Male-to-Female Surgery

The goal is to eradicate “male” features and transform your body into the most “feminine” version of yourself.

If you want to change the appearance and function of your body to the opposite sex, you will need to undergo a series of surgical procedures called Gender Reassignment Surgery (GRS) or Sex Reassignment Surgery.

In the case of MTF (male-to-female), the goal is to eradicate “male” features and transform your body into the most “feminine” version of yourself.

In the case of an FTM (female-to-male), the goals are to eradicate “female” features and transform your body into the most “male” version of yourself.

Gender Dysphoria & GRS

If you have this all-consuming and intense desire to become the opposite of your gender while at the same time strongly hating your gender assigned at birth, then you may have Gender Dysphoria.

Men with gender dysphoria are disgusted with every part of their body that makes them male.

Women with gender dysphoria may hate their developing breasts, long hair, or any feature associated with being female.

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

Surgical Options for Male-to-Female

For MTFs, the goals of gender reassignment surgery are to remove “male” features and give the body a more “feminine” or androgynous appearance (part male, part female – depending on how you identify).

MTF SRS may include some or all of the surgeries listed below.

Each of these surgeries has risks, but they have been shown to help MTFs with physical and/or social dysphoria live more comfortable lives.

The details of breast surgery, facial surgery, voice surgery, and genital surgery are discussed below.

Table here

Breast Implants (Breast Augmentation)

Estrogen makes breasts and nipples grow, but there is a limit to how much breasts can grow from hormones alone.

For MTFs who want larger breasts or a change in breast shape, implants can be placed through an incision under the breast (inframammary), in the armpit (transaxillary), or around the nipple (periareolar).

How will my breasts look and feel after the implants?

Surgically augmented breasts typically look and feel different than non-implanted breasts. Augmented breasts tend to be further apart, firmer, and rounder than naturally developed breasts.

This is especially true for MTFs or non-trans women who receive implants later in life, as their breasts have not undergone the age-related process seen in non-trans women without implants (with age, the skin stretches, and the breasts sag).

Also, MTFs often have larger pectoral muscles and wider breasts than non-trans women.

Working with a surgeon who understands how the skin, muscle shape, and breast development of MTFs differ compared to non-trans women can be helpful in deciding on an implant shape and technique that will achieve the result that looks and feels the way you want.

Looking at pictures of MTF women who have received breast implants can give you a sense of what to expect.

What are breast implants made of?

Most breast implants are filled with saline (saltwater) or silicone.

If you are thinking about whether or not to get implants, you should be aware that all types of breast implants often leak or rupture and need to be removed.

Breast implants are not considered lifelong devices. You will likely need additional surgeries and visits with your surgeon over time.

At some point, your implants will likely need to be removed, and you will need to decide whether or not to replace them.

Implants stretch the skin. If you have your implants removed and do not replace them, your skin will likely be wrinkled, dimpled, or puckered.

Timing of breast augmentation

Estrogen can significantly change breast size and shape in some MTFs.

While breast growth begins soon after taking estrogen, it is slow and gradual, and it typically takes two or more years for breasts to reach their maximum size.

If you can take hormones, it is recommended that you wait at least 18 months to give your breasts time to develop with the hormones.

Hormonal development helps your nipples grow and also stretches the skin of your breast so you can have a more natural-looking implant.

Implants look more natural when used to enlarge existing breasts rather than implanted in a flat breast.

Some MTFs cannot take hormones for medical reasons, do not want the side effects of hormones, or simply want breasts without the other effects of hormones.

Implants may be an option if you cannot take hormones. You will need to work with the surgeon to find a size that fits your nipples, as they will still be small.

Breast surgery can be done as the first (or only) step of surgery or after you have already undergone other types of GRS (such as genital surgery).

What you can expect before and after breast augmentation surgery

In the hospital

If you receive breast implants alone (not along with genital surgery), you will most likely be admitted to the hospital on the day of 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 final physical exam.

The night before surgery, you will not be allowed to eat or drink anything after midnight.

After surgery, you will be monitored by hospital staff when you awaken from anesthesia. Breast augmentation is a relatively simple procedure, and you will likely be discharged home the same day of surgery with medication to control pain.

You will need to have someone drive you to your hotel. In the hospital, you will probably be given antibiotics to reduce the risk of infection while the wound is healing.

After breast surgery

You will wear a special bra and keep your surgical dressings on for three days after surgery. After three days, you may remove the gauze bandages. There are adhesive strips (“steri-strips”) along the incision line that you will keep on.

