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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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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

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

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

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

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

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Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

• Breast augmentation incisions

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

• Placement of breast implants or tissue expanders

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

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

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

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

Genital surgery

• Anatomy before and after penile inversion

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

• Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Research has found that 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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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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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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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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Gender affirming surgery

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What is gender affirming surgery?

Gender affirming surgery refers to a variety of procedures that some trans or gender diverse people may use to affirm their gender.

Surgery is just one option for gender affirming care. All trans and gender diverse people are unique and will choose to affirm their gender in a way that feels right for them.

Gender affirming care might include:

• Social affirmation, such as changing names, pronouns, hair or clothing.
• Legal affirmation, such as changing legal name or gender.
• Medical affirmation, with hormones or surgery.

Read more about gender incongruence, gender dysphoria , and gender affirming care here.

This article talks more about gender affirming surgery.

What happens during gender affirming surgery?

There are many different gender affirming surgeries and procedures. They may include making changes to your face, chest, genitals, or other body parts.

For people assumed male at birth, feminising surgeries may include:

• Breast augmentation with insertion of breast implants.
• Facial feminisation — changing the shape of any or all facial features.
• Vocal surgery — shortening the vocal cords for a higher, more feminine voice.
• Tracheal shave — reducing the size of the ‘Adam’s apple’.
• Fillers or liposuction, to achieve a more typically feminine shape.
• Orchiectomy, or removal of testicles.
• Bottom surgery or ‘genital reconfiguration surgery’, involving changes to the genitals.

Bottom surgery is called ‘genital reconfiguration surgery’. This was previously known as ‘sex reassignment surgery’ or ‘gender confirmation surgery’. The name change shows that your genitals don’t define your sex or gender.

Feminising bottom surgery may involve a combination of the following procedures:

• Removing the testicles (orchiectomy).
• Removing and reshaping tissue from the penis to make a vulva. This includes external labia or lips, and a clitoris. This is known as vulvoplasty.
• Shortening the urethra (tube that you urinate — wee — from).
• Creation of a vaginal canal (vaginoplasty). This is a complicated step which some people choose to skip. After surgery, vaginal dilators will need to be used to maintain the shape of the vaginal canal.

For people assumed female at birth, masculinising surgeries may include:

• Top surgery, with reduction or removal of breast tissue (mastectomy). This creates a flatter or more neutral chest. There are many different techniques used to achieve this.
• Liposuction to achieve a more typically masculine shape.
• Hysterectomy , or removal of the uterus (womb) and ovaries.
• Bottom surgery or genital reconfiguration surgery. This involves changes to the genitals.

Masculinising bottom surgery may involve a combination of the following procedures:

• Hysterectomy, if not already performed.
• Vaginectomy, or removal of the vagina.
• Creation of a penis, which may include metoidioplasty or phalloplasty.
• Metoidioplasty involves making a penis shape wrapping tissue around the clitoris after it is enlarged by testosterone hormone therapy.
• Phalloplasty involves making a larger penis with tissue from the arm, thigh, back, or abdomen. This involves lengthening the urethra to be able to urinate from the tip of the new penis. An inflatable penile implant may be inserted inside the penis to allow an erection.

Is gender affirming surgery right for me?

Choosing to undergo any surgery is a big decision. Everyone affirms their gender in different ways, and that may or may not include surgery.

Surgery is permanent so you need to make sure it’s the right choice for you. Surgery doesn’t make you more or less trans.

Before being able to access gender affirming surgery, you need to meet the criteria below:

• A history of gender incongruence (for 6 months or more).
• The ability to make a fully informed decision.
• Be over the age of 16 for top surgery, or 18 for bottom surgery. Some surgeons will provide surgery to younger people in very specific situations.
• Ensure that any physical or mental health conditions are well managed.

You will need letters of support from a mental health professional before having gender affirming surgery.

