Male to Female Transition: Fundamentals of Sex Reassignment Surgery
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Sex reassignment surgery (SRS) refers to a variety of surgical techniques used to change the bodies of people who have gender dysphoria.
Gender dysphoria, also known as transgenderism or gender identity disorder (GID), is a condition in which a person feels a major mismatch between their biological sex and their gender identity. It is not a type of mental illness, although it was wrongly believed to be one in the past.
People with gender dysphoria can be treated with counseling, hormone therapy, and sex-change surgical procedures. Not every transgender individual requires or wishes to undergo sex-change surgery. Some are treated with counseling only; others may get counseling and/or hormone therapy. But some trans people do end up going through sex-change operations.
Reasons for choosing to have male to female sex reassignment surgery
Male to female sex change operations are for people who are biologically male, but who identify as women and wish to live their lives as women. Many transgender people say they are uncomfortable with their biological sex and its associated gender role. They feel trapped in a body they cannot identify with. According to the American Psychiatric Association, gender identity disorder can cause distress and impair an individual on both social and personal levels.
What are the risks of gender reassignment surgery?
- Immediate risks include bleeding, infection, skin or clitoral necrosis, suture line dehiscence, urinary retention, or vaginal prolapse. Fistulas from the rectum, urethra, or bladder usually present early on.
- Acute bleeding usually originates from the urethra and most often can be controlled with local pressure. If local pressure is unable to achieve hemostasis, then placing a larger catheter (20F) in the urethra alone may stop the bleeding. If necessary, placing a suture around the bleeding site (with the catheter in place) will stop the bleeding in almost all cases. It is not unusual for localized hematomas to spontaneously drain through the vagina or suture line. This usually occurs a week or greater after surgery as the hematomas liquefy. The blood characteristically appears dark and old and is not accompanied by clots.
- Failure to adequately dilate in the immediate postoperative period will likely result in severe vaginal stenosis.
- Partial or complete clitoral necrosis may occur and should be treated conservatively with antibacterial ointments. In the majority of cases, the neurovascular bundle and a portion of the clitoris is still present and will usually maintain good sensitivity.
Vaginoplasty Postoperative Instructions
Focus area | Instructions |
Activity | Avoid strenuous activity for 6 weeks. Avoid swimming or bike riding for 3 months. |
Sitting | For the first month post-op, sitting may be uncomfortable, but not unsafe. Recommendation to use donut ring to relieve pressure at the surgical site. |
Bathing | Resume showering following first postoperative visit, patting incisional areas dry. Do not take baths or submerge in water for 8 weeks post-op. |
Swelling | Labial swelling is normal and will gradually resolve 6-8 weeks postoperatively. Swelling may be aggravated with long-term sitting or standing. For the first week post-op, applying ice on the perineum for 20 minutes every hour can assist in relieving some swelling. |
Sexual intercourse | You may resume sexual intercourse 3 months after surgery unless you have been instructed otherwise. |
Hygiene | Wash hands before and after any contact with the genital area. Shower or wash daily. When washing, wipe from front to back to avoid contamination by bacteria from the anal region. Avoid tight clothing; friction may facilitate bacteria transfer. |
Vaginal discharge | Vaginal discharge that is brownish yellow should be expected in the first 4-6 weeks postoperatively. Bleeding and spotting should be expected in the first 8 weeks postoperatively. Soap and water douche should help reduce this. Chamomile or lavender liquid soap can help cleanse the neovagina as well. |
Tobacco/smoking | Avoid tobacco use or smoking 1 month postoperatively, as this can interfere with the healing process. |
Diet/nausea/constipation | Begin with a liquid diet and increase to your usual diet as tolerated. Anti-nausea medication may be prescribed. Narcotic pain medication may cause constipation; a stool softener such as Colace can help prevent constipation. |
Pain medication | Postoperative pain is normal, and pain medication may be prescribed. Pain medication is to be taken as prescribed and can be switched for Extra Strength Tylenol at any time. |
Dilation | Dilation is an important part of recovery. Dilators may be provided to a patient with instructions regarding dilation in the post-op period. |
Delayed / long-term postoperative maintenance and considerations
Adherence to the dilation regimen is critical to healing and maintaining vaginal depth and girth. After the initial healing period, dilation must continue regularly for at least one year postoperatively. The depth and the width of the vagina should be checked regularly as one tapers down the dilation schedule. If it is noticed that vaginal depth or width are diminishing either by patient report or in-office examination, the dilation schedule should be increased. If the patient experiences difficulty with dilation due to discomfort, installation of lubricant ahead of the dilator with either a 3cc syringe or the applicator device supplied with vaginal antifungals may be helpful. Patients may develop a sensitivity to the preservative in the water-based lubricant; simply changing the brand of lubricant is often an effective solution.
Sensation and orgasm
No major sensory nerves should have been divided during surgery, so sensitivity should not be adversely affected after vaginoplasty. Pre-operative functionality is an important indicator, though it is possible that a previously anorgasmic patient will be orgasmic following vaginoplasty. The combination of prolonged estrogen/anti-androgen therapy and orchiectomy during surgery may result in a reported decline in libido for some patients.
Sex change surgery is irreversible. Therefore anyone wishing to undergo a sex change operation from male to female should carefully consider that decision.
Written by Dude Arnel Flores Lopez, BSN, RN 20 April 2021
Medically reviewed and updated by Dr.Deyn Natthakhet Yaemim, 24 April 2021
- Weyers S, Verstraelen H, Gerris J, Monstrey S, dos Santos Lopes Santiago G, Saerens B, et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009;9(1):102.
- Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.
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