Category Archives: Gender Reassignment Surgery

Review of Gender reassignment surgery: an overview

This article is a good summary of surgeries used in medical transition. It is not a study or review of studies, but it is written by two experienced surgeons from the United Kingdom. They provide some numbers related to complications and some valuable information on specific techniques.

It is important to remember that this is not a scientific study or survey; it is a report by surgeons based on their experience. The results in other clinics may be different. If you are seeking surgery, ask your doctor about their work.

The authors’ discussion of sexual pleasure and orgasm is very limited. They do not discuss patient satisfaction. They do not look at the mental health effects of surgery, either, just the physical outcomes.

As always, there are many areas where we do not yet have any studies and we don’t know the answer. We could use more studies and articles about the various techniques, their outcomes, and their complications. Any evaluation of these techniques should include patient satisfaction and sexual function.

So what are the physical outcomes and complications of various surgeries that the authors discuss?


Some Complications and Risks, Vaginoplasty

Death from pulmonary embolism – 1 in 1000 among recent patients at their clinic.

Pulmonary embolism (blood clot that travels to the lungs) – 2 in 1000 among recent patients at their clinic. The length of the surgery makes blood clots a problem; this clinic works to reduce them.

“MtF surgery can be complicated by all the normal nonspecific complications of major surgery. For instance, venous thromboembolic disease is a particular problem, partly owing to the nature of the operation (pelvic surgery), the prolonged duration of the operation (5 h in some units) and the practice, which is still common, of keeping patients on bed rest for several days after the operation. In our unit, the operative time is reliably in the region of 120–150 min and patients are mobilized immediately after surgery to reduce the risk of thromboembolism. Combined with routine use of low-­molecularweight heparins and compression stockings, we have seen only two pulmonary emboli in the last 1,000 MtF surgical procedures (one of which was fatal).”

Clinically significant bleeding – At least 10%. Most of the bleeding is from the “corpus spongiosum surrounding the urethra.”

“Specific to the operation itself, the most common complication of MtF surgery is bleeding. In units with large numbers, labial hematomas are seldom seen, but do occasionally occur. Most may be managed conservatively, but they do result in an increased incidence of wound dehiscence [opening up along the incision], as observed in our institution. The principle source of postoperative hemorrhage is from the corpus spongiosum surrounding the urethra. Even with meticulous suturing, some 10% of patients will experience clinically significant bleeds. This bleeding may be reduced by leaving the postoperative pressure dressing in place for longer, but that in turn can inhibit patient mobilization and may result in increased risk of thromboembolism.”

Fistula (hole) between the rectum and vagina – 6 in 800 at their clinic in 2008 – the numbers are unknown in general and possibly “seriously under-reported.” The cause is unknown.

Fistuals frequently require further surgery and sometimes lead to the removal of the neovagina.

“When a fistula occurs, a defunctioning colostomy is usually needed. About 50% of fistulas will then close spontaneously, but in the remainder further surgery is needed. In difficult cases, removal of the neovagina may be required.”

Narrowing of the urethra – 3-4% minimum rate. This problem causes “dribbling incontinence.” The narrowing develops a few months after the operation and requires surgery. The surgery is usually effective – “although a few do go on to long-term intermittent catheterization.”

Loss of vaginal depth and width – The authors give no numbers, but believe that these complications are under-reported. The loss of depth could be due to loss of skin; in this case a new vaginoplasty is required using using tissue from the bowel. Loss of depth and width could also be caused by not following a proper dilation routine.

“Again, these complications are probably markedly under-reported, as some patients are effectively celibate or do not need much vaginal depth and width for their chosen sexual activities.”

Growth of hair in the vagina – This is caused by not removing hair either before surgery or perioperatively. There is no cure; if your surgeon is using skin from the scrotum, be sure to have the hair removed.

“Once hair growth is seen in the vault of the neovagina, little can be done to prevent its continued growth, and a number of patients will have to return at intervals for removal of hairballs.”

Overall complicate rate – Under 25%. It is not clear exactly what complications they are including in this number.


The authors don’t give numbers on orgasms or sexual satisfaction. In their experience, the vast majority of innervated neoclitorides have sensations.

Some surgeons create additional erogenous sensation by putting the part of the glans penis left after making the clitoris between the urethra and neoclitoris.

Past techniques led to problems with urethtral fistualas and leaking pee, but the techniques have changed.

“The rate of urinary leakage from urethral fistulas was substantial with this technique and it has now been largely superseded by techniques in which the neurovascular bundle to the glans, which lies between Buck’s fascia and the corpora cavernosa, is preserved. This technique has been widely described and seems to provide good rates of sensitivity and sexual satisfaction.”


Creating labia minora is challenging. The best technique to use will depend on how much skin is left from the penis; this may vary depending on the individual and the surgery. There aren’t any guidelines on how to do this.

“Overall, a balance needs to be achieved between construction of a satisfactory neovagina, and a good, realistic, cosmetic external appearance. To date, no guidelines exist that give an indication of when and how penile or scrotal skin should be used for clitoral hood or labia minora reconstruction, or the ideal penile skin length, depth of the vagina or tissue that should be used. The choice of technique for labioplasty is, therefore, largely that of the individual surgeon.”


The authors describe one technique which has a low rate of immediate complications like bleeding, but can lead to peeing upwards or narrowing of the urethra. In addition, this technique leaves in place some erectile tissue that swells during sexual arousal.

