Sex reassignment, whether from male-to-female or female-to-male, is a complex process involving psychiatric evaluations, psychotherapy and hormonal therapy as well as surgery. The entire sex reassignment process from male to female involves genital and multiple other surgeries, including feminisation procedures such as breast surgery, facial feminisation surgery and voice surgery.
- Sex change surgery is irreversible. Therefore (and obviously) anyone wishing to undergo a sex change operation from male to female should carefully consider that decision.
- 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.
- The non-genital aspects of the male-to-female transition involve a raft of feminisation procedures, including breast enhancement, facial procedures to make the appearance more feminine and voice change surgery to make the voice higher and lighter.
Sex reassignment surgery (SRS) refers to a variety of surgical techniques used to change the bodies of people who have gender dysphoria. The surgeries involved in sex reassignment are also referred to as gender confirming surgery, gender reassignment surgery (GRS) or sex change surgery.
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 counselling, hormone therapy and sex change surgical procedures. Not every transgender individual requires or wishes to undergo sex change surgery. Some are treated with counselling only; others may get counselling and/or hormone therapy. But some trans people do end up going through sex change operations.
Sex change surgery is irreversible. Therefore (and obviously) anyone wishing to undergo a sex change operation from male to female should carefully consider that decision. Although in a few rare instances people who have undergone sex change operations have tried to revert back to their original sex, it is a very costly and not totally successful process. Even then, things are never going to be exactly the same again. Reading stories and experiences of people who had regrets about male-to-female sex reassignment may help you decide what is best for you.
On the positive side, a review of research findings on sexual functioning in transsexuals following hormone therapy and genital surgery published in the Journal of Sexual Medicine in November 2009 concluded that transsexuals have adequate sexual functioning and/or high rates of sexual satisfaction following sex reassignment surgery.
A long-term assessment of physical, mental, and sexual health among 50 transsexual women in Belgium concluded that transsexual women function well on a physical, emotional, psychological and social level. However, they may “suffer from specific difficulties, especially concerning arousal, lubrication, and pain”.
Another Belgian study evaluating sexual and general health outcomes of transsexual’s post-sex-reassignment surgery, published in the Archives of Sexual Behaviour in 2005, was a long-term follow-up of 55 patients, including 32 male-to-female transsexuals. Researchers found relatively few and minor diseases or conditions, which were mostly reversible with appropriate treatment.
Researchers found that after surgery personal expectations “were met at an emotional and social level, but less so at the physical and sexual level”, despite a large number of patients (80%) reporting improvement of their sexuality. The majority of participants reported a change in orgasmic feeling, with male-to-females reporting more intense, smoother, and longer sensations. Over two-thirds of male-to-females said they experienced the secretion of a vaginal fluid during sexual excitation, originating from the Cowper’s glands left in place during surgery.
Accurate statistics on transgender people, their diagnoses and treatments are difficult to find, because not all transgender people are diagnosed with the condition in the first place. The UK’s National Health Service (NHS) website states that about one in 11,500 persons have gender dysphoria.
Statistics from Western Australia show that less than a third of people with gender dysphoria have opted for sex reassignment surgery.
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 duress and impair an individual on both social and personal levels.
Transgender people also report experiencing some form of stigma and discrimination, verbal and physical abuse, threats of violence and actual physical violence proportionately more than others. According to the 2007 Australian Research Centre in Sex, Health & Society publication, ‘Tranznation: A report on the health and well being of sex and gender diverse (Trans) gender people in Australia and New Zealand’:
- A large majority (87.4 %) had experienced at least one form of stigma or discrimination
- Over half (53.4%) reported verbal abuse
- One third (33.6%) had received threats of violence or intimidation
- Nearly one in five (18.6%) had experienced a physical attack or other kind of violence
Transgender people are also likely to experience bullying in schools, workplaces and other social situations.
Gender role changing, hormone therapy and sex change surgery are treatments for this condition.
The operations include transferring a male to a different gender (female) through surgical alterations. These irreversible alterations enable the individual undergoing them to match their external appearance with how they feel inside.
