Surgical Options for the
Transgender Woman

Important Disclaimer: The information on this page is often historical and should not be used to guide surgical decisions.



The first version of this article was written in 1999.  At that time, the term "transsexual woman" commonly meant a man who 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 term 'Bottom surgery' has also become a common term since 2015.


Some Background

It is important not to romanticize SRS/GCS.  It is brutal, major, painful and expensive surgery that involves permanent male castration and infertility, the removal of an often-functional penis, and the creation of a vulva and high maintenance vaginal cavity that imperfectly attempt to mimic cis-female sexual organs, with a loss of sexual libido, enjoyment and the ability to orgasm also likely.  And on top of this is the risk of serious immediate or long-term medical complications.

For some transgender women, GCS and the ability to have vaginal sex is an absolute top priority that is sought as soon as they are legally old enough (usually 18) and can afford it (at least $25,000).  For others it's almost an afterthought - reluctantly undertaken to help pass physically as a woman.

A huge change in the last few decades - at least in the "west" has been the reduction in the age of the patient having GCS.  In the UK the average medium age for GCS performed by the NHS on a transwoman was 42 in 2000, it had decreased to 36 by 2016, and was just 23 in 2023! 



Sex re-assignment surgery arguably goes back thousands of years - particularly if castration is accepted. In the 4th century BC Aristotle was accurately describing the physical results of male castration, and attractive young eunuchs were often the preferred sexual partner(s) of Kings and Nobles in Asia, Africa and beyond.

In China, for two millennium boys and young men - typically in their late teens (i.e. after male puberty) - volunteered to become eunuchs because of the potential financial rewards.  Rather than just the testes, the procedure involved the drastic removal by a knife of all male genitalia (scrotum, penis, and testes) - which were then preserved in alcohol as evidence that they had been born male.  The healed genital area resembled a female vulva, but with no vaginal entrance - just an enlarged urethra entrance due to the insertion of a plug after castration to stop it closing.  This was to ensure that peeing was possible post castration, rather than for any sexual purpose. 

Most survivors of the procedure became court functionaries, but eunuchs castrated before the age of 10 were considered ‘thoroughly pure’ (presumably meaning feminine in both appearance and speech) and were prized as personal servants, i.e. concubines.  A few became the acknowledged 'companion' or even the wife of a senior official - the later including other important eunuchs!

What have the Romans Ever Done for Us?
The Roman Emperor Nero inevitably put a twist on the practice of important men often befriending a eunuch as a sexual partner.  In AD67 he had castrated a teenage boy, Sporus, who bore a remarkable resemblance to his second wife Poppaea Sabina - whom he had kicked to death two years earlier.  He then renamed Sporus as Poppaea Sabina and married her.

Another Roman Emperor, Marcus Aurelius Antoninus, better known as "Elagabalus", is sometimes considered to be the first transsexual woman.  By AD220 (age 16) he was dressing as a woman, had married at least one man, and supposedly offered vast sums to any physician who could provide him with a vagina. 

Imaginative paintings of Sporus (left) and Elagabalus.


Christine Jorgenson, born George

Surgery Becomes An Option

Christine Jorgenson's surgeries in Denmark and the USA between 1951 and 1953 are widely accepted to be first attempt using modern surgical techniques to create female genitalia from male genitalia - including a vagina.

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.

French showgirl Jacqeline Dufresnoy (stage name Coccinelle) risked every surgical feminisation procedure available in the late 1950's and early 1960's including SRS.

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 woman, but never have SRS.


Some Numbers

The first recognised SRS procedure only occurred in 1952, but numbers have grown rapidly ever since - from dozens annually (world-wide) in the 1960's to tens of thousands in the 2020's. 

A BBC report in 2007 claimed that there were 15,000 post-SRS transsexuals in the United Kingdom but this seemed improbably high.  Perhaps more accurately a Gender Variance report in 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.

Since the mid-2000's numbers have been increasing dramatically.  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 UK transgender woman after her SRS by the NHS.  Her request for breast augmentation was rejected.

