How Gender Reassignment Surgery Works
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In 1952 a 27-year-old, former WWII-era GI from New York named George Jorgensen traveled to Denmark, and returned to the U.S. as Christine Jorgensen. Jorgensen, who had described herself as a woman trapped in a man's body, was one of the first to transition from the male to female gender through a process involving hormone therapy and surgical procedures [source: Hadjimatheou ]. In time, she became a trailblazer in seeking those gender reassignment surgeries as these procedures, now known as gender realignment (reconstruction, affirmation or confirmation) surgeries, wouldn't begin in the U.S. until 1966 [source: Wexler ].
Gender identity struggles usually begin in early childhood but descriptions of feeling like a man trapped inside a woman's body, or vice versa, have been identified in and reported by people of all ages. A person living with this an internal conflict may develop anxiety and depression, and go on to be diagnosed with gender dysphoria, formally known as gender identity disorder (GID). Gender dysphoria is a mental health condition that can arise when a person lives with ongoing feelings of being physically incongruous with his or her birth sex — and medical intervention may be beneficial. Identifying as transgender, itself, is considered by scientists to be, at least in part, biological and not a mental illness [source: HRF ].
Being transgender also isn't about anatomy or sexual orientation; it's about internally identifying with a gender status — which could be masculine, feminine, agender or gender fluid — that is different than the one culturally assigned to you based upon your physical characteristics. While some people may never publicly acknowledge their transgender status, others may decide to live as their desired gender — and that could mean changing how they express their gender through transitioning.
Transitioning is often two-fold: a social transition, such as new clothing, a new name and new pronouns; and a medical transition, with treatments such as hormone therapy and surgical procedures. Depending on the needs and wants of each individual, transitioning may include both social and medical transitions; just one of the two; or for those who eschew gender completely, neither.
Diagnosing Gender Dysphoria
Gender affirmation surgery.
Gender transition is a process unique to each individual, and for those who do choose to affirm their gender with a medical transition, the path often consists of counseling and a diagnosis of gender dysphoria, hormone therapy and real-life experience before genital-changing surgeries are performed. Not all transgender people need — or want — these therapies; and, not all transgender people undergo surgery. Those who do choose to medically transition may select a number of procedures, or focus on just "top," "bottom" or cosmetic surgeries. The collection of procedures are also commonly called gender reassignment or — and the process begins long before the procedures do.
It begins with psychotherapy; in addition to providing counsel, mental health professionals assess a person's readiness for hormone therapy and surgery. To become a candidate for gender reassignment surgery, a person must first be diagnosed with gender dysphoria, as defined by the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a common language and standards protocol manual for the classification of mental disorders. Gender dysphoria was previously known as gender identity disorder (GID) and broken into a handful of classifications (such as childhood and adulthood) in the DSM-4. The revision was made not only to help ensure access to care while attempting to reduce the stigma associated with gender identity struggles, but it also removed the concomitance between transgender feelings and mental illness.
Having persistent feelings — for at least six months — that a person's birth sex doesn't align with his or her gender identity isn't considered a behavioral health issue. To be diagnosed with gender dysphoria, adults and adolescents must also exhibit at least two other conditions, including [source: APA ]:
- An outward expression of gender that differs from what society expects
- The desire to be a different gender
- The wish to be treated as a different gender
- The desire to get rid of the primary and secondary sex characteristics of the "wrong" gender
- The wish to have the sexual characteristics of a different gender
- The belief their gender reactions are of a different gender
The desire for gender change cannot be a symptom of another disorder or a chromosomal abnormality. Additionally, these gender identity issues must cause distress, personally, socially, professionally or in any other manner [source: APA ].
After counseling, evaluation and diagnosis, patients don't immediately schedule a vaginectomy (removal of the vagina), or penectomy (removal of the penis). Those who choose gender affirmation surgery will need letters of recommendation from counselors, psychiatrists, psychologists, sexologists and/or therapists prior to major gender reconstructive surgery.
Doctors normally recommend hormone therapy to alter secondary sex characteristics to the desired gender before surgery. Other than surgeries to reconstruct internal and external genitalia (and not counting anything considered a cosmetic procedure), most physical changes are managed with hormone therapy prescribed by an endocrinologist to suppress certain characteristics (such as distribution of body hair) or enhance certain others (such as breast growth). Hormone therapy may continue for a few years (it takes at least two years to achieve maximum results), and may be concurrent with what's known as the Real-Life Experience (RLE), a year dedicated to living openly as one's desired gender, and intended to help adjust — socially, physically and emotionally — to making these significant changes in gender expression [source: WPATH ].
It's difficult to know for certain what the actual numbers are, but the Williams Institute estimates that that about 0.3 percent of the general U.S. population identifies as transgender, although not all of those 1.5 million people will desire or undergo gender affirmation surgery [sources: Gates , Steinmetz ]. Each year between 100 and 500 gender reconstruction surgical procedures are done in the U.S. to treat gender dysphoria. The United States is not a major player in gender dysphoria treatment; estimates range that up to 2,500 people worldwide affirm their gender through surgery every year — and Thailand has long been considered the premiere destination for gender surgeries [sources: Toro , Encyclopedia of Surgery ].
Gender affirmation surgery is performed under the guidelines of World Professional Association for Transgender Health's (WPATH) globally accepted Standards of Care for Gender Identity Disorders (SOC). The types of surgeries to be conducted are decided by the patient's desire and comfort level, as well as finances. Not every patient will want or need the same surgeries, and the process is tailored for each individual. Certain procedures are considered medically necessary to treat gender dysphoria, while other common gender confirmation surgeries such as rhinoplasty and brow lifts are considered cosmetic; for some this new outward appearance may hold more significance than the reconstruction of internal and external genitalia.
Surgeries for trans men (or those assigned female at birth (AFAB)) include:
- Bilateral mastectomy;
- Complete hysterectomy
- Reconstruction of the genitalia with a metoidioplasty (a procedure that allows a surgeon to construct a phallus from the clitoris)
- Ring metoidioplasty (to lengthen the urethra)
- Scrotoplasty (the construction of a scrotum)
- Vaginectomy (to close of the vaginal canal)
- Phalloplasty (the construction of the penis)
A penile implant (a prosthetic otherwise used to treat erectile dysfunction) and testicular implants may also be added to the reconstructed penis and testes. Although the mean length of a reconstructed penis is roughly 2 inches (5 centimeters), 80 percent of trans men in one study reported they were able to engage in sexual intercourse, and most experienced orgasms [source: Harrison ].
Trans women, or those assigned male at birth (AMAB), a group larger in number than trans men, may begin their physical transformation with breast augmentation (implants), as well as with cosmetic surgeries to feminize the face and body, such as facial feminization surgery (FFS) , and gluteal, hip and thigh implants before undergoing genital reconstruction. Surgeries to create female genitalia include:
- Clitoroplasty (the construction of a clitoris)
- Labiaplasty (the creation of a labia from scrotum skin)
- Orchiectomy (testicle removal)
- Prostatectomy (the removal of prostate)
- Urethroplasty (the reconstruction of the urethra)
- Vaginoplasty (the creation of the vaginal canal, made from penile tissue or a colon graft)
- Penectomy (removal of the penis) is usually done concurrently with vaginoplasty, and a clitoral hood is typically constructed from the glans penis.
In the U.S. surgical costs in 2015 may run anywhere from about $25,000 for male-to-female transitions and upwards of $100,000 or more for female-to-male transitions, although typical costs fall between $7,000 and $50,000 [sources: Leitsinger , AP ]. Transgender Brits pay about 10,000 pounds ($15,000) [source: Telegraph ]. And for an extra $8,000, patients transitioning from female to male in Thailand can, for example, upgrade from a 1 inch (2.5 centimeter) penis to one with a few more inches [source: Ehrlich ].
Transgender people who have undergone gender affirmation surgeries are, in almost all cases, happy they did so. In the U.K., for instance, only 2 percent of people who've undergone gender reconstructive surgeries report regretting their physical transformation, compared to 65 percent of cisgender (non-transgender) people who report regretting their plastic surgery choices [source: Tannehill ]. And in the U.S. less than 1 percent of trans women regret their genital reconstruction, a percentage that's been decreasing alongside the risk of developing long-term complications [source: Tannehill ]. More than 80 percent of patients report long-term satisfaction despite (treatable) complications such as vaginal hair growth (a 29 percent prevalence among trans females) and urinary problems (almost the same, at 27 percent) [source: Goddard ]. The rate of regret for trans men is difficult to estimate, as they are smaller in number than trans women [sources: Jarolím , Tannehill ].
Sure, there's the case of Charles Kane, who famously transitioned from a man to a woman in 1997, and then back again. After living as Samantha Kane for seven years, Charles decided he would never pass as a "real woman," neither to himself or to the public, and felt hormone therapy altered his brain into making the original decision [source: Scutti ]. But, Kane is a rarity.
Lots More Information
Author's note: how gender reassignment works.
The terminology surrounding gender identity, expression and affirmation has changed a lot since I first wrote about gender dysphoria, then called gender identity disorder, and the ins and outs of, what was then called gender reassignment surgery. The first thing I noticed 8 years later is that there is a lot more labeling. For instance: A biologically born man who identifies as a woman may be known as an 'affirmed' or 'confirmed' woman, 'transgender' woman, or you may also hear the term 'trans woman' — all in reference to the same woman. For some, 'transsexual' continues to be used. And then there's also the acronyms, such as MTF (or M2F), which stands for male-to-female, and AMAB (or DMAB), indicating 'assigned male at birth' (and 'designated male at birth'). I'm sure I'm overlooking some, too. And it's a similar list for someone assigned female at birth who identifies as a man (AFAB). What seems to be left out, though is the most obvious: male and female, just as those who are cisgender (a term used for non-trans people). (Unless, of course, we're talking about a person whose identity lies somewhere along a spectrum of gender, who may prefer to describe themselves as neither male nor female, but gender fluid.)
Related HowStuffWorks Articles
- How Gender Identity Disorder Works
- Is gender just a matter of choice?
- Stages of Gender Reassignment
- How fluid is gender?
- What is transgender voice therapy?
More Great Links
- National Center for Transgender Equality
- The Williams Institute
- World Professional Organization for Tansgender Health (WPATH)
- Aetna. "Clinical Policy Bulletin: Gender Reassignment Surgery." Sept. 19, 2014. (April 12, 2015) http://www.aetna.com/cpb/medical/data/600_699/0615.html
- American Medical Student Association (AMSA). "Transgender Health Resources." (April 12, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
- American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." Excerpt from: The Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients. Feb. 18, 2011. (April 12, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
- Bilefsky, Dan. "Serbia Becomes a Hub for Sex-Change Surgery." The New York Times. July 23, 2012. (April 12, 2015) http://www.nytimes.com/2012/07/24/world/europe/serbia-becomes-a-hub-for-sex-change-surgery.html
- Dewey, Caitlin. "Confused by Facebook's new gender options? Here's what they mean." The Washington Post. Feb. 14, 2014. (April 12, 2015) http://www.washingtonpost.com/blogs/style-blog/wp/2014/02/14/confused-by-facebooks-new-gender-options-heres-what-they-mean/
- Ehrlich, Richard s. "Everything you always wanted to know about sex... changes." CNN. Feb. 24, 2010. (April 12, 2015) http://travel.cnn.com/bangkok/play/everything-youve-ever-wanted-know-about-sex-changes-379486
- Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
- Goddard, Jonathan C. "Feminizing genitoplasty in adult transsexuals: early and long-term surgical results." BJU International. Vol. 100, no. 3. Pages 607-613. July 2007. (April 12, 2015) http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2007.07017.x/pdf
- Goldberg, Joseph. "When You Don't Feel At Home With Your Gender." WebMD. Sept. 24, 2014. (April 12, 2015) http://www.webmd.com/mental-health/gender-dysphoria
- Hadjimatheou, Chloe. "Christine Jorgensen: 60 years of sex change ops." BBC News. Nov. 30, 2012. (April 12, 2015) http://www.bbc.com/news/magazine-20544095
- Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape. May 20, 2013. (April 12, 2015) http://www.medscape.com/viewarticle/804432
- HealthResearchFunding.og (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 12, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
- International Foundation for Gender Education (IFGE). "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 12, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
- Jarolím, L. "Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks." The Journal of Sexual Medicine. Vol. 6, no. 6. Pages 1635-1644. June 2009. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/19473463
- Kourkounis, Erin. "Tampa transgender teen living life of transition." The Tampa Tribune. (April 12, 2015) http://tbo.com/news/education/tampa-transgender-teen-living-life-of-transition-20150412/
- Lallanilla, Marc. "Gender Reassignment Surgery: How Does It Work?" Huffington Post - HuffPost Healthy Living. Oct. 23, 2015. (April 12, 2015) http://www.huffingtonpost.com/2013/08/23/gender-reassignment-surgery-manning-bradley-chelsea_n_3804247.html
- Leitsinger, Miranda. "Sex Reassignment Surgery at 74: Medicare Win Opens Door for Transgender Seniors." NBC News. Jan. 3, 2015. (April 12, 2015) http://www.nbcnews.com/news/us-news/sex-reassignment-surgery-74-medicare-win-opens-door-transgender-seniors-n276986
- McGinn, Christine. "Services." Gender Wellness Center Papillon. 2010. (April 12, 2015) http://www.drchristinemcginn.com/services/
- Monstrey, Stan J. "Sex Reassignment Surgery in the Female-to-Male Transsexual." Seminars in Plastic Surgery. Vol. 25, no. 3. Pages 229-244. August 2011. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/
- Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. (April 12, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
- Scutti, Susan. "Becoming Transsexual: Getting The Facts On Sex Reassignment Surgery." Medical Daily. Nov. 6, 2014. (April 12, 2015) http://www.medicaldaily.com/becoming-transsexual-getting-facts-sex-reassignment-surgery-309584
- Selvaggi, G. "Genital sensitivity after sex reassignment surgery in transsexual patients." Annals of Plastic Surgery. Vol. 58, no. 4. Pages 427-433. April 2007. (April 12, 2015) http://www.ncbi.nlm.nih.gov/pubmed/17413887
- Tannehill, Brynn."Myths About Transition Regrets." Huffington Post - HuffPost Gay Voices. Jan. 18, 2015. (April 12, 2015) http://www.huffingtonpost.com/brynn-tannehill/myths-about-transition-regrets_b_6160626.html
- The Classroom. "Gender Identity: Trans Keywords." (April 12, 2015) http://the-classroom.org.uk/lgbt-101/gender-identity/keywords-gender-identity/
- The Telegraph. "Number of NHS sex change operations triples." April 21, 2010. (April 12, 2015) http://www.telegraph.co.uk/news/health/news/7613567/Number-of-NHS-sex-change-operations-triples.html
- Toro, Ross. "How Gender Reassignment Surgery Works (Infographic)." LiveScience. Aug. 26, 2013. (April 12, 2015) http://www.livescience.com/39170-how-gender-reassignment-surgery-works-infographic.html
- University of California San Francisco - Center of Excellence for Transgender Health. "Transgender Health Learning Center: Surgical Options." (April 12, 2015) http://transhealth.ucsf.edu/trans?page=protocol-surgery
- University of Miami - Miller School of Medicine. "Plastic Aesthetic and Reconstructive Surgery: Transgender Reassignment." 2015. (April 12, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
- University of Michigan Health System. "Transgender Services: Gender Affirming Surgery." (April 12, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
- USA Today. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 12, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
- Wexler, Laura. "Identity Crisis." Jan. 2007. (June 29, 2015) http://www.baltimorestyle.com/index.php/style/features_article/fe_sexchange_jf07
- World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
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The Ultimate Guide to Gender Reassignment in Thailand
Last fact-checked: 4 January 2023
Gender reassignment surgery (also known as sex-change, gender affirmation, or sex reassignment surgery (SRS)) refers to medical procedures sought by transgender or non-binary individuals which align one’s physical appearance or functional ability with the gender to which they identify.
