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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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Preparing for Gender Affirmation Surgery: Ask the Experts

Preparing for your gender affirmation surgery can be daunting. To help provide some guidance for those considering gender affirmation procedures, our team from the   Johns Hopkins Center for Transgender and Gender Expansive Health (JHCTGEH) answered some questions about what to expect before and after your surgery.

What kind of care should I expect as a transgender individual?

What kind of care should I expect as a transgender individual? Before beginning the process, we recommend reading the World Professional Association for Transgender Health Standards Of Care (SOC). The standards were created by international agreement among health care clinicians and in collaboration with the transgender community. These SOC integrate the latest scientific research on transgender health, as well as the lived experience of the transgender community members. This collaboration is crucial so that doctors can best meet the unique health care needs of transgender and gender-diverse people. It is usually a favorable sign if the hospital you choose for your gender affirmation surgery follows or references these standards in their transgender care practices.

Can I still have children after gender affirmation surgery?

Many transgender individuals choose to undergo fertility preservation before their gender affirmation surgery if having biological children is part of their long-term goals. Discuss all your options, such as sperm banking and egg freezing, with your doctor so that you can create the best plan for future family building. JHCTGEH has fertility specialists on staff to meet with you and develop a plan that meets your goals.

Are there other ways I need to prepare?

It is very important to prepare mentally for your surgery. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts. These conversations and articles may be helpful; however, keep in mind that not everything you read will apply to your situation. If you have questions about whether something applies to your individual care, it is always best to talk to your doctor.

You will also want to think about your recovery plan post-surgery. Do you have friends or family who can help care for you in the days after your surgery? Having a support system is vital to your continued health both right after surgery and long term. Most centers have specific discharge instructions that you will receive after surgery. Ask if you can receive a copy of these instructions in advance so you can familiarize yourself with the information.

An initial intake interview via phone with a clinical specialist.

This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about, clarify what is required by your insurance company for surgery, and develop a plan for next steps. It will make your phone call more productive if you have these documents ready to discuss with the clinician:

• Medications. Information about which prescriptions and over-the-counter medications you are currently taking.
• Insurance. Call your insurance company and find out if your surgery is a “covered benefit" and what their requirements are for you to have surgery.
• Medical Documents. Have at hand the name, address, and contact information for any clinician you see on a regular basis. This includes your primary care clinician, therapists or psychiatrists, and other health specialist you interact with such as a cardiologist or neurologist.

After the intake interview you will need to submit the following documents:

• Pharmacy records and medical records documenting your hormone therapy, if applicable
• Medical records from your primary physician.
• Surgical readiness referral letters from mental health providers documenting their assessment and evaluation

An appointment with your surgeon. 

After your intake, and once you have all of your required documentation submitted you will be scheduled for a surgical consultation. These are in-person visits where you will get to meet the surgeon.  typically include: The specialty nurse and social worker will meet with you first to conduct an assessment of your medical health status and readiness for major surgical procedures. Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey. Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

A preoperative anesthesia and medical evaluation. 

Two to four weeks before your surgery, you may be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

What can I expect after gender affirming surgery?

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs. Depending on your specific surgery and which organs you continue to have, you may need to follow up with a urologist or gynecologist for routine cancer screening. JHCTGEH has primary care clinicians as well as an OB/GYN and urologists on staff.

Among other changes, you may consider updating your name and identification. This list of  resources for transgender and gender diverse individuals can help you in this process.

The Center for Transgender and Gender Expansive Health Team at Johns Hopkins

Embracing diversity and inclusion, the Center for Transgender and Gender Expansive Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.

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Gender Affirmation Surgeries

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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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• 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

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

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

Related Articles

• How Gender Identity Disorder Works
• Is gender just a matter of choice?
• What is transgender voice therapy?
• How fluid is gender?
• Why do girls wear pink and boys wear blue?

