gender reassignment surgery in the uk

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The history of gender reassignment surgeries in the UK

For Pride Month, we are recognising the plastic surgeons who pioneered gender reassignment surgeries (GRS) in the UK. Gender reassignment surgery, also known as gender confirmation surgery or gender affirmation surgery, is a sub-speciality within plastic surgery, developed based on reconstructive procedures used in trauma and in congenital malformations. The specific procedures used for GRS have only been practised in the last 100 years.

Over the last decade, there has been an increase in society acknowledgement and acceptance of gender diverse persons. This catalysed an increase in referrals to gender identity clinics and an increase in the number of gender affirmation surgeries. GRS help by bringing fulfilment to many people who experience gender dysphoria. Gender dysphoria - a distress caused by the incongruence of a person's gender identity and their biological sex, drives the person to seek medical or surgical intervention to align some or all of their physical appearance with their gender identity. Patients with gender dysphoria experience higher rates of psychiatric disorders such as depression and anxiety. Gender-affirming medical intervention tends to resolve the psychiatric disorders that are a direct consequence of gender dysphoria.

Norman Haire (1892-1952) was a medical practitioner and a Sexologist. In his book, The Encyclopaedia of Sexual Knowledge (1933), he describes the first successful GRS. His patient, Dora Richter underwent 3 procedures reassigning from male to female between 1922-1931. The procedures included a vaginoplasty (surgical procedure where a vagina is created).

In the UK, gender reassignment surgeries were pioneered by Sir Harold Gillies. Harold Gillies is most famous for the development of a new method of facial reconstructive surgery, in 1917. During the Second World War, he organized plastic surgery units in various parts of Britain and inspired colleagues to do the same, training many doctors in this field. During the war, Gillies performed genital reconstruction surgeries for wounded soldiers.

British physician Laurence Michael Dillon (born Laura Maude Dillon) felt that they were not truly a woman. Gillies performed the first phalloplasty (surgery performed to construct the penis) on Dillon in 1946. In transitioning from female to male, Dillon underwent a total of 13 operations, over a period of 4 years.

Roberta Cowell (born Robert Marshall Cowell) is the first known Brit to undergo male to female GRS. After meeting Dillon and becoming close, Dillon operated illegally on Cowell. The operation helped her obtain documents confirming that she was intersex and have her birth gender formally re-registered as female. The operation that helped her transition was forbidden as it was considered “disfiguring” of a man who was otherwise qualified to serve in the military. Consequently, Gillies, assisted by American surgeon Ralph Millard performed a vaginoplasty on Roberta in 1951. The technique pioneered by Harold Gillies remained the standard for 40 years.

Gillies requested no publicity for his gender affirmation work.  In response to the objections received from his peers, he replied that he was satisfied by the patient's written sentiments: “To Sir Harold Gillies, I owe my life and my happiness”. “If it gives real happiness,” Gillies wrote of his procedures, “that is the most that any surgeon or medicine can give.” These words highlight the importance of plastic surgery in the mental wellbeing of transgender patients.

The BAPRAS Collection and Archive has an extraordinary assembly of fascinating archive and historical surgical instruments dating from 1900. Visit https://www.bapras.org.uk/professionals/About/bapras-archive or email [email protected] for more information.

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Meet Mr. Inglefield

Education, treatment, and support to achieve lasting contentment with your gendered self.

I established The London Transgender Clinic in 2015 in response to a noticeable increase in enquires from transgender and non-binary patients. Many of these patients were unable to access quality and timely care from the overwhelmed NHS gender services, resulting in high levels of anxiety and stress with suicide and self-harm a major risk. With 15 years of experience in transgender surgery, I wanted to set up a dedicated specialist team providing holistic care to enable individuals to get to the next stepping stone of their transition, with many services provided under one roof.

My team and I are proud to be part of the journey of so many and the positive feedback received over the years has been incredibly motivating. Many praise the exceptionally high standards of care and their improved confidence, health, and overall wellbeing.

This has spurred me to do more and the future is exciting. We will continue to set up our Centre of Excellence using the latest research and innovative technologies. The goal is to treat, support, train and educate the wider community including patients, family, friends, other health professionals, and employers. Plans include the opening of new clinics in Hatfield, Manchester, and Dublin.

We are internationally recognised for our extraordinary patient care and outstanding surgical results. Mr Inglefield and his team prioritise safety and use advanced surgical techniques with cutting edge technology.

Patient Testimonials

"After 9460 days in the wrong body, Christopher Inglefield and the amazing team at London Transgender Clinic changed my life forever. All my life, I never got to develop a relationship with my body because I knew all along it wasn’t mine to begin with. I existed through the years in a survival mode where living in my head became the only place I felt free to be me and so good at it I became that my external reality didn’t matter. Until one day I decided it did! From first flicking that switch in my head, to having my first consultation, to right up until and after my surgery - the entire team have been nothing short of incredible.I didn’t have much of a life before, but now I have a future and for that I’ll forever be grateful"

"When I arrived I was pleased with the cleanliness of the the clinic. I then met Natalie who was carrying out my appointment. She made me feel really relaxed and comfortable. I really enjoyed my time with Natalie as she made the effort to chat with me and made sure I understood everything that was going on. My appointment went well and I can't fault anything. I am looking forward to returning to the London transgender clinic. "

"I spoke with Natalie and Mary Burke and they were absolutely lovely and very professional. Everything I needed to do and bring was made clear, and they were fast, efficient, friendly and so helpful! Would really recommend them. "

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How to find an NHS gender dysphoria clinic

Trans and non-binary people's general health needs are the same as anyone else's. But trans people may have specific health needs in relation to gender dysphoria.

