Male-to-Female Surgery

Not all trans people undergo SRS. For those who do undergo SRS, there are different reasons for having it.

Some people have it to alleviate body dysphoria – a strong discomfort with the mismatch between identity and body.

Others feel OK with their bodies but are very uncomfortable with how other people perceive them (social dysphoria), and want to change their physical appearance to live in a way that better fits their identity.

Deciding to have surgery is a big decision, and GRS is no exception. Therefore, this guide was created to:

• describe options for SRS
• explain possible risks and complications of SRS
• describe what to expect before and after SRS
• discuss issues to consider when deciding whether to have SRS

To continue, click on the option of your choice:

Surgical options for Male-To -women
Surgical options for Female-To -men

Timing of facial/neck surgery

Most FFS techniques can be performed at any point in the transition (at the beginning, in the middle, or after you’ve already had other surgeries).

If you want both forehead and nose surgery, it is recommended that they be done together, as changes to the forehead can affect the shape of the nose.

In general, it is not recommended that you have multiple surgeries performed in quick succession as it puts a lot of stress on your body.

You can safely have FFS done three months before or after a vaginoplasty as long as there are no complications from the procedure that is done first.

If you plan to have a tracheotomy as part of your voice surgery, you should have it done last.

Voice surgery is done after all other surgeries because some types of voice surgery narrow the trachea, making it more complicated to insert the tube that keeps your trachea open during general anesthesia (tracheal intubation).

Tracheal intubation may also reduce the effectiveness of some types of voice surgery.

What to expect before and after facial/neck surgery

If you plan to have electrolysis to remove facial hair, you must stop using it completely at least two weeks before facial surgery.

If you are having chin or jaw surgery, you cannot start electrolysis again until at least three months after surgery. As part of your surgery planning, talk to your surgeon about ways to temporarily get rid of your facial hair before and after surgery.

In the hospital

Many facial surgeons have their own private clinics and can perform minor procedures (such as collagen lip implants) in their offices. If you have major bone reconstruction, you will be operated on in the hospital and admitted the same day as surgery.

You may be asked to come to the hospital the day before surgery to go over information about the surgery and to have a last-minute exam. The night before surgery, you will not be allowed to eat or drink anything after midnight.

What to expect immediately after surgery depends on whether local or general anesthesia was used. Minor procedures are usually performed under local anesthesia (similar to drilling a tooth), and you can go home shortly afterward.

Bone reconstruction or tracheal shaving usually requires a general anesthetic. If you have general anesthesia, you will be monitored by hospital staff when you awaken from the anesthesia.

For minor procedures, you will be discharged the same day of surgery with medication to control pain; for major procedures, you will stay in the hospital overnight. When you are discharged, you will need to have someone drive you to your hotel or take a taxi, as it is not safe to drive immediately after surgery. You will probably be given antibiotics in the hospital to reduce the risk of infection while the wound is healing.

After surgery

Aftercare instructions vary for different types of facial surgery and depend on the specific technique used. Talk with your surgeon before surgery to make sure you understand what to expect and what to do after you leave the hospital and to discuss pain management options.

The following information comes from Dr. Douglas Ousterhout, the inventor of FFS:

• Forehead surgery: pain medication and antibiotics will be prescribed.
• Day after surgery: the bandage around the forehead can be removed. Be careful not to get the dressings used for the nose/chin surgery wet (if you had multiple surgeries at the same time).
• Within eight days after surgery: sutures and staples used to close the incisions are usually removed by the surgeon. Most people feel well enough to return to work at this time (heavy activity should not be done until two weeks after surgery, however).
• Within 10-12 days after surgery: swelling and bruising around the eyes have usually subsided by this time.
• Cheek augmentation: painkillers and antibiotics will be prescribed. You could brush your teeth, as usual, being careful not to brush over the incision line if the implant was placed through the mouth.
• The first 1-3 days after surgery: temporary numbness and swelling may affect speaking, smiling, yawning, and chewing. You should avoid hard to chew foods for the first few weeks.
• Within two weeks after surgery: swelling will usually have subsided by this time.
• Nose surgery: painkillers will be prescribed. If you wear glasses, you will be given special instructions, as the nose pads that hold the glasses on your nose should not touch your nose for a month after surgery.
• The first 1-2 days after surgery: the inner nasal packing stays in to support the nasal tissues in the early stages of healing. The packing will be taken out by the surgeon.
• Day 8 after surgery: the outer packing around your nose will be removed by the surgeon. Be careful not to get the cast wet while it is still on.
• Within two weeks after surgery: the bruising around your nose and eyes will typically have subsided by this time.
• One month after surgery: after this time, it is safe to engage in vigorous activity. You may resume wearing your glasses as usual.
• Chin reduction: Pain medication will be prescribed.
• Recovery time depends on the type of technique performed; if significant bone reconstruction was performed, recovery might take 4-5 weeks, with swelling persisting for up to 3-4 months.
• You can usually return to light work 5-6 days after the procedure.
• Jaw reduction: Painkillers are prescribed.
• The face is usually moderately swollen and bruised after surgery. 10-14 weeks after surgery, most swelling gradually subsides, but it may be difficult to see changes until the swelling is completely gone 3-4 months after surgery.
• You can usually return to work 10-14 days after surgery.
• Lip augmentation: Usually a relatively minor procedure. There may be some swelling, which usually goes down within 10-14 days after the procedure.

