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Surgical Options for the
Transgender Woman

 

Terminology

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 possibly more accurate terms such as Gender Reassignment Surgery (GRS) or Gender Confirmation Surgery.  The uncontentious term 'Bottom surgery' has also become a common term since 2015.

 

Background

The Harry Benjamin International Gender Dysphoria Association periodically publishes standards of care for hormonal and surgical reassignment, and most medical professionals follow this.  I.e. reputable surgeons will refuse to perform SRS on a patient who does not fully meet the standards.  

The key points of the 2001 version of the standards are:

  1. Clinical decisions about both hormonal and surgical reassignment should be made by clinical behavioural scientists with appropriate experience of the diagnosis and treatment of psychological and sexual problems, as well as experience of working with patients with gender dysphoria.
  2. The wish for sex reassignment should have existed for at least two years.
  3. The clinician should have known the patient for at least 3 months before recommending hormonal and 6 months before recommending surgical reassignment.
  4. This recommendation should be supported by a second appropriately qualified clinical behavioural scientist.
  5. The patient should have lived full-time in the preferred role for at least one year before sex re-assignment surgery is recommended.  

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:

  • A natural appearing vulva (external 'bottom' genitalia) including mons pubis, labia minora and majora
  • Functional vagina, with enough depth for penetrative sexual intercourse by a penis
  • Sensate clitoris
  • Moist appearance
  • Hooding of the clitoris
  • Self-lubrication of the vagina (particularly during intercourse)

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 oestrogen hormones and live, work and socialise as a women, but never have SRS.

 


Christine Jorgenson, her 1952 sex-re-assignment is widely considered to be the first using modern surgical techniques. 

Some Numbers

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.


A photo provided by a UK transgendered woman.  The NHS undertook her SRS, but amazingly  wouldn't conduct breast augmentation surgery as well.

Numbers are increasing dramatically.  In the UK, in 2013 the NHS received in 2014 2,500 new referrals of patients with gender dysphoria, just two years later this it was nearly 4,000 (a fifth of which were under age 18).  Historically about half of the referrals will eventually has SRS. 

The NHS currently has the capacity to perform about 480 MTF SRS procedures a year, but 1800 patients are expected to be added to the waiting list in 2016.  To avoid years of waiting, many British transwomen choose to pay to go private, mostly 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 more than 10,000 post-SRS women in the country.  Of these (age of course being a factor), only a handful had their operation in the 1950's  a few dozen in the 1960's, and a few hundred in the 1970's.  The vast majority have had their SRS since 2000.

However, the UK is just a small element of a global picture, it would be very surprising if a cumulative total of one million MTF SRS procedures had not been performed worldwide by the end of 2015.  If the number of operations continues to rapidly increase this could easily reach two million by 2020. 

 

SRS - Before and AfterSex 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:


Bianca Magro had the first legal sex re-assignment operation in Brazil.

  • It is irreversible - if there is any uncertainty don't do it
  • Lack of money for surgery.
  • Potential loss of earnings after surgery.
  • Happy as is, no strong desire or psychological need to have female genitals.
  • A homosexual sexual orientation.
  • An enjoyable sexual relationship as a pre-SRS woman (not the same as 'homosexual')
  • Pressure from a partner, family or friends.
  • Fear of the surgery.
  • A desire to preserve a reproductive capability.
  • A medical problem which prevents major surgery.
Many transwomen - perhaps unwisely - share and celebrate the results of their SRS (aka bottom surgery) on the Internet.  Low definition versions of images published by two happy girls.

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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.


Sexual desire can become a powerful motive for SRS...


... as can be presenting a female physical appearance when nude.  [Note the breast augmentation scars just visible below the areola]

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:

  • A powerful desire to finally match the bodies physical sex with a female psychological gender and social lifestyle.
  • To present a female physical appearance when nude, and remove fear of identification as a "man" due to the presence of male type genitalia.
  • A desire to have 'normal' heterosexual intercourse with men as a woman.
  • Pressure from a partner, family and friends.  This "encouragement" can be excessively strong after a transwoman admits her transsexuality and transitions
  • Fashion and Comfort - Tight and revealing clothes no longer present the "strange bump" fear.  No more genital tucking and taping, or the discomfort of a gaff. 
  • To remove the masculinizing physical effects and/or urges caused by the testes.
  • Health - Concern about long term liver damage due to prolonged use of anti-androgens and high oestrogen and progesterone doses.
  • A strong and sexually exciting desire to have female genitals (a controversial reason).
  • To help a homosexual "man" have sexual relationships with attractive heterosexual men (a very controversial driver).

