Frequently Asked Questions about Sex Reassignment Surgery (SRS)​

October 27, 2018

Frequently Asked Questions about Sex Reassignment Surgery (SRS)

Many transgender people experience a marked incongruence between their experienced gender and their assigned gender, gender dysphoria. Gender dysphoria may cause people to experience major upset and impairment on social and personal levels. For these individuals, gender role changing, hormone therapy, and sex reassignment surgery permit their outside appearance to match what they feel internally.

If you or a loved one are considering sex reassignment surgery, you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects, and the types of surgeries that are available.

Q: Do I need to take hormone therapy before SRS and how long does it take to see the desired results?
A: For transgender individuals desiring sex reassignment surgery, hormone therapy (HT), also called hormone replacement therapy (HRT), involves taking estrogen for a male to female transition. Hormone therapy may be used before, during, and after the surgical transition to another gender. The purpose of hormone therapy is to change the physical appearance into that of the desired gender.

The feminizing effects of estrogen may appear after the first couple of doses, although it may be several years before a person is satisfactorily transitioned. This is especially true of breast development.

Q: What are the effects of estrogen?
A: When a biological male begins taking estrogen, changes include both a reduction in male sexual characteristics and an increase in female characteristics. In addition to decreased sex drive and mood swings as behavioral changes, changes to the body include:
▪ Breast development,
▪ Loss of erection,
▪ Shrinkage of testicles,
▪ Decreased acne,
▪ Decreased facial and body hair,
▪ Decreased muscle mass and strength,
▪ Softer and smoother skin,
▪ Slowing of balding,
▪ Redistribution of fat from abdomen to the hips, thighs, and buttocks.

Q: Are there any other steps required before SRS in addition to hormone therapy?
A: In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in these types of operations, there are other steps which must be accomplished before surgery is performed. Necessary steps may include mental health evaluation, clear and consistent documentation of gender dysphoria, and "real life" test.

Q: When can I start having SRS after my hormone therapy? How long will the operation take?
A: Surgery is delayed until at least one year after the start of hormone therapy and at least two years after the first mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Most often, surgeries involved in sex reassignment surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, so our experienced surgeon will have a thorough discussion with you to get the best solutions for your SRS journey.

Q: I have very limited penile skin and I’m afraid that I cannot get enough depth of vagina. Do I have to consider Sigmoid Colon SRS?
A: With the advance SRS technique we use now, it doesn’t really matter the penile skin availability. We can get skin graft from other area of your body to create the desired depth. Normally, we will use penile skin with scrotal skin graft first and if they are not sufficient, we can opt for abdominal skin graft. From our experience, our patients who have limited penile skin, can get a good depth from this technique which has less risks than Sigmoid Colon SRS.

Q: Which factors does the depth of neovagina depend on?
A: When the operation begins, we will try to create the vaginal cavity as deep as possible but we have to consider patient’s safety as well. Therefore, our limit is at peritoneal reflection (It is a point of an “apron” that covers internal organs such as intestines etc.), going farther than this point can be harmful to your body. Normally the distance between vaginal opening and peritoneal reflection is around 5 to 7 inches. After creating the vaginal cavity, we will use penile skin+scrotal skin graft as vaginal cavity wall. The depth of the neovagina you will get depend on various factors:
▪ The distance from vaginal opening to peritoneal reflection
▪ Skin graft quality: there is possibility that the graft is failed and shrunk and may lose depth after surgery.
▪ Dilation: It is the most important post-op care. All SRS patients have to do it correctly and regularly especially during the first year post-op and lifetime. Failure in dilation can create vaginal stenosis and finally losing depth.

Q: What is the dilation schedule? Do I need to do it forever?
A: During the first year post-op, you need to do dilation 2-3 times a day. After one year, you may do it less to maintain vaginal width and depth.

Q: Can a sexual intercourse substitutes the daily dilation procedure?
A: Even Though you have sex regularly, it cannot be counted as dilation. Patient must use a rigid dilator to enlarge the vaginal cavity and give a small pressure when reach the end to maintain the depth.

Q: Any comment about the quality of life after SRS?
A: Quality of life appears to improve after gender-affirming surgery. One 2017 study found that surgical satisfaction ranged from 94 percent to 100 percent. Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of SRS for those who feel it is their best choice.

Bottom Line on Sex Reassignment Surgery
Sex reassignment surgery is a lengthy process and finding an experienced surgeon who focuses on SRS alone and has performed many of these procedures is a must for successful operations. For those who follow through with these preparation steps, hormone treatment, and surgeries, quality of life appears to be good, and many people state that they would undergo SRS again.



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