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阴道成形术： 由男性到女性的性别重塑手术   历史记录，说明，照片，参考文献和链接。 琳·康维 著 版权@2000-2006，琳·康维。 保留所有权利。 　         右图：一位接受了阴道成形术（SRS）和阴唇成形术的变性女人外生殖器细部（双腿由支架分开，阴唇也部分张开），主刀医生为威斯康星州尼纳市的尤金·施雷恩（Eugene Schrang）医生，医学博士。   翻译：Echo, 梅 [LC updates of 8-06-07; 7-17-09]   Deutsch, English, Espaρol, Franηais, עברית, Nederlands, Portuguκs, Русский,

 

 

        本页面概述了阴道成形术（通常也被称为‘性别重塑手术’（SRS或GRS））的发展历史和手术细节。浏览之前，请参阅本网站其它位置有关性别认定、跨性和变性概念的介绍，这样你就可以理解为什么变性女人要接受这些手术。本页面阐明了从男性变为女性(MtF)的变性女人在术后的确可以拥有女性生殖器官，同时也帮助读者了解变性人为获得新的生理性别而经历的一些严峻考验。
 

 

重要提示：本页面包含可能令一些读者感到震惊或极度不安的图形视觉资料以及其他医学信息。          如果你对手术神经过敏，或对自己的生殖器存在任何焦虑，请不要继续阅读。          18岁以下人士无权接触这些医学信息。进入本页，兹证明你已年满或超过18岁。

 

 

目 录

历史背景

现代性别重塑手术（SRS）的发展

美国早期的性别重塑手术

约翰•霍普金斯大学早期男变女性别重塑手术（SRS）过程图解

性别重塑手术（SRS）在美国成为治疗易性症的公认治疗手段

建议变性者实施阴道成形术（SRS）的现行协议

一些现代阴道成形术（SRS）的效果图片

阴道成形术（SRS）的术后护理

变性女性术后的性唤起、性交及性高潮

谁是当今实施阴道成形术（SRS）最活跃、最出众的医生？

含有多名医生大量阴道成形术（SRS）效果图片的网站

能够降低费用、尽早实现女性化和性别转换的其他选择

通过整容手术完成变性者身体的女性化

彻底的性别矫正所带来的欢乐和奇迹

 

 

 

历史背景

        易性症并不是什么“现代发现”，相反，它是人类性别化中并不罕见和自然发生的一种变化，从古时起便被关注和记录。长久以来，包括北美土著部落在内的很多文明里，变性者可以选择穿着异性服装，以女性的方式生活，包括拥有丈夫。通过外科手术改变外生殖器以减轻强烈跨性别感觉的做法也不是“二十世纪的发明”。在一些文明里，甚至古文明，很多变性者自愿接受手术修正身体，以这样一种方式“改变他们的性别”。

        阉割术的手术方法及作用在古时随处可见，它在驯养动物过程中的应用很快教会人们，在男性人类足够年幼的时候摘除睾丸也可以阻止其男性化发育。这个人将永远像个孩子—或“女孩子气”。通常这种手术也会被强加到俘获的成年男性奴隶身上，以“驯服”他们成为“阉人”。对后青春期的正常男性实施这样的手术，尽管可以略微减轻其性驱动力并急剧降低发育男性肌肉的能力，却并不能改变他们的性别感受和性别认同。

        有关阉割效果的知识积累被进一步延伸，用来帮助男变女的变性者：几千年来，不计其数的变性者主动寻求和接受比纯粹的阉割术风险更大、效果也更显著的手术。在这些手术中，变性者通过睾丸、阴茎和阴囊的全部摘除而被彻底阉割。另外，阴部的外形常常被粗略地塑造成女性阴户的模样。没有人确切知道这是如何开始的，不过这种变性手术在古希腊，特别是性开放的古罗马时期就已广为人知，并常在各种“宗教仪式”中传统化，向经历了这种手术的“女人”赋予社会地位。

        通过接受这些手术，由男变女的年轻变性者（如果她们幸存下来）不仅可以避免发育为男人，同时也获得了看起来与正常女性类似的外生殖器。尽管没有阴道，也缺乏女性荷尔蒙强有力的女性化效果，年轻的变性者在接受此类手术后依然能够作为女性生活得更好。

