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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

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

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

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

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

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American Society of Plastic Surgeons. Gender confirmation surgeries .

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• Patient Care & Health Information
• Tests & Procedures
• Feminizing surgery

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 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

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

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

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

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

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 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

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• 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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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary , to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis )
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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What Is Gender Affirmation Surgery?

Surgery to change the appearance of your body is a common choice for all kinds of people. There are many reasons that people might want to alter their appearance. For transgender or gender nonconforming people, making changes to their bodies is a way of affirming their identity.

A trans person can choose from multiple procedures to make their appearance match their self-identified gender identity. Doctors refer to this as gender "affirmation" surgery.

Trans people might decide to have surgery on their chest, genitals, or face. These surgeries are personal decisions, and each person makes their own choices about what is right for them.

Learn more about gender affirmation surgery and how it helps trans people.

What Does It Mean to Be Transgender or Nonbinary?

Transgender is a word to describe people whose gender identity or gender expression doesn't match the sex they were assigned at birth. Typically, parents and doctors assume a baby's gender based on the appearance of their genitals. But some people grow up and realize that their sense of who they are isn't aligned with how their bodies look. These people are considered transgender.

Trans people may identify as a different gender than what they were assigned at birth. For example, a child assigned male at birth may identify as female. Nonbinary people don't identify as either male or female. They may refer to themselves as "nonbinary" or "genderqueer."

There are many options for trans and nonbinary people to change their appearance so that how they look reflects who they are inside. Many trans people use clothing, hairstyles, or makeup to present a particular look. Some use hormone therapy to refine their secondary sex characteristics. Some people choose surgery that can change their bodies and faces permanently.

Facial Surgery

Facial plastic surgery is popular and accessible for all kinds of people in the U.S. It is not uncommon to have a nose job or a facelift . Cosmetic surgery is great for improving self-esteem and making people feel more like themselves. Trans people can use plastic surgery to adjust the shape of their faces to better reflect their gender identity.

Facial feminization. A person with a masculine face can have surgeries to make their face and neck look more feminine. These can be done in one procedure or through multiple operations. They might ask for:

• Forehead contouring
• Jaw reduction
• Chin surgery
• Hairline advancement
• Cheek augmentation
• Rhinoplasty
• Lip augmentation
• Adam's apple reduction

Facial masculinization. Someone with a feminine face can have surgery to make their face look more masculine. The doctor may do all the procedures at one time or plan multiple surgeries. Doctors usually offer:

• Forehead lengthening
• Jaw reshaping
• Chin contouring
• Adam's apple enhancement

Top Surgery

Breast surgeries are very common in America. The shorthand for breast surgeries is "top surgery." All kinds of people have operations on their breasts , and there are a lot of doctors who can do them. The surgeries that trans people have to change their chests are very similar to typical breast enhancement or breast removal operations.

Transfeminine. When a trans person wants a more feminine bustline, that's called transfeminine top surgery. It involves placing breast implants in a person's chest. It's the same operation that a doctor might do to enlarge someone's breasts or for breast reconstruction .

Transmasculine. Transmasculine top surgery is when a person wants a more masculine chest shape. It is similar to a mastectomy . The doctor removes the breast tissue to flatten the whole chest. The doctor can also contour the skin and reposition the nipples to look more like a typical man's chest.

Bottom Surgery

For people who want to change their genitals, some operations can do that. That is sometimes called bottom surgery. Those are complicated procedures that require doctors with a lot of experience with trans surgeries.

Transmasculine bottom surgery. Some transmasculine people want to remove their uterus and ovaries. They can choose to have a hysterectomy to do that. This reduces the level of female hormones in their bodies and stops their menstrual cycles.

If a person wants to change their external genitals, they can ask for surgery to alter the vaginal opening. A surgeon can also construct a penis for them. There are several techniques for doing this.

Metoidioplasty uses the clitoris and surrounding skin to create a phallus that can become erect and pass urine. A phalloplasty requires grafting skin from another part of the body into the genital region to create a phallus. People can also have surgery to make a scrotum with implants that mimic testicles. ‌

Transfeminine bottom surgery. People who want to reduce the level of male hormones in their bodies may choose to have their testicles removed. This is called an orchiectomy and can be done as an outpatient operation.

Vaginoplasty is an operation to construct a vagina . Doctors use the tissue from the penis and invert it into a person's pelvic area. The follow-up after a vaginoplasty involves using dilators to prevent the new vaginal opening from closing back up.