Your particular needs may be best addressed by transgender health services offered by NHS gender dysphoria clinics (GDCs).

All NHS GDCs are commissioned by NHS England, who set the service specifications for how they work.

A GP or another health professional can refer you directly to one of the GDCs. You do not need an assessment by a mental health service first. Neither does the GP need prior approval from their integrated care board (ICB). 

The websites of the clinics listed on this page also have useful information for you to think about before you see a GP. 

Children and young people's gender services

Children and young people should be referred to the National Referral Support Service for the NHS Children and Young People's Gender Service .

These NHS services specialise in helping young people with gender identity issues. They take referrals from anywhere in England.

Gender dysphoria clinics in London and the southeast

The Tavistock and Portman NHS Foundation Trust: Gender Dysphoria Clinic for Adults

Lief House 3 Sumpter House Finchley Road London NW3 5HR

Phone: 020 8938 7590

Email: [email protected]

The GDC website has an overview of information useful for anyone with gender identity needs, not just those in the area.

Gender dysphoria clinics in the north

Sheffield Health and Social Care NHS Foundation Trust Gender Dysphoria Service

Porterbrook Clinic Michael Carlisle Centre 75 Osborne Road Sheffield S11 9BF

Phone: 0114 271 6671

Email: [email protected]

The  Sheffield clinic's website includes information about referrals, clinic opening hours and links to eligibility criteria.

Leeds and York Partnership NHS Foundation Trust Gender Dysphoria Service

Management Suite 1st Floor The Newsam Centre Seacroft Hospital York Road Leeds LS14 6WB

Phone: 0113 855 6346

Email: [email protected]

The Leeds clinic's website covers referrals, commonly used medicines and information on the clinic's Gender Outreach workers.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Northern Region Gender Dysphoria Service

Benfield House Walkergate Park Benfield Road Newcastle NE6 4PF

Phone: 0191 287 6130

Email: [email protected]

The Northern Region Gender Dysphoria Service website has a range of leaflets, including information about referral, hormones and support groups.

Gender dysphoria clinics in the Midlands

Northamptonshire Healthcare NHS Foundation Trust Gender Dysphoria Clinic

Danetre Hospital H Block London Road Daventry Northamptonshire NN11 4DY

Phone: 03000 272858

Email:  [email protected]

Visit the  Northampton clinic's website for more information about how to get a referral and the role of the GP.

Nottinghamshire Healthcare NHS Foundation Trust The Nottingham Centre for Transgender Health

12 Broad Street Nottingham NG1 3AL

Phone: 0115 876 0160

Email: [email protected]

Visit The Nottingham Centre for Transgender Health website  for more information about how to get a referral.

Gender dysphoria clinics in the southwest

Devon Partnership NHS Trust West of England Specialist Gender Dysphoria Clinic

The Laurels 11-15 Dix's Field Exeter EX1 1QA

Phone: 01392 677 077

Email: [email protected]

The Laurels' website has information about the types of services on offer and the help available during transition.

New gender dysphoria services in 2020

In 2020 new NHS gender dysphoria services for adults will open in Greater Manchester, London and Merseyside.

These services will be delivered by healthcare professionals with specialist skills and based in local NHS areas, such as sexual health services. Full details will be available once each service is opened.

Initially, access to these services will be available to people who are already on a waiting list to be seen at one of the established gender dysphoria clinics.

NHS England will assess how useful these new pilot services are.

Page last reviewed: 13 May 2020 Next review due: 13 May 2023

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Gender Clinic

Gender reconstruction surgery (GRS) (also known as gender reassignment surgery, gender confirmation surgery, sex realignment surgery or, colloquially a sex change) is the surgical procedure (or procedures) by which a transgender person’s physical appearance and function of their existing sexual characteristics are altered to resemble that of their identified gender. It is part of a treatment for gender dysphoria in transgender people.

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The NHS Ends the "Gender-Affirmative Care Model" for Youth in England

Following extensive stakeholder engagement and a systematic review of evidence , England’s National Health Service (NHS) has issued new draft guidance for the treatment of gender dysphoria in minors, which sharply deviates from the “gender-affirming” approach. The previous presumption that gender dysphoric youth <18 need specialty “transgender healthcare” has been supplanted by the developmentally-informed position that most need psychoeducation and psychotherapy. Eligibility determination for medical interventions will be made by a centralized Service and puberty blockers will be delivered only in research protocol settings. The abandonment of the "gender-affirming" model by England had been foreshadowed by The Cass Review's interim report , which defined "affirmative model" as a "model of gender healthcare that originated in the USA."

The reasons for the restructuring of gender services for minors in England are 4-fold. They include (1) a significant and sharp rise in referrals; (2) poorly-understood marked changes in the types of patients referred; (3) scarce and inconclusive evidence to support clinical decision-making, and (4) operational failures of the single gender clinic model, as evidenced by long wait times for initial assessment, and overall concern with the clinical approach.

