationalized and misrepresented by anti-trans activists through terminology such as Genital-mutilation surgery.

Surgical procedures

Genital surgery

For trans women, genital reconstruction usually involves the surgical construction of a vagina, by means of penile inversion or the sigmoid colon neovagina technique; or, more recently, non-penile inversion techniques that make use of scrotal tissue to construct the vaginal canal. For trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty.

Non-binary people often pursue genital surgeries, including the same operations as binary trans people of the same sex assignment, as well as bigenital or gender nullification surgeries. Bigenital operations include androgynoplasty, a procedure that retains the penis, or vagina-preserving phalloplasty.

Genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons.

Other surgeries

As underscored by WPATH, a medically assisted transition from one gender to another may entail any of a variety of non-genital surgical procedures which change primary and/or secondary sex characteristics, any of which are considered "gender-affirming surgery" when undertaken to affirm a person's gender identity. For trans men, these may include mastectomy (removal of the breasts) and chest reconstruction (the shaping of a male-contoured chest), or hysterectomy and bilateral salpingo-oophorectomy (removal of ovaries and Fallopian tubes). For some trans women, facial feminization surgery, hair implants, and breast augmentation are also aesthetic components of their surgical treatment.

Scope and procedures

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery - or bottom surgery (the latter is named in contrast to top surgery, which is surgery to the breasts; bottom surgery does not refer to surgery on the buttocks in this context). However, the meaning of "sex reassignment surgery" has been clarified by the medical subspecialty organization, the World Professional Association for Transgender Health (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for "gender dysphoria" or "transsexualism". According to WPATH, medically necessary sex reassignment surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation ... including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient ...)... and certain facial plastic reconstruction." In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.

Voice feminizing surgery is a procedure in which the overall pitch range of the patients voice is reduced.

Adam's Apple Reduction surgery (chondrolaryngoplasty) or tracheal shaving is a procedure in which the most prominent part of the thyroid cartilage is reduced.

There is also Adam's Apple Enhancement therapy, in which cartilage is used to bring out the Adam's apple in female to male patients.

History

Reports of people seeking gender-confirming surgery (vaginoplasty) go back to the 2nd century, such as the Roman Emperor Elagabalus. The first modern gender-confirming surgery was performed in the 20th century.

20th century

In the US in 1917, Alan L. Hart, an American tuberculosis specialist, became one of the first trans men to undergo hysterectomy and gonadectomy as treatment of what is now called gender dysphoria.

Dora Richter is the first known trans woman to undergo complete male-to-female genital surgery. She was one of several transgender people in the care of sexologist Magnus Hirschfeld at Berlin's Institute for Sexual Research. In 1922, Richter underwent orchiectomy. In early 1931, a penectomy, followed in June by vaginoplasty. Richter is presumed to have died in May 1933, when Nazis attacked the institute and destroyed its records, but her exact fate is not known.

Between 1930 and 1931, Lili Elbe underwent four sex reassignment surgeries, including orchiectomy, an ovarian transplant, and penectomy. In June 1931, she underwent her fourth surgery, including an experimental uterine transplant and vaginoplasty, which she hoped would allow her to give birth. However, her body rejected the transplanted uterus, and she died of post-operative complications in September, at age 48.

A previous sex reassignment surgery (SRS) patient was Magnus Hirschfeld's housekeeper, but their name has not been discovered.

Elmer Belt may have been the first U.S. surgeon to perform gender affirmation surgery, in about 1950.

In 1951, Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male SRS, producing a technique that has become a modern standard, called phalloplasty. Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by the doctors Lebovic and Laub. Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head. Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.

21st century

On 12 June 2003, the European Court of Human Rights ruled in favor of Carola van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as van Kück vs Germany.

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".

As of 2017, some European countries require forced sterilization for the legal recognition of sex reassignment. As of 2020, Japan also requires an individual to undergo sterilization to change their legal sex.

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.

Prevalence

The prevalence of transgender-related surgeries is difficult to measure and likely underestimated. In 2015, the largest survey of transgender people in the United States reported that 25% of respondents reported having undergone such a surgery.

