While most of the world thinks that people are all either women or men, some people are born intersex. This means that the person may have bodily characteristics of either sex and is not exclusively male or female. A more common, yet technically incorrect, term for intersex is hermaphrodite. Hermaphrodite refers to people who have both all of the male and all the female body parts, which is not possible. Another term that has been used is ambiguous genitalia, which may also be incorrect in some cases, since some intersex people have genitals that appear normal. The terms “disorders of sex development” (DSD) or “variations on sex development,” are preferred. This is often discovered shortly after birth and can be addressed with surgery. However, surgery is not always necessary for health reasons, but more for aesthetic or personal reasons.

There are also people who do not identify with their assigned gender, and choose to live their lives as either a nongendered or bigendered person, or who choose to live their lives as the opposite gender to which their genitals would normally indicate. They are known as transsexual or transgender people. According to the medical profession, this is known as gender identity disorder (GID). People with these feelings have usually always felt them or felt them grow stronger over time.

It is not a new phenomenon; people have been changing their gender identity for centuries. While this desire and idea to change is old, there are newer surgical techniques and methods that lead to safer and faster healing procedures. Changing gender is not a fly-by-night decision. Nowadays, it is the product of much soul searching, as well as mental and physical consultations with medical and mental health professionals to ensure that a person is ready for a gender transformation.

What are the Different Types of Sexual Reassignment Surgery?

Sexual reassignment surgery (SRS) occurs when transsexual or transgender adults choose to have surgery to permanently change all or some of their genitals. There are different surgical procedures for transmen who are changing from female genitalia to male genitalia, than there are for transwomen who are changing from male genitalia to female genitalia.

Transmen have many surgical options for modifying both their upper and lower body as well as their face. The most common procedure is a mastectomy to remove the female breasts, and a surgical procedure to shape a male chest. Another group of procedures are the removal of the vaginal tissue, the closure of the vagina and the construction of a penis. However, many transmen opt to skip this surgery because the appearance and usability of the new genitalia has not been perfected yet. Some transmen also opt to have a hysterectomy to remove the uterus, and a salpingo-oophorectomy to remove both the ovaries and the fallopian tubes. Yet, removal of the uterus and the ovaries is not necessary.

Transwomen have fewer surgical options than transmen. They may have a vagina surgically constructed from the unwanted penis. Some transwomen also choose to have facial feminization surgery along with breast implants.

Regardless of how much SRS transmen and women elect to have, to continue to maintain the full appearance of their chosen gender, both must continue with hormone replacement therapy (HRT). HRT helps the body produce to secondary sex characteristics of the desired gender. 

What Happens After Sexual Reassignment Surgery?

For transwomen, there is a lot of recovery after the vaginoplasty (male-to-female surgery that creates a vagina). Immediately after the surgery, there is the possibility of infections, bleeding, a loss of some of the skin that was attached to form the vagina. The larger fear is that a vagina-rectal fistula has occurred. This is when there is a tear in the tissue between the vagina and the rectum that allows feces to exit the body through the vagina. This can happen during or after the surgery, and either way the feces prevents the fistula from healing and can lead to repeated infections.

After vaginoplasty, the new vagina must heal correctly, keep a usable size, and be useful. The women must use vaginal stents to dilate the new vagina multiple times a day, so that the shape and size is maintained for many months after the surgery. As time passes, larger stents can be used, and if there are times without regular intercourse and the vagina begins to tighten, the stents can be used again to maintain size and shape. Women with new vaginas will need to use lubrication both during dilation, and sexual foreplay and intercourse. After intercourse, douching of the new vagina may be necessary to help keep clean and take care of any odors.

Another concern that may arise after a vaginoplasty is urination. Right after the operation, some women have trouble directing the spray of urine. While the opening is correctly placed, as the urethra heals, it may take some time for a woman to figure out how to not spray everywhere.

In time, many transwomen will begin to feel sexual arousal again. Erectile tissue that was left during the SRS will become erect. And as the tissue heals, the feelings of arousal will increase and the tissue in the clitoris and genital region will become more sensitive. The transwomen will feel like masturbating again and the continued stimulation will help with the regrowth of nerves.

