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Why It's Nasty Than Fancy
Most of the jokes either fall flat, or are just plain stupid, such as Garrison talking out loud about her new vagina after the operation, Kyle's, "negroplasty", his father Gerald getting cosmetic surgery to become a dolphin because he, "feels", like one, and Garrison gleefully deciding to have an abortion when she mistakenly thinks she is pregnant. Note that it is taking place during her transition so for constituency following this, we'll use she/her.
The gym teacher is completely unlikable, as he does not let Kyle play basketball, and discriminates against him for being Jewish, which leads Kyle to want to have cosmetic surgery, to become tall and blak, which is racist.
There are some downright disgusting scenes, like the doctor cutting off Garrison's penis and footage of a real-life surgery being shown, and a scene showing Garrison using the women's restroom at the grocery store (she farted causing other women to leave), and Kyle's knees bursting open while playing basketball, which cannot only be disgusting, but disturbing too! Not only that, but It would be played as clip for Season 10 intro.
The infamous live-action sex change is absolutely disturbing, even for an adult audience. To make matters worse, it aired on TV uncensored which begs the question, how did the FCC approve this?
Kyle's design looking like a blak basketball player looks hideous and downright offensive; the same goes for Gerald as a dolphin.
Garrison herself is completely unlikable in this episode.
The infamous line by Mrs. Garrison, "This would mean Iām not really a woman. Iām just a guy with a mutilated penis. You made me into a freak". That is just purely transphobic to say.
It is revealed that Garrison only wanted to have a sex change because she wanted to be able to have a period, get pregnant, and have an abortion. When Garrison finds out none of this is possible since she was not born as a woman, she wants to become a man again, meaning that Garrison was unrealistically uninformed about the kind of surgery she had. Besides, even if you transition and get a sex change, its not entirely possible to do so. Making this episode not only transphobic, but racist too.
The doctor used Garrison's testicles for Kyle's knees, which made no sense at all!
It fails at making fun of transgender, non-binary, and transracial people, to the point where one can call it transphobic while portraying trans people as shallow and superficial when there are almost all legitimate cases of people who don't like the appearances, or identities they were born with.
The episodes try way too hard at inducing shock value and being controversial. That is shown through the inclusion of footage from a real sex change operation and making fun of transracials and otherkin people, even though the final latter isn't mainstream enough to be debated yet.
Overall, this was a bad way to start season nine of South Park.