For top surgery, one letter is required. For bottom surgery two letters are required. For bottom surgery, you are also required to have ‘lived as your current gender’ for 12 months, meaning you have socially transitioned. The letter needs to state that surgery is appropriate for you and is likely to help affirm your gender and reduce any gender dysphoria that may be present.

If you are taking gender affirming hormones, or want to take hormones in the future, you should do this for 12 months before having surgery. This is to allow any significant body changes to occur before surgery.

Most people who have surgery are happy with their results and feel more comfortable in their bodies. But some people are disappointed with the results, or find that any gender dysphoria that was present is not fully resolved. Make sure you discuss any difficult feelings with your doctor or psychologist.

What questions should I ask before surgery?

It’s important to talk about the pros and cons of surgery in detail with your doctor. It’s a good idea to ask to see pictures of how other people look after surgery.

Questions to ask your surgeon include:

• What different surgical techniques are there?
• What are the pros and cons of each technique for me?
• What results can I expect?
• What are the possible risks and complications?

For help in having the discussion, visit healthdirect’s Question Builder .

What should I expect after surgery?

Surgical recovery can be long and uncomfortable. Your surgeon will be able to give you more information on what can be expected before, during, and after surgery. This might include spending time in hospital afterwards, any special dressings, surgical garments, or follow up care.

Make sure you do everything your doctor tells you and go to all follow-up appointments. This will help you get the best results from your surgery.

Having surgery is a big deal. Even if you’ve been looking forward to it and are happy with the result, it can still be quite confronting. It might take some time to get used to your new body.

Talk to your doctor if you are feeling any distress following surgery.

How much will gender affirming surgery cost me?

Gender affirming surgery can be very expensive. It can cost between $20,000 to more than $100,000, depending on which procedures you need.

Your surgeon will be able to tell you how much surgery will cost. The cost may include specialist visits before and after surgery, surgeon and anaesthetist fees, hospital and theatre costs, and any other products or services necessary.

Some costs may be covered by Medicare, such as specialist consults if you have a referral from your doctor. Unfortunately, most gender affirming surgery in Australia is done privately, meaning there will be large out-of-pocket costs.

You should ask your surgeon what Medicare item numbers they use. You can check the Medicare rebate at MBS Online .

Some private health insurance will also help with gender affirming surgery. If you have health insurance, it’s important to check with your health fund first about your level of cover. There is a range of health insurance comparison sites available online, such as privatehealth.gov.au .

Legal matters

Changing your gender on your passport, licence, Medicare card or birth certificate all require separate processes. These vary between states and territories. In some states and territories, you must have undergone specific types of gender affirmation surgery to change the gender marker on your birth certificate.

You can find out more about the specific processes at TransHub .

You are legally protected by the Sex Discrimination Act from discrimination on the grounds of sexual orientation, gender identity or intersex status. Visit the Australian Government Attorney-General’s Department for more details.

Where can I get more information on gender affirming surgery?

• TransHub has information about gender affirming surgery.
• The Gender Centre (NSW) provides resources and support.
• Transgender Victoria has resources and links to other services.
• The Australian Professional Association for Trans Health (AusPATH) lists some providers.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: June 2022

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State health plans must cover gender-affirming surgery, US appeals court rules

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Court says state health-care plans can’t exclude gender-affirming surgery

A federal appellate court in Richmond became the first in the country to rule that state health-care plans must pay for gender-affirming surgeries, a major win for transgender rights amid a nationwide wave of anti-trans activism and legislation.

The decision came from a set of cases out of North Carolina and West Virginia, where state officials argued that their policies were based on cost concerns rather than bias. The U.S. Court of Appeals for the 4th Circuit rejected that argument, saying the plans were discriminating against trans people in need of treatment.

Judge Roger L. Gregory, an appointee of President Bill Clinton, wrote for the majority that the restrictions were “obviously discriminatory” based on both sex and gender.

“In this case, discriminating on the basis of diagnosis is discriminating on the basis of gender identity and sex,” Gregory wrote, because “gender dysphoria is so intimately related to transgender status as to be virtually indistinguishable from it.”

