In the case of male-to-female SRS, some surgeons recommend the cessation of hormone therapy for three weeks prior to the surgery itself. It appears that the female hormones in the genetic female have a blood clotting action that isnot present when a genetic male takes female hormones, increasing the risk of severe bleeding. As stated earlier, male-to-female GRS is considerably moreeffective and successful than female-to-male GRS. The male-to-female procedure can take anywhere from three to five hours, depending upon whether additional skin grafts are required.
The goal of male-to-female SRS is to create female sexual organs that look asnatural as possible and that allow as much sexual arousal as possible. Thisincludes removal of the penile muscle and tissue, the testicles, and reshaping external genitalia to appear female and natural. It also involves creatinga vagina, one deep enough to allow satisfactory intercourse for those who desire intercourse. SRS is therefore cosmetic as well as constructive.
Several techniques can be used to create the vagina; however, the most favored and least invasive technique is using the inverted skin of the penis to line the newly created vaginal cavity. An incision is made from the base to thehead of the penis, and the skin is peeled away from the shaft while remainingattached to the torso. In many procedures, a portion of the penis head (theglans) with its nerve supply in tact is formed into a clitoris. This technique preserves sexual stimulation and enjoyment. If the penis is long enough, noadditional skin grafts will be necessary. If the penis is short, a skin graft will be necessary to line the deepest part of the vaginal cavity. This skinmay be taken from the lower flanks, sides, or above the pubic bone. Unfortunately, this will leave scarring. It is sometimes possible to use the scrotalskin, but all hair must have been removed by several electrolysis treatmentsprior to surgery to prevent hair growth inside the vagina at a later date.
In another type of procedure, the vagina is created using what are called “full thickness” skin grafts. These grafts are obtained from hairless portions of the sides or flanks and the penile skin is then used to create the labia minora and the scrotum skin to create the labia majora. The width and dept of the vagina are usually greater than with the inverted penile skin, and the newvagina has less of a tendency to shrink over time.
Rectosigmoid vaginoplasty utilizes a piece of the rectosigmoid colon insteadof skin grafts or inverted penile tissue. This technique allows for the creation of a deep and lubricated vagina, but is a more invasive and dangerous procedure and rarely the technique of choice.
To keep the new vagina from closing, a balloon-type device called a vaginal stent is inserted and remains in place for the length of the hospital stay, which averages around six days with complete bed rest. Demerol or morphine areusually given intravenously to ease the pain, and the surgical area is kept packed with ice to decrease swelling and bleeding. Because the entire reconstructive procedure cannot be performed in one operation, many individuals choose to have a second operation three months later to enhance the cosmetic appearance of the labia and clitoris.
The most common complication of male-to-female surgery is the strong tendencyfor the vagina to shrink and eventually obliterate itself. Surgery to correct the situation is more difficult and extensive than the initial procedure. It involves making incisions in the inverted penile skin and inserting full thickness skin grafts.
Patients should return to their surgeon for six-month, 12-month, and 24-monthassessment, and seek routine examinations for any particular personal problem that may arise. Follow-up assessments are important to track the social andpsychological development of the individual. Also following surgery, the patient will return to the female hormone regimen, which will continue to reshape the body to a more feminine contour and encourage the growth of breasts. (If larger breasts are desired, saline-filled breast implants can be inserted through an incision along the border of the areola under the breast tissue andthe pectoralis major muscles.) The hormone regimen will continue for the rest of the individual’s life, and the individual should obtain check-ups at least annually.
To enhance their overall femininity, the male-to-female transsexual may alsodecide to have a “cosmetic thyroid cartilage reduction” (tracheal shaving), which reshapes the Adam’s Apple, making it inconspicuous. Also, several voicemodification techniques are available to help raise the pitch of the voice for a more feminine tone. One common and perhaps the safest technique is a “cricothyroid approximation (CTA). In this procedure, the Adam’s Apple is pushedagainst the cricoid cartilage to which it is then stitched. This puts pressure on the vocal cords, tightening them and raising their pitch. This is a reversible procedure, and is of little risk to the vocal chords because the larynx is not involved. However, the permanence of this procedure remains to be determined.
Laser assisted voice adjustment (LAVA) is another option. This endoscopic surgery is irreversible and still considered experimental; however, it has shownsome success in raising the frequency of the male-to-female transsexual’s voice by as much a 100 Hz. The procedure involves reducing the thickness of thevocal chords with a carbon dioxide laser. Reduction in the vocal chord mass,and because as the vocal chords stiffen as they heal, cause they vibrate faster once healed, creating a higher pitch. Drawbacks to this procedure are thepossibility of permanent hoarseness, bleeding, swollen airways that may require hospitalization, and sore throat.
Other surgical procedures may also be considered, such as reshaping of the chin and cheeks, forehead contouring, and rib removal.
Female-to-male surgery has achieved lesser success, due to the difficulty ofbuilding a functioning penis from the much smaller clitoral tissue availablein the female genitals. In some instances, simply removing the breasts adequately satisfies the female-to-male transsexual. Others use a prosthetic penisthat is either glued or strapped on, while yet others choose to undergo a phalloplasty (plastic surgery to attach a penis). Penis construction is not attempted less than a year after the preliminary surgery during which the uterusand ovaries are removed. The procedure entails several surgeries during whicha tube-shaped structure is constructed by peeling and rolling skin from theabdomen or upper thigh and ultimately attaching it over the clitoris to preserve as much sexual stimulation as possible. This procedure often creates unsatisfactory urination ability and, while the penis can be used for intercourse, it is less than perfect. However, the presence of a penis is often highly important to the individual’s overall concept of their body image. While one study in Singapore found that a third of individuals who underwent female-to-male SRS would not choose to do so again, they were all pleased with the reassignment of their gender.
Whether the transition if male-to-female, or female-to-male, once the GRS hasbeen completed continued counseling and social support, particularly from the family, is highly important to enable the individual to readjust in societyas a member of his or her chosen sex. If the individual were socially or emotionally unstable before the operation, more than 30 years of age, or had anunsuitable body build for the new sex, they tend to do less well. In no casestudied did the procedure diminish their ability to work, however.