How Much Does Gender Affirmation Surgery Cost?

Some medical insurance companies will cover some or most parts of your gender-affirming surgery. But many might have certain "exclusions" listed in the plan. They might use language like "services related to sex change" or "sex reassignment surgery." These limitations may vary by state. It's best to reach out to your insurance company by phone or email to confirm the coverage or exclusions.

If your company does cover some costs, they may need a few documents before they approve it.

This can include:

• A gender dysphoria diagnosis in your health records. It's a term used to describe the feeling you have when the sex you're assigned at birth does not match with your gender identity. A doctor can provide a note if it's necessary.
• A letter of support from a mental health professional such as a social worker, psychiatrist , or a therapist.

Gender affirmation surgery can be very expensive. It's best to check with your insurance company to see what type of coverage you have.

If you're planning to pay out-of-pocket, prices may vary depending on the various specialists involved in your case. This can include surgeons, primary care doctors, anesthesiologists, psychiatrists, social workers, and counselors. The procedure costs also vary, and the total bill will include a number of charges, including hospital stay, anesthesia, counseling sessions, medications, and the procedures you elect to have.

Whether you choose facial, top, or bottom or a combination of these procedures, the total bill after your hospital stay can cost anywhere from $5,400 for chin surgery to well over $100,000 for multiple procedures.

Recovery and Mental Health After Gender Affirmation Surgery

Your recovery time may vary. It will depend on the type of surgery you have. But swelling can last anywhere from 2 weeks for facial surgery to up to 4 months or more if you opted for bottom surgery.

Talk to your doctor about when you can get back to your normal day-to-day routine. But in the meantime, make sure to go to your regular follow-up appointments with your doctor. This will help them make sure you're healing well post-surgery.

Most trans and nonbinary people who get gender affirmation surgery report that it improves their overall quality of life. In fact, over 94% of people who opt for surgery say they are satisfied with the results.

Folks who have mental health support before surgery tend to do better, too. One study found that after gender affirmation surgery, a person's need for mental health treatment went down by 8%.

Not all trans and nonbinary people choose to have gender affirmation surgery, or they may only have some of the procedures available. If you are considering surgery, speak with your primary care doctor to discuss what operations might be best for you.

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• Review Article
• Published: 16 May 2017

An overview of female-to-male gender-confirming surgery

• Shane D. Morrison 1 ,
• Mang L. Chen 2 &
• Curtis N. Crane 2  

Nature Reviews Urology volume  14 ,  pages 486–500 ( 2017 ) Cite this article

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• Reconstruction
• Sexual behaviour

Gender-confirming surgery is becoming a more frequently encountered procedure for urologists, plastic surgeons, and gynaecologists

Female-to-male gender-confirming surgery consists of facial masculinization, chest masculinization, body contouring, and genital surgery

Metoidioplasty (hypertrophy with systemic hormones and mobilization of the clitoris with urethroplasty) can produce a sensate microphallus

Phalloplasty can produce an aesthetic and sensate phallus with ability to micturate in a standing position and engage in penetrative sexual intercourse if proper nerve coaptation and prosthetic insertion are performed

Urethral complications following genital surgery in transmen are generally higher than 30% and include urethral fistulas and strictures; revisional urethroplasty can address most urethral complications following genital surgery

Advances in basic sciences, transgender-specific prostheses, and patient-reported outcomes will continue to offer options for improvements in gender-confirming surgery

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

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Powerpoint slide for fig. 1, powerpoint slide for fig. 2, powerpoint slide for fig. 3, powerpoint slide for fig. 4, powerpoint slide for fig. 5, powerpoint slide for fig. 6, powerpoint slide for fig. 7, powerpoint slide for table 1.

Inherent discordance of a patient's gender expression and their anatomy leading to distress

Tissue forming the nipple and surrounding areola on the breast or chest

A physical examination test to determine the patency of the palmar or plantar arches as a correlate for the dominant inflow vessel to the hand or foot. Most commonly it is used in the hand where the radial and ulnar arteries are both occluded with pressure from the examiners hand and each is released sequentially while maintaining the pressure on the other artery. The perfusion of the hand is monitored to ensure both vessels can perfuse the hand.

A person born as a male and whose gender identity is male.

Urological procedure for urethral strictures, in which the ventral aspect of the phallus is opened through the urethra. The urethra is secured to the skin and urine is diverted. A second stage completed months later is used to repair the urethra with grafted tissue over a catheter.

Flaps containing multiple tissue types (skin, bone, mucosa.) based on a single angiosome used for complex reconstruction.