The new NHS guidance recognizes social transition as a form of psychosocial intervention and not a neutral act, as it may have significant effects on psychological functioning. The NHS strongly discourages social transition in children, and clarifies that social transition in adolescents should only be pursued in order to alleviate or prevent clinically-significant distress or significant impairment in social functioning , and following an explicit informed consent process . The NHS states that puberty blockers can only be administered in formal research settings, due to the unknown effects of these interventions and the potential for harm. The NHS has not made an explicit statement about cross-sex hormones , but signaled that they too will likely only be available in research settings. The guidelines do not mention surgery , as surgery has never been a covered benefit under England’s NHS for minors.  

The new NHS guidelines represent a repudiation of the past decade’s approach to management of gender dysphoric minors.  The “gender-affirming” approach, endorsed by WPATH and characterized by the conceptualization of gender-dysphoric minors as “transgender children” has been replaced with a holistic view of identity development in children and adolescents. In addition, there is a new recognition that many gender-dysphoric adolescents suffer from mental illness and neurocognitive difficulties, which make it hard to predict the course of their gender identity development.

The key highlights of the NHS new guidance are provided below.* 

1. Eliminates the “gender clinic” model of care and does away with “affirmation”

• The NHS has eliminated the “gender clinic” model of care where children are seen solely by a specialist gender dysphoria practitioner, replacing it with standard care in children’s hospital settings.
• Rather than “affirming” a transgender identity of young person, staff are encouraged to maintain a broad clinical perspective and to “embed the care of children and young people with gender uncertainty within a broader child and adolescent health context.”
• “Affirmation” has been largely eliminated from the language and the approach. What remains is the guidance to ensure that “assessments should be respectful of the experience of the child or young person and be developmentally informed.”
• Medical transition services will only be available through a centralized specialty Service, established for higher-risk cases. However, not all referred cases to the Service will be accepted, and not all accepted cases will be cleared for medical transition.
• Treatment pathway will be shaped, among other things, by the “clarity, persistence and consistency of gender incongruence, the presence and impact of other clinical needs, and family and social context.”
• The care plan articulated by the Service will be tailored to the specific needs of the individual following careful therapeutic exploration and “may require a focus on supporting other clinical needs and risks with networked local services.”

2. Classifies social gender transition as an active intervention eligible for informed consent

• The NHS is strongly discouraging social gender transition in prepubertal children.
• diagnosis of persistent and consistent gender dysphoria
• consideration and mitigation of risks associated with social transition
• clear and full understanding of the implications of social transition
• a determination of medical necessity of social transition to alleviate or prevent clinically significant distress or impairment in social functioning
• All adolescents will need to provide informed consent to social gender transition.

3. Establishes psychotherapy and psychoeducation as the first and primary line of treatment

• All gender dysphoric youth will first be treated with developmentally-informed psychotherapy and psychoeducation by their local treatment teams.
• Extensive focus has been placed on careful therapeutic exploration, and addressing the broader range of medical conditions in addition to gender dysphoria.
• For those wishing to pursue medical transition, eligibility for hormones will be determined by a centralized Service, upon referral from a GP (general practitioner) or another NHS provider.

4. Sharply curbs medical interventions and confines puberty blockers to research-only settings

• The NHS guidance states that the risks of puberty blockers are unknown and that they can only be administered in formal research settings. The eligibility for research settings is yet to be articulated.
• The NHS guidance leaves open that similar limitations will be imposed on cross-sex hormones due to uncertainty surrounding their use, but makes no immediate statements about restriction in cross-sex hormones use outside of formal research protocols.
• Surgery is not addressed in the guidance as the NHS has never considered surgery appropriate for minors.

5. Establishes new research protocols

• All children and young people being considered for hormone treatment will be prospectively enrolled into a research study.
• The goal of the research study to learn more about the effects of hormonal interventions, and to make a major international contribution of the evidence based in this area of medicine.
• The research will track the children into adulthood.

6. Reinstates the importance of “biological sex”

• The NHS guidance defines “gender incongruence” as a misalignment between the individual’s experience of their gender identity and their biological sex.
• The NHS guidance refers to the need to track biological sex for research purposes and outcome measures.
• Of note, biological sex has not been tracked by GIDS for a significant proportion of referrals in 2020-2021.

7. Reaffirms the preeminence of the DSM-5 diagnosis of “gender dysphoria” for treatment decisions

• The NHS guidance differentiates between the ICD-11 diagnosis of “gender incongruence,” which is not necessarily associated with distress, and the DSM-5 diagnosis of “gender dysphoria,” which is characterized by significant distress and/or functional impairments related to “gender incongruence."
•  The NHS guidance states that treatments should be based on the DSM-5 diagnosis of “gender dysphoria.” 
• Of note, WPATH SOC8 has made the opposite recommendation, instructing to treat based on the provision of the ICD-11 diagnosis of “gender incongruence.” “Gender incongruence” lacks clinical targets for treatment, beyond an individual’s own desire to bring their body into alignment with their internally-held view of their gender identity.