Risks and possible complications of face/neck surgery

Any surgery carries the possible risk of infection, bleeding, pain, and thick red scars. Antibiotics are usually given in the hospital to reduce the risk of infection.

It is normal to experience swelling and bruising after facial surgery. If the skin is very tender or warm and you do not feel well, you should see a doctor to check if you have an infection.

Any surgical procedure that requires general anesthesia is a serious medical procedure. With general anesthesia, there is a risk of an adverse reaction to the anesthesia or, if you lie flat for an extended period of time, a risk of blood clots (which can be fatal).

Surgeons, anesthesiologists, and operating room nurses are experienced in preventing problems and responding to emergencies that occur during surgery. To prevent blood clots, exercise as much as you feel comfortable and drink plenty of water after you are discharged from the hospital.

Get medical help if you have sudden shortness of breath, chest pain, dizziness, or tender, warm, swollen legs – these may be signs of a blood clot, and you may need emergency help.

Possible complications specific to face/neck surgery include:

• Numbness, pain, or difficulty controlling muscles in the operated area: may be temporary (due to swelling) or permanent (due to nerve damage).
• Problems with implants, wires, or screws: infection, resorption, or leakage from the body
• Tracheal shaving: possible damage to the voice
• Difficulty adjusting to the changed appearance after surgery (some patients describe this as feeling as if a stranger is looking at them in the mirror)
• Disappointment with the appearance of the result: eyebrows pulled up too high, the nose looks unnatural, etc.
• Thick red scars or other problems associated with scarring

After the operation

Generally, you begin to feel physically more comfortable in the second week after surgery, but it may take a long time for the wound to heal completely, and there may be pain and soreness for a long time after genital surgery.

You will see the surgeon at least once a week after surgery and periodically thereafter. The surgeon will perform a physical exam to check your overall health and will also check your new clitoris for healing and feeling.

You will be asked questions about your bowel and bladder function, and the surgical incisions will be checked for infection and scarring. If you have had a vaginoplasty, the surgeon will put a finger inside your vagina to check for healing.

For the first eight weeks after your vaginoplasty, you will wear a prosthesis in your vagina most of the time. In the beginning, you will only take it out once a day when you do routine cleaning (initially, you will flush once a day).

The amount of time the prosthesis stays out will gradually increase (according to the surgeon’s protocol). You will need to continue to dilate your vagina every day, either through sex (dildo/penis/finger) or with the dilator to keep your vagina open. If you don’t dilate every day, your vagina can become tight and short.

If you received a graft as part of your vaginoplasty, an incision would be made at the graft site – usually on your abdomen just above your pubic bone. Adhesive strips (“steri-strips”) are used to bring the edges of the wound together and promote healing.

The hospital staff will check this incision and change the dressings regularly. After you go home, make an appointment with your regular GP or nurse to check the healing of the graft site and make sure it is not infected.

It is normal for the incisions to be red, but the redness should not extend more than 1-2 inches beyond the incision (if this happens, see a doctor immediately as this can be a sign of infection). It is also normal to see or feel the suture knot at the end of the incision. The suture knot is not a problem; it will either resolve itself or come to the surface of the skin, in which case a doctor or nurse can cut it off.

You can return to your usual routine when you feel well enough to do so (i.e., when normal movements do not cause pain). This is usually after 4-6 weeks but may take longer in some cases. Until you are fully recovered, you should avoid all activities that raise your heart rate. Talk to your surgeon if you are unsure.