While such surgeries have become increasingly more commonplace around the world thanks to improved techniques and greater awareness of this often-stigmatized issue, the cost of gender reassignment surgery still poses a major stumbling block.
When traveling to Thailand, however, patients save between 60% to 70% on the cost of their surgery (which can total more than $40,000 in countries like Australia, the UK and the US), as well as skip the long waiting lists often found in the West.
Use Medical Departures to find a world-class surgeon in Thailand, one of the world’s leading destinations for gender reassignment.
What Is the Cost of Sex Reassignment Surgery in Thailand?
For many patients, the cost of undergoing gender reassignment surgery in their own country can be prohibitive. By choosing to undergo treatment in Thailand, treatment becomes a much more realistic and attainable dream.
The overall cost will depend upon the extent of the work to be carried out; as a general guide:
A male-to-female sex change (genital reconstruction only) operation in the US could cost as much as USD $25,000 - 30,000 (AUD 36,000 - 44,000)
In Thailand, the same medical treatment at an established, well-regarded facility costs around USD $7,000 - $12,000.
For patients seeking to add breast augmentation (implants), voice feminisation surgery, and Adam’s apple reduction (tracheal shave), prices may often exceed $50,000 in the West.
In Thailand, these surgeries generally cost around two-thirds less than in the US, UK or Australia. Thus, for a package that includes genital reconstruction, breast augmentation and voice feminisation surgery, the total cost is estimated to be USD $15,000 - $25,000.
See the table below comparing SRS prices in Thailand with other countries:
Is Gender Reassignment Surgery Covered by Insurance Companies for Healthcare Providers at Home?
Finding coverage for any transition-related surgery can be a long and challenging process for those who would normally rely on private health insurance.
Many states in the US, for example, have laws that explicitly exclude such coverage, while those companies that do offer financial help typically require patients to endure prolonged hormone therapy, show proof of “ persistent and well-documented gender dysphoria ” over a set period of time and present numerous referral letters from doctors, mental health professionals and even family.
Why Choose Thailand for Gender Reassignment Surgery?
At its peak, Thailand welcomes more than 40 million international visitors a year. And while most tourists are drawn thanks to the allure of the country’s beautiful beaches, ancient temples, sprawling jungles, luxury shopping and exotic cuisine, many others travel for the sole reason of taking advantage of affordable plastic surgery prices–which includes SRS–with treatment carried out in state-of-the-art clinics and hospitals by highly skilled, specialist doctors who are often recognised for their expertise at a global level.
Below, we sum up the reasons to choose Thailand for SRS and related sex affirmation treatments.
Quality of Care: The continued growth of medical tourism in Thailand has seen the emergence of a wealth of world-class facilities, staffed by internationally-trained medical experts.
From modern beauty centers focusing on only select treatments to specialized departments within larger private hospitals, medical travelers now enjoy a healthy choice of well-established facilities that have all been fully verified by Medical Departures. In fact, Thailand is home to the most Joint Commission International (JCI) hospitals in the region and is the gold standard of international medical accreditation.
Some of the Gender Reassignment Specialists: It is also worth noting here that Thailand has been a pioneering country for gender reassignment ; the first surgery was carried out here in 1975. Today, around 90% of the patients undergoing surgery in Thailand are welcomed from abroad.
Scroll down to examine some of our top-rated SRS clinics and hospitals and Thailand, with each dedicated listing page providing more information about the facility, as well as photos, prices, doctor profiles and patient reviews.
Prices: As we have looked at above, patients can typically look forward to saving at least 50% on the price of an SRS procedure in Thailand; many indeed find that the total cost is closer to 70% less than private care in the US, UK and Australia–as these countries will often not include other essential expenses in initial price quotes, such as anesthesia, in-patient care, medication and even consultation fees.
To find out how much you can save in Thailand on sex reassignment surgery, as well as how you can benefit from our Best Price Guarantee , you can connect with our Customer Care Team any time of the day or night.
How to Find the Best Gender Reassignment Surgeons in Thailand
The Medical Departures team takes the necessary time to research the finest hospitals and doctors available, performing background checks to confirm doctor qualifications and verifying associations with professional medical organizations, such as the International Society of Aesthetic Plastic Surgery (ISAPS) .
How Do We Verify Clinics?
Our website contains exclusive listings of reputable clinics and surgeons available throughout Thailand. We have performed site visits to ensure that equipment and facilities are of the highest standard, and we conduct regular reviews with patients that have attended our clinics to ensure that they have received first-class service.
Considering this is a highly-specialized procedure, we make sure that every surgeon performing the procedure is a member of professional organizations both in Thailand and abroad. These can be found listed in the ‘Doctors’ section on each of our clinic/hospital listings, and include:
The Thai Medical Council
Society of Plastic and Reconstructive Surgeons of Thailand
Society of Aesthetic Plastic Surgeons of Thailand
International Society of Plastic and Reconstructive Surgery
Royal College of Surgeons of Thailand
Medical Association of Thailand
We also ensure that surgeons have undertaken rigorous training in the field, such as completing courses provided by the Global Education Institute (GEI) that follow globally-recognised guidelines, standards of care and best practices as set out by the WPATH World Professional Association for Transgender Health .
Best Sex Change Surgeons in Thailand
One of the top facilities in the country for various gender-affirming procedures is the highly-rated Kamol Hospital . Located in Bangkok, Dr. Kamol is globally recognized as one of the most experienced surgeons in the world for gender reassignment. A large team of surgeons is led by Dr. Kamol Pansritum, a world-renowned specialist in plastic surgery who has performed more than 10,000 cases of sex reassignment and facial feminization surgeries.
Kamol Hospital's specialists consist of gynecologists, oral and maxillofacial surgeons, dermatologists, anesthesiologists and other clinical professionals who work as a team to provide the utmost care in the Thai capital.
For more options, take a look at three more trusted facilities in Thailand that offer sex-change surgery to international patients:
Asia Cosmetic Hospital (Bangkok)
Yanhee Hospital Health & Beauty (Bangkok)
MAXi Cosmetic Surgery (Bangkok)
> All Clinics and Hospitals for Gender Reassignment in Thailand
> Clinics and Hospitals for Gender Reassignment in Bangkok
About Gender Reassignment Surgery
Gender reassignment surgery (or “sex reassignment surgery” (SRS)) is the term given to the medical procedure (or procedures) that are utilized to alter the function and physical appearance of a patient’s existing sexual characteristics.
Sometimes referred to as Sex Reassignment Surgery (SRS), the treatment is designed to provide the patient with the physical appearance of their identified gender. The process is also known as sex realignment surgery, gender confirmation surgery or genital reconstruction surgery.
In Brief: What Surgical Procedures Can Gender Reassignment Entail?
There are numerous procedures that can fall under the gender reassignment umbrella, and these surgeries differ between trans men (female to male) and trans women (male to female). The main genital reconstruction procedures (m2f / f2m), are:
For trans men, genital reconstruction usually involves the construction of a penis through either a metoidioplasty or a phalloplasty.
For trans women, the surgical construction of a vagina usually entails a penile inversion or a process known as the sigmoid colon neovagina technique.
For both trans men and trans women, any genital reconstruction surgery will usually involve other procedures, such as:
Other Gender-Affirming Procedures & Plastic Surgery
“Top” surgery, to masculinise the chest
Facial feminization procedures, such as chin augmentation and rhinoplasty
Reduction thyroid chondroplasty (tracheal cartilage shave)
Voice feminisation surgery
Tracheal shave (Adam’s apple reduction)
What Does Male-to-Female Gender Reassignment Surgery Entail?
Ultimately, male-to-female surgery entails reshaping the male genitals into a form that has the appearance of and, where possible, the function of female genitalia. Before any surgery can take place, patients are usually required to undergo hormone replacement therapy (HRT) and, possibly, facial hair removal. Other procedures that a patient may decide to undertake include breast augmentation and facial feminization surgery.
Genital surgery, or vaginoplasty, involves the removal of the testicles before the skin and foreskin of the penis are inverted, keeping the blood and nerve supplies intact to retain sensitivity. A section of the glans penis can also be used to create a clitoris that is fully supplied with nerve endings.
Once this procedure is complete, further surgery (known as labiaplasty) is usually undertaken. This is usually carried out once the surrounding tissues, nerves and blood supply have recovered from the vaginoplasty and is designed to enhance the aesthetic appearance of the newly-created outer vulva.
Apart from genital surgery, patients may opt for other procedures to enhance the overall results. These can include:
Breast augmentation–otherwise known as breast enlargement, can be utilized if hormone therapy fails to yield the desired results (normally with the use of implants)
Facial feminization surgery–a range of cosmetic surgeries designed to modify bone or cartilage structures in areas such as the cheeks, nose, forehead, brow and jaw to give a more feminine appearance
Voice feminization surgery–called glottoplasty, this procedure is used to alter the range or pitch of the patient's vocal cords
Tracheal shave–the reduction of cartilage in the throat to reduce the size of the Adam's apple, giving a more feminine appearance
What Does Female-to-Male Gender Reassignment Surgery Entail?
Unlike the male-to-female procedure, many trans men considering female-to-male surgery do not always undergo genital reassignment surgery.
Specialists usually place more focus on altering the existing physical female anatomical traits to conform to a more masculine appearance. However, it is usual for a patient to undergo hormone treatment using testosterone before any gender reassignment surgery takes place.
Procedures usually include having the internal female sex organs removed (hysterectomy), undergoing a bilateral mastectomy (breast removal) and attaining a more typically male shape to the chest through chest contouring techniques:
Mastectomy–sometimes referred to as "top surgery," this involves the removal of the breasts, repositioning of the nipples, and subsequent reshaping of the chest to give a more masculine, contoured appearance.
Hysterectomy and bilateral salpingo-oophorectomy: a hysterectomy is the removal of the uterus, whilst a bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. For some trans men, this is undertaken to alleviate the discomfort of having female internal reproductive organs, but for many, it is done to reduce the risk of cancer.
Metoidioplasty and phalloplasty–these are genital reconstructive procedures (GRT) used to construct a new penis, either by enlarging the clitoris with androgenic hormones (metoidioplasty) or through using tissue grafts from other parts of the body in conjunction with an erectile prosthetic.
Risks and Complications
As with any other surgical procedure, sex change surgery comes with a set of potential complications, although risk factors can be mitigated by choosing a trusted surgeon (who will be working with an experienced anesthesiologist) as well as following the correct pre-surgical protocols.
Postoperative care is just as important as preoperative care: events such as genitalia swelling, bleeding, nerve damage, pain, inability to walk and difficulties with urination are some of the most reported complications in regard to sex change surgery.
Your surgeon will thoroughly explain any risks associated with surgery and anesthesia during an initial consultation.
For more information, read these safety considerations regarding transfeminine bottom surgery provided by the American Society of Plastic Surgeons.
Where to Go in Thailand for SRS
The first and most-traveled destination in Thailand for sex reassignment surgery is the capital, Bangkok.
Home to the best SRS specialists in the country, sex-change surgery—or at least the concept of it—is fairly commonplace here in this sprawling megacity and does not carry the same negative stigma that it can in many parts of the US, Australia and Europe.
Bangkok is one of the world’s leading medical tourist destinations and also one of the world's most popular spots in Asia for families, couples and solo backpackers looking for an exotic getaway. Before or after your surgery, you will discover a long list of attractions and activities to enjoy. From food, shopping and thriving nightlife districts to taking in the sights and culture of this temple-packed city – you’ll find this fascinating city provides endless opportunities for enjoying Thai hospitality.
Bangkok’s attractions are varied –from dazzling temples and floating markets to designer shopping malls and effervescent nightlife–where you can eat some devilishly delicious street food on the cheap, or indulge in a high-end dining experience at one of the city’s glitzy rooftop restaurants. Bangkok has everything a modern city should have while retaining the allure and uniqueness of the old city.
> Read More: Ultimate Guide to Doctors in Bangkok
Another destination to consider for gender affirmation surgery in Thailand is Phuket. As the country’s largest island province, Phuket offers the same modern infrastructure and amenities as Bangkok–plus the welcome addition of tropical, white-sand beaches that are synonymous with this southern region next to the Andaman Sea.
Although not offering the same wide choice as the capital, we can recommend the superb Phuket Plastic Surgery Institute , which works with a team of more than 10 plastic surgery specialists. These English-speaking doctors are highly experienced and have earned international recognition as leaders in their particular disciplines, which include sex reassignment procedures.
> Read More: Ultimate Guide to Doctors in Phuket
Other Destinations in Thailand
If you are planning to enjoy some downtime before surgery, Thailand has a wealth of other top locations to choose from. Check out these destination guides aimed at medical tourists visiting Northern Thailand (Chiang Mai) and Chonburi province (Pattaya city).
> Ultimate Guide to Doctors in Chiang Mai
> Ultimate Guide to Doctors in Pattaya
In certain cases, medical tourists in Thailand do travel to another location following surgery to complete their recovery. This is usually only permitted following a set number of days or even weeks of bed rest after being discharged from the hospital. Always consult your surgeon about any travel plans you may have and follow aftercare instructions carefully (such as not swimming, engaging in vigorous activity and avoiding the hot sun).