More Great Links

• DSM-5: Gender Dysphoria
• National Center for Transgender Equality
• The Williams Institute
• American Medical Student Association (AMSA). "Transgender Health Resources." 2014. (April 20, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
• American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." 2011. (July 1, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
• AP. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 20, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
• Belkin, Lisa. "Smoother Transitions." The New York Times. Sept. 4, 2008. (Aug. 1, 2011) http://www.nytimes.com/2008/09/04/fashion/04WORK.html
• Crane, Curtis. "The Total Guide to Penile Implants For Transsexual Men." Transhealth. May 2, 2014. (April 20, 2015) http://www.trans-health.com/2013/penile-implants-guide/
• Donaldson James, Susan. "Trans Chaz Bono Eyes Risky Surgery to Construct Penis." ABC News. Jan. 6, 2012. (April 20, 2015) http://abcnews.go.com/Health/transgender-chaz-bono-seeks-penis-genital-surgery-risky/story?id=15299871Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
• Glicksman, Eve. "Transgender today." Monitor on Psychology. Vol. 44, no. 4. Page 36. April 2013. (April 20, 2015) http://www.apa.org/monitor/2013/04/transgender.aspx
• Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape Medical News. May 20, 2013. (April 20, 2015) http://www.medscape.com/viewarticle/804432
• HealthResearchFunding.org (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 20, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
• International Foundation for Gender Education. "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 20, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
• Moskowitz, Clara. "High Suicide Risk, Prejudice Plague Transgender People." LiveScience. Nov. 18, 2010. (April 20, 2015) http://www.livescience.com/11208-high-suicide-risk-prejudice-plague-transgender-people.html
• Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. 2013. (April 20, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
• Public Religion Research Institute. "Survey: Strong Majorities of Americans Favor Rights and Legal Protections for Transgender People." Nov. 3, 2011. (April 20, 2015) http://publicreligion.org/research/2011/11/american-attitudes-towards-transgender-people/#.VSmlgfnF9bw
• Steinmetz, Katy. "Board Rules That Medicare Can Cover Gender Reassignment Surgery." Time. (April 20, 2015) http://time.com/2800307/medicare-gender-reassignment/
• The Philadelphia Center for Transgender Surgery. "Phalloplasty: Frequently Asked Questions." (April 20, 2015) http://www.thetransgendercenter.com/index.php/surgical-procedures/phalloplasty-faqs.html
• U.S. Office of Personnel Management. "Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace." 2015. (April 20, 2015) http://www.opm.gov/diversity/Transgender/Guidance.asp
• University of California, San Francisco - Department of Family and Community Medicine, Center of Excellence for Transgender Health. "Primary Care Protocol for Transgender Patient Care." April 2011. (April 20, 2015) http://transhealth.ucsf.edu/trans?page=protocol-hormones
• University of Miami - Miller School of Medicine, Department of Surgery, Plastic, Aesthetic and Reconstructive Surgery. "Transgender Reassignment." 2015. (April 20, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
• University of Michigan Health System. "Gender Affirming Surgery." (April 20, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
• World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
• World Professional Association for Transgender Health (WPATH). "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide." 2015. (April 20, 2015) http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

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.

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What Is Gender Transitioning?

The process of expressing and affirming one's gender identity

• What It Means
• What It Involves

Social Transitioning

Legal transitioning, medical transitioning, where to find support, how to be an ally.

Gender transitioning describes the process of affirming and expressing one's internal sense of gender rather than the gender assigned to them at birth. It is a process through which transgender and gender-nonconforming people align their presentation or sex characteristics with their gender identity .

Gender transitioning, known more commonly today as gender affirmation, not only involves aesthetic appearances but may also involve changes in social roles, legal recognitions, or physical aspects of the body. Gender transitioning is often described as a binary (male or female) but can also be non-binary , meaning a person is neither strictly male nor female.

This article describes what gender transitioning involves as well as the social, legal, and physical aspects of gender affirmation.

Verywell / Theresa Chiechi

What Does It Mean to Transition?

Gender transitioning is the process by which you express your gender externally ( gender expression ) so that it aligns with how view your gender internally (gender identity). The process has no particular timeline and isn't always linear.

Many transgender and gender-nonconforming people prefer the term "gender affirmation" to "gender transitioning"—in part because transitioning is often taken to mean the process of transforming one medically. In fact, a person doesn't need to undergo medical treatment to affirm their identity, and some transgender people avoid hormones or gender-affirming surgery.

Gender transitioning is a holistic process, addressing all aspects of who a person is inwardly and outwardly. It can be broadly categorized into three types:

• Social transitioning : Relating to how you present yourself to the world
• Legal transitioning : Relating to the recognition of your gender through legal means
• Medical transitioning : Relating to treatments that align your body with your gender identity

Certain aspects of gender transitioning may be more important to some people than others (such as changing your name and gender on your birth certificate). It is also possible to reevaluate and revise your gender identity as part of a lifelong continuum rather than as a step-by-step, one-way process.