        即便在今天的印度和孟加拉国，仍有众多绝望的年轻变性者离家出走，加入到“海吉拉”（Hijra）这个特殊的社会阶层。为了成为海吉拉，这些青少年自愿在原始条件下接受彻底的阉割手术，如同在古时一样，仅使用鸦片作为麻醉剂。多数人在10几岁青春期开始后不久便接受手术，手术效果可以从下面的照片中看到。通过及早实施阉割手术，很多人都避免了男性第二性征的发育（除变声及嗓音变低以外），而且她们的身体也能永久地保持柔软、孩童化以及女性化。

        与流行的说法相反，青春期后进行彻底的外部阉割术并不一定使人“去性化”。青春期后完全去势的年轻海吉拉，重新获得了性唤起的感觉以及性高潮的能力。虽然这种手术心理上的冲击通常会削弱正常男性的性欲，但对年轻变性女孩的影响通常恰恰相反：手术能够使其女性知觉和性欲得到更完全的表达和释放。与现代变性女人术后的情况一样，由于体内留有残余的生殖器组织，许多海吉拉依然能够拥有强烈的性唤起感觉（即使她们没有经由现代性别重塑术而将外部神经组织保留下来，但是她们仍保留了内部的勃起组织和前列腺及其具有的间歇性高潮能力）。虽然海吉拉没有阴道，很多人仍从与男人的插入性性行为（肛交）当中（获得的高潮）享受到极大乐趣。由于经过了彻底的阉割，她们的生殖器及骨盆区看起来非常“女性化”，很多印度男人都很喜欢与她们做爱。相应地，海吉拉接受了她们的命运，以及有限而又实在的可能—在其一生中作为女人找到哪怕是一点点的爱。

一位年轻的印度海吉拉，正在展示其外生殖器

图片来自
塔克西·伊斯卡瓦所著
《海吉拉-印度的第三性》一书

        大部分海吉拉以女性身份和其他海吉拉组成“家族”生活在一起，通过在婚礼和分娩的传统仪式上表演来谋生。在这个卑微而又传统的印度阶层中，很多人也从事卖淫和乞讨的行当。当今的一些海吉拉有幸获得了雌性荷尔蒙，通过促进乳房生长和女性身体曲线自然发育而使身体女性化。在青少年时期接受的阉割手术和女性荷尔蒙的共同作用下，一些当代的海吉拉变得非常美丽，不过遗憾的是，她们既没有女性性器官（阴道），也不能作为女性被社会所接受。

        海吉拉的起源在印度历史中可以追溯到几百年以前，这个流传甚广的习俗，使变性者避免了青少年时期男性化发育的焦虑和命运，也为她们提供了卑微但安全的社会地位。为了“近似地拥有女性性别”，在充分了解自己将永别家人、余生中面对社会地位下降的情况下，这些年轻变性者在痛苦中走向极端，这反映了其内心深处性别冲突真实而又绝望的写照。

        在当今的印度和孟加拉国有几百万海吉拉。欲了解更多信息，请访问金娜（海吉拉）的网站http://www.kinnar.com/和英国广播公司有关孟加拉海吉拉的报道，在塔克西·伊斯卡瓦 （Takeshi Ishikawa）所著的《海吉拉-印度的第三性》（Hijra-The Third Gender in India）一书中，可以找到很多有关海吉拉的精彩图片。一个海吉拉家族的领导者达楠 （海吉拉“导师”）表示，虽然被这个特殊阶层的神秘面纱遮盖了几个世纪，促使这些青少年成为海吉拉的根本原因无疑是易性症。

        “我们的性别认同危机与生俱来，它不是来自模仿或学习，而是促使我们成为女人的一种自然本能。”-达楠

        即使在当今的西方社会，极度绝望的年轻变性女孩自己“选择成为海吉拉”的现象也并不罕见。通过彻底地自我阉割，然后寻求医疗系统进行“修补”，她们因而获得了“实施于生命早期的低成本性别重塑手术（SRS）”。美国的很多女孩就是这么做的，之后她们服用雌激素使自己女性化，很快就变得如女孩般美丽，效果相当不错（不幸的是，阴茎和睾丸皮肤的缺失，使得以后通过性别重塑术构建阴道变得非常困难。）。在美国，更多的年轻变性女孩采取自行去势的方法来避免男性化发育，特别是在美国严格禁止医院对“完整的男性”实施性别重塑手术的50年代及60年代初（见下文）。

