gender reassignment surgery woman

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

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

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

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

Products & Services

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

Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

• Breast augmentation incisions

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

• Placement of breast implants or tissue expanders

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

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

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

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

Genital surgery

• Anatomy before and after penile inversion

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

• Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical trials

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

Feminizing surgery care at Mayo Clinic

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

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

• Opportunities

Mayo Clinic Press

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

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

Help transform healthcare

Your donation can make a difference in the future of healthcare. Give now to support Mayo Clinic's research.

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

Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

American Society of Plastic Surgeons. Gender confirmation surgeries .

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

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

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

What Is Gender Affirmation Surgery?

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

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

Why Is Gender Affirmation Surgery Performed?

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

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

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

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

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

Transgender vs Nonbinary

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

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

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

Hormone Therapy

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

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

Types of hormone therapy include:

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

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

Masculinizing Surgeries

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

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

Top Surgery

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

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

Metoidioplasty

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

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

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

Phalloplasty

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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

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

Gender Nullification

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

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

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

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

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

American Society of Plastic Surgeons. Gender affirmation surgeries .

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Related Articles

Jump to content

Updated visitor policies

Other michigan medicine sites.

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

Michigan Medicine

Federated search page form block, quick links.

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

Gender Confirmation Surgery

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

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

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

Available surgeries:

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

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

Sex Reassignment Surgeries (SRS)

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

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

Male-to-female sex reassignment surgery

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

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

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

Female-to-male sex reassignment

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

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

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

Road closure on Marquam Hill: Part of S.W. Campus Drive is closed until March 2025.

Transgender Health Program

Gender-affirming surgery.

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

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

Our surgical services

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

Top surgery:

• Gender-affirming mastectomy
• Gender-affirming breast augmentation

Bottom surgery:

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

Hysterectomy

Nullification surgery, oophorectomy, orchiectomy.

Bottom surgery options also include:

• Scrotectomy
• Scrotoplasty
• Urethroplasty
• Vaginectomy

Additional gender-affirming options:

• Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

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

For patients

Request services.

Please fill out an online form:

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

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

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

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

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

Some patients choose hysterectomy to:

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

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

How hysterectomy is done

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

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

Considerations and risks

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

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

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

Nullification surgery may include:

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

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

Nullification surgery cannot be reversed. Risks can include:

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

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

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

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

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

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

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

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

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

How orchiectomy is done

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

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

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

Adam’s apple reduction (laryngochrondoplasty)

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

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

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

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

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

OHSU also offers Adams’ apple enhancement surgery.

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

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

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

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

Face options:

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

Body options:

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

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

• Vaccines  
• Masking Guidelines
• Visitor Guidelines  

Gender Affirmation Surgeries

Featured Expert:

Fan Liang, M.D.

Surgeries are not required for gender affirmation, but many patients choose to undergo one or more surgical procedures. Talk with your doctor to discuss what surgical options may be right for you. The following is an overview of gender affirmation surgeries.

• Penile construction (phalloplasty/metoidioplasty) : This surgical procedure can include removal of the vagina (vaginectomy), reconstruction of the urethra and penile reconstruction. Surgeons may use either vaginal tissue or tissue from another part of the body to construct the penis.
• Vaginal construction (vaginoplasty) : This surgical procedure is a multistage process during which surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina, the clitoris (clitoroplasty) and the labia (labiaplasty).
• Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.
• Facial gender surgery can include a variety of procedures to create more feminine features , like reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. 
• Facial gender surgery can also include a series of procedures to create more masculine features , such as forehead lengthening and augmentation; cheek augmentation;  reshaping the nose  and chin;  jaw augmentation ; and thyroid cartilage enhancement to construct an Adam’s apple.
• Hysterectomy : This surgical procedure includes the removal of the uterus and ovaries (oophorectomy). There are options for oocyte storage and fertility preservation that you may want to discuss with your doctor. 
• Some people may combine this procedure with a scrotectomy , which is surgery to remove all or part of the scrotum. For others, the skin of the scrotum can be used in vulvoplasty or vaginoplasty ― the surgical construction of a vulva or vagina.
• The procedure reduces testosterone production and may eliminate the need for continuing therapy with estrogen and androgen-suppressing medications. Your health care practitioner will discuss options such as sperm freezing before orchiectomy that can preserve your ability to become a biological parent.

Recovery After Gender Affirmation Surgeries

Recovery time from a gender affirmation surgery or procedure varies, depending on the procedure. Talk to your doctor about what you can expect.

Treatment Caring for Transgender Patients

Fearing discrimination and hostility, transgender people are often reluctant to seek care. Discover how Paula Neira, Program Director of LGBTQ+ Equity and Education, Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, is working to ensure that all patients — regardless of gender identity — are treated with dignity and respect.

