what is gender reassignment surgery male to female

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

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

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

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

Products & Services

• A Book: Mayo Clinic Family Health Book, 5th Edition
• Available Sexual Health Solutions at Mayo Clinic Store
• Newsletter: Mayo Clinic Health Letter — Digital Edition

Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

• Breast augmentation incisions

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

• Placement of breast implants or tissue expanders

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

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

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

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

Genital surgery

• Anatomy before and after penile inversion

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

• Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

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.
• Doctors & Departments
• Care at Mayo Clinic

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

Make twice the impact

Your gift can go twice as far to advance cancer research and care!

• Search the site GO Please fill out this field.
• Newsletters
• Mental Health
• Social and Public Health

What Is Gender Affirmation Surgery?

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

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

Why Is Gender Affirmation Surgery Performed?

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

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

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

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

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

Transgender vs Nonbinary

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

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

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

Hormone Therapy

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

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

Types of hormone therapy include:

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

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

Masculinizing Surgeries

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

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

Top Surgery

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

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

Metoidioplasty

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

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

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

Phalloplasty

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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

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

Gender Nullification

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

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

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

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

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

American Society of Plastic Surgeons. Gender affirmation surgeries .

Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National estimates of gender-affirming surgery in the US .  JAMA Netw Open . 2023;6(8):e2330348-e2330348. doi:10.1001/jamanetworkopen.2023.30348

Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8 .  Int J Transgend Health . 2022;23(S1):S1-S260. doi:10.1080/26895269.2022.2100644 

Chou J, Kilmer LH, Campbell CA, DeGeorge BR, Stranix JY. Gender-affirming surgery improves mental health outcomes and decreases anti-depressant use in patients with gender dysphoria .  Plast Reconstr Surg Glob Open . 2023;11(6 Suppl):1. doi:10.1097/01.GOX.0000944280.62632.8c

Human Rights Campaign. Get the facts on gender-affirming care .

Human Rights Campaign. Transgender and non-binary people FAQ .

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877–84. doi:10.21037/tau.2016.09.04

Richards JE, Hawley RS. Chapter 8: Sex Determination: How Genes Determine a Developmental Choice . In: Richards JE, Hawley RS, eds. The Human Genome . 3rd ed. Academic Press; 2011: 273-298.

Randolph JF Jr. Gender-affirming hormone therapy for transgender females . Clin Obstet Gynecol . 2018;61(4):705-721. doi:10.1097/GRF.0000000000000396

Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals . J Clin Med . 2020;9(6):1609. doi:10.3390/jcm9061609

Van Boerum MS, Salibian AA, Bluebond-Langner R, Agarwal C. Chest and facial surgery for the transgender patient .  Transl Androl Urol . 2019;8(3):219-227. doi:10.21037/tau.2019.06.18

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes . Transl Androl Urol . 2019;8(3):248–53. doi:10.21037/tau.2019.06.12

Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases .  Front Endocrinol . 2021;12:760284. doi:10.3389/fendo.2021.760284

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The surgical techniques and outcomes of secondary phalloplasty after metoidioplasty in transgender men: an international, multi-center case series .  The Journal of Sexual Medicine . 2019;16(11):1849-1859. doi:10.1016/j.jsxm.2019.07.027

Waterschoot M, Hoebeke P, Verla W, et al. Urethral complications after metoidioplasty for genital gender affirming surgery . J Sex Med . 2021;18(7):1271–9. doi:10.1016/j.jsxm.2020.06.023

Nikolavsky D, Hughes M, Zhao LC. Urologic complications after phalloplasty or metoidioplasty . Clin Plast Surg . 2018;45(3):425–35. doi:10.1016/j.cps.2018.03.013

Nota NM, den Heijer M, Gooren LJ. Evaluation and treatment of gender-dysphoric/gender incongruent adults . In: Feingold KR, Anawalt B, Boyce A, et al., eds.  Endotext . MDText.com, Inc.; 2000.

Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. The uterus in transgender men . Fertil Steril . 2021;116(4):931–5. doi:10.1016/j.fertnstert.2021.07.005

Miller TJ, Wilson SC, Massie JP, Morrison SD, Satterwhite T. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes . JPRAS Open . 2019;21:63-74. doi:10.1016/j.jpra.2019.03.003

Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals . Clin Plast Surg . 2018;45(3):369–80. doi:10.1016/j.cps.2018.03.010

De Boulle K, Furuyama N, Heydenrych I, et al. Considerations for the use of minimally invasive aesthetic procedures for facial remodeling in transgender individuals .  Clin Cosmet Investig Dermatol . 2021;14:513-525. doi:10.2147/CCID.S304032