Prior to surgery

Medical considerations

Some transgender persons present with health conditions including diabetes, asthma, and HIV, which can lead to complications with future therapy and pharmacological management. Typical SRS procedures involve complex medication regimens, including sex hormone therapy, throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including endocrinologists, whom the surgeon may consult when determining if the patient is physically fit for surgery. Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.

People with HIV or hepatitis C may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.

Fertility is also a factor considered in SRS, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.

Gender dysphoric children

Sex reassignment surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it. Preferred treatments for children include puberty blockers, which are thought to have some reversible physical changes, and sex hormones, which reduce the need for future surgery. Medical protocols typically require long-term mental health counseling to verify persistent and genuine gender dysphoria before any intervention, and consent of a parent or guardian or court order is legally required in most jurisdictions.

Intersex children and cases of trauma

Infants born with intersex conditions might undergo interventions at or close to birth. This is controversial because of the human rights implications.

There can be negative outcomes (including PTSD and suicide) that occur when the surgically assigned gender does not match the individual's gender identity, which will only be realized by the individual later in life. Milton Diamond at the John A. Burns School of Medicine, University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.

Standards of care

Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack of providers. An increasing number of surgeons are now training to perform such surgeries. In many regions, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for the Health of Transgender and Gender Diverse People (SOC). The most widespread SOC in this field is published and frequently revised by the World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the United States and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of psychological evaluation and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly referred to as the real life test (RLT)) before sex reassignment surgeries are covered by insurance.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.

Many surgeons require two letters of recommendation for sex reassignment surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents. However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.

Insurance

A growing number of public and commercial health insurance plans in the United States now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and hysterectomy (FTM). For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:

  • a written initial assessment by a qualified licensed mental health professional
  • persistent, well-documented gender dysphoria
  • months of prior physician-supervised hormone therapy

In June 2008, the American Medical Association (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician." Other organizations have issued similar statements, including WPATH, the American Psychological Association, and the National Association of Social Workers.

In 2017, the United States Defense Health Agency for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who is a transgender woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.

Post-procedural considerations

Quality of life and physical health

Several studies have measured quality of life and self-perceived physical health using different scales. Castellano et al. (2015) found similar quality of life compared to a control group for 60 SRS patients two years after surgery. Kuhn et al. (2008), assessing 52 trans women and 3 trans men 15 years after surgery, found quality of life lower than control in domains of health and limitations. De Cuypere et al. (2005), assessing 32 trans women and 23 trans men after surgery, concluded that patients' emotional and social needs were met, but less so their physical and sexual needs. Ainsworth and Spiegel (2010), in a study of 247 trans women, find improvements in mental health after genital reassignment surgery or face feminization surgery.

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision.

Psychological and social consequences

A 2009 review in the International Journal of Transgenderism found that from 1998 onward, studies have shown that "the whole process of gender reassignment is effective in relieving gender dysphoria and that its positive results greatly outweighed any negative consequences", but noted methodological issues in many studies, particularly older ones. A 2010 meta-analysis in Clinical Endocrinology noted the lack of randomization and control groups and reliance of self-reporting in the studies it reviewed, reaching the conclusion "Very low quality evidence suggests that hormonal therapies given to individuals with GID as a part of sex reassignment are likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."

Smith et al. (2001) found that among 20 patients, anxiety, depression and hostility levels were lower after sex reassignment surgery. Wierckx et al. (2011), in a study of 49 trans men, found them in good self-perceived physical and mental health. Dhejne et al. (2011), in a study following 324 transgender people who received sex reassignment surgery from 1973 to 2003, found that they "have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population", concluding that "sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism". Lawrence (2003), in a study of 232 trans women who underwent surgery between 1994 and 2000, found "None reported outright regret and only a few expressed even occasional regret."

Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours. The rejection faced by transgender people is much more severe than what is experienced by lesbian, gay, and bisexual individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.