Taking estrogen is discontinued several weeks before surgery to reduce the risk of blood clots. When you have recovered enough after surgery to be mildly active again, you will be slowly switched back to estrogen.

The surgeon will work with the doctor/nurse who prescribes your hormones to come up with a plan for you to start taking hormones. Because orchiectomy removes the testosterone-producing organs, it is important to work with a doctor who is trained in trans medicine to ensure that you receive an appropriate dose of hormones after surgery.

If you do not want to take estrogen, you will need to take another type of medication to prevent loss of bone density (see Trans People and Osteoporosis, available at Transgender Health Program).

Risks and possible complications of MTF genital surgery.

With all surgical procedures, there is a possible risk of infection, bleeding, pain, and scarring. This is true for orchiectomy and penectomy, as well as vaginoplasty. Antibiotics will likely be given to prevent infection, and the medical professionals who check your dressings the week after surgery will also be watching for infection.

Penectomy and vaginoplasty are performed under general anesthesia. All surgical procedures performed under general anesthesia are major medical procedures. With any surgery, there is a risk of blood clots (which can be fatal) or an adverse reaction to anesthesia.

Surgeons, anesthesiologists, and scrub nurses are experienced in preventing problems and responding to emergencies that occur during surgery. Move around as much as possible after being discharged from the hospital to avoid blood clots, and drink plenty of water.

Get medical help if you have sudden shortness of breath, chest pain, dizziness, or tender, warm, swollen legs – these may be signs of a blood clot, and you may need emergency help.

Possible complications specific to vaginoplasty include:

• Fistula: opening between the rectum and the new vagina.
• Decreased sexual sensation and possibly decreased ability to have an orgasm
  partial or complete death of the tissue used to form the new vagina, labia, or clitoris
• Narrowing or closure of the new vagina or urethra
• Prolapse: the vagina falling out of the body
• Hair growth in the vagina (from hair-bearing tissue used as a vaginal liner)
• Unsatisfactory size or shape of the new vagina, clitoris, or labia

Some of these risks are long-term, while others may only occur in the hospital (where they can be treated by hospital staff).

For example, partial or complete death of the new clitoris, labia, or vaginal mucosa – rare complications – is most likely to occur early in your recovery while you are still in the hospital; by the time you are discharged, the risk is very low. Hospital staff will also take care of any bleeding or swelling that occurs right after surgery.

Your GP or nurse may take care of any minor infections or rupture of a few sutures after you are discharged from the hospital. You will be referred back to your surgeon if:

• You have a serious infection
• You rip so many stitches that the wound keeps opening-up
• You have bleeding with pus for more than a few weeks after surgery (minor bleeding after dilation is normal and can be controlled by applying pressure to the vagina)
• You have vaginal discharge with pus in it
• Gas or feces leaking from your vagina: this indicates a tear between your vagina and rectum
• you have signs of tissue death (mottled skin that becomes progressively darker)
• vaginal penetration is painful or difficult
• You have difficulty urinating, pain when urinating, a decreased amount of urine, or need more time and effort to urinate
• your vagina prolapses (partially leaks)
• You have severe scarring

You need to undergo further surgery if

• the clitoral, vulvar or vaginal tissue is dying off
• You have a tear between the vagina and the rectum (fistula)
• your urethra becomes severely narrowed or blocked
• you have a vaginal prolapse
• You have severe scarring

The decreased sexual sensation is a possible long-term risk of vaginoplasty. In general, sexual outcomes are good. Studies report a range of 63-94% of MTFs that they can have an orgasm after vaginoplasty.

One small study (14 MTFs) found that although physical sensation was diminished after surgery, participants were less dysphoric and felt more comfortable having sex (i.e., had more sex and said they enjoyed it more).

Although the overall results are good, the studies indicate that some MTFs who underwent genital surgery said they could not have orgasms afterward.

Part 1: Am I sure?

There is no one right way to make the decision to have surgery. As with any big, life-changing decision, it’s normal to have doubts, fears, and anxieties about SRS.

But as part of the decision-making process, it’s important to be sure you want to proceed with surgery.

We know from our own experiences and from talking to many other people that everyone’s situation is unique, that there is no one way to make a decision about SRS, and that it is not as simple as a one-time yes or no – it is often a long process shaped not only by inner feelings and beliefs but also by ever-changing external circumstances that are not necessarily within your control (health, money, family commitments, limited access to services, etc.).