Local flap used for advancing tissue generally to cover a wound, but can be used in other procedures. An incision shaped like a V is made through the subcutaneous tissue, advanced into its new position relying on subcutaneous perfusion, and closed in a Y pattern.

Closure of a urethral stricture with a longitudinal incision followed by a transverse closure.

A person born with female sexual organs, but whose gender identity is male

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Morrison, S., Chen, M. & Crane, C. An overview of female-to-male gender-confirming surgery. Nat Rev Urol 14 , 486–500 (2017). https://doi.org/10.1038/nrurol.2017.64

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Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

• Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
• Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
• It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
• In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon  will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

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Vaginoplasty for Gender Affirmation

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Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

1 of 4 in series. Enlarged image .

2 of 4 in series. Enlarged image .

3 of 4 in series. Enlarged image .

4 of 4 in series. Enlarged image .

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

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Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

• Introduction
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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

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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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How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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• Gender Affirmation Surgery

Vaginoplasty / Vulvoplasty

Wpath standards of care.

• Breast Augmentation
• Facial Feminization Surgery
• Orchiectomy
• Vaginoplasty / Vulvuplasty

Gender affirmation surgery for a transfeminine person is sometimes called bottom surgery. These are three surgeries that can help a patient feel more aligned with their gender identity. They are:

• vaginoplasty,
• vulvoplasty, and
• orchiectomy .

Criteria for Vaginoplasty Vulvoplasty in Transfeminine Patients

• Persistent, well documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• be the age of majority in a given country;
• If significant medical or mental health concerns are present, they must be well controlled;
• 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);
• 12 continuous months of living in a gender role that is congruent with their gender identity.

Vaginoplasty

During a vaginoplasty surgery, a surgeon creates both an outer and inner vagina by using skin and tissue from a penis. 

• Your surgeon will use skin from the penis and scrotum to build the inner and outer labia of the vagina
• Your surgeon will create a new opening for the urethra (so you can urinate)
• Your surgeon will use tissue from your foreskin to build the new opening of the vagina (also called the introitus).

Vaginoplasty Procedure

During most vaginoplasties, your surgeon will use a skin graft to create a new vaginal canal (the inside wall of the vagina). To do this, your surgeon will take skin from your scrotum and thin it so it works well as a skin graft. 

If there’s not enough skin from your scrotum to make your new vagina, then your surgeon can take extra skin from the sides of your abdomen where there won’t be a very noticeable scar.

To make your new vaginal canal, your surgeon will create a space between your rectum and bladder. Once your skin graft is inserted, your surgeon will place gauze or spongy material inside the new vaginal canal for 5 days. The gauze puts pressure on the skin graft so it grows like it should into the surrounding vaginal tissue. 

Vaginoplasty & Orgasms

Many transfeminine people wonder if they’ll still be able to have orgasms after having a vaginoplasty.

Your surgeon will use skin from your penis to create a clitoris. This clitoris still has feeling, and most transgender women can have orgasm through clitoral stimulation. 

How Long Will I Be in the Hospital After Vaginoplasty?

Patients are in the hospital for 5 days and mostly rest in bed. Resting will help your skin graft grow into the surrounding tissue in your vaginal canal. 

Your surgeon will also place a compressive bandage on the outside of your vagina. After the outer and inner bandages are removed, most patients feel fine and can leave the hospital.

When Should I Start to Dilate my Vagina After Vaginoplasty?   

Each patient’s situation is different, but we recommend waiting two weeks after your surgery before you start dilating your vagina. Waiting two weeks will let your vagina heal.

Your surgeon will give you vaginal dilators to use at home. You should dilate your vagina two to three times each day for the first six months after your surgery.

Read this instruction sheet on how to dilate your vagina after having a vaginoplasty .

Preparing for Vaginoplasty Surgery  

There are several things that patients need to do before having a vaginoplasty. 

Pursue hair reduction: The first thing you’ll need to do is have hair removal on your scrotum and lower penile skin. Your vaginoplasty surgeon will use this skin to create your new vaginal canal. If hair were to grow inside your new vagina, it would create hygiene problems.

Quit smoking: If you’re a smoker, it’s very important for you to quit. Smoking, vaping, or using any nicotine products decreases blood flow to the area around your genitals and will make it harder for you to heal after your surgery. 

If you’re a recent smoker, we will give you a nicotine urine test to make sure you’ve been able to quit completely. Nicotine takes about a month to wash out of your system before the test results will be negative. 