The authors prefer a different technique which creates a satisfactory direction of pee and which they believe looks better cosmetically. However it has a raised risk of bleeding.

Specifically, with the first technique they “divide the urethra in the proximal bulb and suture the urothelium direct to the skin (bringing the urethra through the anterior skin flap)” and with the second they “spatulate the urethra, and excise some or all of the corpus spongiosum posterior to the urethral meatus.”

Other Surgeries for Trans Women

The authors briefly mention breast augmentation, vocal cord and throat surgery, and facial feminization surgery.

Breast augmentation in trans women is similar to breast augmentation in cis women, but will be affected by the shape and size of the starting breast tissue and muscles.

Speech therapy is required after vocal cord surgery.

“In facial feminization, good results are achieved by shaving of the frontal bossae, the brow ridges, the mandible angles and the chin, accompanied sometimes by rhinoplasty.”


Some Complications and Risks, Metoidioplasty

One of the advantages of a metoidioplasty is that there are few complications and recovery time is “quick.”

“The complication rate is relatively low (overall complication rate <20%)—especially when compared with more elaborate microsurgical techniques, in which complications are reported in 40% of patients.”

The disadvantages of this type of surgery are that it produces a short phallus that may not be capable of sexual penetration. Not everyone can pee standing up.

On the other hand, sexual sensations are well preserved which is a pretty important factor. The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

“…micturition in a standing position is somewhat, but not always, achievable. Despite the small size, some patients report satisfactory intercourse with female partners, and sensation is usually well preserved. Nevertheless, this approach is not well suited to individuals in whom clitoral hypertrophy is less marked, and the small size of the resultant phallus is unsatisfactory for most patients, not least because it is inadequate to show in clothing and for satisfactory sexual penetration.”

Are they trying to cause dysphoria here? I don’t think there are any numbers on what percentages of trans men prefer which form of surgery.

Some Complications and Risks, Phalloplasty

Overall complication rate – Over 40%. it is not clear exactly what complications they are including.

Microsurgical flap failure – Less than 2%.

Fistulas involving the neourethra – 25-30% in most series.

“Most fistulas will eventually close after a period of catheterization, but many require revision surgery.”

Urethral stricture formation (narrowing of the tube that carries pee out of the body) – 18%.

Postmicturition dribble (dribbling after peeing) – In one study, 79% of patients reported this problem.

Erectile function – Most phalloplasty techniques require the insertion of an inflatable prosthesis to become erect for sexual activity. “…the failure rate for penile prostheses is considerable, usually owing to infection of the device…”

We don’t know much about this yet. “Long-term results on the use of these erectile implants in FtM transsexuals is still lacking.”

There are some techniques that do not require a prosthesis, but they may have other issues.

“When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis without requiring a prosthesis. Flaps harvested with bone (for example, fibula or osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection.”

Sexual sensation – For free-flap phalloplasties, “Sexual sensation with retention of ability to orgasm is usually preserved.” The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

Different techniques – There are a few different techniques for phalloplasty, but we don’t have any studies comparing them to see which ones are best.

“To date, the gender team at Ghent University Hospital, Belgium, has published the largest series on phalloplasty (with radial forearm flap technique). The investigators demonstrated that the radial forearm flap is a reliable technique, although evidence that other techniques are similarly reliable, or even better than the radial forearm flap, is lacking.”


An earlier review found few studies of mastectomies specifically for trans men. However, as the authors note here, it is important to have a surgeon experienced in mastectomies for trans men. The surgery is not the same as it is for women.

The authors give no numbers on complications but note that people often need minor revisions for cosmetic reasons.

The authors provide a few notes on techniques:

“The exact technique will depend on the volume of breast tissue, and the skin excess and elasticity. In small breasts, a satisfactory result may be achieved by subcutaneous mastectomy via a circumareolar incision, but in most patients more extensive surgery, with additional noticeable scars, is required. For very ptotic breasts, a breast amputation with free nipple– areola complex graft is indicated. Finally, the nipple itself and the diameter of the areola are often reduced. When done properly, the results may be very satisfactory, but poor technique can lead to unacceptable cosmetic results. Minor revisions to ameliorate the final cosmetic outcome are often required.”

Other Surgeries for Trans Men

For scrotal reconstruction, “As long as this advancement of the neoscrotum to the natural position in front of the legs is carried out, very satisfactory results can be obtained with no major complications.”

The authors say patients should get their uteruses and ovaries removed. They don’t provide any additional information on the procedures.

“Patients will also require hysterectomy and ovariectomy, because of the potential risk of endometrial carcinoma with protracted testosterone use, and are usually accomplished laparoscopically at the time of one of the stages of subsequent phalloplasty. The short blind-ended vagina can be left in place or removed.”

We could use more studies and articles on all of the above surgeries.


“Gender reassignment surgery—in which elective surgery is performed to alter an individual’s body to resemble the other sex and in doing so adapt the body to the patient’s perception and lifestyle—is one of the most challenging surgical disciplines.

In MtF surgery, the technique is largely standardized, but refinements are needed to satisfy specific patient requests, such as vaginal depth and ‘perfect’ cosmetic outcome.

In FtM surgery, the variety of techniques available demonstrates that the ideal technique has not yet been identified and, depending on a patient’s request, a different surgical approach should be used. Furthermore, very few centers have the experience of, and subsequently can offer, different techniques for FtM gender reassignment. Moreover, complications are frequent and limitations to the ideal reconstruction are present with every technique used.

