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slide toggle Demystifying and Navigating Your Options: Gender Reassignment Surgery

Do you have any questions? Check our F.A.Q. section or contact us directly!

Demystifying and Navigating Your Options: Gender Reassignment Surgery

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Medically reviewed by Paul Gonzales on March 25, 2024.

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Previously, the term gender reassignment surgery (GRS) referred to genital reconstruction bottom surgeries like vaginoplasty, vulvoplasty, phalloplasty, or metoidioplasty. Individuals who look up this term on a search engine do so looking for information on gender-affirming procedures generally for transgender, non-binary and gender non-conforming people. This detailed guide breaks down everything you need to know about these procedures, their costs, their eligibility requirements, the potential benefits and risks and more. If you are interested in undergoing any gender-affirming or “gender reassignment” surgery, you can schedule a free, virtual consultation with one of our surgeons.

At the Gender Confirmation Center (GCC), we generally avoid using terminology like GRS in a clinical setting out of the recognition that for the vast majority of our patients, surgeries do not “reassign” anyone’s gender. Rather, surgery can help individuals experience greater alignment with their bodies and greater gender euphoria as a result.

Types of Gender “Reassignment” Surgeries: “Female to Male (FTM)”

Female to Male (FTM) is outdated terminology that the GCC does not use in our clinical practice. This abbreviation leaves out the experiences of many trans masculine and non-binary patients who do not identify with being labeled as a “woman becoming a man.” 

In the past, “FTM gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial estrogenic puberty or procedures that reconstruct a patient’s genitals. We still receive various inquiries about which “FTM” procedures we offer, so below you can find a list of surgeries that have typically been placed under this label. 

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients “into men,” but to help them feel more comfortable, affirmed, and/or aligned with their bodies.

Chest Surgery or Top Surgery

“FTM” top surgery is an antiquated term that refers to gender-affirming chest reconstruction and/or breast reduction. Practices who use this acronym sometimes have limited experience meeting the unique needs of non-binary patients seeking top surgery . Patients who would like to remove their chest tissue to have a flatter chest can choose from a variety of incision options to reach their desired results around chest tightness, contour and/or scar shape. 

Not all patients who pursue top surgery want flat chests. Whether you would like to opt for a breast reduction or a chest reconstruction with some volume left behind, the button buttonhole incision is the most commonly pursued type.

Top surgery patients who would like to maintain an erotic or a high level of sensation in their nipples can ask their surgeon about nerve-preservation techniques . Inversely, many patients who get top surgery choose to have their nipples removed .

Genital Reconstruction or Bottom Surgery

While the following bottom surgery procedures are traditionally put under the “FTM” category, we recognize that not all patients who pursue these procedures identify as men nor are they looking to “masculinize” their genitals.

Two procedures can be used to reconstruct a penis or “neophallus”: metoidioplasty and phalloplasty. Metoidioplasty or “meta” releases the ligaments around the erectile tissue (called a clitoris or penis) to extend it to about 2-4 inches in length. A phalloplasty uses a donor flap (usually from the forearm or thigh) to construct a penis of 4 inches in length or more (depending on availability of tissue). Both procedures can be specialized to allow a patient to maintain erotic sensation in their genitals (nerve preservation) and/or urinate standing up (urethroplasty).

Associated procedures include the removal of the uterus (hysterectomy), the removal of the vaginal canal (vaginectomy), the construction of a scrotum (scrotoplasty), the insertion of penile/testicular implants, and more.

Body Masculinization Surgery (BMS)

Body Masculinization Surgery (BMS) refers to a series of body contouring procedures. Most often, BMS involves liposuction of one or more of the following areas: abdomen, flanks, hips, thighs, buttocks, or arms. BMS can also involve removing unwanted, excess skin from fat loss or liposuction. Occasionally, some patients may opt for silicone pectoral implants alongside or after their top surgery results.

Facial Masculinization Surgery (FMS)

Facial Masculinization Surgery (FMS) refers to a series of procedures that patients can choose from to give their face a more angular, conventionally masculine appearance. In the bottom third of the face, the chin, jaw, or laryngeal prominence (aka Adam’s apple) can be augmented or increased in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be augmented.

Types of Gender “Reassignment” Surgeries: “Male to Female (MTF)”

Male to Female (MTF) is outdated terminology that we do not use in our clinical practice. This abbreviation leaves out the experiences of many trans feminine and non-binary patients who do not identify with being labeled as a “man becoming a woman.”

In the past, “MTF gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial androgenic (testosterone-dominant) puberty and/or reconstruct a patient’s genitals. As a practice, we still get asked by prospective patients about the “MTF” procedures we offer, which is why we have compiled a guide of surgeries that have typically been placed under this category.

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients turn “into women,” but to help them feel greater gender congruence with their bodies.

Breast Augmentation or “MTF” Top Surgery

Typically, for trans feminine and non-binary patients who prefer to have more volume on their chest, breast augmentation with saline or silicone implants allows for greater success in their desired outcomes. Fat grafting procedures limit the amount of volume transferred to the chest based on available body fat that can be safely removed.

Genital Reconstruction or Bottom Surgeries

The most common surgeries that are placed under this category are vaginoplasty and vulvoplasty (also called zero-depth vaginoplasty) procedures. The most common vaginoplasty uses a penile-inversion technique to reconstruct a vaginal canal. However, a penile-preserving vaginoplasty is also another option for patients. Lifelong dilation after this procedure is necessary to maintain the depth of the canal so that it can be used for penetrative sex. Labiaplasty revisions are sometimes sought out by patients wishing to adjust the size, shape and symmetry of their labia and/or clitoral hood.

Before a vaginoplasty, patients may opt to remove the testicles ( orchiectomy ). Patients of varying gender identities undergo orchiectomies for many reasons, such as chronic pain or to simplify their hormone therapy.  For patients who plan to have a vaginoplasty in the future, it’s best to consider the timing of an orchiectomy procedure since scrotal tissue can be used to construct the labia.

Facial Feminization Surgery (FFS)

FFS refers to a series of procedures that a patient can choose from to give their face a softer, more conventionally feminine appearance. In the bottom third of the face, the laryngeal prominence (or Adam’s apple), chin, or jaw can be reduced in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be reduced.

Body Feminization Surgery (BFS)

BFS encompasses a series of body contouring procedures. Most often, BFS involves removal of fat through liposuction of one or more of the following areas: the thighs, the abdomen/waist, or the arms. The fat removed from these areas of the body can be transferred to the buttocks and/or hip areas and is commonly referred to as a Brazilian butt lift (BBL). BFS can also involve removing unwanted excess skin from fat loss or liposuction, a procedure often referred to as a tummy tuck or abdominoplasty.

Evaluating Candidacy for Gender Affirmation Surgery

Strict guidelines evaluate patient readiness for life-altering GRS procedures.

Informed consent

The GCC follows an informed consent model for surgery because it gives patients autonomy over their health. Under this model, adults can consent to procedures if they have received adequate education about their risks, advantages, and potential effects on their health given their unique medical history. Historically, TGD people have had a difficult time accessing quality gender-affirming health care in part because of gatekeeping and discrimination based on requirements set by insurance companies. For example, letters from medical and mental health providers are a part of these requirements. We recognize that therapists and other healthcare providers are invaluable sources of support for patients undergoing a medical gender transition. 

Health factors

We recommend our patients get medical clearance from their primary care provider (PCP) before surgery. If you have medical conditions that may affect your surgery, we can work with your PCP or specialist to ensure a safe recovery. Patients should inform their surgeons of any cardiovascular or respiratory issues, history of anorexia, diabetes, or use of immunosuppressant medications.

Different surgeons may consider a patient’s Body Mass Index (BMI) as part of their eligibility for surgery. You can read more about our requirements and recommendations around BMI here .

We require all our patients to stop smoking or consuming any form of nicotine for at least 3 weeks before and 3 weeks after surgery, as this can lead to significant problems with delayed wound healing. Please do not drink alcohol for at least 1 week before and 1 week after surgery or until prescription pain medications are discontinued.

Insurance requirements

Patients who wish to have their insurance cover their gender affirming surgery need to fulfill certain requirements. You will need to get a letter of support from a mental health professional to confirm that the procedure is medically necessary. If the surgeon is outside of your insurance’s in-network providers, you will need to get a referral letter from your primary care provider (PCP). Additionally, some insurance companies may require that a patient undergo gender-affirming hormone therapy to cover surgery.

Hormone Therapy Considerations

At GCC, we do not require our patients to undergo hormone therapy to access medically necessary, gender-affirming surgeries. That said, undergoing hormones before surgery can help some patients improve the appearance of post-op results.

  • Facial surgery: It may take up to 1.5 years on hormone therapy before soft tissue changes can appear on the face so patients should consider waiting to undergo facial surgery until these changes have settled.
  • Bottom surgery: Maximal bottom growth may take up to 2 years for patients on a standard dose of testosterone so patients should consider undergoing metoidioplasty until maximal growth is achieved for optimal outcomes.
  • Breast augmentation: Maximal breast growth may take up to 1.5 to 2 years for patients on a standard dose of estrogen so patients should consider undergoing breast augmentation until maximal growth is achieved.
  • Body contouring: It may take up to 1.5 years on hormone therapy before the fat redistribution process settles so patients should consider waiting until then before undergoing liposuction or fat grafting procedures.