The transition is known as transsexualism. Men who transition to female are known as male-to-female transsexuals or MTF. They may also be referred to as transsexual females or trans females.
What to expect
Male to female sex change surgery involves multiple operations, both genital and others. In this article we will focus only on the genital aspects of the procedure.
Genital Surgery in MTF transition
The genital surgeries include three distinct procedures: removing male sex organs—the testes and the penis—and the creation of female sex organs both internal and external—vagina, labia and clitoris.
All three stages can be performed as one operation, and usually are. However, they may be done at different stages or not done at all according to the patient’s wishes and the surgeon’s preferences.
Removing the testicles, or orchiectomy
An orchiectomy, the surgical removal of the testicles, can be done before the penis is removed to allow the patient to cut back on the intake of female hormones. Because the testes are the main producers of the male hormone testosterone, removing them also reduces the amount of oestrogen the patient needs to take and thus reduces the risks associated with oestrogen.
Testes sit in a skin pouch, the scrotum. During an orchiectomy some of the scrotum skin is left behind to be used in creating the labia or to line part of the vagina during vaginoplasty. Because the surgery can lead to shrinking of scrotal skin or to skin damage, some surgeons do not recommend an orchiectomy as a separate procedure, especially for those who plan to have a vaginoplasty. If the orchiectomy is done separately, a skin graft from the abdomen can be used where the scrotal skin is unusable.
Removing the penis or penectomy
Penectomy is the surgical removal of the penis. As with orchiectomy, the genital part of the sex change operations can stop with penectomy without proceeding onto the next stage, the creation of female genitals. When done without vaginoplasty, a penectomy is sometimes called nullification. Patients who are not sure they want a vagina will stop with just a penectomy. If proceeding to the next stage, some tissue from the penis will be preserved to be fashioned into a vagina and clitoris.
Penectomy involves creating a shallow vaginal dimple and a new urethral opening to allow for urinating in a sitting position.
For those who are considering vaginoplasty, surgeons do not recommend a penectomy as a separate procedure. This is because the natural skin and tissue from the penis are typically used in vaginoplasty. If you want a vaginoplasty later, you have lost the opportunity to create a neo-vagina with the sensitive skin and tissue of the penis, which are already attached to your body. It is far better to wait and have both procedures done at the same time.
Creating the female genitals
Creating female genitals entails vaginoplasty, labiaplasty and clitoroplasty. Vaginoplasty is the creation of a vagina. Labiaplasty refers to the creation of labia, and clitoroplasty, the creation of the clitoris.
In performing vaginoplasty successfully, your surgeon has to fulfil multiple goals. It is necessary to preserve your ability to have orgasms, to create a clitoris, labia, and an opening to the vagina that both look good and feel good when touched. The created vagina should be able to retain its shape, be sensitive to touch and be sufficiently wide and long enough for sexual penetration. The new vagina should also be moist and elastic, with a hairless lining. Another goal of vaginoplasty is to change the structure of the urinary tract to enable urinating downwards and in a steady stream.
You should make your expectations clear to your surgeon before vaginoplasty surgery. If it is important to you that the vagina be long and wide enough for penile penetration, it may be necessary to have skin grafts. This is usually an option where the penile skin is too small for creating an adequately sized vagina. If this is the case, you will also have to do daily dilations following surgery to maintain the vagina’s shape.
Penile inversion is the most common technique used in vaginoplasty. The technique uses the skin of the penis turned inside out to line walls of the new vagina. Extra skin needed to make the vagina wider and longer is usually taken from the scrotal sac or the lower abdomen. When penile inversion is not possible, because the penis was damaged or removed at an earlier date, a segment of the large intestine may be used instead as the vaginal lining.
The clitoris is created using a small section of the highly sensitive penis head.
The erectile tissue, which gave the penis the ability to become erect, is removed in order to prevent the vagina entrance and the clitoris from becoming overly swollen during sexual arousal.
The urethra—the tube that carries urine from the bladder to outside the body—is found in a different position in females than in males. It is also much longer in biological males than in females. During vaginoplasty, the urethra is shortened and repositioned.