8. Clarifies the meaning of “multidisciplinary teams” as consisting of a wide range of clinicians with relevant expertise, rather than only “gender dysphoria” specialists

• The NHS guidance clarifies that a true multidisciplinary team is comprised not only of “gender dysphoria specialists,” but also of experts in pediatrics, autism, neurodisability and mental health, to enable holistic support and appropriate care for gender dysphoric youth.
• neurodevelopmental disorders such as autistic spectrum conditions
• mental health disorders including depressive conditions, anxiety and trauma
• endocrine conditions including disorders of sexual development pharmacology in the context of gender dysphoria
• risky behaviors such as deliberate self-harm and substance use
• complex family contexts including adoptions and guardianships
• a number of additional requirements for the multidisciplinary team composition and scope of activity have been articulated by the NHS.

9. Establishes primary outcome measures of “distress” and “social functioning”

• The rationale for medical interventions for gender-dysphoric minors has been a moving target, ranging from resolution of gender dysphoria to treatment satisfaction.  The NHS has articulated two main outcome measures of treatment: clinically significant distress and social functioning .
• This is an important development, as it establishes primary outcome measures that can be used by researchers to assess comparative effectiveness of various clinical interventions. 

10. Asserts that those who choose to bypass the newly-established protocol will not be supported by the NHS

• Families and youth planning to obtain hormones directly from online or another external non-NHS source will be strongly advised about the risks.
• Those choosing to take hormones outside the newly established NHS protocol will not be supported in their treatment pathway by NHS providers.
• Child safeguarding investigations may also be initiated if children and young people have obtained hormones outside the established protocols.

With the new NHS guidance, England joins Finland and Sweden as the three European countries who have explicitly deviated from WPATH guidelines and devised treatment approaches that sharply curb gender transition of minors. Psychotherapy will be provided as the first and usually only line of treatment for gender dysphoric youth.

The full text of the NHS guidance can be accessed here .

 * This is a transitional protocol as the NHS works to establish a more mature network of children’s hospitals capable of caring for special needs of gender dysphoric youth. A fuller service specification will be published in 2023-4 following the publication of the Cass Review’s final report .

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FactCheck Q&A: How many children are going to gender identity clinics in the UK?

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• By Georgina Lee
• 24 Oct 2017

Figures seen by the Mirror suggest that as many as 50 children a week are being referred to the UK’s leading gender identity clinic.

FactCheck looks at what we know about children and gender identity services in the UK.

How many children are being referred to gender identity clinics?

Official figures from the Gender Identity Development Service (GIDS) at the Tavistock Centre in London show that 2,016 children were referred to them in 2016-17.

That’s about 39 kids a week over the course of the year.

But the Mirror says it has seen data that shows 1,302 children have visited GIDS in the last six months – which works out at about 50 children a week.

We don’t know yet whether that high referral rate will continue for the rest of the year. If it does, it will mean that the number of children referred to GIDS each week has risen by 2,500 per cent since 2009-10.

The number of children attending GIDS has grown every year since 2009-10, but saw a marked increase in 2015-16 – when patient numbers doubled compared to the previous year.

It’s not clear what caused this.

The British Social Attitudes survey began to collect data on the public’s views towards transgender people for the first time in 2016. They cited the fact that “transgender people and their stories are becoming increasingly visible in society” as part of the reason to address attitudes to gender in the survey.

It’s possible that high-profile transgender people, including Caitlyn Jenner, Chelsea Manning and Laverne Cox have brought the issue of gender identity to a wider range of children and parents.

How many children go on to become transgender adults?

Children who are referred to gender identity clinics like the GIDS at the Tavistock Centre are often diagnosed with “gender dysphoria”.

The NHS describes the condition as one where “a person experiences discomfort or distress because there’s a mismatch between their biological sex and gender identity”.

A 2008 study in the Netherlands concluded that “The majority of children with gender dysphoria will not remain gender dysphoric after puberty”. Although it also found that kids who experience very strong feelings of dysphoria are more likely to still have them in adulthood.

A separate study from 2011 found that only 2 to 27 per cent of pre-pubescent children with gender dysphoria continued to have those feelings once puberty hit.

However, research cited by the Tavistock Centre also suggests that gender dysphoria is more likely to persist into adulthood when it’s reported by kids over the age of 12.

In other words, older children and those with more intense feelings of gender dysphoria in childhood are more likely to become transgender adults.

Younger children who report milder feelings of gender dysphoria are less likely to feel the same after puberty.

The majority of children referred to the gender identity clinic at the Tavistock Centre in 2016-17 were over 13 years old, with the most common ages being 15 and 16 years old. We don’t know how many of these were diagnosed with gender dysphoria.

What treatments can children receive at gender identity clinics?

Not all of the children who are referred to gender identity clinics will be diagnosed with gender dysphoria.

But children who do receive a diagnosis can be treated with synthetic hormones that “block” puberty. According to the NHS, the effects of this treatment “are considered to be fully reversible” and can stop at any time.

Figures revealed to the Mail on Sunday earlier this year suggested that as many as 800 children in England – including some as young as 10 – are being treated with puberty blockers.

Once a child reaches 17 they can be seen in an adult gender clinic, and can receive standard adult treatments for gender dysphoria if it has been clinically diagnosed. This can include stronger cross-sex hormones, which are not necessarily reversible and will eventually make those who take them completely infertile.

The minimum age for gender reassignment surgery is 18 years old.

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Female to Male Gender Reassignment Surgery (FTM GRS)

Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia composed of the penis and scrotum.  

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Female gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as males smoothly such as breast amputation, facial surgery, body surgery, etc.  