Sexuality

Looking specifically at transsexual people's genital sensitivities, both trans men and trans women are capable of maintaining their genital sensitivities after SRS. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexual individuals to avoid unnecessary harm or injuries to the genitals, allowing trans men to obtain an erection by inserting a penile implant after phalloplasty, the ability for transsexual people to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS. Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasms after phalloplasty is to preserve both the clitoris hood and the clitoris underneath the reconstructed phallus.

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse. Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities, implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery. The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics. Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation. The ability to obtain orgasms is positively associated with sexual satisfaction. Frequency and intensity of orgasms are substantially different among trans men and trans women. Almost all female-to-male individuals have revealed an increase in sexual excitement and are capable of achieving orgasms through sexual activity with a partner or via masturbation, whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS. A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female individuals have been encountering longer and more gentle feelings.

The rates of masturbation have also changed after sex reassignment surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies exhibited in most transsexual individuals and 78% of them were able to reach orgasm by masturbation after SRS. A study showed that there were differences in masturbation frequencies between trans men and trans women, in which female-to-male individuals masturbated more often than male to female The possible reasons for the differences in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels). When comparing transgender with cisgender individuals of the same gender, trans women had a similar sexual satisfaction to cis women, but trans men had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.

Intersex rights in Germany

From Wikipedia, the free encyclopedia
 
Intersex rights in Germany
Location of Germany (dark green)

– in Europe (light green & dark grey)
– in the European Union (light green)

Protection of physical integrity and bodily autonomyYes, with loopholes
Protection from discriminationNo
Changing M/F sex classificationsYes
Third gender or sex classificationsYes (since December 2018)
MarriageYes (since 1 October 2017)

Intersex people in Germany have legal recognition of their rights to physical integrity and bodily autonomy, with exceptions, but no specific protections from discrimination on the basis of sex characteristics. In response to an inquiry by the German Ethics Council in 2012, the government passed legislation in 2013 designed to classify some intersex infants as a de facto third category. The legislation has been criticized by civil society and human rights organizations as misguided.

Research published in 2016 found no substantive reduction in the numbers of intersex medical interventions for infants and children with intersex conditions in the period from 2005 to 2014. In 2021 the Bundestag (the German parliament) passed legal protections, albeit protections that have been criticized due to exceptions to the law.

History

The 12th-century canon law collection known as the Decretum Gratiani states that "Whether a hermaphrodite may witness a testament, depends on which sex prevails" ("Hermaphroditus an ad testamentum adhiberi possit, qualitas sexus incalescentis ostendit."). On ordainment, Raming, Macy and Cook found that the Decretum Gratiani states, "item Hermafroditus. If therefore the person is drawn to the feminine more than the male, the person does not receive the order. If the reverse, the person is able to receive but ought not to be ordained on account of deformity and monstrosity." Historical accounts of intersex people are scarce, but 19th-century medical journals document Gottlieb Göttlich, a man who made a living from being studied by medical practitioners, and Karl Dürrge. Dürrge also made his living as a medical subject, but his life also illustrates the historical legal tradition. Assigned female at birth, Dürrge changed name and designation to male as an adult, in line with articles Articles 19-24 of the Prussian Code of 1792, which enabled hermaphrodites to choose to live as either male or female from the age of majority.

In the 20th century, the term intersex was coined by the German-born geneticist Richard Goldschmidt. In 1932 gynecologist and obstetrician Hans Naujoks performed what was described as the first complete and comprehensive intersex surgery and hormone treatment on a patient with both ovarian and testicular tissue, at the University of Marburg. The female patient was described as fully functional after surgery and, starting in 1934, spontaneously menstruated.

Nazi Germany

A pseudo-diagnosis from Nazi Germany in 1943. The text reads: "The intersex type is physical and psychologically expressed. There are also sexual intermediate stages, where female characteristics are only weakly developed. Hair growth is excessive and atypical, the features are male, the voice is deep. Puberty occurs with delay, there is frigidity and reduced fertility in the case of hypoplasia of the gonads and hyperfunction of the pituitary gland, sometimes eunuch-like tall stature, also disorders in the function of the thyroid gland. Often dysmenorrhea is observed."

