Sex Change Surgical Options
Most surgeons will consider as eligible for SRS genital surgery a genetically male "woman" over the age of majority who has undergone at least 12 months continuous female hormonal treatment, and who's also successfully lived for at least a year full-time as a woman. However a surprising large number of women who fulfil these criteria do not immediately seek SRS, or any other genital surgery. The reasons for delaying or avoiding irreversible SRS procedures are very diverse, but include
Its irreversibility, uncertainty as to the strength of one’s transsexuality and a desire to be able to turn back.
A desire to preserve a reproductive capability.
A medical problem which prevents major surgery.
Happy as is, no strong desire or psychological need to have female genitals.
A homosexual sexual orientation.
Fear of the surgery.
Pressure from a partner, family or friends.
Lack of money for surgery.
Potential loss of earnings after surgery.
Unfortunately I haven't yet found any recent (rather than 1960's) statistics on the length of time after a real life transition until genital surgery for male-to-female- women, but I have found some interesting figures for female-to-males. Dr Holly Devor when researching her book FTM: Female-to-Male Transsexuals in Society found that most transsexual men retain some very dramatic physical manifestations of their previous lives as females. More than 1/3 of the 35 participants in her research who discussed this issue said that they began living as men without the aid of either hormone therapies or surgeries. Another 60% of them began their lives as men with the assistance of hormone therapy but, on the average, they did not have their first surgeries for another 3 1/2 years. Only six (15%) of the 39 transsexual men interviewed had had any kind of genital reconstruction surgery. Furthermore, despite the fact that they averaged 6.5 years since beginning hormone therapy, and 7.9 years since beginning to live full-time as men, slightly more than half (51.5%) of those who had not yet had genital surgery said that they were not particularly interested in having any done.
These extraordinary results are not directly relatable to transsexual women as much more difficult and expensive surgical procedures are required for female-to-male sex re-assignment than for male-to-female sex re-assignment. However they do reinforce my own belief that a medium [average] delay of 3 years from full time transition to MTF SRS would probably be near the mark, high though this may appear at first sight given that a common complaint from transsexual women is the need to wait a whole year after transition before being eligible for surgery.
But the reasons to have some form of genital surgery often strengths with time, and most transitioned transsexual women eventually undergo some procedure. Drivers may include:
A powerful desire to finally match the bodies physical sex with a female psychological gender and social lifestyle.
To present a female physical appearance even when nude, and remove fears of visual detection as a "man".
To enable heterosexual relations with men.
A strong and sexually exciting desire to have female genitals.
To remove the masculinizing physical effects and/or urges caused by the testes.
Concern about long term liver damage due to prolonged use of anti-androgens and high oestrogen and progesterone doses.
Comfort, avoidance of testicular discomfort when wearing tight under-wear/swimwear.
Pressure from a partner, family or friends.
Age at SRS
Considerable publicity often surrounds young transsexuals who with the support of their parents transition and have surgery at a very young age - in their teens or early 20's. There is no doubt that this group is becoming more numerous, but it is still only a very small proportion of the transsexual community.
A chart showing the age of legal change of status (usually after SRS) of 712 German transsexuals aged 18 to 79. The mean age is a high 34.
Source: Weitze C., M.D., Osburg S., M.D. (1997)]
There is also a statistically significant group of young transsexual women (often from parts of Asia and Latin America) whose career in the sex industry leads to various surgery procedures in during their teens and 20's, but this is usually in the form of breast augmentation and facial feminising. When (if) they finally decide to have SRS, typically in their late 20's or 30's, it generally marks their move out of the sex industry,
Shemale prostitutes during a "Gay Pride" march.
Even today, half a century after Christine Jorgenson, the vast majority of European and North American transsexual women are in their 30's or 40's before they actively seek to resolve their gender issues. Inevitably this means that the patient age profile of surgeons undertaking sex-re-assignment surgery follows this trend - with a lag of a several years representing the time from the woman commencing treatment to having some form of genital surgery.
For various reasons, very young American and European women are far more likely to use a surgeon in their own country than travel to Thailand, and this will have raised the average age by a few years, but the general picture of a majority of transwomen undergoing SRS in or near their middle age is probably correct.
Surgery Options
The transsexual woman who has transitioned full-time faces a difficult choice between a number of medical options regarding surgery on her male genitalia. In order of increasing complexity and cost these are:
No surgery (although prolonged female hormonal treatment will shrink the male genitalia significantly and will eventually cause permanent chemical castration after about 6-12 months use)
Surgical Castration or Bilateral Orchidectomy, i.e. removal of the testes (or gonads) along with the undesirable masculinising and virilizing effects caused by the testosterone they produce.