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is very complicated and only a handful of surgeons are able to perform this procedure. It is a multi-staged procedure, the first stage is the removal of the uterus, ovary, and vagina. The duration of the procedure is 2-3 hours. The second and later stages are penis and scrotum reconstruction which is at least 6 months later. There are several techniques for penile reconstruction depending on the type of tissue such as skin/fat of the forearm, skin/fat of the thigh, or adjacent tissue around the clitoris. This second stage of surgical time is between 3-5 hours. A penile prosthesis can be incorporated simultaneously or at a later stage. The scrotal prosthesis is also implanted later.  

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-7 days for each stage depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What are the risks.

The most frequent complication of FTM GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis and fistula, unsightly scar, etc. The revision procedure is scar revision, hair transplant, or tattooing to camouflage unsightly scars.   

What is the recovery process?

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patients return to their normal lives but not having to do physical exercise during the first 2 months after surgery. The patient will have a urinary catheter continuously for several weeks to avoid a urinary fistula. If the patient has a penile prosthesis, it would need at least 6 months before sexual intimacy.  

What are the results?

With good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a male role completely and happily either on their own or with their female or male partners.  

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Health And Beauty

Reassigning Your Gender With Surgery: The Facts and How It Is Done

• 1.1 Types Of Gender Reassignment Surgery
• 1.2 Who Is Eligible for Gender Reassignment Surgery?
• 1.3 Health Risks of Gender Reassignment Surgery

and Health Risks

Gender reassignment surgery is an option for individuals who wish to affirm their gender identity and physically transition from their assigned sex to another gender. It’s also known as sex reassignment surgery , gender affirmation surgery, gender-affirming surgery or gender-reassignment surgery. The goal of gender reassignment surgery is to provide the patient with physical characteristics that align with their gender identity.

Types Of Gender Reassignment Surgery

The main types of gender reassignment surgeries are genital surgeries , chest surgeries and facial feminization surgeries . This can include:

• Genital Surgery : This is the most common type of gender reassignment surgery. It is done to change an individual’s genitalia to the opposite sex. This can include vaginoplasty (creating a vagina), metoidioplasty (creating a penis), phalloplasty (creating a penis using a skin graft), orchiectomy (removing the testicles), and vaginectomy (removing the vagina).
• Chest Surgery : This includes breast implants and chest masculinization (removing breast tissue).
• Facial Feminization Surgery : This type of surgery is done to feminize the face by altering features such as the forehead, nose, chin, and jawline.

Who Is Eligible for Gender Reassignment Surgery?

Gender reassignment surgery is an option for individuals who have been diagnosed with gender dysphoria, which is the distress caused by a discrepancy between a person’s assigned gender and their gender identity. Individuals who may consider gender reassignment surgery typically have had a successful course of hormone replacement therapy (HRT) and have been living as a different gender for at least a year before surgery.

Health Risks of Gender Reassignment Surgery

Gender reassignment surgery is a complex and delicate medical procedure that involves multiple steps and carries a number of possible risks and side effects. These include, but are not limited to:

• Excessive Bleeding : This can occur during the surgery itself.
• Infection : As with any surgical procedure, infection is a risk.
• Nerve Damage : This is a risk with any surgery, but is more common with gender reassignment surgery due to the complexity of the procedures.
• Blood Clots : Blood clots can occur during and after the surgery, which can be serious and even lead to death.

Gender reassignment surgery is a major undertaking and can have long-term physical and psychological implications. It is important to practice caution and to speak with a qualified medical professional to determine if it is the best option for an individual.

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Hull University Teaching Hospitals NHS Trust

Gender Affirmation Surgery – Information for patients undergoing top surgery

Patient Experience 10th December 2021

• Reference Number: HEY434-2023
• Departments: Acute Medicine Unit, Breast Services
• Last Updated: 1 December 2023

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Introduction

You will have been referred to the Breast Service following an appropriate referral from the Gender Identity Service, supported by a specialist confirming your diagnosis. The referral confirms that funding is now in place for your surgery.

This leaflet has been produced to reinforce the information that has been given to you about your surgery. Most of your questions should have been answered by this leaflet. It is not intended to replace the discussion between you and your doctor, but if, after reading it you have any concerns or require any further explanation, please discuss this with a member of the healthcare team caring for you. The surgical team comprises a group of surgeons who all work together to provide the best surgical care for you.

It is important that if you decide to have your surgery with us, you are aware of the appointments schedule. You will need to attend all appointments both before (pre) and after (post) surgery. Below is a list of the appointment schedule you are expected to attend if you wish to have surgery with us:

• Pre-surgery: initial consultation with surgeon.
• Pre-surgery: pre-operative assessment prior to the surgery.
• Post-surgery: follow up at around 10 days, for drain removal and nipple/wound check.
• Post-surgery: follow up at 6 months to assess how the surgery has gone and to discuss if any further surgery is necessary.

You will need to agree to attend all of these visits before we can consider you for surgery.

What is this type of breast surgery?

This surgery is an operation to remove most of the breast tissue in order to help create a flatter chest shape.

The operation is performed under general anaesthesia and involves the removal of most of the breast tissue with the preservation of the nipple and areola (coloured area), if possible. The particular surgical technique used is dependent on the breast size of the individual patient and initial assessment:

Liposuction may be used to remove breast tissue via small incisions.

