TERMINOLOGY
For want of a better name acceptable to everyone, this book uses the term SRS which is taken to mean sex reassignment surgery.

RISKS
Reputable surgeons will explain the risks of SRS but it is essential to understand from the outset the risks involved which are as follows.:

• Anyone can die during any surgical procedure although no-one is known to have done so during SRS in the UK.

 
• It may not prove possible to construct a vagina. The surgeon will hopefully do the best (s)he can with the tissues available, but cannot work miracles.

 
• Damage to the rectum and/or bladder during SRS procedure is possible but, assuming the surgeon is eminent in this work, is unlikely to occur.

 
• Following SRS it may be less easy to hold one’s urine in. Conversely, it may become less easy to let it out. The direction of flow out of the body may be more horizontal than in the non-reassigned woman, in which event sit well back on the toilet keeping the thighs together, but not too tightly or the flow may be obstructed.

 
• Susceptibility to rectal cramp due to wind or diarrhoea at any time following SRS may be increased and can be extremely painful.

BEFORE GOING INTO HOSPITAL
Take plenty of light reading material. If you like music, take some cassettes and a personal stereo. You will be in bed and immobile for several days and after an operation one’s attention span is very short until the anaesthetic wears off, so you will need variety. You may find the anaesthetic and other drugs given to you affect your hearing for a few days; loud music may be uncomfortable. Take in some soothing music. Don’t forget headphones and a supply of batteries. Please remember that other patients will be in the vicinity and may be feeling very unwell. Making noise in a hospital is selfishly unsociable. Please use headphones.

If you have any doubts or worries, do ask about them. Ask your surgeon and your psychiatrist before admission. Ask nursing and medical staff whilst you are in hospital; they cannot read your mind. Don’t be a pest, but make sure you know what you need to know about your operation and after-care procedures. A good time to talk is while your bed is being changed, or while you are being examined.

If your surgeon requires it, be sure to have completely stopped hormone treatment 6 to 8 weeks before surgery, depending on the period advised by your consultant. Being completely without hormones for that length of time can be unpleasant; taking them during the weeks immediately before the operation can be life threatening.

It will make the preoperative bowel wash out less traumatic if you stop eating heavy food stuffs two or three days before going into hospital. You can still get energy from a light diet of clear soups, Bovril, grilled fish, etc.

Drinking plenty of water in the last few days before admission into hospital helps to soften the bowel contents, making clearance prior to surgery easier. Bran absorbs water, taking it into the bowel, further helping the softening.

The hospital should provide you with a list of essentials to take in for your stay. Several pairs of knickers will be necessary. Cotton is smoother and softer than synthetic materials, and lets air in. Plain knickers are recommended, with no elastic in the legs; the pressure of elastic can be painful postoperatively. Frills or lace borders can catch external stitches, which can be painful. The best for use during the recovery period are called Netelast, available from chemists; intended for securing dressings. Of a very open, soft construction they assist healing and comfort.

Several changes of night-dress will be necessary. Ideally, these will be front buttoning as you will be given daily injections of heparin to guard against blood clotting and openable night-dresses provide easier access.

If you are intending to undergo vaginoplasty (see glossary, below), it is important to regularly stretch the genital skin during the months before surgery. The more skin tissue there is before surgery, the more the surgeon has to work with, the better the results. Stretching the skin may be distasteful in the short term, but will be beneficial for the rest of the postoperative future.

Before going into hospital, purchase a large supply of salt to leave at home for bathing, after discharge from hospital. It is too heavy to carry during the recovery period so stock up as large a quantity as you can. You must have at least salt two baths daily until well healed to ward off infection. To be of any use about half a pound of salt is required in each bath taken. It is best not to add household disinfectant. Some people prefer to bathe before dilating, helping to relax the muscles, others prefer to bathe after dilating as the latter can be messy. If you have access to a baby bath this enables one sometimes to soak only the relevant anatomy in a smaller volume of water requiring less salt, hence less expense.

IN HOSPITAL BEFORE SURGERY
On admission to hospital it's best to ensure anything you need easy access to is put in the TOP drawer or compartment of your bedside locker. A nurse will take you through an admission procedure, asking a list of standard questions. The surgeon, and possibly the anaesthetist may also visit you to ask a few questions. For your own sake be open, honest and truthful with all your answers. If you have any allergies be sure to mention them. You will be given nothing to eat, but possibly something to drink. In preparation you will be given suppositories, and an enema or laxatives.

