Important Disclaimer: The information on this page is often historical and should not be used to guide surgical decisions.
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Terminology 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!
Castration 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!
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. The key points of the 2001
version of the standards are: SRS
involves major surgical procedures by which the physical appearance and function of
male genitalia are altered to resemble those of a female.
The
ideal results are: However, like all
major surgical procedures, SRS is expensive, very painful, has many
risks and there can be serious complications. There are many transwomen who
take 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. 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. 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
Most surgeons will consider as eligible for SRS genital surgery a genetically male "woman" over the age of majority who has undergone at least 12 months continuous female hormonal treatment, and who's also successfully lived for at least a year full-time as a woman. However, a surprising large number of women who fulfil these criteria do not immediately seek SRS, or any other genital surgery. The reasons for delaying or avoiding SRS procedures are very diverse, but include:
Unfortunately, I haven't yet found any recent (rather than 1960's) statistics on the length of time after a real-life transition until genital surgery for male-to-female- women, but I have found some interesting figures for female-to-males. Dr Holly Devor when researching her book FTM: Female-to-Male Transsexuals in Society found that most transsexual men retain some very dramatic physical manifestations of their previous lives as females. More than 1/3 of the 35 participants in her research who discussed this issue said that they began living as men without the aid of either hormone therapies or surgeries. Another 60% of them began their lives as men with the assistance of hormone therapy but, on the average, they did not have their first surgeries for another 3 1/2 years. Only six (15%) of the 39 transsexual men interviewed had had any kind of genital reconstruction surgery. Furthermore, despite the fact that they averaged 6.5 years since beginning hormone therapy, and 7.9 years since beginning to live full-time as men, slightly more than half (51.5%) of those who had not yet had genital surgery said that they were not particularly interested in having any done. These extraordinary results are not directly relatable to transsexual women as much more difficult and expensive surgical procedures are required for female-to-male sex re-assignment than for male-to-female sex re-assignment. However they do reinforce my own belief that a medium [average] delay of 3 years from full time transition to MTF SRS would probably be near the mark, high though this may appear at first sight given that a common complaint from transsexual women is the need to wait a whole year after transition before being eligible for surgery.
But the reasons to have some form of genital surgery often strengthens with time, and most transitioned transsexual women eventually undergo some procedure. Possible drivers may include:
The importance of the second point cannot be underestimated. Most post-transition but pre-SRS women gradually collect bad experiences, ranging from embarrassment during a security check, an unaware friend who sees too much, the wandering hands of a drunk, to the possibly fatal disappointment of a rapist. In a few countries, a depressing problem is that some homosexual men have sex-change surgery because it is socially and legally more acceptable to be a transsexual woman than an openly homosexual man. Iran is most commonly cited. (Note: this must not be confused with the homosexual transsexual theory).
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.
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:
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:
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.
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 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:
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.
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.
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.
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 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, i 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.
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.
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.
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 disipate 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.
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:
Pelvic floor exercises developed primarily for women after childbirth are theoretically irrelevant for transwomen, but in practice many transwoman 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
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.
Note:
Since writing
this section, one transwoman has contacted me expressing
Age at SRS For decades after Swede Christine Jorgenson had her pioneering SRS in 1957, most empirical evidence and published studies have indicated that a majority of European and North American transsexual women are in their 30's, and 40's before they actively seek to resolve their gender issues. Inevitably this means that the patient age profile of surgeons undertaking sex-re-assignment surgery follows this trend - with a lag of a several years representing the time from the woman commencing treatment to having some form of genital surgery.
Considerable publicity often surrounds young transsexuals who with the support of their 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:
Nationality
Average age
Lowest age
Highest age
Total number
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 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 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.
Sensitivity 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.
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.
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. 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.
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!
Revision Procedures Although I have just suggested that most surgeons now use a "one step" SRS/GCS procedure, the reality is that many women still have revision surgery, typically about 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.
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. Medical evidence is still inconclusive as to extent to which the vagina of a transwomen after a penile or scrotal inversion takes on the characteristics of a "natural" vagina. For example, some medical studies conclude that no significant changes in cell type actually occurs, but in practice clinics can't distinguish the smear test of a transwoman 10-20 years after SRS 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
Pelvic
Floor
The 'First Time' 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:
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.
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.
Regrets
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.
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.
The highlight of my life occured 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 second to realise that it was me! A close second was finally
being able to consumate our marriage with my husband, although 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, not worrying about being
outed in the ladies toilets, and dealing with painful UTI's.
SRS/GCS has changed my life immeasurably and largely for the better.
Nevertheless I've become worried that it has become too easy for a
man or even a teenage boy who is wondering if they are transgender to be quickly sucked in to
the system.
Any man with $25,000 can almost on impulse catch a flight to Thailand and arrive back home two weeks later minus
testes and a penis, and plus breast implants and a neo-vagina.
Whilst in the UK, parents are now discovering from schools that their child has
asked to change their gender, and they can't prevent this legally!
Transwomen are often emerging from the process of changing their
gender much poorer, jobless, disowned by their family and friends, struggling
to pass as a woman, infertile, unable to sexually attract 'normal' men,
and suffering from medical complications.
From my own experience. I favour the rule in the now obsolescent V4 of the Standards of Care for the Health of Transgender and Gender Diverse
People, which prescribes a two year real-world test before a
surgeon performs SRS/GCS.
Finally...
On a good note:
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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(c) 2000 - 2024 Annie Richards
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Last updated: 6 June, 2021
A
natural appearing
vulva (external 'bottom' genitalia) including mons pubis, labia minora and majora 
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