In the perception of the media and the public, a male-to-female transsexual (MTF) is a man who's had sex re-assignment surgery (SRS, also often rather inaccurately called gender re-assignment surgery - GRS) on his/her genitalia. In fact for some transsexual women this is not the case, there are many transsexuals who happily live, work and socialise as women, but who never have sex re-assignment surgery or at least delay it for many years. Most surgeons will consider as eligible for SRS genital surgery a genetically male "woman" over the age of majority who has undergone at least 12 months continuous female hormonal treatment, and who's also successfully lived for at least a year full-time as a woman. However a surprising large number of women who fulfil these criteria do not immediately seek SRS, or any other genital surgery. The reasons for delaying or avoiding SRS procedures are very diverse, but include:
Unfortunately I haven't yet found any recent (rather than 1960's) statistics on the length of time after a real life transition until genital surgery for male-to-female- women, but I have found some interesting figures for female-to-males. Dr Holly Devor when researching her book FTM: Female-to-Male Transsexuals in Society found that most transsexual men retain some very dramatic physical manifestations of their previous lives as females. More than 1/3 of the 35 participants in her research who discussed this issue said that they began living as men without the aid of either hormone therapies or surgeries. Another 60% of them began their lives as men with the assistance of hormone therapy but, on the average, they did not have their first surgeries for another 3 1/2 years. Only six (15%) of the 39 transsexual men interviewed had had any kind of genital reconstruction surgery. Furthermore, despite the fact that they averaged 6.5 years since beginning hormone therapy, and 7.9 years since beginning to live full-time as men, slightly more than half (51.5%) of those who had not yet had genital surgery said that they were not particularly interested in having any done.
These extraordinary results are not directly relatable to transsexual women as much more difficult and expensive surgical procedures are required for female-to-male sex re-assignment than for male-to-female sex re-assignment. However they do reinforce my own belief that a medium [average] delay of 3 years from full time transition to MTF SRS would probably be near the mark, high though this may appear at first sight given that a common complaint from transsexual women is the need to wait a whole year after transition before being eligible for surgery. But the reasons to have some form of genital surgery often strengthens with time, and most transitioned transsexual women eventually undergo some procedure. Possible drivers may include:
The importance of the sercond point can not be underestimated. Post-transition but pre-SRS girl gradually collect bad experiences, ranging from embarrassment during a security check, a friend who sees too much, the wandering hands of a drunk, to the possibly fatal disappointment of a rapist.
Another rather depressing, driver that is now sometimes cited is homosexual men seeking to have sex-change surgery because it has become socially and legally more acceptable to be openly transsexual than openly homosexual (note: this reason must not be confused with the unpopular homosexual transsexual theory). Age at SRS Even today, half a century after Christine Jorgenson, most empirical evidence and published studies indicate that a majority of European and North American transsexual women are in their 30's, and 40's before they actively seek to resolve their gender issues. Inevitably this means that the patient age profile of surgeons undertaking sex-re-assignment surgery follows this trend - with a lag of a several years representing the time from the woman commencing treatment to having some form of genital surgery.
Considerable publicity often surrounds young transsexuals who with the support of their parents transition and have surgery at a very young age - in their teens or early 20's. There is no doubt that this group is becoming more numerous, but it is still only a very small proportion of the transsexual community. There is also a statistically significant group of young transsexual women (often from parts of Asia and Latin America) whose career in the sex industry leads to various surgery procedures in during their teens and 20's, but this is usually in the form of breast augmentation and facial feminisation. When (or if) they finally decide to have SRS, typically in their 30's, it generally marks their move out of the sex industry,
The following table shows the
average age of MTF transsexual
women receiving SRS between 1997-2000 at one clinic in Thailand:
Nationality
Average age
Lowest age
Highest age
Total number
For various reasons, very young American and European women are far more likely to use a surgeon in their own country than travel to Thailand, and this may have raised the average age by a few years, but the general picture of a majority of western transwomen undergoing SRS in or near their middle age is undoubtedly correct, for example an American study of 232 transwomen noted that their average age at the time of surgery was 44, with a range of 18 to 70. Surgery
Options
Figures and statistics are hard to find, but as many as 50% of all transitioned transsexual women may fall in category one, and some will never progress to another category.
If there are any doubts, the best route is always NO surgery. It’s always possible to have surgery later, but it’s impossible to reverse castration or SRS. Even if surgery is decided on, the prior freezing of a sperm sample (if obtainable) may be a sensible measure to help preserve some reproductive options - even as a mother) Castration is most commonly performed with intersexed or gender disordered children, but some transsexual women do find it to be a useful and cheap halfway house to full SRS.
