Surgery is the 3rd, and often final stage, in the 3-step treatment process for gender transition.

There are different types of surgical procedures. These can be broadly divided into those procedures for Male-to-female (MTF) transsexuals and those procedures for Female-to-male (FTM) transsexuals. The surgery itself can be subdivided into Cosmetic procedures (for example, breast or facial surgery) and Genital procedures.

Genital surgery, also known as Gender Reassigment Surgery, can be further divided into cosmetic genital surgery and functioning genital surgery. The main difference is the degree of sexual functioning achieved after surgery, and the latter procedure is therefore considerably more complicated.

The important aspects of genital surgery are covered here, with an outline guide for the different types of operations available. Cosmetic procedures are covered on the Cosmetic Treatments page.

Genital Surgery for MTF transsexuals

Gender Reassignment surgery has evolved considerably since the first recorded procedures in the 1930's. Genital surgery for MTF transsexuals may consist of all or some of the following. The type of procedure depends on individual choice, the recommendations of the surgeon, expectations regarding future sexual activity and certain anatomical limitations (such as the amount of available skin).

Bilateral Orchidectomy. This operation involves the removal of the testicles, and may be the first stage of full gender reassigment surgery or, for some, the only surgery desired. The skin of the scrotum is usually preserved and can be used later to form a neovagina (a vaginal opening) and the neolabia (vaginal skin folds). It is important to time this procedure carefully to maximise the amount of skin available because the scrotal skin tends to get smaller over time with hormone treatment and can vary from individual to individual.

Removal of the Penis. The penis is normally removed as part of the procedure that involves the construction of the labia (skin around the vagina). This can be performed to produced female-looking genitalia (labioplasty) or with the formation of a vagina opening (vaginoplasty) which is obviously a more complex process but allows the potential for penetrative sexual functioning. The urethra (the tube that carries urine from the bladder to the end of the penis) is reconstructed and repositioned (a considerably challenging surgical procedure) to enable female bladder functioning.

Labioplasty. The large majority of the available skin needs to be used to form a neovagina but there is usually enough scrotal skin to make vaginal skin folds/lips in a procedure known as a labioplasty. Sometimes skin from the penis is used. In both cases, the surgery is very successful, not only in producing a very realistic external appearance, but also a degree of sensation for sexual pleasure.

Vaginoplasty. This procedure involves the formation of a vaginal opening, a neovagina. A cavity is created and positioned in a natural space within the male pelvic area. The inside lining of the neovagina is made from the scrotal skin being inverted inwards (extra skin can be obtained from the penis or from skin-grafts from the upper thigh). In some cases, the lining of the neovagina can be made from a small segment of intestine that is carefully removed (usually from the large intestine, a section of it known as the sigmoid colon), but this requires open abdominal surgery and is a much more complex procedure with considerably more potential complications.

Formation of a clitoris. Creating a clitoris that can allow orgasm is becoming increasingly successful, with over 75% people reporting a good sexual functioning (including orgasm). It involves transfering the sensitive area of the skin from the original penis, including all of the important nerve-endings, to a suitable position and make a small skin fold to make the clitoral hood.

Genital Surgery for FTM transsexuals

Surgery for FTM transseuxuals is planned early in the Real Life Experience, perhaps after 12 months or so. This is due, in part, to the rapid action of the masculinising hormones which cause permanent changes, such as body hair and voice deepening. Therefore the presence of breasts can make continuing the RLE really problematic and breast surgery is sometimes considered earlier under these circumstances. Genital surgery has advanced emormously alongside the advances in plastic and reconstructive surgery. Microsurgery has allowed the preservation of important nerves and blood supplies which allows the surgical team to create a penis (phalloplasty), with male bladder functioning and full sensation. The use of inflatable implants has taken the surgery to the next level and is very popular and has impressive results.

Surgery is divided into different stages, including the construction of a penis-like structure (phalloplasty), the complex task of creating a functioning urinary system (urethroplasty) and a number of different cosmetic procedures, such as forming a scrotal sac and insertion of different prostheses (testes and inflatable penile).

Phalloplasty. Creating a penis-like structure is a highly-skilled procedure. Sometimes the clitoris, following enlargement with hormone treatment, is made into a small penis. However most people opt for a flap-type operation which involves taking an area of skin (with its soft tissue, blood and nerve supply) to make a larger phallus. The skin can be taken from the pubic area, from skin from the sides of the tummy or, most commonly, from the forearm. The forearm procedure (known as a free flap phalloplasty) can provide enough skin to create the penis and the tube to carry urine to the end of the penis (the neo-urethra). It is becoming very popular despite the added complication of needing a skin-graft to cover the skin taken from the forearm.

Penile prosthesis. There are different types of penile prosthetic implants. These can be semi-rigid or, more commonly, inflatable. Inflatable ones have several advantages, not only for sexual functioning, but also they are less likely to cause complications from extra pressure on skin and blood vessels. The pump for the inflatable prosthesis can be positioned in the testicular prosthesis, for ease of use.

Urethroplasty. The tube that carries urine along the penis is called the urethra. A new, longer tube (the neo-urethra) therefore needs to be constructed to allow normal urine functioning. The tube is made from a strip of skin taken from the forearm, or sometimes from the lower tummy area. This new tube then carries urine from the clitoral area to the end of the phallus.

Formation of neoscrotum. The creation of a scrotal sac from the original skin and tissue around the vagina is a common procedure. The labia majora can be expanded and stretched surgically to allow the insertion of one or two prosthetic testicles.

Hysterectomy and Oophorectomy. Many people choose to have the womb and ovaries surgically removed. Although it is not essential, it removes the problems regarding future risks of cervical or ovarian cancers, the need for cervical smears and has a number of psychological and emotional advantages. Also the hormone treatment can be reduced to a lower dose, so any side effects and asscciated risks are also reduced. Both procedures are done via key-hole surgery, if possible, and usually at the same time as the phalloplasty procedure, to limit the number of operations and the obvious stress and discomfort caused.

Have you had surgery yourself? Are you in the process of deciding which operation to have? Do you know someone who has experienced the procedures? Let us know your views in our Blog.