Transsexual Sex Reassignment Surgery (male to female)
- Male to Female
- Sex Reassignment Surgery
- Historical notes, descriptions, photos, references
- by Lynn Conway
- Copyright @ 2000-2004, Lynn Conway.
- All Rights Reserved.
- Right: Photo of the details of the genitalia of a TS woman (with
her legs spread in stirrups and her labia partially opened) after
undergoing vaginoplasty (SRS) and labiaplasty performed by Eugene Schrang, M.D. of Neenah,
This page sketches the historical development and surgical details of vaginoplasty surgery (often called sex reassignment surgery - SRS).
Before reading this page, please read the introduction to the
concepts of gender identity, transgenderism and transexualism elsewhere in
this website, so that you'll understand why transsexual women undergo these
operations. This page clarifies that post-operative MtF transsexual women
really do have female genitalia, and will also help readers visualize some of
the ordeals trans women endure to achieve their new physical gender
- IMPORTANT NOTE: This page contains graphic
visual material and other medical information that might shock or be
very disturbing to some readers.
- DO NOT READ ANY FURTHER if you are
squeamish about surgeries, or if you have any anxieties about your own
- Access to this medical information is NOT
AUTHORIZED for those UNDER THE AGE OF 18. By entering this page, you
hereby certify that you are 18 or over.
Transsexualism is not a "modern discovery". Instead it is a not-uncommon,
naturally-occurring variation in human gendering that has been observed and
documented since antiquity. In many cultures, including native tribes in North
America, transsexuals have long had the choice to cross-dress and live their
lives as women, including taking husbands. The surgical alteration of
genitalia to relieve intense cross-gender feelings was also not "invented in
the twentieth century". In some cultures, even ancient ones, many transsexuals
have voluntarily undergone surgeries to modify their bodies in such a way as
to "change their sex".
- The surgical methods and the effects of castration were everywhere for the
ancients' to see. It's use in the domestication of animals quickly taught
ancient people that removal of a human male's testicles at a young enough age
would prevent his masculinization too. Such a person would forever be
childlike - or "girly". These surgeries were also often forcibly done upon
captive adult male slaves in order to "domesticate them" as "eunuchs".
Performing such surgeries on normal post-pubertal males does not change their
gender feelings or gender identity, although is lessens their sexual drives
somewhat and sharply reduces their ability to develop male musculature.
- The accumulating knowledge about the effects of castration was further
extended to help MtF transsexuals: Untold millions of transsexuals over
thousands of years have voluntarily sought and undergone surgeries vastly
riskier and more dramatic in effect than mere castration. In these surgeries
transsexuals are completely emasculated by total removal of the testes, penis
and scrotum. In addition, the external pubic area is often roughly shaped to
look like a girl's vulva. No one knows precisely how it started, but such
transsexual surgeries were well known by the time of ancient Greece and
especially in sexually-permissive ancient Rome, and were often traditionalized
in various "religious rituals" that provided the resulting "women" with a
place in society.
- By undergoing these surgeries, young MtF transsexuals (if they survived)
not only avoided becoming men, but also gained genitalia that looked somewhat
like those of a woman. Although lacking vaginas and lacking the powerfully
feminizing effects of female sex hormones, young transsexuals in the past
could nevertheless live life better as women after undergoing such surgery.
- Even today, very large numbers of desperate young transsexuals in India
and Bangladesh run away from home to join the "Hijra" caste. To become Hijra,
these teens voluntarily undergo fully emasculating surgeries under primitive
conditions, just as they would have in ancient times, with only opium as an
anesthetic. Most undergo the surgery in their teens shortly after the onset of
puberty, with results as seen in photo below. By being castrated just early
enough, many avoid the development of male secondary sex characteristics
(except for the breaking and lowering of the voice), and their bodies can
remain permanently soft, childlike and girly.
- Contrary to popular myth, total external emasculation after puberty does
not necessarily "de-sex" the person. Complete castration after puberty leaves
the young Hijra with her newfound feelings of sexual arousal and her newfound
orgasmic capabilities. While the psychological impact of such surgery would
usually cripple the libido of a normal male, the effect on a young transsexual
girl is usually just the opposite: The surgery can be liberating and can
enable a fuller expression of her sensuality and her female libidinous
feelings. Just as in the case of modern post-operative transsexual women, many
Hijra can have strong feelings of sexual arousal in the inner remnants of
their genitalia (even though they lack the external nerve tissue left by
modern SRS, they retain the internal portions of the erectile corpora
cavernosa and of course the prostate, with its spasmodic orgasmic
capabilities). Although Hijra lack vaginas, many greatly enjoy (to orgasm)
penetrative (anal) sexual activities with men. Because of their complete
external emasculation, Hijra genitalia and pelvic regions look very "girly",
and many men in India greatly enjoy lovemaking with them. The Hijra in turn
accept their fate and their limited, but real, possibilities for finding at
least a little bit of love as a woman in this life.
a photo from the book
Third Gender in India
- Most Hijra live out their lives as women with other Hijra in "family
groups", earning an existance by performing in traditional ceremonies at
weddings and childbirths. Many also work as prostitutes and beggars in this
lowly but traditional Indian caste. Some Hijra today are fortunate to have
access to female hormones, and can feminize their bodies by growing breasts
and developing natural female body contours. The combination of emasculation
as teenagers combined with use of estrogen enables some Hijra now to become
very beautiful - even though, sadly, they do not have female genitalia
(vaginas) and are not socially accepted as women.
- The origins of the Hijra caste goes back hundreds of years in Indian
history. This widespread practice enables transsexuals to escape the angst and
fate of masculinization as teenagers, and provides a safe though lowly place
in society for them. The agonizing extremes to which these transsexual
youngsters will go in order to "approximately have a female gender", with full
knowledge that they will never see their families again and will face social
degradation for the rest of their lives, is a testament to the reality and
extremity of the gender conflict that they face within themselves.
- There are several million in India and Bangladesh today. For more
information see the Kinnar (Hijra) website at http://www.kinnar.com/ and the BBC story on Hijra
in Bangladesh. Many wonderful photos of Hijra can be found in the book
Hijra-The Third Gender
in India , by Takeshi Ishikawa. Although
shrouded in caste secrecy and mystery for centuries, the underlying condition
that compels young teenagers to become Hijra is clearly transsexualism: Says
Dhanam, the leader of a Hijra family (a Hijra 'Guru'):
"We are born with a gender identity crisis. It is not an imitated
or learnt one, but a natural instinct that urges us to be women.'' -
- It is not uncommon even in the modern western world for truly desperate
young transsexual girls to "commit Hijra" upon themselves. By fully
emasculating themselves, and then falling upon the medical system for
"patching up", they can thus achieve a "low-cost SRS early in life". A number
of girls in the U.S. have done this to themselves, and then feminized
themselves with estrogen to quickly become very passable and pretty as girls
(unfortunately, the loss of penile and scrotal skin makes later vaginal
construction by SRS much more difficult). Even larger numbers of young TS
girls in the U.S. have resorted to self-castration in order to avoid
masculinization, especially during the '50s and early '60s when there were
severe restrictions on doing SRS on "intact males" in U.S. hospitals (see
- The long history of traditional 'Hijra-style' surgeries extends from
ancient times right up to today, continuing onward in countries such as India
and Bangladesh. The detailed knowledge of the postoperative effects of the
Hijra-type emasculations provided an important empirical background for the
development modern transsexual surgeries.
The Development of Modern Sex
Reassignment Surgery (SRS)
- [To be added here later: Discussion of advances in plastic
surgery after WW I, and a discussion of the pioneering of vaginoplasty in TS
women around 1930 by F. Abraham, M.D., in Germany - - - see
http://www.symposion.com/ijt/ijtc0302.htm#Case%201 - - - ]
- With the rapid advances in knowledge of sex hormones and plastic surgery
following World War II, it finally became possible to contemplate complete
medical and surgical solutions for transsexualism. During the 1950's,
transsexual women began to benefit enormously from the newly available female
sex hormones, which enable the development of breast, soften the skin and over
time produce female body contours. Also during the 1950's, a few surgeons
began exploratory surgeries to construct vaginas in MtF transsexuals by using
skin grafts taken from the thighs or buttocks, drawing upon then recently
developed techniques for constructing vaginas in intersexed girls.
- Christine Jorgensen, a U.S. citizen, was among the first small group of
transsexuals to undergo such a surgical "change of sex". She was "outed" in
1952 by U.S. print media shortly after her initial surgery, and her story
became a national sensation. Through her story, many transsexuals for the
time learned of the existance of the new hormonal and surgical
treatments. However, access to this new, experimental surgery was limited to a
tiny handful of patients in Europe.
- At the time of Christine's surgery in the '50's, doctors first removed the
transsexual's male organs in one or more surgeries. The patient then waited
through an extended period for healing. Then, in a surgery similar to those
done to create vaginas for intersexed patients, surgeons constructed the
patient's vagina by using skin grafts taken from her thighs or buttocks
(Christine's vaginoplasty surgery was in 1954).
Transsexual pioneer Christine
who underwent an early for of SRS in
- Although patients were extremely pleased with the results (especially when
compared to their previous situations), there were major problems with this
early method. The skin grafts were unreliable, and sometimes partially failed
to "take". The use of extensive grafts also left large disfiguring scars at
the donor sites. In addition, a lot of sensitive genital tissue was forever
lost in the first step, affecting patients' feelings of sexual arousal and
capacity for orgasm.