For satisfactory penetrative sexual intercourse with a man a stretched vaginal depth of at least 6 inches (15 cm) is required, while this is about the mean depth of the neo-vagina of transsexual women, inevitably some women are shallower and this is a major cause of dissatisfaction in the result of SRS. For accommodating intercourse with a well endowed male partner, a vaginal depth of up to 9” (20-22cm) is necessary. This is actually a very considerable depth which is rarely achieved in SRS, it either requires generous penile skin to be present (rarely the case with a MTF transsexual after prolonged female hormonal treatment), or scrotal skin (which requires painful electrolysis beforehand) or colon grafts be used to extend the depth - and even then the internals of the transwoman may be unsuitable for such a deep and broad cavity. On the other hand, most genetic women would also have problems fully accepting such a lucky man! It should also be remembered that reaching and then maintaining full vaginal depth requires the effort of regular dilation and/or then frequent sexual intercourse. For SRS a variety of techniques are used, by far the most common is variations of the penile inversion method, while a rather less common method is variations of the sigmoid colon section method. An interesting debate about the merits of two methods can be found here, but accepted pros and cons can be summarised as:
Regardless of the above, it does appear that after a few years the method of creating the neovagina is relatively unimportant since the functional reaction patterns become identical, including behaviour during arousal and orgasm, as well as lubrication. For example, in the months and years after a penile inversion, the skin graft loses all of its skin characteristics and adapts to its new environment, taking on the exact characteristics of a normal vagina - including normal vaginal PH levels, complete loss of hair, complete loss of pigment, complete loss of sweat glands, and normal vaginal epithelial glycogen levels. The cells actually alter in type, and it is eventually impossible to distinguish between cells collected from the vaginal smear of a genetic woman, and that of a long time (10 or 20 years) post-operative transsexual woman. Also lubrication is rarely a long term problem with a neovagina, while on average it does take slightly longer than with a "natural" vagina, some neovaginas lubricate at least as well and as quickly.
The following factors will influence the results of the SRS and the depth of the vagina:
It is important to re-iterate that the prolonged use of hormones and an orchidectomy has a very negative effect in relation to SRS as in time the penis and scrotum will atrophy to some extent, i.e. the penis size reduces and the scrotal sack shrinks. The earlier that SRS is performed (ideally before hormones are even started!), the better the likely result, indeed some leading surgeons who are anxious to preserve their reputation are reluctant to perform surgery on a patient who has previously had an orchidectomy. Of course this situation contradicts the recommendation of many psychiatrists that a lengthy "real life test", usually associated with a hormone regimen, is essential prior to any genital surgery.
For successful intercourse, arguably sensitivity and even appearance (it's 3:00 am, dark, 5 pints and a bottle of wine consumed ...) are less important than the fact that the neovagina feels totally natural to the man, particularly if the woman is stealth. Adequate depth is just one factor, others include adequate lubrication and the woman’s internal anatomy. In general genetic women (regardless of their height) have broad hips, i.e. a broad pelvis with a pelvic cavity offering plenty of internal volume. They also have a wide pubic arch and a large oval-shaped pelvic inlet – ideal both for giving birth and for sexual intercourse. The result of this skeleton is that even an otherwise petite woman can comfortably and enjoyably accommodate a large penis. Unfortunately arrangements don’t tend to be quite so satisfactory for transwomen, who will have the skeleton of an XY man unless they began female hormones by early puberty. In general transwomen have a narrow pelvis, a tightly angled pubic arch, and a small, partially obstructed, heart-shaped pelvic inlet. For the majority of transwomen their skeletal structure would theoretically rule out natural delivery of a baby, and rather more relevantly the pelvic bone structures of a minority may unnaturally impede or even obstruct a penetrating penis, and also restrict the degree and direction that a neovagina can stretch to accommodate the penis. Another issue is that fact that genetic woman have a strong muscular and ligament framework surrounding their vagina - muscles which act upon the penis during intercourse whether controlled consciously or unconsciously. Transwomen do not have any true vaginal muscles after their SRS – however a combination of determined will-power, constant (i.e. when ever possible through-out the day) internal exercising, and an active sex life can produce good results, e.g. the partner of one transwoman stating his great satisfaction with the vaginal muscular control that his wife had developed 18 months after her surgery.