You will probably be given a bowel wash out, for which try to relax. It is nothing dreadful; a nurse will do all the work. Some time before surgery you may be given a pre-med (to relax you and your muscles) which may make you feel like going to the loo. It is worth trying to go, even if in vain.

Before any major surgery nervousness is perfectly normal and shows you care about yourself, but if you have any serious doubts about the operation, CHANGE YOUR MIND. TELL the surgeon or nursing staff. They only want to help you, they will not be cross or upset, but do be firm. Their job is to do what is right for you.

When you eventually wake up you will promptly find yourself drifting off to sleep again. For at least 24 hours you will continually waken, only to fall asleep again due to the length of time you have spent under heavy general anaesthetic. There will be a drip in your hand, a T-bandage and a catheter between your legs, and surgical stockings on each of your legs. You might feel very cold after waking from the anaesthetic which is normal: ask for extra blankets. Once recovered from the anaesthetic, and all the time you are immobile, make a point of breathing fully in and fully out, slowly, about ten times, at least once an hour, as an exercise. During bed rest this helps keep the lungs clear, resisting infection there.

Whilst recovering, particularly when the drip and catheter have been removed, drink plenty of fluids; you will receive no solid food for a few days. High fluid intake helps to flush out the remnants of drugs given during the immediate postoperative period and prevents infections. You need to drink at least ten glasses (two litres) a day. This also eases bowel movements.

Unfortunately, antibiotics and gastric juices mix to create wind which you must try to expel. This may be painful and possibly messy, but it is better out than in. Turn onto one side and simply relax the anal muscle. Do not try to force wind out; doing so can put excess pressure on the newly formed parts which have yet to mend.

Expect to experience a lot of itching at the surgery site for a number of weeks. This is normal and is allied to tissues healing. Do not attempt to scratch there. You will probably be unable to tell anyway, for many weeks, exactly where an itch is. What was outside is now inside, what was behind may now be in front; nerves need time to reconnect properly, which they largely will over a period of several months.

Bruise-like discolouration (haematoma) is normal and there will be considerable puffy swelling of the tissues. The appearance of the vulva will alter as the weeks pass. It will be very delicate, but probably numbed, for some time. It is important to remember this because it is easy to be too rough with these parts without realising it due to the numbness. The area must be treated like a baby.

Be prepared to feel very much weakened when taking your first wobbly steps post-operatively. Do NOT get out of bed until the medical staff TELL you that you may. Be gentle with your body, it has had quite a shock. SRS is not like having your tonsils or appendix removed: it is major surgery.

Large doses of antibiotics will be administered which may have the side effect of promoting candida (oral thrush). If your mouth feels extremely raw and sore, as if full of razor blades, report this to your nurse who will probably give you Nystatin drops which cure the problem speedily.

Whilst confined to bed after surgery do regular leg exercises, bending the feet up towards the shins, then downwards in line with the legs. Rotate the feet, making the big toes describe wide circles. The aim is to exercise the calf muscles as a temporary substitute for walking, helping to pump blood back up the legs, to prevent the formation of blood clots (thromboses) which are a hazard whilst immobilised after any major surgery. You will be given drugs to prevent clots forming but leg exercises help too, as do the surgical stockings. Regularly ensure the latter are correctly positioned. If you are unsure how they should be arranged, ask your nurse.

Try not to cross your legs during the recovery period; doing so inhibits blood circulation. Take a small cushion or soft cardigan into hospital and put it, folded, between your knees when you lie on your side. This helps circulation and comfort. Be sure it does not overlap onto your calves, inhibiting circulation there.

If discomfort is experienced when sitting, try sitting on a quarter-folded duvet which greatly alleviates discomfort. Lumpy cushions are useless, causing more pain; inevitably the lumps find their way to the most tender parts. Plastic covered seat cushions are more comfortable than cloth ones. If, as is likely, you find sitting up or changing position in bed difficult, ask for a monkey pole to help lift yourself up with your hands. Your arms will be doing a very great deal of extra work over the next few weeks, particularly as you move into or out of chairs and baths, and up and down stairs.

Should you experience pain, tell your nurse. Because it delays healing, part of a nurse’s job is to help minimise pain. If you do not report it and are then seen to be in discomfort, the nurses will, quite rightly, be annoyed because you will have made their job more difficult. There is - ostensibly - no need to be in pain these days but only you know when pain killers have worn off, unless you inform the people caring for you. Laying on one’s front can sometimes help to reduce it. Importantly, report any constipation to the medical staff.