Exploring Your Gender Identity

Gender transitioning is a process that often starts in response to gender dysphoria . Gender dysphoria describes the persistent sense of unease that occurs when the gender you were assigned at birth does not match how you experience or express your gender internally. Some people have experienced symptoms of gender dysphoria as early as 3 or 4 years of age.

Gender dysphoria can be largely informed by the culture you live in, particularly in cultures where there are strict codes as to what is masculine/male and feminine/female.

The unease can be expressed in children in different ways, including:

• A strong preference for clothes typically worn by the other gender
• A strong aversion to clothes typically worn by their own gender
• A strong preference for cross-gender roles in fantasy play
• A strong preference for the toys, games, or activities typically used by the other gender
• A strong preference for playmates of the other gender
• A strong dislike of one’s sexual anatomy

For many, gender dysphoria fully emerges during puberty when awareness about how their body defines them creates internal distress. Feelings of unease may be amplified when a child is described as "tomboy" or "sissy," or is criticized and attacked for "acting like a girl" or "acting like a boy."

With physical changes during puberty, long-standing feelings that "I don't fit in" may evolve into feelings that "I don't fit into my own body." It is then that children or teens may undergo a process referred to as internal transitioning. This is when you start to change how you see yourself.

Gender transitioning/affirmation is the next step. There is no set course as to how a person aligns their internal sense of gender with their outward expression of gender identity. Gender transitioning is not about "changing" or "recreating" oneself. It's about expressing one's authentic self and asserting who you are socially, legally, and/or medically.

Social transitioning involves how a person publicly expresses their gender to the world at large.

Social transition can take many forms:

• Changing your pronouns
• Using your chosen name
• Coming out to friends, family, and colleagues
• Wearing new clothes
• Cutting or styling your hair differently
• Changing your manner (such as how you sit)
• Changing how you speak or use your voice
• Packing (wearing a penile prosthesis to create a penile bulge)
• Tucking (tucking your penis to conceal a penile budge)
• Binding (strapping your chest to hide your breasts)
• Wearing breast and hip prosthetics to accentuate "feminine" curves

Social affirmation may also include playing certain sports, pursuing different lines of work, or partaking in activities that some might typically see as "male" or "female."

Legal transitioning is about legal recognition. It involves changing legal documents to reflect your chosen name, gender, and pronouns.

This includes governmental and non-government documents such as:

• Bank records
• Medical and dental record
• Driver's license
• Voter's registration card
• Birth certificates
• Social Security ID

The provisions allowing for these changes can vary by state.

Some states will only allow changes if "bottom surgery" (genital reconstruction) is performed, while others will allow you to do so without any form of gender-affirming surgery. Other states have begun to offer an "X" gender option for people who are non-binary.

Medical transitioning most commonly involves hormone therapy to develop some of the desired secondary male or female sex characteristics. It can also involve surgery to change certain physical aspects that hormone therapy alone can't change.

Hormone Therapy

Hormone therapy helps people look physically more like the gender they identify as. They are sometimes used on their own and may also be used before gender-affirming surgery to improve outcomes.

Gender-affirming hormone therapy takes two forms:

• Transgender men can take testosterone to help deepen their voice, increase muscle mass, promote body and facial hair, and enlarge their clitoris.
• Transgender women can take estrogen as well as a testosterone blocker to redistribute body fat, increase breast size, reduce male-pattern baldness, and reduce testicle size.

Gender-Affirming Surgery

Gender affirmation surgery is used to align a person's physical appearance to their gender identity. Many hospitals offer gender-affirming surgery through a department of transgender medicine.

Gender-affirming medical procedures include: 

• Breast augmentation : Increasing breast size with implants
• Chest masculinization : Removing and contouring of breast tissues
• Facial surgery : Including facial feminization surgery
• Tracheal shaving : Used to reduce the Adam's apple
• Phalloplasty : Construction of a penis 
• Scrotoplasty : Construction of a scrotum
• Vaginoplasty : Construction of the vaginal canal
• Vulvoplasty : Construction of the outer female genitals
• Orchiectomy : Removal of the testicles

Barriers to Gender Transitioning

Transgender people are protected from public and private insurance discrimination under federal and state laws, including Medicare and Medicaid.