In the UK, in 2013 the NHS received 2,500 new referrals of patients with gender dysphoria, just two years later this 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 1,800 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 about 1,000 UK residents had male-to-female sex re-assignment surgery in 2015 (compared to 9,000 in the USA).  This leads to the projection that there were around 16,000 post-SRS women in the country in 2020 (about 1 in 2000 of the female population).  Of these (allowing for deaths), less than 1000 had their SRS before 2000!

It should also be noted that whilst SRS patients in their teens and twenties have been commonplace in Asia and South America since the 1980's, it was rare in Europe and the USA before the 2010's.

The UK is just a very small element of a global picture, with "sex change hospitals" around the world each now performing hundreds if not thousands of procedures a year.  Whilst clinics in Thailand have the most publicity (e.g. Chettawut Plastic Surgery Centre, Sava Perovic Foundation Surgery, and Phuket International Aesthetic Centre), there are also lower profile but still very substantial clinics in the USA (e.g. Rumercosmetics, Transgender Surgery Institute of Southern California, Mount Sinai Centre for Transgender Medicine and Surgery) and in other countries such as Germany, Australia and Brazil.

Oh yes!  I will book my Sex Re-assignment Surgery today!

I've attempted and failed to find good statistics on the number of MTF SRS procedures that have been performed, but a cumulative total of one million at some point between 2016 and 2020 seems certain.  If forecasts of a continuing 25% annual growth are correct then the number could easily pass two million by the mid-2020's 


Sex Re-assignment Surgery

The diagram to the right compares the organs of a male and a female in abdomen region.  The immediate standout is the primary sexual organs of the male - the prominent penis and testes.  The removal of these makes the two diagrams much more similar - and it's much easier to surgically remove tissue than add!  It takes a closer examination to reveal the woman's primary sexual organs - her ovaries and uterus.  However, there is currently no way that these can be replicated except by very risky and costly implants.  A final examination of the diagrams alights on the path of the female urethra, the vagina, and the extraordinarily complicated vulva area of a woman.  Counting Christine Jorgensen's penectomy operation in 1952 as the first real SRS, surgeons have essentially spent 65+ years refining their procedures for these.

A typical external before and after SRS result (c.2000).

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.  Images published on-line by two happy girls.


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.  [Breasts implants and scaring are obvious on the original hi-res photo]

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 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 1978 film "Let Me Die a Woman" is very dubious, but nevertheless 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 must not be confused with the homosexual transsexual theory). 

Photos of a transwoman's "bottom" before her SRS; a week after surgery; and several months after surgery.  Swelling is obvious in the middle picture; this has gone in the right picture and the overall appearance of the vulva is tidy with the labia majora and minora "lips" apparent.  She claims to have 8.5 inches (22 cm) of vaginal depth, which is very good.


Penile InversionSurgery 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.  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. The removal of the testes (or gonads) along with the undesirable masculinising and virilizing effects caused by the testosterone that they produce.

  3. Limited SRS - vulvoplasty.  This involves the removal of the testes and penis and the formation of female appearing external genitalia, but with no emphasis on vaginal depth.  A labiaplasty will often follow to improve the vulva's external appearance.

  4. Full SRS- vulvoplasty and vaginoplasty.  Removal of the testes and penis and formation of female appearing external genitalia, plus the creation of a neo-vagina with adequate depth for intercourse.  A labiaplasty will again often follow to improve the vulva's appearance.

A pre-op examination.  A lack of skin material to work with due to long term-hormone therapy and orchidectomy is a common problem for surgeons.
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 it’s 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.  It’s always possible to have surgery later, but it’s 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 of the Sigmoid Colon Section method, or Colovaginoplasty.  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
  • Good vaginal depth, 5-7 inches easily maintained
  • Excellent functionality and feel for male 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 long term
  • No neo-vaginal contractures
  • 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.
  • More expensive
  • 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 to achieve and then maintain reasonable depth (4-6 inches)
  • Sexual intercourse likely to require an artificial lubricant (KY Jelly et al).
  • Possible neo-vaginal contractures after surgery
  • Need to douche regularly to avoid an unpleasant vaginal smell and infections
  • Painful electrolysis of scrotal hair used to be recommended - but no longer required by most surgeons.