- During the late 50's and into the 60's, several hundred transsexuals in
the United States came under the care of Harry Benjamin, M.D, a compassionate
physician and endocrinologist who had offices in New York, N.Y. and San
Francisco, CA. Dr. Benjamin was the first physician/researcher to sort out the
distinction between cross-gender identity and homosexuality. Instead of
viewing transsexuals as mentally ill deviants as did most psychiatrists of the
day, he began to visualize transsexuals as truly suffering from a genuine
mis-gendering condition of unknown origins. In efforts to ease their
suffering, he began prescribing estrogen to selected patients in response
their profound pleas for medical feminization. He also maintained close watch
on the results of transsexual surgeries being performed, and began to refer
his most intensely transsexual patients to those surgeons who were obtaining
the best results.
- Dr. Burou performed these surgeries in his clinic in Casablanca, Morocco.
In 1958-60, several famous and very beautiful young "female impersonators"
from the club Le
Carrousel in Paris, France, including Coccinelle (more info) and April Ashley, were successfully
transformed into women by Dr. Burou. Many of the young Le Carrousel girls had
received female hormones as a side-benefit of working at the club, and as a
result had become incredibly beautiful, feminine and sexy. Several returned to
perform at the club after their genital surgery. Their successful "sex
changes" became widely known about, and they became sought after as love
objects by many prominent, wealthy men. Some very wealthy men (including
Aristotle Onassis) would occasionally "sponsor" the sex change surgery of a Le
Carrousel girl, who would then became their mistress for a while.
- Dr. Burou became both famous and notorious as news spread of his work. His
"Clinique du Parc" at 13 Rue La Pebie in Casablanca, Morocco eventually became
besieged by transssexual patients from all over the world. Dr. Burou began
performing many hundreds of these operations every year. In 1973, Dr.
Burou gave his first formal public presentation on his innovative surgical
technique at a major interdiciplinary conference on transsexualism held at
the Stanford University Medical School. By the time of that 1973 conference,
he had performed over 3000 MtF surgical sex reassignments. By that time many
other surgeons around the world had inferred and adapted Dr. Burou's
technique, and were applying it in similar SRS surgeries.
[Note: I'd very much like to find a photo of Dr. Burou for this
website. If you know of any photos of him, please contact me at
Transsexual pioneers Coccinelle
(l) and April Ashley
were among the very first of Dr. Burou's SRS
patients (in 1958, 1960)
- Among the keys to the success of these surgeries were (i) the use of the
skin of the penis and scrotum to form the new labia and a sexually functional
vagina (thus avoiding the source area disfigurement caused in earlier
operations by the use of large, deep skin grafts), and (ii) the careful
dissection and placement of the terminated corpora cavernosa and the saving
and relocation of some of the sensitive nerves and a small amount of erectile
tissue. If done properly, the post-operative patient can have powerful
feelings of sexual arousal (erection of the corpora stumps remaining inside
her body) and can easily be orgasmic (the prostate is left intact, and can
spasm during orgasm just as before SRS - while the nerve tissues throughout
the corpora, the clitoris and the vulva spasm, throb and release at the same
time, just as in any other woman).
- Dr. Benjamin's practice grew rapidly as more and more transsexuals learned
that they could obtain compassionate treatment from him. He began referring
ever larger numbers of patients to surgeons, especially to Dr. Burou in
Casablanca. By the mid 60's, several other top surgeons abroad began
performing SRS surgeries on transsexuals using Dr. Burou's techniques, and Dr.
Benjamin referred patients to these surgeons too. The most notable of these
was Jose Jesus Barbosa, M.D., a prominent plastic surgeon in Mexico (Dr.
Barbosa was Lynn's SRS surgeon, and had performed over 300 SRS's by 1973).
- However, such surgeries were still virtually unheard in the U.S. even in
the mid-to-late 60's. Under intense pressure from religious groups following
the publicity of the Jorgensen case in 1952, most U. S. hospitals installed
policies that explicitly forbade such operations, and religious strictures
were frequently drawn upon to support the witholding of any hormonal or
surgical treatments of transsexuals. Then too, the U.S. medical community in
the 60's thought of transsexuals as "severely psychotic" rather than
biologically mis-gendered. Instead of receiving help for gender-transition
from medical professionals, many transsexuals were forced into mental
institutions, where psychiatrists tried to "cure them of their mental illness"
by electroshock therapy and aversion therapy.
- During the late 50's and into the early 60's, a number of intensely
transsexual girls in the U.S. resorted to castrating themselves in order to
become more feminine and to bypass hospital restrictions on removal of
testicles from "intact males" during SRS. Once no longer intact, the girl
might hope to obtain complete SRS in some hospitals here - if she had the
money to pay for it. See for example, the story of transsexual pioneer Aleshia Brevard.
At a young age and feminized on estrogen, Aleshia became a star performer at
Finocchio's, the world famous "female impersonator" nightclub in San
Francisco. After a self-castration to further feminize herself, Aleshia was
able to undergo SRS in the U.S. in 1962 with the help of Dr. Benjamin. As did
so many postop transsexual women in the 1960's (including Lynn) Aleshia left
her past life behind and entered stealth mode. She went on to become a
showgirl, a "Playboy Bunny" (a hostess at one of the
famous "Playboy" clubs), a widely recognized movie, stage and TV actress, and
got married three times! Aleshia only recently
came out to tell her story in a wonderful book about her amazing life.
Aleshia (pre-op) as the star
at Finocchio's in 1961
Aleshia as an actress
in the early 1980's
Early Sex Reassignment
Surgeries in the U. S.
- Finally, in 1966, surgeons at the John Hopkins Medical Center began
performing a limited number of MtF SRS operations in effort to help some
intensely transsexual patients under care of Hopkins' new gender identity
clinic. The Hopkin's staff believed that transsexuals were mentally ill, but
they also believed that there was no psychological method for reversing the
"incorrectly formed gender identity". In an experimental program they began to
explore the possibility of helping patients via surgery, as was being
recommended by Dr. Benjamin. The Hopkins' Surgeons used a variant of Dr.
- In the fall of 1966, newspapers around the country propagated the
following item from a column in the New York Daily News:
the rounds of Manhattan clubs these nights is a stunning girl who admits she
was a male less than one year ago and that she underwent a sex change
operation at, of all places, Johns Hopkins Hospital in Baltimore.
Surprisingly, the hospital confirms the case, saying surgery followed
psychotherapy. Such operations, although rare in this country, are neither
illegal nor unethical, according to a Johns Hopkins spokesman. Officials at a
number of major hospitals here agreed with Johns Hopkins on the legality and
ethics of the operations but none could recall such an operation ever having
been performed in New York."
Then, on November 21, 1966, the New York
Times published an extensive front-page article on transsexualism. The
Times article provided extensive information on the surgical and hormonal
treatments then being done abroad, and on the new program at John's Hopkins
University Medical Center, where several surgeries had recently been done. The
article also identified Dr. Benjamin as being the world's leading authority on
transsexualism, and as author of a new textbook on the subject entitled The Transsexual
Phenomenon (see this link for an online version of the original text).
Harry Benjamin, M.D.
The great medical pioneer and compassionate
[photo taken by Lynn Conway in
- Dr. Benjamin was the pioneer of the whole new area of medical knowledge of
transsexualism. His paradigm-shifting medical text described his experiences
with many patients over several decades. He was the first researcher to
recognize how gender identity and sexual orientation are two independent
dimensions of each person's human nature. Dr. Benjamin recommend how "intense
transsexuals" could and really should be treated, in order to enable them to
live in the gender they sought. His book documented the results of the new,
innovative surgical and hormonal treatments and put those treatments into a
rational context as therapy for transsexualism. This book gave fresh hope to
many transsexuals, and opened the door for the modern medical approaches that
we now take for granted. At the same time, the fact that Johns Hopkins was
actually doing transsexual surgeries greatly enhanced the visibility of Dr.
Benjamin's theories and the attention that his research results received by
the medical community.
Diagrams of the early John's
Hopkins MtF SRS Procedure
- Following are illustrations that sketch the basic steps in the early
Hopkins surgical method, which is a variation on Georges Burou's method. These
figures are taken from Chapter 22, by Howard W. Jones, Jr., M.D. in
Transsexualism and Sex Reassignment, Richard Green, M.D. and John
Money, Ph.D., Editors; Johns-Hopkins Press, 1969. By this time it was common
to refer to this type of surgery as "sex reassignment surgery" (SRS). The
illustrations were reproduced from an original article by Howard W. Jones,
Jr., Horst K. A. Schirmer, and John E. Hoopes, " A Sex Conversion Operation
for Males with Transsexualism", American Journal of Obstetrics and
Gynecology 100 (1968): 101-9. (Note: See comments following the diagrams
regarding the anatomically misleading/incorrect sketching in the final sketch,
Figure 1. A sketch of the perineum showing the line of primary
Figure 2. The right spermatic cord is clamped and
Figure 3. The primary incision is continued up the ventral side of
the shaft of the penis.
Figure 4. The anterior flap is developed from the skin of the
Figure 5. The urethra is dissected from the shaft of the
Figure 6. The corpora cavernosa are separated to assure a minimal
Figure 7. The perineal dissection.
Figure 8. The perineal dissection has been completed and the
anterior flap perforated to position the urethral meatus.