It has been our experience that people tend to make decisions about SRS in the same way that they make decisions about the rest of their lives.

Some trans people are looking for a strong internal sense that SRS is right and don’t want to be influenced by what other people think, while others want to seek the opinions of friends, family members, other trans people, counselors, or other medical professionals as part of the decision-making process.

Regardless of how you think things through, below are some questions to consider. There are no right answers to these questions; they are just a way to think through different aspects of SRS so you can better understand your feelings, values, and expectations.

• Do you have a clear idea of what you want to look like after SRS? How do you think you would feel if the outcome did not match that mental picture?
• Do you hope that SRS will fix anything, and if so, what?
• What parts of your life might change after the SRS?
• What do you hope might change, and what do you fear might change?
• Do you think your hopes for SRS are realistic? How can you tell if they are or not?
• How much do you know about the possibilities for SRS? What else do you need to know to make an informed decision?
• Are the parts of your body that will be changed by the SRS part of your sexuality? What will happen if you lose this part of your sexuality?
• Who else in your life will be affected by your decision? How do you think these people will feel about you having SRS? How will their reactions affect you?
• What do you think is a “wrong reason” to undergo SRS? What do you think are the “right reasons”?

What SRS will not do for you

SRS can be a great relief for trans people and allow us to live more comfortable lives. But there are some things that SRS will not do.

SRS will not solve all body image issues.The point of SRS is to make you feel more comfortable with your body by bringing your physical features closer to your inner sense of self.

This relief can boost your self-esteem and make you feel more confident and attractive. However, you will find that even after SRS, there are attractiveness standards that you may not meet.

Feeling comfortable with your body is complicated by social pressures and gender stereotypes about appearance.

Some MTFs respond by compulsively dieting, exercising, or undergoing endless surgical corrections to chase an idealized stereotype of attractiveness.

It can be difficult to separate gender dysphoria from body image issues. Professional and peer counseling can be helpful in clarifying your expectations about your appearance and working toward greater self-acceptance after SRS.

SRS will not solve all sexual problems. For some trans people, the desire to feel more comfortable having sex is an important reason to undergo SRS.

SRS can help alleviate feelings of dysphoria that negatively impact sexuality. However, not all sexual problems are due to dysphoria.

Sexuality is complex and can be affected by many things, including physical problems, stress, relationship dynamics, body image issues, past sexual abuse or other types of trauma, and cultural and personal beliefs about sexuality.

An SRS will not automatically fix all of these areas of your life. If you are experiencing sexual difficulties, consider peer or professional counseling to explore the reasons and learn about treatment options for sexual health.

SRS often has a positive impact on sexuality. In numerous studies, the majority of trans people who participated reported increased sexual satisfaction after SRS. But SRS can also have negative effects.

A change in sensation is very common after surgery. You may find that touch is no longer as intense or that it is more intense (to the point of being uncomfortable or painful).

Some MTFs have difficulty reaching orgasm after genital surgery or report that orgasm is less intense. If you decide to have surgery, you also need to consider the possibility that SRS could negatively affect your sexuality and think about how you might deal with that possibility.

Whether you decide to have SRS or not, some trans people find counseling useful in dealing with the impact of internalized transphobia on their sexuality. Living in a transphobic society, many trans people internalize negative messages about being trans.

This can include shame about erotic cross-dressing or other trans-specific sexual desires and fantasies or shame about having a body that does not conform to societal norms. Peer or professional support can be helpful in working toward greater self-acceptance of one’s sexuality (with or without SRS).
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SRS will not turn you into someone else. Many people experience positive emotional changes through SRS. But you will probably find that after the excitement has worn off and you have integrated the changes into your daily life, you are still shy; if you were shy if you didn’t like your laugh, you still don’t, and you are still afraid of spiders.

Whatever you see as your strengths and weaknesses will still be there. Hopefully, you will be happier, and that is good for everyone. SRS can help you become more accepting of yourself.

But if you expect all your problems to go away and that everything will be emotionally and socially easy from now on, you will probably be disappointed.

This extends to mental health issues as well. Trans people who have been depressed due to gender dysphoria may find that SRS greatly alleviates their depression.

However, if you have depression caused by biological factors, the stress of transphobia, or unresolved personal issues, you may still be depressed after SRS. If you have problems with drugs or alcohol, SRS will not necessarily eliminate those problems either.