Patients who expect to have very active sex life as a woman often opt for the colon procedure.  However, the penile inversion procedure (or minor variants of this) remains the dominant procedure recommended by surgeons.  Whilst it's still major surgery, the risk of serious complications is much lower (perhaps just 1%) 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 – 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 don’t 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 after SRS.  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 – however a combination of frequent internal exercising and an active sex life can result in very satisfied male partners.

With modern techniques, surgery at a good clinic is likely to result in a single operation in an external physical 'bottom' appearance that is sufficient (particularly with pubic hair) to not to have to worry in female changing rooms or having sex in a darkened room.  Post surgery problems tend to relate to scaring, a high vulva/vaginal position (due to skeletal limitations) and an excessively large clitoris.  Admittedly, achieving a visual appearance that on intimate examination in daylight is hard to distinguish from a natal women is still likely to require revision surgery to tidy things up, e.g. the labia and clitoral hood.  

For successful intercourse, arguably sensitivity and even appearance (it's 3:00 am, dark, and many pints and a bottle of vodka have been 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 woman’s internal anatomy. 

Some transwomen place great emphasis on having a natural looking vulva area, for example a transwoman working as a female model will frequently have to pass nude backstage with numerous strangers.  Other transwomen may prioritise a sensitive clitoris over good vaginal depth, for sexual reasons that include lesbianism and masturbation desires. 

Overall, it is highly recommended that a transwoman planning to have SRS carefully research both the best procedure and the best surgeon that is likely to best meet her priorities - albeit with no absolute guarantee of success.

The penile inversion procedure is consistently the most common SRS procedure.  The graphic above
dates to 2018 and illustrates a procedure that whilst greatly improved, would still be recognisable
to Dr Burous when he started using it over 60 years earlier.  Click on the image to enlarge.

A before and after diagram showing the the original penile inversion procedure.  Click to enlarge

The Penile Inversion Procedure

The penile inversion technique was pioneered by Dr Georges Burou who first used it at his famous Morocco clinic in 1956.  Its original success was due to its sheer simplicity, albeit still involving major and risky surgery.  Critically it gave patients a functional vagina, often indistinguishable by men from that of a cis-woman.  Whilst the external appearance of the vulva in procedures up to the 1970's often amounted to no more than a slit-like entrance to the neo-vagina, the growth of pubic hair and restricting intimacy to a darkened room often avoided any problems.

The procedure has since been greatly refined and improved, and as of the early 2000's it remains by far the most commonplace MTF SRS procedure - if only because its advantages and problems are so well known by both surgeons and patients. 

The penile inversion technique generally produces satisfactory aesthetic and functional results, although these may of course vary depending on the age, weight, quality and elasticity of the skin, and the overall health of the patient.  A typical result by an average surgeon is:

  • a vaginal cavity which after dilation will allow penetrative sex
  • a sensitive clitoris constructed from the skin of the penis glans
  • erogenous zones (clitoral and vaginal) with the possibility of sexual pleasure
  • a vulva with labia majora and labia minora located in the central portion of the vulva (between the hood and the urinary meatus) and
  • a hood covering the upper part of the clitoris

Six to twelve months after SRS the swelling will have gone, tissue will have healed, scares faded and pubic hair grown.  The genitalia of the woman are then very likely to be passable when nude in a changing room context, and possibly even in an intimate relationship.

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



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.


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.

An animation of the penile inversion procedure, click to view.

A major disadvantage of the penile inversion procedure is the limited depth of the neo-vagina.  Most patients will have been taking female hormones for the several years and as result their penis will have greatly shrunken in size.

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 dilation, 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. 

"I've heard a rumour that the
Doctor had a sideline in SRS operations ..."
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) – more than enough for satisfactory penetrative intercourse with most men.  However the extra step increases the risk of complications such as tearing and dead tissue. 

To accommodate the penis of a well-endowed male partner, a vaginal depth of up to 9” (20-22cm) is 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 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 internal organs may limit during sexual intercourse the mimicking of the vagina of a genetically XX woman with an exceptionally well endowed man.  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).

A picture sequence of a 53-year old transwoman have SRS using the penile inversion technique:

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.