Figure 9. The skin flaps are sutured and placed in position in the
Figure 10. The preservation of the vaginal cavity is assured by use
of a suitable vaginal form.
- Note 1: Figure 10 is quite misleading and does not correspond
to the anatomy the should result from this procedure. In figure 10, the
vaginal opening is way too far forward from the anal opening, and the vaginal
entry is shown going first in horizontally and then turning upwards after
passing a large web of skin in front of the anus. (Compare
this sketch with the later photos of the details of modern SRS results,
especially the one showing the entry of a vaginal stent into a postop's
vagina). This very poorly conceived sketch has likely been the source of
many botched surgeries in the early days, as surgeons copying the Hopkins
procedure may have thought that a thick web of skin was needed in order to
prevent tears into the rectum. Such webs of skin often prevented easy
dilations and intercourse for patients after SRS, leading to vaginal stenosis
(loss of depth and/or width).
- Note 2: Over the years, the techniques for doing SRS have been steadily
refined. It has also became common for post-op MtF's to have additional
genital surgery called "labiaplasty" that construct further details of the
external female genitalia. For more information on modern SRS surgeries, see
the links and the "Photo
Details of Modern SRS Results" below.
SRS Becomes an Accepted
Treatment for Transsexualism in the U.S.
The early Johns Hopkins announcement and publications coincided with the
publication of The Transsexual
Phenomenon, by Harry Benjamin, M.D. in late 1966. The result of many
years of research observations and clinical practice by Dr. Benjamin became
the seminal text on transsexualism. The book finally identified transsexualism
as a distinct, major medical affliction in which patients have an innate
gender identity opposite to the genital sex of their bodies. These theories
and results obtained considerable attention within the U.S. medical community
over the next several years - but most of it was highly skeptical.
Then, following interactions with Dr. Benjamin and some of his patients,
physicians at the Stanford Medical Center started a exploratory gender clinic
in 1969, led by Norman Fisk, M.D. and Donald Laub, M.D. SRS operations were
undertaken on selected MtF patients, and the Stanford clinical and surgical
results further validated the concept of SRS as treatment for those suffering
from intense transsexualism. Acceptance of SRS as a serious and valid
treatment for transsexualism began to slowly spread among thought leaders in
the U.S. medical community. Hospitals around the country began gradually
lifting their bans on transsexual surgeries, and surgeons at various locations
began performing these surgeries on small numbers of selected patients in the
In 1969, Stanley Biber, M.D. a surgeon in Trinidad, Colorado, began
performing MtF SRS vaginoplasty operations using information he obtained from
the surgical team at Johns Hopkins. The excellent successes of his surgeries
became widely known, and patients streamed to him. For many years Dr. Biber
performed over 150 MtF SRS's per year, and by the year 2000 had performed over
4500 of them. A recent USA Today article tells Dr. Biber's story, as
4A -WEDNESDAY MAY 24, 2000 - USA TODAY
Sex-Change nickname makes
Colo. town cringe:
Transformation via surgery
has become common in community
By Pauline Arrillaga
The Associated Press
TRINIDAD, Colo. - The young waitress examined her customers as she
refilled their coffee and haltingly asked whether anyone wanted more
There was Elise, a buxom brunette in a crop top and hip-huggers. Kate,
a Harvard graduate writer in khakis, hand-knit sweater and pearl earrings.
Thea, a graphics designer sporting chic suede boots. And Jackie, a
towering figure in trousers and blazer.
In the lunchtime crowd of merchants, housewives and farmers at the Main
Street Bakery and Cafe, the four stuck out like fashion models on a pig
Retreating to the kitchen, the waitress pulled her boss aside and
stammered, "Those women I'm waiting on? They're men!"
Hardly anyone else gave the foursome a second glance. Not in the
so-called "Sex-Change Capital of the World."
Repeat that phrase to, almost any of the town's 9,500 people and one
would likely get a lecture on what the southern Colorado hamlet should be
known for - its idyllic scenery, comfortable climate and friendly
Most don't mind that more sex-change operations have been done in their
town than anywhere else (about 4,500 to date); they just hate that
"Nobody cares," says Monica Violante, owner of the Main Street Bakery.
"It's just a part of Trinidad."
Town in transition
Although no formal statistics are kept on the number of sex
reassignment surgeries, experts in the field agree that Trinidad's Stanley
Biber - because of the year he began and his age - has performed more than
The International Foundation for Gender Education lists 14 surgeons in
the USA and Canada that do the procedure, and, as spokeswoman Sara Herwig
points out, "Biber's been doing it longer than most."
What makes Trinidad unique is not that it's the sex-change capital of
the world, but the fact that this former mining town has come to accept
its destiny, depend on it and even embrace it.
In 1969, Trinidad was a town in transition. Coal had been king in these
parts since the turn of the century, but after World War II, the mines
began closing. By the late '60s, only a few remained.
Families left, and Main Street, once a bustling collection of.
department stores, car dealerships and restaurants, became a lifeless
shell of shuttered storefronts.
Yet Biber was thriving from his fourth-floor office inside the First
National Bank building.
As Trinidad's-s only general surgeon, Biber did it all - from
delivering babies and removing appendixes to reconstructing the cleft
palates of poor children.
Biber moved here in 1954 after serving as a MASH surgeon in Korea and
finishing a stint at Camp Carson in Colorado Springs.
In those first 15 years, Biber built a comfortable life around a
praactice he loved and a town he adored. In 1969, he encountered the
patient who would forever change both.
A social Worker Biber had met asked him to perform her surgery. "Well,
of course," he told her. "What do you want done?"
"I'm a transsexual," she replied. And Biber asked, "What is that?"
After consulting a New York physician who had done sex reassignment
operations and obtaining hand-drawn sketches from Johns Hopkins
University, Biber agreed to do the surgery. "She was very happy," he
recalls. "And then it started spreading all over."
With less than a handful of doctors performing the procedure, Trinidad
became THE place to come for a sex-change operation, and Biber was THE man
to do it.
The town's sole hospital, Mt. San Rafael, was run by Catholic nuns, and
Biber hid the charts of his first transsexual patients. But he knew he'd
eventually need the approval of the hospital board and his neighbors.
Biber explained his Work to the sisters and local ministers.
I went through the psychology of it all. They decided as long as we
were doing a service and it was a good service, that there was no reason
we couldn't continue doing them," he says.
Soon, Biber was lecturing to the hospital staff and the public.
"We figured that's his way of making a living; more power to him," says
Linda Martinez, 54, a lifelong patient of Biber's.
Not all agree. The Rev. Verlyn Hanson, pastor of the First Baptist
Church for the past three years says the town turned a blind eye to
Biber's work because of the economic boost it provided. "The love of money
is the root of all evil, and people will overlook a lot of evil to have a
stronger economy," he says .
At one point, Biber's operations brought about $1 million a year to the
hospital, according to his estimates. The basic procedure costs about
$11,000, with the hospital taking in a little more than half.
At the height of his practice, Biber performed about 150 transsexual
operations a year. His patients brought families and friends who remained
in town during their loved ones' eight-day hospital stay.
Whether or not people liked what Biber did, they liked the squat,
balding doctor who wore jeans and flannel shirts to work and always said
At 77, Biber has scaled back his transsexual business to about 100
surgeries a year. The majority of his practice remains tending to the ills
of Trinidad's citizens. He knows retirement may not be far off, and he's
in search of a surgeon who will continue his work. "it started here, and I
want the hospital to continue with it," he says.
[end of AP article on Dr.
The Current Protocol for
Referring Transsexuals for Vaginoplasty (SRS)
- Vaginoplasty (sex reassignment surgery) is a dramatic and irrevocable
final step in male to female gender transition. This step is usually taken
only after the deepest introspection and counselling regarding all the
options. For those needing complete gender correction, this surgery is a life
saving and life enhancing miracle, and can enable them to live a full and
joyous life afterwards. However, carrying out of a mistaken urge for such a
complete transformation could lead to permanent and terrifying emotional and
psychological consequences. The background for this process is discussed in
to the concepts of gender identity, transgenderism and transexualism found
elsewhere in Lynn's website.
- The Standards of Care of
the Harry Benjamin International Gender Dysphoria Association (HBIGDA) defines
the currently accepted protocols for the medical treatment of transsexual
women. These Standards cover all aspects of medical treatment, including the
requirements for Real Life Experience (aka, Real Life Test), and other
requirements that must be met before a trans woman is recommended for SRS.
Most surgeons who perform vaginoplasty will only operate on transsexual women
who have been treated under these Standards and who present the corresponding
letters of recommendation for surgery from their case-counsellors.
- For more information on the overall TS treatment and transition
procedures, see Andrea James' TS Roadmap
website, which contains outstanding planning information for anyone
contemplating MtF gender transition. For more details on Vaginoplasty, see Andrea's
Vaginoplasty page and follow the many links there.
Some Photos of Modern
Vaginoplasty (SRS) Results
- During the 80's and especially during the 90's, there were steady advances
in vaginoplasty (SRS) techniques. When performed by the most experienced
surgeons, the SRS results are much more predictable than in earlier years,
both in appearance and function, and there are far fewer incidents of
complications. (Note: We now often use the alternative term Vaginoplasty to
refer to SRS. This term better communicates that the surgical goal is the
construction of functional female genitalia - i.e., a vagina). The
vaginoplasty surgery is often followed several months later by labiaplasty
surgery to refine the external female genitalia (labia).