The complex psychological background of the patients and their expectations further challenge gender reassignment surgeons. The cooperation of the gender team in making a diagnosis, selecting appropriate patients for surgery, and deciding timing and type of surgical procedures to be performed, is crucial in reducing patients’ regrets or minor dissatisfactions (at both physical and psychosocial functioning levels) as a result of possible complications or for not having achieved the result expected.”

Original Source:

Gender reassignment surgery: an overview by Selvaggi G, Bellringer J. in Nat Rev Urol. 2011 May;8(5):274-8.



Transsexualism and Anorexia Nervosa: A Case Report – Review

This is a somewhat surprising case report of a trans man (born female) who developed anorexia nervosa after sex reassignment surgery.

The 24-year-old patient had surgery to remove his breasts, ovaries, and uterus. Afterwards he began binging and purging. He had not had problems with eating behaviors or weight loss before surgery.

This case is similar to the trans woman (born male) in this study who began to diet excessively after sex reassignment surgery. It is, however, different from this trans man who stopped dieting once he was on hormones and menstruation ceased.

The authors suggest that the eating disorder is an “expression of a gender identity process, or a conflict of an acceptance of one’s own sexuality.”

It is easy to understand why someone with gender dysphoria might dislike their body and develop problems eating, but in this case, the patient had already changed his body.

Why did the eating disorder develop after physical transition was complete?

Had he been focused on changing his body with hormones and surgery and then when he was done, he focused on his shape?

Was his eating disorder a sign of persistent body dissatisfaction no matter what he did?

The authors suggest that the patient’s underlying problems may have caused the eating disorder:

“In this case, there was clearly a linkage between a lack of sense in self-efficacy and a body dissatisfaction that continued after the sex change surgery. Discomfort with her/his own body appeared to be more deeply anchored than just being rooted in the wish to change the physical appearance.”

Alternatively, might the surgery have caused an abrupt shift in hormones that led to an eating disorder? More importantly, could adjusting his hormones help him recover from the eating disorder?

We think of testosterone and estrogen as sex hormones, but they are much more than that. Like all hormones, they are part of a complex system of chemicals that affect each other. Specifically, we know that “sex” hormones also play a role in appetite.

“The sex hormones estrogen, progesterone and androgens are involved in the complex regulation of appetite, eating and energy metabolism. In most species, including man, food intake and reproductive functions are closely linked. Thus, during the different hormonal phases of the menstrual cycle daily food intake varies and, moreover, remarkable physiological adaptations of appetite and body composition occur during pregnancy and lactation. In addition, regulation of eating behaviour and metabolic functions by sex hormones is of considerable general importance for women’s health, as indicated by the disturbances in this regulation associated with a number of clinical disorders.”

From “Sex hormones, appetite and eating behaviour in women.”

In this case study, the patient’s estrogen levels would have dropped significantly after his ovaries were removed. In addition, doctors normally reduce the dose of testosterone after surgery, although to a level typical for a man.

Women eat less during the phase of the menstrual cycle when estrogen levels are high, so it is possible that a drop in estrogen levels would be connected to eating more.

Furthermore, bulimia may be connected with polycystic ovary syndrome (PCOS), a syndrome which is characterized by elevated androgen levels.

Testosterone stimulates appetite and high circulating levels of this androgen in women have been associated with impaired impulse control, irritability and depression, i.e., common features of women with bulimia. Accordingly, it has been proposed that elevated levels of androgens may promote bulimic behaviour by influencing craving for food and/or impulse control. Hypothetically, bulimia may, in some cases, have a hormonal, rather than a psychiatric etiology, a suggestion supported by the observation that antiandrogenic treatment reduces bulimic behaviour. This may turn out to be a novel and valuable approach to treating women with BN, particularly those with hyperandrogenic symptoms.

From “Sex hormones, appetite and eating behaviour in women.”

The patient in this case study had symptoms that are typical of bulimia, binging and purging. Perhaps in his case the bulimia was related to the sudden drop in estrogen after surgery coupled with male levels of testosterone.

Most people do not develop eating disorders after sex reassignment surgery. There would have to be other factors involved, possibly genetic or psychological.

We have very little data on eating disorders and gender dysphoria, just a set of case studies.

However, we now have two cases of trans people developing an eating disorder after having surgeries that would have changed their hormones.

In one case, a trans woman began restricting her eating after surgery; in her case the surgery would have decreased her testosterone levels and thus, possibly decreased her appetite.

In this case, a trans man began binging and purging after surgery which would have decreased his estrogen levels and thus, possibly increased his appetite.

We need more research into this question. Do changes in hormones trigger eating disorders in some trans people? Most of all, can we use this to find a way to help trans people with eating disorders?


Original Source:

Transsexualism and Anorexia Nervosa: A Case Report by Fernando FernÁndez-Aranda, Josep Maria Peri, Victor Navarro, Anna BadÍa-Casanovas, Vicente TurOacuten-Gil,& Julio Vallejo-ruiloba in Eating Disorders: The Journal of Treatment and Prevention, Volume 8, Issue 1, 2000 pages 63-66.


More details on the patient:

After surgery, the patient had “2-4 weekly binge episodes with daily vomiting and abuse of laxatives and diuretics.”

He was overly concerned with being fat and wished to be thinner so his body shape wouldn’t look female.