When it comes to age and eligibility for surgery, we are typically asked about 2 populations: adolescents and seniors. The World Professional Association for Transgender Health (WPATH) has outlined in their Standards of Care (SOC), Version 8 , the need for the involvement of caregivers/parents and mental health professionals in the informed consent process for adolescents. If these protocols are followed, the only type of gender-affirming surgery that an adolescent can undergo is top surgery.

As long they are in good health and cleared for surgery, senior patients are eligible for surgery regardless of their age and can achieve good aesthetic outcomes. It’s important to consider what accommodations are necessary to support post-op recovery. You can read more about our eligibility standards here .

Weighing GRS Benefits Against Complications

The decision to undergo “gender reassignment surgery” is a highly personal one. Understanding both the pros and cons provides critical insight.

How GRS Can Transform Lives

The WPATH’s SOC 8 reviews the medical research literature around the long-term effects of gender-affirming surgery on trans and non-binary patients. Gender-affirming procedures report greater satisfaction and lower regret rates compared to similar cosmetic and reconstructive procedures performed in cisgender patients.

  • Improved mental health
  • Improved body-image, etc.
  • Enhanced quality of life

Rates of anxiety, depression, and suicide risk all tend to decrease substantially following surgery for those who need it, which is why these procedures are considered medically necessary for many patients.

Risk Factors and Long-Term Effects

All surgeries carry risks of complications. Generally speaking, patients who optimize their health prior to surgery (e.g., do not smoke tobacco) and manage any pre-existing medical conditions can greatly reduce their risk for complications. Undergoing surgery with a board-certified surgeon who has hospital access privileges can help ensure the integrity of your surgical process. If you have specific questions about surgical complications and how to prevent them, you can consult our content library on this question.

Navigating Emotions

Surgery not only takes a physical, but also an emotional toll on the body. Experiencing pain, inflammation, discomfort and limitations on physical activity occasionally mat result in temporary postoperative depression. Likewise, having to wait weeks or months to have a sense of what your final results from surgery will look like can give some patients temporary feelings of regret during recovery. For this reason, we highly encourage patients to tap into their support networks of friends, (chosen) family and/or mental health professionals during this time. To learn more about the emotional recovery process, click here .

Conclusion: Is Gender Reassignment Surgery the Right Choice?

While gender-affirming surgery has been proven to be positively life-changing for many trans and non-binary individuals. Whether you seek surgery or not, we remain dedicated to your health, empowerment, and right to be your authentic self.

More Articles

Understanding the cost of double incision top surgery: a comprehensive guide, gatekeeping vs. empowerment: accessing gender affirming care, treating gender dysphoria in adolescents, sign up for instructions to get a virtual consultation.

The virtual consultation will be billed to your insurance company. We will accept the insurance reimbursement as payment in full.

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Dr. Scott Mosser Suite 1010, 450 Sutter St San Francisco, CA 94108 Phone: (415) 780-1515 Fax: ( 628) 867-6510

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Should gender reassignment surgery be preceded by a waiting period?

(Shutterstock Image)

(Shutterstock Image)

Many surgeons require people who want to undergo gender reassignment surgery to live through a waiting period and to bring documentation from a therapist. 

It’s impossible to know exactly how many transgender people want to have surgery to change their bodies and align with the gender with which they identify. But it’s not a stretch to guess that they are having trouble getting the procedure covered by their insurance company, or that they simply can’t find a doctor to do the surgery.

Therapists Julia Gottlieb and Jasper Liem work at Philadelphia’s Mazzoni Center and spend a lot of time helping transgender people navigate the sometimes rocky shore of gender reassignment.

Most surgeons require, at minimum, a letter from a licensed therapist confirming that the person requesting gender reassignment surgery has sought counseling and been deemed able to have the procedure. Surgeons in some states require people to have lived in the gender they intend to transition to for as long as two years.

Unfair, says Gottlieb.

“I see this as another way to marginalize a population,” she says. “If you think about it, there are a lot of plastic surgeons out there that trust that if somebody’s coming into their office and they’re saying, ‘Hey, I have agency over my body, I know what decisions I want to make to medically change my body’—like breast augmentation or rhinoplasty—that those surgeons are saying, ‘We need you to prove who you actually say you are.'”

Lieb says this double standard can put those hoping to transition in a precarious position.

“For trans folks, a lot of times, it’s not realistic to have that one year of living in the gender you identify as,” agrees Liem. “So, in plenty of states—Virginia, for example—you can still get fired for being trans. So even though we do see a lot of progress, that doesn’t necessarily mean we’re safe to follow those protocols.”

When pressed how she would solve this issue, Gottlieb simply responds that people should be able to make choices about their bodies freely.

“I’m a firm believer that a person is their own best expert,” she says.

In our interview with Julia Gottlieb and Jasper Liem, they mention the 2015 U.S. Trans Survey . If you want to participate, you can find it here .

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.


Transitioning may involve:

  • Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
  • Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

  • Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
  • Clear and consistent documentation of gender dysphoria
  • A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

  • Beard and mustache growth  
  • Deepening of the voice
  • Enlargement of the clitoris  
  • Increased growth of body hair
  • Increased muscle mass and strength  
  • Increase in the number of red blood cells
  • Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
  • Development of acne, similar to male puberty
  • Baldness or localized hair loss, especially at the temples and crown of the head  
  • Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

  • Aggression  
  • Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

  • Breast development  
  • Loss of erection
  • Shrinkage of testicles  
  • Decreased acne
  • Decreased facial and body hair
  • Decreased muscle mass and strength  
  • Softer and smoother skin
  • Slowing of balding
  • Redistribution of fat from abdomen to the hips, thighs, and buttocks  
  • Decreased sex drive
  • Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

  • Breast augmentation  
  • Facial feminization
  • Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
  • Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
  • Jaw surgery: The jaw bone may be shaved down.
  • Chin reduction: Chin reduction may be performed to soften the chin's angles.
  • Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
  • Lips: A lip lift may be done.
  • Alteration to hairline  
  • Male pattern hair removal
  • Reduction of Adam’s apple  
  • Voice change surgery

Bottom surgery includes:

  • Removal of the penis (penectomy) and scrotum (orchiectomy)  
  • Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

  • Subcutaneous mastectomy/breast reduction surgery.
  • Removal of the uterus and ovaries
  • Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

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Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

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American Society of Plastic Surgeons. Gender confirmation surgeries .

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Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

  • Removal of the testicles alone. This is called orchiectomy.
  • Removal of the penis, called penectomy.
  • Removal of the testicles.
  • Creation of a vagina, called vaginoplasty.
  • Creation of a clitoris, called clitoroplasty.
  • Creation of labia, called labioplasty.
  • Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
  • Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
  • Tummy tuck, called abdominoplasty.
  • Buttock lift, called gluteal augmentation.
  • Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
  • Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
  • Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
  • Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
  • Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

  • Significant medical conditions that haven't been addressed.
  • Behavioral health conditions that haven't been addressed.
  • Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

  • Delayed wound healing
  • Fluid buildup beneath the skin, called seroma
  • Bruising, also called hematoma
  • Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
  • Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
  • A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
  • Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
  • Urinary problems, such as incontinence
  • Pelvic floor problems
  • Permanent scarring
  • Loss of sexual pleasure or function
  • Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

  • Risks and benefits
  • Alternatives to surgery
  • Expectations and goals
  • Social and legal implications
  • Potential complications
  • Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

  • A review of your personal and family medical history
  • A physical exam
  • A review of your vaccinations
  • Screening tests for some conditions and diseases
  • Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
  • Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

  • Gender identity
  • Gender dysphoria
  • Mental health concerns
  • Sexual health concerns
  • The impact of gender identity at work, at school, at home and in social settings
  • The role of social transitioning and hormone therapy before surgery
  • Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
  • Support from family, friends and caregivers
  • Your goals and expectations of treatment
  • Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

  • Moving the hairline to create a smaller forehead
  • Enlarging the lips and cheekbones with implants
  • Reshaping the jaw and chin
  • Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

Breast incisions for breast augmentation

  • Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

Placement of breast implants or tissue expanders

  • Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

Anatomy before and after penile inversion

  • Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

Anatomy before and after bowel flap procedure

  • Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.


Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.


Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Feminizing surgery care at Mayo Clinic

  • Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
  • Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
  • Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
  • AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
  • Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
  • Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
  • Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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Transgender Health Program

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Gender-Affirming Surgery

OHSU surgeons are leaders in gender-diverse care. We provide specialized services tailored to the needs and goals of each patient. We offer:

  • Specialists who do hundreds of surgeries a year.
  • Plastic surgeons, urologists and other specialists who are leading experts in bottom surgery, top surgery and other gender-affirming options.
  • Vocal surgery with a highly trained ear, nose and throat doctor.
  • Peer volunteers who can provide support during visits.
  • Welcoming care for every patient, every gender and every journey.

