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

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

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

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Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

• Breast augmentation incisions

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

• Placement of breast implants or tissue expanders

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

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

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

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

Genital surgery

• Anatomy before and after penile inversion

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

• Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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6. Silva RUM, Abreu FJS, Silva GMV, Santos JVQV, Batezini NSS, Silva Neto B, et al. Step by step male to female transsexual surgery. Int Braz J Urol. (2018) 44:407–8. doi: 10.1590/s1677-5538.ibju.2017.0044

7. Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. Transgender surgery in Denmark from 1994 to 2015: 20-year follow-up study. J Sex Med. (2016) 13:720–5. doi: 10.1016/j.jsxm.2016.01.012

8. Perovic SV, Stanojevic DS, Djordjevic MLJ. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. (2001) 86:843–50. doi: 10.1046/j.1464-410x.2000.00934.x

9. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. (2001) 88:396–402. doi: 10.1046/j.1464-410X.2001.02323.x

10. Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol International. (2010) 84:330–3. doi: 10.1159/000288238

11. Reed H. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin PlasticSurg. (2011) 25:163–74. doi: 10.1055/s-0031-1281486

12. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. (2015) 12:1837–45. doi: 10.1111/jsm.12936

13. Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open. (2015) 6:69–73. doi: 10.1016/j.jpra.2015.09.003

14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol. (2018) 199:760–5. doi: 10.1016/j.juro.2017.10.013

15. Dy GW, Sun J, Granieri MA, Zhao LC. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. (2018) 19:36. doi: 10.1007/s11934-018-0795-y

16. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. (2013) 64:141–9. doi: 10.1016/j.eururo.2012.12.030

17. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med . (2015) 12:1499–512. doi: 10.1111/jsm.12868

18. Hadj-Moussa M, Ohl DA, Kuzon WM. Feminizing genital gender-confirmation surgery. Sex Med Rev. (2018) 6:457–68.e2. doi: 10.1016/j.sxmr.2017.11.005

19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

20. Hess J, Rossi NR, Panic L, Rubben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DtschArztebl Int. (2014) 111:795–801. doi: 10.3238/arztebl.2014.0795

21. Silva DC, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals. J Sex Med. (2016) 13:988–93. doi: 10.1016/j.jsxm.2016.03.370

22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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Phalloplasty for Gender Affirmation

Featured Expert:

Fan Liang, M.D.

Phalloplasty is surgery for masculinizing gender affirmation. Phalloplasty is a multistaged process that may include a variety of procedures, including:

• Creating the penis
• Lengthening the urethra so you are able to stand to urinate
• Creating the tip (glans) of the penis
• Creating the scrotum
• Removing the vagina, uterus and ovaries
• Placing erectile and testicular implants
• Skin grafting from the donor tissue site 

Gender affirmation surgery is customized to each individual. Your surgical plan may include more or fewer of these steps and procedures. Fan Liang, M.D. , medical director of the Center for Transgender and Gender Expansive Health at Johns Hopkins, explains what you should know.

Are there different types of phalloplasty?

Phalloplasty involves using skin flaps, which are areas of skin moved from one area of the body to another. The skin flap is then reshaped, contoured and reattached to the groin to create the penis. There are three approaches the surgeon may use to construct the penis, using skin from the arm (radial forearm free flap), leg (anterolateral thigh flap) or side (latissimus dorsi flap). 

There are pros and cons to each approach. Factors for choosing skin flap locations include the patient’s health and fat distribution, nerve function, blood flow and desired surgical outcomes.

What is a radial forearm free flap?

A radial forearm free flap (RFFF) involves taking the skin, fat, nerves, arteries and veins from your wrist to about halfway up your forearm to create the penis. Typically, the surgeon will use your nondominant hand so it is easier for you to recover and return to your day-to-day activities.

During your surgical consultation, the doctor will check the blood flow to your arm and hand noninvasively. This involves temporarily putting pressure on arteries then releasing the pressure to test blood distribution in the arm and hand.

There are three stages to this procedure.

• Stage 1: The first stage of an RFFF approach is creating the penis using tissue from the forearm. The area where the forearm tissue is taken will require a skin graft. This may occur at the time of the initial phalloplasty surgery, or it may occur three to five weeks afterward. If it occurs later, patients will have a temporary skin covering over the forearm to help it heal.
• Stage 2: The second stage, scheduled about five to six months later, may include lengthening the urethra to allow for urination out of the tip of the penis, creating the scrotum and removing the vagina, and other procedures depending on the patient’s individualized plan.
• Stage 3: The third stage of surgery involves putting in place testicle implants and an erectile device to help the patient achieve an erection. The third stage typically takes place 12 months after the second.

Will I have a say in how the phalloplasty is staged and the surgical plan?

Your gender affirmation surgery is highly personalized. Depending on what is most important to you, your surgery team will work with you on a customized plan beforehand. You and your surgeon will discuss your priorities and decide which procedures are right for you. Each stage will be scheduled to ensure your health and safety and provide the best chance of good results.

How long will I be in the hospital?

After your stage 1 surgery, you will stay as an inpatient for four to five days. Your surgical team will frequently monitor the blood supply to the tissue that has been used to create your new penis and ensure you are able to use the bathroom and walk around after surgery. Procedures for stages 2 and 3 do not require a hospital stay.

Will I need a catheter?

During your inpatient stay for stage 1 surgery, you will have a suprapubic tube that goes directly into your bladder and another catheter in your native urethra for at least five days. It is typically removed in the hospital before you go home.

If you decide not to have urethral lengthening as part of stage 2, you will have a Foley catheter placed in the operating room and removed before you leave the hospital. If you decide to have urethral lengthening, you will go home with a Foley catheter in the new urethra and a suprapubic tube. A clamp ensures that the urethra does not leak urine.

What is a suprapubic tube?

A suprapubic tube (SPT) allows urine to drain from your bladder. It is placed in the lower part of your abdomen, below the belly button. The SPT stays in for four to five weeks, depending on your healing and recovery.

When will my SPT be removed?

Before the SPT is removed, around four weeks after surgery, a urologist will perform a retrograde urethrogram. This involves putting dye into the bladder through the new urethra. An X-ray tracks the dye to see if the new urethra is open and ready for urination. If so, the doctor will clamp the SPT and you will be allowed to urinate from your new urethra. If everything looks good after a few days, the SPT is removed.

Forearm Flap Phalloplasty

Stage 1: phallus creation. Enlarged image .

Stage 2: urethral lengthening and scrotoplasty. Enlarged image .

Stage 3: penile prosthesis. Enlarged image .

Other Skin Flaps Used in Phalloplasty

What is an anterolateral thigh flap.

An anterolateral thigh flap (ALT) uses skin, fat, nerves, arteries and veins from the leg to create a penis.  A special vascular CT scan can help the surgeon  examine the blood supply of each leg to determine which leg will be better for creating the skin flap.

The stage of the ALT phalloplasty are similar to the RFFF. The area where the thigh tissue is taken will also require a skin graft. The resulting scar on the thigh can be covered with shorts.

What is a musculocutaneous latissimus dorsi flap?

A musculocutaneous latissimus dorsi skin flap (MLD) involves the skin, fat, nerves, arteries and veins from the side of your back to create a penis. The surgeon may order a special CT scan to look at the blood flow throughout the donor site area.

The stages of the MLD phalloplasty are similar to the RFFF and ALT. However, the area from which the back tissue is taken usually does not require a skin graft and can be closed in a straight line. The scar can be covered with a shirt. Patients may experience some initial weakness raising their arm, but this improves with time.

How is penis size determined?

Penis size depends on patient preferences and the skin flap harvested from your body. Thinner patients with less fat on the skin flap will have a penis with less girth. Alternatively, patients with a greater amount of fat will have a thicker penis.

The length of the penis depends on the patient’s donor site, but typically it is about 5–6 inches. After the first stage, the penis may decrease in size as postoperative swelling decreases and the tissue settles into its new location.

What determines scrotum size?

Scrotum size is specific to the patient and depends on the amount of skin that is present in the genital area before phalloplasty. The more genital tissue there is, the larger the scrotum and the testicular implants can be.

There are different ways to create the scrotum, including a procedure called V-Y scrotoplasty, a technique that creates a pouch to hold testicular implants. AART silicone round carving blocks have been approved by the FDA to be used as implants.

Procedures to Discuss with Your Physician Before Phalloplasty

Each individual undergoing gender confirmation surgery is different. Your surgeon will work with you to discuss which procedures, and their timing, are best for you and your goals.

Should I have a hysterectomy before phalloplasty surgery?

For those interested in this procedure,  hysterectomies  are typically done before phalloplasty and do not require a vaginectomy.

Urethral Lengthening Before Phalloplasty

If you choose to have urethral lengthening, this procedure involves lengthening your existing urethra so that you are able to urinate out of the tip of the penis. It involves connecting your current urethra to the new urethra created in the shaft of the penis.

Not all patients choose to have urethral lengthening; however, this will be a necessary step if you want to stand when you urinate. It is also important to know that if you decide not to have urethral lengthening in stage 1 of your phalloplasty, it will not be possible to have the lengthening procedure later.

Complications of Urethral Lengthening

The most common complications for urethral lengthening include urethral strictures (narrowed areas of the urethra), fistula (creation of a passageway between the urethra and another location) and diverticula (formation of a pouch in the urethra). This may require an additional surgical procedure to fix.

What is a metoidioplasty?

A metoidioplasty is a surgical procedure to achieve masculine-appearing genitalia with fewer steps than a phalloplasty. The skin of the labia and around the clitoris is lengthened to achieve the appearance of a penis. Some people prefer to undergo a metoidioplasty if they do not want to use tissue from their arms or legs to create a penis or if they prefer a shorter, more straightforward surgery.

A metoidioplasty procedure has a quicker recovery and fewer complications. Surgeons can discuss metoidioplasty with patients and help them decide if this option is right for them.

Will I need to have hair removal?

Yes, before surgery, after you consult with the surgical team and choose a skin flap site, you will get a template for hair removal that you can give to your hair removal professional.

What if I have a tattoo on my preferred donor site?

As long as there is good blood flow and nerve function, donor sites — even those with a tattoo — can be used.