Weight considerations : Keep in mind that patients with a body mass index ( BMI *) greater than 35 are at a higher risk for wound healing problems and complications after surgery.  However, we understand that BMI is not a perfect measure of your overall health. We will discuss how your weight may affect you and the potential benefits of losing weight before surgery. If our team decides that weight loss is the best pre-surgical option for you, we will refer you to our  weight management program .

For some people, vaginoplasty or vulvoplasty may not be possible because of their body shape and weight.

Physical Therapy for Vaginoplasty

Both before and after having a vaginoplasty, your surgeon will recommend that you start seeing a physical therapist. Physical therapy can help you prepare for this surgery.

Vulvoplasty

The vulva is the outside part of the vagina. A vulvoplasty is a type of surgery that uses skin and tissue from a penis to create all of the outside parts of a vagina (except for the vaginal canal). 

The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your surgeon will:

• create a clitoris out of the glans (or head) of the penis,
• create an inner and outer labia from skin on the penis and scrotum,
• create the opening of the urethra so you can urinate, and
• create the introitus (opening of the vagina).

The only thing that’s different between a full vaginoplasty and a vulvoplasty is the internal part of the vaginal canal.

• Vaginoplasty creates a vaginal canal.
• Vulvoplasty creates all the parts of a vagina except for the vaginal canal.

After vulvoplasty, this means you won’t be able to have intercourse or insert a penis into your vagina. 

How Do I Choose Between a Vulvoplasty vs. Vaginoplasty?

A vulvoplasty has a much easier recovery. For example, you won’t need to dilate (or stretch) your vagina.

Another reason to consider vulvoplasty instead of vaginoplasty is because of medical problems or complications. One serious complication after vaginoplasty is called rectal injury. In some cases, a rectal injury can create a hole between your rectum and vagina.

But your chances of developing a rectal injury are much lower if you have a vulvoplasty instead of a vaginoplasty.

Sex & Vaginal Intercourse

Some patients know that they’re not interested in having vaginal intercourse. For these patients, a vulvoplasty may be a better choice.

After a vulvoplasty, you can still have orgasms through clitoral stimulation, just like with vaginoplasty. During a vulvoplasty, your surgeon will create a clitoris from the glans or head of the penis. 

How Long Will I Be in the Hospital After Vulvoplasty?

Patients usually are in the hospital for 3 days after having a vulvoplasty. Your surgical team will give you a compressive dressing that reduces inflammation (swelling) after your surgery.

Most patients rest in bed while they’re healing since the dressing is uncomfortable to walk with. 

After your dressing is removed, you can leave the hospital, usually right at about 3 days.

Find a Surgeon

Post-surgery instructions, vaginal dilation instructions, hear from our patient.

"I definitely feel complete. I feel whole. But that doesn’t describe it… that doesn’t even begin to describe it,” beams Josie Jesse as she sits, finally comfortable, in her new body that reflects who she has always been.

Read Josie Jesse's Story

"Not every trans woman wants to have sexual reassignment surgery. We shouldn't feel subjected to that."

In August, the Missouri Department of Revenue updated the process for gender marker changes on a state ID – now requiring proof of gender affirming surgery or a court order.

Amariah Hardwick is a trans women who lives in St. Louis and is a leader with Transformations, an organization founded and led by trans women of color.

She spoke about the impacts of this change and how the process of transitioning looks different for every person.

Missouri Health Talks gathers Missourians’ stories of access to healthcare in their own words.

Amariah Hardwick: Someone is again trying to come into our lives and tell us how we should transition. Something that's easy to their eyes, something that makes sense to them.

Because if they're requiring that we need to verify that we've had sexual reassignment surgery performed – we're not doing anything but perpetuating the stigma that the only women that exist are the women's with vaginas. That's not entirely true.

"You're saying that we need this documentation to verify that we've had these procedures signed to have our IDs updated, to have an “F” on there, but you guys don't even allocate the resources, health care or benefits to allow these services to be performed."

Sex and gender are two completely different things, and we have to stop combining those together. We have to.

Not every trans woman wants to have sexual reassignment surgery. We shouldn't feel subjected to that because that's what society makes us feel like.

We never said that we were cis women. We said that we're trans women, and with being a trans woman comes with having anatomy that's different than what a cis woman has, which is why we don't identify as cis woman. We identify as trans women.

So let us live within that.

And then also – the thing that makes this tricky is that you're saying that we need this documentation to verify that we've had these procedures signed to, you know, have our IDs updated, to have an “F” on there, but you guys don't even allocate the resources, health care or benefits to allow these services to be performed.