Asokan A, Sudheendran MK. Gender affirming body contouring and physical transformation in transgender individuals .  Indian J Plast Surg . 2022;55(2):179-187. doi:10.1055/s-0042-1749099

Sturm A, Chaiet SR. Chondrolaryngoplasty-thyroid cartilage reduction . Facial Plast Surg Clin North Am . 2019;27(2):267–72. doi:10.1016/j.fsc.2019.01.005

Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery . Transl Androl Urol . 2019;8(3):191-208. doi:10.21037/tau.2019.06.19

Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtranon P. Male-to-female vaginoplasty: Preecha's surgical technique . J Plast Surg Hand Surg . 2015;49(3):153-9. doi:10.3109/2000656X.2014.967253

Okoye E, Saikali SW. Orchiectomy . In: StatPearls [Internet] . Treasure Island (FL): StatPearls Publishing; 2022.

Salgado CJ, Yu K, Lalama MJ. Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations . J Surg Case Rep . 2021;2021(12):rjab553. doi:10.1093/jscr/rjab553

American Society of Plastic Surgeons. What should I expect during my recovery after facial feminization surgery?

American Society of Plastic Surgeons. What should I expect during my recovery after transmasculine bottom surgery?

de Brouwer IJ, Elaut E, Becker-Hebly I, et al. Aftercare needs following gender-affirming surgeries: findings from the ENIGI multicenter European follow-up study .  The Journal of Sexual Medicine . 2021;18(11):1921-1932. doi:10.1016/j.jsxm.2021.08.005

American Society of Plastic Surgeons. What are the risks of transfeminine bottom surgery?

American Society of Plastic Surgeons. What are the risks of transmasculine top surgery?

Khusid E, Sturgis MR, Dorafshar AH, et al. Association between mental health conditions and postoperative complications after gender-affirming surgery .  JAMA Surg . 2022;157(12):1159-1162. doi:10.1001/jamasurg.2022.3917

Related Articles

• Quick Links
• Make An Appointment
• Our Services
• Price Estimate
• Price Transparency
• Pay Your Bill
• Patient Experience
• Careers at UH

Schedule an appointment today

Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

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

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

Penile Inversion Technique for Vaginoplasty

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

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

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

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

Things to Consider Before Having a Penile Inversion Vaginoplasty

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

Postoperative Care of Your New Vagina

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

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

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

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Supplements
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

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

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

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

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

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

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

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

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

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

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

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

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

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

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

American Society of Plastic Surgeons. Gender confirmation surgeries .

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

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

Jump to content

Updated visitor policies

Other michigan medicine sites.

• About Michigan Medicine
• UofMHealth.org
• Medical School
• Find a Clinical Trial

Michigan Medicine

Federated search page form block, quick links.

• Patient Portal Login
• For Health Providers
• Maps & Directions

Gender Confirmation Surgery

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

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

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

Available surgeries:

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

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

Sex Reassignment Surgeries (SRS)

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

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

Male-to-female sex reassignment surgery

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

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

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

Female-to-male sex reassignment

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

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

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

Learn how UpToDate can help you.

Select the option that best describes you

• Medical Professional
• Resident, Fellow, or Student
• Hospital or Institution
• Group Practice
• Patient or Caregiver
• Find in topic

RELATED TOPICS

INTRODUCTION

This topic will review surgeries that are commonly performed as part of feminizing transition. Other topics related to the care of transgender persons include:

● (See "Transgender men: Evaluation and management" .)

● (See "Transgender women: Evaluation and management" .)

● (See "Primary care of transgender individuals" .)

How Gender Reassignment Surgery Works (Infographic)

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

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

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

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

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

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

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

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

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

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

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

Sign up for the Live Science daily newsletter now

Get the world’s most fascinating discoveries delivered straight to your inbox.

Man's years of premature ejaculation had a rare cause

Viagra alternatives? Study of mouse erections hints at new ways to treat erectile dysfunction

Villa near Mount Vesuvius may be where Augustus, Rome's 1st emperor, died

Most Popular

• 2 James Webb telescope confirms there is something seriously wrong with our understanding of the universe
• 3 Quantum computing breakthrough could happen with just hundreds, not millions, of qubits using new error-correction system
• 4 6G speeds hit 100 Gbps in new test — 500 times faster than average 5G cellphones
• 5 Why do people hear their names being called in the woods?
• 2 2 plants randomly mated up to 1 million years ago to give rise to one of the world's most popular drinks
• 3 Tweak to Schrödinger's cat equation could unite Einstein's relativity and quantum mechanics, study hints
• 4 'We were in disbelief': Antarctica is behaving in a way we've never seen before. Can it recover?
• 5 Hundreds of black 'spiders' spotted in mysterious 'Inca City' on Mars in new satellite photos

Healthdirect Free Australian health advice you can count on.