Normal female appearing external genitalia can actually be constructed with little "material" to work with. Indeed it is worth pointing out that with modern techniques a good surgeon will usually produce a vulva that's more text book "female" in appearance than most genetic women actually have! An increasing number of genetic women (particularly in the sex industry) are apparently seeking plastic surgery to "tidy up" their external genitalia to a similar standard.
The external cosmetic problems - even with good
surgeons - tend to relate to scaring, a slightly high vulva/vaginal
position (usually due to skeletal limitations) and a rather too 'robust' appearance.
Vagina Not Required
This 'penis/dildo penetration not required' approach should perhaps be more common than it is as it offers the
transwoman significant health and hygiene benefits - possibly too many
surgeons and patients focus excessively on the creation of a deep
neo-vagina which may not be necessary.
If a transsexual
woman does not plan to have vaginal penetrative sexual intercourse then
clearly there is no need to have a deep vagina formed, and unnecessary
surgical procedures can be avoided and the subsequent dilation effort
also will be spared.
The emphasis can instead be place on achieving the best possible external appearance,
rather than on sexual functionality and enjoyment.
For example surgeons find it difficult to construct from a penis a
sensitive clitoris of natal female size and thus often have to balance
sensitivity with avoiding excessive size - this conundrum disappears if
'good sex' as a woman is not a driver for SRS.
[Since first writing this,
one girl has contacted me expressing her regret at not seeking and
working for the maximum possible vaginal depth during and after
her SRS], Conversely, if sexual intercourse and sexual genitalia able to
accommodate deep penetration in the Missionary Position by even "Mr Big"
are an immediate high priority, the colon section procedure may be preferable to the more common penile
inversion technique despite the risks and complications as it provides a
more convincing looking, self-lubricating and self-cleaning neo-vagina, and arguably
copes better with frequent and robust penile penetrations.
Regrets
While most post-operative
transsexual women don't regret their decision (or claim they don't), a few do - and this fact
cannot be ignored.
C: "If I had been properly
assessed, it would have been obvious that sex-change surgery was
inappropriate for me, I was desperately unhappy and was going for a sex
change because I felt under pressure from my boyfriend.
I'll never have a relationship. Who's going to want me when they could
get a real woman? I am not a woman, I am a sex change, and men know
that. I fundamentally regret having had surgery. I could have
lived as a woman without mutilating my body, but no one talked to me
about the possibility."
M: "If and when you have [SRS] your life will be forever changed,
in more ways than you can possibly imagine and anticipate. Being a woman
is no better than being a man (in fact, in many ways it's a lot worse) -
you just have a new set of problems. For me, being a woman expressed who
I really am, but sometimes I think the cost of that self-expression was
too dear."
W: "Becoming a woman has been a disaster, this
experience has ruined my life. I felt excited when dressing as a
woman but looking back it messed up my head - [psychologists] had me
believing I'd always wanted to be one. [After
SRS] I tried to persuade myself I had no regrets. [A] reversal
won't solve all my problems, I will still be tortured by what I gave up
to become a woman."
Samantha Kane: "The whole experience was very
distressing for me - it was a devastating operation and very difficult. I was a heterosexual male - I have never been gay - and that is why
it didn't make any sense to have [SRS]. I was suffering from a nervous breakdown after the break-up of my
marriage so I was very upset. I took hormones which changed my mind and my body so I wasn't
thinking clearly. After the surgery my mind was a lot clearer and I felt better
... I wanted to live back as a man because I knew I wasn't a woman."
Samantha also found that having sex with her boyfriends was boring, and
that she had "penis envy".
More Information
For
the very interesting results of a Post-Operative Survey of
Transsexual women, see
here.
For
a dire warning about the risks of low cost, back street, SRS, read
this
article. |
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Please send any comments,
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Copyright (c) 2004, Annie Richards
The
decision on which option to select is a personal choice that may
well evolve over time. For example most men who believe that
they are transsexual will start off assuming that they will have
SRS as soon as possible when they seek treatment. However,
after they have benefited from hormones (etc.) and perhaps
transitioned to live as a woman they may no longer see any urgent
need for SRS and it’s only some event years later such as a
relationship with a heterosexual man that eventually causes them
to have SRS. 
SRS
always involves the formation of the entrance to neo-vagina
(i.e. an artificial vagina). However for various reasons this
can be often be quite shallow (just 2-3 inches, 5-7cm). The
decision as whether or not to have a deep vagina suitable for
intercourse is actually a decision which need not always be an
automatic "yes" - particularly for elder women who
perhaps don't intend to lead an active sex life after
surgery.
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