He was moderately underweight, but then “during the last six months, he lost more than 15 kg [33 pounds] of body weight through restricting food intake.”

The Eating Attitudes Test, Eating Disorders Inventory, Body Attitudes Test, and Body Shape Questionairre showed “severe eating pathology and negative body experience.”

The patient also had problems with alcohol and drug abuse, self-mutilation, and suicide attempts, but these had begun at age 17.  He was diagnosed with “gender identity disorder, alcohol dependence, anorexia nervosa (purging subtype), major depression (Axis I), and borderline personality disorder (Axis II).

The patient’s father had obsessive-compulsive disorder and one of his sisters had an affective disorder.

As a child, the patient felt like a boy, didn’t play with girls, tried to hide any feminine parts of his silhouette, and hated feminine features of his body.

Gender Identity Disorder and Eating Disorders – a Review

Three more case reports, three different stories. In each case gender dysphoria is related to the eating disorder, but in each case the relationship is different.

In the first case a trans woman (born male) had an eating disorder in adolescence. After sex reassignment surgery, her eating disorder returned.

In the second case, a trans woman developed an eating disorder when she decided to come out and live as a woman. At the time of the case report, she was on hormones and awaiting surgery.

In the third case, a trans man (born female) who had been living as a man had had long periods of being underweight and not menstruating. He denied dieting or caring about his weight, but he was very dissatisfied with his body. He was purging. Unfortunately, he also had alcoholism and had developed liver disease; he was therefore unable to take hormones.

There is no clear relationship here between transition and eating disorders. In one case, transition made the eating disorder worse. In another deciding to transition was linked to the eating disorder, but taking hormones did not cure the eating disorder.

These are, of course, case studies of only three individuals, so we can not draw any conclusions from them. As with other case studies, it seems that each individual is different.

However, for one of the patients, her eating disorder seems to have started when she decided to live as a woman, like the patients in this studythis study and this one. For some trans women, at least eating disorders are linked to gender dysphoria.

In the case of the trans man, his eating disorder went untreated for many years, like the trans man in this case study.

These cases are from a Swiss hospital program for gender identity disorder.

Case 1 – Trans Woman’s Eating Disorder Returns After Surgery

In early childhood, the patient was gender non-conforming and felt that she was a girl. As a teenager, she felt a deep aversion to her genitals and the development of secondary sex characteristics. She avoided swimming because she was ashamed of her body.

In adolescence, the patient was dissatisfied with her body and dieted until she was underweight (BMI=16.9 kg/m²). She held the weight for several months.

She cross-dressed “moderately” starting at age 20. She was distressed during her compulsory military service. She lived with a woman and later married, but was not very interested in sex. Her marriage only lasted 1½ years and after the divorce she decided to transition.

At age 36 she began taking hormones. Sixteen months later she had sex reassignment surgery and her eating disorder returned:

After the operation she again showed an increasing preoccupation with her body weight and shape. Her eating behavior was again restrictive. She still avoids highly caloric food and warm meals. Although her actual BMI is 20.0 kg/m²she feels too fat and seeks an ‘ideal’ body shape. After the first operation there were some complications and she had to undergo several re-operations. She herself wanted an augmentation of her breasts and is considering further cosmetic operations, which can be interpreted as persistent body dissatisfaction. She engages in excessive sporting activity and has repeatedly had minor injuries partly provoked by taking higher risks.

It is not clear why the eating disorder would return after she had surgery. By the time she had surgery, she had been living as a woman for a few years and taking hormones for over a year.*

Did the change in hormones after surgery affect her eating disorder? After surgery, her testosterone levels would have been lower than most cis women’s and low testosterone is linked to eating disorders in both men and women. In addition, for some women, higher levels of estrogen are linked to eating disorders.

Alternatively, did the complications of her surgery trigger a desire to control her body? Or had she been focused on changing her body with hormones and surgery and then when she was done, she focused on her weight? Or was her eating disorder a sign of persistent body dissatisfaction no matter what she did?

Case 2 – Trans Woman Develops Eating Disorder When She Transitions

The second patient had identified as a girl and felt like an outcast since early childhood. Her teachers did not allow her to play with girls’ toys. She started secretly cross-dressing in elementary school. She was suicidal at age 10 and said she wanted to live as a girl.

The physical changes of puberty were very distressing to the patient. She was attracted to men, but did not have any sexual relationships because she was afraid and because she did not want people to think that she was gay.

The patient attempted suicide at age 20 because of her gender dysphoria. After the suicide attempt, she got psychiatric therapy and decided to come out as a woman. She started to dress as a woman in public.

This is when the eating disorder began:

“Before his** coming-out, his body weight was 120 kg and his height was 1.97 m (BMI30.9 kg/m²). After the suicide attempt he started dieting and lost 40 kg of weight within 2 years. The minimal weight was 80 kg (BMI: 20.6 kg/m²). The eating behavior at the beginning was dietary restriction, followed by purging, binge-eating, and self-inducevomiting. He consumed anorectic medication and engaged in excessive sporting activities. The decision to come-out went hand-in-hand with the ambition to attain a more feminine shape by losing weight. He is convinced that his acceptance as a female would depend greatly on an ideal body shape. The patient is currently under hormonal treatment and the surgical reassignment will soon take place.”

Deciding to transition caused this patient to develop an eating disorder as she tried to change her shape. Socially transitioning and taking hormones did not cure her eating disorder.