Penile Function and Sensation After Phalloplasty

What can i do with a reconstructed penis.

Penis function is determined by what you and your surgery team agree on for your surgical plan. If it is important for you to urinate out of the tip of your penis, then urethral lengthening may be a good choice for you. If sensation is most important, your team will focus on a donor site with good nerve innervation. If penetrative sex is most important, and you would like to maintain an erection, then implanting an erectile prosthetic can be part of your surgery plan.

Can I get an erection after phalloplasty?

In stage 3 phalloplasty, a urologist can place a prosthetic erectile device which will allow you to maintain an erection. As of September 2022, no implantable prosthetic devices have been FDA-approved for phalloplasty. Instead, the surgeon can use a device intended for patients with erectile dysfunction to allow transmasculine patients to achieve an erection. There is a risk of infection and implant rejection with an erectile implant . If this happens, it may take six months before another device can be placed into the penis.

What kind of sensation and feeling can I expect?

Sensation recovery varies by patient. Nerve regeneration can begin as early as three weeks after surgery, but it can take longer in some patients. Sometimes sensation can take up to a year or longer. Return of nerve sensation is not guaranteed. As nerves regenerate and strengthen connections, you might experience shooting pain, tingling or electrical sensations. As time goes on, the tingling feeling begins to subside.

What is nerve hookup during phalloplasty?

Nerve hookup involves taking existing nerves from the donor site, such as the arm, and connecting them to nerves located in the pelvis. This allows you to have sensation in the reconstructed penis.

What is clitoral burying during phalloplasty surgery?

Clitoral burying involves moving the clitoris into the base of the penis to increase sensation. This is typically done at stage 2.

Is orgasm possible after phalloplasty?

Orgasm is possible after phalloplasty, especially if your surgery plan emphasizes preserving sensation. It is important to note that your penis will not ejaculate with semen at the time of orgasm.

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Gender Confirmation Surgery

Gentle, safe, discreet care for postsurgery and beyond.

We don’t need to tell you that changing your physical sex as an adult by undergoing gender confirmation surgery (aka sex reassignment surgery or genital reassignment surgery) is a huge decision. It takes genuine inner strength to become who you are and we want to congratulate and celebrate you, wherever you are on your journey.

If you’re preparing to take the last step to transition from male to female (MtF) with gender confirmation surgery, The Pelvic Hub can help you take care for yourself after surgery, and help you maintain your neo vagina in the long term.

• Written by Emma McGeorge

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Want to learn more about related conditions? Follow the links below to gain a better understanding of the symptoms and treatments.

After Your SRS Surgery

Each person’s experience of MtF gender confirmation surgery— and the recovery that follows— is different. Everyone heals at a different pace. As with any surgery, it’s normal to have symptoms like swelling and soreness.

Vaginas are complex things, and generally higher maintenance than penises. Your neo vagina may be susceptible to yeast infections and urinary tract infections, just like a natal vagina is.

Dilation Therapy for Transgender Patients

After surgery, it’s normal for your body to register your neo vagina as a wound. And similar to with a new piercing, your body will try to heal. Because of this, your neo vagina may start to shrink or develop scar tissue called granulation.

Dilation therapy is an absolute must to keep your neo vagina functional, to minimize scars from forming in your vaginal lining, and to prevent you from losing vaginal depth and width. Usually, MtF transgender patients start using vaginal dilation a few days after surgery and continue to use vaginal dilators, to some degree, for the rest of their lives.

Your surgeon will let you know how to safely use a vaginal dilators, what size to use, and how often you need to employ post-operative vaginal dilation to maintain your neo vagina. If they don’t, you should definitely ask.

Recommended Products for Post-Op Care

We love that these products can help you take care of yourself discreetly from home. However,  we always recommend that you check with your surgeon or physician before using any products on your neo vagina or inside your vaginal opening.

Natural cooling relief

Reusable perineal cooling pads are perfect for cooling the most sensitive and delicate area of your body. Comfortable, cooling and discreet, they are perfect for reducing pain and swelling post-surgery. Also great if you’re prone to yeast infections or urinary tract infections.

Comfortable sitting

You may need a little help sitting without pain in the first few weeks after surgery. A foldable travel pelvic cushion or deluxe foldable travel pelvic cushion are uniquely designed to take the pressure off your neo vagina, helping you sit a little more comfortably.

Gentle, worry-free sex

Using an intimate wearable that allows you to control the depth of penetration into your neo vagina during sex can help you manage any pain you may experience during sexual intercourse. The Ohnut is designed to not just comfortably accommodate penetrative sex but also to feel just like skin. It’s so comfortable (like a gentle hug) you and your partner will barely notice it’s there. And because you no longer have to worry about whether penetration will hurt, this wearable allows both you and your partner to focus on what matters most, connection, enjoyment, and fun.

Are you looking for top-of-the-range, world-class transgender dilators?

Intimate Rose’s vaginal dilators were designed by a pelvic floor health physical therapist and are made from a smooth, body safe, medical grade silicone that's 100% BPA free and designed to glide into your neo vagina for more comfortable use during dilator therapy. They are designed to maintain your neo vagina’s integrity and vaginal depth and are recommended by pelvic floor specialists around the world. Not only are the Intimate Rose vaginal dilators more comfortable and easier to use, but they are also the only FDA registered vaginal silicone dilator and are used in the official Academy of Pelvic Health training courses.

They can also be chilled to help with post-surgical swelling, or used at room temperature. Always check with your surgeon or physician before using any dilator in your neo vagina to make sure you have the size, technique and frequency that is safe for your body, as dilation involves inserting into your neo vaginal canal for maintaining vaginal depth. Your doctor can recommend a dilation regimen that will provide you the most support during the healing process and beyond.

Invest in your health and yourself

Gender confirmation surgery is a big investment, and it doesn’t end when you leave the hospital. It’s  important to take gentle care of yourself after surgery and in the long term.

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BURIED/HIDDEN PENIS CORRECTIVE SURGERY – ADULT

Buried/hidden penis corrective surgery – child, penoscrotal webbing, scrotum reduction, male genital reconstruction, penis enlargement reconstruction, congenital penile curvature, gender confirmation procedures.

MALE TO FEMALE GENDER CONFIRMATION SURGERY

MALE-TO-FEMALE SEX REASSIGNMENT REVISIONS

Female-to-male chest contouring, female to male metaidoioplasty, gender confirmation breast augmentations, cosmetic procedures.

ABDOMINOPLASTY

Breast augmentation, breast reconstruction & breast reduction, liposuction, patient-first policy.

Dr. Alter and the entire team are dedicated to providing every patient with exceptional individualized care—from consultation to recovery. We take the time to learn about your concerns, goals, and desires, so we can build a plan that addresses your concerns and gets you the results you deserve.

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BEVERLY HILLS

NEW YORK CITY

Transgender Health Program

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Gender-Affirming Surgery

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

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

Our surgical services

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

Top surgery:

• Gender-affirming mastectomy
• Gender-affirming breast augmentation

Bottom surgery:

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

Hysterectomy

Nullification surgery, oophorectomy, orchiectomy.

Bottom surgery options also include:

• Scrotectomy
• Scrotoplasty
• Urethroplasty
• Vaginectomy

Additional gender-affirming options:

• Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

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

For patients

Request services.

Please fill out an online form:

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

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

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

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

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

Some patients choose hysterectomy to:

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

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

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

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

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

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

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

Nullification surgery may include:

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

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

Nullification surgery cannot be reversed. Risks can include:

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

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

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

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

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

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

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

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

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

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

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

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

Adam’s apple reduction (laryngochrondoplasty)

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

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

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

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

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

OHSU also offers Adams’ apple enhancement surgery.

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

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

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

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

Face options:

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

Body options:

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

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What to Know About Metoidioplasty (Bottom Surgery)

• Who Qualifies?
• Surgical Techniques
• Neophallus Function
• Surgery Follow-Up
• Where to Have Surgery

Metoidioplasty , or "bottom surgery," is a gender-affirming surgical procedure that involves creating a neophallus (new penis) from a hormonally enlarged clitoris . Transgender men and transmasculine people assigned female at birth (AFAB) may elect for a metoidioplasty if they want their genital appearance to align with their gender identity.

In contrast to the more complex  phalloplasty  that involves several surgeries, metoidioplasty offers a more straightforward phallic reconstruction in one procedure.

During a metoidioplasty, a surgeon cuts the ligaments that connect the clitoris to the pubic bone to release the clitoris and create a penis with erogenous (sexual) sensations. It may also include additional steps, such as urethral lengthening and scrotoplasty (forming a scrotum), to enhance the appearance and functionality of the neophallus. 

This article explores metoidioplasty surgical techniques, the recovery process, and what to expect post-surgery. 

CarlosDavid.org / Getty Images

Who Qualifies for Metoidioplasty Surgery?

Metoidioplasty is a gender-affirming (sex-reassignment) surgery for transgender men assigned female at birth. According to the 2015 U.S. Transgender Survey, about 4% of trans men have undergone the procedure, while another 53% expressed a desire to undergo metoidioplasty in the future.

The World Professional Association for Transgender Health (WPATH) developed the criteria for gender reaffirmation surgeries to ensure optimal physical and psychological outcomes for those pursuing bottom (genital) surgeries. The eligibility criteria for metoidioplasty include the following:

• Ongoing and well-documented gender dysphoria  
• The ability to make informed decisions and provide consent for treatment
• Being 18 years of age or older
• Medical or mental health concerns are well-managed (if applicable)
• At least 12 consecutive months of gender-affirming testosterone therapy 
• Living as a male or masculine-presenting person for at least one year in all settings (e.g., work, school, with family members and community)

Though it is not required, regular visits with a mental health or other medical professional are highly recommended before undergoing a metoidioplasty. 

Metoidioplasty Surgical Techniques

People can choose a few different metoidioplasty surgical techniques depending on their preferences. Other procedures can occur simultaneously (e.g., hysterectomy) if desired. 

Simple Release Metoidioplasty 

In the simple release procedure, ligaments attached to the pubic bone are cut and released, and the clitoris is separated from surrounding tissue to enhance the position and visibility of the clitoris. The labia minora are wrapped around the clitoris to create the glans (head) of the newly formed penis.