During Nazi rule in Germany many intersex people were either killed or hidden from the public. German athlete Dora Ratjen competed in the 1936 Olympic Games in Berlin, placing fourth in the women's high jump. She later competed and set a world record for the women's high jump at the 1938 European Championships. Raised as a girl, tests by the German police concluded that Ratjen was a man. Ratjen later took the name Heinrich Ratjen following an official registry change. Formal sex verification testing was controversially later introduced in sport. Time magazine later reported that Ratjen tearfully confessed that he had been forced by the Nazis to pose as a woman "for the sake of the honor and glory of Germany".

Post World War II

In the 21st century, legal cases by Christiane Völling and Michaela Raab, provide first and later examples of successful legal action against coercive intersex medical interventions.

Also in this century, Germany introduced what may be the first form of third gender recognition in Europe, albeit controversially as a requirement for some intersex infants and otherwise not available. This was introduced as a measure to prevent early intersex medical interventions, but intersex civil society organizations fear that it will encourage such interventions, and there is no evidence of reductions in surgery numbers.

Civil society organizations, including Intergeschlechtliche Menschen, OII Germany and Zwischengeschlecht, have submitted reports to Land, federal and international human rights institutions.

In the spring of 1999, Heike Bödeker coined the term endosex, as an opposite or antonym for the term intersex.

Physical integrity and bodily autonomy

  Legal prohibition of non-consensual medical interventions
  Regulatory suspension of non-consensual medical interventions

The organization Intersexuelle Menschen first submitted a Shadow Report to the United Nations Committee on the Elimination of All Forms of Discrimination Against Women (CEDAW) in July 2008, detailing human rights violations in medical settings and failures to act in the best interests of the child.

In 2010, the German Ethics Council was instructed to review the situation of intersex people in Germany following a demand by CEDAW to protect the human rights of intersex persons. A 2012 report by the German Ethics Council stated that, "Many people who were subjected to a 'normalizing' operation in their childhood have later felt it to have been a mutilation and would never have agreed to it as adults." Legislation was subsequently passed to assign infants who could not be determined as male or female to a de facto third classification.

Research published by Ulrike Klöppel at the Humboldt University in December 2016 shows that, over the period 2005 to 2014, there were no significant trends in numbers of intersex medical interventions. An average of 99 feminizing surgeries took place each year, with a change only to the types of medical classification adopted. Rising numbers of masculinizing surgeries took place, exceeding 1600 per year. Between 10 and 16% of children diagnosed with hypospadias underwent a plastic reconstruction of the penis.

In a hearing of the United Nations Committee on the Elimination of Discrimination against Women, German government stated that irreversible medical interventions were permissible where they are "a life-saving procedure, or the best interest of the child, for example if a child was suicidal."

In 2017, Amnesty International published a report condemning "non-emergency, invasive and irreversible medical treatment with harmful effects" on children born with variations of sex characteristics in Germany and Denmark. It found that surgeries take place with limited psychosocial support, based on gender stereotypes, but without firm evidence. Amnesty International reported that "there are no binding guidelines for the treatment of intersex children".

Legal protections, 2021

A law that provides for a general ban on operations in children and adolescents with 'variations of sex development' ('Varianten der Geschlechtsentwicklung') was passed in the German parliament on 25 March 2021. According to a report in the Deutsches Ärzteblatt, the law is intended to strengthen the self-determined decision-making of children and adolescents and avoid possible damage to their health. Surgical changes to sex characteristics should only take place - even with the consent of the parents - if the operation cannot be postponed until age 14. The majority of legal scholars and psychologists consulted support the approach. The Federal Chamber of Psychotherapists requires the mandatory participation of a counsellor with experience in intersex in an assessment before a possible intervention. While supportive of progress, the law that was finally passed was criticized by the Organisation Intersex International (OII) Germany, OII Europe, and Intergeschlechtliche Menschen e.V., because they provide too many exceptions. Whether the protection takes hold in an individual case depends on whether the medical professional diagnoses the child with variations of sex development (the German implementation of disorders of sex development) or not.