Our surgical services

We offer many gender-affirming surgery options for transgender and nonbinary patients, including options within the following types. We also welcome you to request a procedure that isn’t listed on our pages.

Top surgery:

  • Gender-affirming mastectomy
  • Gender-affirming breast augmentation

Bottom surgery:

  • Phalloplasty and metoidioplasty , including vagina-preserving options
  • Vaginoplasty and vulvoplasty , including penile-preserving options


Nullification surgery, oophorectomy, orchiectomy.

Bottom surgery options also include:

  • Scrotectomy
  • Scrotoplasty
  • Urethroplasty
  • Vaginectomy

Additional gender-affirming options:

  • Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

  • Steps to surgery
  • WPATH standards of care
  • The letter of support needed for some surgeries

For patients

Request services.

Please fill out an online form:

  • I am seeking services for myself.
  • I am seeking services for someone else.

Other questions and concerns

Contact us at:

Refer a patient

  • Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
  • Learn more on our  For Health Care Professionals  page.

At OHSU, our gynecologic surgeon, Dr. Lishiana Shaffer, specializes in hysterectomies (uterus and cervix removal; often combined with oophorectomy, or ovary removal) for gender-diverse patients. She does more than 150 a year.

We also offer a Transgender Gynecology Clinic with a gender-neutral space. Services include surgery. Referrals and appointments are made through the OHSU Center for Women's Health, though the space is not in the center. Call 503-418-4500 to request an appointment.

Some patients choose hysterectomy to:

  • More closely align their bodies with their gender identity.
  • With ovary removal, to remove a main source of the hormone estrogen.
  • To end pain caused by testosterone therapy that shrinks the uterus.
  • To end the need for some gynecologic exams, such Pap smears.

Preparation: We usually recommend a year of hormone therapy first, to shrink the uterus. We don’t require a year of social transition.

Most often, we use a minimally invasive laparoscope and small incisions in the belly. We usually recommend removing fallopian tubes as well, to greatly reduce the risk of ovarian cancer.

Most patients spend one night in the hospital. Recovery typically takes about two weeks. You’re encouraged to walk during that time but to avoid heavy lifting or strenuous exercise.

Hysterectomy is usually safe, and we have a low rate of complications. Risks can include blood clots, infection and scar tissue. Because of a possible link between hysterectomy and higher risk of cardiovascular disease, your doctors may recommend regular tests.

Removing the uterus also ends the ability to carry a child. OHSU fertility experts offer options such as egg freezing before treatment, and connecting patients with a surrogacy service.

OHSU offers nullification surgery to create a gender-neutral look in the groin area.

Nullification surgery may include:

  • Removing the penis (penectomy)
  • Removing the testicles (orchiectomy)
  • Reducing or removing the scrotum (scrotectomy)
  • Shortening the urethra
  • Removing the uterus (hysterectomy)
  • Removing the vagina (vaginectomy)

The procedure takes several hours. Patients can expect to spend one to two nights in the hospital. Recovery typically takes six to eight weeks. Patients are asked to limit walking and to stick to light to moderate activity for four weeks. They should wait three months before bicycling or strenuous activity.

Nullification surgery cannot be reversed. Risks can include:

  • Changes in sensation
  • Dissatisfaction with the final look
  • Healing problems

Removing the penis and testicles or the uterus also affects the ability to conceive a child. OHSU fertility experts offer options such as freezing eggs and connecting patients with a surrogacy service.

Having a gynecologic surgeon remove one or both ovaries is often done at the same time as a hysterectomy. We do nearly all these surgeries with a minimally invasive laparoscope and small incisions in the belly.

Most patients spend one night in the hospital and return to their regular routine in about two weeks.

The ovaries produce estrogen, which helps prevent bone loss and the thickening of arteries. After removal, a patient should be monitored long-term for the risk of osteoporosis and cardiovascular disease.

We encourage patients to keep at least one ovary to preserve fertility without egg freezing. This also preserves some hormone production, which can avoid early menopause.

At OHSU, expert urologists do orchiectomies (testicle removal). Patients may choose this option:

  • To remove the body’s source of testosterone
  • As part of a vaginoplasty or vulvoplasty (surgeries that create a vagina and/or vulva)
  • To relieve dysphoria (some patients choose only this surgery)

Removing the testicles usually means a patient can stop taking a testosterone blocker. Patients may also be able to lower estrogen therapy.

The surgeon makes an incision in the scrotum. The testicles and the spermatic cord, which supplies blood, are removed. Scrotal skin is removed only if the patient specifically requests it. The skin is used if the patient plans a vaginoplasty or vulvoplasty.

You will probably go home the same day. Patients can typically resume normal activities in a week or two.

Reducing testosterone production may increase the risk of bone loss and cardiovascular disease, so we recommend regular tests. Without prior fertility treatment, orchiectomy also ends the ability to produce children. Serious risks are uncommon but include bleeding, infection, nerve damage and scarring.

Adam’s apple reduction (laryngochrondoplasty)

Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins University.

Laryngochrondoplasty is also known as Adam’s apple reduction or a tracheal shave (though the trachea, or windpipe, is not affected).

A surgeon removes thyroid cartilage at the front of the throat to give your neck a smoother appearance. This procedure can often be combined with facial surgery.

Thin incision: At OHSU, this procedure can be done by an ear, nose and throat doctor (otolaryngologist) with detailed knowledge of the neck’s anatomy. The surgeon uses a thin incision, tucked into a neck line or fold. It can also be done by one of our plastic surgeons, typically with other facial surgery.

In an office or an operating room: Our team can do a laryngochrondoplasty in either setting, which may limit a patient’s out-of-pocket expenses.

OHSU also offers Adams’ apple enhancement surgery.

Many patients find that hormone therapy and speech therapy help them achieve a voice that reflects their identity. For others, vocal surgery can be added to raise the voice’s pitch.

Voice therapy: Patients have voice and communication therapy before we consider vocal surgery. Your surgeon and your speech therapist will assess your voice with tests such as videostroboscopy (allowing us to see how your vocal cords work) and acoustic voice analysis.

Effective surgery: We use a surgery called a Wendler glottoplasty. It’s done through the mouth under general anesthesia. The surgeon creates a small controlled scar between the two vocal cords, shortening them to increase tension and raise pitch. Unlike techniques that can lose effectiveness over time, this surgery offers permanent results.

Hormone therapy can bring out desired traits, but it can’t change the underlying structure or remove hair follicles. Our highly trained surgeons and other specialists offer options. Patients usually go home the same day or spend one night in a private room.

Face options:

  • Browlift (done with the forehead)
  • Cheek augmentation
  • Chin surgery (genioplasty), including reductive, implants or bone-cut options
  • Eyelid surgery
  • Face-lift, neck lift
  • Forehead lengthening
  • Forehead reduction, including Type 3 sinus setback and orbital remodeling
  • Hairline advancement (done with the forehead)
  • Jawline contouring
  • Lip lift and/or augmentation
  • Lipofilling (transferring fat using liposuction and filling)
  • Nose job (rhinoplasty)

Body options:

Hormone treatment may not result in fat distribution consistent with your gender. We offer liposuction and fat grafting to reshape areas of the body.

  • Introduction
  • Conclusions
  • Article Information

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

Data Sharing Statement

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

  • 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
  • 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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gender reassignment surgery wait

A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Lindsey Tanner

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Expert Commentary

What the research says about hormones and surgery for transgender youth

Researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of gender-affirming medical treatment for transgender youth.


Republish this article

Creative Commons License

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Chloe Reichel, The Journalist's Resource August 7, 2019

This <a target="_blank" href="https://journalistsresource.org/politics-and-government/gender-confirmation-surgery-transgender-youth-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

In the interest of examining this important news topic through a research lens, Journalist’s Resource collaborated on this story with The Burlington Free Press,  where it first appeared .  This piece is part of the newspaper’s series of stories about transgender youth  in the state.

As Vermont regulators consider changes to Medicaid that would expand access to gender confirmation surgery for transgender youth, researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of the new proposal.

Among other changes,  the proposed rules would eliminate the requirement that transgender individuals on Medicaid must wait until the age of 21  to receive surgery. Individuals over the age of 18 and minors — with informed parental consent — would be eligible.

Such changes are in line with current thinking among academics and physicians in the field. It’s still a fledgling field, as Marci Bowers, a California-based gynecologist and surgeon who specializes in gender confirmation and serves as a professorial lecturer at the Icahn School of Medicine at Mount Sinai points out.

“Kids are coming out very young. A generation ago, they were driven into the closet,” Bowers said. “It’s only these last 20 years or so where instead of that happening, people are getting professional help.”

How common are gender confirmation surgeries in the U.S.?

Estimates suggest that in the U.S., between 2000 and 2014, 10.9% of inpatient visits for transgender people involved gender confirmation surgery. This figure comes from  an analysis of inpatient visits for a nationally representative sample that includes, but is not limited to, transgender patients, which was published in 2018 in the medical journal JAMA Surgery . Over the study period, the number of patients who sought gender confirmation surgery increased annually.