An inframammary fold mastectomy and free nipple areolar grafts (removal of the breast from the fold underneath the breast) results in a scar along the crease of the skin directly under the breast. The nipples may be completely removed and repositioned. If the nipples are not preserved, both nipple and areola tattoos can be done at a later date.

A periareolar reduction may be used by making a circular cut around the outer edge of the areola, leaving the nipple partially attached. Breast tissue is removed and the excess skin is trimmed. The nipple is then repositioned and a ‘purse-string’ (type of stitch) technique is used to pull the skin around the areola tighter together to close the reduced area.

All of these surgical options will be discussed fully as to which will be the most appropriate for you.

Your initial consultation

You will be seen by the consultant surgeon and asked various questions about your general health, as well as being given a physical examination, which will include several measurements of the breast being taken and recorded.  Consent will be required for clinical photography, involving before and after surgery pictures, to complete an accurate visual record.  Each option of surgery will be discussed with you including the risks, advantages and disadvantages of each, as relevant to you.

This consultation provides an opportunity to see pictures of previous pre and postoperative surgery results. You are encouraged to ask questions and discuss any concerns fully with your consultant to understand the potential issues of your surgery. It is important that you have realistic expectations of the final appearance of your chest.

Can there be any complications or risks?

As with all surgery, there can be complications or risks. Your consultant will go through these in detail with you as part of your consultation; however, we have listed some of these below for your reference.  If you have additional concerns regarding risks or complications, please do not hesitate to discuss these with your consultant.

General complications and risks could include:

General surgery risks – bleeding, infection, bruising and scars. Steps are taken to reduce risks, such as injections to help prevent adverse blood clotting; use of compression stockings to help prevent deep vein thrombosis.

Haematoma – a collection of partially clotted blood under the skin at the site of the surgery. This may result in a return to theatre to drain depending on the severity of the haematoma.

Asymmetry – this is when both sides are uneven post-surgery. It may be possible to correct this with further surgery at a later date.

Synmastia – this is when the two scar lines meet at the central point and results in one long scar. This may be unavoidable, but may possibly be corrected by surgery at a later date

Loss of nipple graft – there is a small possibility that the nipple graft may not take and you may lose your nipple graft. It may be possible to have a nipple reconstruction at a later date.

Bruising – is highly likely, this may cause the breast area to become a little discoloured and may spread down towards the abdomen. Your body will absorb this bruising and rarely needs any intervention but if worried, contact the Breast Care Unit.

Seroma – this is a build-up of serous fluid (produced by the body to aid healing) between the tissues and the skin. This fluid is usually absorbed by the body, but if it is present in large amounts, it can be uncomfortable. The fluid can be removed by inserting a fine needle and removing the fluid.  This is quite a common procedure undertaken in the breast clinic outpatient department.

Skin necrosis – occasionally the blood supply to the flaps of skin on either side of the surgical incision is inadequate.  This is significantly more common in people who smoke. The skin involved dies (necrosis) and gradually heals by scarring. If this area is quite extensive, surgical removal may be required, although this is not common.

Nipple necrosis – if the nipple is retained, there is a small possibility that the nipple may lose its blood supply and become necrotic. This means that a poor blood supply to this area may result in the loss of some colour and the nipple may not survive. If this happens, it is possible to have a nipple reconstruction at a later date.

Infection – this may occur despite the routine administration of antibiotics. Any signs of redness, heat, discharge or raised temperature needs to be reported to your health care team. An earlier follow-up appointment can then be made to attend the breast clinic outpatient department.

Fat necrosis – this is a condition that can occur under the skin post-operatively. It results in hard lumps forming within the breast area which can be a concern for the patient. The condition is benign (harmless) and does not carry any risk of cancer. However, all lumps should be investigated appropriately.

Scarring – gradually fades, varying with each individual. If you do suffer from an infection, this can affect scarring; the scar can become thicker than expected and take longer to fade. Even without any infection, some scarring can become thicker and overgrown due to a condition called Keloid (excessive tissue growth in the wound area).

Nipple sensation – this may be lost completely or there may be some small loss or even increased feeling in the cases of surgery retaining the nipple area. There can be no guarantee regarding this.

Skin sensation – it is quite normal for the skin sensation to change with areas of numbness, tingling, small sharp feelings after surgery due to the normal healing process. Again, this can vary greatly from one individual to another.

What will happen after your initial consultation?

After your initial consultation, you will be placed onto a waiting list. When a suitable date becomes available for your surgery, you will receive a letter with appropriate details including:

• A date for your pre-assessment appointment.
• A date for your surgery, times and where to attend.

Pre-operative assessment

You will be sent an appointment approximately 2 weeks before your surgery to attend a pre-operative assessment. The pre-operative assessment will be performed by the nursing staff on the breast care unit and will prepare you for your surgery. It will involve recording your Blood Pressure, pulse and temperature along with height and weight and BMI.  You will be swabbed for MRSA (routine for all surgical procedures) and blood samples will be taken. You do not need to fast for this appointment, but you must be well hydrated (ideally drink water) for us to be able to sample your blood. You may be contacted after this appointment if there are any results which fall outside of normal levels. The blood samples must be performed prior to your surgery and cannot be performed at your local hospital. At this appointment you will receive all the information about your surgery and recovery, so it is important that you attend. We will answer any questions you may have.