- Following are photographs of the details of the female genitalia created
by modern vaginoplasty and labiaplasty. These photos clarify the
remarkably advanced state of modern MtF sex reassignment surgery. In these
cases, the surgeries were performed in 1999-2000 by Eugene Schrang, M.D., of Neenah, WI. The
patients are in the same orientation as in Figure 10 above (i.e., in stirrups
with legs spread and labia separated). The middle photo shows the inner and
outer labia spread apart and is labelled to identify the clitoris (c), the
urethral opening (u) and the vaginal opening (v). The (z's) note locations of
faint z-plasty scar-lines where incisions were made during labiaplasty to
construct the clitoral hood. Note the normal anatomical proximity of the
vaginal and anal openings. (See the web-links at the end of this page for more
photos of SRS and labiaplasty results):
- Here is a photo of the appearance of the external genitalia of a TS
patient one year after SRS (vaginoplasty only) was performed on her in
Montreal, Canada at the Clinic of Yvon
Menard, M.D. and Pierre Brassard, M.D. ( en español
). In this case the patient is shown with her legs
close together and we are looking upwards from the direction of her knees.
Therefore the outer labia are pressed together, and the inner details of her
genitalia are not visible. This photo is fairly typical of the normal-looking
external appearance of TS women's genitalia after basic SRS. Note that
electrolysis can be applied to the genital area so as to remove unwanted hair
from the labial areas, if needed to produce a natural final appearance.
Postoperative Care Following Vaginoplasty
- During the immediate postop period, the woman will be under the good care
of her surgeon and hospital recovery environment. During this time, she will
learn whether her surgery was fully successful, or whether some complications
have occurred and have to be dealt with. Later, after leaving the hospital,
she will have to take a lot of responsibility for long-term ongoing aftercare,
and the long-term outcome of the surgery will depend on how consistently she
performs that aftercare.
- A high percentage of modern SRS surgeries done by the top surgeons are
fully successful, aesthetically and functionally, without any major
complications. However, when done by less experienced surgeons various
complications can and do occur, and even the top surgeons will very
occasionally encounter difficulties. Complications can include minor
infections, bleeding, a sloughing-off and loss of some of the grafted skin.
Most of these minor complications can easily be managed and will be under
control before the woman leaves the hospital.
- However, there is some risk of more serious complications. Anyone
contemplating SRS should understand these risks, and should be sure to go to
only the very TOP surgeons here or abroad who have track records of very low
frequencies of serious complications. The more serious complications include
major infection or bleeding, and damage to the bladder, prostate or major
nerves during the dissection to form the vagina. These complications can be
difficult to control and correct, may require major extension of the hospital
stay, and can lead to permanent uncorrectable damage.
- One of the most feared complications of all is the formation of a
vaginal-rectal fistula. This can occur during the dissection of the vaginal
cavity by accidentally cutting through the rectal wall, or it can occur due to
vaginal-rectal tissue death from pressure of the packing during the immediate
postop period. A fistula enables excrement to bypass the anal stricture and
exude from the vagina. The excrement prevents proper healing of the fistula
and an ongoing danger of infection. The only way to correct the damage is to
perform a colostomy, and
then wear a bag for many months while the fistula heals. Proper dilation of
the neovagina may not be possible during this periond, often leading to
closure of the neovagina. The patient may thus later need a complete redo of
the SRS using skin grafts.
- [Note: This terrible type of complication often goes unreported because
the patient is dependent of the surgeon to correct the damage, and won't want
to alienate him by publicly revealing that the complication has occurred. She
is also usually devastated emotionally and won't want to reveal the horror she
is going through. Be sure to go to one of the TOP surgeons if you want to
minimize the risk of such awful complications.]
- Once released from the hospital, the main concern facing the newly postop
woman is to insure that her neovagina heals properly, and maintains its size
and remains functional. In order to do this, the patient must dilate
frequently using a vaginal stent for an
extended period following surgery. There are a number of sources for such
stents, and your surgeon will most likely recommend a source to you. One
current internet source for stents is Duratek Plastics of
- Vaginal stents typically range in size from about 1-1/8 to 1-1/2 inches or
more in diameter (28 to 38 mm), and must be inserted to full depth (4 to 6
inches or more) into the woman's vagina for 30-40 minutes several times per
day for many months after the surgery. Increasing sizes are used to gradually
widen and maintain the vaginal opening during the postop recovery period.
Later-on, especially during any prolonged periods of sexual inactivity, basic
dilation must be done at least once or twice a week to insure maintenance of
vaginal width and depth. Even after many years, if the woman notices any
tightening or constrictions from one week to the next, the frequency of
dilation must be increased until that tightening episode has passed.
- For more detailed information about dilation techniques and immediate
postop care, carefully study the article Zen and the Art of Postop
Maintenance. We cannot over-emphasize how essential it is to rigorously
perform dilations according to the schedule provided by your surgeon. Many of
the cases where surgical outcomes seem to be poor are actually the result of
women not rigorously dilating, especially during the critical months
immediately following SRS.
- Following is a photo of a newly-postop transsexual woman, whose pubic hair
is still shaven, undergoing one of her initial vaginal dilations (after SRS at
Dr. Suporn clinic in Thailand).
Note that the depth obtainable during SRS is a function of surgical technique,
available penile and scrotal tissue for skin grafts and the patient's pelvic
anatomy. Typical SRS depths for most patients of the better surgeons are in
the range of 4" to 6". Here you see an above average result of SRS: a vaginal
depth of about 6 to 6-1/2 inches. The stent in this photo is 30mm in diameter.
As you can see the stent enters the body at the base of the vulva, and in a
normal angle in line with the main torso. Thus this patient's overall genital
geometry is now the same as for any female, and will accomodate all the usual
positions for sexual intercourse and lovemaking.
- Lynn highly recommends that all women having SRS find a friendly,
trustworthy, competent family practitioner or gynecologist beforehand. Tell
them what you are about to do, so that they can help you with any minor
complications that may be present or may arise once you return from your
surgery. Unfortunately, few physicians have any clue about SRS. Therefore, if
you suddenly have a complication at home after surgery, you may find it very
difficult to get medical help. Many physicians will be afraid of helping for
fear that lack of knowledge may lead them into malpractice problems, etc. It
would be better if more of the top surgeons would write-up some aftercare
information that included a section for general practitioners and
gynecologists regarding postop care. This might help ease the concerns among
local physicians about how to help a postop woman after SRS.
- Note: Lack of local medical care was a huge problem for postop women in
past decades. Many women returning from abroad with major complications in the
1960's and 1970's were unable to find any medical help here in the U.S. Some
were even ejected from ER's they had gone to with life-threatening
complications. Some died for lack of access to basic postop medical care in
the U.S. Fortunately, things aren't this bad anymore in most places. But to be
absolutely safe, be SURE to line up access to local medical care BEFORE going
- All postop patients should be very careful not to let fears and worries
and embarrassments interfere with proper aftercare. If you are having any
medical problems and are in doubt about your condition, go see a doctor! Don't
let a minor infection or bleeding or pain stop you from doing your scheduled
dilations! If there is any problem at all, seek local medical help and also
get back in contact with your primary surgeon. You must not let ANYTHING
interfere with your dilations, or else you risk the loss of your neovagina.
- After a couple of months have passed, healing will begin to be complete
and you can relax a bit. The frequency of scheduled dilations will ease a bit,
and you will begin to feel your new form of sexual arousals. At this point you
are ready to fully begin your new sex life as a woman.
Some Practical Matters:
- Dilations require lubrication, and many postop gals use the water-soluble
lubes such as K-Y for this purpose. However, if you need to lube "on the run"
in rest room or similar situation, K-Y is rather messy because you need to
wash with water to clean it off. Mineral oil is an inexpensive alternative
lubricant for dilation that works well, and it cleans up without necessarily
requiring washing it off. It can be almost completely removed with paper
towels without water, and really isn't very "oily" after all. The only problem
with mineral oil is when travelling you have to pack your bottle of it inside
a zip-lock bag lest it sneak out into your luggage.
- Lubrication is also usually required during sex play and intercourse using
your new vagina. Here too there is a good alternative to the ubiquitous K-Y.
Astroglide is a much better lube. It
takes less of it, and it feels much more "slimy" like natural mucous
secretions do. It lasts well and is water soluble too. The only problem with
it is that the Astroglide bottles have a little pop-up nozzle that it very
sharp at the end - so do be careful when applying it in the heat of passion to
yourself and especially to your lover!
- The postop woman may need to douche occasionally, especially after
intercourse, in order to keep her neovagina clean and odor-free. There are
many over-the-counter preprepared douches that work fine for this. They come
in various scents and concentrations. Lynn prefers the "extra cleansing
vinegar and water" mixtures, but all the mixtures work fine and will leave you
feeling clean and fresh inside. The easiest way to use the douche is to stand
in a bathtub or shower and relax and carefully insert it vertically in line
with your vagina. Once it is in all the way (the tips are about 4" long),
squeeze the bottle empty and let the fluid simply run down your legs. Wipe off
with a wet washcloth, and you're done.
- Most of these prepared douches, such as the Massengill
brand, have a tip that tapers down to a fairly fine end, almost to a point.