The prostate gland, which is found at the neck of the bladder and around the urethra, is not removed during vaginoplasty.
The labia minora, the innermost lips of the vagina, are typically fashioned from leftover penis skin. Labia majora, the outer labia, are created using the skin of the testicles.
Although removal of the testes and the penis can be performed with the creation of the female genitals as a single operation, some surgeons prefer to perform vaginoplasty first and perform labiaplasty and the creation of the clitoral hood as a separate procedure. Separating the procedures can reduce the inflammation caused by the surgery. High levels of inflammation can prevent optimum results in refining the labia and the clitoris. If the operations are done together, it may be necessary to complete a revision surgery after vaginoplasty to refine the appearance of the labia and the clitoris or its hood.
If done alone, an orchiectomy is considered a simple surgery, usually performed under local anaesthesia. It can be completed within an hour. Aftercare is straightforward, and full recovery is possible within two to four weeks.
By contrast, both penectomy and vaginoplasty are major surgeries and need complex care both before and after surgery. See the before and after section of this article for more details.
The non-genital operations in MTF transition
The non-genital aspects of the male-to-female transition involve a raft of feminisation procedures, including breast enhancement, facial procedures to make the appearance more feminine and voice change surgery to make the voice higher and lighter. Hormone therapy and laser hair removal help remove unwanted hair.
Facial feminisation surgery can eliminate or reduce many changes in the facial bones that occur during the late stages of puberty. Male to female transsexuals see these as deformities, making the face look masculine. Surgery can remove or reduce these deformities.
Details of facial and non-facial feminisation procedures is addressed in our Are Women So Different From Men? article.
Following vaginoplasty surgery, the patient will be treated with oestrogen, which helps reshape the body contours of the face. Oestrogen also stimulates breast development.
Before and after surgery
Unlike other cosmetic or reconstructive surgery, one cannot just request it and have the operations to change sex. Most countries around the world require a series of psychological evaluations and eligibility assessments before a person is considered fit for sex change surgery.
In treating transsexual, transgender, and gender nonconforming people, medical professionals use the Standards of Care established by the World Professional Association for Transgender Health (WPATH). These standards of care, based on the best available science and expert professional consensus, are updated from time to time. They provide clinical guidance for health professionals to assist “transsexual, transgender and gender nonconforming people with safe and effective pathways to achieve lasting personal comfort with their gendered selves, in order to maximise their overall health, psychological well-being, and self-fulfillment”.
According to wpath.org, “This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments”.
Sex change surgery usually follows hormone therapy. It is necessary to have a letter from a mental health professional before a physician will begin providing hormone therapy.
Under the WPATH Standards of Care, a number of eligibility and readiness criteria need to be fulfilled before hormone therapy treatment can begin. A patient must be over 18 and understand what hormones can and cannot do medically. It is also necessary to understand the social benefits and risks of hormone therapy. A minimum of three months of psychotherapy or a documented three-month real-life experience is necessary to be eligible for hormone therapy. Patients seeking hormone therapy should show stable or improved mental health and demonstrate their ability to take hormones in a responsible manner. Once a person meets these criteria, a physician will prescribe hormone treatments subject to a basic physical examination.
Hormone therapy will be necessary during all stages of the transition, before, during and after the sex change surgeries. Hormone therapy in male to female transition is important because it helps change the physical appearance to more closely resemble a woman, reducing the male aspects. Hormone therapy also aims to make the taker more comfortable about himself/herself both physically and psychologically. In someone who is undergoing hormone therapy with a view to male to female transition, hormones start the process of changing the body into a more female one.
For some people, all the treatment they need to treat transgenderism is hormone therapy. Because hormones affect the way they feel, they may not have the need to undergo sex change surgery or even begin living in their preferred gender.
For biological males seeking the transition to female, hormone therapy involves taking the female hormones oestrogen and progesterone as well as blocking agents for the male hormone testosterone. Hormones may be taken orally, by injection or in the form of a patch (transdermally).