Ring Metoidioplasty 

Similar to the simple release, this technique involves releasing the clitoral ligaments to lengthen the clitoris. This procedure also involves lengthening the urethra using a flap of tissue from the vaginal wall and labia minora. This procedure gives trans men a micropenis with more girth and the ability to stand while urinating.

Belgrade (Full) Metoidioplasty 

The Belgrade technique, or full metoidioplasty, involves the removal of the vagina (vaginectomy) and releasing the clitoris to lengthen and straighten the clitoris. The urethra is lengthened using vaginal tissue and buccal mucosa (inner cheek) skin grafts. The penis is reconstructed with the remaining clitoral and labial skin to give it more girth.

Then, the labia minor flaps are joined to create a scrotum (scrotoplasty), and testicular implants may be inserted into the newly created scrotum. A penile pump or vacuum is recommended three weeks post-surgery to lengthen the neophallus and prevent retraction.

Simultaneous Procedures 

In addition to metoidioplasty, some trans men may opt for additional procedures performed at the same time to achieve their desired outcomes. These procedures may include:

• Hysterectomy : Removal of the uterus 
• Bilateral salpingo-oophorectomy : Removal of the ovaries and fallopian tubes
• Vaginectomy : Removal of the vagina and surrounding tissues
• Scrotoplasty :   Forms a new scrotum; testicular implants may be placed to give the appearance of natural testicles
• Erectile implant : A device is placed inside the neophallus to help achieve erections

Metoidioplasty vs. Phalloplasty

Metoidioplasty and phalloplasty are surgical options for transgender men seeking gender-affirming genital reconstruction. Metoidioplasty involves using existing genital tissue, such as the hormonally enlarged clitoris, to create a neophallus. It usually results in a smaller but functional neophallus.

Phalloplasty involves constructing a neophallus using various techniques, including grafting tissue from other body parts. This procedure can provide a larger and more visually realistic phallus but is more complex and may require multiple stages. The choice between metoidioplasty and phalloplasty depends on individual preferences, desired outcomes, and considerations such as surgical risk, recovery time, and aesthetic goals.

Risks to Understand Before Metoidioplasty 

While metoidioplasty is generally considered safe, like any surgical intervention, it carries certain risks. Before undergoing metoidioplasty, discuss the risks with a healthcare provider to gain a comprehensive understanding and make an informed decision. 

Potential risks include:

• Urethral stricture or stenosis : Narrowing of the urethral passage, leading to difficulty with urination and potential obstruction of urine flow. Sometimes, urine flow may be blocked entirely, requiring surgery to correct the problem.
• Urethral fistula : An abnormal connection or passageway between the urethra and the skin or surrounding tissues. This can result in urine leakage or an abnormal opening along the neophallus. 
• Sensation changes :   The newly formed penis may have decreased or loss of sensation or feel hypersensitive and tender. 

Function of Neophallus Post-Bottom Surgery

Trans men who have undergone metoidioplasty report high levels of satisfaction with the procedure's results, both in appearance and function.

While a neophallus created through metoidioplasty is usually considered a micropenis (1–4 inches), erections and orgasms are achieved by nearly all who have undergone the procedure. Penetrative sex may or may not be possible. Urinating while standing is possible for most men after metoidioplasty.

Metoidioplasty Recovery Period 

The recovery period following metoidioplasty depends on the specific surgical technique and can vary from person to person. Most people can expect one week of bed rest immediately following the procedure and gradually resume their activities within about six weeks. 

Initially, there will be discomfort, swelling, and bleeding in the genital region, which will gradually subside over time. You may also experience:

• Bruising in the genital area that spreads from the belly down to the legs 
• Itching and short, sharp, shooting sensations as the area heals 
• Numbness at or near the incision sites, which can persist for months 
• Scarring on the genitals that will first appear red or pink and fade over time 

Metoidioplasty Follow-Up (and Asking for Help)

You will need assistance and support during the follow-up period after metoidioplasty, as the recovery process can involve discomfort, limited mobility, and restricted activity. You will need a caretaker for at least a week or two after the procedure—someone who can help with daily tasks such as meal preparation, household chores, and running errands.

Your surgeon may restrict certain activities, such as driving, sex, and heavy lifting. You may need help with transportation to follow-up appointments for about six weeks. Most people can resume their normal activities within six weeks post-surgery. Still, getting the OK from a healthcare provider is important to ensure you are properly healed and to lower the risk of complications. 

Where to Have Metoidioplasty Surgery

Specialized surgeons with experience in transgender healthcare often perform metoidioplasty surgery. The procedure is usually carried out in a hospital or surgical center with the necessary tools and equipment for the surgery. It is essential to choose a reputable medical facility that is experienced in transgender surgeries and maintains a supportive and inclusive environment.

When considering where to have metoidioplasty surgery, start by asking a mental health professional or another healthcare provider for referrals and recommendations of surgeons who specialize in the procedure. They can provide information and guidance on the options available to you. 

Researching and gathering information about the surgeon's qualifications, experience, and success rates, as well as reading reviews or testimonials from other people who have undergone metoidioplasty at the facility, can also help you select the most suitable location for the surgery. Open communication with healthcare providers can ensure that all your questions and concerns are addressed before deciding where to have metoidioplasty surgery.

Metoidioplasty is a gender-affirming surgery for trans-male people assigned female at birth (AFAB). The procedure involves releasing the clitoral ligaments and utilizing the hormonally enlarged clitoris to create a neophallus (new penis).

There are a few different metoidioplasty techniques. Sometimes, people undergo simultaneous procedures, such as hysterectomy and vaginectomy. Metoidioplasty is considered a safe, effective procedure that results in a 1–4 inch functional penis that gives trans men the opportunity to align their physical characteristics with their gender identity. 

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: Techniques and outcomes . Transl Androl Urol . 2019;8(3):248-253. doi:10.21037/tau.2019.06.12

Kjölhede A, Cornelius F, Huss F, Kratz G. Metoidioplasty and groin flap phalloplasty as two surgical methods for the creation of a neophallus in female-to-male gender-confirming surgery: A retrospective study comprising 123 operated patients . JPRAS Open . 2019;22:1-8. doi:10.1016/j.jpra.2019.07.003

Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in gender affirmation: A review . Indian J Plast Surg . 2022;55(2):156-161. doi:10.1055/s-0041-1740081

National Center for Transgender Equality. Injustice at every turn: a report of the national transgender discrimination survey .

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

Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Phalloplasty: techniques and outcomes .  Transl Androl Urol . 2019;8(3):254-265. doi:10.21037/tau.2019.05.05

Alberta Medical Association. Metoidioplasty .

Bordas N, Stojanovic B, Bizic M, et al. Metoidioplasty: Surgical options and outcomes in 813 cases . Front Endocrinol (Lausanne) . 2021;12:760284. doi:10.3389/fendo.2021.760284

TransCare BC. Provincial Health Services Authority. Metoidioplasty .

Michigan Medicine: University of Michigan. What to expect: Metoidioplasty at Michigan Medicine .

TransHealthCare. Metoidioplasty - list of surgeons in the USA .

By Lindsay Curtis Curtis is a writer with over 20 years of experience focused on mental health, sexual health, cancer care, and spinal health.

I Had Gender Confirmation Surgery. Here's What Happened Before, During And After.

Guest Writer

The day after I turned 19, I underwent gender confirmation surgery, or GCS, in Bangkok. An announcement like this is usually followed by a slew of questions, often from total strangers, including, “Do you have a vagina now? If so, does it ... you know ... work? Did it hurt?” and many others.

Actually, when people find out you’re transgender ― whether you’ve surgically transitioned or not ― the questions start almost immediately and they pretty much never stop. They’re often deeply personal questions ― ones you would never dream of asking a cisgender (non-trans) person, but because society typically treats trans bodies as public property, we don’t receive the privacy or dignity that everyone else receives.

Even if these inquiries come from a place of genuine compassion or curiosity, being trans can be an incredibly painful and traumatic experience, and when trans people are asked invasive, often quite rude questions by people who have no right to the answers, it only exacerbates that pain and trauma.

That said, I understand the curiosity that drives these questions. I really do. I understand why it can all seem a bit confusing at first. And because I believe that if there’s a silver bullet for prejudice, ignorance and hate, it’s education, I’ve decided to set the record straight, once and for all, from start to finish. No holds barred. No punches pulled. I will be completely honest about what I went through and how things changed when I came out the other side.

I’m going to do my best to answer these questions so that maybe people will stop asking them. Of course, everyone’s transition is different, and every experience of GCS is unique. Everyone has their own story. This is mine.

“If you’ve ever been through puberty or menopause, you know how awful sudden hormonal shifts can be. By the end of it all, I was physically and emotionally exhausted, and the hardest part hadn’t even begun yet.”

GCS is not something you do on a whim. In Australia, where I live, I needed to have lived full-time as my true gender and be on hormone replacement therapy or HRT, for one full year before I was even allowed to apply for surgery, and it is never legally performed on minors. After that, both a psychologist and a psychiatrist had to sign documents certifying that this procedure was not only very much desired but medically necessary for me.

I also had to choose a surgeon. After an exhaustive search, I chose Dr. Chettawut Tulayaphanich, who specializes in treating gender dysphoric patients and who came highly recommended by my endocrinologist. While there are surgeons in Australia who offer GCS, surgeons overseas, particularly in Thailand, tend to be more affordable and have more experience with the procedure.

After that, all my travel documents had to be lined up — no mean feat when you’re halfway through legally changing your name. I had to undergo a battery of physical, blood and STD tests. My results were then emailed to the clinic overseas. Around this time, I also had to stop taking my HRT until after the surgery. If you’ve ever been through puberty or menopause, you know how awful sudden hormonal shifts can be. By the end of it all, I was physically and emotionally exhausted, and the hardest part hadn’t even begun yet.

My surgery was scheduled for Friday, May 25, 2018. Between the flights, the hotel and the surgery itself, the bill came to about $20,000 AUD. I landed in Bangkok at 2:00 a.m. on the Sunday before my surgery. The following week was a barrage of more tests, consultations and preparation for what was to come. On Tuesday, I was ordered to fast until Friday.