For transmen, the recovery time is dependent on how many procedures he chooses to have. A longer recovery time is expected as the number of procedures increases. The more procedures that are completed together, the more opportunities for complications, infections, and blood loss that can occur. The additional concern with multiple procedures is increased blood loss and therefore, the increased probability of the need for blood transfusion.

There are two types of mastectomy, double incision and keyhole or peri-aeriola. Double incision is recommended for large breasted men, as it allows excess tissue and skin to be removed. The nipples and areolas are removed, resized, and reattached. There will be scarring that will fade in time, and oftentimes the nipples that have been removed and grafted back on do not regain their function-ability. Men with smaller chests can have the keyhole or peri-aeriola procedure in which the surgery removes tissue from under the areolas and later a surgeon may trim the skin around the areola if the skin does not contract enough after the removal of the underlying tissue. This procedure has minimal scarring if done on small chested men. Regardless of the procedure, bruising and swelling will happen, and there is the chance that too much tissue or too little tissue will be left. Nipples have the potential to get infected, and skin may fold or bunch at the nipples or where incisions were made.

Chest reconstruction surgery can be performed after a mastectomy has been performed and healed, or as part of the mastectomy process. Some surgeons will perform the mastectomy/chest reconstruction simultaneously. The reconstruction has similar risks and complications as the mastectomy.

A hysterectomy and salpingo-oophorectomy can be performed a couple different ways, either by cutting across the abdomen, or using laprascopic surgical methods. The cut across the abdomen is about 6 inches long, the uterus, cervix, fallopian tubes and ovaries will be removed from the opening and this procedure will require at least six weeks of recovery. While a laprascopic hysterectomy involves multiple small incisions near the belly button so that cameras and surgical instruments can be inserted to cut out the reproductive organs and the pieces are removed through the vaginal opening. This method has a recovery time of at least three weeks. After either procedure, the man may experience pain when trying to go to the bathroom or pass gas, some vaginal bleeding, and pressure in the abdomen area. As with all surgeries, bruising and swelling may occur, and infection, bleeding, and scarring are possible. With these surgeries addition complications may include: damage to other internal organs, urinary tract or bladder infections, the vagina may collapse since the uterus and other organs are not there to support it, and sexual sensations may change as well.

A vaginectomy, also know as a colpectomy (female to male surgery that removes the vagina), can be completed at the same time as the hysterectomy and salpingo-oophorectomy and is affected by similar complications. After the vaginal tissue is removed, the opening can be closed off and this is known as a colpocleisis. All surgical procedures carry the risk of infection, but the chances of that are lessened as long as there is proper drainage for fluids from the closed area. 

If the vagina has been closed, one type of penis construction is possible, via a process called metoidioplasty. Metoidioplasty utilizes the skin and tissue available in the genital region to lengthen the urethra, form the penis, and the scrotum. This procedure has a high rate of complication, as much as 50 percent because there are often problems with the urethra. Scar tissue may form in the urethra as a result of the surgery and block the flow of urine, or a fistula may form in the urethra. Both of these may heal on their own, but they may also require further surgery. Because this surgery uses tissue that are present, the constructed penis may be small, as it is made from the clitoris. The man most likely will not be able to pee standing up, but he will have excellent sensation in the new penis.

Another penis construction surgery is phalloplasty, which utilizes tissues and nerves from the arm to construct the penis, and is the only way to get a full-sized penis. After the initial surgery to create the penis, the erectile implant can be inserted as soon as 9 months and the testicular implants can be inserted another 6 months later. Unfortunately, this procedure almost always has complications. There are the same possible problems with the urethra as in the metoidioplasty, both scar tissue and the fistula. There can be complication with the erectile devices. And both the penis and the arm may get infected. This surgery produces the most realistic results, and as the new nerves grow and make new connections in the penis will gain sensation.

Is it for You?

These procedures are very complicated and the decision to go through with any sexual reassignment surgery is a permanent one. With all of these surgical procedures, be sure to call your doctor or go to the emergency room if you experience any severe pain, vomiting, heavy bleeding, fever, pain when urinating or lack of bladder control, trouble passing gas or a swollen abdomen. If you are traveling away from home to have any of these procedures it is important to make sure there is a doctor at home who can help you with any complications that may arise once you return. However, with emerging technology and tools that have precision control, sexual reassignment surgery is becoming a more viable option for many who wish to change their sex to the one they truly identify with.