The dubious 1978 film "Let Me Die a Woman" demonstrates the desperation of some transsexuals.

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). 


AJ Clementine had her SRS age 22.  Whilst surgery at this age and earlier has been common in Asia and South America for decades, it was extremely rare in Europe and the USA before the 2010's. 

Age at SRS
In 2007 the BBC reported that there were 15,000 post-operative transsexuals in the United Kingdom.  This was just 1 in 4000 of the population, so no surprise.  What was as surprise was the claim that they had at SRS an average age of 29 - significantly younger than prior European studies.

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.

 
A chart showing the age of legal change of status (usually after SRS) of 712 German transsexuals aged 18 to 79.  The average (mean) age is a 34.
Source: Weitze C., M.D., Osburg S., M.D. (1997)]

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:
 

Nationality

Average age
(Years)

Lowest age
(Years)

Highest age
(Years)

Total number

Thai  26.7 19 45 79
Japanese  39.3 19 54 8
English  39.0 26 53 5
Australia/NZ 40.8 25 50 7
USA/Canada  50.5 22 65 66
All 37.8 19 65 165
                               Source: Phuket Plastic Surgery Clinic, Phuket, Thailand


The story of Vonlee (formerly Harry) Nicole Titlow shows the extremes some transsexuals will go to. After transitioning in her early 20's (left). she's pictured (right) age 33 whilst on trial for helping to murder her uncle Donald Rogers in return for $70,000 that would pay for her SRS.

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 deserves further research.

 

Surgery Options
The transsexual woman who has transitioned full-time faces a difficult choice between a number of medical options regarding surgery on her male genitalia.  In order of increasing complexity and cost these are:

  1. No surgery (although prolonged female hormonal treatment will shrink the male genitalia significantly and will eventually cause permanent chemical castration after about 6-12 months use)

  2. Surgical Castration or Bilateral Orchidectomy, i.e. removal of the testes (or gonads) along with the undesirable masculinising and virilizing effects caused by the testosterone they produce.

  3. chanelle.jpg (9659 bytes)
    Chanelle, post-SRS. She now works as a model.

  4. SRS - removal of the testes and penis and the formation of female appearing external genitalia, but with no emphasis on vaginal depth.  This is usually followed by a labiaplasty several months later.

  5. Full SRS with vaginoplasty - removal of the testes and penis and formation of female appearing external genitalia, formation of a neo-vagina with adequate depth for intercourse.  Again, this will often be followed by a labiaplasty.

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.


The vulva on the left was a runaway favourite in a survey of transsexual women.  Note the minimal amount of hair, the small clitoris, and the generally slight and delicate features.  The vulva on the right is a post-operative result by a leading surgeon taken from the Transsexual Women Resources website.   

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 in the link here, but the accepted pros and cons are summarised in the table below:

  Colon Section Penile Inversion
Advantages
  • Natural-looking vulva
  • No neo-vaginal contractures
  • Excellent functionality
  •  and feel for sexual partners penetrating the neo-vagina
  • The fluid secreted from the intestine acts as a natural lubricant during sexual intercourse
  • Only moderate neo-vaginal dilation required
  • No risk of vaginal hair growth.
  • A relatively simple surgical procedure which greatly reduces possible complications and related side effects.
  • No risk of causing peritonitis or intestinal adhesions associated with colostomy
  • Rapid recovery - 4-6 days in hospital.
  • Usually cheaper.
Disadvantages
  • It's major surgery that affects a healthy colon
  • Prolonged recovery period due to an extensive surgery through abdominal cavity.
  • May develop complications such as peritonitis, intestinal adhesions and necrosis of intestinal graft
  • The vagina may "leak" and smell.  Sanitary pads in the panties can be a permanent requirement.
  • Requires frequent neo-vaginal dilation
  • Possible neo-vaginal contractures after surgery
  • Sexual intercourse may require an artificial lubricant (KY Jelly et al).
  • May need to douche daily to avoid an unpleasant vaginal smell and infections
  • Painful electrolysis of scrotal hair used to be recommended but no longer required most surgeons.