Medical problem? Call 1800 022 222. If you need urgent medical help, call triple zero immediately

healthdirect Australia is a free service where you can talk to a nurse or doctor who can help you know what to do.

Gender affirming surgery

7-minute read

Share via email

There is a total of 5 error s on this form, details are below.

• Please enter your name
• Please enter your email
• Your email is invalid. Please check and try again
• Please enter recipient's email
• Recipient's email is invalid. Please check and try again
• Agree to Terms required

Error: This is required

Error: Not a valid value

What is gender affirming surgery?

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

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

Gender affirming care might include:

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

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

This article talks more about gender affirming surgery.

What happens during gender affirming surgery?

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

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

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

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

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

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

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

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

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

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

Is gender affirming surgery right for me?

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

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

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

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

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

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

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

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

What questions should I ask before surgery?

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

Questions to ask your surgeon include:

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

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

What should I expect after surgery?

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

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

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

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

How much will gender affirming surgery cost me?

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

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

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

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

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

Legal matters

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

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

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

Where can I get more information on gender affirming surgery?

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

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

Last reviewed: June 2022

Search our site for

• Transgender
• Gender Dysphoria

Need more information?

These trusted information partners have more on this topic.

Top results

Understanding Gender Identity | headspace

Gender identity is your sense of whether you are a man, woman, nonbinary, gender fluid or a combination of one or more of these identities. Learn more about gender identity and how you can get help from headspace.

Read more on headspace website

Everything you need to know about gender identity | Gender Identity

If you’ve ever wondered ‘what does gender mean?’, you’re not alone. Gender and identity exists on a diverse spectrum. Learn more about gender in this guide.

Read more on ReachOut.com website

Understanding gender identity and young people | headspace

It's important to understand the ways your young person can express their gender identity. Visit headspace to learn about gender identity in young people.

Gender Identity Examples, Meaning & Definition | Kids Helpline

Gender identity is more than being male or female. Kids Helpline can help you understand what it is and how you can understand your own identity.

Read more on Kids Helpline website

Gender dysphoria & identity: kids & teens | Raising Children Network

Gender identity is feeling male, female, both or neither. Gender dysphoria is when your child is distressed by feeling different from their birth gender.

Read more on raisingchildren.net.au website

Gender dysphoria & diversity: support | Raising Children Network

If your child is gender diverse or experiencing gender dysphoria, support means embracing their gender identity. Your support boosts your child’s wellbeing.

How Emma learnt to accept herself and her gender identity | ReachOut Australia

Emma, a young transgender woman, shares how reaching out for support helped her to accept her gender identity.

Supporting a transgender teenager - ReachOut Parents

Learn how best to support your teen as they embrace their gender identity, with ReachOut Australia and Ross Jacobs from QLife.

Your child’s gender diversity: your family | Raising Children Network

If your child is gender diverse, it’s OK if you and your child’s siblings have mixed feelings about your child’s gender identity. It’s good to seek support.

Gender diversity - a QLife guide for health professionals

Many people assume that gender is binary; that all people are women or men. However, gender can more accurately be thought of as a colour palette, with many possible shades of identity and subtle expressions of gender far beyond only woman or man.

Read more on QLife website

RACGP - LGBTIQA+ Family abuse and violence

Reproduced with permission from The Royal Australian College of General Practitioners

Read more on RACGP - The Royal Australian College of General Practitioners website

RACGP - Care of older LGBTI people

Reproduced with permission from The Royal Australian College of General Practitioners. The historical pathologising of older lesbian, gay, bisexual, transgender and intersex (LGBTI) people’s bodies and relationships continue to adversely affect their health and wellbeing

Bisexuality - a QLife guide for health professionals

Bisexual people are attracted to people of multiple genders and these attractions may be fluid over time.

Young people - QLife guide tip sheet

Social conditions for the acceptance of LGBTI (lesbian, gay, bisexual, transgender and intersex) people have improved dramatically in Australia in recent years.

Coming out, inviting in and disclosure

‘Coming out’ typically refers to acknowledging one’s sexuality or samegender attractions to oneself and disclosing this to others.

Antidepressants in adolescence - Australian Prescriber

Antidepressant drugs are not the first-line treatment for adolescents with mild symptoms of depression.

Read more on Australian Prescriber website

Clinical guidelines – Intersex Human Rights Australia

Are clinical guidelines enough to eliminate human rights violations against intersex people in medical settings? Reviewing the evidence, we believe they are inadequate, and their prerequisites do not exist.