The majority ruled that West Virginia’s policy also violated the Affordable Care Act’s anti-discrimination provision, a finding that has broad implications for other states’ Medicaid programs.

It’s the second ruling in favor of trans rights this month from the 4th Circuit, a once-conservative court that has become a trailblazer in the realm of transgender rights. The court was the first to say trans students had a right to use the bathrooms that align with their gender identity and the first to recognize gender dysphoria as a protected disability. Earlier this month, the court said a federally funded middle school could not ban a trans 13-year-old from playing on the girls’ track and field team.

The decision will be appealed to the Supreme Court, which recently allowed Idaho to enforce a ban on gender-affirming care for minors. West Virginia Attorney General Patrick Morrisey, who is running for governor, said in a statement Monday that he would “take this up to the Supreme Court and win.”

But the conservative-led Supreme Court has been reluctant to engage on these issues, letting multiple 4th Circuit rulings in favor of transgender rights stand. The court also generally waits until there is disagreement between circuit courts before getting involved.

All of these rulings split the 4th Circuit court down ideological lines, with judges appointed by Democrats joining the majority opinion and those appointed by Republicans dissenting. In the lead dissent from the ruling Monday, Judge Jay Richardson, a Trump appointee, wrote that there was no role for the federal court in policing what treatments health-care plans decide to cover.

The majority opinion, Richardson wrote, “treats these cases as new fronts upon which this conflict must be waged. But not every battle is part of a larger war. In the majority’s haste to champion plaintiffs’ cause, today’s result oversteps the bounds of the law.”

Richardson said what mattered is that trans patients have the same coverage of the same conditions as others. For example, he said, a trans patient with uterine cancer could get a hysterectomy under these plans.

“The different coverage accorded to treatments for different diagnoses is … based on medical judgment of biological reality,” he wrote. “States can reasonably decide that certain gender-dysphoria services are not cost-justified, in part because they question the services’ medical efficacy and necessity.”

Other states have banned hormonal treatment and surgery for trans minors; some have restricted care for transgender adults as well. Multiple other states have similar laws against insurance coverage for transition-related treatment. The Biden administration has moved to protect trans Americans through federal regulations, including guidelines released Monday that treat misuse of pronouns or refusal to let transgender employees use their preferred bathroom as workplace harassment.

In West Virginia, transgender Medicaid users challenged the state’s program, which since 2004 has by law banned “transsexual surgeries.” In North Carolina, state employees challenged their coverage, which in 2018 excluded surgical treatment of gender dysphoria — the clinical diagnosis of a disconnect between a person’s gender and birth sex.

Both states insisted that there was no bias in their coverage limitations, only cost concerns. Trans patients, they argued, were entitled to the same health treatments as everyone else but not specialized care.

“There is no service that is covered for a cisgendered person that is not covered for a transgender person meeting the same criteria,” Caleb David, an attorney for West Virginia, told judges on the appellate court during the oral argument. David added that the state had decided to provide psychiatric and hormonal treatment for gender dysphoria — just not surgery.

Advocates for trans patients said there was no medical justification for drawing the line there, when the state would cover such procedures for other conditions. They also said the financial explanation was suspect because so few people get gender-affirming surgery. It’s “a drop in the bucket,” Lambda Legal attorney Tara Borelli said during oral arguments. But even if the cost was significant, she argued, the cost of public health insurance “has to be a shared burden. It can’t be shunted onto the backs of a vulnerable minority group.”

The court agreed, saying cost-cutting could not justify covering the same treatments for health concerns other than gender dysphoria. For example, Gregory noted that under these plans, “cisgender people do receive coverage for certain gender-affirming surgeries,” including breast reconstruction for cancer patients after a mastectomy.