Sex Change FAQs
Q. How old do I need to be for sex change surgery in Thailand?
A. Anyone 20 years old and older is eligible for gender reassignment surgery in Thailand. A person aged between 18 and 20 must receive consent from an authorized guardian.
Q. Will I have to undergo hormone therapy before getting a sex change in Thailand?
A. Yes, hospitals will typically require patients to have undergone hormone therapy for at least one year; reach out to one of our representatives for more information before you book.
Q. Can different sex reassignment procedures be performed concurrently? A. Yes, a team of surgeons can perform certain procedures during the same session of surgery, such as penile inversion vaginoplasty combined with voice feminisation. Other reconstructive surgeries, such as breast/chin augmentation may need to be done separately.
Q. How long do I have to wait to see an SRS surgeon in Thailand?
A. Waiting times for any type of surgery in Thailand are generally much shorter than in the West; Medical Departures can facilitate an initial consultation in a matter of days, depending on the hospital/surgeon of choice.
Q. How long will I need to stay in Thailand to complete my sex change?
A. This will depend on the number and type of procedures to be performed; on average, inpatient length of stay is estimated to be between 5 - 14 days. Your doctor will advise how long you’ll need to stay in the country for recovery and post-surgery care.
Q. How much Is sex change surgery in Thailand?
A. SRS surgery in Thailand typically costs between $7,000 - $12,000 (penile inversion); other associated surgeries generally cost around one-third of prices in the West. You will want to confirm pricing and treatment plan with your chosen clinic(s).
How Do I Get Started?
Booking through Medical Departures maximizes your savings thanks to our Best Price Guarantee which ensures that you pay the lowest rate possible for your treatment. We can even help with additional medical insurance by putting you in touch with a number of independent insurance providers who can offer you preferential rates on their policies.
In Thailand, gender reassignment is affordable and delivers outstanding results. To find out how much you can save, get in touch with a member of our Customer Care Team now and start planning your life-changing surgery today.
How Thailand Became a Global Gender-Change Destination. Bloomberg. 17 October 2015. https://www.bloomberg.com/news/features/2015-10-26/how-thailand-became-a-global-gender-change-destination
WPATH World Professional Association for Transgender Health. Website accessed: 28 November 2022. https://www.wpath.org/gei
International Society of Aesthetic Plastic Surgery. Website accessed: 28 November 2022. https://www.isaps.org/
Joint Commission International. Website accessed: 28 November 2022. https://www.jointcommissioninternational.org/
Brazier, Yvette. What you need to know about breast augmentation. Medical News Today. 3 April 2017. https://www.medicalnewstoday.com/articles/263567.php
Vaginoplasty and Labiaplasty. WebMD. 19 April 2019. https://www.webmd.com/women/guide/vaginoplasty-and-labiaplasty-procedures
A, Brooke. Is Gender Reassignment Surgery Covered by Health Insurance? Mira. 23 August 2022 .https://www.talktomira.com/post/is-gender-reassignment-surgery-covered-by-health-insurance
Transfeminine Bottom Surgery. American Society of Plastic Surgeons. Website accessed: 28 November 2022. https://www.plasticsurgery.org/reconstructive-procedures/transfeminine-bottom-surgery/safety
MEET OUR SURGEONS
- dr. theerapong, - dr. wilasinee, about clinic.
MTF SEX CHANGE SURGERY
Non - surgery
Preparing for transgender surgery in thailand - step by step guide.
Thailand is an extremely attractive destination for patients seeking Sex Reassignment Surgery (SRS) – also known as transgender surgery, gender affirmation surgery or sex reassignment surgery. Many SRS patients choose to travel to Thailand for the procedure, because transgender surgery in Thailand is generally more affordable than in Western countries. But don’t be fooled into thinking that just because something is cheap, it won’t be high quality.
Thailand has many world-class surgeons in the field of SRS along with international standard medical facilities. In fact, Thai surgeons have contributed enormously to the development of SRS and gender surgery. Thailand’s first transgender surgery was performed nearly five decades ago, in 1975, and today Thailand holds the world record for the most transgender surgeries performed every year.
Thailand is also a very tolerant country, and Thai people in general have positive attitudes to transsexual and LGBTQ people.
With that said, transgender surgery is a life changing procedure that requires careful preparation. There are quite a few steps that must be completed to make sure you achieve excellent outcomes for your surgery. If you or a loved one is considering transgender surgery in Thailand, here is a short guide to help you understand and prepare for what is involved.
How to Prepare for Transgender Surgery
1. stop hormone therapy.
Generally speaking, all hormone treatments should be stopped approximately one month before surgery. This is especially important in case of male-to-female transgender surgery. The female hormone, estrogen, can increase the risk of certain complications, such as blood clots, during surgery, so it is important to come off hormones for at least four weeks before. Individual factors (such as smoking or being overweight) may also affect the length of time, so speak to your consultant about this.
Hormone treatments can usually be resumed after 3-4 weeks or when the surgical wound is completely healed.
2. Referral from a Psychiatrist
In order to undergo transgender surgery in Thailand, you will need to submit two referral letters. The first referral should be from a licensed psychiatrist in your own country. There is no standard format for this, but the letter must confirm that you have been diagnosed with body dysmorphia and that you are mentally and physically ready to undergo surgery. The letter should be no older than 6 months.
You’ll also need a referral letter from a psychiatrist in Thailand. This can only be obtained in person after you arrive in Thailand. You can book the appointment on your own or use a dedicated concierge service, such as the Add-On Aftercare Package provided by Interplast Clinic in Bangkok.
3. HIV Test
You will need to take an HIV test before your surgery. You can do this before you arrive in Thailand, but the results should be no older than 3 months. While having an HIV infection does not necessarily prevent you from undergoing transgender surgery, it is important for the hospital to know your status as this can help prevent any complications during surgery as well as during post-operative recovery.
4. Any Other Medical Certificates
If you have any congenital diseases that require regular medication, it’s also important that you have your physical examination results and a certificate from your internal medicine physician. Furthermore, if you’re taking any regular medication, you should discuss this with your surgeon beforehand to make sure there will be no complications.
5. Stop Smoking & Drinking Alcohol
If you’re a smoker, it is recommended that you stop at least one month before your surgery. Studies have shown that quitting smoking before any major surgery can decrease the risk of complications, including post-operative blood clots, pneumonia, and heart attacks.
Quitting cigarettes before surgery also makes a huge difference to post operation recovery. Cigarettes contain carbon monoxide which depletes the body’s tissue of oxygen it needs to heal. Patients who stop smoking at least four weeks before surgery experience better outcomes in terms of wound healing and have a lower risk of infections.
You should also abstain from drinking alcohol in the weeks leading up to surgery. One of the main reasons is that alcohol can thin the blood, which interferes with the blood’s ability to clot, which in turn can make it more difficult for surgeons to control bleeding during surgery.
You should avoid smoking and drinking alcohol in the post operation recovery period to reduce your risk of complications and to promote healing.
6. Laser Hair Removal
Genital laser hair removal (genital electrolysis) is absolutely necessary before any male to female transgender surgery. The amount of hair that needs to be removed depends on the technique used in the surgery, so always make sure to discuss this beforehand with your surgeon.
For example, the most popular SRS technique, penile inversion vaginoplasty, involves the surgeon using skin from the penile shaft, scrotum and perineum to construct a neovagina. Any hair that can grow on these areas, if not treated, can grow back inside the neovagina. This is not just potentially aesthetically unpleasing but can lead to irritation and infections as well as discomfort and pain during sex.
The hair growing inside the neovagina is extremely hard to treat after the operation, so the area must be completely and permanently cleared before surgery.
The genital electrolysis must be performed at least 2-3 times and completed at least two weeks before your surgery.
On average, patients will be admitted to hospital for about a week and should prepare to stay in Thailand for three weeks after surgery. Remember that you’ll also need to obtain a referral from a psychiatrist in Thailand before your operation – all this needs to be factored in when booking flights and hotels.
One important thing is to ensure that you have someone to take care of you for the weeks following your discharge from hospital. There are quite a few things you will need to navigate in the post-operation period, from wound cleaning and pain management to dilation and beyond.
If you’re travelling to Thailand for your transgender surgery alone, you should enquire if the operating clinic can arrange a concierge service to simplify the pre and post-operative experience for you. For example, at Interplast Clinic, we have a dedicated Add-On Aftercare Package for transgender patients, which includes all the personal assistance you need the minute you step off the plane until you’re ready to go home again.
Your concierge at Interplast Clinic is typically a person who has gone through transgender surgery themselves, and they are there to help you feel more comfortable. Your concierge will arrive to pick you up from the airport. They will arrange all transfers and will be available 24/7 before your operation and during your recovery at the hospital. They will also visit you daily to assist with wound cleaning and dilation at your hotel post-surgery.
If you’d like to know more about MTF transgender surgery at Interplast Clinic in Bangkok, speak to one of our consultants today.
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GENDER REASSIGNMENT SURGERY Overseas
Also commonly called Sex Reassignment Surgery (SRS), this procedure helps individuals become the person they want to be by transitioning them into the gender they associate with. It is becoming a very common procedure with more and more individuals taking the next step in their transition. At the moment we offer male to female transition only.
INDIVIDUAL HOSPITAL PRICING IS LISTED FURTHER DOWN THE PAGE
If you would like to obtain a personalised quote for Gender Reassignment Surgery Overseas, please refer to our Enquiry page.
Beverly Wilshire Medical Centre +
Phuket Plastic Surgery Institute (PPSI) +
Phyathai 2 Hospital +
Yanhee International Hospital +
What you need to know
BEST CANDIDATES +
The best candidate for Gender Reassignment Surgery (GRS) is someone who is:
- unhappy with the gender they are and wish to become the gender they associate with
- fully aware that this is a permanent procedure
- aware of all of the steps involved
- aware of any legalities that are required in their country for changing their name, gender etc
Because this is significant, life-changing surgery, it is important that you are physically, mentally and emotionally ready. As with any cosmetic surgery procedure, it is imperative you speak to someone you trust, are happy in your life and are psychologically ready.
PREPARING FOR YOUR PROCEDURE +
It is important to discuss with your doctors and with us any:
- Medical conditions you have
- Any medication you are taking - prescription, herbal and non-prescription
Once you arrive at your destination you will have a physical evaluation with your surgeon, where you will discuss your goals and concerns and finalise the plan for surgery. At this examination your surgeon will determine the best procedure for you and explain it to you in detail, including any limitations. It is important that you head into surgery with realistic goals. It is during this examination that your surgeon may also make recommendations for other procedures.
In the lead-up to your surgery, it is important you do the following:
Stop smoking. Smoking can cause problems with circulation and increase the possibility of complications.
What does gender reassignment surgery include?
The process of sex reassignment surgery (SRS) is to help people transition into the gender they align themselves with. There are various procedures, some of which can be done at the same time and some that must be staggered for medical purposes. There is female to male transitioning, but we currently only offer male-to-female transitioning. The five common procedures Beautiful You Holidays offers are; Orchiectomy, Penectomy, Vaginoplasty, Facial Feminisation and Body Contouring (including breast augmentation).
At what age can you change your gender?
In New Zealand, the minimum age for considering gender reassignment surgery is currently adults over 18 years of age. Anyone under this minimum age is not legally entitled to undergo any of the procedures above, even with the consent of an adult.
Can you reverse gender reassignment surgery?
The decision to undergo SRS isn’t one to be taken lightly. We ensure candidates understand the steps and legalities involved, and that patients understand that this is a permanent procedure. In the extremely rare case that someone who has undergone gender reassignment surgery wants to reverse the surgery, please consult a doctor.
WHAT TO EXPECT +
There are several procedures involved with a male to female gender reassignment, some of which can be performed at the same time. How many procedures you have done at the same time will depend on your own wishes along with the recommendations of your surgeon.
Orchiectomy (removal of the testicles)
An orchiectomy is a quick procedure and is often performed as part of a more comprehensive reassignment process. It is imperative to understand that without testicles the male hormone testosterone will not be produced.
Penectomy (removal of the penis)
This procedure can be performed as a single procedure or as part of the gender reassignment process should you want to create female genitals. During the penectomy, the urethra will be shortened and redirected.
Vaginoplasty (creating a vagina)
A vaginoplasty is used to create a vagina and is often done by using the skin of the penis and turning it inside out to create the walls of the vagina. The specifics depend on the size of the penis and the surgeon's techniques. During this procedure, it is also common to alter the urethra by is shortening and repositioning it so that it functions as it would in a female body.
A vaginoplasty is done to improve the function of the body part and should not be confused with labiaplasty, which is more of an aesthetic change. While performing a vaginoplasty, it is common to include a labiaplasty and clitoroplasty to create female genitals that are aesthetic, minimally scarred, and sensitive to sexual arousal.
The techniques used to feminise a face vary based on the client’s facial structure and features, with the following procedures used:
- Face lift
- Otoplasty (ear pinning)
- Rhinoplasty (nose surgery)
- Tracheal shave (reducing the size of the Adam’s Apple)
The techniques used vary from client to client, with the following procedures used:
- Tummy tuck
- Breast augmentation
- Buttock implant
LENGTH OF SURGERY +
The length of surgery depends on the procedures performed, your body and your surgeon’s recommendations. It is common to stay in the hospital for 14 nights.
Recovery and post-op care:
While your recovery will depend on the procedures performed, it is common to experience pain and discomfort following the surgery, which will be managed by painkillers prescribed by your surgeon.
Your surgeon will give you instructions on how to perform periodic dilation (stretching the vagina walls). You will be given a dilator to wear inside the vagina to ensure it does not close over or change in shape. It is common to do this for eight weeks following your vaginoplasty, with the frequency gradually reducing. The vagina should be cleaned regularly as per your surgeon’s specific instructions.
You will be able to return to light work 4 to 6 weeks after surgery, and slowly being more strenuous work and exercise around 6 to 8 weeks after surgery.
Length of stay:
Most surgeons recommend staying on holiday for at least 21 days, during which time you will have regular follow-up appointments with your surgeon. To get the most out of your recovery time we suggest you partake in gentle exercise, yoga classes and treat yourself to some pampering. If you are feeling up to it, there is plenty to see and do in Phuket, Bangkok and Kuala Lumpur.