Case 3 – Trans Man with a Long-standing Eating Disorder

This is a very depressing case.

The patient preferred boys’ games growing up and felt he belonged with the boys. At age 6 he was sent to the school counselor because he refused to play with girls. His breasts caused him distress, but he did not bind them or self-mutilate. He got his period at age 14, but had secondary amenorrhea (no period for six months or more) for many years.

He was attracted to females and had had only female partners. His partners accepted him as male.

He had been living “in the male role” for over 20 years, but had never had any medical treatments for his gender dysphoria. He had refused to take estrogen for his amenorrhea, however.

The patient was underweight when he came to the gender identity clinic and he had been very underweight in the past.

Her** minimal weight at the age of 40 was 33 kg (BMI: 13.5 kg/m²).*** She reported longlasting periods of underweight accompanied by amenorrhea. She denied ever having intended to diet deliberately. She reported no binge-eating or self-induced vomiting, but she was purging. She denied preoccupation with her weight but reported a strong body dissatisfaction.

The authors could not treat her with hormones, however, because of “severe liver disease and the psychic instability and alcohol dependence.”

Although the patient denied it, it might be that he was keeping his weight down in order to avoid having periods.

Social transition did not help this patient with his eating disorder. We can’t know whether or not hormones would have helped him since he was medically unable to take them.

Gender dysphoria is clearly linked to the eating disorders of the two trans women and possibly linked to the trans man’s eating disorder. Transitioning did not cure the trans women’s eating disorders, however. In one case surgery led to the symptoms returning after many years.

Original Source (full text):

Gender Identity Disorder and Eating Disorders by U. Hepp, G. Milos in International Journal of Eating Disorders,12/2002; 32(4):473-8.


*In Switzerland at the time of these case studies, trans people had to live as their preferred gender for at least a year before they could get hormones. After at least 6 to 12 months on hormones, they were eligible for surgery.

** The authors of this study refer to the patients by their birth sex unless they have fully and legally transitioned.

*** A BMI under 16 is dangerous, a BMI of 13 is a serious problem.

Ability of an orally administered lactobacilli preparation to improve the quality of the neovaginal microflora in male to female transsexual women – Review and a possible health benefit

This is a very cool study that found that trans women could improve the microflora in their neovaginas by taking lactobacilli orally.

Trans women might need to keep taking the lactobacilli pills to maintain the good microflora in their neovaginas.

Why would you want to do this?

Well in addition to other benefits, mostly for digestion, lactobacilli can help to treat bacterial infections in the vagina and it may help prevent urinary tract infections.

According to the authors of the study, many trans women don’t have enough lactobacilli in their neovagina.

“The microflora of male to female transsexual women is a complex symbiosis of aerobic and anaerobic species with a very limited number of lactobacilli. It has substantial similarity to the abnormal vaginal microflora characteristic of bacterial vaginosis (BV) [1,2]. Weyers et al. reported that, although transsexual women show serum oestradiol levels comparable to those of postmenopausal women taking oestrogen replacement therapy, their neovaginal environment does not support the growth of lactobacilli [1]. In one study [1], only one of thirty transsexual women had neovaginal colonisation with lactobacilli. Another study of transsexual women, the same authors [2] found a neovaginal lactobacilli colonisation rate of 4%.”

In this study, the authors found a higher rate of neovaginal lactobacilli colonisation, however, everyone who took the lactobacilli improved their scores.

The study was a good, randomized test of whether or not the lactobacilli worked, using 60 trans women split into two groups (one taking the lactobacilli, one not).

The bottom line – Post-op trans women should talk to their doctors about whether they should take lactobacilli.

Their discussion of their results:

“The results of this prospective randomised controlled study show that oral administration of L. crispatus, L. rhamnosus, L. jensenii and L. gasseri significantly improved the neovaginal microflora and reduced the Nugent score in a group of transsexual women. Also, the microflora was significantly enriched with lactobacilli after oral supplementation compared to placebo. The combination of Lactobacillus spp. used in this study is the only one published as the physiologic mixture of female vaginal lactobacilli microflora [15]. We used an innovative probiotic lactobacilli composition containing four of the most common lactobacilli isolated from the microflora of healthy women’s vaginas [15] for treatment of 7 days’ duration. Weyers et al. reported that colonisation of the neovagina of transsexual women with lactobacilli is minimal [1,2]. According to Nugent, an intermediate vaginal microflora is defined by a reduction and BV by an absence of lactobacilli with the presence of Gram negative bacteria in both cases [14]. The small number of publications on the standard neovaginal microflora and the near lack of evidence of lactic acid bacteria in the transsexual genital tract area are a challenge for investigations in this population. While transsexual women have normal female anatomy, there is no uterus and no connection of the neovagina to the pelvic cavity, which is why the risk of pelvic inflammatory disease is low. We were therefore able to include all transsexual women without clinical signs of infection, including those with asymptomatic BV. To our knowledge, this is the first study to allow a direct assessment of the comparative effect of oral probiotic lactobacilli and placebo on BV.

The gastrointestinal tract plays an important role as a reservoir for the vaginal colonisation by Lactobacillusspp. [4], [5] and [6]. Both vaginal and oral applications of lactobacilli have been shown to improve the vaginal microflora of both pre- and post-menopausal women [3], [9], [10] and [11]. The results of this study indicate that oral lactobacilli have a similar effect on the neovaginal flora of transsexual women. Descriptive analyses of the difference in Nugent score showed a reduction of −0.18 in the intervention group and an increase of +0.92 in the control group.