North Carolina began covering gender-affirming care in 2017 and stopped the following year, when Republican Dale Folwell became state treasurer. Julia McKeown, a professor at North Carolina State University, accepted her job in 2016, a few years into fully transitioning after a lifetime of “being adamant about what my gender was” but being limited in expressing it. She spent months preparing for surgery, only to be forced to cover the full cost along with all other treatment.

“It’s like having the rug pulled out from under you,” she said. “In some ways it’s worse than going in and knowing it was going to be denied.” She cut into her retirement savings rather than delay the surgery, calling herself “fortunate” to be able to do so.

McKeown grew up in a rural town in Florida and spent years pretending to be a man for fear of social and professional exclusion. Joining the lawsuit meant exposing herself to hate mail from strangers.

“In an ideal world, I would have loved to just move on with my life” after the surgery, she said. “At the same time, I feel a moral obligation to help those who can’t speak up for themselves, and for those who risk being fired or who have dependents on the state health-care plan who need access to treatment.”

Twenty-one Republican-led states asked the court to rule against the plaintiffs, focusing on disagreement over what physical interventions should be available to trans youth. But most major medical plans and the federal government cover gender transition treatment, which has been endorsed by mainstream medical associations. Studies indicate very few people who transition regret doing so or seek to reverse the changes, including those who start treatment in their teens.

Seventeen Democratic-led states and the District of Columbia urged the court to rule for the coverage, saying their “experience demonstrates that protecting access to gender-affirming care improves health outcomes for our transgender residents at little cost.”

An earlier version of this story reported that the contested insurance plans covered mastectomies for cancer patients but not for trans women. The plans covered mastectomies for all cancer patients, but did not cover the procedure for trans men who wanted their breasts removed to treat gender dysphoria.

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On CloseUp, Joyce Craig said she supports giving families and their children the power to decide on gender reassignment surgery if they consult with a doctor.

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Heated arguments at the Supreme Court in newest abortion case

Nina Totenberg

The Supreme Court heard arguments in a case examining a federal-state conflict over emergency abortions. Catie Dull/NPR hide caption

The Supreme Court heard arguments in a case examining a federal-state conflict over emergency abortions.

Inscrutable. That is the only word to accurately describe the Supreme Court's latest abortion argument Thursday.

At issue is a clash between federal and state law about how pregnant women must be treated in the emergency room. Specifically, whether a state may ban medical termination of a pregnancy if the woman's health, but not her life, is in grave danger.

Supreme Court to examine a federal-state conflict over emergency abortions

The case centers on a law enacted in 1986 to stop hospitals from turning away uninsured patients or dumping them on other hospitals. It's known as the Emergency Medical Treatment and Labor Act, or EMTALA. The law says that as a condition for receiving Medicare funds, hospital emergency departments must stabilize a patient whose life or health is at risk. If the hospital can't do that, it must provide safe transport to a facility that can.

But Idaho and a few other states have now enacted laws that ban emergency abortions unless the mother's life, but not her health, is at risk.

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What's at stake as the supreme court hears idaho case about abortion in emergencies.

At the Supreme Court lectern Thursday, Idaho Solicitor General Joshua Turner defended the restrictive law, declaring that the state is entitled to make decisions about the practice of medicine within its borders. But he faced some unusually angry questions from the court's three liberal justices, all women, with an occasional assist from conservative Justice Amy Coney Barrett, who is firmly opposed to abortion.

Justice Sonia Sotomayor hammered Turner with a series of real-life examples of women in dire health circumstances, who would be denied a medically necessary abortion under the Idaho law. She interrupted him so often that Chief Justice John Roberts at one point intervened to lower the temperature and get an answer from Turner.

Drawing an analogy not involving abortion, Sotomayor, a diabetic, observed that "no state licensing law" would permit the state to tell doctors, "don't treat diabetics with insulin, treat them only with [far less effective] pills.... Federal law would say you can't do that."

Supreme Court allows Idaho abortion ban to be enacted, first such ruling since Dobbs

Justice Elena Kagan asked Turner what in EMTALA says that a woman has to be at "death's door" before doctors treat her with a necessary emergency abortion to stabilize her condition.