At this time, you can shower, being careful not to get the Steri-Strips soaked (it is OK if they are splashed with a little water, but do not run water directly over them).

After showering, gently pat the Steri-Strips dry. They will fall off by themselves after 7-10 days.

It is normal for the incisions to be red, but the redness should not extend more than 1-2 cm beyond the incision (if this happens, see a doctor immediately as this may 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.

A moderate amount of bruising and swelling is normal. Your breasts will probably feel sore and swollen for at least a month after surgery. If you have severe swelling, you should see a doctor.

Sharp pains, burning pains, or general discomfort are part of the healing process and will go away over time. Usually, severe discomfort passes 1-2 days after the operation.

Three to five days after surgery, you can begin special breast massage exercises that your surgeon will show you.

You can return to your usual routine when you feel well enough to do so (that is when normal movements do not cause pain). This usually takes 1-2 weeks but can take longer in some cases.

You should avoid any activities that get your heart rate up for 3 to 4 weeks.

Risks and possible complications of breast implants

Any surgical procedure that requires general anesthesia is a serious medical procedure. With any surgery, there is a risk of blood clots (which can be fatal) or an adverse reaction to the anesthetic.

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 soft, warm, swollen legs – these may be signs of a blood clot, and you may need emergency help.

In addition to the risks from blood clots, any surgery also 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 for the breasts to hurt after surgery and for the incision line to be red. If the redness extends more than 1-2 cm beyond the end of the incision, the skin is very tender or warm, and you do not feel well, see a doctor and check if you have an infection.

Possible complications specifically with breast implants are:

Capsular contracture: thickening and contraction of scar tissue that naturally forms around the implant (some scar tissue is normal; excess can be a problem)
One-sided breast size, shape, or position (one side looks different from the other)
Lopsided nipple placement (one side looks higher than the other)
Wrinkling of the skin over the implant: more likely if you are thin or your breasts have not developed well after hormone treatment
Problems with the implant: leakage, rupture, infection, or falling out of the body
Change in sensation at the nipples/skin of the breast: less sensation or more intense sensation

Your GP or nurse may take care of minor infections or unraveling of some sutures after you are discharged from the hospital. You will be referred back to your surgeon if so many sutures break that the wound keeps opening or if fluid/blood accumulates in your breast.

You will probably need further surgery if:

there are problems with the implant: the surgeon will need to take your implant out but can replace it later
Your breasts or nipples are lopsided: the surgeon will wait 4-6 months after surgery to see how the implant is adjusting
You have severe capsular contracture (scar tissue makes your breasts too firm, distorts their shape, or causes you pain)
You have severe scarring

MTF Face and Neck Surgery

During puberty, testosterone causes many changes in the MTF body, including the development of the skull and facial bones and the cartilage of the face and neck.

After puberty, hormone therapy may make the facial skin look softer and cause minor changes in the fat/muscle structure of the face, but hormones cannot change the basic structure of the face and neck; only surgery can reshape the contours of bone and cartilage.

MTFs have different ideas about-face and neck surgery. Some consider it very important to reduce their gender dysphoria and improve their fitness.

Others are concerned that MTFs may feel pressured to undergo face and neck surgery to meet conventional standards of attractiveness for women.

As with any other type of SRS, there is no right or wrong answer to the question of whether to undergo face or neck surgery: it is a personal choice.

Tracheal Shave

Rings of cartilage surround the trachea in the throat/neck. In “men,” the thyroid cartilage tends to protrude forward in a more pronounced point than in “women.”

This point is sometimes called the “Adam’s apple” or laryngeal protrusion.

The thyroid cartilage can be surgically altered (“tracheal shave” or chondrolaryngoplasty) to reduce the size and prominence of the laryngeal protrusion. This can be done at the same time as vocal cord surgery.

Facial Feminization Surgery (FFS)

FFS involves two types of techniques: surgery on the bones or cartilage of the skull or work on the soft tissue covering the bones/cartilage.

Bone reconstruction in FFS is based on the differences between the average “male” and “female” skull.

Soft tissue work may be performed to augment work on the bone or in lieu of bone reconstruction when relatively small changes are desired. Soft tissue work is less invasive than bone reconstruction.

FFS may include surgical changes in any of the following areas:


Facial Feminization Surgery creator Douglas Ousterhout emphasizes surgical alteration of the forehead as an important part of facial “feminization,” based on three differences in facial structure between non-trans women and men: As the images on the right show, “men” tend to have a relatively flat slope from the hairline to the eyebrows, while “female” skulls tend to be more domed.

As the pictures to the right show, “males” tend to have a heavier bony ridge just above the eyes (brow hump).