We found a significant improvement in the Nugent score in 48.5% of women in the intervention group, compared with only 14.8% in the control group. Lactobacilli concentrations assessed by culture and real-time PCR were 5–6 times higher in the intervention than in the control group, with these differences being statistically significant.

The sample size calculation in this study was based on neovaginal lactobacilli colonization rates of up to 4% reported in the literature [1] and [2]. In the present study, however, 30% of the women in both the intervention and control groups had a normal lactobacillus microflora (Nugent score ≤3). This was an unexpected finding contrasting with the current literature [1] and [2]. Because oral lactobacillus supplementation cannot be expected to change a neovaginal microflora dominated by lactobacilli, this unexpectedly high proportion of women with a normal lactobacillus flora may have led to an underestimation of the treatment effect. We therefore carried out a subgroup analysis including only women with a baseline Nugent score above 4, corresponding to either an intermediate microflora or BV. Even then, after 7 days of treatment with oral lactobacilli, we found an improvement in the Nugent score in the intervention group and no change in the control group. The results of this subgroup analysis are comparable with the results of one of our earlier studies on the effect of lactobacilli on postmenopausal women, which showed an improvement in Nugent scores [11]. In contrast to the previous study with a lactobacilli treatment duration of 14 days, however, the improvement in the current was already seen after 7 days of oral lactobacilli. The renewed increase of the Nugent score two weeks after the end of oral therapy indicates that extended oral probiotic therapy may be necessary to maintain a lactobacilli-dominated microbiota.

This study had several limitations. With a specific study group of male to female transsexual women and very limited number of patients visiting our clinic we could observe only a small sample size in our study. The therapy duration was limited to 7 days: we assume that longer treatment with probiotics could obtain a better outcome. Microbiology analyses of CFU’s and c/ml were presented only for presumptive lactobacilli. In the next step we will include other bacteria with similar colony characteristics, such as Gardnerella vaginalis and Atopobium vaginae to present more detailed data. This study is first to observe male to female transsexual women using probiotics and we are aware of our initial oversights.

In summary, this first study on the effect of oral probiotics on the neovaginal microflora of transsexual women found that oral administration of lactobacilli resulted in a significant improvement in the Nugent score and a change of the neovaginal microflora. These observations are consistent with previous results obtained in pre- and post-menopausal women. The increase of the Nugent score two weeks after the end of oral therapy provides a possible need for extended oral probiotic therapy for maintenance of a lactobacilli-dominated microbiota. In addition, this study shows that even asymptomatic BV may be improved to a normal microflora by 7 days of oral supplementation of lactobacilli.”

Original Aritcle:

Ability of an orally administered lactobacilli preparation to improve the quality of the neovaginal microflora in male to female transsexual women by Ulrike KaufmannKonrad J. DomigChristina I. LippitschManuel Kraler, Julian Marschalek, Wolfgang Kneifel, Herbert Kiss, Ljubomir Petricevic in European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 172, January 2014, Pages 102–105.

Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery – Review

This study is seriously flawed and overstates its conclusion that surgery is associated with improved mental-health related quality of life for trans women.

The authors of the study surveyed 247 trans women. They administered a questionnaire made from three surveys. The first part asked about the person’s age and their transition, the second part asked six questions related to their face, and the third part was the San Francisco 36-question health questionnaire (SF36v2).

The authors found that:

1. Trans women who had had any form of surgery had mental health outcomes equal to the general female population; trans women who had not had any surgery had mental health outcomes that were worse than the general population. It did not make any difference what type of surgery they had; FFS, gender reassignment surgery, or both.

2. All the trans women in their study had better physical health than the general female population.

3. Trans women who had had FFS had significantly higher scores on the six question Facial Feminization Survey than trans women who had not had FFS.

The biggest hole in this study (and you could drive a truck through it) is that the trans women who had had surgery were significantly different from the trans women who had not had surgery. The differences were important and relevant to the study’s results.

a) 95% of the surgery group were also taking hormones while only 66% of the non-surgery group were taking hormones.* It may be that the hormones and not the surgeries were responsible for the improved well-being.

b) 54% of the surgery group had transitioned more than five years ago while only 24% of the non-surgery group had transitioned more than five years ago.* It may be that being further along in transition was responsible for the improved well-being. There are many reasons this could be true including more time for family adjustment, having had more therapy, or knowing more about how to present as a woman.

It could also be that some people find that transition does not help them in the first few years of transition and drop out; this might mean that the group of people who are further along in transition does not include as many people who have difficulties with transition.

c) Facial feminization surgery and gender reassignment surgery are expensive and are usually paid for by individuals in the United States. It may be that the surgery group was significantly richer than the non-surgery group.

The finding that trans women had better physical health than the general female population is a baffling one. It suggests that the group of trans women who answered the survey were significantly different from the general population.

The finding also raises the question of whether you would expect the trans women who answered this survey to have a better mental health related quality of life than the general public.

Which brings us to the problems with the sample. The size of the sample in this study is a good one: 247 people, 100 who had surgery, 147 who did not. The sample may not be representative, however.

Participants were recruited from people who had received care from an FFS surgeon or clinic and people who were involved in transgender support groups or organizations. Most of the surveys were given online, but a paper version was given at a transgender health conference. People who have seen a surgeon are more likely to be well-off; FFS costs mentioned on one forum ranged from $23,000  to $64,000. The low end of the spectrum was for surgery abroad.