PRECONDITIONS AND RISKS +
Risks and complications are minimised by using the care and services of our highly-skilled, trusted doctors and nurses. However, with every precaution taken complications can still occur. These are rare and few patients experience any issues. If you have any concerns about your procedure and the possible preconditions and risks, please discuss them with your doctor and nurses.
Potential risks include:
- Hematoma (which can be treated either through puncture or surgery, depending on the size)
- Nipple necrosis (which can be corrected with aesthetic procedures to reconstruct the nipples should this happen)
OTHER PROCEDURES TO CONSIDER +
If you would like to take advantage of your time away, there are other non-surgical procedures you can add so you return home feeling refreshed. These include cosmetic fillers, laser resurfacing and chemical peels.
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Terms and Conditions
Male to Female Gender Affirmation Surgery
Male to Female Gender Affirmation Surgery (Sex Reassignment Surgery) involves remodeling the male genitals into a form with the appearance of, and the function of female genitalia.
The Medical Council of Thailand defines “Gender Affirmation Surgery (Sex Reassignment Surgery)” as surgical techniques conducted to change the gender of a patient from male to female or female to male, including the use of hormones from one gender to the other.
A simpler explanation is that it is a surgical procedure in which the patient’s sex organs are altered as well as function to satisfy their desires.
Male to female gender affirmation surgery, then, is surgery that involves transforming the male genitalia into the female genitalia, which comprises the following procedures:
- Creation of the External Female Genitalia (vulva)
- Design of the New Vagina (neovagina)
In most cases, your surgeon performs sex reassignment surgery during the last phase of the transgender process.
Transgender reassignment is a complex process that begins with the patient living in the gender they desire for some time, taking hormones to achieve the necessary physical changes, and undergoing surgery on other bodily parts, such as the breasts and genitals.
Gender affirmation surgery is a delicate and complex type of surgery and, once done, cannot be easily reversed. The primary purpose is to fulfill psychological and physical needs.
Patients who wish to undergo this surgery must first meet the World Professional Association for Transgender Health (WPATH) criteria. This criterion ensures that the individual will live happily with the new gender they desire to be transformed to after the procedure and minimize the possibility of making a significant “Wrong Decision” and regretting it for the rest of their life.
Not all transgender people undergo SRS. Those who do have SRS for a variety of reasons.
Some people use it to alleviate bodily dysphoria — intense discomfort caused by a mismatch between identity and body.
Others are comfortable with their bodies but are incredibly uncomfortable with how others see them (social dysphoria) and wish to alter their physical appearance to live a life more consistent with their identity.
Choosing surgery for any health problem is a significant decision, and Sexual Reassignment Surgery is no exception.
This guide’s objective is to:
- describe MTF-SRS alternatives,
- identify potential risks and consequences associated with MTF-SRS,
- detail what to expect before and after MTF-SRS, and
- explore factors to consider when deciding to have SRS.
MTF patients who are considering SRS will find this guide very helpful. It may also benefit partners, family members, and others curious about SRS.
- Surgical Procedures for MTFs
- Breast Augmentation Surgery
- Procedures of the Face & Neck
- Genital Surgery
SRS’s goals for MTFs are to diminish “male” traits and make the body appear more “feminine.”
MTF SRS may entail some or all of the following surgeries. These surgical procedures carry risks but have improved the quality of life for MTFs experiencing physical or social dysphoria.
Breast surgery, facial surgery, and genital surgery are all addressed in length here. In addition, you can read about voice change surgery here.
Estrogen causes breasts and nipples to grow, but there is a limit to how much breasts can grow on their own.
MTFs who want larger breasts or a change in breast shape can have implants inserted through an incision under the breast, armpit, or around the nipple.
What will the appearance and feel of my breasts be like after implants?
Surgically augmented breasts typically look and feel different than non-implanted breasts. For example, augmented breasts are generally wider, firmer, and rounder than naturally developed breasts.
This difference is especially true for MTFs or non-trans women who get implants later in life because their breasts have not gone through the age-related process seen in non-trans women without implants (the skin stretches and the breasts droop as we get older).
Furthermore, MTFs frequently have larger chest muscles and a broader chest than non-trans women.
Working with a surgeon who understands how MTF skin, muscle shape, and breast development differs from that of non-trans women can be beneficial in deciding on an implant shape and technique that will produce the desired result.
Viewing photos of MTFs who have had breast implants can give you an idea of what to expect. You can also request that surgeons show you before and after pictures of their patients.
Materials used to make breast implants.
Most breast implants are made of saline (saltwater) or silicone.
A word of caution regarding silicone injections
Semi-solid implants are used for breast augmentation, with the liquid filler surrounded by a solid shell that keeps the fill contained. Some MTFs who cannot afford surgery have attempted to augment their breasts, hips, cheeks, lips, or buttocks by purchasing liquid silicone and injecting it themselves or having an injection performed by a friend or unlicensed health worker.
Injection of liquid silicone (also known as “free silicone”) is extremely dangerous and, as a result, is not permitted as a medical procedure.
There are serious health risks associated with liquid silicone, including permanent disfigurement, lung disease, brain damage, and death.
If you have ever received a liquid silicone injection, you should consult a doctor as soon as possible.
When deciding whether or not to get breast implants, it is essential to keep in mind that all types of breast implants frequently leak or rupture and must be removed.
Breast implants are not considered lifetime devices. Therefore, you will almost certainly require additional surgeries and visits to your surgeon in the future.
Your implants will almost certainly have to be removed at some point, and you will have to decide whether or not to replace them.
Implants stretch the skin. If implants are removed but not replaced, your skin will be wrinkled, dimpled, or puckered.
Breast augmentation timing
In some MTFs, estrogen can significantly alter breast size and shape. While breast growth begins soon after beginning estrogen therapy, it is slow and gradual, and it typically takes two or more years for breasts to reach their maximum size.
If you can take hormones, it is recommended that you wait at least 18 months to allow your breasts to develop.
Hormonal development will aid in the growth of your nipples and the stretching of your chest skin, resulting in a more natural-looking implant.
Instead of being implanted into a flat chest, implants look more natural when augmenting existing breasts.
Some MTFs are unable to take hormones due to medical reasons, do not want the side effects of hormones, or enjoy breasts without the other effects of hormones. If you are unable to take hormones, implants may be an option.
Breast surgery can be performed as the first (or only) step in surgery or after you’ve had other types of SRS (e.g., genital surgery).
What to Expect Before and Following Breast Augmentation
In a hospital.
You will come to the hospital on the day of your surgery to review pre-surgery information and have a last-minute physical exam.
You will be instructed not to eat or drink after midnight the night before surgery.
After your surgery, hospital personnel will monitor you as you awaken from anesthesia.
You will most likely be given antibiotics to help reduce the risk of infection while your wounds heal in the hospital.
Following breast surgery
You will be required to wear a special bra and leave the surgical dressings on for as long as the surgeon requires.
Your surgeon or nurse will determine the right time for you to take a shower.
It is usual for the incisions to be red, but the redness should not extend beyond the incision for more than 1–2 cm (if this occurs, see a doctor immediately because it could be a sign of infection).
It is also customary to see or feel the knot in the stitches at the incision’s end. But, again, the stitch knot is not a problem; it will either dissolve on its own or come to the surface of your skin, where it can be clipped free by a doctor or nurse.
A moderate amount of bruising and swelling is expected. Your breasts will most likely be sore and swollen for at least a month following surgery. Consult a doctor if you have a lot of swelling. During the healing process, sharp shooting pain, burning pain, or general discomfort are expected and eventually subside.
Severe discomfort usually subsides 1–2 days after surgery.
You can resume your routine when you feel well enough to do so (i.e., regular movements do not cause pain). This usually takes 1–2 weeks, but it can take longer in some cases.
For the next 3–4 weeks, avoid any activity that causes your heart rate to rise.
Breast implant dangers and potential complications
Any surgery requiring general anesthesia is a serious medical procedure. There is a risk of blood clots (which can be fatal) or an adverse reaction to the anesthetic with any surgery.
Surgeons, anesthetists, and surgical nurses have extensive experience preventing problems and responding to emergencies during surgery. To avoid blood clots after being discharged from the hospital, move around as much as you feel comfortable and drink plenty of water.
Obtain immediate medical attention if you experience sudden shortness of breath, chest pain, dizziness, or tender, warm, and swollen legs. You may have a blood clot and require immediate medical attention.
Aside from the risks of blood clots, every surgery carries the risk of infection, bleeding, pain, and thick red scars. Antibiotics are commonly administered in hospitals to reduce the risk of infection.
It is usual for the breasts to be sore and the incision line to be red after surgery. If the redness extends more than 1–2 cm beyond the incision, the skin is tender or warm, and you don’t feel well, see a doctor to rule out an infection.
The following are some of the potential complications associated with breast implants:
- Capsular contracture: thickening and contraction of scar tissue that forms naturally around the implant (some scar tissue is okay; an excess can be problematic).
- Lopsided breast size, shape, or position (one side appears larger or smaller than the other)
- Asymmetrical placement of the nipple (one side looks higher than the other)
- Rippling of the skin over the implant is more likely if you are thin or your breasts haven’t appropriately developed after hormone therapy.
- Implant problem: leakage, rupture, infection, or implant coming out of the body Change in sensation to nipples/breast skin: less or more intense feeling.
You will almost certainly require additional surgery if:
- there are implant problems: the surgeon will have to remove your implant but can replace it later
- your breasts or nipples are lopsided: the surgeon will wait 4–6 months after surgery to see how the implant settles
- you have severe capsular contracture (the scar tissue is making your breasts excessively firm, distorting their shape, or causing you pain)
During puberty, testosterone causes numerous changes in MTF bodies, including the formation of skull and face bones and cartilage in the face and neck.
Although hormone therapy can soften the skin of the face and cause minor changes in the fat/muscle structure of the face after puberty, hormones cannot change the basic structure of the face and neck; only surgery can reshape the contours of bone and cartilage.
MTFs have varying perspectives on face and neck surgery. Some believe it is critical in reducing gender dysphoria and enhancing passability.
Others are concerned that MTFs may feel pressured to undergo face and neck surgery to meet conventional standards of female attractiveness.
There is no right or wrong answer regarding whether to have a face or neck surgery, as with any other type of SRS: it is a personal decision.
In the throat/neck, cartilage rings surround the windpipe. The thyroid cartilage juts forward more pronouncedly in “males” than in “females.”
This point is also known as the “Adam’s apple” or the laryngeal prominence.
The thyroid cartilage can be surgically altered (“tracheal shave” or chondrolaryngoplasty) to reduce the size and visibility of the laryngeal prominence.
This surgery can be done concurrently or separately from voice surgery.
Facial feminization surgery (FFS)
FFS techniques are divided into surgery into the bones or cartilages of the skull and work on the soft tissue that covers the bone/cartilage.
The differences between the average “male” and “female” skulls are used to reconstruct bones in FFS. In addition, soft tissue work may be performed to supplement or replace bone reconstruction if only minor changes are desired.
Soft tissue surgery is less invasive than bone surgery.
FFS can include surgical modifications to any of the following areas:
Based on three differences in the facial structure of non-trans women and men, FFS creator Douglas Ousterhout emphasizes the surgical change of the forehead as a crucial part of facial “feminization”:
- As shown in the image below, “male” skulls have a relatively flat slope from the hairline to the brows, whereas “female” skulls are more curved.
- As shown in the image below, “males” have a thicker bony ridge just above the eyes (brow bossing).
- “Males” have a longer distance between their brows and their hairline than “females,” even if they do not have “male”- pattern baldness (which further increases this distance).
The following surgical changes to the forehead can be performed as part of FFS:
- Brow shave: removing brow bossing by grinding down the orbital rims (upper edge of eye sockets).
- forehead implant: using synthetic bone-filler to round out a flat forehead;
- brow lift: tightening of the skin on the brows and raising of the brows
- hairline and scalp advancement: bringing the hairline and scalp forward
Surgical Procedures of the Chin and Jaws
FFS creator Douglas Ousterhout describes three differences in the structure of non-trans women’s and men’s chins and jaws:
- As shown in the image below, “male” chins are broader and squarer, whereas “female” chins are pointed and narrower.
- The distance between the bottom lip and the base of the chin is shorter in “females” than in “males.”
- “Male” jaws have fuller back corners, with the bone having a sharper angle and flaring out away from the face and a more prominent masseter (chewing) muscle.
Female jaws have a gradual curve from the ear to the chin, with a less square and full shape in the back.
The chin and jaw FFS is performed through the mouth and incisions around the lower gums.
The following surgical changes to the chin and jaw can be performed as part of FFS:
- removing bone from the back corner of the jaw to make it less prominent;
- removing bone from the chin and reshaping it to look more tapered, less square, and shorter;
- using implants if the chin is receding;
- liposuction under the chin to make the lower part of the face appear less heavy;
Rhinoplasty is the surgical procedure used to alter the appearance of the nose. Some MTFs want to change the appearance of their nostrils or the tip of their nose.
Other times, MTFs who have forehead surgery will be advised to have surgery on the nose bridge so that the flow from nose to forehead appears smooth.
Among the nose changes that can be made as part of FFS are:
- removing bone from the bridge of the nose to make it flatter;
- removing width from the nose to make it thinner;
- shortening the nose by removing some cartilage at the tip of the nose; and narrowing the nostrils
Cheek augmentation can be performed to highlight the “cheekbones” (zygomatic arch), making the cheeks more prominent and the chin/jaw appear smaller.
Bone grafts, synthetic implants, and fat implants can all be used for augmentation.
Among the lip surgical changes that can be performed as part of FFS are:
- removing skin from the area between the nose and the top lip to raise the upper lip
- using implants to make the lips appear fuller
Face/neck surgery timing
Most FFS techniques can be performed at any point in the transition (at the beginning, middle, or end of the process).
If you want both forehead and nose surgery, it is best to have them done simultaneously because changes to the forehead can affect the shape of the nose.
Multiple surgeries close together are generally not recommended because they put a lot of strain on your body.
What to Expect Before and Following Face/Neck Surgery
If you have electrolysis to help remove facial hair, you must stop it at least two weeks before having face surgery.
If you are having chin or jaw surgery, you will not be able to resume electrolysis for at least three months.
Talk with your surgeon about ways to temporarily remove facial hair before and after surgery as part of your pre-surgery planning.
In the hospital
You may be asked to come to the hospital on the day of the surgery to review pre-surgery information and have a last-minute physical exam. In addition, you will be instructed not to eat or drink after midnight the night before surgery.