SRS will not provide you with a perfect community. For some trans people, SRS is a ritual that reaffirms that they are who they say they are. Making physical changes is a way to show the rest of the world who you are so that other people can see it.

This process of self-discovery can be very liberating, but it is no guarantee that you will find acceptance or understanding.

Some MTFs hope that after they make physical changes, they will be recognized as “real” women or feel more accepted by the trans community.

But the idea that trans people are not “real” if they have not changed their bodies is transphobic, and communities or groups that hold this belief are unlikely to be fully respectful of trans people’s identities and bodies.

During the various stages of transition, it is common to dream of finding an ideal community of trans people. When undergoing SRS, there can be a particular urge to find other people who have gone through similar experiences.

There are a lot of very cool trans people to talk to about SRS. But having SRS doesn’t automatically make trans people welcoming, responsive, or sensitive to the needs of others, and despite some shared experiences, you’ll likely find that no trans person accurately reflects your personal experiences, identity, and beliefs.

Emotional preparation for SRS also includes being realistic about the likelihood that you will sometimes feel lonely and alone after you start taking hormones.

Part 2: Am I ready?

It is not enough to be sure that SRS is right for you: you should also be sure that it is the right time in your life to have SRS.

This depends both on whether you are ready to endure the physical stress and psychological adjustment associated with SRS and whether you are ready to deal with the reactions of others.

Patients must be both physically and psychologically ready for any type of surgery. Physical readiness means that you are in reasonable overall health and that you have met all of your surgeon’s physical requirements (e.g., electrolysis prior to vaginoplasty).

Physical readiness also means that you have made arrangements for physical care after surgery – having a safe place to recuperate after surgery, understanding what is involved in postoperative care, and having friends, family, or medical professionals who can help you with your care.

Mental health readiness doesn’t mean you don’t have mental health problems or life stresses. It means you have:

1. A solid sense of your gender identity. SRS is not for people who are just beginning to ask, explore, and think about questions about gender identity. If you are thinking about SRS as part of your initial process of exploring gender issues, give yourself some time to get a clear sense of how you identify and how the surgery will contribute to that sense of self before making a decision.

2. Have enough mental stability to make an informed decision about your medical care. Times of chaos and crisis are not the best times to make big decisions. When you are in crisis, it can be difficult to think clearly and make fully informed decisions.

If you are having a hard time making general life decisions because you are overwhelmed by anxiety, depression, drug or alcohol problems, family stress, work problems, or other issues, you may not be able to make a big decision, such as whether to have surgery and what type of surgery to have.

Get support from peers or professionals to work on the issues that are making it hard for you to think things through, and then come back to the question of whether to undergo SRS when your thoughts are clearer.

Have enough coping skills and support to get through the typical stresses of SRS. Trans people often feel elated and liberated after SRS, but it is also common to experience emotional highs and lows after surgery.

It can be difficult to adjust to the way the body looks and feels different, to cope with pain or other physical complications, and to deal with other people’s reactions.

For some loved ones, SRS is the first time they truly understand that gender issues will not go away and that you really are trans.

This can be a difficult emotional process for them and affect the support they can offer. If you feel that you don’t have the emotional resilience to deal with these possibilities, now is not the time for SRS.

If you are sure that SRS is right for you, but you are not sure that you are ready at this time in your life, you do not have to give up on SRS altogether. You can still work toward SRS by thinking about what might help you get to the point where you are ready – counseling, advocacy, peer support, etc. – and slowly but steadily making changes in your life to get closer to readiness.

What happens if I regret having surgery?

Surgery is a drastic experience. Dissatisfaction, disappointment, and doubt are relatively common after any surgery and (for trans and non-trans people) typically relate to postoperative pain, surgical complications, the discrepancy between the hoped-for and actual outcome, a sense of “now what?”, and the reactions of other people.

These are all normal parts of the adjustment and usually resolve within the first year after surgery. Studies have found that about 1% of MTFs who undergo SRS experience deep and long-lasting regret.

If you are having difficulty coping with the surgical ups and downs, peer and professional counseling can be helpful. It is important that the counselor has a lot of experience with trans issues and understands the problems associated with surgery.

The Transgender Health Programme(place link to THP) can help you find mental health professionals with this experience. Many people who have lingering regrets find peace with their decision to have surgery – even if they wouldn’t do it again, they feel it was the right decision at the time.

Some people decide that the surgery and transition were wrong for them and want the transition back. This is a big decision and should not be made without professional advice.