BANGKOK, Thailand -- Using a penis to create a vagina is relatively easy, compared to the surgical difficulty of constructing a penis with a clitoris.

Thailand's most famous transgender surgeon, Dr. Preecha Tiewtranon, bends people both ways.

"I have done more than 3,500 of this kind of operation in 30 years," Preecha says during an interview at his modern, three-story, white-walled Preecha Aesthetic Institute on upmarket Thonglor Road. (Pai)

The Thai government recently changed its law on transgender operations, and now requires Thais to wait at least one year before undergoing a sex change.

In response to the new law, Preecha says he sends his Thai patients to two psychiatrists, to confirm the individuals qualify.

Most of Preecha's patients, however, are men from America, Australia, Europe, China, Japan, South Korea and the Middle East, who become women.

Preecha leads a staff of 15 plastic surgeons.

After a surgeon slices off the male organ, and plumps the breasts with implants, the newly created woman can usually enjoy sexual relations and climax, he says.

"Eighty percent have a relationship with a man. The rest become the so-called lesbian. About 80 percent of the patients are able to get the orgasm," Preecha says, describing the result of a male-to-female sex change.

"Orgasm depends on so many factors. If the patient receives a big dose of hormones, then it suppresses the orgasm. The patient must reduce the dose.

"If the patient is old, and the patient has diabetes, the chance to get the orgasm is low. But they get the sexual pleasure OK," he says, indicating some sensuality inside their new vagina.

"In the young patient, it depends on the partner. If they get the good partner, they will get the orgasm."

Displaying excruciatingly graphic medical photos on his computer's screen, Preecha explains why it is much more difficult to turn a woman into a man.

The medical and cosmetic problems convince most women to opt for a very small penis, instead of an average-sized longer one.

"To do the long penis involves a very big operation, and quite a lot of mutilation, because the patient will have big scarring on the side of their belly, or on the arm, or the thigh, from the skin graft or the skin flap.

"Today, we have more and more patients wanting the so-called 'small penis,' or the 'micro penis.' We usually elongate the clitoris, and the patient is able to have about one-inch of a penis.

"He can stand up to urinate in the toilet. They still can stimulate themselves with masturbation. They can achieve sensation."

Sexual intercourse, however, is not possible with a one-inch penis.

"Of course they cannot do penetration. Too short. Only rubbing around. But they still can enjoy sexual pleasure."

The other advantage is "no scar at all." Skin graphs, from elsewhere on the body, are not needed if an entire phallus is not required.

"Longer, you need a lot of skin. Average size? We can do six inches, eight inches. But average is about four. It depends on the wish of the patient.

"Four inches is enough for insertion. But even you go for four inches, you still have the scar." Preecha says his handful of Japanese female-to-male patients tell him they can earn more money after they get their penises.

"Now they like to do the small one-inch, because in Japan, you are able to get a promotion when you are the man. After you do the one-inch, you go back and apply to be a 'Mister.' When you are 'Mister,' you get a higher salary in Japan.

"They want a penis for the job," but that is not the only reason Japanese women undergo surgery to become men, he says.

Whatever the size, Preecha creates a penis by tugging a woman's clitoris outward.

"We keep the clitoris. The patient, after they have the penis, the clitoris is still there. And they can stimulate."

To make a penis longer than one-inch, a tubular shape must be added, which can function in ways similar to the real thing -- albeit with some numbness.

"The reconstructed phallus, the penis, has no sensation. They are able to stand up and have urination. They are able to rub it, and feel like they are getting the female partner excited.

"And they are able to get the hardness, by using the silicone implant, and have the sexual intercourse."

Switching sex, under a surgeon's blade, takes time.

If you are a woman, who wants to become a man, "you have to go through multiple operations. There is no such 'one stop', like male-to-female.

"Male-to-female you can do 'one stop,' get everything in two weeks, and then you go back home -- recuperation for another two weeks -- and then you are completely a woman.

"In six weeks, you can start to have the partner. Male-to-female is straight forward."

Female-to-male, however, increases the patient's future risk, especially if a woman requests a penis long enough for penetration.

"The more you do the penetration, the silicone could extrude. When you have the extrusion back home, the cost is so high to go to see the doctor," Preecha says.

The relatively low cost of surgery in Thailand is why so many patients choose Bangkok for sex change operations.

Another woe, for women who become men with an insertable phallus, involves possible "leakage of urine, because in the [original] female, the opening for urine is just at the skin level. You have to make it longer, so the connection is [vulnerable to] leaking.

"If they are in Thailand, it is very simple to repair. But back home, they don't have the experience to do it."

Preecha charges female patients 12,000 U.S. dollars for a one-inch penis, which includes deflating the breasts and removing the uterus and ovaries.

A longer phallus boosts the total cost to almost 20,000 U.S. dollars.

Males pay 9,000 to 20,000 U.S. dollars or more to become females, and comprise the overwhelming majority of Preecha's patients.

Business is booming, especially because his clinic also does plastic surgery on noses, eyelids, and for other cosmetic purposes, including liposuction.

Preecha said he will open another clinic in Hanoi, Vietnam, later this year. He also hopes to expand to Dubai.

Monika Weiss, 29, from San Francisco, California, underwent a partial male-to-female change at Preecha's clinic in January, and is considering a final penis cut.

"I paid one-third of what I would have paid in America for the same procedures," Weiss said in an interview while recovering in Bangkok. "It was 10,700 U.S. dollars.

"This was basically my first semi-permanent move to see if being a transgender, being a woman, was the right move for me. I've been on female hormones for 11 years, and most people in San Francisco still take me as male.

"So I was hoping this would push me, and that most people would start perceiving me as female. We shall see."

One of Preecha's surgeons gave Weiss breast implants, a "new nose" and other procedures to "feminize my face."

Weiss says she may return for "sexual reassignment surgery, to remove my penis and make it into a vagina. It depends on money at this point, and how all this works out for me."

Weiss is comparing two options for a vagina.

"They can invert what's there, and put it inside. It's called a 'penile inversion.' That is about 8,000 dollars here in Thailand.

"They have another procedure, where they use a piece of your colon to create a vagina," which costs 20,000 U.S. dollars, Weiss says.

"I would probably go for the colon one, because it is a better quality. Certain complications are lessened with that, and it's more durable.

"And I've been told that it feels more real."

Weiss is anxious, however, about a possible loss of orgasm after either operation. "It is always a concern."


Richard S Ehrlich is a Bangkok-based journalist who has reported news from Asia since 1978. He is co-author of Hello My Big Big Honey!, a non-fiction book of investigative journalism. His web page is Asia Coorespondent

(Copyright 2010 Richard S Ehrlich)