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

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

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

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Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

Breast incisions for breast augmentation

  • 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

  • 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

  • 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

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.
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What Is Gender Affirmation Surgery?

gender reassignment surgery woman

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.


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


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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

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

Gender Nullification

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

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

  • Breast tissue removal
  • Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

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

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

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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 .

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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

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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?

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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

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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


Transitioning 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

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Female to Male Gender Reassignment Surgery (FTM GRS)

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

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

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

Interested in having this procedure?

Useful Information

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

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

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


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

Additional Information

What are the risks.

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

What is the recovery process?

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

What are the results?

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

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Preparing for Gender Affirmation Surgery: Ask the Experts

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

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

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

Can I still have children after gender affirmation surgery?

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

Are there other ways I need to prepare?

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

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

An initial intake interview via phone with a clinical specialist.

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

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

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

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

An appointment with your surgeon. 

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

A preoperative anesthesia and medical evaluation. 

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

What can I expect after gender affirming surgery?

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

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

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

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

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Gender 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.

How Gender Reassignment Surgery Works (Infographic)

Infographics: How surgery can change the sex of an individual.

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

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

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

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

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

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

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

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

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

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

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

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Gender Surgeons in United States

Learn about Surgeons in the U.S. who offer Male to Female (MTF) and Female to Male (FTM) procedures, also known as Gender Confirmation Surgery (GCS), Sex Reassignment Surgery (SRS) or Gender Reassignment Surgery (GRS).

Dr. Bauback Safa

Highly Experienced Phalloplasty Surgeon in San Francisco

Dr. Safa is an internationally renowned Reconstructive Microsurgeon and the Medical Director of the San Francisco Transgender Institute. He and his team have performed more than 700 Phalloplasty surgeries since 2012, making him one of the most experienced Phalloplasty surgeons in the world.

Dr. Scott Mosser

Dr. Scott Mosser - Top Surgery San Francisco

Dr. Mosser is an award-winning surgeon in San Francisco who has been helping transgender and non-binary patients for more than 13 years. He is board-certified by the American Board of Plastic Surgeons, co-founder of the American Society of Gender Surgeons (ASGS), Founder of the Gender Institute at Saint Francis Memorial Hospital, a member of WPATH, and co-chair of the Surgery and Beyond professional conference. Dr. Mosser is California’s FTN / FTM Top Surgery and Breast Augmentation expert.

Dr. Heidi Wittenberg

Experienced Urogynecologist in San Francisco Specializing in Gender-Affirming Bottom Surgery Procedures

Dr. Wittenberg is a highly experienced urogynecologist and reconstructive pelvic surgeon in San Francisco who works exclusively with trans and non-binary patients. Dr. Wittenberg is the Director of MoZaic Care, which specializes in gender affirming genital and pelvic surgeries, a Founder Surgeon and Co-Director of the first SRC accredited Center of Excellence in Gender Confirmation Surgery at Greenbrae Surgery Center, and the Medical Director of the Gender Institute at Saint Francis Memorial Hospital.

Dr. Toby Meltzer

Dr. Toby R. Meltzer - Gender Reassignment Surgery

Dr. Meltzer is a plastic and reconstructive surgeon who has been performing gender-affirming procedures since the early ’90s. Dr. Meltzer is widely recognized as one of the leading surgeons in the field of Gender Surgery, having completed over 4000 surgeries. He currently performs approximately 200 genital reconstruction surgery cases per year in Scottsdale, Arizona.

Dr. Charles Garramone

Dr. Charles Garramone

Dr. Garramone is one of the most experienced Top Surgery surgeons in the world, having performed thousands of Top Surgery procedures since 2005. With Dr. Garramone, you won’t have to worry about what your Top Surgery results will look like. His FTM Top Surgery technique is sought after by thousands of patients for its consistent and predictable results.

Dr. Mang Chen

Reconstructive Urologist Specializing in Transmasculine Bottom Surgery

Dr. Chen is a highly experienced Reconstructive Urologist in San Francisco who specializes in bottom surgery procedures for transmasculine individuals. He has performed hundreds of Phalloplasty, Metoidioplasty and related procedures, and has deep expertise in urological repair surgeries.

