Sex change surgery from male to female involves reshaping the male genitals into a form with the appearance of and, as far as possible, the function of female genitalia. Prior to any surgeries, transwomen usually undergo hormone replacement therapy and facial hair removal. Other surgeries undergone by transwomen may include Facial feminization surgery and various other procedures.

For changing anatomical sex from male to female, the testicles are removed and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951) to form a fully sensate vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hair follicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.

Some surgeons would inject a female hormone to shrink the whole penis and testicles. The male sex organ will become smaller, and they will be inserted into the body. The surgeon will insert a tube as the vagina.

In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty). These linings may not provide the same sensate qualities as results from the penile inversion method, but the vaginal opening is identical, and the degree of sensation is approximately the same as that of most women so pleasure should not be less.

Surgeon's requirements, procedures and recommendations in the days before and after, and the months following these procedures vary enormously.

Plastic surgery, since it involves skin, is never an exact art, and cosmetic refining to the outer vulva is sometimes required. Some surgeons prefer to do most of the crafting of the outer vulva as a second surgery, when other tissues, blood and nerve supplies have recovered from the first surgery. This relatively minor surgery, which is usually performed only under local anaesthetic, is called labiaplasty.

The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is especially affected by smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage. However, in the best cases, when recovery from surgery is complete, it is very difficult for even a gynecologist to detect women who have undergone vaginoplasty on a surface level.

Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. However, many post-op trans women report that the skin used to line their vaginas develops mucosal qualities from months to years post-op. For others lubrication is needed when having sex and occasional douching is advised so that bacteria does not start to grow and give off odors.

Because the human body treats the new vagina as a wound, any current technique of vaginoplasty requires some long-term maintenance of volume (vaginal dilation), by the patient, using medical graduated dilators, dildos, or suitable substitutes, to keep the vagina open. It is very important to note that sexual intercourse is not always an adequate method of performing dilation.

Regular application of estrogen into the vagina, for which there are several standard products, may help but this must be calculated into total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually or, in extreme cases under anaesthetic.