What to expect immediately following surgery is determined by whether a local or general anesthetic was used.
Minor procedures are typically performed under local anesthetic (similar to having a tooth drilled), and you can return home shortly afterward. However, a general anesthetic is usually required for bone reconstruction or tracheal shave.
If you have a general anesthetic, hospital staff will monitor you as you awaken. For minor procedures, you will be sent home the same day as surgery with pain medication; for more extensive procedures, you will be admitted to the hospital for the night.
You will need to have someone drive you to your hotel or take a taxi when you are discharged because it is unsafe to drive right after surgery.
You will be given antibiotics to help reduce the risk of infection as your wounds heal in the hospital.
The aftercare instructions differ depending on the type of facial surgery and the technique used. Discuss pain management options with your surgeon before surgery to ensure you understand what to expect and what you need to do after being discharged from the hospital.
Dr. Douglas Ousterhout, the creator of FFS, provided the following information:
- The surgeon usually removes sutures and staples used to close scalp incisions within eight days of surgery. Most people feel well enough to return to work by this point (though vigorous activity should be avoided for the first two weeks after surgery).
- Within 10–12 days of surgery: Swelling and bruising around the eyes usually resolve by this time.
- Within two weeks of surgery: Swelling should have subsided by this point.
- For the first 1–2 days after surgery, internal nasal packing will be left to support nasal tissues during the healing process.
- Bruising around the nose and eyes usually fades within two weeks of surgery.
- One month after surgery: It is safe to resume strenuous activity. You can continue wearing your glasses as usual.
- You can usually return to light work 5–6 days after surgery.
- The face is usually moderately swollen and bruised after surgery.
- Jaw reduction: Pain medication will be prescribed. Most of the swelling fades gradually over 10–14 weeks, but it can be difficult to see improvement until the swelling has completely subsided. You can usually return to work 10–14 days after surgery.
- Lip augmentation: This is usually a minor procedure. Swelling may occur, but it usually subsides within 10–14 days of surgery.
Face/neck surgery risks and potential complications
Every surgery carries the risk of infection, bleeding, pain, and the formation of thick red scars. Antibiotics are commonly administered in hospital to reduce the risk of infection.
It is usual for swelling and bruising to occur after facial surgery. If your skin is very tender or warm, and you are not feeling well, consult a doctor to determine whether you have an infection.
Any surgery requiring general anesthesia is a serious medical procedure. There is a risk of an adverse reaction to general anesthesia or, if you are lying flat for an extended period, of blood clots (which can be fatal). However, surgeons, anesthetists, and surgical nurses have extensive experience preventing problems and responding to emergencies during surgery.
To avoid blood clots after being discharged from the hospital, move around as much as you feel comfortable and drink plenty of water. If you experience sudden shortness of breath, chest pain, dizziness, or tender, warm, and swollen legs, seek emergency medical attention. These symptoms may indicate a blood clot, and you may require immediate medical attention.
The following are some of the risks associated with face/neck surgery:
- numbness, pain, or difficulty controlling the muscles of the operated-on area: this can be temporary (due to swelling) or permanent (from nerve damage)
- Implant, wire, or screw issue: infection, reabsorption, or coming out of the body
- tracheal shave: possible voice damage
- difficulty adjusting to looking different after surgery (some people describe this as feeling like a stranger is looking back at them when they look in the mirror)
- Disappointment with the appearance of results: eyebrows raised too high, the nose looks unnatural, etc.
Preparation for Genital Surgery at Yanhee hospital
Preparing for Genital Surgery begins with the physician taking a medical history, assessing the patient’s desire to be transgender, and reviewing the transgender procedures done previously.
The doctor will then perform a complete physical examination of the patient and assess if the individual is ready for the surgery according to the following assessment criteria:
- If you are under the age of 18 years, you are ineligible to have surgery. If you are over the age of 18 but under the age of 20, you must submit consent signed by your legal guardians.
- The patient must have undergone psychiatric evaluation from 2 psychiatrists and been diagnosed as having “Gender Dysphoria,” to be written by both psychiatrists in two separate medical certificates.
- The patient must have no underlying physical or psychiatric diseases that will pose potential threats or dangers to the patient when going through anesthesia or the major surgical procedure.
- The patient must have gone through hormonal replacement therapy for at least one year.
- The patient must have lived in the opposite gender for at least one year.
After that, the doctor will perform a complete physical examination on the patient, perform blood tests, and do an x-ray. If abnormalities or congenital diseases are detected, the patient will consult with corresponding specialists to participate in the assessment.
A patient must stop taking medicines or supplements which may increase bleeding tendencies, such as aspirin, clopidogrel, herbs like cordyceps, ginkgo, ginseng, garlic, cod liver oil, collagen, and vitamin E at least two weeks before the surgery.
The patient must refrain from taking the hormones for replacement therapy for at least a month before surgery to prevent deep venous thrombosis as a postoperative complication.
Patients who smoke or use products containing nicotine, such as e-cigarettes, nicotine gum, or the nicotine patch, must discontinue using these for at least two months before and after surgery because nicotine slows down the healing process of the surgical wound.
Patients taking alcoholic beverages should refrain from taking these a week before the surgery. In addition, patients should eat soft food with less dietary fiber a week before surgery to avoid the accumulation of much residue in the intestines and leave it cleaner and more ready for the surgery.
Proper genital hygiene must be done by regularly washing well with soap and water.
Patients’ diseases or conditions that require more intensive examination or correction before sex-change surgery can be done:
- Congenital diseases or congenital disabilities that affect body functions such as heart, lung, liver, or severe kidney diseases
- Chronic diseases that are in the process of treatment, such as cancer, Systemic Lupus Erythematosus (SLE)
- HIV, Hepatitis B, and Hepatitis C
- Reproductive disorders such as phimosis and paraphimosis, hypospadias, cryptorchidism, lumps or tumors of the sexual organ, or a history of introducing foreign substances into the sexual organ, etc.
- Inguinal and abdominal hernias
Diseases or conditions in patients that will disqualify them from undergoing Sex Change Surgery:
- Congenital diseases that are not completely treated
- Unstable patients with psychiatric disorders
- Patients using illegal narcotics
Techniques for Male to Female Gender Affirmation Surgery
Male to female gender affirmation surgery (sex change surgery) is divided into two major types according to the technique used to create the vagina:
- Graft Technique (Penile Skin Inversion Technique)
- Techniques that use tissue from the abdomen, including Colon Vaginoplasty Technique and Peritoneal Vaginoplasty Technique
The Graft Technique means sex change surgery using the same genital skin to create a new vagina. This method does not require abdominal surgery and can avoid scarring around the abdomen.
The depth of the vagina depends mainly on the natural anatomy of the patient’s pelvis. However, on average, the vaginal depth is 5.5-6 inches.
The graft technique is the standard method used for the first sex-change surgery, is not very complicated, and does not put the patient at high risk. However, after the surgery, the new vagina must be taken care of by regularly dilating the vagina, especially during the first year.
The graft technique is used to create a complete external female genitalia, including the clitoris, clitoral hood and frenulum, labia majora, labia minora, and urethral orifice. It can also keep the sensory nerves in different strategic points entirely.
Suppose the patient has less genital skin, which may not be enough to perform the graft method, but does not want to undergo abdominal surgery. In that case, he may still choose the graft method using skin from other areas, such as from the groin or thigh, but the disadvantage is that there will be additional scars in those areas.
Advantages-Disadvantages of Graft Technique Sex Change Surgery
- Able to create a complete external genitalia
- Create a vagina that is deep and functional
- No abdominal surgery is required
- The vagina can be constricted or shallower if not adequately and adequately dilated.
- No lubricant inside the vagina
- There may be additional scars if graft from the other areas is used.
Colon Vaginoplasty Technique
The Colon Vaginoplasty Technique requires abdominal surgery, and the colon is used to create a vagina. This method has the advantage of creating a deeper, more durable vagina without any constriction.
However, the “vulvar entrance” area may still be constricted or narrowed due to the contraction of the wound. Therefore, the transgender patient who underwent this method still has to dilate the vagina to prevent narrowing at the area of the vaginal entrance.
The Colon Vaginoplasty Technique is often used in corrective surgery to increase vaginal depth. It may also be done as the first surgery if the patient has less genital skin. The appearance of the external genitalia is the same as that of the graft method in all aspects.
The walls of the vagina formed from the colon have mucous membranes that look sticky and stagnant inside so that the entrance area is often dry.
Consequently, doctors recommend that patients use lubricants each time they engage in sexual intercourse to prevent abrasions due to excessive friction.
Patients who have had recto-sigmoid vaginoplasty sex change will need more long-term self-care than those using the other surgical techniques. In addition, patients must have regular follow-up visits to the doctor.
The patient must monitor the patency of the entrance and see that it is always open so that the mucus can be drained. Otherwise, the neovaginal closed-loop obstruction may occur. If patients want to be examined or screened for colon cancer by colonoscopy, an endoscopic examination of the internal aspect of the vagina will also be required.
In addition, intra-abdominal surgery may create an adhesion band, which may later cause abdominal pain.
Advantages-Disadvantages of Colon Vaginoplasty Technique
- The vagina is deep and has strong durability.
- Creates a mucous membrane inside the vagina
- Able to develop a complete external genitalia
- Entails abdominal surgery where the colon is cut and sutured
- The entrance to the vagina created may be constricted if the dilation is not good.
- There is a chance of the patient’s developing various colonic diseases such as colon cancer and inflammatory bowel disease.
- May develop peritoneal adhesions due to intra-abdominal surgery.
- It creates a scar on the abdomen.
Penile-Peritoneal Vaginoplasty technique (PPV)
The PPV technique entails abdominal surgery, but it will use the peritoneum to create a new vagina (not the colon). This technique is often used for reconstructive surgery but can also be done as a first surgery if the patient does not have enough genital skin for grafting.
The peritoneum can produce a lubricant which is a clear yellow liquid.
However, the entrance to the vagina is still made of skin so that it can be dry and prone to abrasions as well. Hence, the doctor always recommends using a lubricant each time the patient engages in sexual intercourse.
The characteristics of the external genitalia created through peritoneal surgery are the same as those made through the grafting and bowel technique in all aspects.
Pros-Cons of the PPV Technique
- The vagina is deeper than that created through the grafting technique.
- Lubrication present inside the vagina
- Creates a complete and functional external genitalia
- Entails abdominal surgery
- If not dilated well enough, the peritoneal junction at the entrance may be constricted.
- Peritoneal tissues may form adhesions due to abdominal surgery.
- There will be scar formation on the abdomen.
How deep will the vagina be after gender affirmation surgery?
Gender Affirmation Surgery can create a vagina with a depth equal to its usual depth in a patient’s pelvis, about 5.5 – 6 inches. However, the vagina created may be deeper by about 1-2 inches more, depending on where the surgery was done using the PPV technique.
Will the new genitals have sensation?
The surgeon will collect sensory nerves to build a new genitalia sensation spot which consists of the clitoris, inner labia, and around the urethra, all of which can be capable of external sexual stimulation. The internal aspect of the vagina will not have direct sensory nerves. However, the patient may still feel sexual pleasure by external stimulation around the prostate gland area in some cases.
Recovery Time for each Surgical Technique
The Grafting Technique
- The patient will stay in the hospital for a total of 9 days.
- The doctor will not allow the patient to get off the bed for the first three days after the surgery, will only allow him to eat soft meals, and will see to it that the wound is covered with two layers of gauze urinary catheter and drainage.
- During the 4th day after surgery, the doctor will remove the outer layers of gauze and allow the patient to get off the bed.
- During the 7th day after surgery, the doctor will remove the remaining gauze, the urinary catheter, and drainage and give the patient instructions about vaginal dilation. The patient will then be discharged from the hospital if no complications are encountered.
- After surgery, the patient should rest for about one month to recover from all the inconvenient movements. Vaginal dilation has to be performed every day.
The Colon and PPV techniques
- For the colon and PPV techniques, the patient has to stay in the hospital for 9 days. The doctor will remove all gauzes, urinary catheter, and drainage on the 4th day and give the patient instructions on dilating the vagina. The patient will be discharged from the hospital if no complications are encountered.
- The patient should rest for full recovery after sex reassignment surgery with the colon and PPV technique, for about one month if it is the first operation and for about two weeks if it is reconstructive surgery.
External Wound Care
There are two kinds of medications for external use to be used for dressing:
- Povidone Iodine Solution – to be applied over the wound around the outer labia
- Povidone Iodine Gel – to be applied over the wound around the inner labia and around the urethra
Always dress the wound using these two medications for external use after urination and vaginal dilation. In addition, the patient has to wear sanitary napkins to absorb any bloodstains. Usually, the surgical wound will be healed within 2-3 weeks without post-surgical complications.
The patient must use the douching method after performing vaginal dilation by mixing the saline solution with Povidone Iodine Solution with a 1:10 ration (Ex. Saline 100 cc. with Povidone Iodine Solution 10 cc) and douche for 100-200 cc. at a time.
Do not squat or spread the legs before the surgical wound is completely healed, as activities like these may cause surgical wound dehiscence. Also, do not use soap and water for douching the vagina as these may irritate.
The doctor will usually allow the patient to engage in sexual intercourse after the surgery (if the wound in the vagina is already completely healed). However, an unpleasant vaginal odor may be present during the first 3-6 months due to the residual bloodstains.
The patient must avoid sour or fermented food because it may cause the surgical wound area to swell for a long time.
Information/Instructions about Vaginal Dilation
- Vaginal dilation is essential, especially during the first year after surgery, due to the wound healing process, which causes the contraction of the vagina (contraction can occur in whatever surgical technique is used). Contraction is more intense during the first year after surgery but will gradually decrease after one year.
- The patient should use the rigid dilators properly prepared by the doctor. The patient should perform vaginal dilation two times a day for 30-60 minutes per session, increasing the size of dilators according to the doctor’s instructions during the first year after surgery. After one year, the patient should perform vaginal dilation once a week, using the dilator with the biggest size.
- For additional vaginal dilation, the patient is instructed to insert a soft silicone dilator into the patient’s vagina before she goes to sleep. The patient must also wear panties to prevent the soft silicone dilator from slipping out.
Information by: Dr.Worapon Rattanalert
Frequently asked questions (MTF)
Q: In the Transgender by Penile Peritoneal Vaginoplasty (PPV) technique, lubrication is like in the vagina. Is there no need to use a lubricating gel when having sexual intercourse?