        历史悠久的传统“海吉拉式”手术从古时一直延续至今，而且仍在印度和孟加拉等国继续使用。有关海吉拉式阉割术术后效果的详尽知识，为现代变性手术的发展提供了重要的经验背景。

 

 

 

现代性别重塑手术(SRS)的发展

        [此处以后将添加：有关第一次世界大战后整形手术发展的讨论，以及1930年前后医学博士F·亚伯拉罕 （F. Abraham）在德国为变性女性开创性地实施阴道成形术的讨论---见：http://www.symposion.com/ijt/ijtc0302.htm#Case%201 - - -]

        随着第二次世界大战后性荷尔蒙和整形手术知识的迅速发展，为易性症设计完整的医药及手术解决方案终于成为可能。在50年代，变性女性开始极大地获益于新兴的女性荷尔蒙，这些药物促进乳房发育和皮肤柔软，并随着时间的推移产生女性曲线。同样是在50年代，少数外科医生汲取了在女性两性人阴道重塑手术中的最新技术进展，开始尝试使用取自大腿或者臀部的皮片为变性女性塑造阴道。

        美国人克里斯蒂·乔根森（Christine Jorgensen），是最早接受这种外科性“性别改变”的一小部分变性人中的一员。1952年，接受初期手术后不久她便被美国报界传媒曝光，其经历引起举国轰动。通过她的故事，很多变性人第一次了解到这种新型荷尔蒙及外科疗法的存在。然而，只有少许欧洲患者才能接受这种新型的试验性手术。

        在克里斯蒂接受手术的50年代，医生们首先通过一次或多次手术摘除变性者的男性器官，随后患者需要经过一段延续期等待康复。接下来，通过近似于为两性人患者创建阴道的手术，外科医生利用取自患者大腿或臀部的皮片为其重建阴道（克里斯蒂的阴道成形术完成于1954年）。

变性先驱克里斯蒂·乔根森
早在1952-1954年间接受了变性手术

 

        虽然患者对手术效果相当满意（特别是与她们先前的情况相比），但是这种早期的手术方法存在很大问题。移植的皮片不可靠，部分皮片有时无法“存活”，大块皮片的使用也令供区留下了难看的大范围疤痕。另外，大量敏感的生殖器组织在第一步手术中被永久性地切除，影响了患者性唤起的感觉和获得性高潮的能力。

        从50年代末到60年代，数百名美国变性者得到了医学博士哈里·本杰明（Harry Benjamin）医生的帮助，他是一位富于同情心的内科医生和内分泌学家，在纽约市及加州旧金山市均设有办公地点。本杰明医生是第一位将跨性别认同和同性恋区分开来的医生和学者，他认为变性者实际是经受着一种原因未明的性别认知错误疾病，而不像当时的多数精神病学家那样，将变性者视为患有精神疾病的不正常人。为了减轻她们的痛苦，满足其对药物女性化治疗的强烈要求，本杰明医生开始有选择地为一些患者开具雌激素处方。同时他也对正在实施的变性手术效果保持密切关注，并开始向要求最强烈的变性患者推荐那些取得了最佳手术效果的医生。

        然后，在50年代末，一位名叫乔治·布罗（Georges Burou）的法国整形医生，医学博士，为男变女的变性者发明了阴茎反转男变女性别重塑手术的现代术式，布罗医生的手术方法在不断的改进中沿用至今。布罗医生的经典创新在于，利用男性性器官作为构建包括阴道在内的新女性性器官的皮肤和性敏感组织来源。

 

 

感谢法国的Pascale找到了布罗医生的这些照片
[摘自1970年7月份《国家警察公报》（一份美国男性杂志）的一篇文章]

 

 

        布罗医生在其位于摩洛哥卡萨布兰卡的诊所内实施这些手术。1958-1960年间，一些来自法国巴黎拉·卡拉尔索俱乐部的出名且年轻貌美的“反串旦角”，包括可可西尼尔 （Coccinelle）（更多信息） ，斑比（Bambi）和艾普莉尔·阿希礼 （April Ashley），经过布罗医生的手术成功地变为女人。作为在该俱乐部工作的额外好处，许多拉·卡拉尔索女孩获得了女性荷尔蒙，她们由此变得难以置信的美丽、性感和富于女性化。有些人在性器官手术后返回俱乐部继续从事表演。她们成功的“性别转换”变得家喻户晓，并因此被许多显赫富有的男人作为求爱对象。一些特别富有的人（包括亚里士多德·欧纳西斯）有时会“资助”拉·卡拉尔索俱乐部的女孩完成变性手术，而她则会在一段时间内充当其情妇。

