Criteria
Patient must be at least age 18 years of age. Patients will require permission from parents if under 20 years old.

Patients must be diagnosed with at least one of the following disorders: gender identity disorder, gender dysphoria, or associated conditions (anxiety, depression).

Patients must have undergone at least one year of antiandrogens or/and hormones.

Patients are required to have lived full-time in the cross-gender role for at least 1 year (supported by Identification Documents).

Patients must have approval from a psychiatrist (MD), psychiatric social worker (PhD), or clinical psychologist (PhD).

Surgical Procedure
This procedure is a combination of a penile skin inversion and an immediate full thickness skin graft. The vaginal canal and opening is created beneath the urethral opening and prostate gland.Vaginal depth is of concern to most patients. The most important factor in creating this depth is the amount of penile shaft skin. Our technique lengthens the depth of the vagina by using the full thickness skin graft from the scrotal. Hair on the scrotum must be removed so that the skin graft is placed at the distal end of the penile skin flap. This technique can lengthen the depth at least 2 more inches.

A portion of the glans (head of the penis), with its nerves and vessels, is converted into a clitoris. In so doing, the clitoris will be functional in sensation as well as in appearance.

The excess erectile tissue around the urethra should be removed in order to avoid symptoms that stem from engorged erectile tissue during sexual arousal, that may result in the narrowing of the vaginal opening.

Colon transposition is used for patients who need more depth (exceeding 8 inches). As of 2002, we have performed over 550 of successful colon transposition operations.

Duration of Operation
Three hours

Risks and Complications
Infections;Infections are usually only minor and do not cause pulmonary or systemic infections.

Short Vagina;Depth usually reaches six inches and will continue to extend after 6-12 months due to the maturation of scar tissue. In case of very short vagina, the second operation can be done after 6 months by using the sigmoid colon procedure (US $7,500).

Rectovagina Fistula:A very serious complication of SRS, where a hole develops between the colon and the vagina.There are 3 out of 1000 + cases all were well taken care of.

Side Effects
Wound disruptsions. There will be strong tension in the area around the fourchet of the new vagina perineum. Wound care will be required, but will heal within one month.

Unable to urinate. Urination difficulty sometimes occurs after the urine catheter is removed, due to the swollen stump at the opening of the shortened urethra. In such cases, the urine catheter should be retained for several more days. Eventually urination will return to normal.

Bleeding. You may experience oozing blood around the gauze dressing after the first day after surgery due to bleeding through the stump of the urethral opening. This may require repacking or suturing.

After Care
Before being discharged from the hospital to the hotel, a nurse will teach you how to take care of your vagina and prescribe more medications. The stiches will be removed after seven to ten days. You will then be able to return home.

Recovery
The neovagina can function within 6 weeks.

Results
After 6 weeks, the patient should be able to engage in neovaginal intercourse. During sexual arousal, there is some vaginal lubrication - though in most cases the patient should apply lubricant jelly at the vaginal opening prior to intercourse (as with dilation). Typically during arousal, mild swelling of the urethral meatus from excess corpus spongiosum may occur which can be corrected for cosmetic improvement without additional cost if the patient returns to Thailand. During sex, sensation at the vaginal opening, inner labia, and neoclitoris can be comparable, and certainly more sustained after climax, than previously in the male sex. It is essential to avoid any strenuous activity which can complicate recovery.

Hospital Admission
Five nights admission to hospital.

Anesthetic
General anesthesia (you are asleep)

Pre Operative Care
After release from BNH Hospital the patient will recover with the aid of liaison at the hotel. During recovery in the hotel, the patient must follow patient instructions, including:

(1) Dilating is the most important thing you can do to ensure the success of your surgery. If the patient does not dialate responsibly, this can result in the shortening of depth and width of the newly made vagina because of the scar contracture.
(2) Failure to dilate properly can result in serious injury. You will be instructed to gently dilate into the right direction after the vaginal packing is removed.
(3) Dilation can be painful for the first weeks, but is essential for developing maximum depth and ensuring post operative functioning of the neovagina.

During the recovery period, after each dilation session:

The wound should be washed gently with Hibiscrub (pink colour) in the shower followed by douching while seated in the toilet:

(i) douche proportion = 5-10 ml (cc) of Betadine solution mixed with bottled water until container is full;
(ii) insert the douche to full depth, squeeze, and hold tightly the container;
(iii) while holding tightly the container, extract the douche;
(iv) keep the wound dry and apply Betadine solution with cotton balls; and
(v) apply Kemicitine ointment with a cotton applicator. If there is some bleeding, press or apply pressure with a dry cotton ball to the site for 15 minutes. During the first weeks after surgery, feminine knapkins (tampons) should be changed several times per day due to normal vaginal bleeding during recovery.

Patient can return to female hormones as before surgery after two months. You should consult your endocrinologist to re-adjust the dosage. A sudden change in hormone levels, for some individuals, may result in the fluctuation of emotion.