SRS - removal of the testes and male genitalia and the formation of female appearing external genitalia, but with no emphasis on vaginal depth. This is usually followed by a labiaplasty several months later.
Full SRS with vaginoplasty - removal of the testes and male genitalia and formation of female appearing external genitalia, formation of a neo-female genitalia with adequate depth for intercourse. Again this will often be followed by a labiaplasty.
Chanelle, post-SRS. She now works as a model.
Figures and statistics are hard to find, but as many as 50% of all transitioned transsexual women may fall in category one, and some will never progress to another category.
The decision on which option to select is a personal choice that may well evolve over time. For example most men who believe that they are transsexual will start off assuming that they will have SRS as soon as possible when they seek treatment. However, after they have benefited from hormones (etc.) and perhaps transitioned to live as a woman they may no longer see any urgent need for SRS and it’s only some event years later such as a relationship with a heterosexual man that eventually causes them to have SRS.
If there are any doubts, the best route is always NO surgery. It’s always possible to have surgery later, but it’s impossible to reverse castration or SRS. Even if surgery is decided on, the prior freezing of a sperm sample (if obtainable) may be a sensible measure to help preserve some reproductive options - even as a mother)
Castration is most commonly performed with intersexed or gender disordered children, but some transsexual women do find it to be a useful and cheap halfway house to full SRS.
SRS always involves the formation of the entrance to neo-female genitalia (i.e. an artificial female genitalia). However for very reasons this can be often be quite shallow (just 2-3 inches, 5-7cm) . The decision as whether or not to have a deep female genitalia suitable for intercourse is actually a decision which need not always be an automatic "yes" - particularly for elder women who perhaps don't intend to lead an active sex life after surgery.
For satisfactory penetrative sexual intercourse with a man a stretched vaginal depth of at least 6 inches (15 cm) is required, while this is about the mean depth of the neo-female genitalia of transsexual women, inevitably some women are shallower and this is a major cause of dissatisfaction in the result of SRS.
But for accommodating intercourse with a well endowed male partner, a vaginal depth of up to 9” (20-22cm) is necessary. This is actually a very considerable depth which is rarely achieved in SRS, it either requires generous penile skin to be present (rarely the case with the MTF transsexual after prolonged female hormonal treatment), or scrotal skin (which requires painful electrolysis beforehand) or colon grafts be used to extend the depth - and even then the internals of the transwoman may be unsuitable for such a deep and broad cavity. One the other hand, most genetic women would also have problems fully accepting such a lucky man! It also should be remembered that reaching and maintaining vaginal depth requires frequent sexual intercourse or the effort of regular dilation.
For SRS, by far the most common method is variations of the penile inversion method, a rather less common method is variations of the sigmoid colon section method.
It is important to re-iterate that the prolonged use of hormones and an orchidectomy has a very negative effect in relation to SRS as in time the male genitalia and scrotum will atrophy to some extent, i.e. the male genitalia size reduces and the scrotal sack shrinks. The earlier that SRS is performed (ideally before hormones are even started!), the better the likely result, and some surgeons are reluctant to perform surgery on a patient who has previously had an orchidectomy. Of course this situation contradicts the recommendation of many psychiatrists that a lengthy "real life test", usually associated with a hormone regimen, is essential prior to any genital surgery.
However, normal female appearing external genitalia can be constructed with little "material" to work with. Indeed it is worth pointing out that with modern techniques a good surgeon can often produce a vulva that's more text book "female" in appearance than most genetic women actually have!
If a transsexual woman does not plan to have vaginal penetrative sexual intercourse then clearly there is no need to have a deep female genitalia formed, and unnecessary surgical procedures can be avoided and the subsequent dilation effort will be spared. This approach should perhaps be more common than it is as it offers the woman significant health and hygiene benefits - perhaps too many surgeons and patients focus excessively on the creation of a deep neo-female genitalia which may not be necessary. Conversely, if sexual intercourse and sexual genitalia able to accommodate deep penetration in the Missionary Position by even "Mr Big" are a very high priority, the colon section procedure may be preferable to the more common penile inversion technique despite the risks and complications as it provides a more convincing looking, self-lubricating and self-cleaning neo-female genitalia, and arguably copes better with frequent and robust penile penetrations.
For the very interesting results of a Post-Operative Survey of Transsexual women, see here.
For a dire warning about the risks of low cost, back street, SRS, read this article.
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