 

        随着布罗医生的工作不断被报道，舆论对其褒贬不一。其座落于摩洛哥卡萨布兰卡市卢·拉·佩比13号的“杜·帕克诊所”，最终吸引了世界各地的变性患者蜂拥而至。布罗医生开始以每年数百例的速度实施这种手术。1973年，在斯坦福大学医学院举行的有关易性症的一次重要跨学科会议上，布罗医生首次公开演讲，介绍其创新的手术技术。 截止到参加1973年的那次会议为止，他已经进行了超过3000例的男变女性别重塑手术。从那时起，世界各地的很多外科医生推断和改进了布罗医生的技术，并应用到类似的性别重塑手术当中。

   

 

变性先驱可可西尼尔（左） ，斑比和艾普莉尔·阿希礼（右） 是最早接受布罗医生性别重塑手术的患者（1958-1960年期间）

 

        这些手术取得成功的关键在于：（1）利用阴茎和阴囊的皮肤构造了新的阴唇和有性功能的阴道，（这样就避免了早期术式中使用大面积深层皮片所造成的供区瘢痕）；（2）小心地剥离及放置了残余的阴茎海绵体，对一些敏感神经和小部分勃起组织予以保留和重新定位，如果操作得当，患者在术后可以拥有强烈的性唤起感觉（保留在体内的海绵体残端会勃起），并能轻易地获得性高潮（前列腺保留完好，可以象变性手术前那样在性高潮中抽搐—而海绵体、阴蒂和阴户的神经组织则会同时抽搐、搏动和释放，这与任何其他女性一样。）

        随着越来越多的变性者听说可以得到本杰明医生富有同情心的治疗，他的工作也得以快速进展。他开始向外科医生们，尤其是卡萨布兰卡的布罗医生推荐更多病人。到了60年代中期，美国以外的一些顶尖外科医生开始使用布罗医生的技术为变性者实施性别重塑手术，于是本杰明医生也向他们推荐患者。其中最值得注意的是墨西哥著名整形外科医生杰西·耶稣·巴尔博萨（Jose Jesus Barbosa）（巴尔博萨医生是琳的性别重塑手术医生，到1973年已实施此类手术超过300例）。

        然而，即便到了60年代中后期，在美国也几乎没有人听说过这种手术。1952年乔根森事件公开以后，在宗教团体的强大压力下，多数美国医院都制定了政策明令禁止这种手术，而宗教上的苛评也经常被用来支持有关禁止为变性者进行任何荷尔蒙及手术治疗的观点。随后，60年代的美国医学界也把变性者看作是有“严重的精神疾病”，而不是生物学上的性别错位。许多易性症者非但没有得到医学专家性别转换上的帮助，反被强迫送进了精神病院。在那里，精神病医师尝试使用电击和厌恶疗法“治疗他们的精神疾病”。

        从50年代末到60年代初，为了变得更加女性化，并且绕过医院有关摘除“完整男性”睾丸的禁令，一些激进的美国变性女孩采取了自我阉割的手段。一旦身体不再完整，如果有钱支付相关费用，她们就有希望在美国的一些医院获得完整的性别重塑手术。例如，变性先驱阿蕾西娅·博拉芙德 （Aleshia Brevard）的故事。通过在年轻时服用雌激素达到女性化，阿蕾西娅成为旧金山以“女性模仿秀”而闻名于世的费诺奇奥夜总会的明星艺人。为了使自己更加女性化，她自行实施了阉割术，后在本杰明医生的帮助下于1962年在美国接受了性别重塑手术。像许多在60年代完成性别重塑手术的变性女性（包括琳）那样，阿蕾西娅摆脱了旧生活并进入潜藏模式。她继续从事演艺事业，担当“花花公子兔女郎”（一家著名的“花花公子”俱乐部的女招待），她成为了广为人知的电影、舞台和电视三栖明星，并且三度结婚。阿蕾西娅直到最近才在一部精彩的自传中与我们分享了她的精彩生活。

 

 

1961年，作为费诺奇奥俱乐部明星 “李·肖”的阿蕾西娅（术前）

1962年，完成性别重塑手术不久的阿蕾西娅

80年代初，作为处于潜藏模式中的女演员 的阿蕾西娅

 