Further, the percentage of gender confirmation surgeries that are “genital surgeries” — commonly referred to as bottom surgeries — has increased over time. Between 2000 and 2005, 72% of gender confirmation surgeries were bottom surgeries; from 2006 to 2011, that number increased to 84%. And the number of patients insured by Medicare or Medicaid seeking these procedures increased threefold between 2012-2013 and 2014.

As societal acceptance of gender diversity has grown, medical thinking has changed, too, Bowers notes.

“At least in the academic circles, in the medical circles, we realize that yes, it’s valid, that yes, kids do better after treatment, yes, surgery is appropriate, and why wait till 21?” Bowers said. “That’s really completely arbitrary. In fact, it’s probably cruel.”

“Most of the research is on older patients,” Elizabeth Boskey, a social worker at the Center for Gender Surgery at Boston Children’s Hospital and co-author of several research papers on gender confirmation gender-affirming surgery in youth, notes. “But there is evidence in the literature about just overall improved health, reduced anxiety, increased ability to function, for individuals after they have these gender-affirming surgeries.”

What does research say about treatment of transgender youth?

A  review of the latest research on gender-affirming hormones and surgery in transgender youth , published in a June 2019 edition of The Lancet Diabetes & Endocrinology , supports Bowers’ assertions that gender confirmation surgery benefits adolescents, though it does not go as far as to recommend specific age guidelines.

“Several preliminary studies have shown benefits of gender-affirming surgery in adolescents, particularly regarding bilateral mastectomy in transgender adolescent males, but there is a scarcity of literature to guide clinical practice for surgical vaginoplasty in transgender adolescent females,” the authors write. “The optimal age and developmental stage for initiating [cross sex hormones] and performing gender-affirming surgeries remains to be clarified.”

The  World Professional Association for Transgender Health  (WPATH), a leading organization for transgender health worldwide whose membership consists of physicians and educators, publishes Standards of Care and Ethical Guidelines for the treatment of transgender patients.

Though WPATH’s Standards of Care was last updated in 2011 and is under revision, even the current standards suggest that individuals at the age of majority in a given country (for the United States, that’s 18) who have lived for at least 12 months in accordance with their gender identity should be eligible for genital surgery, and that chest surgeries can be done earlier.

“I think it’s important to recognize for all of these standards of care, these are flexible guidelines,” says Loren Schechter, director of the  Center for Gender Confirmation Surgery  at  Weiss Memorial Hospital , clinical professor of surgery at the University of Illinois at Chicago, and co-lead for the revision of the WPATH standards of care surgery chapter for adolescents and adults. “It is not necessarily uncommon that we will currently perform bottom surgeries under the legal age of majority now.”

Schechter also indicated that the revision of the standards will likely include lowered age guidelines.

One reason to give transgender youth access to surgery

Schechter maintains that there are many reasons why minors should be eligible to receive gender confirmation surgery.

“One of them is that post-operative care in a supportive environment is very important,” Schechter said. “So, for example, for those individuals going off to college, the ability to recuperate while at home in a supportive environment and parents during that post-operative period is quite important. Trying to have your post-operative care in a dorm room after surgery is it is not necessarily an ideal scenario.”

This reasoning was echoed in a  paper published in the Journal of Sexual Medicine in April 2017 . For the study, researchers asked 20 WPATH-affiliated surgeons practicing in the U.S. about whether and why they performed genital surgery on transgender female minors.

Respondents noted the beneficial recovery environment some minor patients may have.

“Some surgeons viewed timing the procedure before college attendance as a harm reduction measure: Younger patients who have the support of their families, support of their parents, and can have the operation while they are still at home, as opposed to being alone at school or at work, anecdotally tend to do much better than someone who is alone and doesn’t have appropriate support.”

Others suggest that receiving surgery as a minor might allow the patient to “fully socially transition” in their next phase, such as in college.

Who is ready for surgery? Considerations beyond age

Physicians involved in the study also noted that while the number of minors requesting information about genital surgery had increased, psychological maturity is their main criteria for approval.

As one interviewed surgeon put it, “Age is arbitrary. The true measures of how well a patient will do are based on maturity, discipline and support.”

Eleven of the 20 surgeons interviewed had performed such surgeries. Minors ranged in age from 15 to “a day before 18.” About two-thirds of surgeons interviewed believe that such decisions should be made on a case-by-case basis rather than in strict adherence with current WPATH guidelines, which advises to wait until 18 in the U.S.

Boskey, who works for the Center for Gender Surgery at Boston Children’s Hospital, notes: “Just setting the age guidelines in place doesn’t remove the need to appropriately assess whether the surgery is something that should be happening,” she said.

“They’re going to need to make certain that the patient is appropriate for that surgery, that they are being diagnosed with gender dysphoria, that they are taking hormones as appropriate, that they are living in their affirmed gender, that they are aware of all of the life-changing nature of these surgeries,” she said. “These are surgeries that require pretty intense assessment to make certain that they’re appropriate. But that needs to come from the clinical side, rather than the insurance side.”

Will trans youth regret surgery? What the research says

Research supports the benefits of early interventions.

A 2018 study published in JAMA Pediatrics of 136 transmasculine youth and young adults between the ages of 13 and 25 receiving care at Children’s Hospital of Los Angeles finds that, on average,  chest dysphoria, or distress caused by one’s chest, was significantly higher among participants who had not received chest reconstruction surgery as compared with those who did .

Serious complications among the surgery group were rare, and only one of the 68 patients who received surgery reported experiencing regret sometimes, with the other 67 reporting no regret over the procedure. The time that had elapsed between surgery and the survey ranged from less than 1 year to 5 years.

“Given these findings,” the authors conclude, “professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.”

Those who study the impact of early access to gender confirming surgeries often point to research from the Netherlands, home to one of the earliest comprehensive gender clinics.

“[T]hey’ve probably got the most data on transgender, gender non-conforming adolescents, who have been followed longitudinally, prospectively in the most rigorous way — that data indicates that people do well with early access and early interventions,” Schechter says. “By early, I mean late adolescence — we’re not, of course, talking about operating on children.”

Adolescents who were the first 22 people to receive gender confirming surgery at the clinic in the Netherlands  showed after surgery that they no longer experienced distress over their gender, according to a 1997 publication in the Journal of the American Academy of Child & Adolescent Psychiatry .

The study also showed that the 22 adolescents scored within the normal range for a number of psychological measures.

Further, the authors note, “Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.”

A follow-up study, published four years later, of another group of 20 adolescents receiving surgery after the first group of 22  confirmed the initial findings .

Another, later study in the Netherlands focused on the outcomes of  55 transgender young adults  who received gender confirmation surgery between 2004 and 2011. The participants all “were generally satisfied with their physical appearance and none regretted treatment.”

Moreover, gender dysphoria was alleviated, mental health improved, and well-being among those studied was similar to or better than their peers in the general population.

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Why surgery wait times put transgender people at risk of suicide

gender reassignment surgery wait

Written by Iman Sheikh

Apr 29, 2015

transgender symbol

The Ontario Ministry of Health has designated only a single site to evaluate the eligibility of transgender people seeking surgery.

A prescription for 450 mg of the anti-psychotic drug Seroquel.

This was the answer Rachel Lauren Clark received when she told doctors at a Toronto hospital she wanted gender reassignment surgery (GRS). The regular adult dose is 50 mg.

Article continues below

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“I was a zombie,” she said, “a complete and utter zombie. I took it at eight o’clock at night and woke up at eight in the morning and couldn’t even function. So then they gave me another drug called Modafinil, which they give to narcolepsy patients to wake them up.”

Clark took the pharmacological cocktail for a year before she realized the only drug that could fix her gender dysphoria was estrogen. A psychiatrist suggested to then 40-year-old Clark that if she was even remotely considering GRS, also known as sex reassignment surgery, she should start the process immediately. Clark did. She received a date for her surgery: June 8, 2015. Just 11 days shy of her 46th birthday.

Why the six-year delay in treatment? Because the Ontario Ministry of Health has designated only a single site to evaluate the eligibility of transgender people seeking surgery. In fact, the Adult Gender Identity Clinic at Toronto’s Centre for Addiction and Mental Health (CAMH) is the sole gatekeeper for access to GRS – not only for patients across Ontario, but also those in Newfoundland and Labrador .

The surgery, even once an initial meeting with a doctor has been completed, is still years away for those who want it. The process looks something like this: a transgender person seeking surgery must have completed a year of hormone replacement therapy, as well as lived for at least a year in the gender for which they‘re undergoing GRS before a doctor will consider advancing their case. Then the person needs additional consultations with at least two different CAMH doctors, and both must agree the patient is a strong candidate. Only then will gender reassignment surgery be covered by OHIP.

Once the surgery has been approved, there’s only one clinic in Canada, located in Montreal, which performs the entire range of gender reassignment surgeries. It has a six- to eight-month waiting list. CAMH Gender Identity Clinic Head Dr. Chris McIntosh said the waiting list will continue to grow unless the Ministry also develops expertise in other parts of the province.