“Males” tend to have a long-distance from the eyebrows to the hairline than “females,” even without “male” balding (which further increases this distance).

Surgical changes to the forehead that may be performed as part of FFS include:

  • Forehead shaving: grinding down the orbital rims (upper edge of the eye sockets) to remove the forehead ridges.
  • Forehead implant: use of synthetic bone filler to round out a flat forehead
  • Forehead reconstruction: removing part of the skull, reshaping and replacing (using wires/screws to hold the new bone in place)
  • Forehead lift: tightening of the forehead skin and lifting of the eyebrows
  • Scalp advancement: advancement of the scalp and hairline.

Chin and Jaws

Chin and jaw FFS creator Douglas Ousterhout describe three differences in the structure of the chin and jaw of non-trans women and men: as the images to the right show, “male” chins tend to be wider and more angular, while “female” chins tend to be more pointed and narrow.

The length from the lower lip to the base of the chin tends to be shorter on “female” than “male” chins.

The posterior corners of “male” jaws tend to be fuller, with the bone having a sharper angle and flaring away from the face and a more pronounced masseter (chewing muscle).

“Female” jaws tend to have a gradual curve from ear to chin, with a less square and fuller shape in the back.

Chin and jaw FFS is performed through the mouth via incisions around the lower gums. Surgical changes to the chin and jaw that may be performed as part of an FFS include:

  • Removal of bone from the back corner of the jaw, possibly with removal of part of the masseter muscle to make it less prominent
  • Removal of bone from the chin and reshaping the chin to make it look more tapered, less angular, and shorter
  • Use of implants or bone filler paste if the chin is receding
  • Surgical rotation of the jaw: a clockwise rotation pushes the chin and the back corner of the jaw back, making them look smaller
  • Liposuction under the chin to make the lower half of the face appear less heavy


Surgery to change the appearance of the nose is called rhinoplasty. Some MTFs want their nostrils or the tip of their nose to look different.

In other cases, MTFs who are having brow surgery are recommended to have surgery on the bridge of the nose to make the transition from the nose to the forehead look even.

Surgical changes to the nose that may be performed as part of an FFS include:

  • Reduction of the bone from the bridge of the nose to make it flatter.
  • Reducing the width of the nose to make it thinner
  • Shortening the nose by removing some of the cartilage at the tip of the nose
  • Narrowing of the nostrils


Cheek augmentation can be performed to accentuate the “cheekbones” (zygomatic arches), make the cheeks more prominent, and also make the chin/jaw look smaller.

Augmentation can be performed with bone grafts, synthetic implants, or fat implants. Alternatively, the cheekbones can be cut and repositioned with a bone wedge.


Surgical changes to the lips that may be performed as part of FFS include:

  • removing the skin between the nose and upper lip to raise the upper lip
  • angling the section of skin between the nose and upper lip backward
  • using implants to make the lips look fuller


In some MTFs, the position of the ears is changed so that they lie flatter against the head (“ear flattening” or otoplasty), or the size of the earlobes is reduced.

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

Genital Surgery

MTF genital surgery may include:

  • Removal of the testicles (orchiectomy)
  • Removal of the penis (penectomy)
  • Creation of a vagina (vaginoplasty), labia (labiaplasty), and clitoris (clitoroplasty).

Usually, these three types of surgeries are performed together. However, some MTFs want to have their testicles removed as early as possible so they can take fewer hormones (to reduce the risks associated with estrogen).

Others aren’t sure if they want the full vaginoplasty and want to have their testicles removed to see how partial surgery feels.

Some people on the MTF spectrum don’t want a vagina (they prefer to have just the penis removed) or aren’t comfortable with the health risks of vaginoplasty.

For this reason, we have included information about the “orchiectomy only” or “penectomy only” options for MTF genital surgery.


Testes (also called testicles or gonads) are the organs that produce sperm and most of the testosterone in “men.”

The testes are located in a sac of skin called the scrotum. In MTF orchiectomy, the testicles are removed, but the scrotal skin is typically left behind to form labia and line part of the vagina (in vaginoplasty – see below).

With orchiectomy, even if the scrotal skin is not removed, there is a risk of shrinkage or damage to the skin. Because of this risk, some surgeons advise against performing the orchiectomy as a separate procedure if you wish to have a vaginoplasty at a later date.

Other surgeons are not as concerned about this because a skin graft can be taken from the abdomen if the scrotal skin is not usable.


Penectomy is the removal of the penis. When performed without vaginoplasty, it is sometimes referred to as “nullification.” A shallow vaginal depression is created, and a new urethral opening is created to allow urination while sitting.

