The scene in which Garrison undergoes his sex change originally featured over five minutes of real sex change footage because of the lack of ideas. Eventually, the sex change footage was trimmed to three brief one second shots after Comedy Central disapproved and after the idea of Gerald Broflovski's dolphin operation was brought up.
Trey Parker claims that he came close to quitting the show due to the stress this episode caused him. It is often considered to be one of the worst episodes of South Park.
Ms. Garrison's sex reassignment surgery is performed by Dr. Stanley Biber, a real physician who worked at the Trinidad Medical Center. After his death, Dr. Marci Bowers took over his practice.
In the scene where arena security are attempting to stop Garrison and the gang from entering the venue, the 2 mall cops from the Fingerbang episode are among the guards.