Read more on Intersex Human Rights Australia website

For Health Professionals | Cancer in Aboriginal and Torres Strait Islander People - Our mob and cancer

Culturally appropriate, optimal cancer care for Aboriginal and Torres Strait Islander people Cancer is the third leading cause of burden of disease for Aboriginal and Torres Strait Islander people

Read more on Cancer Australia - Our Mob and Cancer website

The Health and Care of First Nations Australians | Ausmed

First Nations Australians are diverse peoples with a variety of histories, cultures, languages and experiences. In order to deliver appropriate and culturally competent care, it is essential to understand the care needs and health of First Nations peoples.

Read more on Ausmed Education website

Healthdirect Australia is not responsible for the content and advertising on the external website you are now entering.

Healthdirect 24hr 7 days a week hotline

24 hour health advice you can count on

1800 022 222

Government Accredited with over 140 information partners

We are a government-funded service, providing quality, approved health information and advice

Healthdirect Australia acknowledges the Traditional Owners of Country throughout Australia and their continuing connection to land, sea and community. We pay our respects to the Traditional Owners and to Elders both past and present.

© 2024 Healthdirect Australia Limited

Support for this browser is being discontinued

Support for this browser is being discontinued for this site

• Internet Explorer 11 and lower

We currently support Microsoft Edge, Chrome, Firefox and Safari. For more information, please visit the links below:

• Chrome by Google
• Firefox by Mozilla
• Microsoft Edge
• Safari by Apple

You are welcome to continue browsing this site with this browser. Some features, tools or interaction may not work correctly.

• Reference Manager
• Simple TEXT file

People also looked at

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.

1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-non-conforming people, version 7. Int J Transgend. (2012) 13:165–232. doi: 10.1080/15532739.2011.700873

CrossRef Full Text | Google Scholar

2. Massie JP, Morrison SD, Maasdam JV, Satterwhite T. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast Reconstruct Surg. (2018) 141:911–921. doi: 10.1097/PRS.0000000000004427

PubMed Abstract | CrossRef Full Text | Google Scholar

3. Pan S, Honig SC. Gender-affirming surgery: current concepts. Curr Urol Rep . (2018) 19:62. doi: 10.1007/s11934-018-0809-9

4. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int . (2007) 100:607–13. doi: 10.1111/j.1464-410X.2007.07017.x

5. Rossi NR, Hintz F, Krege S, Rübben H, Vom DF, Hess J. Gender reassignment surgery – a 13 year review of surgical outcomes. Eur Urol Suppl . (2013) 12:e559. doi: 10.1016/S1569-9056(13)61042-8

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

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

• Medium Text

Sign up here.

Reporting By Brendan Pierson in New York, Editing by Alexia Garamfalvi and Bill Berkrot

Our Standards: The Thomson Reuters Trust Principles. New Tab , opens new tab

Thomson Reuters

Brendan Pierson reports on product liability litigation and on all areas of health care law. He can be reached at [email protected].

Read Next / Editor's Picks

Industry Insight Chevron

Mike Scarcella, David Thomas

Karen Sloan

Henry Engler

Diana Novak Jones

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MORE SECTIONS

• Social Casino

MORE FROM THE SUN

• Newsletters

I had surgery to become a man but regretted it so I changed back to a woman five years later – now my body Is ruined

• Julie Bindel
• Published : 16:00 ET, May 3 2024
• Published : Invalid Date,

SINEAD WATSON, is a bright, humorous woman who speaks her mind and has a permanent twinkle in her eyes.

But just over a decade ago, 33-year-old Sinead temporarily became Sean, a surly, angry trans man.

At the age of 20, feeling desperately unhappy, and suffering trauma from serious sexual assaults perpetrated by men , she discovered online trans communities.

Sinead convinced herself that all of her problems would disappear if she underwent gender reassignment treatment.

Then, at 23 — having presented as “gender dysphoric” at the Sandyford Gender Clinic in Glasgow — Sinead was able to transition to a trans man with little pushback.

But within five years of her first appointment she was “deeply regretting” her decision and, aged 27, began living as a woman again.

Today, Sinead is in permanent pain and discomfort as a result of taking the male hormone ­testosterone, and has scars where her breasts used to be.

She has been living in a homeless hostel for the past six months after the breakdown of a three-year relationship, and has struggled with alcoholism .

Sinead tells me: “I’m currently single. My relationship was in tatters because I couldn’t cope with all the trauma in my life.”

Sinead is angry at the professionals at Sandyford, who she claims led her to believe she could escape her female body.