These tapered tips can be a bit painful to insert, especially during the first
months after SRS. Since the shafts get larger as you insert further, you can
sometime feel the rather sharp flutes along the shaft (slot where the fluid
will be ejected from the bottle). Therefore, you'll need to use quite a bit of
lube all along those shafts in order to insert those tips, and the sensation
may still be unpleasant.
- However, there is one brand of douche, "Summers
Eve" which uses a wider, hemispherical tip the size of a small finger, and
the shaft behind the tip is smaller in diameter than the tip. Summers Eve
douches insert very easily and painlessly with only a small amount of lube on
- Initially, when newly postop, the girl may have difficulty with her urine
unpredictably "spraying" all over the place when she sits to pee. However, as
her urethral opening heals, she will gradually be able to direct her urine
into a more predictable stream. This may take some learning on exactly how to
sit and how to position the urethral opening when peeing - learning some
things that all GG's had to do when they were little girls.
- Many newly postop gals at some point suddenly become overly concerned
about whether their new genitalia are going to look perfectly normal and
whether they are "deep enough" for intercourse. These concerns can be very
disabling and prevent the woman from relaxing, having fun, learning her body
well, and then going out and dating and becoming open to sexual activities
with a partner. This can become a kind of panic as the possibility of sexual
intercourse as a woman begins to present itself. Newly postop women need to
know that as long as they have at least 4" of depth, they will be able to have
fun sex with most average-sized men. More than 4" is defintely better, but 4"
is just enough. Many postops have about that much depth and do just fine in
relationships with men. Also, most men find female genitalia a bit scary and
just don't look all that closely. If you are a fun sexual partner and your
genitalia are sexually functional, then you should have no concerns about
- It also turns out that most men find postop women quite wonderful feeling
during intercourse, because postops are usually "tighter" than other girls
those men have made love to. Postop women can also "snatch" their lovers'
penises and apply pressure by tightening their abdominal muscles, just as GG's
do, and thus make themselves even tighter. However, you must be sure to
regularly dilate to at least 35mm in width (1-3/8 inch) in order to take in an
average-sized male, and 38mm is even better (1-1/2 inch). Remember, your
vagina is not as elastic in diameter as a GG's vagina. It will stretch out
only to the maximum size you've dilated to, and will then go no further. If
you are in doubt about someone's size, be sure to carefully "feel the width"
of your date before indicating a desire for intercourse. That way you can see
if he's likely fit into you. If he's definitely too wide, you can decide that
you are "too tired" that night. Then find someone else to date.
Sexual Arousal, Lovemaking
and Orgasm in Postoperative Transsexual Women
- Many myths surround the effects of SRS on libido, sexuality and orgasm.
Many preop TS women are understandably concerned about whether they will be
able to fully enjoy and eagerly participate in lovemaking after SRS. Of
special interests and concern is whether postop TS women can fully experience
sexual arousal and orgasm. The ability to easily become aroused, to desire
intimate and sensual contact, and to achieve sexual release through orgasm is
a precious gift to bring into love relationships, especially when combined
with a desire to give full and complete pleasure to one's love partner too. A
loss of these capabilities could ruin the woman's chances of experiencing her
full humanity after transition, especially for finding and enjoying a
passionate, deeply-bonded love relationship. However, as we'll see, SRS can
provide those for whom it is right the chance to fully experience the joys of
sex and lovemaking - and thus to finally enjoy a full human life.
- Myths vs Reality, and the decision to undergo SRS
- Many people simply assume that the loss of the external male genitalia
will result in a complete loss of sexuality. This very naive myth
unnecessarily frightens many preop women, and it also furthers prejudice
against postop TS women, who are often thought of by the general public as
having "desexed themselves".
- Certainly a typical male would suffer a catastrophic impact on body image
and libido from the loss of his external genitalia. However, it has long been
known that with counseling and practice, even males who have lost their
genitalia to cancer can recover the
capability for arousal and orgasm.
- Furthermore, intensely TS women are not "regular guys". They do not suffer
a negative impact on body image as a result of SRS, but instead find a greatly
enhanced body image. The experiences of countless Hijra girls in India
demonstrates that even primitive forms of SRS do not desex transsexual girls
and in fact helps many of them. SRS has the opposite effect on intensely TS
women as would the emasculation of a typical male. SRS usually releases and
enhances the libidos of TS women, enabling them to frequently and fully
"turn-on" and enjoy their physical sexuality and lovemaking, including
achievement of orgasm during intercourse with a partner.
- The myths and misunderstandings about the effects of SRS cause many preop
TS women to remain in a state of indecision about having surgery. Although
feeling an intense need to undergo SRS to achieve physical conformity with
their gender identity, some preops may also feel extreme anxiety about whether
or not they will still experience sexual arousal and orgasm after SRS.
- This anxiety is enhanced by stories heard from many TS transition
failures, including the cases of intense cross-dressers, drag queens and
crossdressers who mistakenly underwent SRS for various sexual reasons and then
found that their male libidos were greatly reduced and their male orgasmic
capability eliminated. See the
"WARNING section" in Lynn's TS information pages, for clarification of
what can happen when male-gendered crossdressers or drag queens become
misguided and have SRS. There have been so many of these misguided cases that
the urban myths about SRS have escalated over the years, and there is now a
lot of confusion about what to expect after SRS.
- On the other hand, many other transsexual girls learn to visualize from
their preop sexual experiences (as Lynn did) that they'll probably still
"turn-on" sexually and be orgasmic as women after SRS: Many preop women hide
their genitals by inserting the testicles up into the abdomen, and then
tightly tucking the male organ back through the crotch (with tight underwear
or taping). In this configuration, the penis cannot usually get enough blood
supply for full external penile erection. Even though the external part of the
penis cannot erect when tucked tightly, the girl nevetheless experiences the
familiar female "glow" and warmth throughout her interior genital region when
she is aroused, for example, by a man's warm attentions. In addition, the
corpora cavernosa shafts inside her body can become erect once the girl is
sexually aroused, and that arousal feels really wonderful - even though the
external part of the penis is flaccid. Sexual stimulation by rubbing and
caressing the genital area and the breasts can then lead to orgasm for a girl
who is sufficiently aroused.
- From experiences like this, preop women can visualize that after
undergoing SRS the remaining internal stumps of her corpora will still engorge
and become erect, and that she can experience similar feelings of sexual
arousal when she is postop. In addition, the postop woman can now also
experience wonderful sensations from caressing her clitoris, which, in
contrast to the previously hidden penis, can now be openly played with without
her experiencing angst about her body-image.
- There are thus many dimensions to postop women's sexuality, and the actual
postop effects of SRS on arousal and orgasm vary greatly from case to case.
Those who are male-gendered, and who have male sexual urges focused in the
external genitalia, are likely to experience great loss over time. Those who
are "in between somewhere" will likely experience a mixture of losses and
gains. Those who are female gendered and who have strong female sexual urges
are likely to benefit greatly, as a whole new life of sensuality, sexuality
and lovemaking opens up to them. All of this is of course contingent upon the
person having a normal-level of libido, having no "hang-ups" about being
sensual and sexual, and also upon a successful surgical result.
- Thus the decision for SRS must be taken with great internal soul searching
and introspection, and with complete honesty with oneself about one's own
gender identity, body image and likely psychic reactions to the body changes
of SRS. This is especially true if sexual arousal and orgasm are very
important in one's life. However, for those for whom SRS is the right thing to
do, that surgery can release them fully from the physical gender trap they had
been living in, and free them to experience their full humanity in sexual and
- Initial sexual response of postoperative TS women: Entering a second
- There is a wide range of libidos in postop women, just as in natal women.
Some women are very highly sexed, the majority are moderately sexed, and some
are asexual and have little libido at all. This section is relevant for those
postop women who have healthy libidos, who experience sexual arousals and who
desire ongoing sexual fulfillment and orgasms.
- Most postop women having healthy libidos begin to experience their first
postop arousals within a month or two after surgery. After a initial period of
low sensations and even numbness, they then experience "turning on" due to
engorgement of remaining internal erectile tissue (corpora and spongiosum)
that was left during SRS. The arousals produce a feeling of "erection", but
one that is different than for guys, since it is inside their bodies.
- For some postop women, it may take much longer for these arousals to
begin, especially if they were inactive sexually and/or asexual prior to SRS
due to their gender angst. However, even these postop women will eventually
begin to experience genital arousals and the onset of sexual desires if they
have active libidos.
Consider also these words from
the webpage Zen and the Art of
Post-Operative Maintenance: "Another factor in sexual function is
your endocrine system...After surgery, some women find that their adrenal glands
(the other source of testosterone) do not produce enough to provide adequate
libido or orgasm. You may require a small amount of supplemental testosterone to
regain functioning. The amount required is typically far below the amount
that will cause any other unwanted side effects, such as hair growth. Not
everyone requires this, but keep in mind that some do."
Many natal women who are having
difficulty in feeling turned-on and in achieving orgasms (especially
post-menopausal women) are now taking Estratest tablets,
which contain a combination of estrogen and small amounts of testosterone.
Although Estratest is a somewhat controversial treatment, many natal women began
taking it after it was featured in a story on
Oprah Winfrey's hugely popular television show in the U.S. As a result of
this news, and of advice like that on the Zen page, some post-op women who were
experiencing difficulty in arousals and orgasms began using Estratest too, and
some report that the therapy helps them. These tablets contain either 1.25 mg or
0.625 mg of estrogens (as in Premarin tablets), but also include a small amount
of testosterone in each pill (for more information, see this link). There
may be some kind of threshold effect involved here, whereby some women need a
small amount of testosterone to maintain orgasmic capability. On the other hand,
many other postop (and post-menopausal) women enjoy strong orgasms even in the
complete absence of testosterone.