A: The entrance to the vulva is still a graft (skin), so it tends to be dry. Lubricants are still recommended every time you engage in sexual intercourse to prevent abrasions due to friction at the vulvar entrance.
Q: Is there a need to dilate the genitalia in Penile Peritoneal vaginoplasty (PPV) technique?
A: Yes, because the contraction of the wound can also narrow the entrance to the vagina.
Q: Is there a chance of contracting sexually transmitted diseases in the new genitalia?
A: There is a chance of contracting STDs by sexual intercourse at the new genitalia.
Q: Should a patient take hormone replacement therapy after sex reassignment surgery?
A: After sex reassignment surgery, female hormonal drugs must be used under the supervision of a physician to prevent “surgical menopause” or a sudden lack of sex hormones. Transgender women taking estrogen and anti-testosterone medication before surgery must stop taking the anti-testosterone medicines after surgery, and estrogen can be used singly.
Q: How often should patients visit the surgeon for a follow-up?
A: The patient should visit the hospital for follow–up during the first year after surgery to check the wound healing process and depth of the genitalia. After one year, the patient should see the surgeon at least once a year for an external genital examination and internal endoscopy.
Deciding to have SRS
There is no single correct way to decide whether or not to have surgery. It is natural to have doubts, fears, and anxieties about SRS, as with any significant life decision. However, as part of the decision-making process, you must be sure to proceed with surgery.
From our own experiences and from listening to many other people, we know that each person’s situation is unique, that there is no one way to decide, and that it is not as simple as a one-time yes or no. Instead, it is often a lengthy process shaped not only by internal feelings and beliefs but also by ever-changing external circumstances that are not always under your control (health, money, family responsibilities, limited access to services, etc.)
People, in our experience, make decisions about SRS in the same way they make decisions about the rest of their lives. For example, some trans-people seek a solid internal feeling that SRS is correct and do not want to be influenced by others. In contrast, others seek advice from friends, family members, other trans-people, counselors, or other health professionals as part of the decision-making process.
Some questions to consider are listed below, regardless of how you think things through. Of course, there are no correct answers to these questions; they are prompted for you to consider various aspects of SRS better to understand your feelings, values, and expectations.
- Do you have a clear mental image of how you want to appear after SRS?
- What do you think you’ll feel if the results don’t match your mental image?
- Do you expect SRS to fix anything, and if so, what?
- What aspects of your life might change as a result of SRS?
- What would you like to see change, and what would you like to stay the same?
- Do you believe your expectations for SRS are realistic? How can you tell if they’re genuine or not?
- How well do you understand the SRS options? What else do you need to know to make an informed decision?
- Do you consider the parts of your body that SRS will alter to be a part of your sexuality? What if you lose that aspect of your sexuality?
- Will your decision have an impact on anyone else in your life? How do you think they’ll react to the fact that you have SRS? What effect will their reactions have on you?
- What do you consider a “wrong reason” for having SRS? What do you consider to be the “right reasons”?
What SRS cannot provide for You
SRS can provide significant relief to trans-people and live more comfortably. But there are some things that SRS will not do.
1. SRS will not solve all body image issues.
The goal of SRS is to make you feel more at ease in your own skin by bringing physical characteristics closer to your internal sense of self. This alleviation can boost your self-esteem and make you feel more confident and attractive.
However, you will discover that there are attractiveness standards after SRS that you may not meet.
The social pressures and gender stereotypes about appearance make it difficult to be comfortable in your own skin. Unfortunately, some MTFs respond by obsessively dieting, exercising, or undergoing endless surgical revisions to achieve an idealized stereotype of attractiveness.
It can be challenging to distinguish between gender dysphoria and body image issues. Professional and peer counseling can help you sort out your appearance expectations and work toward greater self-acceptance after SRS.
2. SRS will not solve all sexual issues.
Wanting to feel more comfortable about sex is essential for some trans-people to have SRS. This is because SRS can help alleviate dysphoria, which harms sexuality. However, dysphoria is not the cause of all sexual problems.
Sexuality is a complex issue that various factors can influence, including physical problems, stress, relationship dynamics, body image issues, past sexual abuse or other types of trauma, and cultural and personal beliefs about sexuality.
SRS will not automatically resolve all of these issues in your life. If you are experiencing sexual difficulties, consider seeking peer or professional counseling to investigate the causes and learn about sexual health treatment options. If you need help finding a trans-positive sexual health professional, the Transgender Health Program can help.
SRS frequently has a positive effect on sexuality. Most Trans people who participated in numerous studies reported increased sexual satisfaction after SRS. However, SRS can have a negative impact. Changes in sensation are widespread following surgery. You may discover that touch is less intense or more intense (to the point of being uncomfortable or painful).
Some MTFs report difficulty reaching orgasm following genital surgery or that orgasm is less intense. When deciding whether to have surgery, you must consider the possibility that SRS will harm your sexuality and how you will cope with that possibility.
Whether or not you choose SRS, some trans-people find that counseling can help them deal with the effects of internalized transphobia on their sexuality. Many trans-people internalize negative messages about being Trans due to growing up in a transphobic society. This can include feelings of shame about erotic cross-dressing or other trans-specific sexual desires and fantasies, as well as feelings of guilt about having a body that does not conform to societal norms.
Peer or professional support can be beneficial in achieving greater self-acceptance of your sexuality (with or without SRS).
3. SRS will not transform you into someone else.
SRS causes many people to experience positive emotional changes. However, once the excitement wears off and you’ve incorporated the changes into your daily life, you’ll likely discover that if you were shy, you’re still shy. If you didn’t like your laugh, you still don’t, and you’re still afraid of spiders.
Whatever you consider being, your strengths and weaknesses will remain. Hopefully, you will be happier, which is beneficial to everyone. SRS may assist you in becoming more accepting of yourself. However, if you expect that all of your problems will go away and that everything will be easy emotionally and socially from now on, you will most likely be disappointed.
This includes mental health issues as well. Trans-people who are depressed due to gender dysphoria may find that SRS significantly reduces their depression. However, if your depression is caused by biological factors, transphobia-related stress, or unresolved personal issues, you may still be depressed after SRS. Similarly, if you have a problem with drugs or alcohol, SRS will not necessarily solve your problem.
4. SRS will not provide you with an ideal community.
For some trans-people, SRS is a ritual that confirms that they are who they claim to be. Making physical changes is a way of exposing yourself to the rest of the world so that others can see who you are. This process of self-discovery can be very liberating, but it does not guarantee acceptance or understanding.
Some MTFs believe that by undergoing physical transformations, they will be validated as “real” women or feel more accepted by the trans-community. However, the notion that trans-people aren’t “real” unless they change their bodies is transphobic, and communities or groups that hold this belief are unlikely to be fully respectful of trans-people’s identities and bodies.
It’s common to fantasize about finding an ideal community of trans-people during the various stages of transition. There may be a strong desire to connect with others who have gone through similar experiences when undergoing SRS.
There are a lot of really cool trans-people to talk to about SRS. However, having SRS does not automatically make trans people welcoming, approachable, or sensitive to the needs of others, and you will likely find that no trans person will exactly mirror your personal experiences, identity, and beliefs.
Being realistic about the possibility of feeling lonely and alone after starting hormone therapy is an integral part of emotionally preparing for SRS.
Am I Prepared?
It’s not enough to know if SRS is suitable for you; you should also see if it’s the right time in your life for SRS. Your readiness determines this for the physical stress and mental adjustment that SRS entails and your willingness to deal with the reactions of others.
As discussed in the booklet Getting surgery (available from the Transgender Health Program ), the patient must be physically and psychologically prepared for any surgery. Physical readiness denotes that you are in generally good health and have completed any physical requirements imposed by your surgeon (e.g., electrolysis before vaginoplasty).
Physical readiness also includes making plans for the physical care you will require following surgery, such as having a safe place to recover after surgery, understanding what is involved in aftercare, and having friends, family, or health professionals who can assist you.
Mental readiness does not imply that you are free of mental health issues or life stresses; instead, it means that you have:
1. A strong sense of one’s gender identity
SRS is not for people just beginning to question, explore, and think about gender identity issues. Allow yourself some time to get a clear sense of how you identify and how the surgery will contribute to this sense of self if you consider SRS as part of your initial process of exploring gender issues before making a decision.
2. Mental stability is sufficient to make an informed decision about your medical care
Making significant decisions during chaos and crisis is not a good idea. When you’re in a crisis, it can be challenging to think clearly and make fully informed decisions. If you’re having trouble making general life decisions because you’re overwhelmed by anxiety, depression, or drug or alcohol issues,
You’re not in a good place to make a big decision like whether to have surgery and what kind of surgery to have if you’re dealing with family problems, work problems, or other issues. So instead, seek peer or professional help to address whatever is interfering with your ability to think clearly, and then return to the question of whether SRS is necessary when your mind is clearer.
3. Sufficient coping skills and supports to withstand the typical SRS stresses after SRS , trans-people often feel exhilarated and liberated, but it is also common to experience emotional ups and downs. It can be challenging to adjust to changes in your body’s appearance and feel, to deal with pain or other physical complications, and to deal with the reactions of others.
For some loved ones, SRS is the first time it truly sinks in that gender issues aren’t going away and that you are, in fact, Trans. This can be a complex emotional process for them, affecting the support they can provide. SRS is not for you if you do not believe you have the emotional fortitude to deal with these possibilities.
If you are confident that SRS is suitable for you but are unsure whether you are ready at this time in your life, you do not have to abandon SRS entirely. Instead, you can still work towards SRS by considering what might help you get to the point where you are ready – counseling, advocacy, peer support, and so on – and gradually but steadily making life changes to get closer to readiness.
What Happens If I Change My Mind About Having Surgery?
Surgery is a humbling experience. Dissatisfaction, disappointment, and doubt are relatively common after any surgery, and (for Trans and non-trans people) typically relate to post-operative pain, surgical complications, the discrepancy between hoped-for and actual results, a sense of “now what?”, and other people’s reactions. These are normal parts of the adjustment process and usually resolve within the first year after surgery.
According to studies, approximately 1% of MTFs who undergo SRS have profound and long-lasting regrets.
If you are having difficulty coping with the ups and downs of surgery, peer and professional counseling can be beneficial. However, it is critical that the counselor has extensive experience with Trans issues and understands surgical matters.
Many people who have persistent regret come to terms with their decision to have surgery – even if they wouldn’t do it again, they believe it was the right decision at the time. On the other hand, some people decide that surgery and transition were not for them and wish to return to their pre-transition state. This is a significant decision that should not be made without professional advice.
Male to Female Surgery – Additional FAQs
Q1: will i be asleep during the male to female sex reassignment surgery.
The anesthesiologist will administer general anesthesia to keep you asleep and pain-free during surgery.
Q2: How long will I be in the hospital?
Answer : After surgery, you will be admitted for at least 7 – 9 days.
Q3: What will the post-op period be like?
Answer : To protect the surgical site, you will need to sleep with your legs separated for 5-7 days. During this period, you will be on a liquid diet with low fiber content so frequency of defecation is decreased. After about a week, you will be encouraged to start walking. Depending on your rate of healing, your doctor may also resume your hormone prescription after one week.
PRICE AND PACKAGES
Take the first step and contact us through our no-cost virtual consultation . During this process, we will recommend options that will work best for you. Every client is different, so our virtual consultants and surgeons tailor the procedure to match each person’s needs.
Dr. Kittichai Sipiyarak
Specialty: Plastic Surgery
Dr. Worapon Ratanalert
Contact us today.
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‘They just go to Thailand’: the long and costly wait for gender-affirming surgery in Australia
Transgender Australians seeking lower body procedures can go to just a handful of local surgeons. It means long waits, huge costs and difficult decisions
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T wo years ago, Kavitha Sivasamy, an articulate, elegant Canberra lawyer, began to face her fears about undergoing gender-affirming surgery. “It’s really scary to go through something so invasive,” she says.
Gender dysphoria had been causing “a lot of distress” in Sivasamy’s day-to-day life. “It can prevent you getting out the door, having and keeping a job, sustaining healthy relationships,” the 27-year-old says. “The list goes on.”
She embarked on a course of hormone replacement therapy, and she liked the physical changes she was seeing, but this meant her “genital dysphoria became more salient”. There was a disconnect between her aspirations for her body and how it looked in the moment.
But Australia is facing a shortfall in surgeons who perform lower body gender-affirming procedures. So , in a route that experts say more Australian trans people are taking, Sivasamy will travel to Thailand for surgery under a medical tourism company’s “one-month care package”. Like some others, she will access her superannuation to pay for the $30,000 procedure.
Sivasamy made her choice after spending many months researching the experiences that others had of surgery. She decided a peritoneal pull-through, adapted from a procedure pioneered in India on cisgender women born without a vagina, was the type of vaginoplasty with the most positive benefits for her.
The standard vaginoplasty has long been a penile inversion, where penis skin is refashioned as the lining of a new vagina. The newer method, using tissue from the patient’s peritoneum membrane in the abdominal cavity, is said to offer greater vaginal depth. However, there is a lack of data on post-surgical quality of life for trans patients.
Sivasamy had been referred to Dr Kieran Hart , a Canberra-based urologist who performs this procedure, but she soon learned that she might have to wait a year and a half to have the surgery here. The idea of delay only compounded her distress.
“Having overcome family, workplace and social barriers, why put the critical years of your 20s and 30s on hold because of the wait in Australia?” she says. She will fly to Bangkok in May.
One surgeon, 120 patients waiting
Only a handful of Australian surgeons offer lower body gender-affirming surgery such as vaginoplasty for trans women, with even fewer offering phalloplasty (penis creation) for trans men. No surgical college offers formal training guidelines, forcing doctors to learn overseas.
Trans health advocates say Medicare is “woeful” and failing to offer any item numbers for medical procedures specifically for gender incongruence, causing confusion about what, if any, aspects of gender-affirming surgeries are eligible for government subsidy.
Private health insurance coverage for gender-affirming surgery is often prohibitively expensive. Even a fully insured person is left out of pocket by up to $20,000 for a vaginoplasty performed in Australia.
An evidence brief prepared in 2021 by the New South Wales community health organisation ACON found that most states and territories have elective surgery policies that “explicitly restrict access to surgical interventions for trans people through public health systems”, forcing trans people into local private care or surgery abroad.
Dr Clara Tuck Meng Soo , a GP and the president of the Australian Professional Association for Trans Health (Auspath), says a lot of her patients “now don’t even bother to go on the waitlist; they just choose to go to Thailand”.