“The number of people seeking intervention surgery is so much greater than it ever was before,” he noted. “It’s probably due to the general awareness of transgender issues. It’s expanding all the time, and people who would have never thought that this was something they would do start to consider it as a possibility.”

Bypassing the CAMH process and paying out of pocket is also an option. The Montreal clinic performs private surgeries with the same prerequisites for candidates as public surgeries (hormone replacement therapy and a year of living experience), but accepts letters of recommendation – two for SRS and one for breast augmentation or top surgery – from a therapist, counselor, psychologist, psychiatrist or social worker. One letter must be from someone with a Ph.D., and the other from someone with at least a master's degree.

The clinic charges approximately $20,100 for male-to-female sex reassignment surgery and $8,000 for breast implants. The female-to-male process costs approximately $10,000 for top surgery, and $45,000 for a phalloplasty. Many transgender Canadians also travel out-of-country, to places such as Thailand, where the cost of gender reassignment surgery is only 30-50 per cent of North American prices. As of 2014, two to three patients receiving male-to-female reassignment surgery  per day in Thailand are foreigners.

One of the biggest concerns around the long wait times for Ontario is the adverse effects it has on the mental health of transgender people. For Rachel Lauren Clark, her stress levels were off the charts.

“I have a female brain and male sex characteristics,” she said. “It caused me a lot of anguish and psychological pain. There’s a lot of risk around being a trans person. You hear comments like, ‘If I saw a trans person in the change room with my wife, I would kill them.’”

Suicide is a serious risk for transgender people awaiting gender reassignment surgery. Trans PULSE, a research project created to look at problems related to transgender communities, found 50 per cent of transgender Ontarians seriously considered suicide because they were transgender. Around 43 per cent had actually attempted suicide.

“Trans people are at the highest risk of suicide and self-harm between the period that they’ve mentally decided to transition and when they complete their medical transition,” said N. Nicole Nussbaum, former president of Canadian Professional Association for Transgender Health and staff lawyer at Legal Aid Ontario.

Most medical professionals in Ontario are also not trained to deal with transgender issues, making reducing suicide rates particularly challenging.

“We’re very concerned because there isn’t very good education in most medical schools about trans issues,” CAMH’s Dr. McIntosh said. “Most of the people who practice now would have received no training in this. Gender dysphoria is quite distinct from psychosis. Anti-psychotics are not an appropriate course of treatment.”

Mental health is just one of the many areas affected by inordinately delayed surgery times. According to Clark, a current student at U of T’s Emmanuel College, who moved to Toronto from New York in 2003, she can’t get a student loan because she can’t change her name on her Permanent Resident card until the surgery is complete. Also, her PR card is expired because she has to appear in person to renew it. The problem: she has been living as a female for the last three years.

“My PR card has my name and gender as male,” she explained. “They’ll let me renew it with the old information but I have to appear as that former person and gender to do that, and I look nothing like the old photo.”

Because of the PR card dilemma, Clark hasn’t visited her mother in three years. Whenever she enters or exits Canada, she’s interrogated by border control officers.

“You get dragged into customs and they ask a load of questions,” she said. “They’re not doing this in a private room, it’s in front of everybody and it’s a hugely embarrassing situation that’s very, very difficult. For me, it’s not even worth it to travel.”

Employment is another issue affected by delayed wait times for surgery. Despite an almost 30-year career in IT, it was very difficult for Clark to find a job when she came out as a transgender woman.

“There’s quite a bit of employment discrimination ,” Nussbaum said. “We know transgender people have trouble getting references in their current name and gender. We need some policy at the federal level.”

Bill C-279 , a federal transgender rights bill that would add gender identity to the list of grounds protected from discrimination under the Canadian Human Rights Act and under the hate propaganda section of the Criminal Code, has been stalled in the Senate for three years. Calgary MP Rob Anders strongly opposed the bill, saying its goal is to give men access to women's washrooms , which led to the nickname "bathroom bill."

“Instead of making it about basic human rights, they’ve made it about whether transgender women are going to go into the washroom and rape women and children,” said Clark. “They’re saying, ‘Rachel’s going to walk into the washroom with her completely useless penis and rape my wife or my granddaughter.’ The idea behind that reaches all new levels of absurdity.”

A Ministry of Health spokesperson said the government’s exploring options around wait times and points of access to surgery, but didn’t provide specifics. CAMH’s Dr. McIntosh stressed the urgency of the Ministry getting involved.

“We really want the province to help us,” he said. “Often times, people may decide this is really what they want to do and be quite sure about it. Then they contact CAMH and are told that we’re currently seeing people who were referred 18 months ago. Unfortunately we are seeing increased rates of suicide ideation, and because our clinic is so small, we can’t offer any treatment ourselves.”

Image credit: PhotoComIX/Flickr.com

Iman Sheikh

Iman Sheikh is a former digital media producer at TVO.org. 

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Transgender Surgery FAQs

Is gender reassignment surgery safe.

Like all types of surgery, gender-confirmation procedures carry risk. That’s why we thoroughly evaluate your health before planning surgery. Our experienced team follows best practices when it comes to your safety.  

How common is gender reassignment surgery?

Gender reassignment (confirmation) surgery is more common in transgender men (42 to 54%) than transgender women (28%). Top (chest gender confirmation) surgery is performed approximately twice as often as bottom (genital) surgery. In studies that assessed transgender men and women as an aggregate, top surgery accounts for 8 to 25% and bottom surgery accounts for 4 to 13%.  Review study details .

How long does it take to transition to another gender?

The length of your journey depends on your individual needs and choices. Along with surgical procedures, you might also have hormone therapy, voice therapy, and counseling. It’s up to you where to start and when you feel you’ve met your goals.

Can breasts grow back after top surgery?

Removed breast tissue doesn’t grow back. We do leave some fat behind to create natural-looking chest contours. While this fat can enlarge like fat anywhere on the body, it likely will not take on a feminine appearance.

Transgender Australians waiting years for gender-affirming surgery, as Medicare bid looms

A woman holding a pride flag at a rally.

  • In short: Only a handful of Australian surgeons offer certain gender-affirming procedures, meaning transgender people are waiting for years or seeking options overseas
  • What's next? An application has been made to list gender-affirming surgeries as specific Medicare items, to help address high costs and low availability

For trans woman Abbie Clark, feelings of gender dysphoria have been coming and going since she was a kid.

She didn't initially know what it meant to be trans, but she knew she would rather be a woman than a man.

"When I wanted to transition, I didn't know where to go," the 30-year-old Ballarat woman said.

"I didn't know what service I needed to look at, I didn't know who I needed to talk to."

A woman in glasses taking a selfie.

Ms Clark had surgery on Trans Day of Visibility last year, three years after starting hormone treatment and a year-and-a-half after her consultation with the surgeon.

Transgender Australians are spending years waiting for gender-affirming surgery, which is still required in some states to change birth certificate gender markers.

Gender-affirming surgery refers to a variety of procedures, including mastectomies, breast augmentation, facial feminisation and vocal chord surgery, as well as genital surgery.

Genital surgeries, such as vaginoplasty (creation of a vagina) and phalloplasty (creation of a penis), are known in the trans community as bottom surgeries.

Doctors in the field and trans people say there are only five Australian surgeons regularly performing these procedures. 

Ms Clark's out-of-pocket surgery costs were $25,000, which would have been much higher had she not had private health insurance, which covered around $15,000 in hospital expenses.

A woman with red hair in a pink sweater

Medicare contributed about $2,000 to the surgeon's fees.

"A lot of it's considered cosmetic. It's not, because in many cases, it is literally life-changing," Ms Clark said.

Now, for the first time, an application has been made to the commonwealth health department to list gender-affirming procedures on Medicare by the Australian Society of Plastic Surgeons. 

Trans people, surgeons and advocates argue a better system of public funding for the surgeries could cut costs for patients and hospitals, as well as address availability concerns.

Australia 'behind other countries' on gender-affirming care

The president of the Australian Society of Plastic Surgeons, Nicola Dean, said the society made the Medicare application to the Department of Health as part of a collaborative effort with trans organisations and other health professionals to improve access to the surgery.

Dr Dean said this could incentivise more surgeons to join the field and provide better data on how many surgeries were taking place in Australia.

"A lot of it goes on a bit under the radar," she said.

"I think Australia is really quite behind other countries."

A doctor with glasses.

A Department of Health spokesperson confirmed it had received an application requesting the Medical Services Advisory Committee (MSAC) consider publicly funding gender-affirmation surgery and consultations under Medicare.

The department is currently considering if the request is suitable to be considered by MSAC.

A spokesperson said some Medicare rebates were already available "if the services are deemed by the treating practitioner to be clinically relevant to the care of their patient".

Surgeons have told the ABC the lack of specific Medicare item numbers for gender-affirming surgeries means costs are unpredictable and not transparent, and some procedures aren't covered.