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:

  • The patients body size and BMI (the smaller and lighter the better)
  • Circumcision (preferably not)
  • Length of penis (the longer the better)
  • Circumference and girth of the penis (greater the better, ideally more than 3 inches / 7 cm when 'excited')
  • Amount of scrotal skin (the more abundant the better)



Top is a drawing of the front of a male pelvis, in the middle is a female pelvis showing its far larger pelvic opening  Bottom is a drawing of a female vagina accommodating a penis during intercourse, it shows how the penis is confined by bones - the pubic arch bones at the front and the coccyx bones at the back.  The smaller pelvic gap of a transwoman can be an odd and uncomfortable constriction for a man penetrating her 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.
 
Vulva of a gentic XX woman
The labelled upper picture shows the vulva of a typical genetic woman, the lower that of a transsexual woman.  In general genetic women have a slightly higher placed, more delicate but less 'tidy' vulva.

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


A superb animation of the penile inversion procedure, click to view.

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).

An Overview of the Male-to-Female Sex Reassignment Surgery (Vaginoplasty)
Penile Skin Inversion Procedure


Before

After

1) An incision is made on the scrotum and the testicles removed. Most of the penis is amputated, but the skin and nerves are carefully preserved.
2) A vaginal cavity is made, the skin of the penis is turned inside out and  used to cover the inner parts of the neovagina. The very sensitive glans goes deep inside and acts like the cervix of the uterus.
3) A clitoris is constructed from sensitive erectile tissue taken from the penis (some surgeons use a small part of the glans), and the scrotal skin used to build the labia majora.
4) A later labiaplasty may sometimes be needed to "tidy things up" and hood the clitoris.
With a good surgeon, the final aspect should be indistinguishable from real female genitalia.

 

Another representation of the "penis inversion" Male-to-Female Sex Change Procedure


1. An incision is made around the base of the penis.
2. The skin is peeled back as intact tube and the erectile tissue is removed.
3. A vagina is constructed in the perineum and lined with the inverted penis skin.
4. The skin of the scrum is sectioned and the testes are removed.
5. The scrotum skin is used to make a labia, and the urethra is brought out and positioned above the vagina.
6. The operation is complete.

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.


A photo provided by Dr Chettawut of a patient after SRS using the
scrotal inversion procedure. Unsurprisingly this shows an excellent result.


A photo provided by a patient of Dr Suporn in Thailand, three years after SRS.  The result is good, but natal women typically have a more prominent clitoris and more obvious labia "lips".

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 .  


A vaginoplasty peritoneal pull through operation on a transwoman, probably  performed by Dr Heidi Wittenburg.  The after photo (right) isn't very helpful! 

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.

Fish Scales

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.

 

natasha.jpg (9862 bytes)
Natasha celebrates  her SRS, but  unfortunately as a woman she is now at increased risks of several cancers compared to a man.

Cancer Risk

A consideration rarely taken in to account by transwoman is the increased risk of cancer resulting from their medical treatments.  

Breast Cancer

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.

Vaginal Cancer

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.

Cervical 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.

 


Scans of the pelvic region are used to design a tube like 3D-scaffold for each patient, the vagina is then built on this

The Future
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.

In 2016, the 25 year old transwoman and model Maria Maddalena Bulfer featured alongside Eva Robbins in a transgender awareness campaign.

Caveat Emptor - Buyer Beware
It was the 1976 when first started to wonder if I was a transsexual (transgender and suffering from gender dysphoria in modern terminology).  At that time only a few clinics (E.g. the John Hopkins Gender Identity Clinic) and surgeons (most famously Dr Georges Burou in Morrocco) were performing sex-reassignment-surgery, perhaps a few hundred operations per year world-wide.  Forty year later there is

Regrets
While most post-operative transsexual women don't regret their decision (or claim they don't), a few do - and this fact cannot be ignored. 

Sam to Samantha to Charles to Samantha again

C: "If 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".

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 surgery.
 

Dr Carlos Cury (centre) with some of his post-operative transsexual patients in a photograph for the Brazilian magazine "Hands".  His secretary, Guta is in the white dress to the left of Dr Cury.

Guta Silveira was one of Dr Cury's patients, and is now his secretary.

More Information

For the very interesting results of a Post-Operative Survey of Transsexual women, see here.

For a dire warning about the risks of low cost, back street SRS, read this article.

  


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Last updated: 6 June, 2016