Even so, Medicaid programs in nine states offer no coverage of gender-affirming medical treatments, and only two (Illinois and Maine) offer the comprehensive standard of care recommended by the World Professional Association for Transgender Health (WPATH).

Medicare also has no consistent policy regarding the approval of gender-affirming surgery. It instead relies on precedents in individual states to direct whether a treatment is approved or not. As such, states in which Medicaid coverage is denied may also be more likely to deny Medicare coverage.

In terms of private insurance, most providers have removed restrictions on gender-affirming care. Although larger insurers (like Aetna and Cigna) usually cover a more comprehensive array of services, in full or in part, many smaller insurers do not (or may only cover things like hormone therapy).

Even if treatments are covered, private insurers will often require psychological evaluations and health screenings that non-transgender people would never be asked to undergo (such as for breast reconstruction).

Another barrier is stigma and discrimination. Studies have shown that no less than 53% of transgender people report being harassed or bullied in public. Others report family or partner disapproval as the main reason why they abandon gender affirmation.

These factors can discourage transgender people from seeking gender-affirming care or embarking on treatments they would otherwise desire.

Gender transitioning can be complex and overwhelming, but there are organizations that can help with everything from insurance coverage to simply having someone to share your feelings with.

Here are some of the leading support organizations:

• Transgender Institute offers individual and group therapy for transgender youths and adults to better cope with stigma, discrimination, family issues, substance abuse problems, and transphobia .
• World Professional Association for Transgender Health offers a list of mental health providers by state who are experienced and trained in gender-affirming care.
• Pride Counseling is a paid mobile app that connects users to licensed therapists specializing in LGBTQI+ counseling.
• National Center for Transgender Equality offers a step-by-step guide to help transgender people obtain insurance coverage for gender-affirming care.
• The Trevor Project offers a 24/7 hotline for transgender youths in crisis or in need of a safe space to talk.
• Gay & Lesbian Alliance Against Defamation (GLAAD ) offers a comprehensive list of resources for transgender adults and youth.
• Transgender Legal Defense and Eductions Fund offers resources to assist with legal affirmation, insurance access, financial assistance, and legal action for transgender people who are unjustly denied gender-affirming care.

If you know someone who is transgender or is considering transitioning, learning how to be supportive is the best way to be an ally. Educate yourself about gender and gender transitioning. Everyone's transition is different, and there is no right or wrong way to do it.

Take the first step by asking the person's pronouns and affirmed name. It’s an act of respect, and everyone deserves to be addressed in the way they choose.

Gender transitioning, more commonly known today as gender affirmation, is the process taken by transgender people to align their internal gender identity with their external gender expression.

Gender transitioning may involve social affirmation (such as dressing differently or coming out to friends and family), legal affirmation (changing your name and gender on legal documents), or medical affirmation (using hormones and/or surgery to change certain physical aspects of your body). Transgender people can pursue some or all of these.

Barriers to gender transitioning include cost, lack of insurance, stigma, discrimination, and lack of family or partner support.

Gülgöz S, Glazier JJ, Enright EA, et al. Similarity in transgender and cisgender children’s gender development.  PNAS . 2019;116(49):24480-24485. doi: 10.1073/pnas.1909367116

King WM, Gamerel KE. A scoping review examining social and legal gender affirmation and health among transgender populations . Transgend Health. 2021;6(1):5–22.. doi:10.1089/trgh.2020.0025

Irwig MS, Childs K, Hancock AB. Effects of testosterone on the transgender male voice. Andrology . 2017;5(1):107-112. doi: 10.1111/andr.12278

Tangpricha V, den Heijer M. Oestrogen and anti-androgen therapy for transgender women.   Lancet Diabetes Endocrinol . 2017;5(4):291-300. doi: 10.1016/S2213-8587(16)30319-9

National Center for Transgender Equality. Know Your Rights in Health Care.

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services .

Center of Medicare and Medicaid Services. Gender dysphoria and gender reassignment surgery .

Transgender Legal Defense and Education Fund. Health insurance medical policies .

National Center for Transgender Equality and National Gay and Lesbian Task Force. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey.

Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors leading to “detransition” among transgender and gender diverse people in the United States: a mixed-methods analysis . LGBT Health. May/June 2021;8(4):273–80. doi:10.1089/lgbt.2020.0437

By S. Nicole Lane Lane is a freelance health journalist focusing on sexual health and LGBTQ wellness based in Chicago, Illinois. She began writing about health after living with vaginismus for eight years.

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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Female to Male Gender Reassignment Surgery (FTM GRS)

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

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

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

Interested in having this procedure?

Useful Information

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

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

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

Inpatient/Outpatient

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

Additional Information

What are the risks.

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

What is the recovery process?

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

What are the results?

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

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Hours of operation, gender affirming surgery (sex reassignment surgery).

Thank you for your interest in gender affirming surgery at Denver Health. There is no one-size-fits-all approach for the gender affirmation process and we are here to support you in your journey. We are proud to offer surgeries with a truly talented multi-disciplinary team of surgeons. Our services are growing as the unique needs of each individual evolve. Currently we offer the following gender affirming surgeries: MTF Top Surgery , FTM Top Surgery , Orchiectomy ,  FTM Hysterectomy , and  Vaginoplasty  surgeries.

What is Gender Affirming Surgery?

Gender affirming surgery, also known as sex reassignment surgery (SRS) or confirmation surgery, is the surgical procedure(s) by which a transgender or non-binary person’s physical appearance and functional abilities are changed to align with the gender they know themselves to be.

Complete Our Surgical Interest Form

If you are interested in a gender affirmation surgery at Denver Health, please complete one of the following forms.

Top Surgery and Hysterectomy

For vaginoplasty, breast augmentation and orchiectomy, our approach to surgical assessment.

Denver Health adheres to the guidelines for surgical assessment as described in the World Professional Association for Transgender Health Standards of Care, 8th Version . The standards were created by international agreement using the latest scientific research on transgender health so that doctors can best meet the unique health care needs of transgender and gender-nonconforming people. Most insurance companies also adhere to these guidelines.

Patients may provide referral letters from their own outside mental health providers, or the assessment process via our Behavioral Health team. Patients seeking to undergo the assessment at Denver Health should make an appointment with our Behavioral Health Team .

Read more about common frequently asked general surgery questions:

How long will my hospital stay be.

Hospital stays will vary based on specific patient response. 

MTF top surgery, FTM chest surgery, FTM Hysterectomy, and orchiectomy surgery patients are usually released from the hospital the same day of surgery. Vaginoplasty patients typically spend 3 days in the hospital during recovery. 

What medications will I be prescribed after surgery?

You will likely receive painkillers and antibiotics to reduce the chance of infection.

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• Health Conditions

Vaginoplasty: Gender Confirmation Surgery

A vaginoplasty is a medical procedure that constructs or repairs a vagina. It treats a variety of medical conditions and can be a form of gender affirming surgery.

For transgender and nonbinary people interested in gender confirmation surgery, a vaginoplasty is the process during which surgeons construct a vaginal cavity between the rectum and the urethra. The goal of the vaginoplasty is to create a vagina out of penile tissue — one with the depth and appearance of a biologically developed vagina.

Penile inversion procedure

The most common vaginoplasty technique is a penile inversion procedure. In this technique, penile skin is used to construct the vaginal lining. The labia majora are created using scrotal skin, and the clitoris is built from the sensitive skin at the tip of the penis. The prostate is left in place, where it can serve as an erogenous zone similar to the G-spot.

In some cases, there is not enough skin to achieve the necessary vaginal depth, so surgeons will take a skin graft from the upper hip, lower abdomen, or inner thigh. Scarring from the donation site is typically hidden or minimal.

The use of skin grafting to build the vulva is a topic of controversy among plastic surgeons. Some believe that the extra skin allows for a better cosmetic appearance. Others believe that functionality should not be sacrificed. Skin from donation sites is never as sensitive as skin from the genitals.

The penile inversion vaginoplasty is considered the gold standard genital reconstruction technique among plastic surgeons, and it is recommended by the Center of Excellence for Transgender Health .

Colon procedure

There is another technique that uses the lining of the colon instead of penile skin. Research on the outcomes of this surgery is limited.

One positive aspect of this procedure is that the tissue is self-lubricating, whereas vaginas made from penile tissue are dependent upon artificial lubrication. Because of the associated risks, however, colon tissue is typically used only in the event of a failed penile inversion.