"That understanding is a humble one with respect to the federalism role of the states as the primary care provider for the citizens, not the federal government," Turner answered.

"It may be too humble for women's health, you know," Kagan observed, caustically.

And Justice Ketanji Brown Jackson said that EMTALA established a "federal mandate" that preempts state laws.

Pummeled with questions, Idaho's Turner refused to commit to which health-threatening conditions could be legally treated with abortions under state law. Could an abortion take place to preserve a woman's organs? Her fertility? To save her from future debilitating kidney disease or strokes?

Turner's ambiguous answers prompted surprise from Justice Barrett, a mother of seven who has herself had miscarriages. "Counsel, I'm kind of shocked actually because I thought your own expert had said below that these kinds of cases were covered. And you're now saying they're not? Turner's replay clearly didn't satisfy her. She accused him of "hedging."

Chief Justice Roberts asked who would make the decision, other than the doctor, as to what constitutes a permissible emergency abortion and what the standard would be.

Turner replied that there is no objective standard, just a subjective one. The doctor's decision would not be judged based on what a "reasonable doctor" would do, only on whether he personally acted in good faith.

Arguing the other side of the case on behalf of the Biden administration, Solicitor General Elizabeth Prelogar faced an equal barrage of questions, mainly from the court's conservative justices.

Could a woman's psychological health be justification for an emergency abortion? No, replied Prelogar.

Three justices—Roberts, Barrett, and Neil Gorsuch—all asked if EMTALA provides exceptions for doctors or hospitals with religious objections to abortion.

Prelogar replied that conscience objections exempt both from performing abortions under EMTALA, but she added that the Department of Health and Human Services "had never come across a hospital that had a blanket objection to providing life-preserving and health-preserving pregnancy termination care."

Several conservative justices also sought to flesh out what limits there might be to laws that condition federal aid, such as the funding to hospitals governed by EMTALA. Barrett and Gorsuch, for instance, asked if gender-reassignment surgery could be banned at hospitals as a condition for receiving federal money.

Prelogar replied that in her view Congress has that power.

And Justice Samuel Alito, author of the decision overturning Roe v. Wade, looked up at the clock at one point and observed that an hour and a half into the argument, "one potentially very important phrase in EMTALA has hardly been mentioned...and that is EMTALA's reference to the woman's 'unborn child.'"

"The statute did nothing to displace the woman herself as an individual with an emergency medical condition," Prelogar replied. "In many of the cases you're thinking about, there is no possible way to stabilize the unborn child...it's inevitable that the pregnancy is going to be lost, but Idaho would deny women treatment in that circumstance even though it's senseless."

A decision in the case is expected in the summer.

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W. Virginia and N. Carolina’s transgender care coverage policies discriminate, judges rule

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West Virginia and North Carolina’s refusal to cover certain healthcare for transgender people with government-sponsored insurance is discriminatory, a federal appeals court ruled Monday in a case likely headed to the U.S. Supreme Court.

The Richmond-based 4th U.S. Circuit Court of Appeals ruled 8-6 in the case involving coverage of gender-affirming care by North Carolina’s state employee health plan and the coverage of gender-affirming surgery by West Virginia Medicaid.

“The coverage exclusions facially discriminate on the basis of sex and gender identity, and are not substantially related to an important government interest,” Judge Roger Gregory, first appointed by former President Clinton and reappointed by former President George W. Bush, wrote in the majority opinion.

The ruling follows a decision earlier this month by 4th Circuit judges that West Virginia’s transgender sports ban violates the rights of a teen athlete under Title IX, the federal civil rights law that prohibits sex-based discrimination in schools.

Like with the transgender sports law ruling, West Virginia Atty. Gen. Patrick Morrisey said his office planned to appeal Monday’s health care case decision.