In 2021, a petition to federal parliament for gender-affirming surgery to be included on Medicare gained nearly 150,000 signatures — the fifth most-signed petition on the Australian parliament website.

Surgeons inundated with hundreds of booking requests

Clinical guidelines written by the Royal Children's Hospital Melbourne and endorsed by the Australian Professional Association for Trans Health (AusPATH)  advise delaying genital surgery for trans people until adulthood . Surgeons spoken to by the ABC said they would only perform bottom surgeries for people over the age of 18.

Kieran Hart, a surgeon at ACT Urology in Canberra, said he had been swamped with requests for vaginoplasty and orchiectomy (removal of testicles) procedures. 

In Dr Hart's first year in 2018, he performed three gender-affirming surgeries. Last year, he did 60.

He has about 150 people booked in for surgery, and 100 for consultations. His waiting list has only recently reopened.

"There's been hundreds who have been trying to get consults while I closed the books for a while," he said.

A smiling man in scrubs in a hospital room.

The wait time is around two years, and about 90 per cent of his clients come from interstate.

He said private hospitals doing gender-affirming surgery "almost lose money" because the procedures were not listed on Medicare, meaning surgeons have to use different item numbers that   don't quite line up with the procedure.

But Dr Hart said seeing the outcomes for trans women made it some of the most rewarding work a surgeon could do.

"It's just quite remarkable how resilient they are, but also what difference you make to their happiness and mental health," he said.

Advocates point to numerous studies which back the mental health benefits of gender-affirming surgeries for adults.

In a 2014 peer-reviewed study of 188 trans Australians, the 42.5 per cent of respondents who had undergone gender-affirming surgery reported higher levels of physical and mental health than those who had not had surgery . The difficulties in accessing surgery in Australia mean post-surgery survey sample sizes tend to be small.

A peer-reviewed analysis of the 2015 US Transgender Survey , which had 27,715 respondents, found the 13 per cent who had undergone gender-affirming surgeries in the preceding two years experienced a 42 per cent reduction in psychological distress and a 44 per cent reduction in suicidal ideation, compared to those who desired surgery but had not had it.

Not all trans people wish to undergo surgery, and for many of those who do, it is not financially viable — with nearly all surgeries taking place in the private system due to state government policy settings on elective surgery.

For trans men, getting a phalloplasty in Australia is even more difficult, with only two surgeons offering the procedure.

One is Brisbane-based Dr Hans Goossen, whose new patients might expect to wait six to 12 months for an initial consultation.

After completing surgical training in urology and reconstruction, he spent two years overseas learning the skills to do gender-affirming surgeries.

"It's still a relatively new field in Australia," he said.

"Until recently, most patients had to travel overseas."

Bottom surgeries for trans men include metoidioplasty and phalloplasty.

An insured patient might expect to pay $80,000 out-of-pocket, for what is a complicated and lengthy series of three or more operations. This includes costs associated with the surgery, anaesthetic, hospital stay, preparation and recovery.

"I understand people's frustration with the fact that it's currently not available in the public hospital system, and that it costs a lot of money and it's therefore not affordable for everyone," he said.

Dr Goossen wants to see federal or state governments fund a certain amount of surgeries per year, like in New Zealand , reducing the need for patients to spend tens of thousands of dollars on the procedures.

Another surgeon, David Caminer, started regularly performing phalloplasty and vaginoplasty procedures this year at his practices in Sydney and Wollongong.

Dr Caminer said even if the procedures ended up being listed on Medicare, patient costs would still be high due to Medicare not keeping up with inflation.

"The only way to get it cheaper, or for nothing, is to do it through the public hospitals," he said.

He said some private hospitals were religious, and did not permit gender-affirming surgeries to be performed or taught there.

"They won't allow you to do it, because it's not really keeping with their religious belief," he said.

After a religious hospital told Dr Caminer he could not perform a phalloplasty on a patient there, he's struggled to find another hospital with an intensive care unit to do the procedure. The patient has pre-existing health conditions so would require close monitoring.

"There's not that many intensive care units in the private sector," he said.

"It's taking me a lot of time and effort, we're still trying."

Official training and support needed, surgeons say

To address the surgeon shortage, Dr Hart said the relevant medical societies and colleges could do more to introduce trainees to gender dysphoria theory and basic gender-affirming procedures.

"The College of Surgeons, we don't have a formalised training pathway for it at this point in time," he said.

"It's not really recognised in the curriculums for the Urological Society or the plastic surgeons' society."

A spokesperson the Royal Australasian College of Surgeons (RACS) said gender-affirming surgery was complex and required multidisciplinary consultation.

"While RACS supports the training of gender-affirmation surgery, it is important to note that the limited number of cases and the highly specialised nature of this field requires specific focus for a limited number of surgeons," they said.

A group of people hold a trans pride flag above them as they walk through a city

Dr Dean from the Australian Society of Plastic Surgeons said in conjunction with RACS, her organisation provided plastic and reconstructive surgery training which was applicable to gender-affirming surgery, but there should be funding to send surgeons overseas to learn.

"We do have the basics of how to do the genital surgery, but it does need expertise to be built up," she said.

"And I think that it will take quite some time for people to learn off the few Australian surgeons that are doing this surgery."

Thailand a better option for some trans Australians

About one in five patients access their superannuation to pay for surgery at Dr Hart's clinic, he said.

Sav Zwickl, a director with AusPATH, said this could put a financial strain on trans people.

"They spend years saving for surgery, and there's often no option but to access their super and, of course, that has long-term implications down the road for their financial situation," the researcher, who is trans and non-binary, said.

Sav Zwickl smiles widely while wearing a coat.

Dr Zwickl said many trans people went to Thailand for surgery, where surgeons were generally "very skilled and experienced in performing gender-affirming surgeries".

"That's a case of a lack of surgeons [in Australia], but also some procedures that people are looking for are not available in Australia at all," they said.

Anne *  went to Thailand for her bottom surgery in 2012, after being quoted $30,000 for surgery in Australia.

"Surgery in Thailand was a lot more affordable than what it was in Australia," she said.

"Thailand has been performing these surgeries over there for thousands of trans women for decades."

To fund the surgery and overseas trip, she spent more than two years living in financial hardship.

Without surgery, she wouldn't have been able to change her gender marker on her Queensland birth certificate, a requirement that only changed in June.

"I wanted to make sure that all my legal documentation was consistent," she said.

"Without having a birth certificate and official documentation, you're always having to explain yourself."

New South Wales and Western Australia are the only states still requiring gender diverse people to undergo medical procedures to update their birth certificate gender marker.

In WA, a "gender reassignment board" judges applications by trans people to change their gender, although the state is in the process of repealing these laws.

Surgery and the approval of a panel is required to legally change gender in NSW, but a spokesperson for the attorney-general said during the election campaign, Labor had committed to reviewing the legislation in consultation with trans and gender diverse communities.

The spokesperson said work had not yet started on reviewing the legislation.

Post surgery and legal recognition, life's a bit easier

Anne said she had no regrets about her decision to get surgery.

"It stopped the gender dysphoria, the thoughts of self-harm and suicide that I was experiencing," she said.

It's not lost on her that many trans people struggle to access surgery, but she's grateful to have a body she feels more at home in.

"I finally felt complete," Anne said. 

Ms Clark can breathe a sigh of relief having overcome the hurdles of surgery.

"I've honestly never been happier, now that it's finally all sorted," she said.

"I occasionally catch places where I've forgotten to change my name, but by and large, it's so simple now."

*Name has been changed.

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  • v.26(4); 2018 Nov

Language: English | French

Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care

La chirurgie de réassignation de genre pour les personnes transgenres : la perception de satisfaction et d’obstacles aux soins, hadal el-hadi.

1 University of Calgary, Calgary, Alberta, Canada

Claire Temple-Oberle

Alan robertson harrop.

The purpose of this study was to examine the perceived satisfaction and barriers to care for transgender patients after they decide to undergo gender-affirming surgery (GAS).

A survey consisting of 21 multiple-choice and short-answer questions was distributed to transgender organizations and online forums across Canada and the United States. The data were then analyzed using descriptive statistics.

There were 32 participants, 12 who identified as female to male and 20 as male to female. The mean age was 36 years, with a range of 18 to 81 years. The mean age of their first GAS was 33 years, and the range of wait time was 6 months to 7 years. Most of the participants received information about GAS from transgender websites and transgender surgery clinics (91% and 50%, respectively). Most participants (74%) felt like they had access to appropriate care and 89% felt like their surgeons provided enough information about GAS. There were 38% of participants who would change their experience with GAS. Participants stated several barriers toward receiving GAS: financial (73%), finding a physician (65%), and access to information (63%). Surgical transition was important to the quality of life for 91% of participants and 100% were happy with their decision to undergo GAS.


Transgender participants demonstrated that GAS is important to their quality of life and this study showed significant barriers to GAS.

La présente étude visait à examiner la perception de satisfaction et d’obstacles aux soins de la part des patients transgenres après qu’ils ont décidé de subir une opération de réassignation de genre (ORG).