In any event, once a postop woman
begins experiencing arousals, the nerves in the clitoris and vulvar surfaces
become highly sensitized, and sensual and sexy feeling permeate her body. Then,
just as during pubertal sexual awakening, she will automatically feel urges to
play with her body and to masturbate. The arousals will gradually intensify as
her genital area fully heals from the SRS. Masturbation and sexual activity can
likely play a role in helping neural regeneration and sensitivity during this
There are many ways to masturbate, but one favorite way for girls to do it is
to "rub on a pillow". The girl does this by lying face down on her bed, with a
firm pillow between her legs. This way she can rub her vulva and clitoris on the
pillow while squeezing it, putting pressure on her clit and also being able to
thrust and thrash around. At the same time she can play with her breasts and
body with her hands. Alternatively, she can rub her clitoris with the fingers of
one hand while squeezing her legs and thrashing around to stimulate her body.
And there are many other ways to stimulate arousals and produce orgasms,
including using vibrators and other women's
sex toys. Girls discover these ways just as automatically as boys discover
"jerking off", even though girls have been more secretive about it our society
in the past.
While masturbating, the pubertal girl will suddenly begin to experience her
first orgasms, and she is then on her way to developing her full sexuality as a
woman. In just the same way, the postop woman needs to explore her new sexual
anatomy and masturbate, and learn her new sexual responses and experience her
first orgasms as a woman - learning what most girls do in their teens during
This ongoing pubertal aspect of immediate postop life can be very thrilling
and exciting, but also very confusing and scary for the woman, much in the same
way that the onset of sexual maturity is for any teenager.
For some insights into this process, I highly recommend that you read the
very candid webpage by entitled "M -> F Transexual
Post-Op Orgasms - A Personal Perspective", by Monica Stewart. Monica's site
stresses the need to gain experience with your new sexual responses prior to
having intercourse. It is also important to try to get over hang-ups about
what's "OK" and what's "naughty". Then too, many woman enjoy experiencing
playful anal stimulation, including using sex toys to overcome inhibitions and
enhance arousals. Most women also learn to use fantasies to trigger and enhance
arousals and orgasms. Those fantasies can be used during masturbation, and then
later used to help heighten one's experiences during intercourse with a lover.
Thus we see that transition and SRS are just the very beginning: They enable
the girl enter her new puberty. What she will make of herself as a woman is yet
to be determined!
- Some advice to postop women about finding the right lover and losing
- This section is aimed at postop women who have gained some experience with
their new bodies and new sexual responses, and for whom "losing your
virginity" is now a "goal". This can be a good thing to get behind you,
because you'll be much more comfortable in the knowledge that you can really
"do it", and it'll be easier the next time when it might really count.
- By doing this you can get over your fears of whether you will pass or
"look OK" in the sack, and whether your body or scars or whatever will lead to
comments or difficulties. It turns out that most guys won't notice a thing
even in very problematic cases as long you are sexually functional. Most guys
just don't look very close. And there is such a wide range of vulvar
appearances among natal women that most postop women look OK anyways. So
you'll soon be able to relax about all that, and feel comfortable "cutting
loose" and enjoying lovemaking without being self-conscious.
- However, it is important to avoid doing it with just "any guy", especially
someone whose persona or approach doesn't turn you on, or who doesn't try to
make you feel good. Instead try hard to find someone you have something in
common with, and with whom you can test out if there is any "chemistry" in
advance, before jumping into the sack. And of course, you really should try to
figure out if the guy is a nice person who won't get violent with you if he
somehow "finds out".
- One mistake many girls make is to hope for too much and too quickly, and
then becoming greatly disappointed with how sex feels. By expecting sex with
"just any guy" to be fun, they can become extremely disappointed. They may
mistakingly think that guys know how to turn them on, instead of needing to
get aroused themselves. They may simply discover that they have little or no
genital sensation when they are not turned on, even with the man penetrating
them and ejaculating into them. This can erroneously lead them to believe that
they "lack sensation", leading to all sorts of fears and worries.
- However, not "feeling much" when having sex with a man while you are not
turned on is pretty much the same for ALL women, TS or not! It is a
common experience nowadays among young teenage girls who cave in under
pressure to "have sex with someone". It's not even a lot different from the
situation a guy who isn't turned on faces while being pressured to have sex by
a girl. Touching, rubbing and attempting intercourse simply do not feel good
and do not produce results, unless you are turned on! That's why "being in
love" with someone really does mean something folks!
- Only if your libido kicks-in and you get a feeling of "erection" or warm
arousal, will all the external sensitive tissue begin to give really good
sensation and will sex be fun and potentially lead to orgasm. Also, just as
for any GG, postop women should not expect much sensation from inside the
vagina. Most of the sensation when you are turned on will be from the external
clitoral area and the outer vulva (for the TS woman there will also be strong
sensations from the erect corpora and the prostate inside her).
- So, the problem is how to find a guy whose presence and voice and warm
touch makes you feel "melty", and who turns you on and makes you feel really
comfortable and sensual and excited. You'll know it when it happens. Then
definitely do jump into the sack and let your inhibitions go!
- Many of these same issues arise for postop gals who seek women as love
partners. They may feel even stronger concerns about whether their bodies and
genitals look OK, and whether they will really be accepted as women. On the
other hand, they may feel a lot less physical fear of their partners than do
gals going out with men. Beyond this, the situations are similar: For
lovemaking to work, you and your partner must both be aroused and be
comfortable with each other, and you must find sweet and compatible ways to
share and enjoy lovemaking together.
- Even if you find a good loving partner who turns you on and who is a good
lover, you may still need some advance practice in order to easily reach
orgasm. Some of this depends upon the sexual positions you both like best, and
upon how you have previously been masturbating. You may need to modify your
private masturbation habits, and migrate to positions and stimulations more
similar to those you experience during intercourse with your partner. Also, be
sure to TELL your partner what you like. If he or she enjoys being with you
and wants to make you happy, they will try to help you feel good. But they
can't do that if they don't know what you like.
- Thinking about intercourse positions
- Some intercourse positions make it easier for a woman to reach orgasm than
others. Most guys will let YOU tell them or guide them towards what you like
(i.e., what position sequence you like to use). However, if you don't tell
them what you like, you may end up flat on your back in the "missionary
position" and get nothing out of it even IF you are turned on!
- Remember, you are no different from GG women in that most of your sexual
sensations will come from your clitoral area and outer-areas of the vulva, and
you won't feel much sensation from down inside your vagina unless you are
highly aroused. Therefore, just like most other women, simple penile
penetration alone is not going to do much for you (contrary to most guys'
misconceptions about female sexual response). Thus you don't want to leave it
up to your man to just do it his way. It's very important to have some ideas
of positions and lovemaking moves that will make you feel really good too.
- For many women it may be easiest to control your erotic sensations during
penetrative intercourse if you are "kneeling on top". Thus the "woman on top"
photo of Jenny Hildouaki below) is considered by some women to be the
easiest way to reach orgasm through intercourse alone, even without extra
manual clitoral stimulation.
- Kneeling on top of her partner, the woman can control the speed, rhythm
and angle of penetration in a way that arouses her most. She can move her
pelvis against her partner's so that her clitoris rubs against his pubic bone
(and pressure can be applied to her aroused corpora stumps, inside her and
just behind the clitoris), which is an effective way to trigger an orgasm in
many cases. At the same time, either the woman or her man can play with her
breasts, adding to the erotic sensations she feels. If kneeling all the way
down doesn't quite work, the woman can raise her torso slightly so that either
she or her man can play with her clitoris by hand even while he is still
inside her. In order to develop some insight into these possibilities, watch how "Leticia" (Halle Berry)
reaches for her orgasm in the final lovemaking session of her academy
award-winning performance in the movie "Monster's Ball".
- Instead of trying to "both come at once", as if that were some sort of
ideal goal, it is usually best for the woman to come first. That way she can
be sure to come even if it takes some time. Playfully and lovingly swapping
back and forth between penetration and then manual or oral stimulation of the
girl's clitoris and vulva can help her get really hot and reach orgasm.
Whatever works, works. Then, once the woman has had her orgasm, she can flip
over and wrap her legs firmly around her man's back, and let him enjoy
mounting her from above and thrusting hard into her while he approaches his
orgasm and ejaculation.
- Note: If the man has difficulty "staying up" long enough for the woman to
reach orgasm, the solution is simple: Viagra! With Viagra almost any man can get
good firm erections, and many healthy men can easily "stay up" for an hour or
more by using it. Women should not hesitate to suggest Viagra to their men,
because it can be a wonderful lovemaking enhancer. Since Viagra helps their
men stay excited longer and takes pressure off their men, it can help women
reach orgasms who otherwise can't reach orgasm soon enough - by giving them
plenty of time to reach a climax.
- These same concerns arise if your partner is a woman. There is a need to
explore for positions and methods that work, and for signaling about things
such as shifting positions, who should come first this time, etc. The shared
experiences of developing really satisfying lovemaking skills together is an
important part of falling deeply in love and fully emotionally bonding with
- Some differences between earlier male vs later female genital
experiences, arousals and orgasms
- The results of SRS are made immediately obvious to the postop woman by one
important effect: She now has to "sit down to pee". Peeing isn't as easy as
before, and every time you pee you are reminded that you are now a girl,
reminded in the same way that all the other girls are.