“Decisions like this one, from a court dominated by Obama and Biden appointees, cannot stand: we’ll take this up to the Supreme Court and win,” Morrisey said in a statement.

After the ruling, West Virginia plaintiff Shauntae Anderson, a Black transgender woman and West Virginia Medicaid participant, called her state’s refusal to cover her care “deeply dehumanizing.”

“I am so relieved that this court ruling puts us one step closer to the day when Medicaid can no longer deny transgender West Virginians access to the essential healthcare that our doctors say is necessary for us,” Anderson said in a statement.

A spokesperson for North Carolina State Treasurer Dale Folwell, whose department oversees the state’s health plan, said the agency was still reviewing the decision Monday but would have a response later.

During oral arguments in September, at least two judges said it’s likely the case will eventually reach the U.S. Supreme Court. Both states appealed separate lower court rulings that found the denial of gender-affirming care to be discriminatory and unconstitutional. Two panels of three 4th Circuit judges heard arguments in both cases last year before deciding to intertwine the two cases and see them presented before the full court.

In June 2022, a North Carolina trial court demanded the state plan pay for “medically necessary services,” including hormone therapy and some surgeries, for transgender employees and their children. The judge had ruled in favor of the employees and their dependents, who said in a 2019 lawsuit that they were denied coverage for gender-affirming care under the plan.

The North Carolina state insurance plan provides medical coverage for more than 750,000 teachers, state employees, retirees, lawmakers and their dependents. While it provides counseling for gender dysphoria and other diagnosed mental health conditions, it does not cover treatment “in connection with sex changes or modifications and related care.”

In August 2022, a federal judge ruled West Virginia’s Medicaid program must provide coverage for gender-affirming care for transgender residents.

An original lawsuit filed in 2020 also named state employee health plans. A settlement with The Health Plan of West Virginia Inc. in 2022 led to the removal of the exclusion on gender-affirming care in that company’s Public Employees Insurance Agency plans.

During September’s oral arguments, attorneys for North Carolina said the state-sponsored plan is not required to cover gender-affirming hormone therapy or surgery because being transgender is not an illness. They claimed only a subset of transgender people suffer from gender dysphoria, a diagnosis of distress over gender identity that does not match a person’s assigned sex.

Before offering pharmaceutical or surgical intervention, medical guidelines call for thorough psychological assessments to confirm gender dysphoria before starting any treatment.

West Virginia attorneys said the U.S. Centers for Medicare & Medicaid Services has declined to issue a national coverage decision on gender-affirming surgery.

State lawyers said West Virginia’s policy is not a case of discrimination, either, but of a state trying to best utilize limited resources. West Virginia has a $128 million deficit in Medicaid for the next year, projected to expand to $256 million in 2025.

Unlike North Carolina, the state has covered hormone therapy and other pharmaceutical treatments for transgender people since 2017.

Willingham writes for the Associated Press.

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LGBTQ+ rights in Iraq: how morality laws ramped up

Same-sex relationships and gender reassignment surgery are now criminalised in latest attack on targeted community

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Human rights groups have condemned a bill passed by Iraq's parliament that criminalises  s ame-sex relationships, with jail terms of between 10 and 15 years.

According to a copy of the legislation seen by Reuters , the law aims to "protect Iraqi society from moral depravity and the calls for homosexuality that have overtaken the world".

Amnesty International's Iraq researcher Razaw Salihy said that Iraq had "effectively codified in law the discrimination and violence" that members of the LGBTQ+ community have "been subjected to with absolute impunity for years".

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What is in the new law?

As well as a penalty of between 10 and 15 years in prison for same-sex relations, the Law on Combating Prostitution and Homosexuality mandates at least seven years in jail for anybody who promotes homosexuality or prostitution, and between one and three years for anyone who changes their "biological gender" or wilfully dresses in an effeminate manner. 

Doctors who perform gender reassignment surgery, men who "intentionally" act like women and those who engage in "wife swapping" will also face prison terms under the new legislation, said the BBC .

Why has it been introduced now?