When the nursing staff or doctor tell you to begin walking around, do so gently. You will tire easily but exercise is very important in preventing blood clots. Having just undergone major surgery and major anaesthesia, you will only be able to walk a certain distance before needing to rest (rather than to merely stop walking), and you will only be able to gauge this distance by trial and error. You have to get back to your bed, and the yet to be attempted return journey is included in that distance; this makes it tricky to predict how far is too far. Don’t be stranded. "Too far" is when you very first begin to feel weary.

If you start going out of the hospital, keep some money handy for a taxi should you need one to get back. Always tell your nurse where you are going, even within the confines of the hospital. If you are asked not to leave the hospital grounds but you ignore the request and anything unpleasant befalls you in your absence, you will not be under the protection of the NHS or private clinic whilst absent without leave. In plain English, if you disobey the rules and come unstuck, you will have only yourself to blame.

Please bear in mind that very few hospitals perform adult reassignment surgery. You are therefore an ambassador for all who follow you. Awkward customers are never popular with any profession which interfaces with the public; model customers are. Disobeying hospital rules which apply to all patients would not only make you unpopular, but could mar goodwill shown to the next patient. Whilst you are in hospital, the staff are responsible for your life. You trusted the surgeon with it: trust and respect his/her staff too.

At this stage it can be alarming to find oneself unable to get out of the bath due to considerable, general weakness. The solution is to turn over onto all fours first. Take it slowly and be careful - slipping and doing the splits hurts: lots.

CONVALESCENCE AND RECOVERY AT HOME
Until three months after surgery, heavy objects should not be lifted, moved, or carried. Even seemingly ‘small’ items of shopping can be far too heavy. Otherwise, get as much ordinary gentle exercise as possible. Further, it takes some time to purge the anaesthetic from the body and fresh air and exercise encourage the body’s systems to work properly again, helping to speed healing.

Thrush (candida) may develop any time henceforth in the vagina, evidenced by redness and itching, but is quickly cured there by use of Canesten cream, available from the chemist with or without prescription. It comes with instructions; until completely familiar with one's new anatomy it's best to use a mirror and be very gentle when applying the cream.

DILATION
Before and after dilation wash your hands well and keep the equipment clean. A plastic sandwich box or kidney bowl will keep the dilators and gels clean, out of sight and protected. One clinic advises keeping them in a mild solution of Milton, more usually used to sterilise babies' bottles.

It is useful to obtain a small flat piece of plastic on which to mix the gels. Alternatively, they can be applied directly to the dilator, or applied internally beforehand, using the Betadine applicator as will be explained shortly. Mixing lubricant and Betadine on the dilator before insertion can be messy, the gel tending to make the Betadine slip off unless they are applied in separate spirals, one in-between the other. Betadine is less fluid when cold.

Dilators should be inserted slowly, following a slight downwards direction initially, and then a gently pivoting upward tilt once inserted (see diagram below). Also, slowly turn the dilator to help distribute the gels. Slow, gentle progress is best for success. If it hurts, stop, relax, wait, then try again.
 

(Right click image to view or save full size.) Diagram showing ~ approximately ~ at which point to being tilting the dilator slightly upwards. (External parts omitted for clarity.)

Vaginal lubricants must be water soluble to avoid accumulation of bacteria. For this reason Vaseline / petroleum jelly and baby oil are not suitable for internal use.

If your vagina is deeper than about half the length of the dilator, you might find all the gel rubs off it before it is fully home which can be very painful, the tip then being dry. The remedy is to copy nature, lubricating the vagina instead of the dilator by loading the Betadine applicator with gel and Betadine, lubricating its tip, inserting it carefully and deeply, then discharging the lubricant into the vagina. Either way, lubricating the tips of both the applicator and the dilator is recommended to help their insertion.

Dilation itself should be continued for 10 - 20 minutes. The equipment should then be washed with soap and warm water after use, drying on a clean towel reserved for that purpose. Being usually made of acrylic (Perspex), dilators will not withstand boiling and it isn’t necessary. Considerable care needs to be taken not to drop them (e.g., into the sink) whilst they are slippery. Chipped dilators are uncomfortable, or even dangerous, to use. Kitchen towels are useful both to place the dilator on after use (you have to get off the bed and to a sink and, initially at least, need both hands free), and to carry them to the sink. Kitchen towels don't always flush easily down the loo, unless first held under running water and then wrung out.