So, here we are, once again, reaping the consequences of ignorant minds.

Cis counterparts need to understand that there is no such thing as fully transitioning. There are phases of transition, and some of those are voluntary, all of those are voluntary.

If someone says, “These are my pronouns.” Those are their pronouns – we honor those.

Just how when someone says in the neighborhood, “Yeah, my name is Brandon, but I like to go by Bran,” we respect that.

If someone doesn't choose to legally transition or medically transition or socially transition – we don't host a power in our vessels to validate someone's livelihood and also their identities. We don't. At all.

That's something that even can be said in our community, in the trans community, because there's, you know, generations before us think like, “Oh, well, you haven't had this, you haven't had that, you're not a trans woman.”

Well, who are you to tell me what I am?

We don't know what background they come from. We don't we don't know what their names mean to them.

So, we can’t tell someone that's just because you don't conform to what the vast majority of society, what social constructions has instilled in all of us – just because I practice that and you don't, I'm going to invalidate you. We don't host that power at all.

Trump repeats false claims that children are undergoing transgender surgery during the school day

Former President Donald Trump repeated his false claim that children are undergoing transition-related surgery during their school day, worsening fears among some conservatives that educators are pushing children to become transgender and aiding transitions without parental awareness.

“Can you imagine you’re a parent and your son leaves the house and you say, ‘Jimmy, I love you so much, go have a good day in school,’ and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?” Trump said Saturday at a campaign rally in Wisconsin, a vital swing state. 

Trump made similar remarks — saying children were returning home from school after having had surgical procedures — the previous weekend at an event hosted by Moms for Liberty, a parent activist group that has gained outsized influence in conservative politics in recent years.

Asked by one of the group’s co-founders how he would address the “explosion in the number of children who identify as transgender,” Trump said: “Your kid goes to school and comes home a few days later with an operation. The school decides what’s going to happen with your child.”

There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure elsewhere. 

About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare . In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers . Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

A spokesperson for Trump’s campaign did not substantiate his claims and pointed NBC News to reports about parents’ being left in the dark about their children’s gender transitions at school. 

“President Trump will ensure all Americans are treated equally under the law regardless of race, gender or sexual orientation,” said the spokesperson, Karoline Leavitt.

Kate King, president of the National Association of School Nurses, said that even when it comes to administering over-the-counter medication such as Advil or Tylenol, school nurses need explicit permission from a physician and a parent.

“There is no way that anyone is doing surgery in a classroom in schools,” she said when she was asked about Trump’s remarks.

Trump’s claims stand out even amid years of allegations by conservative politicians and right-wing media pundits that teachers, Democratic lawmakers and LGBTQ adults are “grooming” or “indoctrinating” children to become gay or transgender. 

The practice of labeling LGBTQ people, particularly gay men and trans women, as “groomers” and “pedophiles” of children had been relegated to the margins for decades, but the tropes resurfaced during the heated debate over Florida’s so-called Don’t Say Gay law, which Gov. Ron DeSantis signed in March 2022. The law limits the instruction of sexual orientation and gender identity in school and has been replicated in states across the country.

At the Republican National Convention in July, at least a dozen speakers — including DeSantis and Rep. Marjorie Taylor Greene, R-Ga. — mentioned gender identity or sexuality negatively in their speeches, according to an NBC News analysis. DeSantis, for example, alleged that Democrats want to “impose gender ideology” on kindergartners.

Nearly 70% of public K-12 teachers who have been teaching for more than one year said topics related to sexual orientation and gender identity “rarely or never” come up in their classrooms, according to a recent poll from the Pew Research Center. Half of all teachers polled, including 62% of elementary school teachers, said elementary school students should not learn about gender identity in school.

Trump vowed last year that if he is re-elected he would abolish gender-affirming care for minors, which he equated to “child abuse” and “child sexual mutilation.” This year, Trump also said he would roll back Title IX protections for transgender students “on day one” of his potential second presidential administration.

His campaign website says he would, if he is re-elected, cut federal funding for schools that push “gender ideology on our children” and “keep men out of women’s sports.”

More broadly, Trump has promised to eliminate the Education Department, claiming that doing so would give states more authority over education.

During his first administration, Trump barred trans people from enlisting in the military — which he has vowed to do again if he is re-elected — and rolled back several antidiscrimination protections for LGBTQ people. 

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Matt Lavietes is a reporter for NBC Out.