Iraq had been among the few Islamic nations that did not explicitly criminalise same-sex relations , but "loosely defined" morality clauses in its penal code have been used to "target" LGBTQ+ people, said The Independent .

The new legislation was backed by conservative Shia Muslim parties that form the largest coalition in Iraq's mainly Muslim parliament. It is "a significant step in combating sexual deviancy given the infiltration of unique cases contradicting Islamic and societal values", Amir al-Maamouri, an independent MP, told Shafaq News.

It is indeed "sweeping", said Pink News , although "less extreme than originally planned", after a clause in an earlier version of the bill that called for the death penalty for same-sex acts was removed due to opposition from the US and Europe.

What has the reaction been?

The amended legislation has sparked condemnation from human rights groups and the international community.

It is "dangerous and worrying", said UK Foreign Secretary David Cameron. A statement from the US State Department said the law "threatens those most at risk in Iraqi society" and "can be used to hamper free speech and expression and inhibit the operations of NGOs across Iraq". The law would also weaken Iraq's ability to diversify its economy and attract foreign investment, the department said.

Data collected in 2022, reported by Pink News , suggested that just 2% of Iraq's population support homosexuality, while 55% oppose it. Ordinary Iraqis interviewed on Sunday expressed "mixed views" on the new law, said The Associated Press . 

What was the law before?

"Public perception and morality clauses in its penal code" mean that LGBTQ+ people have been "routinely targeted domestically and institutionally", said Pink News.

A 2022 report by Human Rights Watch said armed groups in Iraq were abducting, raping, torturing and killing lesbian, gay, bisexual and transgender people, and accused the Iraqi government of failing to hold perpetrators accountable.

The words "homosexual" and "gender" were banned in the media and on social media platforms in 2023. Officials claimed the move would safeguard societal values and maintain public order.

Over the past year, major Iraqi parties have "stepped up" criticism of LGBTQ+ rights, said Al Jazeera , "with rainbow flags frequently being burned in protests by both governing and opposition conservative Shia Muslim factions".

Renewed outbreaks of violence against Iraq's LGBTQ+ community have seen several people killed, including 28-year-old trans blogger Simsim, who was stabbed to death by unknown assailants in the city of Diwaniyah in February.

The new law "rubber-stamps" the country's "appalling record of rights violations", said Rasha Younes, deputy director of the LGBTQ+ rights programme at Human Rights Watch, marking "a serious blow to fundamental human rights".

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West Virginia’s and North Carolina’s transgender care coverage policies discriminate, judges rule

FILE - Connor Thonen-Fleck addresses reporters while his parents stand by his side, March 11, 2019, in Durham, N.C. West Virginia and North Carolina’s refusal to cover certain health care for transgender people with government-sponsored insurance is discriminatory, a federal appeals court ruled Monday, April 29, 2024 in a case likely headed to the U.S. Supreme Court. (AP Photo/ Jonathan Drew, FIle)

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CHARLESTON, W.Va. (AP) — West Virginia’s and North Carolina’s refusal to cover certain health care for transgender people with government-sponsored insurance is discriminatory, a federal appeals court ruled Monday in a case likely headed to the U.S. Supreme Court.

The Richmond-based 4th U.S. Circuit Court of Appeals ruled 8-6 in the case involving coverage of gender-affirming care by North Carolina’s state employee health plan and the coverage of gender-affirming surgery by West Virginia Medicaid.

Specifically, North Carolina’s policy bars treatment or studies “leading to or in connection with sex changes or modifications and related care,” while West Virginia’s bars coverage of “transsexual surgery.”

“The coverage exclusions facially discriminate on the basis of sex and gender identity, and are not substantially related to an important government interest,” Judge Roger Gregory, first appointed by former President Bill Clinton and re-appointed by former President George W. Bush, wrote in the majority opinion.

Similar cases are under consideration in courts across the country, but Monday’s is the first U.S. Court of Appeals decision to consider government-sponsored coverage exclusions of gender affirming medical care — and whether those exclusions are lawful.

