This is a 2010 study of the functional and cosmetic outcomes of the surgical techniques used at a German clinic. They followed 50 trans women who had surgery between May 2001 and April 2008. The surgeries were all performed by the same surgeon who had extensive surgical experience.
Before surgery, all the patients had completed a two year “real life” test and had been recommended for surgery by two independent psychiatrists. They had been on hormones for at least one year, although they stopped taking hormones a month before the surgery.
The patients were sent a questionnaire to follow-up on sexual function and patient satisfaction with the surgery. All 50 patients completed the questionnaire; the mean follow-up time was 3 years.
Outcomes of Surgery
One person regretted the surgery and became clinically depressed. They attempted suicide twice and had not fully recovered two years later.
The patient was 24 years old and the authors suggest that the ideal age for surgery is 30 years old. They also recommend thorough evaluation and good counseling before surgery.
This is consistent with other studies that found a regret rate after surgery of 3-4%. In a group of 50 people getting the surgery, you would expect one or two people to wish that they had not had the surgery.
The patient regretted the surgery 3 days after the operation.
6% had bleeding after surgery
4% required operative revision due to the bleeding (two of the three who had bleeding)
10% had shrinkage of the vagina which could be corrected by a second surgical intervention
4% had a minor bulge in the anterior vaginal wall which could be easily fixed with simple excision
There were no post-operative rectocele (bulge of the rectum into the vagina) or urethrovesical fistulae.
The authors of the study say that the incidence of surgical complications was comparable to the data in the literature.
The 6% of patients with bleeding that they report is better than the 10% reported by a United Kingdom clinic in this review.
Their rate of complications is considerably better than this 2001 study at a different German hospital which reported that “Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.”
They do not report any problems with narrowing of the urethra, which is also an improvement over the 3-4% reported by the clinic in the Untied Kingdom.
They do not report any problems with pulmonary embolisms or fistualae between the rectum and vagina. These are problems that are relatively rare and you might not expect to see them in a group of only 50 people; the review from the United Kingdom reported a rate of 2 in 1000 pulmonary embolisms with 1 death. They also reported a rate of 6 in 800 rectal fistulae.
6% subcuntaneous hematoma that did not require any further therapy (i.e. they had a ruptured blood vessel causing a lump or bruise under the skin)
Mean operative time – 190 (160–220) minutes or 3.16 (2,66- 3.66) hours
Mean depth of the vagina – 10 (6–14) cm or 3.93 (2.36-5.51) inches
Median hospital stay – 10 (6–14) days
In comparison, the United Kingdom clinic reported an operative time of 120-150 minutes, while the 2001 German study reported a mean time of 6.3 hours with a range of 4-9 hours.
Satisfaction with results at follow-up
10% of the patients were dissatisfied with the appearance of their labia
90% were satisfied with the appearance of their genitals
We need more research on how to construct labia that are satisfactory for all trans women.
Depth of Vagina:
20% were dissatisfied with the depth of their vagina
80% were satisfied with the depth of their vagina
4% were still dissatisfied with their vagina after a second operation
Of the ten women who were dissatisfied with the depth of their vagina, eight had a new operation to augment the vagina. Of the women who had the second operation, two were still dissatisfied (25%). Perhaps the secondary operation could be improved.
We need to know more – why were 20% dissatisfied with the depth of their vagina? What can be done to ensure that all trans women have vaginas that are deep enough?
How deep were the vaginas at follow-up? Were there some women whose vaginas were not deep who were satisfied anyway?
5% of the trans women having regular sexual intercourse experienced pain during intercourse; 84% of the trans women were having regular sexual intercourse
70% of the trans women reported achieving clitoral orgasm
The authors are not clear here, but it looks like 30% of the trans women who had this surgery are unable to achieve orgasm. This is a serious problem; they should have addressed it more fully.
Were some of the women not attempting orgasm? Did everyone answer the question?
At one point the authors say, “84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm” – that would change the numbers to 35 out of 42 women which would be better (although it would still leave 17% of the sexually active women not having orgasms). On the other hand, they also say, “Of the 50 patients, 35 (70%) reported achieving clitoral orgasm.”
As it stands, it looks like a large percentage of trans women are not having orgasms after surgery. That would be a problem and worthy of more discussion in the results. The ability to orgasm is an important, vital aspect of the outcome of these surgeries.
In addition, doctors and surgeons need to address the problem of pain during intercourse. Is there something trans women can do themselves to reduce the pain? Can the surgeries be improved in this area?
From their Discussion and Conclusions:
“The incidence of surgical complications was comparable to the literature data. The most common complication (10%) in the follow-up was shrinkage of the neovagina. In all cases a second surgical correction was necessary to definitively solve the problem. In all patients vaginopexy to the sacrospinous ligament was carried out, reducing the rate of neovaginal prolapse as described in the literature.
After 3 years, 49 patients were satisfied and did not regret or had doubts about having undergone sexual reassignment surgery. The only exception was a 24-year old patient who, 3 days after the operation, regretted his decision. After that, he developed a strong depression which needed psychological therapy. Two years after surgery, the patient had still not recovered completely and had attempted suicide twice.
We agree with Rehman and Melman that the best age to undergo sexual reassignment surgery is 30 years, an age that enables patients to adjust socially and sexually, increasing the possibility to develop attractiveness and allowing the patients to mature in dealing with new life stresses. Moreover, before undergoing such surgery, it is our opinion that all patients at all ages need deep and intensive psychological examination and must be informed about all the functional and cosmetic risks associated with this operation and, above all, about the impossibility of regretting the decision and returning to their natural gender.
With improvements in surgical technique over the years, male-to-female gender-transforming surgery can assure satisfying cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains a central important aspect for obtaining optimal results.”
The full article includes graphic pictures of surgery as well as details of their technique; you can get it at the link below.
Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients by Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, Fornara P in Urol Int. 2010;84(3):330-3.