Surgery

Apart from upper and lower surgery, some trans women opt to have additional surgical procedures to feminise their bodies further.

These may include:

Thyroid chondroplasty or tracheal shave

This is where the Adam’s apple is reduced in size by shaving some of the cartilage surrounding the windpipe. People who were assigned male bodied at birth usually have more cartilage here, which is why their Adam’s apple often juts out more than someone who was assigned female bodied at birth.

Facial feminising

Some trans women choose to have additional surgery to ‘soften’ their facial features - this is not generally available on the NHS. This type of surgery can include procedures to reshape the forehead, chin, jaw, and/or nose or to reduce the size of the earlobes and position of the ears. Some trans women also have surgery to emphasise their cheekbones and lips.

Body reshaping

This could include reshaping the buttock and body shape using liposuction to achieve a more ‘curved’ body. Male bodied people tend to have flatter, smaller buttocks than female bodied people, so some trans women opt to have buttock augmentation. This is where a more rounded appearance is given using liposuction or implants.

Crico-thyroid approximation – or voice feminisation

This is where the pitch of the voice is raised through surgery on the larynx. There are several types of surgery but the most common is crico-thyroid approximation. Outcomes seem to be varied and some people end up with either a high pitched voice or a raspy one. Another option is to have speech therapy to alter your voice.

Hair removal

Removal of the hair on the penis and genitals prior to lower surgery is necessary to ensure that no hairs grow inside your new vagina. You can read more about this on the Depilation tab. 

Some trans women have hair on other parts of the body removed – this may be through electrolysis, which is a method of permanently removing hair or through temporary methods such as waxing or shaving.

Electrolysis involves putting a very fine needle into the hair follicle and then passing an electrical current into it to damage it. This damage prevents any other hairs growing from this follicle.

Hair transplant to mitigate male-pattern baldness

Some trans women do have surgery to correct male-pattern baldness. This involves removing hair follicles from the back of the head and transplanting onto the affected areas where the hair will continue to grow.

If you’re planning to have lower surgery where your penile skin will be used to line your vagina, it’s important that you discuss with your surgeon which area of hair needs to be removed. Discuss this well in advance of your surgery date, as it can take many months for hair to be permanently removed. If the hair isn’t removed it can continue to grow inside your vagina, where it will be impossible to remove permanently.

This can be uncomfortable and may lead to ingrown hairs. Also hair growing in the vagina might be pulled out accidentally during sex, causing irritated skin - which can provide a route for sexually transmitted infections (STIs) and HIV to get into your body.

Some trans women also chose to have facial or other body hair removed.

Electrolysis

Hair on the penis and the scrotum will usually be removed by electrolysis as this will permanently remove the hair and stop any more hairs growing from that follicle. When you have electrolysis, a fine needle is inserted into the hair follicle and a tiny electrical current is passed through to damage the lower part of it. This means no more hairs will be able to grow from that follicle in the future.

It can take a few months to remove all of the hair from your genital area so when planning lower surgery, factor the hair removal into the timetable. Discuss this with your surgeon who may be able to recommend a good practitioner to carry out your electrolysis. Electrolysis is the only permanent method of hair removal.

Laser hair removal

Laser treatment can be used to temporarily remove hair, although it tends to grow back three to six months later. Laser treatment works quickly and is less likely to cause pain than electrolysis.

Intense pulsed light therapy (IPL) hair removal

Intense pulsed light therapy is a form of temporary hair reduction which works in a similar way to laser treatment. Hair follicles are targeted with light pulses which cause the hair to fall out and stop any more hairs growing from that follicle. This treatment tends to be more successful on people who have dark hair and is not effective for people with light hair.

Upper surgery is where breasts are constructed using implants. Surgery can give you larger breasts and can also allow you to decide on the shape of them. Implants are inserted through an incision either under the breast, in the armpit or around the nipple.

Not all trans women have upper surgery, and those who do may not want to have lower surgery as well.

Speak to your GP to find out whether upper surgery is available on the NHS in your area.

We all produce the sex hormones oestrogen and testosterone but people who were labelled ‘female’ at birth have more oestrogen and people who were labelled ‘male’ at birth have more testosterone. Many trans women take oestrogen and one effect of this is that it will feminise you – as well as reducing facial and bodily hair growth, it will increase the fat on your hips and breasts.

It is advised that if you are taking hormone treatment, you should wait at least 18 months before having breast implants. This is because it can take up to two years for your breasts to complete their growth once you start hormone treatment.

Although oestrogen is likely to result in minimal changes to the size your breasts, you will have more natural-looking breasts if implants are attached to your existing breast tissue. Your nipples are more likely to get larger as a result of hormone treatment. Implants placed onto a flat chest with a smaller nipple will look less natural. You may also find that your nipple sensitivity changes after upper surgery – your nipples could be a lot more or a lot less sensitive.