Most read in Fabulous

Chilling texts of 'killer' dad who made son run on treadmill days before death

China blasts rocket to mysterious far side of Moon to collect first-ever samples

Eurovision on ISIS alert in Sweden amid warnings terrorists will attack fans

Whoopi Goldberg claims her clergyman dad was gay in raw new memoir

She says: “I now must live with the many permanent consequences of the ‘treatment’ I received there.

“I realised I had made a terrible mistake when I woke up after my double mastectomy.

“By then I had grown a beard, and my voice had deepened as a result of the testosterone I’d taken. I felt there was no going back.”

Sinead understands now that she was actually suffering from body dysphoria.

She explains: “When I was seen by gender clinicians, I was allowed to make a monumental, life-changing decision but I wasn’t offered in-depth counselling. Instead, I was effectively left to self-diagnose.

“What I clearly needed was therapy. I had been the victim of sexual abuse and I told them, ‘I’m just out of psychiatric hospital. I’ve been suicidal. I have all these issues’.

“What they should have said is, ‘Let’s talk about how you ended up there’.

“But they didn’t ask me any questions about my ­history of trauma and abuse.

“If they had told me, ‘You’ve had some terrible experiences relating to men sexualising you because of your breasts, but there’s nothing wrong with them,’ I may not have felt the need to have them cut off.”

Instead, they affirmed Sinead immediately at her first appointment, calling out her name to see the ­clinician: “He’s ready for you, Mr Watson.”

Sinead was single-minded in pursuit of her goal to transition.

For example, when asked about being an inpatient at a psychiatric unit in 2014, she said it was because she was depressed that she hadn’t transitioned yet, which was a lie.

Her voice shaking with emotion, she says: “It was their job to scrutinise what had been happening in my life that led to severe breakdowns and suicide attempts.”

Sinead was given pamphlets listing the side-effects of testosterone, and was asked how long she had been living as a man (the requirement is two years before cross-sex hormones can be prescribed).

She says: “I told them two years, and they just took my word for it.”

Self-diagnose

Just five months later, Sinead was given her first dose of testosterone, which causes physical changes including a deeper voice, scalp hair loss, and increased body and facial hair.

After two years on the hormone, Sinead elected to undergo a double mastectomy, in July 2017.

Before the surgery she was warned she could lose complete sensation and that her nipples could fall off.

Afterwards, she says: “I woke up and I’d had my breasts removed. It wasn’t how I thought it would be.

“I thought I would wake up and feel amazing. But I can’t really explain what it feels like to have no sensation on your chest.

“I was in so much pain I couldn’t even go to the toilet by myself.”

After Sinead broke down in front of her GP, she was finally referred to a therapist.

She says: “When I said I regretted my transition, they suggested that I was perhaps non-binary. It was ­dizzying.

“I felt ready to kill myself. But I couldn’t put my loved ones through any more, so I decided to go online and find other detransitioned women.

“I found a surprisingly large ­number of them. And then they told me their stories.

“I basically went from being ­horrifically depressed and suicidal to so, so angry”.

Most of the detransitioners Sinead is in contact with are in their early 20s.

What I clearly needed was therapy... but they didn’t ask any questions about my history of trauma and abuse Sinead Watson

She says: “When they started talking about it on trans forums and said they thought they’d made a terrible mistake, they were told, ‘That’s ­normal, you’ll get over it’.”

But in light of last month’s damning report into the practices of the Gender Identity Development Service (GIDS) at London’s Tavistock NHS Trust , NHS Scotland has announced that it will pause puberty blockers being given to children.

When Dr Hilary Cass’s team asked Sinead about her treatment at Sandyford, they were shocked to learn how quickly she was prescribed ­testosterone, and asked about its permanent effects.

She says: “Sex is very painful for me. I’ve got chronic joint pain that I need to take oestrogen to combat. I have absolutely no sensation on my chest. I am furious to find that, in response to the announcement about puberty blockers being stopped in Scotland, there are still some private clinicians advertising online.

“They are saying, ‘If you can’t get puberty blockers via the gender clinic, we can send them to you’.”

I ask Sinead what she proposes the Government should do in light of the Cass Review that said children had been let down.

She says: “I want our First Minister to come out and condemn what has been done to young people in these clinics.”

Life has been hard since Sinead decided to speak out.

She has received a barrage of abuse from trans activists who believe she has betrayed the community.

She admits: “If I had known back then the abuse I was going to receive, I would never have waived my ­anonymity. But I will do what I can to stop this terrible mistreatment of vulnerable young people.”

Sinead points to the many women using online crowd-funding pages to raise cash for their “top surgery”.