- On the other hand, there is a really great advantage to having female
genitals that soon becomes obvious too: Your sexual arousals are no longer
"visible to others". Just as for any other woman, the postop woman does not
have to constantly suppress her arousals like men do. She can let herself get
aroused any time she wants to, and can stay aroused for long periods of time
without others "seeing anything", just as many other women do (this is another
reason so many women smile a lot!).
- It's great to be able to engage in fantasies and visualizations and get
aroused at any time you want to. This freedom can help a woman create and
firmly establish a healthy libido. She can hook-up her brain with her genitals
without much "censorship" going on. Even though her libido is not as heavily
stimulated by the large doses of testosterone that men have, neither does she
have to tame and control her libido like men do theirs. Therefore, on balance,
a woman can generally feel "sexy" much more of the time than a man can.
- Lynn speculates that a lot of men have problems with getting erections
simply because they have to constantly avoid having erections. In other words,
they get much more practice in avoiding erections than they do in getting
them! Women do not need to "censor" their arousals in that way. If they have
no religious or other types of hang-ups about sex and lovemaking, they can
easily practice and enjoy getting aroused as much as they like, and can
develop very healthy libidos as a result. This advantage can help the postop
woman get into her sexuality fairly quickly and help her learn a lot in just
the first year or two postop.
- Once she begins experiencing arousals and engaging in sexual activities,
one major thing becomes immediately obvious. Orgasm feels really different as
a woman. It may not be quite as easy to achieve and may take longer to
achieve, but it can be a much more powerful sensation than any she ever
experienced before as a boy.
- Following SRS, the perfunctory feeling of male ejaculation during orgasm
is gone forever. Instead, you can build up your sexual arousal to a much
higher level without ejaculation bringing things to a halt. It may take more
time to reach it, but you can now experience a more powerful orgasm - with the
old male ejaculation feeling now replaced by an intense neural discharge and
spasm throughout the entire genital area during orgasm. It feels kind of like
you are being gently stimulated with electricity inside and throughout your
entire genital region. The experience can vary a lot from orgasm to orgasm in
the way in which the "neural halo and spasmodic colors" of the orgasm develop,
spread, and feel. It seems almost as if most men so easily and quickly reach
ejaculation that they never manage to get "high enough" sexually to trigger
this more powerful form of orgasm.
- In addition, there are real differences in "body feelings" during
lovemaking between the male and female experience (although many of these
feelings will be "female" in form for preop TS women too). Most males are
usually stimulated visually by their partner's body-appearance. Once aroused,
they usually feel a growing "tightness inside" and a desire to "grab and hold
and thrust and penetrate". This desire comes on suddenly, and quickly becomes
quite overpowering, with most of the sexual sensations coming only from within
the penis itself. However, when the release of orgasm occurs, it is usually
much more perfunctory than for a woman, being accompanied by a few spurts of
semen and a few grunts and that's it. The ejaculation is then followed by
quite a sudden letdown and loss of any interest in sexual activity.
- The sexual experience for the postop woman is much more "internal" within
and throughout her whole body than for a male. The arousal may start in her
genitals, but then can spread all through her lower body, especially inside
the muscles, and her skin all over her body becomes more sensitized to
caressing and touching. Instead of sexual arousal being just in the genitals
as in a male, the estrogen seems to also enable a powerful "heat" to fill the
woman's whole body once she is aroused - and especially once she is being
penetrated. Having this heat come over her in the absence of a partner, and
without any satisfaction, can make her feel like "climbing the walls" or
"thrashing around in her bed".
- Since her whole body becomes much more sensitive to touch as she get fully
aroused, she is not stimulated so much by her partner's appearance as by the
way he (or she) touches her and manipulates her body and the way his (or her)
voice sounds. She doesn't feel the hard focused drive to quickly achieve
orgasm as do males, but instead feels a desire to let go and thrash around and
be "handled" and gradually heighten her erotic feelings. It isn't what she is
seeing that counts as much as what she is feeling and hearing and how her body
is being manipulated by her partner, as she yields to the wonders of sexual
heat and lovemaking. And usually she'll like to take some time to do this and
enjoy this, instead of just "rushing for ejaculation" like most guys do.
- Finally, she will get up on a "plateau" and realize that an orgasm is
going to come. This is a truly wonderful feeling. At some point, the orgasm
starts and spreads throughout her genital area, with the genital nerves
becoming tremendously sensitized as it spreads. The sensation of the orgasm
will vary a lot from orgasm to orgasm (more variably than in the male).
Sometimes it will be weak, but sometimes it can be amazingly intense, and the
feeling varies a lot in form and "color" from orgasm to orgasm.
- Just like natal women, trans women often experience a strong urge to
"vocalize" just before and during orgasm - moaning, squealing, screaming and
making other loud noises while they come. The sound and internal body
sensation of these vocalizations can greatly heighten the intensity of the
orgasmic experience for many women. Postop women shouldn't be afraid to let
out loud moans or screams when they come. It is perfectly natural, and can
help transform ordinary orgasms into ecstatic ones. In contrast, very few men
vocalize when they ejaculate, other than making a few grunts. Perhaps the
difference is hormonal, with testosterone blocking these emotional
vocalizations, just as it blocks emotions such as "crying" in males.
- After climax the trans woman feels a sudden relaxing and calming effect
that is somewhat similar to what it is like for boys. But unlike when she was
a boy, she may often feel aroused and sexy again rather soon after having sex,
often getting firm internal erections again soon after her orgasms. Even
though it may be difficult for her to achieve orgasm again until some time has
passed (a few hours to a day or so), she may feel a desire for sex again right
away anyways. These re-arousals are a really wonderful feeling, and can enable
sweet sessions of touching and snuggling with a loving partner after
- Measuring and documenting postop orgasmic response in TS
- As part of an effort to better measure and document postop women's sexual
capabilities, Lynn participated in first scientific physiologic study of
orgasm in postop TS women, in June 1999. This research was conducted by Rom
Birnbaum, as part of her Ph.D. studies at the Institute for the Advanced Study of Human
Sexuality in San Francisco, CA. Space was provided space for Rom's
equipment and for conducting the research studies by Club Eros, a gay men's
club in San Francisco. Although seemingly a strange place to conduct research
studies on women, this "sex-friendly" site in the Castro Area was a good place
for accommodating a wide range of research subjects and control subjects,
during daytime "off-hours" at the club.
- Research subjects were instrumented with electronic sensors (using
measurement techniques evolved from the pioneering work of Masters
and Johnson in their early studies of orgasm), and then engaged in
masturbation in a comfortable, private environment in an effort to achieve
orgasm. A number of the postop TS women, including Lynn, achieved orgasm as
measured directly by Rom's instrumentation. Lynn's case was particularly
important, since she demonstrated that the capacity for very intense orgasms
can endure for many decades after SRS (Lynn was 31 years postop at the time of
this research). Dr. Birnbaum's work demonstrated scientifically for the first
time what many postop women and their lovers have known all along, namely that
strong orgasms can be fully enjoyed by many TS women. Rom published her Ph.D.
thesis results in 2000 (see following abstract).
Abstract: First physiologic study of orgasm in
postoperative male-to-female transsexuals.
Ph.D. dissertation, The Institute for Advanced
Study of Human Sexuality, San Francisco (Oct. 18,
- Objective: To determine whether data generated by a
physiological sex research study would support the hypothesis that
orgasmic capacity can be retained and/or gained after sex reassignment
surgery in the postoperative male-to-female transsexual. Design:
Controlled laboratory-based analysis of responses to masturbation to
orgasm(s). Setting: A mobile sex research laboratory setup
predominately in two central San Francisco locations. Participants: A
volunteer sample of eleven postoperative male-to-female transsexuals
as well as twenty-nine control group participants divided into five
groups: eleven nontranssexual males, nine nontranssexual females, five
preoperative male-to-female transsexuals, two intersexual people and
two female-to-male transsexuals. These totals include one participant
who joined the study first as a preoperative male-to-female
participant, and returned again later as a postoperative
male-to-female participant. Intervention: One protocol including
measurements of preorgasmic, orgasmic, and postorgasmic responses;
response time determined per individual. Dependent variables: Pressure
waveform patterns produced by involuntary contractions of the anal
musculature, heart rate, and blood pressure. Results: Of the eleven
postoperative male-to-female study group participants, eight
self-reported orgasm and three of these eight produced orgasmic
contraction episodes similar to those produced by control group
participants in this study and subjects in previous physiological
studies of orgasm. Furthermore, no statistically significant
differences were found between contraction patterns produced by study
and control groups in terms of duration of orgasmic contractions,
intraorgasmic amplitude changes, number of orgasmic contractions per
series, mean intervals between the first four contractions, mean
intervals between all contractions, or orgasmic heart rates.
Conclusions: Data from this study strongly support the hypothesis that
orgasmic capacity can be retained and/or gained after sex reassignment
surgery in the postoperative male-to-female transsexual. However,
given the limited sample sizes, projected percentages of orgasmic
capacity in the postoperative male-to-female transsexual population
Lynn Conway and Rom Birnbaum at Club Eros
in San Francisco, where Rom made the first scientific physiologic
measurements of orgasm in postop TS women, in
- The range of experiences of many postop women - - effects on sexual
orientation and the moderate unpredictability of postop sexual orientation - -
long-term effects - - some of Lynn's own experiences - - [ to be completed] -
Who are the most active,
prominent surgeons doing vaginoplasty (SRS) now?