The procedure begins with an incision down the centerline of the scrotum from the base of the penis and a catheter is inserted into the urethra. The muscles making up the pelvic floor are separated to make a path for the neovagina to pass through and into the body. The ductus deferens are cut and the testes removed (and sent to pathology for examination). Then a radial incision is made on the skin of the penis just under the glans and the penis skin is dissected from the shaft.

The degloved penis is pulled through the skin into the scrotal opening and is further dissected: the corpora cavernosa are separated and cut off at the base and discarded; the urethra and the glans cap connected to the neurovascular bundle are retained.

The glans is reduced by removing epithelial tissue — this becomes the neoclitoris and is placed at the base of the corpora cavernosa via a small incision in the skin which had been at the top of the base of the penis.

 Another small incision is made about 1 cm below there and the urethra is passed through and cut at skin level and both are sutured into place.

The penile shaft skin is sutured together at the glans end (sometimes additional skin is attached to give extra depth, then pulled inside out such that the epidermis is on the interior of the resulting tube. This is fed between the pelvic floor muscles and form the neovagina. A stent or packing is inserted to hold the shape of the neovagina for the first week.

Skin from the base of the penis is reformed to make labia minora, and scrotal skin used to make labia majora, which closes the body back up. Sometimes excess scrotal skin is used to add depth to the neovagina before the skin is inverted and inserted.


Non-Penile Inversion Procedures

In Western Europe and North America penile inversion vaginoplasty remains by far the most common SRS technique.  But there are alternatives.

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


Sigmoid Colon Procedure

The sigmoid colon section vaginoplasty procedure is the next most popular SRS technique after penile inversion.  This uses a section of the sigmoid colon to create the vaginal lining.

This transsexual woman sought SRS after a circumcision, an orchiectomy and many years taking oestrogen.  The lack of "material" to work with resulted in the surgeon recommending the Sigmoid Colon Vaginoplasty.
It is an intrusive procedure in which the intra-abdominal cavity must be entered via a low transverse abdominal incision (similar to a caesarean section incision in a biological female).   A sigmoid colon section approximately 6-7 inches in length is cut out and harvested through the incision, with the rest of the colon reconnected.  This extracted segment of the lower colon is thick-walled, large in diameter and flexible.  The colon section is then relocated and connected to external genital skin flaps to construct a neovagina and its entrance.  Orchiectomy, penectomy, labiaplasty and clitoroplasty procedures are performed as required to create the external appearance of a female vulva.

This procedure has several significant advantages over penile inversion.  It results in a well-proportioned vagina which has good and easily maintained vaginal depth.  It provides a convincing and natural feeling neo-vagina to male partners, and is self-lubricating and self-cleaning.  As such, it is particularly well suited to women who anticipate having a very active sex life with frequent and robust penile penetrations, and want a vagina able to accommodate deep penetration in the missionary position by even "Mr Big". Unsurprisingly, it is the preferred procedure for shemale to post-SRS escorts.

The procedure is very suitable for patients who have a have a very small penis, e.g., due to an orchiectomy.  It is can also be used as corrective surgery for patients with inadequate vaginal depth after penile inversion SRS.

However, although the procedure is well proven, both the cost and medical risks are higher than the penile inversion procedure because of its more complex and intrusive nature.


A photo of a patient of Dr Suporn in Thailand, three years after SRS.  The result is good, but natal cis 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 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 major advantage is that the scrotal skin can be stretched, so a small penis is less likely to 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 - but subsequent hair growth their vagina is reported by some patients. 

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 to maintain depth, but it's slightly less demanding than penile inversion where the dilation is often trying to increase vaginal depth.

Although the penile inversion procedure is clearly considered in medical publications to be a superior and and more advanced procedure, there is no doubt that Thai surgeons are consistently achieving excellent results with this technique.

Penile Peritoneal Vaginoplasty (PPV)

The peritoneal pull through procedure was originally developed in India in the 1960's as the 'Davydov technique', to help natal cis women who were born without a vagina.  The peritoneum is basically a bag of loose tissue that encircles the inside of the abdomen and holds the guts in place, and it is very similar in characteristics to the lining of a vagina. 

It surprisingly took nearly 60 years before it was realised that a variant of this procedure could be applied to sex-reassignment surgery. 

