Sex reassignment surgery (initialized as SRS; also known as gender reassignment surgery, genital reconstruction surgery, sex affirmation surgery, sex realignment surgery or sex-change operation) is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex. It is part of a treatment for gender identity disorder/gender dysphoria in transsexual and transgender people.
Male to female sexual reassignment surgery involves a series of procedures from hair removal to breast implants to vaginoplasty (reshaping the penis and testicles to look and function like a vagina). Men considering sexual reassignment surgery also usually opt for hormone treatments to complete many of the endocrinological changes necessary for the transformation.
Other terms for SRS include sex reconstruction surgery, gender confirmation surgery, and more clinical terms, such as feminizing genitoplasty or penectomy, orchidectomy and vaginoplasty are used medically for trans women, with masculinizing genitoplasty often similarly used for trans men.
People who pursue sex reassignment surgery are usually referred to as transsexual; "trans" - across, through, change; "sexual" - pertaining to the sexual characteristics (not sexual actions) of a person. More recently, people pursuing SRS often identify as transgender instead of transsexual.
MTF SRS Surgery Overview
While procedures for male to female surgery tend to vary, in most cases, the plastic surgeon removes the testicles and inverts the foreskin and penis to form a flap that preserves the nerve endings and blood supply. The glans sometimes forms the innervated clitoris. Circumcised patients or a shortage of skin for the inside of the vagina may require the use of scrotal skin from which the pubic hair follicles have been removed. The rest of the scrotal skin becomes the labia majora. Where there is an extreme shortage of skin, grafts can be taken from the thighs, hips, or colon.
Further surgery in the form of a labiaplasty may be necessary as a follow-up procedure to enhance the appearance of the outer vulva once the tissues, nerve endings, and blood supply have recovered from the original male to female surgery.
After the procedure, the patient must maintain vaginal dilation with medical graduated dilators, dildos, or similar substitutes. Sporadic sexual intercourse is not sufficiently effective for this purpose. Patients typically also require regular applications of estrogen in the vagina as part of their prescribed estrogen dosage. With the help of a gel-based lubricant, vaginal intercourse is usually possible within 2 to 3 months of the surgery.
Best Candidates for a Sex Change
The Standards of care for gender identity disorders – WPATH (World Professional Association for Transgender Health) the earliest sets of clinical guidelines for the express purpose of ensuring “lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment.” These standards are still the most well-known; however, other sets of SOCs, protocols and guidelines do exist, especially outside the USA.
Patient must be at least age 18 years of age. Patients will require permission from parents if under 20 years old. Patients must be diagnosed with at least one of the following disorders: gender identity disorder, gender dysphoria, or associated conditions (anxiety, depression). Patients must have undergone at least one year of antiandrogens or/and hormones. Patients are required to have lived full-time in the cross-gender role for at least 1 year (supported by Identification Documents). Patients must have approval from a psychiatrist (MD), psychiatric social worker (PhD), or clinical psychologist (PhD).
If you cannot provide the complete documents 2 months prior to your scheduled surgery date you may be required to see 1 or 2 Psychiatrists in Thailand to confirm your eligibility for SRS. This would be at an additional cost.
Preparing for SRS Surgery
Patients must complete a health check up within three months prior to SRS. Patients must also be confirmed by a private physician to be free from serious medical diseases and must pass the following blood tests:
- CBC, HIV Electrolytes, FBS, Creatinine Urinalysis
- Alkaline Phosphatase, Chest X-ray
- SGOT LDH EKG
Patients must discontinue hormone treatment at least fourteen days prior to surgery. Hormones should be halted to reduce the risk of thrombosis (blood clots). Oral tablets should be halted two weeks prior to surgery and injectables should be halted four weeks prior to surgery. Oral antiandrogens can be halted three days before surgery (four weeks if injectables). Aspirin and smoking should be halted two weeks before surgery.
Two letters are required from foreign patients. One letter must be from either a medical doctor or a psychologist states that the person is a candidate for SRS. The other letter may be from any doctor, showing proof of having been on hormones for at least one year.
Sex Change Surgery Overview
Sex reassignment surgery (initialized as SRS; also known as genital reconstruction surgery, sex affirmation surgery, sex realignment surgery or sex-change operation) is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex. It is part of a treatment for gender identity disorder/gender dysphoria in transsexual and transgender people.
Other terms for SRS include gender reassignment surgery, sex reconstruction surgery, genital reconstruction surgery, gender confirmation surgery, and more clinical terms, such as feminizing genitoplasty or penectomy, orchidectomy and Vaginoplasty are used medically for transgender women.
Which procedure should you select (Penile Skin Inversion or Sigmoid Colon) For SRS (MtF), there are 2 main surgeries:
- Penile Skin Inversion
- Sigmoid Colon
SRS with Penile Skin Inversion or Sigmoid Colon each provided the sensational glans clitoris, labiaplasty and vaginoplasty in one stage with 3 different techniques:
- Long Penis (>6 inches, erect) = Penile Skin Inversion (PSI)
- Medium Penis (2-6 inches, erect) = Penile Skin Inversion (PSI) with Scrotal Skin Graft (SSG)
- Short Penis (<2 inches, erect) = Penile Skin Inversion (PSI, SSG) with Sigmoid Colon Graft (SCG)
Penile Skin Inversion Vaginoplasty
This procedure is a combination of a penile skin inversion and an immediate full thickness skin graft. The vaginal canal and opening is created beneath the urethral opening and prostate gland. Vaginal depth is of concern to most patients. The most important factor in creating this depth is the amount of penile shaft skin. The technique that lengthens the depth of the vagina is using the full thickness skin graft from the scrotal. Hair on the scrotum must be removed so that the skin graft is placed at the distal end of the penile skin flap. This technique can lengthen the depth at least 2 more inches.