 

美国早期的性别重塑手术

        终于，在新的霍普金斯性别认定门诊管理下，为帮助那些要求强烈的变性者，约翰·霍普金斯医学中心的医生们从1966年开始实施为数有限的从男性到女性的性别重塑手术。霍普金斯的医疗人员相信变性者患有心理疾病，但他们同时也认为没有心理疗法可以彻底改变这种“错误形成的性别认同”。在一个实验性的项目里，他们采纳了本杰明医生的提议，开始探索通过手术来帮助病人的可行性。霍普金斯的外科医生们使用了经过改进的布罗医生的手术方法。

        1966年秋，美国的报纸纷纷转载了《纽约每日新闻》（New York Daily News）的一则新闻，如下：

        “这些夜晚以来在曼哈顿的俱乐部巡回演出的一个迷人女孩，承认自己在不到一年以前还是男性，而且她就是在巴尔的摩的约翰·霍普金斯医院接受的变性手术。令人惊讶的是，院方承认了这一事实，并称手术是在心理治疗后实施。约翰·霍普金斯医院的发言人表示，尽管这种手术在美国十分罕见，但它既不违法也不有悖于道德准则。美国一些主要医院的官员对约翰·霍普金斯医院有关手术合法性和道德观的看法表示赞同，但没有人记得曾有这样一例手术在纽约实施过。”

        然后，在1966年11月21日，《纽约时报》 （New York Times）以很大篇幅在头版刊登了一篇关于易性症的文章。该文对当时国外实施手术和荷尔蒙治疗以及约翰·霍普金斯大学医学中心的新项目进行了广泛介绍，该中心当时新近实施了好几例这种手术。这篇文章同时也将本杰明医生认定为全球易性症研究领域最重要的权威，一部有关该主题的书名为《变性现象》（The Transsexual Phenomenon）（参阅原文在线版本）新著的作者。

哈里·本杰明，医学博士

伟大的医学先驱和热心的内科医生
[琳·康维摄于1973年]

        本杰明医生是易性症医学学科这个全新领域的先驱。他具有范式转换意义的医学论著描述了几十年来与众多患者接触的经历。他是第一位确定性别认同和性取向是每个人天性中两个独立方面的学者。为了让“急切的变性者”能够按其追求的性别生活，本杰明医生建议他们确实应该接受治疗以及如何治疗。他的书记录了新兴的手术和荷尔蒙治疗方法的效果，并把这些疗法作为治疗易性症的一种合理选择。这部著作给诸多易性症者以新的希望，也为我们现在习以为常的现代医疗手段开启了大门。与此同时，本杰明医生的理论及医学界对其研究成果给予的关注，也因约翰·霍普金斯医院实施变性手术的事实极大地提高了能见度。

 

 

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 10.)

 

 

Figure 1. A sketch of the perineum showing the line of primary incision.

 

 

 

 

Figure 2. The right spermatic cord is clamped and ligated.

 

 

 

 

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 penis.

 

 

 

 

Figure 5. The urethra is dissected from the shaft of the penis.

 

 

 

 

Figure 6. The corpora cavernosa are separated to assure a minimal stump.

 

 

 

 

 

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 vaginal cavity.

 

 

 

 

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 U.S.

 

In 1969 Stanley Biber, M.D. (1924-2006*), 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 USA Today article told Dr. Biber's story, as follows:

 

*Stanley Biber, M.D.

 

Dr. Biber was one of the pioneering surgeons of the 20th century.  Over a 35 year period beginning in 1969, he performed over 5000 sex reassignment surgeries, almost single-handedly establishing SRS as an acknowledged and accepted treatment for transsexualism in the U.S.  Much beloved by the trans community, Dr. Biber passed away on Monday January, 16, 2006 at the age of 82.

 

 

 

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 the introduction 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):

 

 

Results of modern SRS surgeries performed by Eugene Schrang, M.D., of Neenah, WI

 

 

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 espaρol ).  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 (SRS)

 

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 Canada.

 

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 for SRS.

 

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 the tip.

 

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 "looking perfect".

