Male to Female (MTF) Gender Reassignment Surgery (GRS) - Sex Change Surgery

The goal of transsexual surgery (sex change surgery) is to provide an aesthetically attractive and functional result which permits both effortless intromission and full orgasmic potential. Creation of an adequate vaginal pouch, a sensate and hooded clitoris, and a feminine vulva with delicate labia are paramount. Ultimate conjugation of the labial axis to the anterior midline (fourchette or commissure) requires a second stage procedure called a labiaplasty. To maintain and extend vaginal depth, medical grade dildos will be worn for a portion of each day. After suitable wound healing, sexual activity is a natural way to establish the permanency of the result.

The Orchiectomy Procedure is an independent procedure that can be performed for those who wish to eliminate testosterone surge and achieve some degree of secondary feminization without complete penectomy and vaginoplasty.

As this is an irreversible procedure, 2 letters of therapy clearance are required. One therapist (psychologist, psychiatrist, social worker, sexologist) must have a doctoral degree, and one of the two therapists must know the patient for an extended period of time. Conceivably one of the two therapists can satisfy the requirements for a doctoral degree and knowing the patient for an extended period of time. Consideration may be given to sperm banking prior to orchiectomy.

- Metoidioplasty (phallic clitoral enlargement)
- Penile Implantation for the Neo-Phallus patient
- Insertion of Testicular Implants into Labia

A.        Metoidioplasty or Metaidoioplasty (phallic clitoral enlargement) - Sex    Change Surgery

The procedure confers the advantage of minimal surgery with preservation of natural sensation and erectile function. Donor site forearm scars avoided. Overweight patients may achieve greater length with pubic lipectomy which will recess the body surface line.

In this sex change procedure the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. When the female tissues have been primed with testosterone, the clitoral head may resemble an adolescent glans penis. An embryonic urethral plate must be teased away from the underside of the clitoris to permit outward extension and a visible erection.

For those patients who desire to void standing after this sex change procedure, the urethra is extended into the neo-penis. This may be accomplished simultaneously or performed secondarily using either a vaginal flap or buccal mucosal graft.

Please understand in that metoidioplasty (sex change surgery) involves a fair amount of tissue transfer, some degree of post-operative swelling is expected. Complications may include but are not limited to less than anticipated length, torquing of the clitoris (usually amenable to release), loss of sensation, tissue necrosis, localised infection, persistent tenderness or hypersensitivity, transient or permanent narrowing of the vaginal opening which may render the vagina incapable of penile penetration, urethral narrowing, urethral obstruction, and urethral fistula (leakage of urine anywhere along the pathway of urethral extension). Between the first and second stages leading to urethral extension, voiding patterns and trajectory may be forwards or backwards and may splash wetting perineal, labial and vaginal skin.

B.        Penile Implantation for the Neo-Phallus patient.

A penile prosthesis confers the wherewithal to penetrate which may be the defining moment for a successful conclusion to gender reassignment surgery. Clearly the intimacy of complete sexual contact is sought equally by patients and their partners.

C.        Insertion of Testicular Implants into Labia.

This should be performed as a procedure unto itself or with urethral extension to minimise complications. To prepare the labia majora for implantation, a tissue expander may be employed for a few months. This also creates a more pleasing scrotal appearance.

Most people who undergo male-to-female sex change operations are pleased with the results despite some minor complications, according to the largest study ever of sex change results.

Researchers surveyed 222 patients who had sex change operations and found nearly 90% of them were happy with the results soon after surgery and nearly half were eventually able to achieve orgasm as a woman after a later follow-up.

The results suggest that most men who undergo a sex change to become a woman are happy with the cosmetic and functional results even though complications, such as vaginal hair growth and urinary problems, can occur.

“Despite these problems, which were mainly minor and easily corrected by secondary surgery, 76% of the patients who provided detailed feedback were happy with the cosmetic result of their surgery and 80% said the surgery had met their expectations,”
says researcher Jonathan C. Goddard, MD, a urologist at University Hospitals of Leicester NHS Trust in the U.K., in a news release.

The study analyzed the early results of 222 patients who had a male-to-female sex change operation between 1994 and 2004. Seventy of these sex change patients were also contacted an average of three years later to obtain long-term follow-up information.

The men ranged in age from 19 to 76 with an average age of 43. Nine out of 10 of the sex change patients had a clitoris and vagina created during the procedure.
The results showed that 88% of sex change patients were happy with the initial results at their first follow-up appointment. Among those contacted about three years later, 76% said the cosmetic results were acceptable.

Researchers also found that among those contacted for follow-up:

• 23% of the patients had, or were having, regular vaginal intercourse.
• 61% were happy with the depth of their vagina.
• 98% had a sensitive clitoris.
• 48% were able to achieve clitoral orgasm.

The study also showed that minor complications were relatively common. For example:

• 14% had clitoral discomfort, but none had elected to have their clitoris removed.
• 29% were troubled by vaginal hair growth.
• 27% reported urinary problems, and the majority of these needed revision surgery.

“The outcome of this complex surgery depends on a number of factors,” says Goddard. “These include the technical experience of the surgeon, the amount and quality of tissue that each patient has available for reconstruction and, most importantly, the realistic expectations of the patients themselves.”