On Wednesday, I had my big consultation with the surgeon himself. I had to take off my clothes in front of a room full of strangers (and my mother) and have the most intimate parts of my body examined, probed and photographed. Dr. Chettawut explained to me the exact process of the operation using multiple, very detailed, very realistic diagrams. You can read more about this process and see one of those diagrams here .

The most common method for creating a neo-vagina is a “penile inversion” technique where the genitals are, just as the name implies, inverted. In my case, the procedure was a little more complicated. Rather than being inverted outright, the genitals are removed and then reutilized to create different parts of the neo-vagina. The vaginal lining is made up of scrotal tissue and groin skin grafts. Because of this, unlike many other post-op trans women, my vagina can self-lubricate thanks to the preservation of certain secretory glands around the urethral and vaginal opening. Penile and prepuce skin was used to construct an anatomically accurate labia minora. The result is a vagina that looks and functions, sans periods and childbirth, more or less identically to that of a cis woman.

On the day of the operation, a car picked me up from my hotel and took me to the clinic. I surrendered my clothes and my phone and lay down on a gurney and waited to be wheeled into the operating theater. You may not believe me, but at that moment, I wasn’t scared ― not even a little bit. Maybe I was too exhausted to be afraid. Or maybe it was because I would rather have died on that operating table than go on living in the body into which I’d been born.

At 2:58 p.m., the nurses wheeled me into the operating theater, and the anesthesiologist placed a breathing mask on my face. I remember making a bad joke about the taste of the gas in my mouth as the lights went dim and I drifted into unconsciousness.

When I woke up, everything was a blur. The voices I heard sounded like they were far away, and I could feel the hands of the nurses on my body as they moved me from the operating table to a gurney. I felt absolutely nothing between my legs. I couldn’t move or speak.

They wheeled me to a small room outside the operating theater, and someone said something about checking on me later. Then I was left alone in the dark. I remember feeling thirsty, and I found myself struggling to breathe. Every breath felt too shallow, like I couldn’t get enough air into my lungs. I drifted in and out of sleep, content to simply lie still in the dark. At that point, there was no pain ― that came later.

The next day, I was moved to my own room and finally given water to drink. After that, I was gradually allowed to start eating again. Soon, the pain started. At first, it was a dull ache, but within 24 hours, it had become an unbearable agony that radiated out from the surgery site up through my entire abdomen.

I spent three or four days at the clinic before being moved back to my hotel. My daily routine consisted of taking several different kinds of painkillers and antibiotics at breakfast, lunch, dinner and bedtime, and watching a lot of Netflix to ease the boredom in between my doses. The idea was to medicate me enough so that I would be comfortable during the day and sleep through the night, but the painkillers always wore off too quickly. Each night became a grueling marathon of agony, and I would wait, desperate for the morning ― and my next set of pills ― to arrive.

I slept in stops and starts during the day, when the pills softened my excruciating pain into a strong but bearable ache. I cried at least once a day when I was alone, sometimes from the pain, sometimes from missing my partner, who was waiting for me back home in Sydney. Often, I found myself crying for no reason at all.

Each day, I was visited by nurses from the clinic. After about a week, I was told it was time for me to start dilation. For the uninitiated, when a seven-inch hole is created in your body, your body treats it like a wound and tries to close it up. Obviously, that would defeat the purpose of GCS, so the vagina is kept open using glass cylinders called dilators. I was given five of them, numbered zero to four, all about eight inches long, ranging from one and a half centimeters to about one and a half inches in width. Thanks to the technique my surgeon used, my vagina was able to accommodate a little more than seven inches in depth. Many trans women get five inches, sometimes even less. It all comes down to the skill of the surgeon, how diligent you are about sticking to your dilation schedule, and luck.

“After about a week, I was told it was time for me to start dilation. For the uninitiated, when a seven-inch hole is created in your body, your body treats it like a wound and tries to close it up.”

The process began with the nurses performing the dilation, and after that, it would be up to me. That first time, when the gauze packing was taken out of my vagina and that first, narrow glass rod (about the width of a large pen) was placed inside me, I lay back on the bed and caught my breath as I stared at the ceiling. It hurt a little, but not as much as I’d expected.

The sensation of something being inside my new vagina was beyond description. The novelty, the strangeness of it, the sudden sense of my mind and body being in harmony with one another after so many years of dissonance ... I can only imagine it might compare to how Dorothy felt stepping into Oz and seeing her sepia world turn to color. For the first time, I felt the reality of my new body set in, and despite everything, at that moment, I felt utterly breathless with joy.

One thing I expected after the surgery, but which nothing could have prepared me for, was the bleeding that I experienced after the gauze was removed. The amount of blood I lost over the next several months was almost unimaginable. When someone tells me I’ve never had a period and therefore I can’t possibly imagine what it must be like to be a “real” woman, I like to joke that I did have periods, I just got all of them at once. Every time I limped to the bathroom, a trail of blood followed me there and back. I changed my pads twice a day for a month, and every morning, the hotel staff would come and change my sheets which, despite the extra-absorptive pads I wore overnight, were soaked through with a massive pool of blood.

Two weeks later, a week before I was set to return home to Australia, the nurses noticed something off about how I was healing and I had to go back under the knife.

The first time I was operated on, I received general anesthesia. This time, I was awake and the anesthesia was local. It took three separate needles in my new vagina to administer the numbing agent, and even with it, over the next hour and a half, I felt everything, and I mean everything , as my new vagina was cut apart, rearranged and stitched back together. It was and remains the single most painful experience of my life.

By some miracle, I was still able to go home the following week. The second surgery had gone well, and I was starting to heal properly. I could now walk short distances with the aid of a walking stick but I still needed a wheelchair at the airport to make it to the plane. It took another two months before I was even close to being fully healed.

I’ve since read many accounts by other trans women about what dilation was like for them. Some of them almost never have to dilate after seven or eight months. A lot of them say the pain was negligible as they continued to dilate to keep their vagina open. I wasn’t so lucky. The best way I can describe dilating after I left Thailand is to liken it to inserting a serrated knife seven inches deep into an open wound and then holding it there for two and a half hours. Even now, four years later, I still need to dilate for one hour a day to maintain my depth and elasticity. The pain started to taper off after about three months, and I barely think about it now. It’s as much a part of my day as brushing my teeth and taking a shower. It seems strange now to think that this isn’t the body I was born into.

A lot of people have made headlines ― not just recently, but for years now ― talking about GCS and transgender people more broadly. Almost all of them have one thing in common: They’ve never actually been through it. I’d be willing to bet they’ve never even spoken to someone who has. I have been through it ― and it was harder than words could ever describe. It was terrifying. It was expensive. And it was the best thing I have ever done for myself.

I say this to all readers, but especially to any who might be thinking about undergoing GCS themselves: It doesn’t fix everything. When you’re finally healed and you go back to your day-to-day life, you’re still, at your core, the same person you were before GCS. You don’t live the rest of your life in a state of perpetual bliss. But what did change for me is that now, when I look in the mirror or when I look down at my body, I see my body, not someone else’s. When someone touches me, I don’t flinch or feel ashamed and disgusted. When I feel the right parts between my legs, most of the time I don’t feel euphoric, but I feel OK, and after a lifetime of agonizing incongruity between my body and brain, just feeling OK is absolutely priceless.

So there you have it. Now, let’s quickly get a few of the other more common questions out of the way: Yes, it looks like a vagina; yes, I can have vaginal sex and orgasm; no, I can’t give birth; yes, it was absolutely, beyond a shadow of a doubt worth it.

Lastly, it’s important to note that not every trans person wants or needs to undergo GCS. Some trans people only go on HRT, and some only transition socially. Gender originates not in the body but in the brain. Studies have shown that the brains of trans people are structurally closer to those of the gender they identify with than that of the gender they were presumed to have at birth .

To say I was born with a female brain in a male body is not just an expression, it’s a material and scientific fact. Wanting to express yourself and live as your true gender is not, as Bill Maher so crassly put it , analogous to wanting to be a “pirate.”

There is no one right way to be trans, any more than there is one right way to be a cis man or woman. I needed GCS just to feel comfortable in my own body, but not everyone feels that way, and many people that do need it can’t access it.

It can cost $50,000 or more to undergo GCS in Australia, and for plenty of trans people — for whom rates of poverty and unemployment are significantly higher than the national average — even the $20,000 I paid (half of which my parents covered) is out of reach. It doesn’t mean their gender is any less valid or that they should be treated any differently.

“There is no one right way to be trans, any more than there is one right way to be a cis man or woman. I needed GCS just to feel comfortable in my own body, but not everyone feels that way, and many people that do need it can’t access it.”

I’m incredibly grateful to have been able to undergo GCS. It’s no exaggeration to say it saved my life, and the fact that it remains inaccessible to so many people who need it is heartbreaking.

Gender dysphoria can be painful, and for some of us, myself included, it’s unbearable without medical intervention. I’m also grateful to have a family that supported me both during and after the procedure. Too many trans people (some of whom I know personally) have been either shunned or abandoned outright by unsupportive families after coming out.

Everyone’s experience is different, but for me and many other people, being trans is hard, even without factoring in the stigma and hate that is still so rampant in our society. But that does not mean that trans people are broken. It doesn’t mean they’re oddities or freaks. We’re different, and different can be confusing. Different can be scary. It seems written into our DNA to be scared of what we don’t understand. But the more we know, the less confusing and scary these identities and experiences become. That’s why I wrote this. And there are resources available online, at your local bookstore and at LGBT community centers.

Ignorance isn’t a virtue. If you don’t understand something, educate yourself. Research, read, and if you know a trans person and if they’re comfortable with talking about their life, ask (politely). But be OK if they don’t want to answer your questions. Many trans people don’t, and the obligation shouldn’t be on us. We’re human beings and deserve to be treated as such. We deserve to be treated with respect and dignity, just like you.

Elizabeth Walker is a 23-year-old trans woman living in Sydney. She studies animation and works part-time as a freelance writer. She started transitioning at the age of 15 and hasn’t looked back. Her hobbies include photography, ice skating and trail hiking. She has a loving partner of four years and two fur babies that she loves with all her heart.

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Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

Affiliations.