This procedure uses a small amount of penile inversion combined with a peritoneum pull through technique to create the neovaginal canal.  Essentially the outer labia and visible vagina is made using penile and scrotal skin whilst the inner vaginal canal is made using the peritoneal.

A vaginoplasty peritoneal pull through operation on a transwoman, apparently performed by Dr Heidi Wittenburg.  The "after" photo (right) is uninformative. 

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.

The Kamol Hospital in Thailand - used by a thousand transwoman every year - has become a major advocate of the PPV technique.   Two patients are shown, one and four months after surgery.  The lack of obvious scaring is a huge positive compared to penile inversion.
The first procedure on a transwoman was only performed in 2017.  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 a neovagina. 

Claimed advantages over other techniques include a quicker and painful recovery, far less visible scaring, and less dilation and douching.  Perhaps the decisive factor for many transwomen is that the resulting neo-vagina is apparently often indistinguishable by a man from that of a cis-woman when having intercourse.  The lubrication, elasticity, depth and smell are also supposedly excellent.  Restrictions and discomfort related to the shape of the transwoman's pelvic girdle are the most likely problem if the man is well endowed.

Despite the apparent positives, it is important to realise that this is still a very new procedure and that the surgeons who are using this technique are inexperienced with it.  The initial excitement will dissipate as problems and risks inevitably emerge.  I have struggled to find patient feedback and where I have it is often far from positive, indicating that the procedure is not a panacea and that serious complications can occur.  For example, the promise of a neo-vagina with good depth that doesn't require dilation is not confirmed by some patients.


Fish Scales

A recently developed technique to help the development of 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 mould, 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.


Maintenance of a Neo-Vagina

Vaginoplasty involving the creation of a vaginal cavity requires on-going care that the woman will have to integrate into her daily routine for the rest of her life.  This care involves a protocol of regular vaginal dilations and genital hygiene.  Failure to follow the recommended procedures could result in the closure of the vaginal cavity; difficulty in urinating; as well as complications such as urinary tract and other infections, sores and vaginal discharges, and abnormal communication between the vaginal and rectal cavities.  Whilst the exact regimen is dependent on the procedure that was used, the transwoman will need to:

  • Undertake the recommended dilation of her neo-vagina
  • Wash her hands with soap and water before dilation or touching her genital area
  • Clean the dilator with soap and warm water before and after each use
  • Regularly douche her neo-vagina with soapy water

Pelvic floor exercises developed primarily for women after childbirth are theoretically irrelevant for transwomen, but in practice many transwomen have found them to be very helpful.  The exercises can mitigate painful or insufficient vaginal dilations, as well help any urinary leakage after surgery.


Vagina Not Required
Many transsexual women have SRS with little or no expectation of having a subsequent active sex life with men.  Follow-up surveys (typically two years after SRS) find that 15-20% of patients have not yet had vaginal sex, i.e. their vagina 'penetrated' by a penis during coitus.  The actual percentage is probably higher - particularly among those over age 40.  If a transsexual woman does not plan to have vaginal penetrative sexual intercourse then clearly there is no need to have a deep neo-vagina formed, and unnecessary surgical procedures can be avoided and the subsequent dilation effort will also be avoided 

Vulvoplasty is an alternative gender-affirming, lower body surgery that creates the vulva (including mons, labia, clitoris, and urethral opening) and removal of penis, scrotum, and testes.   The key difference from vaginaplasty is that no vagina is created, but there can still be an erogenous (clitoral) zone with the possibility of sexual pleasure via self-stimulation or with a partner.

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.


Valentina modelling panties.
It was assumed for many years that the model Valentina Sampaio had followed this approach.  When she emerged as a top model in 2017, she was already openly transgender and admitted to having had some form of 'bottom surgery' in 2014 (age 18).  However, it wasn't clear that this was full SRS and she has never had a publicly acknowledged boyfriend.  As a result, it became assumed that she had only had limited surgery (e.g. orchiectomy and vulvoplasty) to feminise her external genitalia and avoid problems when modelling skimpy outfits.  It was thus a surprise when during an interview in December 2021 she stated that she had had a full SRS/GCS.

Note:  Since writing this section, one transwoman has contacted me expressing
her regret at not seeking a functional vagina when she had her vulvoplast

AJ Clementine had her SRS at a relatively youthful age of22. 

 chanelle.jpg (9659 bytes)
Chanelle is more typical, she had SRS age 32.