Many people who have a vaginoplasty end up having a second surgery to improve the cosmetic appearance of the labia. A second surgery, called a labiaplasty, provides an opportunity for surgeons to work with healed tissue, where they can correct the positioning of the urethra and vaginal lips. According to the Center of Excellence for Transgender Health , a secondary labiaplasty, which is much less invasive, ensures the best cosmetic results.

What happens during the procedure?

On the morning of your surgery you will meet with your surgeon and an anesthesiologist. They will give you an overview of how the day is going to play out. They will probably give you an antianxiety medication or another sedative to help you relax. Then they will bring you to the operating room.

During your penile inversion vaginoplasty, you will be under general anesthesia, lying on your back with your legs up in stirrups.

The procedure is complex, involving delicate tissue, vasculature, and nerve fibers. Here are some of the broad strokes:

• The testicles are removed and discarded.
• The new vaginal cavity is carved out in the space between the urethra and the rectum.
• A penile prosthesis (surgical dildo) is inserted into the cavity to hold the shape.
• The skin is removed from the penis. This skin forms a pouch which is sutured and inverted.
• A triangular piece of glans penis (the bulbous tip) is removed to become the clitoris.
• The urethra is removed, shortened, and prepared for repositioning before the remaining parts of the penis are amputated and discarded.

Everything is sutured together and bandages are applied. The whole procedure takes two to five hours. The bandages and a catheter typically remain in place for four days, after which time postoperative steps should be taken.

Risks and complications

There are always risks associated with surgery, but vaginoplasty complications are rare. Infections can usually be cleared up with antibiotics. Some immediate postsurgical risks include:

• skin or clitoral necrosis
• rupture of the sutures
• urinary retention
• vaginal prolapse

Preparing for surgery

Some of the skin around the scrotum is hairy, as are the areas where skin grafts are taken from. Talk to your surgeon about where your new vaginal skin will be harvested. You may choose to complete a full course of electrolysis to eliminate the potential for vaginal hair growth. This can take several weeks or months.

Follow your surgeon’s instructions on the night before and morning of your surgery. Generally, you should not eat or drink anything after midnight on the night prior to going under anesthesia.

Other presurgery tips:

• Talk to other people who have gotten bottom surgery about their experiences.
• Talk with a therapist or counselor in the months prior to your surgery to mentally prepare yourself.
• Make plans for your reproductive future. Talk to your doctor about your fertility preservation options (saving sperm samples).
• Make a postoperative plan with your family and friends; you will need lots of support.

How much does it cost?

The average cost for a penile inversion vaginoplasty is around $20,000 without insurance. This includes a few days in the hospital, plus anesthesia. However, this is only for one surgery. If you want a secondary labiaplasty, the costs increase.

Many people who get vaginoplasties also undergo breast augmentation and facial feminization surgeries, which are very expensive. You should also keep in mind the cost of electrolysis, which can add up to thousands of dollars.

Costs will vary depending on your insurance coverage, where you live, and where you get your surgery done.

The long-term success of your vaginoplasty will depend largely on how well you follow the postoperative instructions. Your surgeon will give you a vaginal dilatator to begin using as soon as your bandages are removed. This dilation device must be used daily for at least one year to maintain the desired vaginal depth and girth.

Your surgeon will provide you with a dilation schedule. Typically, it involves inserting the dilator for 10 minutes, three times per day for the first three months and once per day for the next three months. Then, you’ll do it two to three times per week for at least one year. The diameter of the dilator will also increase as the months go by.

Recovery do’s and don’ts

• Don’t take a bath or submerge yourself in water for eight weeks.
• Don’t do strenuous activity for six weeks.
• Don’t swim or ride a bike for three months.
• Showering is fine after your first postoperative visit.
• Do sit on a donut ring for comfort.
• Don’t have sexual intercourse for three months.
• Do apply ice for 20 minutes every hour of the first week.
• Don’t worry about swelling.
• Do expect vaginal discharge and bleeding for the first four to eight weeks.
• Do avoid tobacco products for at least one month.
• Be careful of pain medication; take it only as long as absolutely necessary.