Your operation

You will need to contact Ward 16 or the Day Surgery Centre directly if you require someone to accompany you. Otherwise, you will need to attend the ward alone at 07:30. Arrival at 07.30 allows time for your surgeon to talk to you, explain the procedure and any risks or complications which may be involved. If you are still happy to go ahead, the surgeon will ask you to sign a consent form and will mark your body on the area for surgery, using a skin marking pen. The anaesthetist will also review you and ensure that you are fit enough for surgery. The ward will have a rough estimation of the time of your surgery, you may wish to update your family or friends of this estimated time.

There is no room for family/friends to stay at the hospital during your surgery so they will need to book into local accommodation.

It may be a number of hours before your surgery, we suggest bringing something to occupy you. When your surgery time nears, the ward staff will ask you to put on a surgical gown, this is backless so you will need a dressing gown to put on over it and a pair of soft shoes/slippers as you will walk to theatre. You will also be fitted with a pair of white anti embolic socks which help to prevent blood clots post-surgery. We advise that you continue to wear these for two weeks post-surgery.

Post-operatively

Following surgery, you will wake up in  he recovery suite. This is a high observation area where you will be monitored until you are considered well enough to return to the ward. The staff will perform blood pressure and pulse checks and you may have an oxygen mask on. This will be removed once you have fully recovered from the anaesthetic.

You may have been fitted with a pair of “Flowtron boots” during your surgery. These are self-inflating devices which wrap around the lower leg. These inflate and help to improve blood flow back up the leg to reduce the risk of blood clots. These will be removed once you have recovered. You will need to leave the white anti embolic socks on.

The nursing staff will try to ensure that you have appropriate pain relief, but it is normal for patients to experience some level of discomfort. Please purchase appropriate pain relief in preparation for hospital discharge (e.g. paracetamol and ibuprofen).

You will be fitted with a binder in theatre following your surgery, this will be padded with cotton wool. The binder is used to reduce scarring, the pressure from the garment helps to flatten scars. You will need to wear the binder for 6 weeks post-surgery, but you are able remove to wash.

You will have 2 drains following your surgery, these help to prevent any fluid build-up between the tissue and the skin. You will be discharged home with the drains, the nursing staff will show you how to empty and re-vacuum them. You should be provided with bags to carry the drains in from the ward before discharge.

The normal length of stay for this type of surgery is 2 nights. You will be reviewed by your surgeon the day following your surgery and if you have experienced no complications, you may be discharged at this point. For the 24 hours immediately following discharge, you will need to have accommodation within a 30-minute travelling time. If you attend the hospital alone, you will need to be admitted for 2 nights post-surgery. If you are travelling by car, it is advisable to put a cushion or soft pillow under your seat belt for comfort and protection post-surgery. For legal reasons, you will still need to wear a seat belt. If you are travelling by public transport, we strongly advise against carrying heavy bags. Before discharge home, the nurse will advise you of activities to avoid and exercises to perform.

You will receive an appointment to attend the dressing’s clinic approximately 10 days post-surgery. It is important that you attend this appointment as we will check to ensure that your suture line is healing, check your nipple grafts have taken and give you important advice and instructions.  At this appointment we will remove the drains and all dressings.  We will redress both your surgical suture line and nipple grafts. You will need to buy surgical tape (micropore tape) to cover the suture line whilst you have your binder on. The micropore tape is an important part of your wound care routine and is discussed in more detail below. The nurse will show you how and where to apply the micropore tape. You will need to keep your nipples grafts covered whilst you are wearing your binder. We will advise on wound care dressings and how to care for your nipple grafts at the dressing clinic appointment too. You will need to continue to wear the binder for 6 weeks post-surgery. You are not able to drive whilst you have your drains in, as a result, you will need to make arrangements for someone to bring you to this appointment (see attached ‘Day 10 Post Surgery Wound Care instructions guide’)

The recuperation period post-surgery normally takes 4-6 weeks. It is normal to have some bruising and swelling, but this will settle with time. You are able to go out of the house and perform normal activates, but are strongly advised against any heavy lifting or carrying. It is advisable to avoid any activities which involve the over use of your arms or raising your arms over your head for the first 4-6 weeks. We do advise that you take some time off work, the length depends on the type of job you do. If you have a heavy manual job, you should take the full 6 weeks, other jobs may only need 4 weeks. Upon request, the ward can provide a sick note to cover this period. It is not advisable to drive a car for the first 2-3 weeks, as you will need to have a full range of upper body movement and be able to perform an emergency stop. You may find you are not insured if you drive too early post-surgery.

After 6 weeks you can remove your binder and start scar moisturise and massage (see below section). You will need to continue to use the surgical tape for 3 months post-surgery.

At 6 weeks if everything is healed and healthy you can gradually start upper body exercises. By this time you should be able to go back to work and perform all your usual activities. Swimming and vigorous upper body exercise can be resumed 3 months post-surgery.

How to care for your wounds

As mentioned above, please refer to the ‘Day 10 Post Surgery Wound Care instruction guide’ below.

Following your wound review/drain removal at the dressing clinic it is important to continue with the micropore tape to your healing wounds/scar lines for 3 months. The micropore tape will give support and protection to the healing wounds and reduced friction on the scars. Without the micropore tape wounds may become open, scars are likely to be wider and more prominent once fully healed.