Removal of the penis as a separate procedure is not recommended if you are considering vaginoplasty at a later date, as skin and tissue from the penis are typically used in vaginoplasty.

In other words, do not have a penectomy performed first if you think you may want a vaginoplasty later.


The term vaginoplasty encompasses several procedures designed to turn “male” genitals into “female” genitals.

Usually, most of the surgery is performed in one step (removal of the testicles, partial removal of the penis, and creation of a vagina, clitoris, and labia), but some surgeons prefer to work on the labia and clitoral hood in a second surgical step.

In vaginoplasty, the surgeon’s goals are:

  • To preserve the ability to have orgasms.
  • To create the clitoris, labia, and opening of the vagina (introitus) so that they look realistic and maintain good touch sensation (i.e., can be felt when touched).
  • To create a vagina that retains its shape, is sensitive to touch, is wide and long enough for sexual penetration (with fingers, a dildo, or a penis), and has a moist, elastic, and hairless lining.
  • To modify the structures of the urinary tract so that you urinate downward and in a steady stream.

As part of the decision-making process about vaginoplasty, it is important that you talk to the surgeon about how important each of these points is to you, as your goals will determine the techniques that will be used.

For example, if it is very important to you that your vagina is long and wide enough to accommodate a penis or dildo, you may need to use grafts if your penis is too small to create a large enough vagina (and you will also need to perform daily dilation after surgery).

The most common technique for creating a vagina is penile inversion. This technique involves skinning the penis and turning the skin inside out to line the walls of the new vagina.

In some cases, additional skin is needed to make the vagina longer or wider; this is usually taken from the lower abdomen or scrotum.

A segment of your colon may be used to create the vagina if penile inversion fails or is not possible (for example, because your penis was damaged or removed when you were younger).

As part of penile inversion, a small portion of the tip of the penis – the part that is most sensitive – is used to create a new clitoris.

Erectile tissue, which gives the penis the ability to become hard, is removed so that the vaginal entrance and clitoris do not swell excessively when you are sexually aroused.

The tube that carries urine from the bladder to the outside (urethra) is longer in “men” than in “women” and is in a slightly different position. The urethra is shortened and repositioned as part of a vaginoplasty. The prostate (it sits at the neck of the bladder, around the urethra) is not removed.

The labia minora (inner labia) are typically made from skin remnants of the penis. The outer labia (labia majora) are typically made from testicular skin.

After vaginoplasty, revisions are sometimes needed to refine the appearance of the labia as well as the clitoris or its hood.

What to expect before and after genital surgery

When performed alone, orchiectomy is generally considered a simple procedure that can be performed under local anesthesia and completed in less than an hour. It is routinely performed on “men” who have prostate or testicular cancer, and follow-up is generally straightforward, with a full recovery in 2-4 weeks.

Penectomy and vaginoplasty are both major surgeries that require more complex care before and after surgery. The following information relates specifically to these more complex surgeries.

At the hospital

You will be admitted to the hospital the day before your surgery. Blood will be drawn to check your general health, and electrodes will probably be placed on your chest (electrocardiogram) to measure your heart function; if there are any concerns about your lungs, a chest X-ray will be taken.

You will also have a “bowel prep” to clean out your bowels. This will help to avoid any problems during the operation, and it will also give you a few days rest, so you don’t have to strain to go to the toilet after the operation.

You should not eat or drink anything after midnight the night before the operation. The area where the surgery will be performed will be shaved.

After surgery, you will be monitored by hospital staff while you awaken from the anesthesia. You will then stay in hospital until you have recovered enough to be discharged home – this usually takes 6-8 days.

In the early stages of recovery, you will need to be on bed rest (i.e. you will not be allowed to get up and walk around).

You will likely be hooked up to a PCA (patient-controlled analgesia) machine, which will allow you to take pain medication as needed (up to a certain limit, which is safe). You will also be given antibiotics and medications to prevent blood clots.

During vaginoplasty, a rod-shaped prosthesis is inserted into your vagina and left there for five days to allow the skin lining the new vagina to bond with the vaginal wall.

A sterile tube (catheter) will be placed in your new urethra to empty your bladder.

Five days after surgery, both the catheter and the prosthesis will be removed so the surgeon can check your healing.

You will be given instructions on how to care for your vagina and an information sheet to follow at home. You will usually stay in hospital for 1-3 days afterward to make sure everything is healing well.

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.

The decision for SRS

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).
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.

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No. 11 Nakhon In Road, Talat Khwan Subdistrict,
Mueang District, Nonthaburi Province 11000

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