• 1 From the Department of Plastic and Reconstructive Surgery.
• 2 School of Medicine.
• 3 Department of Obstetrics and Gynecology.
• 4 Department of Urology.
• 5 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA.
• PMID: 36149983
• DOI: 10.1097/SAP.0000000000003233

Background: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

Methods: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

Results: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

Conclusion: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

• Follow-Up Studies
• Gender Dysphoria* / surgery
• Sex Reassignment Surgery*
• Transgender Persons* / psychology
• Transsexualism* / psychology

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Post-Op; life after Reassignment or Orchiectomy

Not all transgender patients undergo gender reassignment surgery (GRS) but for those who do so there are many challenges facing them.  GRS is a major crossroads in the trans journey involving two abrupt alterations, one structural, the other both structural & functional.

Life after surgery

The first change involves the external genitalia, shifting from penis to vagina which people focus upon almost exclusively, while ignoring the deeper changes.  This procedure doesn’t influence the rest of the body in terms of its functions, its state of general health or its metabolism.  It is purely local & structural.  In contrast the second procedure involves removal of the primary sex organs or gonads; a process which people frequently forget or choose to ignore, despite its life-changing influences.   The gonads are the sources of our sexual hormones and include the ovaries in women & the testes in men.  The sexual hormones they elaborate in turn influence the fetal development, before we are even born, of our sexual characteristics, including either the penis or the vagina, thus determining what shows up at birth.  Now when it comes to the consequences of GRS the focus is far too often placed on these external genitalia because they are the outward, visible declarations of our sexuality and sexual identities, but removal of the gonads is far more important, being as it is both irreversible & potentially cataclysmic in terms of our physical & mental health.

What exactly is being lost here, functionally? 

In the male to female transsexual, removal of the testes translates hormonally into the loss of adult male levels of testosterone.  Male levels of testosterone are both defeminizing and masculinizing, keeping in mind that defeminization and masculinization are two separate issues even though they may operate synergistically, like the two engines of a twin-engine airoplane. Slow down one engine and/or speed up the other & the plane will turn in a certain direction.   To clarify, let’s look at this scenario in terms of the breast, an obvious, sexually-defining hormonal target.  Because well-developed breasts are a hallmark characteristic of the female condition, people tend to think of them as targets solely for the feminizing hormones, in other words for estradiol and progesterone, but the fact is that androgens such as testosterone also have a significant impact on the breast, although in a defeminizing way that opposes the feminizing influences of estrogen and progesterone. Breast size and development depend on the net balance between feminizing & androgenizing hormones, the hormonal balance-sheet.  Why does this matter?   Consider the case of a 40-year-old woman who has had both of her ovaries surgically removed for valid health reasons. Does this surgery cause her to become dramatically masculine, overnight?  The answer is that despite a dramatic loss of feminizing hormonal influences, there is no reason for her breasts to become masculinized, because she simply does not possess a male-typic level of testosterone capable of masculinizing her. Now in contrast consider a trans-woman who’s been taking effective doses of feminizing hormones for three full years, at a dosage sufficient enough to chemically castrate her. What will happen when she suddenly discontinues feminizing hormone therapy? The answer is that while it may take some months, depending on her dose of feminizing hormones and how long-acting they happen to be, sooner or later her testes will come back online. Sometime after that her breasts will begin to shrink back in the male direction, as a result of the masculinizing effects of her reemerging androgens, in contrast to the genetic female where there isn’t sufficient androgen present to effectively masculinize her.

Orchiectomy

So orchiectomy, the process of having one’s testicles removed surgically, is the most important of the processes involved with GRS as well as being permanant.  Some patients however will have an orchiectomy without GRS, in an effort to accelerate feminization while reducing the need for higher hormonal doses.  Either way, the patient in question is being castrated.  The hormonal consequences will be just the same, involving severe, abrupt deprivation from testosterone. 

Removal of the testes in the genetic male and of the ovaries in the genetic female leads to a sudden, severe hormonal drop off with testosterone depletion in both cases. Testosterone levels nosedive down to levels below those even characteristic of the genetic female norm.  Female castration occurs following an operation known as a TAH-BSO, which is applied in young women for a variety of health reasons including endometriosis and cancer. The bodies of these young women have been accustomed, up until the moment when their ovaries were removed, to the presence of generous levels of the sexual hormones even including testosterone, lying within the normal female range.  Hormonal withdrawal in these women, not only from estradiol & progesterone but also from testosterone is abrupt & drastic & the consequences can be seismic, both physically & mentally.  And the same set of problems that genetic women experience when surgically castrated tend also to crop up in trans-women following orchiectomy, unless some form of adequate hormone therapy is maintained so as to prevent hormonal deprivation.  Unfortunately, replacement hormone therapy is rarely either administered or sought after in the post-operative trans-woman. 

Hormone deprivation

The two kinds of patients for whom precision hormone therapy is most critically needed include the genetic woman who has undergone a premature menopause consequent to surgical removal of the ovaries and the post-operative trans-woman.  Their problems are just about identical as are their symptoms & the forces that drive them.  Treatment in both groups requires considerable professional expertise as well as an awareness on the part of both types of patient that even when hot flashes fade away, the body still suffers from the consequences of hormonal depletion.  So the optimal post-surgical life for both the trans-woman & the young genetic woman who has lost her ovaries, mentally, emotionally, intellectually, sexually & in a broadly physical sense involves optimal, expertly administered precision HRT. 

Lack of HRT

For many but not all trans-women, gender reassignment is the ultimate goal, the moment when one crosses the gender river.  But this moment, far from being an end, a culmination, is actually only the beginning.  Once the testes have been removed, the only significant source of sex hormones is hormonal therapy arriving from the outside.  Despite this, many if not most post-operative trans-women, believing they have now reached their ultimate feminine goal, back off from receiving feminizing hormone therapy or quit it completely, believing as they do that having a vagina is all they need.  This is a terrible mistake. 

Problems assailing the post-op trans-woman

Far too many post-operative trans-women receive little or no ongoing hormone therapy, focused medical follow-up or problem-oriented health monitoring.  This might have been a vaguely acceptable approach in the past, when we believed that sex hormones were only sexual in their influences, but now we know better.  Now finally appreciating the true scope of sex hormone influence, not only slow but rapid & not only sexual but broadly physical & critically mental, it behooves us to show more insight & more medical responsibility.  We need to become more aware of the importance of the body’s hormonal milieu. 

The symptoms

It shouldn’t be so surprising therefore to discover that many post-operative trans-women, having achieved their life’s desire, are surprisingly tired, haggard & disappointed, lacking physical energy & assailed by frequent episodes of anxiety, panic attacks, mood swings, depression & even suicidal urgings, not because of who they are as many judgmentally assume, looking with jaundiced eye at the trans-woman & her life choices, but because of hormonal deficiency & lack of adequate, precisely metered hormonal care.  And they lack both sexual interest & orgasmic function as well.    Other more easily overlooked problems include changes in personality, either overt or subtle, cognitive dysfunction including glitches in memory & concentration, generalized aches & pains resembling so called fibromyalgia, frequent headaches, insomnia & irritable bowel symptoms.  And these are just the obvious, overt problems.  At the same time, unbeknownst to the patient, sex hormone depletion is inexorably fueling the silent development of early heart disease, osteoporosis, dementia, insulin resistance & weight gain, cholesterol problems & accelerated cosmetic aging. 

How can we be so negligent?

Considering these dire consequences of chronic hormone depletion, how can this standard of care, this deplorable deficiency continue?  Because modern medicine is still far too symptoms-oriented in its approach, depending on the use of addictive sedatives and analgesics such as opiates, as well as mind-numbing, sex-destroying anti-depressants & marijuana, drugs that, despite frequently being ineffective, may be not only dangerous but riddled with side-effects that further compound the complications of castration, such as brain-fog, worsening sexual dysfunction, weight gain, even diabetes.  Better treatments are available that happen to be user-friendly, even sex-friendly, methods that actually work based on a precision form of hormone therapy.  These methods won’t be found in rigid protocols, medical cookbooks, so called standards of care or the frozen bibles of managed care. 

Perhaps people don’t care what happens to a group of people whom they sometimes find embarrassing or discomforting such as the transgendered.  Whatever the reason, it is urgently needed that we change the current approach, not only for trans-women but for those genetic women who are crossing the threshold of menopause as well.  Ultimately only the trans-woman herself can force the issue of improved post-operative health care, & that is why we at O’Dea Medical have placed a particular emphasis on post-operative trans-care, not only vaginal care but care for the brain, the mind, the bones, the heart, the metabolism, the life!   Crossing the gender river & achieving ones goal should make the trans-woman feel her verybest ever.  Unfortunately the lack of ambient feminizing hormones even in the absence of testicles or of male levels of testosterone may cause the gender dysphoria that for so long has bothered the trans-woman emotionally to continue unabated.  More than ever before trans-hormone therapy needs to be precise & accurate after GRS since it has now become the only significant source of sexual hormones in her body.  Dips & depletions in the presence of hormones at this point have a far greater negative impact than in the pre-operative transsexual, who may dislike her continued production of male hormones but who at least isn’t hormonally running on empty. 

What about oral hormone therapy in the post GRS trans-woman?

Of those few women who do continue on hormone therapy after GRS, the majority are taking oral estrogen from their family doctors, without accompanying progesterone or testosterone treatment.  This can be a problem.  First of all many trans-women at the time of gender reassignment simply haven’t received adequate feminizing therapy so far, and although they are now demasculinized, they have still been far from adequately feminized.  Some of these women, when now introduced to truly effective forms of feminizing HRT for the very first time, will continue to progressively feminize for another 5 or so more years as they play catch up.   Oral hormone therapy is thoroughly inadequate for these women since oral estradiol is mainly converted into estrone and is very short acting, leaving the body totally depleted for more than half the day.  And finally testosterone therapy in very subtle dosages may also be necessary. 

The bottom line

To sum up, many post-GRS or post-orchiectomy women feel that with their testes removed & a functional vagina surgically created, they are now fully transitioned & have all the femininity they will ever need, particularly if they have already obtained breast implants, silicone injections & other measures of faux femininity.  The problem with this kind of thinking is that while surgery may have removed their source of masculinizing hormones, it does nothing to create a source of feminizing hormones.   This is a dangerous road to travel since it carries with it a host of physical & mental problems, problems too easily blamed on the marginalized trans-woman herself instead of her lack of hormones.  The hard fact is that once the trans-woman recovers from surgery, she is on her own, often medically abandoned, isolated & thoroughly undertreated.      The good news is that precision hormone therapy can restore this woman, emotionally, intellectually, sexually and physically to a state of good health while often dispensing with the need for symptomatic care, but that requires good judgment & hormonal expertise.