Hormone therapy will have to continue after the sex change operation, but will be tapered off – especially oestrogen — for a couple of weeks before surgery to reduce the risk of blood clots.
Real life experience
In addition to hormone therapy, a person wishing to have male to female sex change surgery may need to live for a time as a female before the sex change operations can take place.
They will also have to undergo extensive psychological and psychiatric assessment to ascertain suitability, get referrals from at least two psychiatrists and attend counselling sessions.
There are several things you can do to prepare for any surgery and these apply to each of the different procedures involved in sex change operations and the feminisation procedures that follow.
Preparing for surgery
Typically you’ll be admitted to hospital the day before your surgery and will spend that night in hospital. Blood tests, overall health checks and measures of your heart function are routine procedures to expect before surgery. You may be give a chest X-ray if there are concerns about your lung function. A “bowel prep” cleans out your intestines, helping prevent problems during surgery and eliminating bowel movements for a couple of days after surgery. You will be asked not to eat or drink after midnight the day before surgery. Your genital area will be shaved as part of the surgery preparations.
There are a number of things you can do after any surgery to ensure a speedy and successful recovery.
Here are the specifics of what you need to know about the recovery period following male to female genital surgery.
Hospital staff will closely monitor you as you come out of the anaesthetic. It is necessary to stay in hospital until you are sufficiently recovered to go home. Usually this is about six to eight days after surgery, unless only testicle removal was involved. Both penectomy and vaginoplasty are serious surgeries and need longer recovery periods.
During the early stages of recovery, you will be restricted to bed rest and probably hooked up to a patient-controlled analgesia (PCA) machine. Expect to be given antibiotics and medications that help prevent blood clots.
Following vaginoplasty, a rod-shaped prosthesis will be placed in your vagina. It will be left in place for up to five days to help the skin lining your new vagina properly attach itself to the vaginal wall. A catheter will be placed in the new urethra to drain urine from your bladder. Both of these will be removed about five days after surgery to enable the surgeon to see how you are healing.
You will be given detailed instructions on how to take care of your vagina once you go home. Typically, you will remain in hospital one to three more days to make sure you are healing well.
By the second week you will start to feel more comfortable physically, but your recovery will take a long time. It is natural to experience pain and soreness for a long time after genital surgery.
After surgery, your surgeon will see you at least once a week. Expect a physical exam to check your general health. After a vaginoplasty, it is normal for the surgeon to check healing inside the vagina.
Your surgeon will also check the clitoris for healing and for sensation. Surgical incisions will be checked for scarring and infection. Be ready to answer questions about your bowel movements and bladder function.
If a newly created vagina is not dilated every day after surgery, it may become shorter and narrower than you wish it to be. This is why for the first eight weeks following vaginoplasty you will be asked to wear a prosthesis inside the vagina at all times. At first you will take it out once a day to clean it, and the period of time you leave it out will gradually increase.
To keep your vagina open, you will still need to continue to dilate it every day. Otherwise, over time the vagina may become narrow and short.
If your vaginoplasty involved a graft, you will also need to take care of the healing at the graft site.
Most people feel well enough to get back to their usual routines within four to six weeks. By this time, normal movement should not cause any pain. In some cases, healing takes longer. It is important to avoid rigorous activity that might raise your heart rate until full recovery. Your surgeon will help you determine your limits and which specific activities are safe or unsafe.
Testes removal puts an end to most of your testosterone production, but once you feel well enough to resume light activities, oestrogen therapy will resume again, tailored to your specific needs. It is important to work with—and listen to—a surgeon who has training in trans medicine to ensure you are taking an appropriate dose of hormones after your surgery. If you would prefer not to take oestrogen, it is necessary to substitute another type of medication to prevent loss of bone density. Without proper hormone treatments, trans people can be at risk of osteoporosis.
Possible risks and complications
As with any surgical procedure there are risks involved in a male to female sex change procedure. You should be fully aware of potential risks and complications involved in any surgical procedure before you elect to have the surgery. It is always better to err on the side of caution.