Terrible mistreatment

She says: “My body is ruined and I get little sympathy and support, so why are money and resources being poured into funds and services to do the same to other women?”

Despite everything, Sinead is still ­optimistic, because the closure of GIDS could spell the end for other gender clinics such as Sandyford.

Determined, she says: “Children are being harmed. Every time these places are investigated, horrific information is revealed. The public can’t stay ignorant for ever.

“Sandyford, and all gender clinics, should be shut down, before more lives are destroyed.”

When Sinead split from her boyfriend late last year, she says she was left with “no self-esteem and no money”.

But she now says her future is “looking brighter”.

She has been accepted for universal credit so she can now afford food and has been offered a flat.

She says: “It was really scary for a while but I can make hot meals which is nice.

“In terms of the future, I would love to meet The One.

Read More on The US Sun

Powerball winner Edwin Castro pictured with security at $3.8m Malibu house

“And I have over a decade of customer service experience, so ­fingers crossed.

“The last few years have been hell, but I’m coming through it.”

• Body Shapes
• Mental Health and illness
• Operations and Surgery
• Print Features
• The Sun Newspaper
• Trans and gender identity issues

MORE SECTIONS

• Dear Deidre
• Visual Stories

MORE FROM THE SUN

• Newsletters
• Deliver my newspaper
• Sun Vouchers
• The Sun Digital Newspaper

I had surgery to become a man but regretted it so I changed back to a woman five years later – now my body Is ruined

• Julie Bindel
• Published : 21:00, 3 May 2024
• Published : Invalid Date,

SINEAD WATSON, is a bright, humorous woman who speaks her mind and has a permanent twinkle in her eyes.

But just over a decade ago, 33-year-old Sinead temporarily became Sean, a surly, angry trans man.

At the age of 20, feeling desperately unhappy, and suffering trauma from serious sexual assaults perpetrated by men , she discovered online trans communities .

Sinead convinced herself that all of her problems would disappear if she underwent gender reassignment treatment .

Then, at 23 — having presented as “gender dysphoric” at the Sandyford Gender Clinic in Glasgow — Sinead was able to transition to a trans man with little pushback.

But within five years of her first appointment she was “deeply regretting” her decision and, aged 27, began living as a woman again.

Read More on Fabulous

Cheeky celebs who bared it ALL for Naked Gardening Day… and then kept on stripping

‘Eight months? You mean years?’ people gasp as mum shows off giant baby bump

Today, Sinead is in permanent pain and discomfort as a result of taking the male hormone ­testosterone , and has scars where her breasts used to be.

She has been living in a homeless hostel for the past six months after the breakdown of a three-year relationship, and has struggled with alcoholism .

Sinead tells me: “I’m currently single. My relationship was in tatters because I couldn’t cope with all the trauma in my life.”

Sinead is angry at the professionals at Sandyford, who she claims led her to believe she could escape her female body.

Most read in Fabulous

My 'worn once' shoes from Vinted arrived battered, stained & different sizes

Alison Hammond charges son, 19, rent despite being multi-millionaire

Emotions may run high but trust your ability to make everyone happy

She says: “I now must live with the many permanent consequences of the ‘treatment’ I received there.

“I realised I had made a terrible mistake when I woke up after my double mastectomy.

“By then I had grown a beard, and my voice had deepened as a result of the testosterone I’d taken. I felt there was no going back.”

Sinead understands now that she was actually suffering from body dysphoria .

She explains: “When I was seen by gender clinicians, I was allowed to make a monumental, life-changing decision but I wasn’t offered in-depth counselling. Instead, I was effectively left to self-diagnose.

“What I clearly needed was therapy. I had been the victim of sexual abuse and I told them, ‘I’m just out of psychiatric hospital. I’ve been suicidal. I have all these issues’.

“What they should have said is, ‘Let’s talk about how you ended up there’.

“But they didn’t ask me any questions about my ­history of trauma and abuse.

“If they had told me, ‘You’ve had some terrible experiences relating to men sexualising you because of your breasts, but there’s nothing wrong with them,’ I may not have felt the need to have them cut off.”

Instead, they affirmed Sinead immediately at her first appointment, calling out her name to see the ­clinician: “He’s ready for you, Mr Watson.”

Sinead was single-minded in pursuit of her goal to transition .

For example, when asked about being an inpatient at a psychiatric unit in 2014, she said it was because she was depressed that she hadn’t transitioned yet, which was a lie.

Her voice shaking with emotion, she says: “It was their job to scrutinise what had been happening in my life that led to severe breakdowns and suicide attempts.”