Remedies and claims for compensation

  Explicit protection from discrimination on grounds of sex characteristics
  Explicit protection on grounds of intersex status
  Explicit protection on grounds of intersex within attribute of sex

Two legal cases seeking compensation for "unwanted, harmful medical interventions" have succeeded, those of Christiane Völling and Michaela Raab. Both were adults at the time of the medical interventions. There appear to be no statutory provisions offering compensation, however, at a hearing of the United Nations Committee on the Elimination of Discrimination against Women in February 2017, the German government said that a compensation fund for victims of intersex genital mutilation is under discussion.

Christiane Völling case

In Germany in 2011, Christiane Völling won what may be the first successful case against non-consensual "normalizing" medical treatment. The surgeon was ordered to pay €100,000 in damages after a legal battle that began in 2007, thirty years after the removal of her reproductive organs.

Michaela Raab case

In 2015, Michaela Raab sued doctors in Nuremberg, Germany, who failed to properly advise her. Doctors stated that they "were only acting according to the norms of the time - which sought to protect patients against the psychosocial effects of learning the full truth about their chromosomes". On 17 December 2015, the Nuremberg State Court ruled that the University of Erlangen-Nuremberg Clinic must pay damages and compensation.

Identification documents

  Nonbinary / third gender available as voluntary opt-in
  Opt-in for intersex people only
  Mandatory for some born intersex, and opt in
  Mandatory for some born intersex
  Nonbinary / third gender not legally recognized / no data

In November 2013, Germany became the first European country to allow "indeterminate" sex, requiring this where a child may not be assigned male or female. This was criticized by intersex civil society organizations such as OII Germany and Zwischengeschlecht who argued that "if a child's anatomy does not, in the view of physicians, conform to the category of male or the category of female, there is no option but to withhold the male or female labels given to all other children." The German Ethics Council and the Swiss National Advisory Commission also criticized the law, saying that "instead of individuals deciding for themselves at maturity, decisions concerning sex assignment are made in infancy by physicians and parents."

Many intersex advocates in Germany and elsewhere have suggesting that the law might encourage surgical interventions, rather than reduce them. The Council of Europe Issue Paper on intersex restates these concerns:

Human rights practitioners fear that the lack of freedom of choice regarding the entry in the gender marker field may now lead to an increase in stigmatisation and to "forced outings" of those children whose sex remains undetermined. This has raised the concern that the law may also lead to an increase in pressure on parents of intersex children to decide in favour of one sex.

13 October 2018: protest for third gender in front of the Bundeskanzleramt

In June 2016, Germany's High Court ruled that German law would not allow entry of a third option of "inter" or "diverse" in the birth registry. The High Court said it found no violation of the plaintiff's basic rights since intersex people have been able since 2013 to leave the gender entry in German birth registries blank. In November 2017, the German Constitutional Court ruled that civil status law must allow a third gender option. Open sex entries don't "reflect that the complainant does not see themself as a genderless person, but rather perceives themself as having a gender beyond male or female". This ruling was followed in August 2018 by a cabinet decision to create a new sex classification, "diverse", for intersex people only. This has been criticized for failing to address concerns about medical interventions, and for failing to make this non-binary gender category available to non-intersex people. The proposal was approved by the Bundestag in December 2018. On 22 December 2018, the adopted act entered into force, allowing the choice for intersex people (both at birth and at a later age) between "female", "male", "diverse" and no gender marker at all. In case of a change later in life, first names can also be changed. In the meantime, an appeals court had held that a nonbinary status must also be open to non-intersex non-binary people; the adopted act does not address this category of people and their situation therefore remains unclear pending additional case-law.

Marriage

Since 2017, persons classified as neither male nor female (or intersex people) can legally marry another person of any sex/gender within Germany. Since 1 October 2017, same-sex marriage became legal within Germany and registered partnerships that had been legally available since 2001, were abolished. Same-sex step adoption has also been legal since 2005 and was expanded in 2013 to allow someone in a same-sex relationship to adopt a child already adopted by their partner and full adoption rights for same-sex couples has been legally available since 1 October 2017 within Germany.

Child abandonment

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Child_abandonment ...