After surgery

As with lower surgery, you will have to take some time out to recover after upper surgery. Your surgeon will advise you on how to care for your new breasts in the days after surgery, and you will need to rest for a week or two. You may need to ask someone to help you with housework or shopping during this time.

If you have upper surgery at the same time as lower surgery, you will need more time to recover. Have a plan in place before going to hospital so that you get all the help you need after your surgery.

Lifespan

Breast implants do have a lifespan, so it may be that you will need to have them replaced at some point. Your surgeon should give you more information about this.

Breast screening

In the UK women aged between 50 and 70 are offered breast screening (known as a mammogram or breast X-ray) to look for any early signs of breast cancer. You should get a letter inviting you to attend between your 50th and 53rd birthdays – although by the end of 2012 screening will begin at the age of 47. If you don’t receive a letter, speak to your GP or clinician to ask for a referral.

You can find more information about breast augmentation at The Transhealth resource library. 

Trans women come in different shapes and sizes. We all have different and equally valid ways of expressing our gender:

• You might not have had surgery or take hormones.
• You might have surgery and/or take hormones.
• You might just take hormones.
• You may have had upper surgery to construct breasts.
• Or you may have had lower surgery – this is where your genitals are reconstructed so that you have a vagina.

Different procedures

Penile and testicular skin

In the UK, the most common procedure to create the vagina involves using the skin from the penis and possibly the scrotum. This depends on how much skin is available from the penis – if you have been taking hormones, your penis may have shrunk which will reduce the amount of skin available. Likewise if you are circumcised there may be less skin available. If this is the case, the surgeon will probably also use skin from your testicles or your urethral flap. It is important that all the hair is removed from your penis, testicles and any other skin.

The skin will be used to form a vagina, inner and outer labia and a clitoris. The skin from the tip of the penis forms the clitoris as the skin is sensitive and means you should still be able to orgasm. The urethra will be made shorter and moved so that you can urinate sitting down.

Surgery will take around five hours and you will need to stay in hospital for around a week. It will take a further six to 12 weeks to fully recover from surgery and you may need help with housework and shopping.

Intestinal implant (colovaginoplasty)

A less common procedure is where the vagina is constructed using tissue from the colon. This is usually only carried out if there isn’t enough skin on the penis and scrotum to form the vagina. This not used often because it involves major abdominal surgery which can cause bowel problems later on. A vagina formed from colon skin can be prone to excessive discharge and (because the skin is a mucous membrane) it may be more vulnerable to sexually transmitted infections (STIs).

Sex

Although everyone has a different healing process, it can take around two to three months after surgery before you will feel like having sex. Also note that some doctors recommend waiting from two to three months before having penetrative vaginal sex, to allow the area to heal. Even then there's things to consider about having sex post-lower surgery and it's vital to keep abreast of your sexual health at a clinic.

Advice about surgery

If you want more advice about surgery, the Gender Identity Research and Education Society (GIRES) is a good starting point.

They have also produced a detailed guide to lower surgery. 

After lower surgery

After lower surgery, there are a few hygiene tips worth bearing in mind. Some of them could also help prevent you from getting a sexually transmitted infection (STI).

Using dilators

A dilator is a cylindrical piece of plastic which you insert into your vagina to stretch the skin and prevent the vagina from closing after lower surgery. Your doctor will advise you how often to do this, although most trans women use them two or three times a day immediately after surgery, then reduce this to twice a week later on.

Dilators can be uncomfortable but will help stop your vaginal tissue shrinking and keep your vagina open - using them daily will help you to have comfortable penetrative sex.

Lubrication and dilation

It is important to use lots of lubrication when inserting a dilator as this will make it much easier to insert and will also reduce the chances of damage to your vagina.

Remember to be gentle when using dilators (and when you insert anything into your vagina) as tearing can be a route into your body for STIs or HIV.

Douching

After surgery, you will need to douche your vagina to keep it clean. Your healthcare team will advise you how often to do this, but many trans women douche daily after surgery then reduce the frequency to twice a week.

Douching will not protect you from STIs or get rid of one you already have.

Fistulas

A rare complication after surgery can be a fistula between the vagina and the rectum. This is where an opening forms and can lead to bleeding and faeces leaking into the vagina – if this happens, seek urgent medical help as the fistula will need to be operated on.

Preventing bacterial infections

When using the toilet wipe from front to back, otherwise, bacteria from your anus could be transferred to your vagina or your urethra, which could cause a bacterial infection.

This is also the case during sex – if your partner penetrates your anus and then your vagina (or vice versa) with their penis or a sex toy, use a new condom to avoid transferring bacteria.