Les chercheurs ont distribué un sondage composé de 21 questions à choix multiple et à réponse courte aux organisations transgenres et aux forums en ligne du Canada et des États-Unis. Ils ont ensuite analysé les données à l’aide de statistiques descriptives.


Au total, 32 personnes ont participé au sondage. Douze se sont identifiés comme hommes trans et 20, comme femmes trans. Ils avaient un âge moyen de 36 ans (plage de 18 à 81 ans). Ils avaient un âge moyen de 33 ans lors de leur première ORG et avaient dû attendre de six mois à sept ans pour la subir. La plupart des participants avaient reçu de l’information au sujet de l’ORG dans des sites pour les personnes transgenres et des cliniques chirurgicales de réassignation de genre (91 % et 50 %, respectivement). La plupart des participants (74 %) trouvaient qu’ils avaient eu accès à des soins appropriés et 89 % trouvaient que leur chirurgien leur avait fourni assez d’information sur l’ORG. Cependant, 38 % des participants auraient modifié leur expérience de l’ORG. Les participants ont souligné plusieurs obstacles à l’ORG : la question financière (73 %), la quête d’un médecin (65 %) et l’accès à l’information (63 %). La transition chirurgicale était importante pour la qualité de vie de 91 % des participants et ils étaient tous heureux d’avoir subi une ORG.

Les participants transgenres ont démontré que l’ORG est importante pour leur qualité de vie, et la présente étude a établi qu’ils devaient affronter des obstacles substantiels pour y accéder.


Gender dysphoria refers to a desire to be treated and identified as a gender that is contrary to one’s gender at birth and can result in significant distress and/or impairment. 1 These individuals, collectively referred to as the transgender community, have historically been marginalized and have been the subjects of discrimination. 2 In recent years, however, the transgender population is becoming more vocal, more visible, more accepted, and less stigmatized. 2 They are also seeking pharmacological and surgical transition at earlier ages and in higher numbers. 3

Despite this progressive movement, transgender patients (TGPs) continue to encounter many barriers in their efforts to access treatment. 4 – 7 The process of transition for many TGPs is often a long and arduous one with many obstacles to overcome. 6

The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary professional association that publishes standards of care for transgender and gender nonconforming persons. Its goal is “to provide clinical guidance for health professionals to assist transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well being, and self-fulfillment”. 8 The WPATH outlines consensus-based general criteria for gender-affirming surgery (GAS) 8 which are as follows:

  • Persistent, well-documented gender dysphoria;
  • Capacity to make a fully informed decision and to consent for treatment;
  • Age of majority in a given country;
  • If significant medical or mental health concerns are present, they must be reasonably well controlled.

In addition, WPATH outlines specific criteria for specific surgical procedures in patients who meet the general criteria. For example, specific criteria for hysterectomy and salpingo-oophorectomy in female to male (FtM) patients and for orchidectomy in male to female (MtF) patients include “12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual)”. 8 Specific criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients include all of the above as well as “12 continuous months of living in a gender role that is congruent with their gender identity,” also referred to as “real-life experience.” 8 Appropriate implementation of the WPATH standards of care requires proper assessment and written documentation by qualified mental health professional. In addition, all members of the patient’s health-care delivery team must be united in decision and share responsibility for making irreversible changes. This qualitative study examines perceived satisfaction and perceived barriers to care in a group of TGPs who have undergone GAS or are considering GAS.

Between November 2015 and January 2016, a 21-question survey was distributed to transgender organizations across Canada and the United States and was posted online through transgender forums. In total, 25 transgender organizations were contacted, and they were divided into 10 Canadian organizations, 10 American organizations, and 5 American and Canadian organizations. Transgender individuals were invited to participate if they were MtF, FtM, or other trans-identifying adults. Survey respondents were required to be over the age of 18, American or Canadian citizens, and to be considering, or have undergone, GAS in their transition. The survey was distributed using an online secure platform, and data were collected in a confidential and anonymous manner. Each respondent received a standard recruitment message that included implied consent by completing the survey. The University of Calgary ethics review board provided approval for this project (Ethics ID: REB15-2219).

The survey consisted of multiple-choice and short-answer questions pertaining to demographic information, treatment to date, barriers to care, impact of treatment on quality of life, and satisfaction with treatment. The domains that were identified were based off an extensive literature review of the barriers to health care that the transgender population faced. The data were read and analyzed by the primary investigator (H.E.-H.). Quantitative statistics were performed to determine the demographics of the respondents. Qualitative statistics were also performed to assess the ordinal variables of attitudes (strongly agree, agree, disagree, strongly disagree, and not applicable).


Thirty-two self-identified transgender adults completed the survey. Seventeen were American (53%) and 15 were Canadian (47%). Twelve identified as FtM (37.5%) and 20 as MtF (62.5%). The mean age of the respondents was 33 years, with a range of 18 to 81 years.

Treatments Received

Fifty-nine percent of respondents had previously undergone some form of GAS. The mean age of their first GAS was 33 ± 7.3 years, and the range of wait time was 6 months to 7 years. The mean time between deciding to include surgery in the treatment of their gender dysphoria to ultimately having surgery was 2.8 ± 0.9 years and a range 0.5 to 7 years.

The medical and surgical treatment received by FtM respondents included various combinations of none, hormonal therapy, mastectomy or breast reducing/contouring, hysterectomy and bilateral salpingo-oophorectomy, and genital reconstructive procedures ( Figure 1 ). The medical and surgical treatment received by MtF respondents included various combinations of none, hormonal therapy, facial feminizing surgery, top surgery such as breast augmentation, and lastly genital reconstructive procedures ( Figure 2 ). Within the FtM group, 41.7% had bottom surgery which included any of the following: metoidioplasty, urethroplasty, vaginectomy, scrotoplasty, phalloplasty, hysterectomy, and bilateral salpingo-oophorectomy. Within the MtF, 40% had bottom surgery which included orchiectomy, penectomy, labiaplasty, clitoroplasty, and vaginoplasty.

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Female to male procedures.

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Male to female procedures.

Information Access

Transgender websites were a main source of information for 94% of the respondents, and surgery clinics in 50% ( Table 1 ). Ninety-four percent of respondents stated that public websites influenced their treatment decisions, with one stating that “the Internet made me realize I could do all the things I wanted to do.” Half of the respondents (50%) received information about GAS from transgender surgery clinics. Thirty-eight percent received information from relatives/friends/acquaintances. Thirty-one percent received information about GAS from a mental health professional and 16% received information from their family doctor. Magazines were not used frequently (9%) as a source of information for GAS. One respondent felt that there was a “lack of information about transgender struggles, options for transitioning, and how these procedures work for people who have not consulted a medical professional.” Another respondent felt that it would have been “helpful to have some sort of resource or way of comparing outcomes from different surgeons and how satisfied people [were] with different aspects of the results.”

Sources of Information About GAS for Respondents.

Abbreviations: FTM, female to male; GAS, gender-affirming surgery; MTF, male to female.

Barriers to Care

Potential barriers listed on the survey included financial, access to information, support from family and friends, finding a physician, discrimination, uncertainty about their decision, family planning, and denial for care by a health-care worker ( Figure 3 ). The majority of respondents agreed that finances (73%), finding a physician (65%), lack of support from family and friends (64%), and difficulty with access to information (63%) were barriers to GAS. On the other hand, very few respondents felt that denial by a health-care worker (16%), family planning (22%), uncertainty about their decision (23%), or discrimination (30%) were barriers to care. Respondents repeatedly mentioned finance as a barrier: “While other aspects of access to care could have been improved, affordability was, by far, the biggest barrier.”

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Barriers to gender-affirming surgery.

Impact of Treatment on Quality of Life

Eighty-four percent of respondents agreed that their surgical transition was important to their quality of life. One respondent stated that “before surgery, I had a lot of depression and dysphoria centered around that part of my body, and surgery alleviated this.” Another respondent stated that GAS had a profound impact on their psyche and that the “tiny persistent force alerting me to the ‘wrongness’ between my legs has disappeared, and I can finally go about my life and move on, like other people can.”

All respondents who had received GAS agreed that they were happy with their decision to undergo GAS. One respondent stated: “My body feels like mine,” and another stated that this was the “best thing I ever did for myself.” For one respondent, GAS was lifesaving: “After 3 attempts at suicide, I knew that life was no longer possible without transition.” A major aspect of gender dysphoria is the desire to be treated and identified as the expressed gender, as one respondent stated eloquently: “The surgery has given me what I should have been born with. I have always felt that the Y chromosome was a birth defect!”


Most respondents were satisfied with their GAS experience, with comments such as it was “nice actually liking my body for once” and that they “have nothing but pleasant memories of the event, from start to finish.” Surgical transition was important to the quality of life for 91% of respondents and 100% were happy with their decision to undergo GAS. Thirty-two percent of respondents felt that they would change some aspect of their experience with GAS, in particular: timeliness of their surgeries (n = 1), finding a different surgeon (n = 1), having more of a local surgical support community (n = 1), insurance coverage (n = 1), improvement in the surgeries (lack of lubrication and depth of vagina; n = 1), and scar placement (n = 1). There was no statistical difference between the FtM and MtF groups, nor was there a statistical difference between their satisfaction rates between medical and surgical treatments.