To answer a commonly asked question, the average woman’s vagina is between four and six inches deep, is a potential space (normally collapsed, see diagram above), and few women are aware of, or discuss, its dimensions unless medically.

PAIN
Theoretically, postoperative pain should not be a great problem. In practice the amount experienced varies greatly from one person to another, from nothing at all to agony, from a few weeks to many months. In some cases it may continue for three years or more. This variation appears to depend upon:

• How much tissue was removed and the depth of the new vaginal cavity;

 
• How well the surgery was performed;

 
• The individual's reaction to pain (related to biochemistry, not bravado);

 
• Whether one understands one's new, temporary limitations. Sexual experimentation too soon after surgery can lead to a prolapse (glossary, later), as can physical exertion during the recovery period. Walking, or even standing, for too long can increase pain. Sexual intercourse within 12 weeks of surgery is certainly not advised.

To help lessen pain, try to relax the tummy muscles rather than tensing them against it. Ordinary analgesics should help, assisting sleep, but it is very important to keep strictly to the recommended dose, noting that it applies to ANY 24 hour period. If taking them regularly, keep a note of the time when each dose is taken. In medicine, 24 periods do not automatically end at midnight. Be aware that if the maximum is eight tablets in 24 hours, six taken during the second half of one day, plus TWO taken at the start of the next day, will equal eight in 24 hours. Paracetomol overdose can be symptomless but fatal: keep tabs on the tabs.

If any part of the surgery site appears a definite greenish colour, seek urgent medical advice, preferably from the hospital where the surgery was performed (e.g., by telephone) or from the nearest A&E (Casualty, ER) Unit. This is very unlikely to happen but it is important to know what to do if it does happen.

Expect to experience short, sharp sensations like insect bites for a number of weeks. These can occur at any moment due to tissues healing and absorbent stitches dissolving. They are sudden, very sharp but short, not dreadfully painful, but embarrassingly impossible to ignore. Onlookers will wonder why you suddenly squirmed: put it down to wind.

Another common question concerns why sharp discomfort is felt when inserting a dilator too far. This is usually due to the way in which the lining of the vagina has to be anchored into place and can be illustrated by pushing your tongue up between your front teeth and upper lip as hard as you can. That will hurt for exactly the same reason, so don’t do it!

If a surface infection or unpleasant smell develops, four hourly external applications of Betadine gel, used sparingly, should solve the problem but call your GP if it persists for more than two days. During healing, a semi-solid, pale yellow substance may exude from wounds. Known as sloughing, this is a normal part of healing. Do not try to pick it off nor scrub it with a flannel. Salt baths will gradually dissolve it.

Once healing is under way, gentle application of a good unscented moisturising cream to the external scars will decrease irritation, helping them soften and heal. Petroleum jelly is useful - externally only - speeding the healing of sutured (stitched) wounds. It should not be used internally.

Try to prevent, rather than cure, constipation. Return to normal bowel movements by way of diet (prunes, bran, brown rice), walking, and adequate fluids rather than laxatives, to save straining. If necessary, a mild pharmaceutical laxative can be taken but note: postoperatively, lactulose taken orally can cause excruciating and debilitating rectal pain, probably cramp.

HYGIENE
Keep your genitals clean. Gently wash the outside in warm salt water regularly until all surface tissues are well healed. Make good use of medium or heavy duty sanitary pads at first, changing to panty liners as staining lessens. Underwear may need to be changed twice a day at first, and Betadine has an embarrassing colour.

Female hygiene is more particular than the male. The genitalia should be frequently and gently washed clean once the stitches begin to fall away. Douche kits can be bought from chemists (ask the pharmacist) or prescribed, and used to wash out internal stitches, spent gel and, possibly, dried blood. Once healed, warm salt water suffices in the douche; soap used internally can make the tissues sore. Douching requires care. The Betadine VC kit is not user friendly.

Copious amounts of povidone-iodine (eg. Betadine gel) should not be used for ever more as skin can become sensitized to it. From about 12 weeks postoperatively it is only necessary to apply a small quantity well into the vagina, preferably weekly, before sleep, giving it time to do its cleansing without fighting gravity. Lubricative gel can thenceforth be used alone for dilation or intercourse at other times. For intercourse and day-to-day comfort but not dilation, lubricants suitable for use by post menopausal women, such as Replens or Senselle, can be used, and are much less obvious.