A portion of the glans (head of the penis), with its nerves and vessels, is converted into a clitoris. In so doing, the clitoris will be functional in sensation as well as in appearance.
The excess erectile tissue around the urethra should be removed in order to avoid symptoms that stem from engorged erectile tissue during sexual arousal, that may result in the narrowing of the vaginal opening.
Colon transposition is used for patients who need more depth (exceeding 8 inches).
The bowels are prepared mechanically, the patient is placed in lithotomy. A silmultaneous abdominal and perineal approach are operated by two specialized surgeons( the general / plastic surgeon and the abdominal surgeon), then the abdominal surgeon prepares the bowel through the short low Pfannenstiel incision. The sigmoid colon is isolated about 15-20-cm-long, with the vascular pedicle from the inferior mesenteric and superior hemorrhoidal system, the remaining two ends of the colon is anastomosed by the continuance, one layer closure.
The plastic surgeon starts the perineal dissection by transversely incising the end pouch of the penile skin or the end of vaginal mucosa in the case of vaginal astresia. The dissection is carried out by eletrocautery, by palpating the urethral catheter anterior up to the retrobladder properitoneal space and the peritoneum is incised and enlarged. The general surgeon deliver the colon through the peritoneal opening after closing the proximal end, generally the rectosigmoid opening could be pulled down to the perineal skin without any tension, the anastomosis is made to the vaginal skin cuff at 1- 2 inches from the perineum, using the interrupted chronic catgut.
The results that can be expected after sex change operations depend on whether the surgery was male-female reassignment or female-male, the amount of additional cosmetic surgery necessary to alter the gender appearance and the individual patients' response to surgery.
Patients can expect sexual reassignment surgery to give them the genitalia of the opposite sex.
Recovery After Transgender Surgery
After surgery, pain that is easily controlled by medication usually will subside in a few days. Dressings have been applied; we will be replaced a few days. Sutures will be removed within a week of surgery. Although the surgeon has made every effort to keep scars as inconspicuous as possible, they are the inevitable result of surgery. Minimal swelling and discoloration of the breasts will disappear rapidly.
Healing process may occur for weeks or even months following surgery.
Dilation will be given an instruction during follow up visits.
The decision on when to return to work and normal activities depends on how fast you heal and how you fee. To permit proper healing, you should avoid over activity and refrain from overhead lifting.
GRS Post Operative Care
The wound should be washed gently with Hibiscrub (pink color) in the shower followed by douching while seated in the toilet:
- Douche solution (proportion) = 5-10 ml (cc) of Beta dine solution mixed with 1L of water or until the container is full.
- Insert the douche to full depth, squeeze, and hold tightly the container.
- While holding tightly the container, extract the douche.
Keep the wound dry and apply Beta dine solution with cotton balls; and apply Kemicitine ointment with a cotton applicator. If there is some bleeding, press or apply pressure with a dry cotton ball to the site for 15 minutes. During the first weeks after surgery, feminine knapkins (tampons) should be changed several times per day due to normal vaginal bleeding during recovery.
After one month of SRS operation you will be required to start applying Premarin cream to your neo-vagina. Apply two times a day to soften your neo-vagina. This would generally take around six months.
You can return to female hormones as before surgery or after two weeks. You should consult your endocrinologist to re-adjust the dosage. A sudden change in hormone levels, for some individuals, may result in the fluctuation of emotion.
After the 3rd month post-op, you should be able to engage in normal vaginal. We recommend using gel as a form of lubrication. If you are healing well you can engage in intercourse after 2 months. In general, patients may engage in sexual intercourse after they get to dilator number 6.
Patients can resume taking female hormones in 10 - 14 days after the surgery but the need for hormones is less than prior to surgery, about 1/2 to 1/4 of preoperative doses. Before returning to hormones it is recommended that you check with our surgeon first. Our clinic director can assist you on what types and doses should be taken.
Possible Sex Change Risks
Before being discharged from the hospital to the hotel, a nurse will teach you how to take care of your vagina and prescribe more medications. The stiches will be removed after seven to ten days. You will then be able to return home.
Usually there is no wound infection, no intra abdominal complications, such as infection, peritonitis, obstruction, ileus, leakage of the anastomosis.The patients are lubricated vaginal canal. The mucous discharge is usually excessive during the first few months and later subsided. The vaginal atresia patients menstruate through the newly constructed colonic vagina and the short low Pfannenstiel incision was well camouflaged by underwear bikini.
Risks of Sex Change Surgery Include:
- Post-operative bleeding or Hematoma
- Wound healing problem
- Recto-vaginal fistula
- Partial or complete flap necrosis
- Intravaginal hair growth
- Hypertrophic scaring