The ruling follows a decision earlier this month by 4th Circuit judges that West Virginia’s transgender sports ban violates the rights of a teen athlete under Title IX, the federal civil rights law that prohibits sex-based discrimination in schools.

Like with the transgender sports law ruling, West Virginia Attorney General Patrick Morrisey said his office planned to appeal Monday’s health care case decision.

“Decisions like this one, from a court dominated by Obama- and Biden-appointees, cannot stand: we’ll take this up to the Supreme Court and win,” Morrisey said in a statement.

North Carolina State Treasurer Dale Folwell, whose department oversees the state’s health plan, said in a news release that Monday’s majority decision was in “direct conflict” with other decisions from federal appeals courts and hopefully will be corrected by the U.S. Supreme Court.

Folwell said the State Health Plan is threatened by financial challenges as the plan’s member grows older and their health declines.

“Accordingly, the Plan cannot be everything for everyone,” Folwell said. “Untethered to the reality of the Plan’s fiscal situation, the majority opinion opens the way for any dissatisfied individual to override the Plan’s reasoned and responsible decisions and drive the Plan towards collapse.”

In the majority opinion, judges said the cost of treatment is not a sufficient argument to support upholding a policy found to be discriminatory.

“Especially where government budgets are involved, there will frequently be a ‘rational’ basis for discrimination,” Judge Gregory wrote.

Both states appealed separate lower court rulings that found the denial of gender-affirming care to be discriminatory and unconstitutional. Two panels of three Fourth Circuit judges heard arguments in both cases last year before deciding to intertwine the two cases and see them presented before the full court.

In June 2022, a North Carolina trial court demanded the state plan pay for “medically necessary services,” including hormone therapy and some surgeries, for transgender employees and their children. The judge had ruled in favor of the employees and their dependents, who said in a 2019 lawsuit that they were denied coverage for gender-affirming care under the plan.

The North Carolina state insurance plan provides medical coverage for more than 750,000 teachers, state employees, retirees, lawmakers and their dependents.

In August 2022, a federal judge ruled West Virginia’s Medicaid program must provide coverage for gender-affirming care for transgender residents.

An original lawsuit filed in 2020 also named state employee health plans. A settlement with The Health Plan of West Virginia Inc. in 2022 led to the removal of the exclusion on gender-affirming care in that company’s Public Employees Insurance Agency plans.

The states’ lawyers argued that treatments for gender dysphoria — all treatments in North Carolina and surgical treatments in West Virginia — are excluded from coverage for everyone, regardless of their gender identity. They claimed only a subset of transgender people suffer from gender dysphoria, a diagnosis of distress over gender identity that does not match a person’s assigned sex.

Before offering pharmaceutical or surgical intervention, medical guidelines call for thorough psychological assessments to confirm gender dysphoria before starting any treatment.

In his opinion, Gregory said that in his view, gender dysphoria is “so intimately related to transgender status as to be virtually indistinguishable from it.”

“We hold that gender dysphoria, a diagnosis inextricable from transgender status, is a proxy for transgender identity,” the judge wrote. “And coverage exclusions that bar treatments for gender dysphoria bar treatments on the basis of transgender identity by proxy.”

Unlike North Carolina, West Virginia has covered hormone therapy and other pharmaceutical treatments for transgender people since 2017. Gregory noted that West Virginia’s program partially or fully covers surgeries to remove and reconstruct sexual organs for non-gender dysphoria-related diagnoses, such as cancer.

After the ruling, West Virginia plaintiff Shauntae Anderson, a Black transgender woman and West Virginia Medicaid participant, called her state’s refusal to cover her care “deeply dehumanizing.”

“I am so relieved that this court ruling puts us one step closer to the day when Medicaid can no longer deny transgender West Virginians access to the essential healthcare that our doctors say is necessary for us,” Anderson said in a statement.