“We have very high rates of mental health harm , and this care and affirmation and support is critical to reducing that harm,” says Soo, who is a trans woman. “But shouldn’t we also be able to access care that we feel we need as a human right?”
Hart says he has 120 trans patients booked and waiting for gender-affirming surgeries, with another 70 scheduled for consultations, and estimates “probably 10 times more” trans people are waiting for surgery across Australia.
Hart has closed his bookings and will reopen them in the second half of this year for consultations to be held in 2024 – with potential surgeries months later.
However, he says he will expedite a surgery if a psychiatrist or family is worried a patient might not survive an 18-month wait. Transgender people have vastly higher self-harm rates than the general population – a 2021 study found 43% of trans Australians surveyed had attempted suicide .
Like others performing lower body gender-affirming surgeries in Australia, Hart came by training in the area by chance: he was taught by the late Phil Thomas at London’s Charing Cross hospital. Hart had only travelled there to train in prostate and bladder cancer surgery.
Based on follow-ups of how patients fared physically and mentally after the procedures, Hart is “convinced” that surgery “must drop the suicide rate”.
Over the past year, Hart’s workload increased in part because of the waves of referrals he was getting from two surgeons winding down their vaginoplasty procedures, including Melbourne plastic surgeon Andrew Ives . Until recently Ives a high profile in the field, but, as his office confirmed in an email, he ceased performing vaginoplasty and labiaplasty procedures at the end of 2022.
In February, Melbourne’s Monash Gender Clinic told patients that it was only then booking appointments for patients referred in August 2021, and that Melbourne plastic surgeon Cheng Lo , trained in vaginoplasty and labiaplasty by Ives, has “very long wait lists”. Cheng did not respond to interview requests.
Hart says: “Andy Ives and I were looking at doing a formalised training program [for gender-affirming surgery], and as he stepped back I’ve looked at doing it myself, but it’s a daunting task. The [Royal Australasian] College of Surgeons has been a bit slow on the uptake for it, like every facet of the transgender sphere.”
In May, the college will hold a scientific congress titled Equity in Surgery in Adelaide, including for the first time talks on transgender healthcare. The college’s president, Sally Langley, admits in the program that the college’s surgeons “have not fully represented the gender … composition of our community”, but declined an interview request.
The many kinds of risk
Sivasamy acknowledges there are “risks” in having surgery in Thailand, but says the country “pioneered a lot of these procedures”.
Travelling abroad for these surgeries, even to a country that has pioneered them, comes with warnings of caution. Soo mentions reports of trans women suffering vagina narrowing or urethra complications after surgery, both in Australia and overseas. The question is: once the patient is back in Australia, who corrects the error?
Hart says surgeons are reluctant to fix another surgeon’s mistakes: “It’s impractical coming from Perth to Canberra to have it fixed up, but it’s far more practical than getting to Bangkok. As a developed nation there’s no reason people should be going overseas.”
Soo says there is also a shortfall of GPs, psychologists and other practitioners in trans health, but evidence “shows if you provide gender-affirming care, be it hormone treatment, surgery and/or social affirmation, [trans] people have very good mental health virtually indistinguishable from cisgender peers”.
Associate Prof Nicola Dean, the president of the Australian Society of Plastic Surgeons, says the federal government must create a dedicated suite of Medicare rebate item numbers for procedures for people with gender incongruence. This would encourage more surgeons into the field, Dean says, giving the surgeries a “stamp of legitimacy”.
For instance, the Medicare item number for a mastectomy was created on the assumption the procedure would be for a cisgender woman with breast cancer. “So using it for a trans man having surgery [to affirm his identity] leaves the doctor feeling vulnerable about whether they’re allowed to use those item numbers,” Dean says.
“It leaves the patient vulnerable because they’re often not sure of the financial implications.”
Associate Prof Peter Haertsch , a Sydney-based plastic surgeon, says he continues to perform about six vaginoplasty procedures a year. At his peak he was performing 30 gender-affirming procedures a year in Australia, beginning in the late 1980s after training in London.
Heartsch says some Australian surgeons have recently exited the field, but he doesn’t know why. “I have tried and am still trying to get some form of help in the way of government funding,” he says.
Another Sydney plastic surgeon, Dr David Caminer, says he performed his first vaginoplasty on a trans person in 2015, after which he toured the US and Europe to watch surgical units perform gender-affirming surgeries.
Up to the end of 2022 he had performed only a few vaginoplasties on trans patients, mainly with the penile inversion technique. But Caminer says so far in 2023 he has performed seven vaginoplasties due to the growing demand. “It was really since Andy Ives stopped doing it that I’ve been inundated with requests,” he says.
The Brisbane-based Dr Hans Goossen , who did not respond to interview requests, performs nearly all the phalloplasty procedures on trans men in Australia, according to the various trans health advocates Guardian Australia spoke to. Another surgeon, the Melbourne-based Dr Gideon Blecher , “has trained in phalloplasty and he is still trying to establish the program in Melbourne”, a spokesperson for Blecher said.
Fiona Bisshop, a Brisbane-based GP and former president of Auspath, says phalloplasty is particularly difficult for trans men to access in Australia, costing more than twice as much as a vaginoplasty. Bishop says almost all phalloplasty procedures have some complication, but three of her trans male patients who went overseas had particularly “terrible outcomes”.
“You can have some very bad experiences over in Thailand,” she says. “There are communication difficulties: the surgeons and hospital staff don’t speak very much English.”
Bisshop says many of her trans patients have “given up on gender-affirmation surgeries, because it is completely out of financial reach”, and she calls the “lack of respectability” afforded to gender-affirming surgery a “vicious circle”, because it is not offered in Australian teaching hospitals where physicians would normally train.
Sydney-based Teddy Cook , ACON’s director of community health, says gender-affirming care means many types of “health interventions of critical need”, and such needs must be “depathologised” and trans people given autonomy.
The lack of comprehensive gender-affirming healthcare in Australia may be because this care is misunderstood as simply cosmetic or solely related to genital surgery, and because trans people are “seen through a lens of being mentally ill, as opposed to just being a natural part of human diversity”, Cook says.
Cook, who is a trans man, says not all trans people seek surgical intervention: “It’s up to the individual what sort of steps they take medically, but cruel legal gender recognition laws in NSW and other states still force surgical sterilisation to update a birth certificate.”
Cook says no reliable figures exist on how many trans people there are in Australia to better plan health services. When unveiling a 10-year national action plan for LGBTQ+ health in March, the assistant health minister, Ged Kearney, said attorney general Mark Dreyfus “might have things to say” about counting LGBTQ+ people in the census, but no announcement has been forthcoming.
As Sivasamy readies for her flight to Thailand, she knows she is one of the lucky ones, not least because she has enough money at a young age to finance the trip.
“The majority of people my age don’t have the superannuation funds to get this done,” she says.
She then opens her palms and waves her hands away, as if to banish doubts about a lack of contingency plan after the procedure. “Definitely, if there’s a readmission surgery necessary, I don’t have the money for that, you know?”
She laughs. “I have no idea what would happen. We’ll just have to cross that route if we come to it.”
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The Development of Sex Reassignment Surgery in Thailand: A Social Perspective
1 Division of Plastic & Reconstructive Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
2 Department of Plastic Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg Gröna Stråket 8, 41345 Gothenburg, Sweden
Apichai angspatt, pornthep pungrasmi, poonpismai suwajo, preecha tiewtranon.
3 Preecha Aesthetic Institute (PAI), Bangkok 10110, Thailand
This paper reviews the development of gender reassignment in Thailand during the period of 1975–2012, in terms of social attitude, epidemiology, surgical patients' profile, law and regulation, religion, and patients' path from psychiatric assessment to surgery. Thailand healthcare for transsexual patients is described. Figures related to the number of sex reassignment surgeries performed in Thailand over the past 30 years are reported. Transsexual individuals are only apparently integrated within the Thail society: the law system of Thailand in fact, does not guarantee to transsexuals the same rights as in other Western countries; the governmental healthcare does not offer free treatments for transsexual patients. In favor of the transsexual healthcare, instead, the Medical Council of Thailand recently published a policy entitled “Criteria for the treatment of sex change, Census 2009.” The goal of this policy was to improve the care of transsexual patients in Thailand, by implementing the Standards of Care of the World Professional Association of Transgender Health. Currently, in Thailand, there are 6 major private groups performing sex reassignment surgery, and mostly performing surgery to patients coming from abroad. Particularly, the largest of these (Preecha's group) has performed nearly 3000 vaginoplasties for male-to-female transsexuals in the last 30 years.
A comparative study of international centers performing GRS has been previously published [ 1 ]. This survey reported on the standards and policies used in 1995 by 19 clinics located in Europe and North America. Today, surgical treatment (as well as the entire transsexual healthcare) is standardized in University Hospitals and is based on the Standards of Care (SOC) published by the World Professional Association for Transgender Health (WPATH) [ 2 – 6 ]. The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieve lasting personal comfort and to maximize their overall healthcare. This assistance may include primary care, gynecological and urological care, reproductive options, voice and communication therapy, mental health services, and hormonal and surgical therapy.
Usually, the patient is referred from the General Practitioner (GP) to a mental health professional with a special interest in GD and eventually to a physician who can prescribe hormonal therapy. After a minimum of 12 months of continuous experience of living in an identity-congruent gender role under the control of the mental health professional and a minimum of 12 months of hormonal therapy, with a confirmed diagnosis of GD, the transsexual patient is referred for genital surgery [ 2 ]. At the end of the gender reassignment, patients still need to be provided with health assistance for life, to monitor the general health conditions and the surgical outcomes.
Dr. Preecha Tiewtranon and Dr. Prakob Thongpeaw performed the first male-to-female sex reassignment surgery in Thailand at the Chulalongkorn University Hospital (CUH) in Bangkok in 1975 [ 7 ]. At that time, the society had negative thinking about the transsexual patients and the surgical procedure [ 7 ].
Previously, no paper has reported on the past and present social and health care provided to transsexual patients in Thailand. The scope of this paper is to review the development of sex reassignment in Thailand during the period of 1975–2012 in terms of epidemiology, religion and social attitude, law and regulations, surgical patients' profile, and patients' path from psychiatric assessment to surgery. We were not able to find any other studies describing the development of sex reassignment surgery in other cultures or countries.
In Europe, the most recent epidemiological studies and review about transsexualism report prevalence ranging from 1 : 11,900 to 1 : 45,000 for male-to-female persons (MTF) and 1 : 30,400 to 1 : 200,000 for female-to-male (FTM) persons [ 8 ], with an increasing number of patients seeking assistance in the recent years [ 9 ]. Particularly, in The Netherlands the prevalence of people wishing to receive hormonal or surgical therapy because of the incongruent gender identity is 0.6% for biological males and 0.2% for biological females [ 10 ].
In Asia, a recent report calculated the rates in Japan to be 1 : 25,000 for male-to-female and 1 : 12,000 for female-to-male [ 11 ].
Another study from the University of Singapore showed that the transsexuals number in this island is 35.2 per 100,000 inhabitants (1 : 2,900) for FTM and 12 per 100,000 (1 : 8300) for FTM [ 12 ].
Finally, the unpublished studies from Winter [ 13 , 14 ] are calculating a prevalence of 0.3 to 0.6% MTF persons in Thailand.
Currently, the Chulalongkorn University, Bangkok, Thailand, is in the process of granting a study and collecting data on the prevalence of transsexualism in Thailand. Since it is possible to observe and find transsexual people in any public place such as school, universities, and any working place, a much higher incidence of transsexualism in Thailand is expected, compared to the data reported in the world literature.
3. Influence of Religion and Social Attitude on Gender Reassignment
Thailand is roughly 95% Buddhist. Winter and Udomsak have already published an overview on the position of Thailand transsexual within the Buddhist religion and society [ 15 ].
As in other South-East Asian societies, nonnormative gender categories form part of the indigenous cultural tradition [ 16 ], with the common belief until the beginning of last century of the existence of three sexes: male, female, and male-female [ 17 ].
Jackson (1988) [ 18 ] reports that the Buddhist Vinaya text (a code of conduct for monks) identified four main sex/gender categories: males, females, ubhatobyanjanaka (hermaphrodites), and pandaka (males displaying a variety of other nonnormative anatomies or sexual preference) [ 15 ].
Today, the terms transgender and transsexual are seldom used in Thailand. Instead, Kathoey , a word originally used todenote hermaphrodites is used today to describe a male-to-female transsexual [ 18 ].
Unlike Christians, Buddhists cannot point to specific religious laws or teachings forbidding homosexuality, transsexuals, or gay marriage. One of the fundamental teachings of Buddhism is tolerance of those who act differently or hold different views. At first blush, this tolerance (if not acceptance) would seem to extend to transsexuals in Thailand. Transsexuals, in fact, are integrated into everyday life, and physical or verbal assault on transsexuals in public is extremely rare [ 17 ].
Again, Buddhism may play a role. While the Buddhist focus on tolerance does in part shape Thailand society's tolerant view of transsexuals, the Buddhist principle of karma may provide an alternative explanation: Thai people believe that people are born kathoey because they are being punished on this life of their misdemeanor of a previous one [ 17 , 19 ].
The standard karmic tale, in fact, is that transsexuals were formerly “playboys” in their former lives and, as a result of breaking so many lovelorn hearts of women, they were imposed the ultimate punishment, making them a woman trapped in a man's body, forever doomed to unrequited love. Therefore, they are a group to be pitied, not protected.
In the past, in fact, the Thai society had negative thinking about the transsexual individuals and the surgical procedure; particularly, the Thai society disliked patients' appearance and their overacting manners; furthermore, transsexual people were considered to have low education and no taste and were believed to work mainly in the sex industry [ 20 ].
Thai people also believed that the result of the surgery was not good, giving lots of complications [ 20 ].
It was not long ago (December 1996) [ 15 ] when a transsexual student enrolled in an education program at a public university murdered a female friend; in response to this, another well-known higher education institution in charge of Thailand's teaching universities banned transgender and homosexual students from attending their teacher training facilities.
At the time, transsexuals were variously referred to as “sexually deviant” and “sick…mentally” by members of the institute, and they were considered of having a bad influence on children. This argument was simply keeping in line with the Department of Mental Health, which at the time considered homosexuality a mental disorder. Subsequent pressure from both Thai and Western gay rights groups soon forced a repeal of the ban.
Up to day, kathoey have become so prominent a part of modern Thai culture that the authorities have taken steps to reduce their profile, for example, making it more difficult for them to work as teachers or tour guides and advising television stations to curb MTF appearance on shows [ 15 ].