Currently, there are many treatment options for gender dysphoria, including hormone treatment, real-life experience, counseling, psychotherapy, and GAS. 9 The physical transition from one sex to another allows TGPs to resolve the distress and conflict they had, ultimately bringing patients closer to achieving personal wellness. 9 Other studies have demonstrated an undeniable beneficial effect of GAS on postoperative outcomes such as subjective well-being, cosmesis, and sexual function. 9 – 14 Gender-affirming surgery has been part of the treatment of gender dysphoria for more than 80 years and is now widely accepted as therapeutic. 8 Respondent bias could explain the high level of satisfaction among survey respondents, and nonresponders may not be as happy, may have had a bad outcome, or may have had a failed procedure.

The transgender community has specific health information needs and concerns. 15 – 17 Particular areas of need include information pertaining to types of treatment, health-care proxy, cancer, adolescent depression and suicide, adoption, sexual health and practices, HIV infection, surrogate parenting, mental health issues, transgender health issues, intimate partner violence, and intimate partner loss. 18 Obtaining information from health specialists remains challenging for patients, in particular information regarding GAS options, procedures, and outcomes specific to their own situation.

Financial issues and confusion around funding of care represent another barrier to care for many patients. No province provides coverage for the full range of transition-related services or procedures. 19 Examples of procedures recommended by the Canadian Professional Association for Transgendered Health that provincial health plans currently do not cover include tracheal shaving, vocal cord tightening, hair removal, and facial feminization. These matters are further complicated by uncertainty among both providers and provincial payors about what is regarded as “medically necessary” and what is “cosmetic.”

Patients in many geographic locations face a limitation in the number of qualified mental health professionals who perform assessments required to proceed with surgery as well as limitation in the number of surgeons who perform GAS. 20 Transgender health care is not yet incorporated into the medical education curriculum, and therefore, most health-care professionals lack the requisite knowledge to provide accurate treatment and management for TGPs. 21 – 23 Despite the progress to advance transgender-specific health care, the transgender population continues to endure discrimination and underrepresentation. 24 Some patients therefore travel to other jurisdictions to receive consultation and treatment, requiring the patient to pay out of pocket in most cases. This results in a patient-perceived inertia in navigating the pathway toward GAS. 25

A final barrier for transition within the transgender community is lack of social support. There is stigma attached to not conforming to one’s biological gender, which in turn leads to prejudice, discrimination, isolation, and possible ostracization. 26 , 27 For these reasons, many transgender individuals are hesitant or are reluctant to disclose their gender identity due to the possibility of negative consequences. 6 This in turn contributes to marginalization and poor health outcomes within this population. 27 – 30 There is room for improvement in socio-structural interventions tailored to promote support among the transgender population.

This study demonstrates the high level of satisfaction and improved quality of life in transgender respondents undergoing GAS. This marginalized population reports persistent barriers spanning financial, social, and qualified provider issues that should be addressed.

Level of Evidence: Level 4, Therapeutic

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Wellington man Vic Roper, 30, who despaired of ever being able to get gender reassignment surgery.

New Zealand reduces 30-year wait for gender reassignment surgery

Relief for trans community after country fell behind in offering the procedure

The New Zealand government has lifted a cap on gender reassignment surgery to address a 30-year plus waiting list.

Under the previous government the state funded three male-to-female surgeries and one female-to-male every two years. The waiting list for around 100 people stretched into the decades.

Under the new Labour coalition government the old cap will become the new minimum number of surgeries to be performed every two years.

The news was greeted with elation by the trans community, who said they felt they were finally being respected and acknowledged by the government.

“It is going to make such a lot of different to a lot of people, and there is great relief and excitement in the trans community,” said Lynda Whitehead, an advocate for Tranzaction Aoteroa.

“It gives people hope, and before there was very little or no hope. As a community we have been ignored and put on the back burner for a long time. But it feels like our concerns have finally fallen on sympathetic ears.”

In the 1990s New Zealand was a world leader in reassignment surgery, with the comparatively low cost of the operation and progressive attitude towards the delicate procedure attracting patients from around the globe.

But when the country’s only specialist surgeon retired in 2014, the waiting list for the complex and costly procedure ballooned, with advocates saying trans people were getting “desperate” and “frustrated” with the situation and taking risks with cut-rate surgeries overseas.

Vic Roper told the Guardian in 2016 that he saw “no point” in joining the waiting list for surgery as “by the time I got to the top of the list, I would be too old to appreciate it”.

“Trans people have an incredibly high suicide rate and this is practical action that will help people have an improved sense of mental health and wellbeing,” said Roper, who is scheduled for surgery in November.

“It was not a waiting list before, it was a ‘We’ll put your name here and never think about it again’ list. I feel the Labour government has a really different perspective on the country and who gets priority. They are really thinking about minority groups and trying to give them more of an even playing field.”

Dr Andy Simpson, New Zealand’s chief medical officer, said there were 111 people waiting for surgery: 84 male to female, and 27 female to male. It was unclear how long it would take to address the backlog but there was an interim arrangement of referring patients at the top of the list to a surgeon in the private sector. “So far, eight patients have been referred to this private sector surgeon for consultation.”

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  • New Zealand

Most viewed

Gender reassignment surgery: an overview


  • 1 Gender Surgery Unit, Charing Cross Hospital, Imperial College NHS Trust, 179-183 Fulham Palace Road, London W6 8QZ, UK.
  • PMID: 21487386
  • DOI: 10.1038/nrurol.2011.46

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

Publication types

  • Plastic Surgery Procedures / methods*
  • Plastic Surgery Procedures / psychology
  • Postoperative Complications / prevention & control
  • Postoperative Complications / psychology
  • Sex Reassignment Surgery / methods*
  • Sex Reassignment Surgery / psychology
  • Transsexualism / diagnosis
  • Transsexualism / psychology
  • Transsexualism / surgery*

Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery: Study

Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery: Study

Attempted suicide rates among people who identified as transgender more than doubled after receiving a vaginoplasty, according to a peer-reviewed study published in The Journal of Urology.

Researchers found the rates of psychiatric emergencies were high both before and after gender-altering surgery, with similar overall rates in both groups. However, suicide attempts were markedly higher in those who received vaginoplasties.

“In fact, our observed rate of suicide attempts in the phalloplasty group is actually similar to the general population, while the vaginoplasty group’s rate is more than double that of the general population,” the study authors wrote.

Among the 869 patients who underwent vaginoplasty, 38 patients attempted suicide—with nine attempts before surgery, 25 after surgery, and four attempts before and after surgery. Researchers found a 1.5 percent overall risk of suicide before vaginoplasty and a 3.3 percent risk of suicide after the procedure. Almost 3 percent of those who attempted suicide after undergoing vaginoplasty did not present with a risk of suicide prior to surgery.

Among the 357 biologically female patients who underwent phalloplasty, there were six suicide attempts with a 0.8 percent risk of suicide before and after surgery.

‘Affirmation at All Costs’: What Internal Files Reveal About Transgender Care

Overall, the proportion of those who experienced an emergency room and inpatient psychiatric encounter outside of suicide attempts was similar between the vaginoplasty and phalloplasty groups. Approximately 22.2 percent and 20.7 percent of patients, respectively, experienced at least one psychiatric encounter.

Suicide Rate 19-Fold Higher

“It’s hard to refute this paper because it’s a longitudinal study,” Dr. Oliva said. “In Sweden, everyone is in a database, and through diagnosis codes, they’re able to follow what happens to every citizen in terms of their medical history. They waited more than 10 years after people had surgery and found that death by suicide had an adjusted hazard ratio of 19.1.”

Surgical Procedures

A penial inversion is the most commonly performed procedure where the skin is removed from the penis and inverted to form a pouch that is inserted into the vaginal cavity created between the urethra and the rectum. Surgeons then partially remove, shorten, and reposition the urethra and create a labia majora, labia minora, and clitoris.

Another surgical method involves using a robotic system that enables surgeons to reach into the body through a small incision in the belly button to create a vaginal canal. The type of vaginoplasty performed varies among patients. For example, younger patients who have never experienced puberty may have insufficient penile skin to do a standard penile inversion.

Vaginoplasty Associated With Serious Risks

“For cosmetic surgery, if the complication rate was more than 2 percent to 3 percent, you wouldn’t have any patients,” Dr. Oliva told The Epoch Times. “These are very high percentage rates that we just accept.”

Dr. Oliva said complications with these surgical procedures are very high and he thinks this is why suicide rates are so high.

“People think this is going to solve the problem and it doesn’t,” he said.

US Physicians Received Billions From Pharmaceutical and Medical Device Industry, New Research Finds

US Physicians Received Billions From Pharmaceutical and Medical Device Industry, New Research Finds

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