Sinead was given pamphlets listing the side-effects of testosterone, and was asked how long she had been living as a man (the requirement is two years before cross-sex hormones can be prescribed).

She says: “I told them two years, and they just took my word for it.”

Self-diagnose

Just five months later, Sinead was given her first dose of testosterone, which causes physical changes including a deeper voice, scalp hair loss, and increased body and facial hair.

After two years on the hormone, Sinead elected to undergo a double mastectomy , in July 2017.

Before the surgery she was warned she could lose complete sensation and that her nipples could fall off.

Afterwards, she says: “I woke up and I’d had my breasts removed. It wasn’t how I thought it would be.

“I thought I would wake up and feel amazing. But I can’t really explain what it feels like to have no sensation on your chest.

“I was in so much pain I couldn’t even go to the toilet by myself.”

After Sinead broke down in front of her GP , she was finally referred to a therapist.

She says: “When I said I regretted my transition, they suggested that I was perhaps non-binary. It was ­dizzying.

“I felt ready to kill myself. But I couldn’t put my loved ones through any more, so I decided to go online and find other detransitioned women.

“I found a surprisingly large ­number of them. And then they told me their stories.

“I basically went from being ­horrifically depressed and suicidal to so, so angry”.

Most of the detransitioners Sinead is in contact with are in their early 20s.

What I clearly needed was therapy... but they didn’t ask any questions about my history of trauma and abuse Sinead Watson

She says: “When they started talking about it on trans forums and said they thought they’d made a terrible mistake, they were told, ‘That’s ­normal, you’ll get over it’.”

But in light of last month’s damning report into the practices of the Gender Identity Development Service (GIDS) at London’s Tavistock NHS Trust , NHS Scotland has announced that it will pause puberty blockers being given to children.

When Dr Hilary Cass’s team asked Sinead about her treatment at Sandyford, they were shocked to learn how quickly she was prescribed ­testosterone, and asked about its permanent effects.

She says: “Sex is very painful for me. I’ve got chronic joint pain that I need to take oestrogen to combat. I have absolutely no sensation on my chest. I am furious to find that, in response to the announcement about puberty blockers being stopped in Scotland, there are still some private clinicians advertising online.

“They are saying, ‘If you can’t get puberty blockers via the gender clinic, we can send them to you’.”

I ask Sinead what she proposes the Government should do in light of the Cass Review that said children had been let down.

She says: “I want our First Minister to come out and condemn what has been done to young people in these clinics.”

Life has been hard since Sinead decided to speak out.

She has received a barrage of abuse from trans activists who believe she has betrayed the community.

She admits: “If I had known back then the abuse I was going to receive, I would never have waived my ­anonymity. But I will do what I can to stop this terrible mistreatment of vulnerable young people.”

Sinead points to the many women using online crowd-funding pages to raise cash for their “top surgery”.

Terrible mistreatment

She says: “My body is ruined and I get little sympathy and support, so why are money and resources being poured into funds and services to do the same to other women?”

Despite everything, Sinead is still ­optimistic, because the closure of GIDS could spell the end for other gender clinics such as Sandyford.

Determined, she says: “Children are being harmed. Every time these places are investigated, horrific information is revealed. The public can’t stay ignorant for ever.

“Sandyford, and all gender clinics, should be shut down, before more lives are destroyed.”

When Sinead split from her boyfriend late last year, she says she was left with “no self-esteem and no money”.

But she now says her future is “looking brighter”.

She has been accepted for universal credit so she can now afford food and has been offered a flat.

She says: “It was really scary for a while but I can make hot meals which is nice.

“In terms of the future, I would love to meet The One.

READ MORE SUN STORIES

Love Islander reveals he’s ‘unemployed’ a year after being kicked out of villa

I'm a mum of 4 but spend under £200 a MONTH on food with my 'snap happy' method

“And I have over a decade of customer service experience, so ­fingers crossed.

“The last few years have been hell, but I’m coming through it.”

• Body Shapes
• Mental Health and illness
• Operations and Surgery
• Print Features
• The Sun Newspaper
• Trans and gender identity issues

• Election 2024
• Entertainment
• Newsletters
• Photography
• Personal Finance
• AP Investigations
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Election Results
• Delegate Tracker
• AP & Elections
• Auto Racing
• 2024 Paris Olympic Games
• Movie reviews
• Book reviews
• Personal finance
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Mississippi Republicans revive bill to regulate transgender bathroom use in schools