Specific complications that could occur during or after a vaginoplasty procedure include:
- An opening, tear or fistula between the rectum and new vagina. This should be brought to the immediate attention of your surgeon. You may experience signs such as gas or faeces leaking from the vagina.
- A drop in sexual sensation and possibly a decrease in the ability to have an orgasm. This is a potential long-term risk of vaginoplasty. Various studies report the ability to have an orgasm following vaginoplasty in male to female transition within the range of 63 percent to 94 percent. Some transwomen however, have reported an inability to orgasm after surgery.
- Total or partial death in the tissue used to make the new vagina, clitoris or the labia. This complication is rare and most likely to occur in the very early part of the recovery period, often before you are discharged from the hospital. The risk of it developing after discharge is minimal. Tissue death is indicated by mottled skin becoming progressively darker with time.
- Rupture of multiple stitches that open up the wound.
- Narrowing or closure of the new vagina, which you will experience as difficulty or pain during vaginal penetration.
- Narrowing or closure of the restructured urethra, causing difficulty in urinating, painful urination or a significant reduction in the amount of urine excreted. If you experience any of this, or find that you need increased time and effort to urinate, tell the surgeon without delay.
- Prolapse, either full or partial, when the vagina falls out of the body. Contact your surgeon immediately if this occurs.
- Hair-bearing tissue used in lining the vagina causing hair growth.
- Dissatisfaction with the shape or size of the vagina, the clitoris or the labia.
Some of the above are long-terms risks of genital surgery. Other complications, such as bleeding, swelling, minor infections or rupture of stitches can be handled by nursing staff.
You must contact your surgeon in cases of serious infections or bleeding more than a few weeks after surgery, vaginal discharge or severe scarring. A small amount of bleeding after dilation is normal and is usually controlled by putting pressure on the vagina.
After discharge from hospital, you need to move around as much as is comfortable. Staying hydrated can help prevent blood clots, so be vigilant about drinking lots of water. You should seek emergency care if you suddenly experience shortness of breath, dizziness, chest pain or tender, warm swollen legs. All these can be signs of a blood clot.
Revision surgery may be necessary in case of tissue death in the clitoris, labia or vagina, a tear between vagina and rectum, severe scarring or vaginal prolapse.
Rough costs involved
Costs depend on the specific procedures involved. A male to female sex change operation could cost up to $30,000 (AUD).
The costs for male to female sex reassignment surgery vary by surgeon and facility. Costs quoted usually include the fee for the surgeon, hospital fees, surgery fee, and fees for the anaesthetist, a Surgery Care Kit including aftercare items, and multiple post surgery consultations.
At present although Medicare covers many of the major surgeries needed for male to female transition, there is a huge gap between the Medicare payments and the amounts charged by surgeons. The gap can often run into thousands of dollars. There is a similar situation in respect of private medical insurance as well.
Some of the other surgeries like breast enhancement, facial surgery and hormone therapy, all of which help complete the transition, are currently not covered by Medicare or by private health funds.
In some states, it may also be a challenge to find a qualified and experienced surgeon for sex change operations for a male to female transition.
This information is correct as of 2019.
Klein C, Sexual functioning in transsexuals following hormone therapy and genital surgery: a review. The journal of sexual medicine. J Sex Med. 2009 Nov;6(11):2922-39; quiz 2940-1. doi: 10.1111/j.1743-6109.2009.01370.x. Accessed on 17 Jan 2013 at http://www.ncbi.nlm.nih.gov/pubmed/20092545.
 Weyers S, Elaut E, De Sutter P, Gerris J, T’Sjoen G, Heylens G, De Cuypere G, Verstraelen H. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med. 2009 Mar;6(3):752-60. doi: 10.1111/j.1743-6109.2008.01082.x. Epub 2008 Nov 17. Accessed on 17 Jan. 13 at http://www.ncbi.nlm.nih.gov/pubmed/19040622
 The World Professional Association for Transgender Health (WPATH), formerly known as the (Harry Benjamin International Gender Dysphoria Association, HBIGDA), is a professional organisation devoted to the understanding and treatment of gender identity disorders.