You may shower with the micropore tape in place, pat the tape dry after showering and leave in place. Remove and re-apply the tape twice weekly.

How to care for your scars – moisturise and massage

Any surgery to the skin will leave a scar. Scars can take 12-18 months to fully heal and mature, whilst going through a process of stages. Initially, scars may be red, hard, itchy, raised and lumpy. With time, patience and scar care, scars may become lighter in colour and softer to touch. Avoid scratching or picking your scars.

Three months following your surgery start scar moisturising and massage using Bio Oil or a non-scented emollient is recommended (only to fully healed wounds). Scar massage can help to improve the overall appearance of your scars. To massage the scars use short circular finger movements to apply the Bio Oil or emollient twice daily on the scar lines and surrounding skin, for up to 10 minutes.  Start the massage with a gentle, light pressure. Aim to increase the pressure to a deeper, firmer massage after the first week. This massage technique should not be painful and should be used on all scars – including the nipple area. Please read the manufacturers product information prior to use.

Some people produce excess scar tissue during the healing process, these scars may start to become hypertrophic. Hypertrophic scars are usually raised, firm and uncomfortable. Specialist silicone-based scar tape products are available, which may help with hypertrophic scars. Your surgeon does not recommend routine use of silicone based scar products, these products should only be used if your scar is hypertrophic 6 months post-surgery. Please ensure you read the manufacturers guidance carefully, should you choose to use a silicone scar product.

Further scar care – sun protection

Scars are sensitive, exposure to sunlight and tanning bed UV radiation can cause scars to burn easily. It is recommended to avoid exposing your scar to the sun and tanning beds for the initial 12-18 months following surgery, whilst scars mature.

After this time use a high sun protection factor (SPF 30 or higher including UVA/UVB protection). Apply the SPF cream to your scars before exposing them to sunlight. Re-apply SPF cream frequently and generously at least every 2-4 hours or sooner after swimming or sweating. Follow the manufacturer’s guidance on the SPF products you choose to use.

Avoid scar exposure when the sun’s rays are strongest (in the UK this is late spring, through the summer until early autumn). There is no SPF cream which provides a total sun block, please be cautious when exposing scars to sun light or UV sun beds. Sun burn and skin tanning will cause scars to become more visible (darker/hyper pigmented).

Follow up and further treatments

You will be reviewed at 6 months post-surgery which will allow your surgeon to access how well you have healed and whether any further surgery is necessary. Photographs will be recorded for audit purposes to ensure an accurate record.

The surgeries that may be considered are:

Liposuction – this involves the removal of extra fatty/glandular tissue from the breast/armpit area to help create a flatter contour. This procedure may sometimes be undertaken at the same time as the mastectomy (removal of the breast) or at a later date, when post-operative swelling has subsided, allowing particular areas of concern to be identified and discussed.

Dog-ear correction – this refers to the possible, puckered appearance of the skin at the end of the scar line, looking like a little flap. This can be removed by a minor operation at a later date.

Nipple reconstruction – a procedure can be undertaken to replace the lost nipple, if not retained, by creating a small lump projecting from the skin on the breast. This could be done at a later date, once the original wound area has healed properly.

Nipple/areola tattoo – the area around the nipple can be tattooed with colour onto the skin, either around an existing nipple or colour shading applied to provide definition of nipple and areola. This procedure can produce extremely realistic results.

Gender Affirmation Post-Surgery Wound Care instruction guide

This information is relevant once your post-surgery drains have been removed at day 10

• Binder to be worn for a total of 6 weeks from day of surgery, can be removed to wash binder and bathe
• Can use deodorant under arms
• Drain dressings can be removed after 72 hours (3 days)
• For first 7 days post drain removal shower only on back or shallow bath and wash  hair over sink
• After 7 days can wash and shower as normal
• If you develop any new redness , swelling, discharge, pain or the area is  hot to touch contact own GP to rule out any infection
• Avoid any heavy exercise for the first 6 weeks such as heavy housework, going to the gym, weight training, and carrying heavy objects. You can then gradually increase your exercises and start to work out. You should wait 3 months to start swimming and vigorous upper body workouts.
• You will need 4-6 weeks off work post-surgery depending on your job. The ward should have provided you with a sick note. Your GP can provide additional sick notes as needed.

Any other concerns or questions, please, do not hesitate to contact the Breast Care Unit on 01482622679 (leave a clear voice message, with your name/HEY number and phone number) or our email address is hyp-tr.breastcareunit.nurses@nhs.net.

General Advice and Consent Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team. Consent to treatment Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information. The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid . That means: you must be able to give your consent you must be given enough information to enable you to make a decision you must be acting under your own free will and not under the strong influence of another person Information about you We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data. We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you. Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You . If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.

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Gender affirmation surgery

• Male breast surgery
• Mommy makeover
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• Our location & team

This is also known as sex-reassignment surgery or gender-reassignment surgery. These surgeries help patients’ physical appearance and function, as well as resemble their identified gender.

The surgery can be divided into “top surgery” and “bottom surgery.”

• “Top surgery” creates breasts for male-to-female transgender patients or removes breasts for female-to-male transgender patients.
• “Bottom surgery” for male-to-female transgender patients includes removing male genitalia and creating female genitalia.
• “Bottom surgery” for female-to-male transgender patients includes creating male genitalia from one’s own tissues or using of implants in combination with one’s own tissue.

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