 

By the way, quite a few GG women have confusions and concerns about "how they look". A recent controversy in Australia clarifies this issue: Most GG women have not seen the details of many other women's vulvas, but nowadays they may often see photos of other women in their boyfriends or husbands' porno magazines. In Australia the men's magazines such as Playboy and Penthouse are forced to digitally "pretty-up" and simplify the appearance of women's genitals in their photos in order to be sold without plastic-wrap covers. As a result of seeing these modified photos, many women in Australia have now gotten a very unrealistic notion of what most women's vulvas look like, and this has led to many women there to seek out plastic surgeons to make their genitals "look normal"! This story should help more postop TS women to relax a bit and not worry so much about "how they look". There is a very wide range of vulvar appearances, and most postops these days fit somewhere within the rather "normal-looking" part of that spectrum.

 

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 " 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.

 

SRS Warning

 

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 lovemaking relationships.

 

 

Initial sexual response of postoperative TS women: Entering a second puberty

 

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 period.

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 puberty.

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 your virginity

 

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" position (see 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 your partner.

 

Once you are comfortable making love and reaching orgasm in basic sex-positions, you and your partner may want to explore more advanced techniques in order to keep your love-life fun and exciting. There is a wide variety of excellent books and videos available to help you in this. For starters, you could check out books like How to Be a Great Lover: Girlfriend-to-Girlfriend Time-Tested Techniques That Will Blow His Mind and The Good Girl's Guide to Bad Girl Sex. Also, take a look at videos like The Guide to Advanced Sexual Positions. Such books and videos can also help a woman get over various hang-ups and become more comfortable thinking about and then enjoying lovemaking.

 

 

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 intercourse.

 

 

Measuring and documenting postop orgasmic response in TS women

 

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. Birnbaum, R.   Ph.D. dissertation, The Institute for Advanced Study of Human Sexuality, San Francisco (Oct. 18, 2000). Contact: poststudy@aol.com   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 are unavailable.

 

 

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 1999.

 

 

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 espaρol ) in Montreal, Canada, and Suporn Watanyusakul, M.D. ("Dr. Suporn") in Chornburi, Thailand. 

 

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 SRS section 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 (christine@glamazon.net). 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!]

 

The TS women's support site contains links to many photographs of SRS surgical results of many surgeons. One link contains a series of 25 photographs of an SRS performed by Toby Meltzer, M. D. of Scottsdale, AZ. Another link contains a detailed sequence of photos of a labiaplasty performed by Dr. Meltzer.

 

Spanish actress Carla Antonelli's website also contains a very detailed "still-frame-video" sequence of SRS. Another site contains a photo sequence of SRS performed in the UK.

 

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 in 1968.

 

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 life

 

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 $6000 to $8000 (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 U.S.

 

For more information about the Thai surgeons, see the TS Womens' Resources SRS page. See also Dr. Suporn Watanyusakul's website and photos of recent SRS at his clinic. For another recent example of Dr. Suporn's work (May 2002), see the webpage of a girl from Finland describing her SRS experiences and showing photos of her SRS results (in English).

 

 

Photos of recent vaginoplasty (SRS) results by Dr. Suporn on a girl from Finland (at 5 months postop)

 

 

Also see the websites for the Preecha Aesthetic Institute (Dr. Preecha Tiewtranon), the Aesthetic Plastic Surgery center in Bangkok (Dr. Pichet Rodchareon), and the Plastic Surgery Center in Phuket (Dr. Sanguan Kunaporn), including a sequence of photos of SRS surgery by Dr.Sanguan Kunaporn.

 

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 this Orchiectomy page.

 

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.

 

For more detailed information about orchiectomy, see Sherry's website. Sherry is a transgender girl who underwent orchiectomy in 1999 as part of her preparation for gender transition. In her website she describes her own experiences and provides a lot of up to date information about orchiectomy, including a list of surgeons. See in particular her pages entitled "Questions I am Often Asked About My Castration" and "Orchiectomy for Transsexuals". See also Andrea James' new Orchiectomy page.

 

 

 

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 Dr. Suporn, 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 a discussion of breast development in TS women, along with many photos of unaugmented development, see this Breast Development webpage.

 

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 a discussion of breast augmentation with many photos, see this Breast Augmentation webpage.

 

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 responsive women.

 

The extent of body modification and feminization now possible by early medical intervention and lots of effort can be seen in many photos of young transsexual women (such as those of Amanda Lear (France), Roberta Close (Brazil), Carolyn Cossey (U.S.) and Julia Sommers (Australia)).

 

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:

 

 

 

 

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