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 parent's transition have surgery at a very young age - in their teens or in exceptional cases even earlier.  There is no doubt that this group is rapidly becoming more numerous, but it is still only a 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:


Average age

Lowest age

Highest age

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. She transitioned in her early 20's (left) but couldn't afford SRS.  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 surgery. (USA)

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.


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.  In cisgender women, i.e., those assigned as female at birth, an optimal vaginal microbiota includes microbial communities such as the Lactobacillus species. 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. 

Unfortunately for MTF transgender women, the pH in penile inversion (i.e. skin-lined) neovaginas is elevated after surgery, discouraging the growth of acidic preferring Lactobacilli, with colonisation of bacteria from skin or intestinal micro-organisms occurring instead.  Their neo-vagina is thus very likely to inherit the bacteria that populate penile skin such as Porphyromonas - these are less helpful and 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 MTF recipient to insert into her neovagina a similar way to a tampon.  Hopefully the newly introduced bacterium will then populate and multiply in their new home and reduce undesirable infections and their side effects.

If the trial results are good, this may become a routine procedure for post GCS women in a few years' time.



Sex re-assignment techniques used until the 1980's placed no emphasis on preserving and relocating nerves, as a result most patients had little or no physical feeling in their clitoris, vulva or vagina.  Sexual stimulation was essentially mental, with little physical reinforcement.  The introduction of the penile inversion technique was a vast improvement as nerves were preserved.  The latest techniques relocate nerves at the tip of the penis to the clitoris, usually (but not always) resulting in excellent sensitivity.  Indeed, some transwomen now complain that their clitoris is too sensitive, leading to problems in daily life, e.g. when cycling. 



Ava began hormones as a teenager and had SRS age 20.  She has reasonable breast development but with the small areola typical of transwomen.  Her vulva (pixelated) is very tidy but would benefit from a labiaplasty procedure to provide a hood to the clitoris.
Caveat Emptor - Buyer Beware

You get what you pay for where SRS/GCS surgery is concerned, although the best surgeons and clinics in Thailand do seem to now offer better value than those in the USA, Europe and Australia.

  • An excellent vulva appearance doesn't always equate to a sensitive clitoris and vagina

  • A sensitive clitoris and vagina don't always equate to a natural looking vulva  

  • The very best surgical results, particularly after a "tidy up" labiaplasty procedure, are visually hard (but not impossible) to detect compared to a natal woman  

  • Problems such prominent scaring, rawness, irritation, vaginal discharges, unpleasant smells, excessive sensitivity, lack of sensitivity, vaginal hair growth, urinary tract infections ... These are commonplace issues and hard if not impossible to resolve.


Camel Toe
A common problem for all women is that when wearing panties or a bikini, the fabric can be sucked into their vagina, leading to what is called a 'camel toe' appearance.  Post-SRS transwomen are particularly susceptible to this problem as their vulva entrance is less protected by surrounding tissues, particularly if they haven't had a procedure to hood their clitoris.  As such a regular 'camel toe' has become an outing indicator, and ironically pre-SRS tucking can result in a better appearance when clothed!

Surgical Advances

It's hard to underestimate the constant advances in SRS/GCS surgical techniques.  Like buying a car, next year's model is always going to be better.

This picture of an SRS procedure is from a medical textbook printed in 1979.  It could easily be a shot from a 1930's horror movie!

Between the 1960's and 1980's only a handful of hospitals, clinics and surgeons around the world conducted SRS operations.  Visually, the results were often brutal, with the vulva area having little resemblance to that of a natal woman.  Pubic hair was used to conceal this.  Photos of only the very best results - often after multiple revisions - appear in contemporary books and magazines. 

The 1990's saw the advent of celebrity SRS surgeons who tried to justify their high fees by pioneering new procedures such as colovaginoplasty, but complications were all too common.  At least one follow-up revision procedure was generally required, e.g. to hood the clitoris.