• Reconstructive Procedures

Gender Confirmation Surgeries Transgender-Specific Facial, Top and Bottom Procedures

What surgical options are available to transgender and gender non-conforming patients? Gender confirmation surgeries, also known as gender affirmation surgeries, are performed by a multispecialty team that typically includes board-certified plastic surgeons. The goal is to give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be. Listed below are many of the available procedures for transwomen (MTF) and transmen (FTM) to aid in their journey.

Facial Feminization Surgery

Transfeminine top surgery, transfeminine bottom surgery, facial masculinization surgery, transmasculine top surgery, transmasculine bottom surgery, on the blog.

Facial feminization surgery is a combination of procedures designed to soften the facial features and feminize the face. There are many procedures that are available to feminize the face.

• Facial feminization surgery improves gender dysphoria in trans women Josef Hadeed, MD, FACS
• The impact of COVID-19 on gender dysphoria patients Cristiane Ueno, MD

On The Vlog

Facial feminization surgery is always tailored to the individual, but as ASPS member Justine Lee, MD, PhD, explains there are general characteristics such as hairline, brow bones, cheeks and jawline that many patients note and plastic surgeons plan for.

• Gender Affirmation Top Surgery with Dr. Julie Hansen

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Medindia » Articles » Procedure » Gender-Reassignment Surgery: Everything You Need to Know

Gender-Reassignment Surgery: Everything You Need to Know

• Indications

Non-Surgical Procedures

• Surgical Procedures

Risks in Non-Surgical and Surgical Procedures

• Whom to consult?
• Pre-Op Considerations
• Post-Op Considerations

Impact on Mental Health

• Cost of the Surgery

Gender reassignment surgery, also known as gender-affirming surgery, is a medical procedure or series of procedures aimed at altering an individual's physical appearance and sexual characteristics to align with their gender identity.

In Simple words, it can be defined as the alteration of a person's physical sex characteristics by surgery in order to match the person’s gender identity

This transformative process is often pursued by transgender individuals, as well as some cisgender and non-binary individuals. It involves various surgical interventions to modify primary and secondary sexual characteristics, thereby affirming an individual's gender identity( 1 ✔ ✔ Trusted Source Sex Reassignment Surgery in the Female-to-Male Transsexual Go to source ).

Alternative Names for Gender-Affirming Surgery

• Gender reassignment surgery (GRS)
• Gender-affirmation surgery
• Gender confirmation surgery
• Sex reassignment surgery

Who Can Get Gender Reassignment Surgery?

Transgender individuals.

Transgender individuals are those whose gender identity differs from the sex they were assigned at birth. Many transgender individuals experience gender dysphoria, a condition characterized by distress or discomfort caused by a misalignment between their gender identity and physical body. Gender reassignment surgery is often sought by transgender individuals as part of their transition journey to alleviate gender dysphoria and align their physical appearance with their gender identity.

Trans Women: Assigned male at birth but identify and live as women. Trans women may pursue feminizing surgeries such as vaginoplasty (creation of a vagina), breast augmentation, facial feminization surgery, and voice feminization surgery to affirm their gender identity.

Trans Men: Assigned female at birth but identify and live as men. Trans men may undergo masculinizing surgeries such as chest reconstruction (removal of breast tissue), hysterectomy (removal of the uterus), and phalloplasty or metoidioplasty (creation of a penis) to align their bodies with their gender identity.

Intersex Individuals

Intersex is a term used to describe individuals who are born with variations in their biological sex characteristics (chromosomes, gonads (testes/ovaries), reproductive organs (prostate/uterus) or external genitalia (penis/clitoris)) that do not fit typical definitions of male or female..

Intersex Individuals with Gender Dysphoria: While intersex individuals can be transgender if their gender identity does not match the sex they were raised or assigned as, some intersex individuals may experience distress or discomfort, known as gender dysphoria , due to a misalignment between their gender identity and assigned sex characteristics, and seek gender-affirming surgery to align their physical appearance with their gender identity( 2 ✔ ✔ Trusted Source Gender Affirmation Surgeries Go to source ).

Drag Performers

Drag performers are individuals who utilize clothing, makeup, and performance art to explore and celebrate gender expression. They are typically associated with a gender different from their own. These performers engage in drag for various reasons, including self-expression, artistic exploration, and entertainment purposes.

While some drag performers may identify as transgender or non-binary and use drag as a form of self-expression or exploration of their gender identity, others may identify as cisgender and engage in drag purely for entertainment or artistic expression.

Drag Queens and Drag Kings : Drag queens are typically male individuals who dress in feminine attire and adopt exaggerated female personas for performance. Drag kings, on the other hand, present as male or masculine while performing. While some drag performers may identify as transgender and may ultimately pursue gender-affirming surgeries, the act of performing drag does not inherently imply a desire for surgical intervention.

Individuals with Klinefelter Syndrome

Klinefelter syndrome is a chromosomal condition in which individuals are born with an extra X chromosome (XXY), resulting in differences in sexual development and often leading to infertility and other physical characteristics such as tall stature, reduced muscle mass, and gynecomastia (enlarged breast tissue in males)( 4 ✔ ✔ Trusted Source Klinefelter syndrome Go to source ).

While not directly related to transgender identity, some individuals with Klinefelter syndrome may experience gender dysphoria and seek gender-affirming treatments, including surgery. These individuals may undergo procedures to modify their physical characteristics to better align with their gender identity and alleviate distress associated with gender dysphoria.

Non-Binary Individuals

"Non-binary" is a term used to describe individuals whose gender identity does not exclusively align with the categories of male or female. This is a deeply personal and internal sense of one's own gender. Non-binary individuals may identify as both, neither, a combination of both, or as a gender entirely different from male or female.

Bigenital Operation: Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Some non-binary individuals may opt for these surgeries to achieve a physical presentation that aligns with their gender identity while maintaining aspects of their original anatomy. These surgeries cater to the diverse spectrum of gender identities and expressions and provide options for individuals who do not fit within the traditional binary understanding of gender.

"Cisgender" is a term used to describe individuals whose gender identity aligns with the sex they were assigned at birth. In other words, someone who is cisgender identifies as the gender typically associated with the biological sex they were born with. For example, a person who was assigned female at birth and identifies as a woman is considered cisgender. The term "cisgender" is often used in contrast to "transgender," which describes individuals whose gender identity differs from the sex they were assigned at birth

While gender dysphoria is often associated with transgender individuals, cisgender people can also experience it. In some cases, cisgender individuals with severe gender dysphoria may seek gender-affirming surgeries to alleviate their distress and bring their physical appearance into alignment with their gender identity. These surgeries are typically pursued after extensive evaluation and therapy, and they can significantly improve the mental health and well-being of individuals experiencing gender dysphoria.

Is Gender Dysphoria the only Reason for Gender Reassignment Surgery?

No, not only gender dysphoric individuals seek gender reassignment surgery. While gender dysphoria is a common reason why individuals pursue gender-affirming surgeries, it's not the only factor. Some people may choose to undergo these surgeries for reasons beyond alleviating distress associated with gender dysphoria.

For example, individuals with intersex variations may seek gender-affirming surgeries to align their physical appearance with their gender identity, even if they do not experience gender dysphoria. Similarly, some non-binary individuals may opt for surgeries to achieve a physical presentation that better aligns with their gender identity, regardless of whether they experience gender dysphoria.

Furthermore, some cisgender individuals may also undergo gender-affirming surgeries for reasons related to body dysmorphia or dissatisfaction with their physical appearance, rather than gender dysphoria.

Ultimately, the decision to pursue gender reassignment surgery is deeply personal and can be influenced by a variety of factors beyond gender dysphoria alone.

Hormonal injections is the only available non-surgical procedure.It isa form of hormone replacement therapy (HRT) commonly used in transgender healthcare to induce and maintain desired physical changes consistent with an individual's gender identity.

These injections typically involve the administration of testosterone for transmasculine individuals (female-to-male, or FtM) and estrogen for transfeminine individuals (male-to-female, or MtF).

Testosterone Injections (for Transmasculine Individuals)

Purpose : Testosterone injections are administered to induce masculine changes, such as increased facial and body hair growth, deepening of the voice, muscle development, and redistribution of body fat.

Types of Testosterone : There are different formulations of testosterone available for injection, including testosterone cypionate, testosterone enanthate, and testosterone undecanoate.

Administration : Testosterone injections are typically administered intramuscularly (into the muscle) in either the gluteal (buttocks) or deltoid (upper arm) muscle.

Dosage and Frequency : The dosage and frequency of testosterone injections can vary depending on individual factors such as age, weight, hormone levels, and desired changes. Typically, injections are administered every one to two weeks to maintain stable testosterone levels in the body.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant markers is essential to ensure the safety and effectiveness of testosterone therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Estrogen Injections (for Transfeminine Individuals)

Purpose : Estrogen injections are administered to induce feminine changes, such as breastdevelopment, redistribution of body fat, softening of the skin, and reduction of muscle mass.

Types of Estrogen : The most common form of estrogen used in injections is estradiol valerate.

Administration : Estrogen injections are typically administered intramuscularly, similar to testosterone injections, in the gluteal or deltoid muscle.

Dosage and Frequency : The dosage and frequency of estrogen injections vary depending on individual factors and treatment goals. Typically, injections are administered every one to two weeks.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant parameters is crucial for ensuring the safety and effectiveness of estrogen therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Time Frame of Use of Hormonal Injections

Initiation : Hormonal injections are often initiated after a thorough evaluation by healthcare providers, including discussions about treatment goals, potential risks and benefits, and informed consent. The timing of initiation may vary depending on individual factors such as age, readiness for treatment, and presence of any underlying health conditions.

Duration : Hormonal injections are typically used as part of long-term hormone replacement therapy to maintain desired physical changes and support overall well-being. The duration of hormone therapy may vary from individual to individual and often continues indefinitely, especially for those who desire ongoing maintenance of gender-affirming changes.