ANATOMY

Vulva: all external female genitalia are collectively called the vulva.
 
Labia majora: puffy outer lips on each side of the vulva.
 
Labia minora: central soft folds of skin between the labia majora.
 
Vagina: the internal canal (not the parts outside).
 
Urethra: tube conveying urine out of the body.
 
Clitoris: very sensitive part near top of the vulva.
 
G spot (Grafenberg spot): very sensitive erogenous area just inside the vagina, towards the front of the body. During surgery, the prostate gland is usually left intact. It, and the pudendal nerve, are located in the same region as the G spot and both are usually sexually sensitive (see diagram above).

TOILET
After using the toilet, one must wipe oneself in the direction away from the vagina; the anus must be wiped backwards, the vulva must be wiped forwards. This is because the healthy bowel has necessary bacteria present which are unwelcome further forwards where they can cause infections. Wiping correctly minimises the chances of such self infection. These comments apply to all women. Mnemonic: ‘bum backwards’.

Wiping after urination can cause soreness which is lessened by gently pulling the pubic (hair bearing) skin in the direction towards one’s tummy just enough to tighten the vulva whilst wiping, preventing it from being pulled by the tissue. Cheap, rough toilet paper is best avoided. Kitchen roll is very soft and, unlike most toilet roll tissues, does not leave its own irritating debris behind.

IMPORTANT NOTES
Initially the urethra (water outlet) will be swollen, taking much longer to settle down postoperatively than will the rest of the genitalia. It may be impossible to pass water tidily at first, the stream resembling a garden sprinkler for some weeks. Sit well back, keeping the thighs gently together.

Extreme difficulty in urinating which persists for more than two days (three at the most) must be treated as an emergency and help urgently sought from the surgeon or the nearest A&E (Casualty, ER) Unit. If necessary, the GP must be side-stepped because untreated urine retention can be fatal. Provided help is sought quickly, the solution is usually simple. If in doubt, telephone the hospital where the SRS was performed, asking to speak to a nurse or doctor on the ward.

All surgery always carries risks. There is a risk of failure, a risk of death, and no two people react to, nor recover from, any surgery in the same way. Nobody can guarantee perfect results.

Surgeons are human beings, not magicians. They can only do their best with what they are given, both with the materials (your body) and in themselves. Two-way communication and co-operation are essential.

At the time of writing it is not possible in Britain to achieve the exact appearance or function of female genitalia by way of SRS which remains a compromise between appearance, sensitivity and function.

Find out what is to be done. Look at books on female anatomy, noting the wide variation of shape and form but not expecting an exact replica. TELL the surgeon what you hope for. ASK him/her about anything you don’t know, or are uncertain, about. She/he cannot read your mind and is not a monster. The best rules of thumb are as follows.
 

• DON’T ASK OTHER PEOPLE, ASK THE PERSON DOING THE JOB.

 
• YOU ARE PAYING FOR IT, ONE WAY OR ANOTHER. IF THIS WERE YOUR CAR, IN A GARAGE, YOU WOULD ASK QUESTIONS. IT IS YOUR BODY, AND THERE ARE NO SPARE PARTS AVAILABLE.

 
• ASK THE QUESTIONS AT THE RIGHT END OF THE JOB.

 
• IF THINGS GO WRONG, GO BACK TO THE SAME SURGEON.

 
• SURGEONS, AND THE NHS, ARE WELL INSURED. IF YOU GENUINELY DON’T GET SATISFACTION, MAKE A FUSS, POLITELY AT FIRST, BUT VERY FIRMLY IF YOU STILL DON’T GET SATISFACTION.

 
• YOU ARE WHO SPENDS THE REST OF YOUR LIFE LIVING WITH YOUR BODY.

 
• DO NOT EXPECT MIRACLES AND DO NOT BE UNREASONABLE OR RUDE.

X-RAY EXAMINATIONS
If undergoing x-ray of the pelvis or abdomen at any time postoperatively for any reason, it is a good idea to tell the radiographer and/or doctor that sex reassignment surgery has occurred. For good reasons most surgeons leave the prostate gland intact although never-ts women do not have one. As it will show up on x-ray as a ‘shadow’ which ‘ought not to be there’, its unexplained presence could cause confusion and the wrong assumption that this perfectly normal (for you) ‘shadow’ is something sinister. Be wise: advise.
 

A GLOSSARY OF RELEVANT MEDICAL TERMINOLOGY

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