According to a study by Dr. Winter, Hong Kong University students showed a marked male antipathy towards male gender variance [ 21 ].
At the opposite, more recently, several transsexual individuals became successful in their careers, especially in the entertainment and mass media industry such as the actors, singers, reporters, and even models.
Transsexual beauty pageants, such as Miss Tiffany's Universe and Miss Alcazar, are held in Thailand and televised nationally each year.
Today, Thailand appears to live up to its worldwide reputation as a place where transsexuals can experience greater freedom and acceptance than in other nations.
Particularly, transsexuals' appearance and manners seem to the Thai population much more similar to the way ladies are acting and behaving. At the same time, the sex surgical conversion got more and more the reputation of being successful, both domestically and internationally. In fact, parallel to the explosion of the tourism market (90's) in Thailand, more foreigners were coming to Thailand to receive sex change operations. The Thai population has been witnessing this medical tourism for the past 20 years [ 20 ].
In spite of this new Thai face, a closer look at its society and culture, however, still reveals a society with a decidedly mixed view of transsexuals [ 22 ].
4. Law and Regulations
4.1. law and society.
Thailand legal system reflects the Thai society [ 23 ].
As far as the government of Thailand is concerned, male-to-female transsexuals are legally men. Transsexuals cannot legally change their gender on their ID cards, leading to problems with potential employers. Many employers do not want possible complications involved with hiring a transsexual if an equally qualified “normal” person can be hired. Because of this, the vast majority is relegated to occupations traditionally held by women, that is, waitresses, hairdressers, makeup artists, and vendors, even if they are university graduates. Transsexuals' birth gender must remain the same on their passports as well; a fact that can lead to confusion and unwanted scrutiny at border crossings and immigration checkpoints. Thailand also prohibits same sex marriage, meaning that when the partner of a transsexual dies, the deceased's family receives any or all assets [ 24 ].
In the past years, there have been some positive developments since the transsexuals and the gay community in general have achieved some legal gains. In 2002, in fact, the Department of Mental Health, under intense pressure from the gay community, removed homosexuality from its list of mental disorders. This decision helped to pave the way for the Thai military to announce in 2005 that it would discontinue its practice of dismissing transsexual and gay recruits for having “a severe mental disorder” and the subsequent announcement in March 2008 that the military would be adding a “third category” for transsexuals [ 24 ]. This third category would allow transsexuals to be dismissed from service due to “an illness that cannot be cured in thirty days”, thereby removing the scarlet letter of “mental disorder” from their service records-records that must be provided at each job interview and with each loan application.
4.2. Regulations for the Treatment of Gender Reassignment
Until 2009, there was no definite rule to regulate gender reassignment in Thailand; nevertheless, some plastic surgeons (as the authors of the present manuscript) were still following the SOC as suggested by the WPATH, as for the criteria to select and treat transsexual patients. However, until 2008, there were many cases of castrations to teenagers, performed by nonurologists and nonplastic surgeons, and this made the social and the mass media upset and panic [ 23 , 24 ].
As a consequence, pressure was put on the Thailand Medical Council to regulate the medical practice for the treatment of transsexual patients; subsequently, the Thailand Medical Council published a policy entitled “Criteria for the treatment of sex change, Census 2009”, which was effective from November 25, 2009. Among the criteria, patients have to be over 20 years of age, or they can be between 18 and 20 and have consent of at least 1 guardian. Also, patients should have documents to approve their surgery from 2 different psychiatrists. For other details, the SOC of the HBIGDA/WPATH should be followed, including furthermore, the real life experience for at least 1 year [ 23 , 24 ].
5. Thailand Health Care for Transsexual Patients
In spite of the fact that the Thailand Medical Council posed regulations on the treatments of transsexual patients, Thailand Government hospitals generally do not offer free treatments (psychological assessment, hormonal or surgery) to transsexual patients.
For this reason, Thaitranssexuals seek for all their gender treatments privately.
Most of the Thai transsexual patients do not visit the psychiatrist at the onset of the gender dysphoria: in fact, they do not believe that psychiatrists can be of any help to them, but only for signing for the diagnosis, which is allowing the surgeon to proceed with the surgery. Further to this, the quality of the care organization offered at the psychiatrist services (and other medical services) in the Government hospitals is presenting with long waiting queues; finally, very few psychiatrists in Thailand are currently interested in this field, and these psychiatrists are practicing in private settings. As a consequence, most of the transsexual patients visit the psychiatrist only when they decide to get the surgery done.
The hormonal treatment is a very weak point within the treatment, too: very few endocrinologists in Thailand have experience in this field, and patients prefer to listen to senior fellows of their society, accepting suggestions passed to each other as word of mouth, rather than giving their trust into endocrinologists. As a consequence, nearly all the transsexuals use hormones, but very few of them are under the care of endocrinologists. Hormones are usually bought directly from the pharmacy; no prescription is required.
Thai transsexuals mostly start with the hormonal treatment when in secondary school (14-15 years old). The popular hormones used are the contraceptive pill such as Progynova; Diane-35; Premarin; once a day; and/or Progynon/Proluton injection every 1-2 weeks. Some patients also add Androcur.
Sex reassignment surgery is usually performed when patients are in their 20's, and at this age most of the patients have received hormonal therapy for at least 5 years.
Nearly all the surgical treatments are performed privately. The Government finances surgical treatments rarely, and for teaching purposes only. These surgical treatments are exclusively performed at CUH and, more recently, at Lerdsin General Hospital in Bangkok. Even in these cases, surgery is not offered free of charge, but patients have to pay for some of the hospital costs. In 2012, 8 vaginoplasty operations in MTF transsexuals were performed at CUH (see Table 1 ). Three to four mastectomies in FTM transsexuals and 2 penile reconstructions (usually metaidoioplasty, with less than 10 procedures performed in the last 20 years) are also performed at CUH per year.
Number of vaginoplasty procedures performed at Chulalongkorn University Hospital.
For transsexual patients coming from abroad and seeking private sex reassignment surgery in Thailand, letters confirming diagnosis of gender dysphoria from psychologists/psychiatrists from the patient's homeland are regularly accepted.
Currently, while in the University Hospitals all patients are from Thailand, within the private sector the ratio of foreigner to Thailand patients is 10 : 1 (see below).
Opposite to surgery for MTF transsexuals, surgery for FTM transsexuals is not common in Thailand even within the private sector.
Thai transsexuals receiving vaginoplasty are usually followed up until 1 year postop, while foreigner transsexuals are usually receiving their last followup with their surgeon 2 weeks postop; then, they are instructed to continue their care with endocrinologists or gynecologists in their home countries. They might come to Thailand for later followups if needed, but this is uncommon.
6. Surgeons' Profile
To date, there are about 20 Thai surgeons able to perform SRS. However, the highest number of the procedures (MTF only) in concentrated among 6 major groups are as follows: PAI (Preecha's Aesthetic Institute) (Bangkok), Suporn (Pattaya, Cholburee), Chettawut (Bangkok), Kamol (Bangkok), Sanguan (Phuket), and Yanhee (Bangkok).
By directly interviewing the surgeons involved in GRS in Thailand, we calculated the ratio between Thai and Foreigner patients surgeries operated in Thailand in the past years. All the above-mentioned Bangkok-based centers are included in this survey, except Yanhee.
Between 1985–1990, only 5% of the transsexual patients operated in Thailand were foreigners; at the opposite, 90% of the transsexual patients operated in Thailand in the period 2010–2012 were foreigners (see Table 2 ).
Ratio of the Thai/Foreign MTF transsexual patients operated in Thailand.
Now a day, there are at least 2 or 3 foreigner patients operated per day in Thailand, and receiving MTF-SRS.
Since 1985, the mean age of the Thailand transsexual patients is 27 years old (17–50).
Mean age of the foreigner transsexual patients is 46 years old (16–72).
Foreign patients resulted to have higher degrees (e.g. medical doctors, engineers, lawyers, police officers, etc.), more successful and stable in their profession, rather than Thai patients.
Since the first Thailand's sex change surgery in 1975, the Thai social attitude, law system, and regulations to treat transsexual patients have very much improved. Particularly, the WPATH SOC are full in place within the regulations presented by the Thailand Medical Council. In spite of these improvements, Thai transsexual individuals are not fully integrated within the society, the law system does not guarantee to transsexuals the same rights as in other Western countries, and health treatments for gender dysphoria (psychiatric assessment, hormonal and surgical treatments) are not provided free of charge within the umbrella of the Government Hospitals, but these are paid by the patients themselves. On the other hand, we believe that the way Thai transsexuals appear in the media and to the Western world, the current Thailand economy allowing for surgery at a cost cheaper than in Western country, and the experience progressively achieved by Thai surgeons over the past 30 years contributed to an increasing number of foreign patients coming and receiving gender reassignment surgery in Thailand.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this paper.
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Gender Reassignment Surgery in Thailand
If you're paying out of pocket for Gender Reassignment Surgery, Thailand offers an unbeatable combination of highly experienced GRS Surgeons, state-of-the-art medical facilities, affordability, and the warm hospitality that has made the country the tourism jewel of Southeast Asia. In this introduction to Gender Reassignment Surgery in Thailand you'll find out why Thailand continues to top the list of surgery destinations for trans women year after year.
"Thailand is the most popular overseas destination for patients seeking sex-reassignment surgery." — Josef Woodman, CEO of Patients Beyond Borders ( Bloomberg )
The Land of GRS Experts
Thailand boasts several international experts in Transgender Surgery. These are Surgeons who have impeccable academic and medical training, a decade or more of experience performing GRS, and are globally recognized as experts in the field. They work at top-notch, accredited hospitals (JCI, ISO or HA) and have a history of delivering satisfying results. Many have performed GRS thousands of times, and have far more experience than some of the popular Surgeons in the U.S.
Bloomberg recently reported that there are at least 100 Thai doctors qualified to perform Gender Reassignment Surgery, though a recent study identified 6 primary clinics: Kamol (Bangkok), PAI (Preecha's Aesthetic Institute) (Bangkok), Suporn (Pattaya, Cholburee), Chettawut (Bangkok), Sanguan (Phuket), and Yanhee (Bangkok).
"They have the best doctors here and I feel I can count on them." — Eimy, GRS patient ( Bloomberg )
"[Thailand's] got the reputation and it's well set up. The Thais are doing a perfectly satisfactory and safe job." — Dr. James Bellringer, a urological surgeon who's performed more than 1,000 male-to-female operations in London. ( Bloomberg )
World-Class GRS Facilities
Based in Bangkok, Dr. Kamol Pansritum has completed over 5,000 Gender Reassignment surgeries since 1997. Dr. Kamol currently performs more than 200 MTF Vaginoplasty surgeries a year. Page after page of testimonials on his website include glowing reviews and heartfelt thanks from satisfied patients from around the world.
Dr. Kamol runs his own surgical facility: the JCI-accredited Kamol Hospital . Featuring the most advanced medical equipment and technology available, Kamol Hospital's operating rooms are among the most advanced in the world. The elegantly-designed Kamol Hospital also has luxurious patient rooms and recovery apartments.
Dr. Pichet Rodchareon is the Chief Plastic Surgeon at the Bangkok Plastic Surgery private hospital located in the heart of exciting downtown Bangkok. Dr. Pichet is considered one of top SRS surgeons in Thailand. His training includes plastic surgery, hand surgery, craniofacial and maxillofacial surgery. This experience and training have given Dr. Pichet the skill to provide his patients with superior aesthetic and functional results.
Dr. Pichet's private hospital is equipped with the most advanced medical equipment available, modern patient rooms and an elegant reception area.
Cost-friendly Gender Reassignment Surgery
The relatively low cost of Gender Reassignment Surgery in Thailand is one of the reasons why so many patients choose to come here. That GRS is easily accessed in Thailand can be attributed in part to the country's liberal views about sex and LGBT people.
For centuries, Thailand has embodied a relative openness in navigating categories of sexuality and gender. Walk down the street in Bangkok, and you're likely to see people labeled as kathoey, or "ladyboys." The nation has one of the largest transgender populations in the world, a fact many people — surgeons, therapists, transgender people — find difficult to explain. Maybe it's the relatively open Buddhist culture, one surgeon speculated. Perhaps it's out of financial necessity, others suggested, alluding to a high demand for kathoey sex workers. — Source
Whatever the reasons, Thailand now has a worldwide reputation as a global center for Gender Reassignment Surgery, and as a place where transgender people can experience greater freedom and acceptance compared to other countries.
Trans women pay $10,000 to $25,000 USD or more to surgically transition in Thailand, compared to three or four times as much in the U.S. Without a doubt, having surgery in Thailand—possibly the world's foremost destination for GRS—can net you huge savings!
WATCH NOW! Dr. Kamol and Kamol Hospital were featured on Secret Lives of Women , a reality television series that aired on WE: Women's Entertainment. Watch Cristina Juanes' amazing transformation in Thailand, where she has Breast Augmentation, Tracheal Shave, Vaginoplasty and FFS. Note: Contains graphic operating room scenes and is not safe for work.
Warm Thai Hospitality
"I am in Bangkok at Dr. Kamol's Hospital having been rigorously retested, x-rayed etc and declared fit for surgery and with one sleep to go this afternoon from which I shall emerge, re-birthed female & the woman that I have always believed I should have been born." Three weeks later... "I have arrived where my heart has been all of my life. I feel at one with myself for the first time." — Divvi De Vendre
People who have traveled to Thailand often use worlds like "friendly" and "helpful" to describe the local people they encounter. True to the reputation, the GRS clinics in Thailand have focused on providing the highest quality of care coupled with the friendliness you would expect in Thailand. Many trans women have come home from Thailand raving not just about the skill and capability of the staff, but also about the staff who have become new friends.
For those who would like extra help with planning surgery and travel, specialized concierge services are also available. Your personal concierge can assist with:
- Travel planning
- Document preparation
- Medical test documents
- Language interpretation
- Post-operative care (at your hotel)
The expertise in GRS developed by Thai surgeons over the past three decades has contributed to an increasing number of foreign patients receiving Gender Reassignment Surgery in Thailand. There are now at least 2 or 3 foreign patients operated on per day in Thailand (receiving MTF GRS.) With its highly qualified Surgeons, advanced medical facilities, lower costs and warm hospitality, it's easy to see why Thailand has become the leading Transgender Surgery destination.
Get Started Here!
- Call: +662 559 0155
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