In 2016, 25-year old post-SRS transwoman Maria Maddalena Bulfer featured in a transgender awareness campaign in Italy.  She had a photo shoot "More than a woman" in Milan where she hid nothing.  The original caption to the above photo was "M. wears Blugirl Folies"!  (Italy)
Since 2000 there has been immense improvements in the quality of surgery, whilst the cost of a SRS operation has reduced substantially.  This is no doubt driven by a once niche and heavily subsidised medical procedure exploding into a market worth over $300 million in 2019.  With revisions, some MTF women now have a vulva that is far closer in appearance to a textbook diagram than that of most cis women!

The focus for new procedures has moved to the internal organs, in particular creating a vagina that doesn't require frequent dilation in order to achieve and then maintain depth.

Another change is the pain resulting from the surgery.  Ask any transwoman who had SRS before 2000 about her experience and she will recall in vivid detail the extreme pain she suffered in the week after surgery.  Twenty years later some patients are more likely to discuss their desperate need for a shower!

Dr Carlos Cury (fourth from right) 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. (Brazil)

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

Revision Procedures

Although many surgeons now advertise a "one step" SRS/GCS procedure, the reality is that many women still have revision surgery, typically a year after the primary surgery. 

There are two main reasons, the first and unfortunately most common is to resolve complications such as excessive scaring, too much erectile tissue remaining, lack of vaginal depth, tearing and bleeding.

The second reason is cosmetic surgery to tidy-up and fine tune the external appearance of the vulva.  Even the most successful operations through to the 1990's would now be considered "hachette jobs" when compared to the external visual appearance of a natal woman.   In the 2020's, transgender women are seeking a textbook standard vulva that few cis women have in reality! 

Cancer Risk
A consideration rarely taken into account by transwoman is the moderately 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.

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

Vaginal Cancer

Unlike men, a post-SRS transwoman faces the risk of cancer in her neo-vaginal tissues.  This risk is greatly raised as 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.    

Medical evidence is still inconclusive as to extent to which the neovagina of a post-SRS/GCS transwomen takes on the characteristics of a "natural" female vagina.  Whilst some medical studies have concluded that no significant changes in cell type actually occurs, clinics neverthless find that the cervical smear test of a transwoman 10-20 years after SRS is often indistinguishable from that of a natal woman.

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 transwomen with a neo-cervix, particularly if they are sexually active.

Farrah Lirises is a transwoman who vocally advocates the need for all transwoman to exercise daily to preserve their health, maintain a feminine appearance, and avoid problems such as incontinence.

Pelvic Floor
MTF Gender Confirmation Surgery often seems to ignore fundamentals, such as the need to pee!  Many transwomen suffer from incontinence after surgery and have to use sanitary pads to hide this.  Daily Kegel pelvic floor exercises can help significantly, developing latent muscles not needed by men.

Cis women are born with a thin piece of mucosal tissue - the hymen - that surrounds or partially covers their vaginal opening.  This will be broken the first time that she has sexual intercourse with a man, resulting in some pain and bleeding.  The construction of a hymen is considered pointless as part of a SRS procedure as it will be destroyed by dilation.  However some transwomen - mostly Asian - who are about to marry have a hymenoplasty performed in advance of the wedding at a cost of about $3000, allowing them to consumate the mariage with the physical evidence that they are a virgin.

The 'First Time'
After having SRS that involves the creation of a neo-vagina, many transwomen then face the moment that their transition and costly medical treatment has led up to - having penetrative, penis-in-vagina (PIV) sex with a man.  I.e. losing their virginity as a woman.  Even in a modern western society, this still has huge significance - mentally, socially, culturally and morally.

After SRS, some transwomen want coitus as soon as possible, others might be reluctant but are under huge pressure from an over-eager male partner, whilst a few have become scared about the whole idea. 

A few tips for the first time with a man:

  • Wait at least three and ideally four months after surgery before having sex.  Let everything heal, scaring subside and pubic hair start to regrow

  • If possible, find a man you are attracted too and trust.  Let him know that it's your first time and ask him to take things slowly and gently

  • Dilate as close you can to having coitus.  Ensure that you have at least 5 inches of vaginal depth - anything less will be problematic as it can't accommodate the average male penis

  • Use a water based vaginal lubricant with no fragrance.  Don't assume that you will have sufficient self-lubrication until that becomes proven

  • Stick to the basic sexual positions.  Try 'missionary' first, on top ('cowgirl') second.  Don't even think about 'doggie' or any position where a narrow male-type pelvic inlet might cause mutual discomfort

  • It will probably be impossible but try to relax - use candles, burn incense, play peaceful background music

  • Upon feeling penile penetration for the very first time - don't panic!  The male penis is made of flesh and blood and is designed by nature to fit a woman's vagina.   For a transwoman it's actually less likely to cause problems and pain than moving up a size in dilator.

Almost no transwoman will orgasm the first time they have penetrative PIV sex.  A male orgasm is predominantly physically induced - it's centred on the ejaculation of sperm from his penis deep into a woman's vagina so that he can reproduce   A virile young man may be able to orgasm again in as little as 15 minutes, but that increases to hours with age.

By contrast, a female orgasm is essentially nature offering an incentive to encourage a woman to have intercourse with a man and get pregnant.  It involves a mix of mental and physical stimulation - and as a bonus she can, unlike a man, enjoy multiple orgasms during a typical 5 to 10 minutes long period of penetrative intercourse.  Also, again unlike men, a woman's ability to orgasm is unaffected by age, at least prior to menopause.

In order to have an orgasm, a transwoman has to both adapt to and enjoy the physical stimulation of her new genitalia, whilst also developing her mental fantasies, e.g. having sex with a famous male hunk, or having sex on a tropical beach.   Wearing sexy lingerie, dressing up, and even bondage may also help a transwoman in achieving that critical first ever orgasm as a woman.  The active encouragement and help of her sexual partner is a wonderful aid where this is possible.  

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 surgery to reduce his breasts and reconstruct a penis.  Extra-ordinarily, in 2018 he decided that she preferred being Samantha after all, and transitioned again and had another round of feminisation surgery!  Over 21 years he/she spent £150,000 (well over $200,000) on surgery.

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 Lancelet 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.

Pre-surgery 3D scans of a transwoman's pelvic region can be used to create a scaffold for the creation of an optimal neo-vagina using penile and scrotal skin.
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.

I'm not religious but as a transwoman I find interesting that Genesis 2:21-22, reads “The Lord God caused a deep sleep to fall upon the man and while he slept took one of his ribs and closed up flesh in its place. And the rib that the Lord God took from the man he built into a woman.”
My Experience

As described elsewhere, after years of deliberation I finally had GCS/SRS (vaginoplasty) in late 2004.  The procedure went well and although the recovery was painful it certainly wasn't the horrendous nightmare that other women had experience.  The only time I really cried out was when a catheter was removed.

After I returned home, my body was still healing and adjusting.  For weeks, even months, my subconscious mind still confusingly associated nerve endings with parts of my old male anatomy, several times I woke at night needing to go to the loo and in my sleepy haze found myself standing over the toilet convinced that I had a penis!  My life also seemed to be dominated by the boring routine of dilation.

However, the highlight of my life occurred about a month after my SRS when I went into the bathroom for a shower.  After de-robing I turned around and was surprised to see an attractive naked woman in the mirror.  It took a moment to realise that it was me! 

A close second was finally being able to consummate our marriage with my husband.  I was bit too worried at the time about the potential problems to rank this first - as it really should be.  In hindsight it was amazing how quickly my new normal became having vaginal intercourse as a woman.  But almost inevitably there was a problem, I had become susceptible to painful UTI's.

A few years after my vaginoplasty I had a "tidy up" surgical procedure to improve the appearance of my vulva.  Since then, I've had no doubt that I can visually pass as a woman and pass an intimate search, e.g. by police or custom officers.  This has immensely reduced the stress I had felt since transitioning, and there is no doubt that SRS/GCS has changed my life immeasurably and largely for the better.



On a good note:

An exceptionally good SRS/GCS result.  Age 25, Robin had GCS with Dr Littleton, the pictures are taken after revision surgery a year later. The appearance of her vulva is now of a textbook standard - far better than most cis-woman! (Netherlands)

More Information

In 2013 I completed a survey conducted by Transgender Equality Network Ireland (TENI), the resulting report is worth reading and I suspect that other Western European countries will have very similar results.

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, 2021