A group of Republican women from throughout the state watch procedures in the Senate chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Sen. Brice Wiggins, R-Pascagoula, gestures while speaking at the well before the body in the Senate chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Sen. Derrick Simmons, D-Greenville, gestures while speaking at the well before the body in the Senate chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Sen. Angela Hill, R-Picayune, addresses the legislators in the Senate Chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Sen. Bradford Blackmon, D-Canton, asks a question in the Senate chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Senate President Pro Tempore Sen. Dean Kirby, R-Pearl, holds a folder with files for the Senate Rules Committee, in the Senate Chamber at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Rep. Joey Hood, R-Ackerman, explains a bill to regulate transgender people’s use of bathrooms, locker rooms and dormitories in public education buildings, before the House at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Rep. John Faulkner, D-Holly Springs, asks a question on a bill to regulate transgender people’s use of bathrooms, locker rooms and dormitories in public education buildings, before the House at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Rep. Jansen Owen, R-Poplarville, asks a question regarding a bill to regulate transgender people’s use of bathrooms, locker rooms and dormitories in public education buildings, before the House at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

Mississippi State Rep. Fabian Nelson, D-Jackson, asks for a clarification on a bill to regulate transgender people’s use of bathrooms, locker rooms and dormitories in public education buildings, before the House at the state Capitol in Jackson, Miss., Thursday, May 2, 2024. (AP Photo/Rogelio V. Solis)

• Copy Link copied

JACKSON, Miss. (AP) — Mississippi’s Republican-led Legislature completed a last-ditch effort Thursday to revive a bill to regulate transgender people’s use of bathrooms , locker rooms and dormitories in public education buildings.

Lawmakers pushed the proposal through the House and Senate in the final days of their four-month session after negotiations between the chambers broke down Monday on an earlier proposal. Republicans said they received a flurry of messages urging them to bring the bill back to life.

“This probably, to a lot of our constituents and to a lot of people in this chamber, is probably the most important bill that we brought up,” said Senate President Pro Tempore Dean Kirby, a Republican.

The legislation would require all public education institutions to equip their buildings with single-sex restrooms, changing areas and dormitories.

People would only be allowed to enter spaces that correspond to their sex assigned at birth, regardless of their appearance or any procedures they’ve had to affirm their gender identity. Those who violate the policy could be sued, but schools, colleges and universities would be protected from liability.

Democrats said the bill would put transgender people at risk. They also criticized Republicans for spending time on the issue as other legislative priorities remained unfinished.

“It just baffles me that we have things we can do to improve the state of Mississippi for all people, for all people, but we get so pumped on something that’s national politics,” said Rep. Jeffrey Hulum III, a Democrat. “It is not my job to criticize how people live their lives.”

Republicans said they were standing up for female family members on college campuses and pointed to several Republican women, wearing red, as they looked on from the Senate gallery.

One of those women was Anja Baker, a member of the Mississippi Federation of Republican Women from the Jackson suburb of Rankin County. Baker said she works with social service providers and was concerned women would be crowded out of spaces they rely on.

“They only have so many resources, and they need to have their locations and resources protected for the women that need them instead of getting caught in a game of identity politics,” Baker said.

Advocacy groups emailed her and other Republican women late Wednesday urging them to show up Thursday at the Capitol. That came after an initial measure mandating single-sex spaces stalled, causing an embittered back-and-forth between top legislators.

Just before a Monday night deadline, the House offered a plan that would let people file lawsuits seeking monetary damages if someone uses a bathroom not assigned to their gender, said Senate Judiciary A Committee Chairman Brice Wiggins, a Republican. Wiggins said that made it an unacceptable “trial lawyer bill.”

House Judiciary A Committee Chairman Joey Hood, also a Republican, said the Senate forced the House into accepting a weaker proposal. The bill would let people sue, but they would be unable to claim compensatory damages from any lawsuit. As a result, Hood and other House members said the bill they ultimately approved would likely fail to deter people from entering spaces that don’t align with their sex assigned at birth.

Hood said he hopes the Legislature would introduce legislation in 2025 with stronger penalties.

Another proposal failed this year that would have denied the legal recognition of transgender people by writing into law that “there are only two sexes, and every individual is either male or female.”

In 2021, Republican Gov. Tate Reeves signed legislation to ban transgender athletes from competing on girls’ or women’s sports teams. Last year, he signed a bill to ban gender-affirming hormones or surgery for anyone younger than 18.

The Mississippi proposals were among several bills being considered in state legislatures around the country as Republicans try to restrict transgender people’s access to gender-affirming care, bathrooms and sports, among other things.

Michael Goldberg is a corps member for the Associated Press/Report for America Statehouse News Initiative. Report for America is a nonprofit national service program that places journalists in local newsrooms to report on undercovered issues. Follow him at @mikergoldberg .