The fascinating story behind the development of sex reassignment surgery in Morocco

Authors: Karim Moutchou, M.D., Fez Faculty of Medicine and Pharmacy

       Zineb Mekouar, Medical Student, Fez Faculty of Medicine and Pharmacy


    Although most medical discoveries and inventions are the fruit of years or decades of focused research, some occur in unexpected circumstances.


    For example, Alexander Fleming discovered penicillin when he found that mold he had mixed with bacteria, which he forgot in petri dishes before going on vacation, inhibited the growth of the bacteria. Similarly, radiologist Charles Dotter performed the first heart angioplasty when his catheter, which was destined for the heart chambers and valves, accidentally slipped into one of the coronary arteries. He discovered then that the patient survived, and that he could use this technique to visualize the artery.



    In this article, we explore the relatively unknown and unexpected story of the invention of modern male-to-female (MTF) sex reassignment surgery (SRS), one of the most intriguing and complicated plastic surgery procedures in the world. Nowadays, it is mostly performed in East Asia and in Western countries; however, modern SRS techniques emerged in Morocco, a country where they are no longer recognized or allowed.


    Credit for this discovery goes to George Burou, a French doctor who spent most of his life performing the surgery in the country’s economic capital, Casablanca.


Biography of George Burou


    George Burou, M.D., was an enigmatic French gynecologist who pioneered SRS for transgender women. He was born on September 6, 1910, in Tarbes in the Hautes Pyrénées, France. He spent his childhood in Algiers, where his father worked as a French language teacher.


    Burou studied medicine at the Algiers University of Medicine and served as a surgeon in the military in several countries before ending his service and returning to his childhood town. There, in 1939, he opened a gynecology clinic. He later moved to Casablanca in Morocco, where he and his wife built their private clinic, which they named Clinique du Parc (Park Clinic). Although he never intended to specialize in SRS, Burou independently developed the anterior pedicle penile skin flap inversion vaginoplasty at his clinic between 1956 and 1958.


    After that, he performed over 800 vaginoplasties for transgender patients from all over the world.


    His death in 1987 was as poetic as the life he led, as he drowned on his boat after running out of fuel in Mohammedia, a coast now near Casablanca[LT1] .


    Even though his discretion because of the controversial nature of his work made him relatively unknown, his legacy lives on, and we recognize his work as the basis of SRS for many plastic surgeons.



A unique doctor-patient relationship


    Dr. Burou’s patients often described him as a charismatic, devoted, and humble man. He did not do his work for the money or the fame. In fact, he offered to reduce the cost of the procedure for those who could not afford it, and he did not want to receive credit for his work in the media.


    After the surgery, he generally did not like to offer follow up visits, for, as he explained, the patients did not want to be reminded of the surgery, but wanted to get on with their new lives.


His vision of transgender rights


    One of the most defining aspects of Dr. Burou’s work is that he had a socially progressive view of his patients’ experiences. Although transgenderism was—and still is—considered a disease by some and a variety of homosexuality by others, he used to say that his patients were not homosexuals, but women stuck in men’s bodies.


    Therefore, he believed he performed plastic surgery designed to give his patients the bodies they desired. Nonetheless, he explained to them that they could never give birth to children because of the absence of internal genital organs.


The story of Patient Zero and the first experience


    In a rare interview, Dr. Burou explained how he stumbled onto his revolutionary technique. He said a sound engineer who “was tired of living like a man” asked him to do it. After the engineer insisted on going through the surgery, the doctor tried it, not knowing whether there was a precedent for the case. When the surgery was a success, he felt empowered to try it again and again. Although he usually never stayed in touch with former patients, he knew that his first patient lived a long and fulfilling life after the operation.


    Because of his discreet personality, Dr. Burou only presented this case 17 years later at a symposium at Stanford University. Later, he was very impressed by how the technique was adopted and developed by different doctors around the world, and he thanked surgeons in the United States for continuing his work.


Coccinelle and other famous patients


    The doctor’s desire to remain discreet and avoid media attention contrasted with the sensitive nature of the subject and the fame that his patients achieved after their transitions.


    Coccinelle was a famous transgender French dancer and a performer in Paris’ most famous clubs. After she underwent the surgery as Dr. Burou’s eighth patient, she did not keep his identity secret as he desired. He said he felt as though she had broken their agreement when he found his name in newspapers and magazines.


    However, Coccinelle was just one of many of his then-famous patients. April Ashley was the first openly transgender women in the United Kingdom, and she worked in the same cabaret as Coccinelle. Dr. Burou performed her surgery when she was 25. She wrote an article afterward titled “Goodbye M’sieur, Hello Mamselle, the Doctor Said.” Other famous patients included British historian Jan Morris and the performer Naughty Lola.



Transgender medical and legal rights in Morocco


    Decades after Dr. Burou’s death, transgender rights have seen a great decline in Morocco. The country that witnessed the birth of MTF SRS offers very few protections and rights, if any, for transgender people and for the LGBTQ+ community at large.


    Even though the constitution prohibits discrimination based on gender, there is no mention of transgender people's rights, and there is no legal path by which a person can change their gender officially.


    In the medical field, textbooks and professors do not teach medical students anything about gender related topics. Doctors are not allowed—or equipped with the required knowledge—to help their transgender patients with their medical needs, including hormone therapy and surgery.


    In addition, having a transgender identity is widely believed to be a psychiatric disease and an abnormal state of mind that can and should be changed.


Conclusion


    Under the most unlikely circumstances, when transsexuality was still controversial and poorly understood, and in a country where it was—and still is—a taboo, Georges Burou taught every physician a crucial lesson: to put the needs of the patient first. Before convenience, before money, and above everything else, he freed many people from the bodies in which they suffocated and opened the way for many other physicians to do so.

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