Discontinuation : In some cases, individuals may choose to discontinue hormonal injections for various reasons, such as personal preference, changes in health status, or the achievement of desired physical changes. It's essential for individuals to discuss any plans to discontinue hormone therapy with their healthcare provider to ensure proper management of any potential effects or complications.

Surgical Procedures: Gender Affirming Surgery

These surgical procedures play vital roles in gender affirmation for transgender individuals, aligning their physical appearance with their gender identity( 3 ✔ ✔ Trusted Source Gender Confirmation Surgery Go to source ).

Male-to-Female (MtF) Transitions:

• Tracheal Shave: This procedure reduces the prominence of the Adam's apple, a typically male characteristic, to create a smoother, more feminine neck contour.
• Breast Augmentation: Transfeminine individuals undergo breast augmentation to develop fuller, more feminine breast contours. Breast implants are placed behind breast tissue or chest muscle to achieve the desired size and shape.
• Facial Feminization Surgery (FFS): FFS encompasses various surgical procedures aimed at feminizing facial features. Techniques may include forehead contouring, rhinoplasty , cheek augmentation, chin and jaw reshaping, tracheal shave, lip augmentation, and hairline lowering to achieve a more traditionally feminine appearance.
• Male-to-Female Genital Sex Reassignment (Vaginoplasty): This surgical procedure constructs female genitalia for transfeminine individuals seeking alignment with their gender identity. Techniques involve using penile and scrotal tissue to create the vaginal canal, labia, and clitoral hood. The procedure may also include the creation of a neurovascular neoclitoris, providing both aesthetic and functional female genitalia in one operation.

Female-to-Male (FtM) Transitions:

• Hysterectomy and Oophorectomy: This procedure involves the removal of the uterus and ovaries, reducing the production of female hormones (estrogen and progesterone).
• Vaginectomy: Vaginectomy is the surgical removal of the vaginal canal, aligning the physical anatomy with a masculine appearance.
• Chest Reconstruction (Top Surgery): FtM individuals undergo chest reconstruction surgery to remove breast tissue and reshape the chest to achieve a more masculine contour. Techniques include subcutaneous mastectomy or double mastectomy with or without nipple reconstruction.
• Female-to-Male Genital Sex Reassignment (Phalloplasty): Phalloplasty is a surgical procedure to construct a phallus for FtM individuals seeking male genitalia. The radial forearm flap method is commonly used, involving tissue grafting from the forearm to create the phallus and urethra for standing urination. This procedure can be performed concurrently with a hysterectomy/vaginectomy to complete the transition process. A scrotum with testicular implants may be constructed in a second stage.

These surgical interventions are integral to gender affirmation for transgender individuals, helping align their physical appearance with their gender identity and alleviating gender dysphoria. Each procedure is tailored to the individual's unique needs and goals, reflecting the diversity of experiences within the transgender community.

Risks in Hormone Therapies

• Cardiovascular Risks : Hormone replacement therapy (HRT) may increase the risk of cardiovascular events such as heart attacks and strokes, especially in older individuals or those with pre-existing cardiovascular conditions.
• Thromboembolic Events : Estrogen therapy, particularly in forms like oral contraceptives, may elevate the risk of blood clots, leading to thromboembolic events such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
• Endocrine Disruption : Hormone therapies can disrupt the body's natural hormone balance, leading to potential complications such as metabolic disturbances, including insulin resistance and dyslipidemia.
• Breast Cancer Risk : Some studies suggest that long-term use of hormone replacement therapy, especially estrogen-only formulations, may increase the risk of breast cancer in transgender women.
• Liver Dysfunction : Hormone therapies, particularly oral estrogen formulations, may affect liver function and increase the risk of liver disease or dysfunction.

Risks in Gender Reassignment Surgeries

• Surgical Complications : As with any surgical procedure, gender reassignment surgeries carry risks such as infection, bleeding , anesthesia complications, and adverse reactions to medications.
• Scarring : Gender-affirming surgeries, especially those involving breast augmentation, chest reconstruction, or genital reconstruction, may result in visible scarring that could impact body image and self-esteem.
• Loss of Sensation : Surgeries involving genital reconstruction, such as vaginoplasty or phalloplasty, may result in loss of sensation or altered sensation in the genital region, affecting sexual function and satisfaction.
• Functional Complications : Some individuals may experience functional complications post-surgery, such as urinary incontinence , erectile dysfunction, or difficulties with sexual arousal or orgasm.
• Psychological Impact : Gender reassignment surgeries can have profound psychological effects, including adjustment difficulties, post-operative depression, and challenges related to body image and identity.

Guidance on Surgical Procedures: Whom to Consult?

When contemplating gender reassignment surgery, it's essential for individuals to consult with a team of experienced healthcare providers specializing in transgender care. Here's whom to consider consulting:

1. Gender-Affirming Surgeons

Gender-affirming surgeons specialize in performing gender reassignment surgeries and have expertise in various surgical techniques, including chest surgery (for both masculinization and feminization procedures), genital reconstruction, and facial feminization surgery. These surgeons can provide comprehensive information about the surgical options available, discuss the potential risks and benefits, and guide individuals through the decision-making process.

2. Endocrinologists

Endocrinologists play a crucial role in managing hormone therapy for transgender individuals. They can provide guidance on hormone replacement therapy (HRT), including the use of testosterone for transmasculine individuals and estrogen for transfeminine individuals. Endocrinologists can assess hormone levels, monitor any potential side effects, and adjust hormone regimens as needed to support the transition process.

3. Mental Health Professionals

Mental health professionals, such as psychologists, psychiatrists, or licensed therapists, offer invaluable support throughout the gender transition journey. They can assist individuals in exploring their gender identity, coping with gender dysphoria, and addressing any psychological concerns or challenges that may arise before, during, or after surgery. Mental health professionals also play a role in assessing readiness for surgery and providing pre- and post-operative counseling and support.

4. Primary Care Physicians

Primary care physicians are essential members of the healthcare team and can provide general medical care, coordinate referrals to specialists, and monitor overall health and well-being. They can also assist with managing any pre-existing medical conditions and ensuring that individuals are physically fit for surgery.

5. Support Groups and Advocacy Organizations

Support groups and advocacy organizations within the transgender community can offer valuable peer support, resources, and information about gender-affirming surgeries. These groups provide opportunities for individuals to connect with others who have undergone similar experiences, share insights, and seek guidance from those who have navigated the transition process.

Consulting with a multidisciplinary team of healthcare providers ensures that individuals receive comprehensive care tailored to their unique needs and goals. This collaborative approach helps individuals make informed decisions about gender reassignment surgery and supports their overall health and well-being throughout the transition process.

Pre-operative Considerations

1. Medical Considerations

Transgender individuals may have preexisting health conditions like diabetes , asthma , or HIV, which can impact their eligibility for surgery and postoperative care. Surgeons often consult with endocrinologists to assess the patient's physical fitness for surgery, especially considering the complex medication regimens involved in hormone therapy before and after surgery.

2. Fertility Concerns

Patients considering sex reassignment surgery (SRS) are informed about potential infertility, particularly if procedures like orchiectomy or oophorectomy are performed as part of the transition process. Preservation of fertility options may be discussed before surgery.

3. Age and Consent

SRS is generally not performed on children under 18, with rare exceptions made for adolescents based on healthcare provider assessments and potential benefits or risks. Consent from parents or legal guardians is required, along with long-term mental health counseling to confirm persistent gender dysphoria.

4. Intersex and Trauma Cases

Infants born with intersex traits may undergo surgical interventions at or near birth, raising ethical concerns about human rights implications. Trauma cases also require careful consideration, as surgically assigned gender may not align with the individual's gender identity, leading to negative outcomes later in life.

5. Standards of Care

Many regions follow Standards of Care for the Health of Transgender and Gender Diverse People (SOC), such as those published by the World Professional Association for Transgender Health (WPATH). These guidelines outline minimum requirements for treatment, including psychological evaluation and living as the desired gender before surgery.

6. Insurance Coverage

Obtaining insurance coverage for SRS may require documented assessments by mental health professionals, evidence of persistent gender dysphoria, and completion of physician-supervised hormone therapy for a specified duration.

Post-operative Considerations

1. Quality of Life and Physical Health

Studies assessing postoperative quality of life vary, with some reporting similar quality to control groups while others note lower quality in domains of health and limitations. Overall, many individuals report improvements in mental health, satisfaction with physical appearance, and overall well-being after surgery.

2. Psychological and Social Consequences

SRS has been shown to be effective in relieving gender dysphoria, though some studies highlight methodological limitations. Patients often report reduced anxiety, depression , and hostility levels post-surgery, with improvements in self-perceived physical and mental health.

3. Sexuality and Sexual Satisfaction

SRS can significantly impact individuals' sexual experiences and satisfaction. Most transsexual individuals report enjoying better sex lives and improved sexual satisfaction after surgery, with changes in orgasm frequency, intensity, and masturbation habits observed. However, satisfaction levels may vary between trans men and trans women, and expectations for sexual aspects of life may differ from cisgender individuals.

4. Continued Support

Comprehensive postoperative care involves ongoing psychological support, management of any complications, and assistance with adjustment to physical changes. Social support networks play a crucial role in helping individuals navigate their post-surgical experiences and integrate their gender identities into their daily lives.

The denial or limited access to gender-affirming surgeries can have severe consequences for the mental health and well-being of transgender individuals.

1. Persistent Gender Dysphoria

Without access to surgery, transgender individuals may continue to experience intense distress and discomfort due to the misalignment between their gender identity and physical characteristics. This persistent gender dysphoria can lead to heightened anxiety, depression, and a sense of hopelessness.

2. Heightened Anxiety

Living in a body that does not align with one's gender identity can contribute to persistent anxiety. The frustration of being unable to access necessary medical care and the ongoing struggle to navigate societal expectations can exacerbate feelings of stress and worry.

3. Increased Depression

Untreated gender dysphoria and the inability to undergo gender-affirming surgeries can lead to deepening feelings of depression and despair. Transgender individuals may struggle with low self-esteem, feelings of worthlessness, and a sense of isolation from not being able to live authentically.