How we reviewed this article:

• Buncamper ME,et al. (2015). Aesthetic and functional outcomes of neovaginoplasty usingpenile skin in male‐to‐female transsexuals. DOI: https://doi.org/10.1111/jsm.12914
• Buncamper ME,et al. (2016). Surgical outcome after penile inversion vaginoplasty: A retrospectivestudy of 475 transgender women. DOI: https://doi.org/10.1097/PRS.0000000000002684
• BuncamperME, et al. (2017). Penile inversion vaginoplasty with or without additional full-thicknessskin graft: To graft or not to graft? DOI: https://doi.org/10.1097/PRS.0000000000003108
• HorbachSE, et al. (2015). Outcome of vaginoplasty in male‐to‐female transgenders:A systematic review of surgical techniques. DOI: https://doi.org/10.1111/jsm.12868
• Maleto female price list. (n.d.). http://www.thetransgendercenter.com/index.php/mtf-price-list.html
• Meltzer T. (2016). Vaginoplasty procedures,complications and aftercare. http://transhealth.ucsf.edu/trans?page=guidelines-vaginoplasty
• MTF vaginoplasty:What patients need to know before choosing a technique. (n.d.). http://www.mtfsurgery.net/mtf-vaginoplasty.htm
• Preparing forgender affirmation surgery. (n.d.). http://www.hopkinsmedicine.org/health/articles-and-answers/ask-the-expert/preparing-for-gender-affirmation-surgery-ask-the-experts
• Sigurjonsson H, et al. (2016).Solely penile skin for neovaginal construction in sex reassignment surgery.DOI: http://doi.org/10.1097/GOX.0000000000000761
• What is avaginoplasty? (n.d.). https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/vaginoplasty
• Van der Sluis WM, et al. (2016). Revision vaginoplasty:A comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thicknessskin graft vaginoplasty. DOI: https://doi.org/10.1097/PRS.0000000000002598

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A decision to undertake gender reassignment is made when an individual feels that his or her gender at birth does not match their gender identity. This is called ‘gender dysphoria’ and is a recognised medical condition.

Gender reassignment refers to individuals, whether staff, who either:

• Have undergone, intend to undergo or are currently undergoing gender reassignment (medical and surgical treatment to alter the body).
• Do not intend to undergo medical treatment but wish to live permanently in a different gender from their gender at birth.

‘Transition’ refers to the process and/or the period of time during which gender reassignment occurs (with or without medical intervention).

Not all people who undertake gender reassignment decide to undergo medical or surgical treatment to alter the body. However, some do and this process may take several years. Additionally, there is a process by which a person can obtain a Gender Recognition Certificate , which changes their legal gender.

People who have undertaken gender reassignment are sometimes referred to as Transgender or Trans (see glossary ).

Transgender and sexual orientation

It should be noted that sexual orientation and transgender are not inter-related. It is incorrect to assume that someone who undertakes gender reassignment is lesbian or gay or that his or her sexual orientation will change after gender reassignment. However, historically the campaigns advocating equality for both transgender and lesbian, gay and bisexual communities have often been associated with each other. As a result, the University's staff and student support networks have established diversity networks that include both Sexual Orientation and Transgender groups.

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Trump Is Convinced That Trans Kids Are Getting Gender-Affirming Surgeries… at School?

Teachers might be crowdfunding for students’ basic school supplies , but according to Trump’s (false and completely baseless) claims, free sex change procedures are being offered on this year’s curriculums.

Ahead of Tuesday night’s debate, Republican presidential candidate Donald Trump has been spreading lies about transgender people on his campaign trail once again. Most recently, at a rally in Mosinee, Wisconsin this past Saturday, Trump repeated the unfounded lie that children are, for some reason, receiving gender-affirming surgery at school behind their parents’ backs.

“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,” Trump said in a video posted to X. “Can you even imagine this? What the hell is wrong with our country?”

This content can also be viewed on the site it originates from.

There are many things wrong with this country, but children seeking gender affirming care is not one of them. Not only are surgeries for trans minors vanishingly rare , but research has shown that when minors do have access to gender-affirming hormone therapy, it has an overwhelmingly positive effects on trans youth’s mental health . The World Professional Association for Transgender Health (WPATH), an international body of experts that writes the standards of gender-affirming care, states that patients must be of the age of majority in order to undergo bottom surgery.

The Trump campaign, in fact, could not come up with any evidence of a school granting a child access to gender-affirming surgery without parental consent after CNN pressed them on the issue Monday.