If the trans women answering the survey were in fact richer than the general public, it would explain why they had better physical health than most women. It might also mean that they should have had a better mental health quality of life than most women.

The authors do not discuss the order of the questions in the survey, but there may be another potential problem in the survey, depending on how it was done. Asking people questions about themselves can influence how they do on a test. It might be that asking people if they have had surgery or how long they have been on hormones affects their mood. Patients who want to have surgery but have not yet had it might feel sad or less confident. This might affect answers to questions about things like how happy they were in the last week. It matters if the demographic questions were at the end or the beginning.

Similarly, the questions about the face and its femininity might affect the mood of someone who wants FFS but cannot afford it.**

What about the results for the Facial Feminization Survey?

The authors say that one limitation of the survey is that it has not been tested in previous investigations. It was adapted from a survey originally designed for pre- and post-operative evaluations of the same patient. It is also a fairly brief questionnaire with only six items.

On the other hand, the questions are highly relevant ones that look at feelings about your face and how those feelings affect your life. It looks like a reasonable measurement tool.

Unfortunately, the data for this part of the survey has the same problem as the quality of life section. There are important and fairly large differences between the FFS group and the non-FFS group.

The study combines the groups that had FFS or FFS and gender reassignment surgery into one group and then combines the gender reassignment surgery only group with the non-surgery group. Because the non-surgery group is larger and includes so many more people who are not on hormones and/or are early in their transition, the non-FFS group ends up with more people who are not on hormones and/or are earlier in their transition.

So 93% of the people who had FFS were also on hormones while only 71% of the people who had not had FFS were taking hormones.* This is still a large difference and raises the question of whether trans women on hormones are happier with their faces – or just happier in general. (For any-surgery versus no-surgery the numbers are 95% vs. 66%.)

In addition, 47% of the people who had FFS had transitioned more than five years ago compared to only 32% of the people who had not had FFS.* (For any-surgery versus no-surgery the numbers are 54% vs. 24%.)

Finally, 100% of the people who had FFS had had surgery while only 17% of the non-FFS group had had surgery. It could be that any type of surgery improved mental health and therefore feelings about the face. More likely, being able to afford any type of surgery could be associated with having more money. The FFS group might be richer than the non-FFS group.

So we can’t be sure whether the FFS group felt better about their face due to FFS, hormones, or length of time since they started their transition. There might also be some other important difference that made them happier with their faces such as having a larger income.

Another concern about the study is that this seems to have been a middle-aged group of people. The mean age for the no surgery group was 46. For the FFS only group, the mean age was 51, for the gender reassignment surgery only group the mean age was 50, and for the group who had had both types of surgeries, the mean age was 49. This sample does not seem to be representative of all trans women, although it is unclear how this would affect the results.

As in many studies of FFS, one of the authors of the study is an expert in facial feminization surgery. This may mean he has a bias in favor of believing that it works.

What can we conclude from this study?

We need more research in this area!

Despite everything, this research is an important first step. We have no other studies that attempt to quantify the effects of facial feminization surgery. As doctors have said in many other studies, we need this data,

This study could have been greatly improved if the authors had controlled for hormonal status and length of time since the beginning of transition. Perhaps they can still use the data to do this.

It would also have helped if the authors had asked questions about income, education, and occupation and controlled for these important variables.

As it is, we can not conclude anything about the benefits of facial feminization surgery from this study.

The study provides some support for the idea that something about transition is beneficial to trans women. Even here, though, there is still a possibility that another factor like income was the important one.

We need someone, ideally someone with a background in psychological research, to re-do this study or one like it using a better sampling technique and controlling for important factors.

Original Article:

Quality of life of individuals with and without facial feminization
surgery or gender reassignment surgery by Tiffiny A. Ainsworth, Jeffrey H. Spiegel in Qual Life Res (2010) 19:1019–1024. 


*These numbers and other percentages were calculated by George Davis based on data tables provided in the study.

** The Facial Feminization Survey was adapted from an FFS outcomes evaluation form. The original form includes questions specifically related to whether or not the patient wants FFS or other surgery. I am assuming these questions were not used in the survey for this study; however, if they were, they might significantly affect the mood of people who want surgery but have not had it. This would be in addition to any possible effect from asking people how they felt about their face.

Dr. Paul Tessier and Facial Skeletal Masculinization – Review

The article is partly a tribute to Dr. Paul Tessier who trained Dr. Ousterhout and mostly a description of techniques use to masculinize the face. So far, the author has only performed facial masculinization on six men, but he has performed some of the individual techniques involved many times.

The article discusses the various techniques used and some of the possible complications. There are good before and after photos – the person is posed the same way. I can easily see the differences in the faces. The faces are more masculine after surgery, but they were also clearly men’s faces before surgery.

Chin masculinization has sometimes resulted in facial numbness that is usually temporary, but there have been cases where it was not. The author says he has reduced this problem over time.

As in most of this research, the study is written by the person who performed the operations and might therefore be biased in favor of the work.

Original Article:

Dr. Paul Tessier and Facial Skeletal Masculinization by Ousterhout, Douglas K. MD, DDS, in Annals of Plastic Surgery Issue: Volume 67(6), December 2011, p S10–S15.