4. Social Withdrawal

The distress caused by the incongruence between one's gender identity and physical appearance can result in social withdrawal and avoidance of social interactions. Transgender individuals may feel ashamed or uncomfortable in social settings, leading to further isolation and loneliness.

5. Suicidal Ideation

The lack of access to gender-affirming surgeries and the ongoing struggle with gender dysphoria can significantly increase the risk of suicidal thoughts and behaviors. Without the hope of being able to live authentically and alleviate their distress, transgender individuals may experience profound feelings of hopelessness and desperation.

Click here to know more about Mental health in transgender community

Affordable Surgery Options

Gender-affirming surgeries, including gender reassignment surgery (GRS), vary widely in cost globally. Affordable options exist in countries like Turkey, Brazil, Argentina, and Belgium. Turkey offers the most budget-friendly option, followed by Brazil, Argentina, and Belgium. While these countries provide competitive prices, individuals should consider factors beyond cost, such as healthcare quality and legal protections.

Click here for detailed information on the global cost of these surgeries and to find out which options are more affordable

In summary, gender reassignment surgery serves as a vital tool in validating the gender identities of transgender and intersex individuals, enabling them to harmonize their external appearance with their innate sense of self. Despite its transformative potential, many face obstacles in accessing this essential care, including financial constraints, inadequate insurance coverage, and legal hurdles.

As society progresses towards greater awareness and acceptance of transgender rights, it's imperative to prioritize equitable access to gender-affirming treatments and offer unwavering support to individuals throughout their transition journey. By dismantling these barriers and fostering inclusivity within healthcare systems, we can empower transgender individuals to live authentically and flourish in their gender identity.

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• Sex Reassignment Surgery in the Female-to-Male Transsexual - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/)
• Gender Affirmation Surgeries - (https://www.hopkinsmedicine.org/health/wellness-and-prevention/gender-affirmation-surgeries)
• Gender Confirmation Surgery - (https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery)
• Klinefelter syndrome - (https://www.nhs.uk/conditions/klinefelters-syndrome/)

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• Neuroscience for Kids - (http://faculty.washington.edu/chudler/words.html)
• What the Stroop Effect Reveals About Our Minds - (https://lesley.edu/article/what-the-stroop-effect-reveals-about-our-minds)
• The Emotional Stroop Effect Is Modulated by the Biological Salience and Motivational Intensity Inherent in Stimuli - (https://www.frontiersin.org/articles/10.3389/fpsyg.2019.03023/full)
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• The Stroop Effect - (https://www.simplypsychology.org/stroop-effect.html)
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• Stroop Effect - (https://conductscience.com/portfolio/stroop-effect/#:~:text=Stroop%20effect%20has%20many%20practical,bipolar%20disorder%2C%20or%20major%20depression.)
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StarTribune

Ethics panel takes up complaint against republican senator who sent graphic video link.

An ethics panel Tuesday delayed action for yet another day on the question of whether Sen. Glenn Gruenhagen violated the norms of the state Senate by sending to his 66 colleagues a link to a video about gender-affirming surgery.

Sen. Erin Maye Quade, DFL-Apple Valley, filed the complaint against the Glencoe Republican in April 2023, but the Senate's ethics subcommittee didn't take it up until now. The four-person panel agreed to think about it and come back at 3 p.m. Wednesday to decide what, if anything, should be done.

The timing of the meeting was a concern for the two Republicans on the committee, who noted that the hearing occurred only after a complaint was recently filed against Sen. Nicole Mitchell, DFL-Woodbury, over her alleged attempted first-degree burglary of the Detroit Lakes home of her father's widow.

"The perception is the only reason we have this complaint in front of us now is because the other complaint was filed," Sen. Jeremy Miller, R-Winona, said. Sen. Andrew Mathews, R-Princeton, expressed similar concerns.

For more than two hours, the committee heard from and questioned Maye Quade and Gruenhagen before agreeing on a motion by Sen. Mary Kunesh, DFL-New Brighton, to think about it overnight.

Mathews initially moved for a finding of no probable cause for wrongdoing. But the motion failed on a tie with the two Republicans voting for it and Kunesh and Chair Bobby Joe Champion, DFL-Minneapolis, against it.

Maye Quade argued that by sending a link of gender-affirming surgery to all senators last year, Gruenhagen violated the Senate norms and should be sent to sensitivity training on LGBTQIA+ matters. She said Gruenhagen labeled the contents "extremely graphic and disturbing" and "sent it anyway."

She said the email was gratuitous and not related to pending legislation. "We can and should express our opinions and educate each other about topics," she said, but added that Gruenhagen's email "demonstrated a deep lack of understanding about LGBTQIA+ people."

Gruenhagen countered that he was providing information about a bill passed late last April. "We have an obligation and a responsibility to do the research," Gruenhagen said. He said the email linked to an academic, medical video created to train physicians on male to female gender reassignment surgery.

"You had to click twice to get to the videos. You could have hit erase," he said. "What's at stake is whether a member can share information, even if it's explicit, on a bill that's coming before the Senate to vote on."

The bill, which is now law , provided protections from legal repercussions and extradition orders for transgender people and their families traveling to Minnesota for treatment.

Rochelle Olson is a reporter on the politics and government team.

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Opinion Psychiatrists learned the wrong lesson from the gay rights movement

Advocates for puberty blockers don’t have science on their side.

Benjamin Ryan is an independent journalist and has been covering LGBTQ health for over two decades.

Five decades ago, the world’s most powerful psychiatric association changed the course of LGBTQ civil rights history when it removed homosexuality from its influential bible of mental health disorders.

At annual meetings of the American Psychiatric Association during the early 1970s, activists and internal reformers compelled the association to host panels and discussions on the merits of the relevant research, fostering a rigorous debate about whether homosexuality should still be considered a pathology. The science won in 1974 and set in motion a parade of legal victories for the gay rights movement, including the right for same-sex couples to wed .

APA members gather in New York on Saturday for this same crucial meeting . The summit should again serve as a watershed moment in the care of LGBTQ people. This time, the pressing question facing American psychiatrists is how best to treat children who are distressed about their gender. In response to emerging analyses of the available research, health officials in several European nations have sharply restricted the use of puberty blockers and cross-sex hormones in this population — in some countries to research settings only. But the APA still endorses the use of these drugs as a front-line intervention for minors.

In 1974, the science lined up neatly with the demands of gay rights activists. But today, the science of pediatric gender medicine is uncertain, so it doesn’t back the cause the of groups leading the contemporary LGBTQ civil rights movement in the United States.

GLAAD has gone so far as to insist that “ the science is settled ” regarding pediatric gender transition. It is not. In fact, the field of pediatric gender medicine is woefully compromised by a critical lack of quality research . Evidence-based-medicine experts insist that we simply do not know whether gender-transition treatment is safe and effective for minors.

Understandably, APA leaders — and other empathetic everyday people — are wary of repeating the mistakes of the past and are inclined to stand with LGBTQ advocates, particularly as conservative groups fight for all manner of restrictive laws that target kids who identify as transgender.

During the past decade, nations across the globe saw a surge in children and adolescents with gender-related distress, a population with a high rate of other psychiatric conditions , autism and self-harm . This phenomenon has occurred amid an overall crisis in youth mental health . It is not a betrayal of gender-distressed young people’s complex needs to demand the highest possible quality of evidence to determine whether prescribing them medications that could rob them of their fertility and sexual function are in their best interest. It is the APA’s responsibility, free from ideology or politics, to make such demands — which are, in fact, in service of these young people’s well-being.

The APA’s signaling on best practices for the care of such young people is of paramount importance. The offices of psychiatrists and other mental health professionals are often the entry point into gender-transition medicalization. And in U.S. gender clinics, a therapist typically must approve a minor’s referral to an endocrinologist for puberty blockers or cross-sex hormones.

The APA has been notably silent on a landmark report published last month that was commissioned by the British National Health Service. Called the Cass Review , it concluded that pediatric gender-transition treatment is based on “remarkably weak evidence.” The report is supported by seven independently conducted systematic literature reviews — the gold standard of scientific evidence. Their findings were in line with those of six previous such reviews, conducted by European and North American investigators and published since 2019.

The program for the 2024 APA annual meeting lists only one panel that touches on pediatric gender-transition treatment, titled “Channeling Your Passion and ‘Inner Outrage’ by Promoting Public Policy for Evidence-Based Transgender Care.”

The panel notably includes Jack Turban, a University of California at San Francisco child psychiatrist and a vocal supporter of broad access to gender-transition treatment. This week, he lashed out at the Cass Review on X and asserted that the associated literature reviews “ scored some of the studies incorrectly .” Turban didn’t mention the reviews deemed a few of his own widely referenced papers to be low quality.

The APA’s meeting has a proud history of transforming open debate over LGBTQ-related research and care and should do the same for trans-identifying kids. This should include asking themselves whether LGBTQ activism that once enhanced the understanding of science about this population is now clouding it.

The 1972 APA meeting included a panel featuring a gay psychiatrist who wore a gruesome costume mask and wig that disguised his identity. He opened his mouth and regaled a rapt crowd with his searing story about the agony of working from within the closet.

At the 1973 APA meeting, one psychiatrist panelist proclaimed, “All my gay patients are sick!” to which another replied, “ All my straight patients are sick! ” This rejoinder pointed to a fatal flaw in the research that had supported considering homosexuality a mental illness: Those supposedly scientific papers were largely based on psychiatric patients, not the general gay public; therefore their conclusions were weak and inconclusive.

The APA board was finally convinced. At the end of that year, it voted that homosexuality was not a mental disorder. The organization’s full membership effectively ratified this decision when a majority voted down a referendum to overturn it on April 8, 1974.

In March, I asked APA President Petros Levounis, who like me is a gay man, if the organization was taking into consideration the recent review papers on pediatric gender medicine.

“We do look very closely to international research,” Levounis, a psychiatrist, told me. “But this is something that has to also come through U.S. channels before we finalize our opinion.”

Now is the time for rigorous and open scientific debate in the United States about this vital subject among the nation’s psychiatrists. The APA needs to remember the power of its annual meeting to foster such a transformative free exchange of ideas. It needs to trade silence for science.

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