Campaign spokesperson Karoline Leavitt instead focused on the broader debate about “parents’ rights” and trans children at schools, telling CNN, “I have personally spoken to several individuals whose children were undergoing transition, being called entirely different names at school and the parents were never notified. These cases don’t always make the news because parents fear backlash, but their stories are nevertheless truthful and very concerning.” However, as CNN mentioned, any evidence of Trump’s claim that gender-affirming surgeries have been made available at schools remains to be seen.

Not even Trump’s staunchest allies could point to evidence of children receiving gender-affirming surgery at school. CNN asked Moms for Liberty cofounder Tiffany Justice for any information on that phenomenon, to which she said, “Are kids getting surgery in school? No they’re not.” However, she also said that she was “thankful” that he made the false claim, since it brought attention to the “issue” of social transition, or children being allowed to use different names and pronouns at school. Additionally, Thomas Jipping, a senior legal fellow at the Heritage Foundation told CNN that “Trump’s point is completely valid” even though he was also “not aware of a specific incident yet where it has gone that far, where it has gone from social to medical transition.”

Chase Strangio, the Deputy Director for Transgender Justice at the ACLU's LGBT & HIV Project, said in a post on X that the sentiment was hardly worth gracing with a response, writing, “No one needs to verify this to know it is absurd.”

“Schools don’t perform surgery period (and obviously - they can barely afford books),” he wrote. “Gender-affirming medical care doesn’t happen without parental consent. Don’t ‘investigate’ the claim. Show what animates it.”

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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. 

Follow live updates on the 2024 election

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.

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New NAIA Infra Corp. says terminal reassignments 'will surely happen'

New NAIA Infrastructure Corp. (NNIC), the private proponent that will take over the Ninoy Aquino International Airport (NAIA), on Monday said terminal reassignments will surely happen, in a bid to decongest the gateway and improve efficiency. According to NNIC general manager Angelito Alvarez, the group had already engaged with several consultants regarding the reassignment of terminals being used by airlines to improve passenger experience and boost flight efficiency. “This is something that will surely happen,” he said during the EJAP-SMC Aviation Forum in Makati City, as the group is tasked to increase aircraft movements per hour to 48 flights from the current 41 flights. “There’s really congestion at the airport so if we will maintain the status quo, you can just imagine the impact on the passenger experience, so we will need to do something while the new Terminal 2 extension still to be built,” he added. Alvarez was referring to a new passenger terminal building that is planned to be built on the site currently occupied by the Philippines Village Hotel, which will be connected to NAIA Terminal 2. Under its plan, NNIC said NAIA Terminal 1 will be used by flag carrier Philippine Airlines, while Terminal 2 will be a purely domestic terminal, including those of Cebu Pacific. Terminal 3 will cater to all the foreign airlines currently operating in Terminal 1. Terminal 4, meanwhile, will cater to AirAsia flights that are currently in Terminal 2. “With regards to the terminal reassignment, the end-state will happen only in about two years once the Terminal 2 extension will be completed,” Alvarez said. He noted, however, that this would be a gradual process due to the space limitation, with the first phase involving AirAsia moving from Terminal 2 to Terminal 4. The vacated wing will then accommodate Cebu Pacific which will move from Terminal 3. The space left in Terminal 3 will then be occupied by foreign airlines that are operating in Terminal 1. “It will be a gradual process. That’s the best that we can do at this point in time. As I stated earlier, things can only normalize once this Terminal 2 extension is completed,” Alvarez said.

For their part, officials of carriers such as AirAsia Philippines, Cebu Pacific, and Philippine Airlines said they are open to working with the NNIC on the reassignment. NNIC, made up of San Miguel Holdings Corp., RMM Asian Logistics Inc., RLW Aviation Development Inc., and Incheon International Airport Corp., is set to take over NAIA on September 14, 2024. Previously called SMC SAP & Co. Consortium, NNIC in March inked a P170.6-billion concession agreement with the Department of Transportation (DOTr) to take over NAIA after it offered the highest share of its future revenues from operating the gateway to the government. The group committed at least P122.3 billion in capital investments for the entire 25-year concession period, equivalent to P4.89 billion per year. It would need to make an upfront payment of P30 billion to the government, and another P2 billion in annual payments for the duration of the contract. —LDF, GMA Integrated News