Dr. Loren Schechter

Dr. Loren Schechter - Gender Confirmation Surgery in Chicago

Dr. Schechter is one of the country’s foremost experts on transgender surgery. He is the Medical Director of the Gender Affirmation Surgery Program at Rush University Medical Center in Chicago. Dr. Schechter has been performing gender-affirming surgeries for more than 20 years. Since 2013, he has performed approximately 100-150 gender-affirming procedures every year. He offers the full spectrum of gender-affirming procedures.

Dr. Andrew Watt

Highly Accomplished Phalloplasty Surgeon in San Francisco

Dr. Watt is a Reconstructive Microsurgeon at the Buncke Clinic, widely considered to be the birthplace of microsurgery. He is a highly accomplished Phalloplasty surgeon, having performed hundreds of microvascular Phalloplasty and related procedures with his team in San Francisco.

Dr. Adam Bonnington

Highly Skilled Obstetrician-Gynecologist in San Francisco Specializing in Gender-Affirming Bottom Surgery Procedures

Dr. Bonnington is a highly skilled obstetrician-gynecologist in San Francisco who is passionate about working with underrepresented patient populations and has a particular interest in caring for transgender and gender expansive individuals. Dr. Bonnington joined MoZaic Care as a Surgical Associate in 2020 and performs Vaginoplasty, Orchiectomy and Hysterectomy.

Dr. Walter Lin

Dr. Walter Lin - Gender-Affirming Top Surgery FTM/MTF/NB

Dr. Lin is a fellowship-trained Plastic Surgeon at the Buncke Clinic in San Francisco. Dr. Lin has a sub-specialization in reconstructive microsurgery and is dedicated to the advancement of care in microsurgical reconstruction of the extremities, breast, and lymphatic systems. His experience in these areas has contributed to his exceptional skills in gender-affirming Top Surgery and Breast Augmentation.

Dr. Angela Rodriguez

Dr. Angela Rodriguez | Facial Feminization & Vaginoplasty Expert

Dr. Rodriguez is a board-certified plastic surgeon in San Francisco who is dedicated full time to providing surgical care for transgender patients. Dr. Rodriguez had 14 years of craniofacial, aesthetic and pediatric plastic surgery experience before becoming a Gender Surgeon. She has a special interest in Facial Feminization and is also highly proficient in Vaginoplasty and Top Surgery.

Dr. Daniel Crane

Dr. Daniel Crane - Top Surgery and Facial Feminization in Florida

Dr. Crane is a plastic surgeon who joined Dr. Drew Schnitt’s Inspire Aesthetics in 2022, expanding access to gender-affirming surgical care in South Florida. After completing a highly specialized aesthetic surgery fellowship where he performed countless breast, body contouring and facial surgeries, Dr. Crane worked with Dr. Schnitt to refine his skills with Top Surgery and Facial Feminization. His broad training in plastic and aesthetic surgery provides him with the knowledge and experience to help you achieve your transition goals.

Dr. Drew Schnitt

Dr. Drew Schnitt - Gender-Affirming Plastic Surgery in Florida

Dr. Schnitt is a board certified cosmetic, plastic, reconstructive and craniofacial surgeon who has been practicing in South Florida since 2002. His experience in cosmetic and craniofacial surgery makes him an excellent choice for gender-affirming facial surgery, as well as Top Surgery, Breast Augmentation and Body Sculpting.

Dr. Daniel Jacobs

The Gender Confirmation Center Expands Access to Top Surgery With Addition of Dr. Daniel Jacobs

Dr. Jacobs is an award-winning and board-certified plastic surgeon in San Francisco who joined The Gender Confirmation Center in July, 2022. Dr. Jacobs has more than 30 years of plastic surgery experience and provides outstanding surgical care for transmasculine, transfeminine and non-binary patients.

Dr. Joel Beck

Dr. Joel Beck - Gender-Affirming Surgery Charlotte

Dr. Beck is a board certified plastic and reconstructive surgeon who has been performing transgender surgery procedures since 2003. Based in Charlotte NC, Dr. Beck routinely performs Facial Feminization Surgery, Breast Augmentation, Top Surgery, Body Contouring and Hair Restoration.

Top Surgery Summer Special Price: $6500

Dr. Josef Hadeed

Dr. Josef Hadeed - Gender Surgery in Los Angeles and Miami

Dr. Hadeed is a board-certified surgeon who specializes in Transgender Surgery, including chest/breast procedures, facial surgeries and body sculpting for both trans men and women. Dr. Hadeed’s practice now has two locations: Beverly Hills, California and Miami, Florida.

Dr. Michelle Lee

Dr. Michelle Lee - Top Surgery in Los Angeles, California

Dr. Lee is a fellowship-trained and board-certified plastic surgeon with deep expertise in aesthetic and reconstructive procedures for the chest/breast and face. Based in Beverly Hills, California, Dr. Lee is as well-known for her surgical precision as she is for the compassion, care and understanding that she has for all of her patients. She has the skill and artistry to help produce the aesthetic goals that transgender and non-binary patients seek with Top Surgery, Breast Augmentation and Facial Gender Confirmation Surgery.

Dr. Russell Sassani

Dr. Russell Sassani - FTM Top Surgery Florida

Dr. Sassani is a board certified plastic and reconstructive surgeon who performs chest procedures, facial surgeries and body sculpting for both trans men and women in Florida. With unanimous 5 star reviews from his trans male patients, Dr. Sassani has quickly become one of the most popular Top Surgery surgeons in the Southeastern United States.

Dr. Daniel J. Freet

Dr. Daniel Freet - Gender Affirming Surgery at the University of Texas

Dr. Freet leads a multidisciplinary team at the University of Texas that performs both male-to-female and female-to-male surgery procedures, including facial and chest surgeries as well as Vaginoplasty, Metoidioplasty and Phalloplasty. Dr. Freet accepts both insurance and Medicare.

Dr. Alvina Won

Dr. Alvina Won - Top Surgery Seattle

Dr. Won is a board-certified surgeon who is committed to providing the highest quality of care in a welcoming environment for all patients. Dr. Won gained significant experience with gender-affirming surgery during a year-long cosmetic surgery fellowship. Finding this work to be extremely gratifying and interesting, Dr. Won now devotes part of her practice to serving the transgender patient population. Based in Washington state, just north of Seattle, she offers Top Surgery, Breast and Buttock Augmentation, and Body Sculpting.

Dr. Gabriel Del Corral

Dr. Gabriel Del Corral - Gender Affirming Surgery in Washington DC

Dr. Del Corral is a double board-certified plastic and reconstructive surgeon who offers Gender Affirmation Surgery at the MedStar Center for Gender Affirmation in Washington D.C. and Baltimore, Maryland. He is an Assistant Professor of Plastic Surgery at Medstar Georgetown University Hospital. Dr. Del Corral is fellowship trained in microsurgery, and has expertise in reconstructive surgery, maxillofacial surgery and cosmetic surgery. He specializes in gender-affirming procedures with a special focus on Vaginoplasty, Facial Feminization and Phalloplasty.

Dr. Praful Ramineni

gender reassignment surgery woman

Dr. Ramineni is a board-certified plastic and reconstructive surgeon with over 15 years of experience. Based in Washington, D.C., Dr. Ramineni performs upwards of 600 surgeries a year and has a specialization in Gender Affirmation Surgery. Recognized for his exceptional surgical skills and natural-looking results, Dr. Ramineni’s patients also praise his friendly, compassionate and professional nature.

Dr. Cassie Nghiem

Dr. Cassie Nghiem - Top Surgery in Washington DC, Maryland and Virginia

Dr. Nghiem is an Ivy League-educated, fellowship-trained plastic surgeon in Washington, D.C. who specializes in transgender surgery, including Chest Masculinization and Breast Augmentation. She believes in a shared vision and works closely with her patients to deliver the best quality care that is in line with their needs. Known for her surgical skill and artistry, Dr. Nghiem’s patients also love her kind and caring demeanor.

Dr. Curtis Crane

Dr. Curtis Crane - Gender Surgeon in Austin Texas

Dr. Crane is a board-certified plastic surgeon who performs Gender Affirming Surgery procedures in Austin, Texas. Dr. Crane is one of only a few surgeons in the world who is trained as both a plastic surgeon and urologist and has also completed fellowships in reconstructive urology and gender reassignment surgery. He has been performing gender surgery since 2005.


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MTF Gender Confirmation: Genital Construction

The specifics, the takeaway.

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As part of a transgender individual’s transition, genital reassignment surgery alters male genitalia into female genitalia.

Written By: Erin Storm, PA-C

Published: October 07, 2021

Last updated: February 18, 2022

  • Procedure Overview
  • Ideal Candidate
  • Side Effects
  • Average Cost

thumbs-up Pros

  • Can Help Complete A Gender Affirmation Journey

thumbs-down Cons

  • Potentially Cost Prohibitive

Invasiveness Score

Invasiveness is graded based on factors such as anesthesia practices, incisions, and recovery notes common to this procedure.

Average Recovery


Surgical Procedure

$ 7000 - $ 24000

What is a male to female (MTF) gender reassignment surgery?

Male to female (MTF) gender reassignment surgery is also known as sex reassignment surgery (SRS), genital construction, and generally as Gender Confirmation Surgery. These procedures are used to remove and alter male genitalia into traditional female genitalia. Plastic surgeons will remove the scrotum, perform a penile inversion to create the neovagina, remove and alter penile erectile tissue to form the clitoral tissue of the clitoris, and construct labia usually from scrotal tissue. The prostate gland is left intact. These procedures create fully functional female genitalia in transgender patients.

Typically gender reassignment surgery is performed as a last step in a transgender individuals transition journey. Guidelines from The World Professional Association for Transgender Health (WPATH) state candidates must have letters of recommendation from their mental health provider and physician, have been living full time as a woman for one year, and have completed one year of hormonal therapy to be eligible.

Information on facial feminization surgeries, top surgeries (like a breast construction), and other male to female gender affirming surgeries as part of a gender transition for transwomen can be found in our comprehensive guide to MTF gender affirmation solutions .

What concerns does a MTF gender reassignment surgery treat?

  • Transfeminine Bottom Surgery & Genital Construction : Male to female gender reassignment surgery creates female genitalia that are aesthetically authentic and functional. A vaginoplasty, penectomy, orchiectomy (testicle removal), clitoroplasty, and labiaplasty are typically performed.

Who is the ideal candidate for a MTF gender reassignment surgery?

The ideal candidate for MTF gender reassignment surgery is a transgender women seeking to complete her physical embodiment of her gender identity. This reconstructive genital surgery creates functioning female genitalia.

MTF gender reassignment surgery is not recommended for those who have not been on hormone therapy for one year, have not been living full time as a woman for one year, do not have letters of recommendation from their mental health provider and physician, children under the age of 18, and those with certain chronic medical conditions.

What is the average recovery associated with a MTF gender reassignment surgery?

Most patients experience four to six weeks of recovery time following a MTF gender reassignment surgery. Patients can expect bruising, swelling, and tenderness following the procedure. A urinary catheter is placed for one week and vaginal packing as well which may cause a sensation of fullness. Vaginal dilation is a component of the procedure and the patient will be advised on how to complete this progressive dilation at home over the course of a few weeks.

What are the potential side effects of a MTF gender reassignment surgery?

Possible side effects following a MTF gender reassignment surgery include bleeding, swelling, bruising, site infection, altered sensation, difficulty urinating, difficulty with sexual function, prolonged edema, and complications from anesthesia or the procedure.

What can someone expect from the results of a MTF gender reassignment surgery?

The results of MTF gender reassignment surgery are permanent. This procedure creates functional female genitalia and removes all male genitalia. The prostate gland is left intact which is important for transgender individuals ongoing healthcare and preventative screenings.

What is the average cost of a MTF gender reassignment surgery?

What to expect.

A MTF Gender Reassignment Surgery creates female genitalia. Here is a quick guide for what to expect before, during, and after a MTF Gender Reassignment Surgery:

Before Surgery

  • Prophylactic antibiotics or antivirals may be prescribed
  • Stop taking blood thinning medications two weeks prior to surgery. Blood thinners may include, Advil, Tylenol, Aspirin, and prescription anticoagulants
  • Stop smoking four weeks prior to the procedure and continue cessation for four weeks post op
  • No alcohol two days prior to the procedure
  • Do not eat or drink six hours before

During Surgery

  • General anesthesia
  • A penile inversion is performed to create the vaginal canal
  • The scrotum is removed
  • Skin grafts are used to create the labia and vulva
  • Erectile tissue is removed from the new vaginal walls, and erectile tissue from the head of the penis is used to create the clitoris
  • ​The urethra is shortened

Immediately After Treatment

  • Swelling, bruising, and tenderness

1 - 30 After Treatment & Beyond

  • Resume most activities after a few days
  • Swelling typically resolves within a few weeks
  • Avoid strenuous activity for two to four weeks
  • Remove urinary catheter and vaginal packing after one week
  • Continue progressive vaginal dilation

Result Notes

  • Results are permanent
  • Proper aftercare will ensure optimal results

Gender confirmation surgeries for transgender individuals are an important component of transgender health and in creating an embodied gender identity. Gender reassignment surgery allows transgender women who feel it is a part of their transition to more fully embrace their gender identity.

To learn more about our content creation practices,  visit our Editorial Process page .

Source List

AEDIT uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

  • American Society of Plastic Surgeons Gender Confirmation Surgeries plasticsurgery.org
  • Karel E Y Claes Chest Surgery for Transgender and Gender Nonconforming Individuals PubMed.gov ; 2018-07-02

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Learn More About MTF Gender Confirmation: Genital Construction in The AEDITION

Gender Transitioning And Skincare: Taking Care Of Your Changing Face

Gender Transitioning And Skincare: Taking Care Of Your Changing Face

Side effects of hormone therapy often show up on the skin in the form of acne, pigmentation, and uneven skin texture. Here’s what you need to know about the most common skin concerns and treatment options.

A Guide To Non-Surgical Facial Feminization

A Guide To Non-Surgical Facial Feminization

Facial feminization procedures have been gaining popularity among men hoping to look more approachable or transition to female as well as among women hoping to have a more feminine appearance.

Finding The Right Plastic Surgeon, Dermatologist, Or Cosmetic Dentist

Finding The Right Plastic Surgeon, Dermatologist, Or Cosmetic Dentist

When considering a cosmetic procedure, it is so important to find the right doctor for you.

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First transgender woman in Mass. receives vaginoplasty outside Boston, as statewide care expands

A woman sits looking straight at the camera with a slight smile.

  • tori_bedford

In mid-May, Chrissi Bates placed an order at a Market Basket bakery counter — a marble cake with orange flowers and the words “WELCOME TO WOMANHOOD” piped in pink icing across the top.

The cake was Bates’ final preparation for a long-awaited gender-affirmation surgery, a significant turning point in her own life and a new chapter for transgender healthcare in western Massachusetts.

Hours later, Bates became the first patient to receive a gender-affirming vaginoplasty, or bottom surgery, at UMass Memorial Hospital in Worcester, the first known procedure at a Massachusetts hospital outside of Boston. As Bates was wheeled to the operating room on a gurney, hospital staff buzzed, nurses stopped to share their excitement and medical residents gathered to observe the seven-hour surgery.

“It’s really just about trying to be my most authentic self,” Bates said. “I feel like I’m making history, I really do. I know it happens in Boston, but for this area, it significantly changes the landscape for access to care.”

Bates is one of a growing number of people in Massachusetts and across the country to undergo gender-affirming surgeries as insurance coverage has expanded for transgender care over the last decade. Between 2016 and 2020, nearly 50,000 patients underwent gender-affirming surgery, according to a Columbia University study published last year.

But transgender healthcare is still limited, particularly outside of major city centers. More than a quarter of transgender patients in rural areas, including parts of Massachusetts, reported that they had no access to gender-affirming primary care, and more than half said they had to travel two hours or more to see a doctor, according to a 2022 Fenway Health/Harvard University study.

Bates’ surgeon, Dr. Ashley Alford, says she came to UMass last summer with a plan to address that gap. With Bates as the first patient and a slate of some 15 people in line behind her, Alford is working to establish a clinic at UMass for gender-affirming surgical and psychological care, tentatively named the TRANScend Clinic.

“It’s all about accessibility,” Alford said. “I’m hoping to build it and they will come.”

Chrissi Bates, 29, applies makeup in her bathroom mirror, April 17, 2024

Dallas Ducar — who founded the Northampton-based healthcare center Transhealth in 2021 in response to a call for more resources for trans people in rural areas — says Bates’ surgery is reflective of needed change.

“This is really a historic moment, a milestone for gender affirming care in the state,” she said. “There’s really an importance in expanding care beyond major urban centers.”

Becoming Chrissi Bates

Bates says she knew she was different as a child but didn’t see a way out.

She said she had a conservative Catholic upbringing that provided little space for gender expression. In her senior year of high school, she came out as gay to a few close friends.

“I would look in the mirror and I just always felt like I was in the wrong body,’’ she said. “It wasn’t until later in high school, when I started dressing in women’s clothes.”

She also was a victim of commercial sexual exploitation. Bates experienced homelessness and poverty as a child and sexual assault as a teenager, when she engaged in survival sex work. She was featured in a GBH News investigation focused on boy victims of the sex trade and became an advocate for exploited youth.

She now works with homeless youth at a nonprofit in Worcester, using her lived experience to help other young people access housing.

Chrissi Bates, 29, in Kelvingrove Park, on a trip to London Saturday June 8, 2024

After years of therapy, she began to seek gender-affirming care. UMass Memorial in Worcester was the logical choice. The hospital is about 15 miles from her home. As a child, she used to go there to see a pediatrician. And it’s where she already has gone for hormones, voice surgery and a facial feminization operation as she’s continued her transition over the last few years.

Bates says the whole process has made her feel affirmed — especially by the way doctors took her seriously and treated her with respect.

“I broke down,” she said, “because it’s just so nice to see doctors actually hearing my concerns.”

Across the country, mistreatment from medical providers continues to be an issue for transgender and nonbinary patients. A 2022 report from the U.S. Transgender Survey found that nearly half of all respondents who saw a doctor in the previous year reported at least one negative experience with a provider, including physical or emotional abuse.

Chrissi Bates with Dr. Ashley Alford at UMass Memorial Hospital in Worcester, May 30, 2024

Bates says she feels privileged for the treatment — and she’s hoping she can open the door for other people to feel safe and get the care they need.

“It just makes me want to advocate for so many other people that are lost and really stuck,” she said. “I’ve been there, and it was really dark at one point.”

A surgery milestone

Alford, Bates’ surgeon, found herself drawn to gender-affirming surgery during a urology residency at the University of Minnesota. She worked with older patients who waited years for surgery, including one who waited 65 years for a vaginoplasty.

“It’s a much more emotional kind of satisfaction, seeing patients, for the first time in their life, being happy to see themselves naked,” she said. “It’s just life-changing for patients, and they come back as completely different people. Finally their body aligns with how they’ve always felt.”

Alford says she became motivated to expand transgender care into more rural areas during a year-long fellowship at the NYU Langone Health medical center, where she saw patients who had to travel long distances and spend considerable amounts of money to access care.

“It made me realize that if I could bring services just up north three hours, it would make it so much more accessible to so many more people, ” she said.

At UMass, Alford also is bringing with her a modern process developed in 2017 at NYU. The process, which uses abdominal tissue and an assist from robotic technology, aims to achieve a more realistic and functional vagina than more commonly-practiced procedures.

Bates is the first patient in New England to undergo this kind of gender-affirming surgery, medical experts say.

Chrissi Bates, 29, prepares for her surgery at UMass Memorial Hospital in Worcester, May 13, 2024

Dr. Alex Keuroghlian, who founded and leads the psychiatry gender identity program at Massachusetts General Hospital, says it’s important to have these kinds of options outside of Boston.

Keuroghlian identified “dramatic needs” among transgender patients in rural areas of Massachusetts in a 2021 study . The study found transgender patients in rural areas faced a lack of healthcare providers, were refused treatment and were more likely to experience discrimination.

“I love the fact that a cutting-edge vaginoplasty would be available outside of the Boston area. It’s important to have options within the state,” Keuroghlian told GBH News. “People will often travel as far as they need to, to have the gender-affirming surgical procedure that’s right for them. So having new surgical options in Massachusetts and having these not necessarily all be concentrated in Boston is wonderful.”

Though the record of gender-affirming bottom surgeries in the United States dates back to the early 20th century, barriers persist. Roughly a quarter of transgender patients are denied healthcare services, leading to a 73% higher risk of attempted suicide, according to research from Wright State University in Ohio.

An anti-trans political movement also has gathered steam in recent years. In 2023, state legislators across the country introduced more than 100 pieces of legislation banning aspects of gender-affirming medical care, according to data from the American Civil Liberties Union.

Alford says there are still women in certain areas of the country who have to buy hormones through the black market because they can’t get a doctor to prescribe them the drugs they need.

“Even now, there’s still an underground transgender health care movement,’’ she said. “It’s very, very sad, but that is the unfortunate state of this country right now.”

Getting approved

Patients who manage to access medical care have to navigate policy hurdles to get insurance coverage.

Bates worked with Alford to make sure her insurance applications reflected guidelines laid out by the World Professional Association for Transgender Health, or WPATH. That includes a doctor’s note proving that she’d been on hormones for at least a year and that any medical issues were under control.

She also needed letters of support from mental health providers diagnosing her with gender dysphoria, a medical term for the state of psychological distress experienced when a person’s gender identity doesn’t match the sex they were assigned at birth.

WPATH urged medical providers and insurers to move away from “gender dysphoria” as a prerequisite for approval.

Doctors like Keuroghlian have pushed for insurers to stop requiring a psychological diagnosis of gender dysphoria as part of a movement to “uncouple the inherent stigma” and modernize the process.

“When you require letters by mental health professionals, that automatically creates an additional set of barriers,” he said. “There’s this implication that this is somehow a mental health problem, which we know it absolutely isn’t.”

Chrissi Bates with her partner Andrew, preparing for surgery at UMass Memorial Hospital in Worcester, May 13, 2024

Bates says, for her part, she never felt comfortable with the parts of her body that didn’t match who she was inside.

“I just never identified with it or felt satisfaction from it,” she said. “But it doesn’t make people any less trans, if they do like it or they don’t. It’s just really about how you identify on the gender spectrum and about letting people do what they want.”

She says she will continue to follow up with Alford over the next six months and work on a series of exercises to strengthen her pelvic floor and adjust to the change. As she continues to heal, she says she’s feeling more and more confident in her new body.

When she saw herself for the first time after her surgery, Bates was overjoyed.

“Every time I wake up, I’m just like, 'wow, this is even more me. I’m becoming more me,'’’ she said. “It’s an honor and a privilege to be able to be who I actually am.”

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Supreme Court ruling on transgender surgery could impact Arizona

Arizona Superintendent of Public Instruction Tom Horne speaks to reporters in Phoenix on Wednesday, May 24, 2023. Horne has submitted a formal legal response in his defense of a lawsuit challenging the state law that "prohibits biological boys from playing on girls’ teams." At far right is Marshi Smith, the 2005 NCAA and Pac-10 Conference Women’s backstroke champion who competed at the University of Arizona.

By Howard Fischer Capitol Media Services

PHOENIX -- The decision Monday by the U.S. Supreme Court to take up the question of whether states can ban transgender medical care for minors could have an impact on Arizona.

A 2022 Arizona law bans at least part of what the high court will take up next session: gender reassignment surgery on those younger than 18. That is part of the Tennessee law which is being challenged by the Biden administration and trans youths in that state as a violation of constitutional equal protection rights as well as parental rights to make decisions for their own children.

If the justices conclude that statute is unconstitutional, the Arizona law will go away. But the Tennessee law that the justices will review has something that doesn't exist in Arizona: a ban on hormonal treatments and other non-surgical transition aid. That means minors here will be able to continue to get that kind of medical care regardless of what the Supreme Court rules.

It wasn't the way Senate President Warren Petersen wanted the Arizona law to read. The Gilbert Republican actually tried to get colleagues to adopt a law very similar to Tennessee.

His original proposal, dubbed the "Arizona Children Deserve Help Not Arm Act,'' would have made it illegal for a doctor or other health care professional from providing gender transition procedures to any individual younger than 18. That included not just surgery but also puberty-blocking drugs, cross-sex hormones "or other mechanisms to promote the development of feminizing or masculinizing features in the opposition biological sex ... performed for the purpose of assisting an individual with gender transition.'' It did contain exceptions, including those born with chromosomal irregularities or lacks sex steroid hormone production.

But Petersen found himself unable to line up the votes as Republican Sen. Tyler Pace aligned with Democrats to keep the bill from getting out of the Senate Committee on Health and Human Services.

Pace, a Mesa Republican who is no longer in the Legislature, said at the time he originally favored what Petersen Proposed. But he said that changed after hearing comments from children and their parents who "are using these avenues of medical treatment to save lives.''

"I don't want my vote to stop those great things,'' he said.

In the end, the bill that got out of the Senate -- and eventually was adopted by the House -- was the one Pace said he could support.

It bans "irreversible gender reassignment surgery'' to any individual younger than 18. And it does include the same exceptions that were in Petersen's original bill.

In deciding to sign the legislation, then-Gov. Doug Ducey specifically pointed out that the measure does not prohibit doctors from providing puberty-blocking hormones or any other hormone therapy to minors.

"SB 1138 delays any irreversible gender reassignment surgery until the age of 18,'' Ducey explained.

"The reason is simple and common sense,'' he continued. "This is a decision that will dramatically affect the rest of an individuals' life, including the ability of that individual to become a biological parent later in life.''

And Ducey said there's nothing wrong with providing different standards between what adults can do with their bodies versus what can happen with children, even in cases where the parents agree.

"Throughout law, children are protected from making irreversible decisions, including buying certain products or participating in activities that can have lifelong health implications,'' he said. "These decisions should be made when an individual reaches adulthood.

The governor also said that many doctors who perform these procedures have concluded it is not "within the standards of care'' to do so on children.

The day that Ducey signed the ban on transgender surgery on minors was the same day he inked his approval to a separate law that spells out that anyone not born female cannot participate in girls' interscholastic or intramural sports.

Ducey denied that it was denying any opportunity to transgender girls, saying they remain free to compete on coed teams.

"It's a way where all can participate,'' the governor said. "But those that are in competitive environments can have a level playing field.''

A federal judge already has ruled that two transgender girls are allowed to participate in girls' sports, though she has not struck down the entire statute. State schools chief Tom Horne and GOP legislative leaders are appealing that decision.

On X and Threads: @azcapmedia

Q Daily, 11, said he'd prefer not to grow up. But he is now on the cusp of middle school, adolescence and facing his changing body. And for a transgender child, this time of life is particularly complex.

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UP man who was forced to undergo sex reassignment surgery narrates ordeal

It all began as Mujahid, a class 12 student, first crossed paths with Om Prakash at a local factory where Prakash held a supervisory role. Despite initial helpfulness, their relationship turned ugly when Prakash allegedly began sexually harassing Mujahid for over two years, leveraging threats of releasing compromising videos and harm to his family.

gender reassignment surgery woman

New Delhi: Mohammed Mujahid, a 20-year-old from Sanjak village in Uttar Pradesh’s Muzaffarnagar district, found himself at the centre of a harrowing ordeal when a trusted acquaintance allegedly orchestrated his forced gender reassignment surgery.

UP police dept in dilemma as 2 female cops apply for gender change surgery

The situation escalated drastically on June 3 when Prakash reportedly lured Mujahid to a location, drugged him and upon awakening, informed him that he had undergone a sex change procedure against his will. Shocked and in pain, Mujahid discovered his genitals were surgically removed at Begrajpur Medical College. His distress was compounded by allegations that Prakash posed as his guardian during the procedure.

Family files police complaint

Mujahid’s family, upon being alerted by him, rushed to the hospital, demanding justice and action against Prakash and the medical team involved, particularly Dr Farooqi, who performed the surgery. They accused the hospital of negligence for not verifying identities properly. In response to the family’s complaint, Muzaffarnagar Police initiated legal proceedings, arresting Om Prakash under sections including voluntarily causing grievous hurt, cheating, and unnatural offenses

Hospital denies allegations

However, hospital authorities, represented by Chief Medical Superintendent Kirti Goswami, refuted allegations of deception, saying that Mujahid had willingly sought sex reassignment surgery and had been visiting the hospital for consultations over two months. The case has sparked widespread outrage and calls for justice, with Mujahid’s family seeking intervention from Uttar Pradesh Chief Minister Yogi Adityanath.

All we know about Tajikistan’s hijab ban:  A controversial move towards “Tajiki” identity...


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