The most prominent SRS surgeons in the U.S. today are Toby Meltzer, M. D. of Scottsdale, Arizona
and Eugene Schrang, M.D. of Neenah,
Wisconsin. These surgeons are in their prime, are performing hundreds of SRS
each year, and are achieving outstanding results in appearance, function and
sensitivity. Marci Bowers, M.D., a
surgeon who has worked closely with Dr. Biber, has recently taken over his
practice in Trinidad, Colorado and is reported to be doing excellent SRS
surgeries there (Dr. Biber is now retired). There are also other expert
surgeons performing high-quality SRS's in various other countries around the
world, most notably Yvon Ménard, M.D.
and Pierre Brassard, M.D. ( en español
) in Montreal, Canada, and Suporn Watanyusakul, M.D. ("Dr. Suporn")
in Chornburi, Thailand.
Marci Bowers, M.D.
Toby Meltzer, M.D.
Eugene Schrang, M.D.
- For information on many surgeons performing excellent vaginoplasty (SRS)
operations both here and abroad, see Andrea's
Vaginoplasty page and follow the many links there. See also the
- of TS
Women's Support Site and The
New Sex Change Indigo Pages for information and links to SRS surgeons in
many countries. The new European
TS Information pages provide information about many excellent European
surgeons. There are also a number of surgeons in Thailand
who are now performing good quality SRS's, and the costs of surgery there are
much lower than for comparable work elsewhere in the world.
- Important note: In past years, few surgeons would operate on girls who
were HIV+. This compounded the tragedy of being TS for the small minority of
women who had been forced to live "on the streets" and had contracted this
dread disease. However, surgical techniques have improved to where SRS can now
be done without risk to expert surgical teams, although extra procedures are
required that may raise costs. For information about surgeons who accept HIV+
patients, contact Christine Beatty
(firstname.lastname@example.org). Christine herself survived life on the streets, and
went on to become a successful postop woman. She reports that the following
expert surgeons now accept otherwise healthy HIV+ patients: Toby Meltzer, M.D.: Same price as HIV- ;
Sanguan Kunaporn, M.D.: 30%
price increase for HIV+ ; Preecha Tiewtranon,
M.D.: $1000 extra from HIV+ ; Eugene
Schrang, M.D.: Unspecified extra change.
Sites containing photos of
many vaginoplasty (SRS) results from many surgeons
[VIEW WITH CAUTION! The photo sequences listed here are definitely NOT
FOR THE SQUEAMISH!]
- And here is a link to
a photo of an early surgery done by Dr. Biber in Trinidad, Colorado in
1976. Dr. Biber became justifiably famous among T-girls in the U.S. for such
results, and they've flocked to him ever since. The early surgical technique
and results are very similar to Lynn's sex reassignment surgery, which was
performed by the famous Mexican plastic surgeon J. J. Barbosa, M.D. way back
- Lynn had follow-up surgery for vaginal deepening and labiaplasty performed
by Dr. Schrang (in November 2000), in
order to bring her results up to modern standards. Dr. Schrang also has
extensive experience in successfully correcting SRS complications surgeries
done elsewhere. Gwendolyn Ann
Smith has created a webpage, "Transsexual's Guide to
Neenah", that provides a lot of practical information about undergoing SRS
by Dr. Schrang at Theda Clark Regional Medical Center in Neenah, WI.
Options that can reduce
costs and enable feminization and transition earlier in
- One of the greatest difficulties faced by young, intense transsexuals who
are very certain of their need to undergo complete gender correction is the
high cost of transition and the long time-period (several years) to get
everything approved. The overall costs of counselling, hormones, electrolysis
and surgeries is typically $30K to $40K in the U.S. Because of their gender
condition, many younger transsexuals are unable to obtain good enough
employment to save money fast enough to achieve a timely transition. Meantime,
they are often doomed to watch as their bodies continue to masculinize (even
if taking estrogen) which makes a successful and complete transition seem
further and further out of reach.
- Recent developments, including easier and earlier access to female
hormones and antiandrogens (ordered from overseas pharmacy sites via the web).
There are also several new sex-change
surgery clinics in Thailand , where SRS costs only about $4000 to $6000 (see
New York Times article of May 6, 2001). Easier access to hormones and
surgery have made it much easier for young transsexual girls to feminize
themselves while young and to achieve complete gender transition while in
their twenties. The Thai surgeons do not insist on the full HBIGDA protocol
(and instead make their own informed decision whether a patient is suitable
for SRS), thus greatly reducing the financial burden and logistical
complexities of having to go to two counselors or psychiatrists for several
years in order to get the letters of approval for SRS required here in the
- However, anyone going to Thailand for SRS should make very certain that
they are going to one of the handful of reputable surgeons there who are doing
high-quality SRS's using modern surgical techniques in the best hospitals.
There has long been a tradition in Thailand of doing what superficial
"Hijra-style" SRS's which do not create a full vagina. These are inexpensive
surgeries (on the order of $1000 to $1500). Many Katheoy "working girls"
undergo these surgeries, not being able to afford the full SRS surgeries (if
someone does not need a full SRS, a Kathoey-type surgery might be an option to
consider). Bottom line is that anyone going to Thailand should carefully
research the latest
information on Thai surgeons, and avoid going to the "lowest bidder" for
such an important and life-changing surgery .
- As an even less expensive alternative, transsexuals in the U.S. can now
take advantage of fairly easy access to orchiectomy. After orchiectomy
(castration) a T-girl's body will not be further maimed by testosterone, and
the feminizing effect of female sex hormones is much more rapid and more
pronounced (especially in younger girls). This option can enable younger
T-girls to rapidly become feminized and passable, and to buy some time to save
money for SRS without feeling such desperate urgency. For more information on
this type of surgery, see the Orchiectomy page
in Annie Richards' website.
- In the past, many T-girls went to Dr. Robert Barham in Portland Oregon for
orchiectomies, who charged about $1000 for the surgery. Although Dr. Barham is
no longer doing these surgeries, his protocols are worth documenting as being
what you might expect elsewhere: Dr. Barham required that you had
transgender counseling for one year and been on hormone replacement therapy
for one year and had passed a recent HIV status test. His protocol involved
seeing you at least one day before the procedure to discuss the procedure, the
implications and the risks. The procedure was then generally done on the
following day in his office. He used bilateral spermatic cord blocks for
anesthesia. The procedure itself took approximately one hour. Following the
procedure it was best if you can remained in bed with ice packs for 12 to 24
hours. He also asked that you stay in town for 48 hours, to take care of any
problems that might arise, and also to give you a chance to begin healing
before returning home.
Completion of transsexual
body feminization by cosmetic surgeries
- Many transsexual women also undergo breast augmentation surgery, facial
feminization surgery and various cosmetic surgeries to further feminize their
bodies. Anne Lawrence's site contains photos of recent breast augmentation
surgery on transsexual women, and Lynn's FFS site
contains information on facial feminization. To give you an idea of the
wonderful results now achievable, here are some photos of breast augmentations
performed on hormonally-feminized transsexual women (these were done by a
surgeon in Thailand):
- However, it is important to note that many TS women achieve very
satisfactory breast development without augmentation, especially if they
started their transitions while in their teens. For an extensive discussion of
breast development in TS women, along with many photos of unaugmented
development, see Annie Richards Breast
- The decision of whether to augment or not is very similar for a TS women
as for any other woman - a complex one with many tradeoffs of appearance vs
sensation vs risks of complications. In many cases of small development,
augmentation can bring a lot of satisfaction, but in many other cases it may
be quite unnecessary and carry unwanted risks. For an extensive discussion of
breast augmentation with many photos, see Annie Richards' Breast
Carla Antonelli's website
contains a page of
photos of pretty T-girls where you can see even more results of breast
augmentation surgery. Perhaps even more importantly, her page conveys images
of the wonderful results that these young women obtained from feminization
early in their lives. The ongoing moral to the story is this: If a T-girl
knows for sure that she inevitably must become a woman, she should immediately
seek medical help to stop any further masculinization and begin her
feminization as early in her life as possible - in her mid-teens if she can.
Courage and decisiveness in seeking gender correction while still young will
dramatically improve her chances for a full and complete life.
The joys and wonders of
complete gender correction
- Modern medical advances have brought us a long way from the ancient
methods used in traditional "Hijra-style" surgical treatments of
transsexualism. Modern sex hormone therapy, vaginoplasty (SRS) surgery, facial
feminization surgery and cosmetic surgeries can substantially modify an MtF
transsexual's body to properly match her innate gender, especially if
treatment is started early enough in life. It is now possible for many postop
women to feel totally gender-congruent in their transformed bodies, and to be
able to very comfortably and passionately enter into loving relationships
(either heterosexual or lesbian, as the case may be) as sensual, sexually
- The joys and wonders of being able to resolve the transsexual condition
and to then live a full life as a warm, loving woman in the resulting female
body are suggested by the following beautiful photographs of Jenny Hiloudaki
(Greece). Jenny started on female sex hormones at the age of 13 and
underwent vaginoplasty (SRS) at the age of 20: