The first version of this article was written in 1999. At that time, the term "transsexual woman" commonly meant a man who had had, or was planning to have "sex re-assignment surgery" (SRS). This article still often uses the abbreviation 'SRS' rather than more recent and accurate terms such as Gender Reassignment Surgery (GRS) or Gender Confirmation Surgery. 'Bottom surgery' has also become a common term since 2015.
The Harry Benjamin International Gender Dysphoria Association periodically publishes standards of care for hormonal and surgical reassignment, and most medical professionals follow this. The main points of the 2001 standard include the following:
SRS involves major surgical procedures by which the physical appearance and function of male genitalia are altered to resemble those of a female.
The ideal results are:
However, like all major surgical procedures, SRS is expensive, very painful, has many risks and there can be serious complications. There are many transwomen who take hormones and live, work and socialise as women, but never have SRS.
The first recognised SRS procedure only occurred in 1952, but numbers have grown rapidly ever since. A BBC report in 2007 suggested that there were 15,000 post-SRS transsexuals in the United Kingdom (1 in 4000 of the population), although this seems high for the date. Contrarily, the Gender Variance report of 2009 estimated that in the UK there were 10,000 transitioned transsexuals, 3,500 of whom had had SRS - of which 80% of were MTF, implying 2,800 post-operative transwomen.
In the United Kingdom, the National Health Service (NHS) performed 137 SRS operations (all MTF) in 2009 (compared to just 54 in 2004); another 90 were funded by UK health insurance companies; and the Gender Identity Research and Education Society charity estimates that at least 150 such procedures are paid for personally by the patient each year - these are usually performed overseas, most commonly in Thailand or the USA. I.e. a total of perhaps 380 UK residents had male-to-female surgery in 2009.
But numbers are increasing dramatically - by up to 50% a year! In 2013 the ;NHS received 2,500 new referrals of patients with gender dysphoria, this increased to nearly 4,000 (80% MTF, a fifth of which were under age 18) in 2015. Some 80-90% of NHS MTF patients receive hormone treatment and about 60% eventually go on to have SRS (i.e. potentially 1,800 of the 2015 referrals), although there is a huge backlog at every stage due to a lack of specialist medical staff. The NHS now (2016) has the capacity to perform about 480 MTF SRS procedures a year, but this is still far short of demand. Many British transwomen go private to avoid the long waiting times, most to surgeons in Thailand and the USA.
Based on trends, a reasonable guesstimate is that at least 1,000 UK residents had male-to-female sex re-assignment surgery in 2015. This leads to the projection that there are now probably 10,000+ post-SRS women in the country (including just a few dozen who had operations performed in the 1960's or even the 1950's).
However, the UK is just a very small element of a global picture, indeed it would be very surprising if the one millionth MTF SRS procedure hasn't already been performed.
Sex Re-assignment Surgery
Most surgeons will consider as eligible for SRS genital surgery a genetically male "woman" over the age of majority who has undergone at least 12 months continuous female hormonal treatment, and who's also successfully lived for at least a year full-time as a woman. However, a surprising large number of women who fulfil these criteria do not immediately seek SRS, or any other genital surgery. The reasons for delaying or avoiding SRS procedures are very diverse, but include:
Unfortunately, I haven't yet found any recent (rather than 1960's) statistics on the length of time after a real-life transition until genital surgery for male-to-female- women, but I have found some interesting figures for female-to-males. Dr Holly Devor when researching her book FTM: Female-to-Male Transsexuals in Society found that most transsexual men retain some very dramatic physical manifestations of their previous lives as females. More than 1/3 of the 35 participants in her research who discussed this issue said that they began living as men without the aid of either hormone therapies or surgeries. Another 60% of them began their lives as men with the assistance of hormone therapy but, on the average, they did not have their first surgeries for another 3 1/2 years. Only six (15%) of the 39 transsexual men interviewed had had any kind of genital reconstruction surgery. Furthermore, despite the fact that they averaged 6.5 years since beginning hormone therapy, and 7.9 years since beginning to live full-time as men, slightly more than half (51.5%) of those who had not yet had genital surgery said that they were not particularly interested in having any done.
These extraordinary results are not directly relatable to transsexual women as much more difficult and expensive surgical procedures are required for female-to-male sex re-assignment than for male-to-female sex re-assignment. However they do reinforce my own belief that a medium [average] delay of 3 years from full time transition to MTF SRS would probably be near the mark, high though this may appear at first sight given that a common complaint from transsexual women is the need to wait a whole year after transition before being eligible for surgery.
But the reasons to have some form of genital surgery often strengthens with time, and most transitioned transsexual women eventually undergo some procedure. Possible drivers may include:
The importance of the second point cannot be underestimated. Most post-transition but pre-SRS women gradually collect bad experiences, ranging from embarrassment during a security check, an unaware friend who sees too much, the wandering hands of a drunk, to the possibly fatal disappointment of a rapist.
In a few countries, a depressing problem is that some homosexual men have sex-change surgery because it is socially and legally more acceptable to be a transsexual woman than an openly homosexual man. Iran is most commonly cited. (Note: this should must not be confused with the homosexual transsexual theory).
Age at SRS
For decades after Swede Christine Jorgenson had her pioneering SRS in 1957, most empirical evidence and published studies have indicated that a majority of European and North American transsexual women are in their 30's, and 40's before they actively seek to resolve their gender issues. Inevitably this means that the patient age profile of surgeons undertaking sex-re-assignment surgery follows this trend - with a lag of a several years representing the time from the woman commencing treatment to having some form of genital surgery.
Considerable publicity often surrounds young transsexuals who with the support of their parents transition and have surgery at a very young age - in their teens or early 20's. There is no doubt that this group is becoming more numerous, but it is still only a very small proportion of the transsexual community.
There is also a statistically significant group of young transsexual women (often from parts of Asia and Latin America) whose career in the sex industry leads to various surgery procedures in during their teens and 20's, but this is usually in the form of breast augmentation and facial feminisation. When (or if) they finally decide to have SRS, typically in their 30's, it generally marks their move out of the sex industry,
The following table shows the
age of MTF transsexual women receiving SRS between 1997-2000 at one
clinic in Thailand:
Whilst the numbers are small, the general picture that a majority of western transwomen undergo SRS in or near their middle age is undoubtedly correct, for example an American study of 232 transwomen noted that their average age at the time of surgery was 44, with a range of 18 to 70. Similarly in the UK, the average patient age for 137 SRS procedures performed by the NHS in 2009 was 42, and only one patient was under 21. Cost is often a big issue, but the typical Asian transwoman seems to be able to find the money and will to have SRS at a least decade before the typical Westerner does. The huge difference in the age profiles of Asian and Western transwomen deservers further research.
Figures and statistics are hard to find, but as many as 50% of all transitioned transsexual women may fall in category one, and some will never progress to another category.
The decision on which option to select is a personal choice that may well evolve over time. For example, most men who believe that they are transsexual will start off assuming that they will have SRS as soon as possible when they seek treatment. However, after they have benefited from hormones (etc.) and perhaps transitioned to live as a woman they may no longer see any urgent need for SRS and itís only some event years later such as a relationship with a heterosexual man that eventually causes them to have SRS.
If there are any doubts, the best route is always NO surgery. Itís always possible to have surgery later, but itís impossible to reverse castration or SRS. Even if surgery is decided on, the prior freezing of a sperm sample (if obtainable) may be a sensible measure to help preserve some reproductive options - even as a mother.
Castration is most commonly performed with intersex or gender disordered children, but some transsexual women do find it to be a useful and cheap halfway house to full SRS.
For SRS a variety of techniques are used. By far the most common is variations of the Penile Inversion method. A less common procedure is variations the Sigmoid Colon Section method. Other techniques include the Scrotal Inversion Procedure and the new Peritoneal Pull-Through Vaginoplasty Procedure.
SRS always involves the formation of the entrance to neo-vagina (i.e. an artificial vagina). However for various reasons this can be often be quite shallow (just 2-3 inches, 5-7cm). The decision as whether to have a deep vagina suitable for penetrative intercourse by a penis need not always be an automatic "yes" - particularly for elder women who perhaps don't intend to lead an active sex life after surgery. Reaching and then maintaining full vaginal depth often requires the effort of regular dilation and/or then frequent sexual intercourse.
An interesting debate about the merits of two most popular SRS procedures can be found here, but the accepted pros and cons are summarised in the table below:
Through the 1990's, patients who expected to have very active sex life as a woman often opted for the colon procedure. However, since the early 2000's the penile inversion procedure (or minor variants of this) has been the dominant procedure recommended by surgeons. Whilst its still major surgery, the risk of serious complications is much lower (perhaps 1% compared to 10%) and the procedure has been refined to reduce earlier problems such as vaginal hair growth. The need for time consuming dilation in order to maintain vaginal depth has become the biggest complaint from patients.
The following factors will influence the results of the SRS and the depth of the vagina:
It is important to re-iterate that the prolonged use of hormones and an orchidectomy has a very negative effect in relation to SRS as in time the penis and scrotum will atrophy to some extent, i.e. the penis size reduces and the scrotal sack shrinks. The earlier that SRS is performed (ideally before hormones are even started!), the better the likely result, indeed some leading surgeons who are anxious to preserve their reputation are reluctant to perform surgery on a patient who has previously had an orchiectomy. Of course this situation contradicts the recommendation of many psychiatrists that a lengthy "real life test", usually associated with a hormone regimen, is essential prior to any genital surgery.
In general genetic women (regardless of their height) have broad hips, i.e. a broad pelvis with a pelvic cavity offering plenty of internal volume. They also have a wide pubic arch and a large oval-shaped pelvic inlet Ė ideal both for giving birth and for sexual intercourse. The result of this skeleton is that even an otherwise petite woman can comfortably and enjoyably accommodate a large penis. Unfortunately arrangements donít tend to be quite so satisfactory for transwomen - in general they have a narrow pelvis, a tightly angled pubic arch, and a small, partially obstructed, heart-shaped pelvic inlet. For the majority of transwomen their skeletal structure would theoretically rule out natural delivery of a baby, and rather more relevantly the pelvic bone structures of a minority may unnaturally (for the man) impede or even obstruct a penetrating penis, and also restrict the degree and direction that a neovagina can stretch to accommodate the penis.
Another issue is that fact that genetic woman have a strong muscular and ligament framework surrounding their vagina - muscles which act upon the penis during intercourse whether controlled consciously or unconsciously. Transwomen do not have any true vaginal muscles after their SRS Ė however a combination of frequent internal exercising and an active sex life can result in very satisfied male partners.
With modern techniques a good surgeon can often construct from the penis of a male-to-female patient a vulva that's more text book "female" in appearance than most genetic women actually have! Post surgery external cosmetic problems tend to relate to scaring, a high vulva/vaginal position (due to skeletal limitations) and an excessively large clitoris.
For successful intercourse, arguably sensitivity and even appearance (it's 3:00 am, dark, 5 pints and a bottle of wine consumed ...) are less important than the fact that the neovagina feels totally natural to the man, particularly if the woman is stealth. Adequate depth is just one factor, others include adequate lubrication and the womanís internal anatomy.
The Penile Inversion Procedure
For satisfactory penetrative sexual intercourse with the averagely endowed man, a vaginal depth of 6 inches (15 cm) is required. Unfortunately this is difficult to achieve with the popular penile inversion SRS procedure - using just penile skin may result in a vaginal depth as shallow as 2 inches (5 cm). After a year of diligent, the likely depth is still just 4 - 5 inches (10 - 12.7 cm). Insufficient vaginal depth is the biggest single cause of dissatisfaction in the results of SRS using the penile inversion technique.
As a result, surgeons have developed many variants of the penile inversion technique in order to improve virginal depth. For example supplementing the penile skin with a scrotal skin graft will double the initial depth to 4 inches (10 cm). Regular dilation can then extend this to desirable 6 inches (15 cm) Ė more than enough for satisfactory penetrative intercourse with most men. However the extra step increases the risk of complications such as dead tissue.
To accommodate the penis of a well endowed male partner, a vaginal depth of up to 9Ē (20-22cm) may be necessary. Whilst many natal cis-women will also have a problem fully accepting such a lucky man, their vagina is very stretchy in nature and doesn't have the unexpected dead-end of a transwoman's neo-vagina. The best surgical options for a very deep neovagina are a colon graft or peritoneum flaps - but even then the transwoman's pelvic skeleton and internals may limit during sexual intercourse the mimicking of the vagina of a genetically XX woman. For example (as noted above), the narrow pelvic opening of most transwoman will physically prevent their neovagina accommodating a penis with a girth much greater than 5" (13 cm).
Click on the picture below for a photo gallery of a patient undergoing sex re-assignment surgery using a variant of the penile inversion technique, with a scrotal skin graft to increase the depth of her neovagina.
Non-Penile Inversion Procedures
As described above, in Western Europe and North America the penile inversion vaginaplasty is currently by far the most common technique of SRS. But there are serious alternatives.
Scrotal Inversion Procedure
In Thailand - where nearly as many SRS procedures are performed annually as the he rest of the world put together - most surgeons use a scrotal inversion procedure. Instead of the penis, they use the scrotum to create a vagina. A big advantage is that the scrotal skin can be stretched, so a small penis is less likely to affect affect vaginal depth unless an orchidectomy (castration) has already been performed. During the surgery the surgeon will remove the hair follicles from the scrotal skin, so electrolysis is not required. The surgeon will try not to remove the bulbourethral glands (Cowper's gland's) as these help to provide lubrication during sexual arousal. Immediately after surgery, 15 cm (6 inches) of vaginal depth is typical, and 18-19 cm (7 inches) common. Post-surgery dilation is still required in order to maintain depth, but it's slightly less demanding than penile inversion which is often trying to increase vaginal depth.
Although the penile inversion procedure is technically a more advanced procedure, there is no doubt that Thai surgeons are consistently achieving excellent results with other techniques.
Peritoneal Pull-Through Vaginoplasty
The peritoneum is basically a bag of loose tissue that encircles the inside of the abdomen and holds the guts in place. The peritoneal pull through procedure was originally developed in India to help natal women who were born without a vagina. The first procedure on a transwoman was performed in 2017 and it has since become an increasingly popular option for male-to-female SRS patients - particularly if they lack sufficient penile or scrotal skin to line the neovagina .
During surgery, a laparoscope and several instruments are inserted through small 5-8 mm incisions on the abdomen. These instruments are used to create a space between the lower urinary tract (urethra, prostatic urethra, and bladder) and rectum. This space will become the future vagina. Abdominal (peritoneal) lining is then pulled through to the area between the urethra and the rectum to line a portion of the vaginal canal. The top of the new vagina is separated from the abdominal contents by closing the peritoneal lining approximately 15 cm from the vaginal opening. The remainder of the vaginoplasty procedures (labiaplasty, clitoroplasty, penectomy, orchiectomy, partial urethrectomy, and other associated procedures) are similar to that of the penile inversion technique.
Peritoneal pull through has the theoretical benefits over the penile inversion technique of having lubrication, needing less dilation, less douching, less maintenance, and more depth. This option is also theoretically less risky than sigmoid colon vaginas - not having the risk of anastomosis breakdown, having less risk of prolapse, not having odorous mucus discharge, and no need for monitoring colon pathology. However because the procedure is still so new for transwomen, it remains to be seen how real the advantages are.
Another recently developed technique for lining a neovagina is the use of tilapia fish skin! The first procedure on a transwoman was only in April 2019, but it has rapidly gained in popularity.
In this procedure a vaginal acrylic mould covered with processed and sterilized tilapia fish skin is inserted and accommodated into the newly created cavity. The grey external side of the tilapia skin (scales removed) stays in contact with the acrylic mold, while the white internal side of the tilapia skin, which was previously attached to the fish's muscle, is in contact with the walls of the neocavity. The mould is held in position by sutures in the labia majora, thus preventing expulsion.
The patient remains in bed rest for 9 days, by which time the tilapia fish skin has been partially reabsorbed and has encouraged the development of vaginal wall tissue. The acrylic mould is removed and a larger plastic mould (8-9 cm long) is inserted, the patient is advised to wear this day and night for a month. She then needs to wear it every night unless engaging in regular normal sexual intercourse. Analysis of the neovaginal wall of one patient 180 days after surgery showed the presence of a stratified squamous epithelium with five cell layers, small ectatic (swollen) blood vessels and occasional desquamated epithelial (shedding) cells - not perfect but significantly better than the neovaginal lining of most transwomen.
A Healthy Vagina
One rarely mentioned problem that a transwoman faces after SRS is that her new vagina lacks the complex community of 'good' micro-organisms that help to keep the vagina of a natal cis-woman healthy. These microbes play an important role in preventing unpleasant bacterial infections (including sexually transmitted and urinary tract infections), vaginal discharges, and an excessively strong fishy smell emitting from the vulva area. They also reduce or eliminate the need for douches or vaginal washes.
In MTF transgender women, the pH in penile inversion (i.e. skin-lined) neovaginas is elevated, owing to an inability to support the growth of acidic lactobacilli, with colonisation of bacteria from skin or intestinal micro-organisms instead. This may increase susceptibility to recurrent neovaginal infections.
A possible solution being explored in 2019 by John Hopkins University in the USA is the use of vaginal fluid transplants. The concept is very simple - a donor woman inserts and then removes a flexible plastic disc - similar to a menstrual cup or a contraceptive diaphragm - to collect fluid from her vagina which is filled with 'good' bacterium. The fluid is then drawn up into an applicator for the recipient to insert in to her neovagina a similar way to a tampon. Hopefully the newly introduced bacterium will then populate and multiply in their new home., and reduce.
If the trial results are good, this may become a common a procedure in a few years time. One to watch!
Vagina Not Required
Many transsexual women have SRS with little or no expectation of having subsequent penetrative sexual intercourse. Based on limited evidence it seems that about one in six post-SRS women have never had their vagina 'penetrated' during sexual relations.
If a transsexual woman does not plan to have vaginal penetrative sexual intercourse then clearly there is no need to have a deep vagina formed, and unnecessary surgical procedures can be avoided and the subsequent dilation effort will also be spared.
The 'penis/dildo penetration not required' approach offers the transwoman significant health and hygiene benefits, possibly too many surgeons and patients focus excessively on the creation of a deep neo-vagina which may not be necessary. The emphasis can instead be place on achieving the best possible external appearance, rather than on sexual functionality and enjoyment. For example surgeons find it difficult to construct from a penis a sensitive clitoris of natal female size and thus often have to balance sensitivity with avoiding excessive size - this conundrum disappears if 'good sex' as a woman is not a driver for SRS.
Conversely, if sexual intercourse and sexual genitalia able to accommodate deep penetration in the Missionary Position by even "Mr Big" are an immediate high priority, the colon section procedure may be preferable to the more common penile inversion technique despite the risks and complications as it provides a more convincing looking, self-lubricating and self-cleaning neo-vagina, and arguably copes better with frequent and robust penile penetrations.
Note: Since writing this section, one transwoman has contacted me expressing her regret at not seeking and working for the maximum possible vaginal depth during and after her SRS.
A consideration rarely taken in to account by transwoman is the increased risk of cancer resulting from their medical treatments.
Unsurprisingly the transwoman's risk of breast cancer is greatly increased by hormone therapy when compared to men, although studies have so far concluded that the incidence rate is still below that of natal women. The relatively rare cases of breast cancer in transwomen are often associated with excessive self-medication of oestrogen hormones.
Unlike men, a post-SRS transwomen faces the risk of cancer in her neo-vaginal tissues.
The risk is greatly raised if the cells lining a neo-vagina slowly alter in type to that of a normal female vagina (technically a nonkeratinizing mucosal type squamous epithelium) - including normal vaginal PH levels, complete loss of hair, complete loss of pigment, complete loss of sweat glands, and normal vaginal epithelial glycogen levels.
The anecdotal evidence of many transwomen after a penile or scrotal inversion suggests that the skin graft does indeed gradually take on the characteristics of a "natural" vagina, e.g. I've seen claims that a smear test of a transwoman 10-20 years after SRS is impossible to distinguish from a natal woman. However most medical studies seem to be conclude that no significant changes in cell type actually occurs.
Overall, the risk of cancer in the neo-vagina tissues of a post-SRS woman is probably very low. Nevertheless, having smear tests every 3-5 years should be considered as a pre-caution - particularly if there is a family history of cancer.
Some surgeons used to suture the glans of the penis in the most distal (inner) area of the neo-vagina to simulate a cervix (neo-cervix). Dr Stanley Biber - a leading surgeon in the 1970's to 1990's - was a particular advocate of this technique. It's now a very rare procedure, but several transwomen have had cancer in the tissues of their neo-cervix. Regular Pap tests are thus highly recommended for the few transwoman with a neo-cervix, particularly if they are sexually active.
A serious possibility for the future is that transsexual women may be implanted with female sexual organs grown from their own cells. For example, a report in a 2014 edition of the medical magazine Lanclet described how four women (all teenagers) born without vagina's had had new vaginas grown in a laboratory and implanted by doctors at the Wake Forest Baptist Medical Centre in the USA.
The women's vaginas did not form properly while they were still inside their mother's womb, a condition known as vaginal aplasia. Current treatments normally involve surgically creating a cavity, which is then lined with skin grafts or parts of the intestine - transsexual women essentially undergo the same surgical treatment.
Under the new procedure a tissue sample and a biodegradable scaffold are used to grow vaginas in the right size and shape for each woman - as well as being an exact tissue match. After surgery, the woman all reported normal levels of "desire, arousal, lubrication, orgasm, satisfaction" and painless intercourse.
Caveat Emptor - Buyer Beware
I had been properly assessed, it would have been obvious that sex-change
surgery was inappropriate for me, I was desperately unhappy and was
going for a sex change because I felt under pressure from my boyfriend.
I'll never have a relationship. Who's going to want me when they
could get a real woman? I am not a woman, I am a sex change, and
men know that. I fundamentally regret having had surgery. I
could have lived as a woman without mutilating my body, but no one
talked to me about the possibility."
M: "If and when you have [SRS] your life
will be forever changed, in more ways than you can possibly imagine and
anticipate. Being a woman is no better than being a man (in fact,
in many ways it's a lot worse) - you just have a new set of problems.
For me, being a woman expressed who I really am, but sometimes I think
the cost of that self-expression was too dear."
W: "Becoming a woman has been a disaster, this
experience has ruined my life. I felt excited when dressing as a
woman but looking back it messed up my head - [psychologists] had me
believing I'd always wanted to be one. [After SRS] I tried to
persuade myself I had no regrets. [A] reversal won't solve all my
problems, I will still be tortured by what I gave up to become a woman."
Samantha Kane: "The whole experience was very
distressing for me - it was a devastating operation and very difficult.
I was a heterosexual male - I have never been gay - and that is why it
didn't make any sense to have [SRS]. I was suffering from a
nervous breakdown after the break-up of my marriage so I was very upset.
I took hormones which changed my mind and my body so I wasn't thinking
clearly. After the surgery my mind was a lot clearer and I felt
better ... I wanted to live back as a man because I knew I wasn't
a woman." Samantha also found that having sex with her boyfriends
was boring, and that she had "penis envy".
M: "If and when you have [SRS] your life will be forever changed, in more ways than you can possibly imagine and anticipate. Being a woman is no better than being a man (in fact, in many ways it's a lot worse) - you just have a new set of problems. For me, being a woman expressed who I really am, but sometimes I think the cost of that self-expression was too dear."
W: "Becoming a woman has been a disaster, this experience has ruined my life. I felt excited when dressing as a woman but looking back it messed up my head - [psychologists] had me believing I'd always wanted to be one. [After SRS] I tried to persuade myself I had no regrets. [A] reversal won't solve all my problems, I will still be tortured by what I gave up to become a woman."
Samantha Kane: "The whole experience was very distressing for me - it was a devastating operation and very difficult. I was a heterosexual male - I have never been gay - and that is why it didn't make any sense to have [SRS]. I was suffering from a nervous breakdown after the break-up of my marriage so I was very upset. I took hormones which changed my mind and my body so I wasn't thinking clearly. After the surgery my mind was a lot clearer and I felt better ... I wanted to live back as a man because I knew I wasn't a woman." Samantha also found that having sex with her boyfriends was boring, and that she had "penis envy".
In the last case, Sam had SRS in 1997 to become Samantha, but reverted
to male in 2004 and had more surgery to help this as far as possible.
Extra-ordinarily, in 2018 he decided that she prefered being Samantha
after all, and again transitioned and had feminisation surgery. In
the last 21 years he/she has spent £150,000 (well over $200,000) on
the very interesting results of a Post-Operative Survey of
Transsexual women, see
a dire warning about the risks of low cost, back street SRS, read
For the very interesting results of a Post-Operative Survey of Transsexual women, see here.
a dire warning about the risks of low cost, back street SRS, read
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