Appendix to Orgasm after Vaginoplasty

Further information on the studies used in the article Orgasm after Vaginoplasty.

Lawrence, 2005 (USA):

Surgeries were performed between 1994-2000, all by the same surgeon (Dr. Meltzer).

232 trans women returned an anonymous questionnaire by mail; 227 answered the question on orgasm by masturbation.

Follow-up time after surgery was a minimum of one year.

32% of the eligible participants returned the survey.

The technique used was described as “penile-inversion vaginoplasty and clitoroplasty using a portion of the glans penis on a dorsal neurovascular pedicle.”

18% were never able to achieve orgasm by masturbation; 15% were not able to orgasm from any sexual activity. 

Imbimbo et al., 2009 (Italy):

Surgeries were performed between 1992-2006 at the same institution.

139 trans women participated, 93 completed questionnaires at the clinic, 46 had phone interviews. 33 women answered the question on masturbation.

Follow up-time after surgery was 12-18 months.

85% of eligible participants took part in the study.

Three different techniques were used, 34% of the trans women had penile skin inversion, 61% had peno-scrotal flap, and 5% had an enterovaginoplasty.

18% of the trans women were never able to orgasm by masturbation; 14% of the trans women complained of anorgasmia

Buncamper et al., 2015 (the Netherlands):

Surgeries were performed between 2007-2010 VUmc in Amsterdam.

49 trans women completed questionnaires at their clinic.

Follow-up time after surgery was 1.9-5.8 years (average = 4.1 years).

61% of eligible participants took part in the study.

A penile skin inversion technique was used.

10% had not had orgasm after surgery.

Selvaggi et al., 2007 (Belgium):

Surgeries were performed between 1986-2001 at Ghent University Hospital.

30 trans women were personally interviewed by a team of experts:*

Follow-up time after surgery was a minimum of one year.

51% of eligible participants took part in the study. (All French patients were excluded from consideration for the study; 24% of all patients participated.)

Technique was described as “vaginoclitoroplasties with the penoscrotal inverted skin flap modified and dorsal glans pedicled flap,” however there may have been some earlier patients with a different technique; this is unclear.

15% had not experienced orgasm after surgery during any sexual practice.

Giraldo et al., 2004  (Spain):

Surgeries were performed “during the last two years” by the same surgeon (Giraldo)

16 trans women were given structured interviews at follow-up visits.

Follow-up time is unclear.

100% of eligible participants took part in the study.

The new technique is described as a “corona glans clitoroplasty with urethropreputial vestibuloplasty.”

0% had problems – all the women reported the ability to achieve orgasm

Note: This study is about a modification to the technique for creating a clitoris.

Hess et al., 2014 (Germany):

Surgeries were performed between 2004-2010 at the Essen University Hospital’s Department of Urology.

119 trans women returned anonymous questionnaires by mail, 91 answered the question “How easy it is for you to achieve orgasm?”

Follow up time was 1-7 years.

47% of eligible participants took part in the study.

The technique used was a penile inversion vaginoplasty with sensitive clitoroplasty; they did it in a two-step process.

18% said they never achieve orgasm; however it is unclear if they were sexually active or not.

Perovic et al., 2000 (Yugoslavia):

Surgeries were performed between 1994-1999.

89 trans women were interviewed.

Follow-up time was 0.25-6 years (mean = 4 years).

100% of eligible participants took part in the study.

The technique used was a penile inversion with penile skin and urethral flap and a clitoris from the glans.

It looks like 18% had not experienced orgasm during vaginal sex, but it is possible that some of the women were not sexually active.

Goddard et al., 2007 (United Kingdom):

Surgeries were performed between 1994-2004 in Leicester.

70 trans women were interviewed by a telephone questionnaire; 64 of them had had a clitoroplasty:

Follow-up time was 9-96 months (median = 3 years).

30% of eligible participants took part in the study.

233 patients had penectomy, urethroplasty, and labiaplasty, 202 had skin-lined vaginas. A penoscrotal flap was preferentially used. 207 had neoclitorises created. A sensate clitoris was made with a proximal dorsal triangle of the glans penis maintained on its neurovascular bundle.

It looks like 52% of the women with clitorses were not able to achieve clitoral orgasm, but again it is not clear if they were sexually active.

Wagner et al., 2010, (Germany):

Surgeries were performed between 2001-2008 at Martin Luther University in Halle by a single surgeon with extensive surgical experience.

50 trans women completed a questionnaire.

Follow-up time is unclear, but the mean was 3 years.

100% of eligible participants took part in the study.

A penile-inversion technique was used with a neoclitoris made from the glans cap.

It looks like between 17% and 30% were not able to achieve clitoral orgasm, depending on whether or not the patients were sexually active.

Salvador et al., 2012 (Brazil):

Surgeries were performed between 2000-2004 at the Hospital de Clínicas de Porto Alegre.

52 trans women participated in the study. It is unclear how they were surveyed, but based on this earlier study, it could have been a combination of a questionnaire and interview.

Follow-up time was a minimum of two years.

75% of eligible participants took part in the study.

The study gives no information on the surgical technique used.

8% did not consider vaginal sex pleasurable, however, only one woman said sexual intercourse was unsatisfactory (2%).


*The exact number of the participants is unclear because this study is one of a pair using the same participants. The other study by de Cuypere et al. did in-depth interviews with 32 trans women while this one focused on testing the sensitivity of the genitals for 30 trans women.