Find a Doctor

Specializing In:

• Transgender Health
• Gender Affirmation Surgery

Find a Treatment Center

• Center for Transgender and Gender Expansive Health

Find Additional Treatment Centers at:

• Howard County Medical Center
• Sibley Memorial Hospital
• Suburban Hospital

Request an Appointment

Metoidioplasty for Gender Affirming Care

Transgender and Gender-Diverse Voice Care

Facial Masculinization Surgery

Related Topics

• LGBTQ Health
• Gender Affirmation

Advertisement

Stages of Gender Reassignment

• Share Content on Facebook
• Share Content on LinkedIn
• Share Content on Flipboard
• Share Content on Reddit
• Share Content via Email

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

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

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

Gender Dysphoria: Diagnosis and Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lots More Information

Author's note: stages of gender reassignment.

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

Related Articles

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

More Great Links

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

Please copy/paste the following text to properly cite this HowStuffWorks.com article:

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

Schedule an appointment today

Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

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

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

Penile Inversion Technique for Vaginoplasty

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

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

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

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

Things to Consider Before Having a Penile Inversion Vaginoplasty

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

Postoperative Care of Your New Vagina

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

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

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

Fact Check: Walz Did NOT Approve Legislation That Overrules Existing Protocols On Age For Gender-Affirming Surgeries

• Aug 9, 2024
• by: Uliana Malashenko

Did Minnesota Gov. Tim Walz sign a bill "allowing gender reassignment surgery for children"? No, that's not true: No state law sets a specific minimum age for gender-affirming surgical interventions, a Minnesota lawmaker told Lead Stories. Major health care providers do not operate on people under 18. One bill signed into law protects youth access to those services discussed in broad terms, but doesn't address a specific age.

The claim reproduced a frequent misconception about gender-affirming care: It ignores that such care is not limited to surgeries and includes many other treatments such as mental health services, puberty blockers and hormone therapies.

The claim appeared in a post (archived here ) on X, formerly known as Twitter, on August 6, 2024, by @BRICSinfo. It said:

Tim Walz, the VP selection for Kamala Harris, signed a bill allowing gender reassignment surgery for children and a bill requiring schools to stock tampons in boys' bathrooms. Donald Trump says he will ban gender reassignment surgery for children in all 50 states.

This is what the post looked like on X at the time of writing:

(Source: X screenshot taken on Wed Aug 7 15:37:05 2024 UTC)

What are the laws?

Rep. Leigh Finke (archived here ) who sponsored several key bills concerning gender-affirming care in Minnesota, told Lead Stories via email on August 8, 2024:

No law in Minnesota has been passed addressing the age of receiving gender affirming care, including surgery. We simply protected access to gender affirming care as it already existed for those who require it ... Standards of care in Minnesota follow the national and international guidelines for gender affirming care. Like all heathcare decisions, gender affirming care is highly personal and individualized. Families, patients, and doctors are best able to make those decisions, not the government. Minnesota's largest providers of gender affirming care do not perform any surgeries on individuals under 18.

Neither legislation about youth transgender health (archived here ), sometimes referred to as the "trans refuge" law (archived here ), nor the Governor's Executive Order on "Protecting and Supporting the Rights of Minnesota's LGBTQIA+ Community Members to Seek and Receive Gender Affirming Health Care Services" (archived here ) contains any provisions overriding existing medical protocols or sets a specific minimum-age bar for what the post called "gender reassignment surgery."

Both pieces of legislation went into effect in 2023. They discuss gender-affirming care in general terms to ensure that those who need care recognized as medically necessary (archived here ) by the Centers for Disease Control and Prevention, can safely access it.

Neither define such care exclusively as surgery. In reality, gender care can be many other things (archived here ). The transgender refuge law doesn't even explicitly mention surgical interventions -- it focuses on mental health services and other aspects of gender-affirming care.

Finke, a member of the Minnesota Democratic-Farmer-Labor Party, added:

In 2024, I carried a bill to require gender affirming care coverage among certain health care plans in the state of Minnesota. This law also did not address standards of care, including age. At no point has Minnesota legislature in the past two years passed legislation to change the standards of gender affirming care--including the age at which surgery could be conducted-- in Minnesota.

In June 2023, the Minnesota Reformer news website reported (archived here ) that "most medical centers require individuals to be at least 18 years old for bottom surgery and chest, or 'top,' surgery."

In the spring of 2024, as Minnesota's gender care legislative actions made the news, Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children's Minnesota, told MPR (archived here ), a local public radio station, that the state does not perform gender-affirming surgeries on patients under 18 years old.

Lead Stories searched Minnesota statutes, laws and rules , but did not find anything that would explicitly set a minimum age for gender-affirming surgeries.

What are the surgeries?

" Gender (or sex) reassignment surgery " (archived here ), as the post on X calls it, is an outdated term (archived here ). It was once used primarily to refer to the medical interventions that change a person's genitalia.

The World Professional Association for Transgender Health (WPATH) manual (archived here ) -- one of the most authoritative sources of evidence-based gender care recommendations -- suggests on page 59 the term "gender-affirming surgeries," instead, . The current term incorporates several more interventions, and not all of them concern genitalia or the chest area, according to the appendix , attached to Chapter 13.

The newer term and its definition are consistent with the wording used by Minnesota's Department of Human Services (archived here ).

Who counts as a child?

In Minnesota, a child, or a minor, is any person younger than 18 (archived here ). After that, a person is generally considered an adult for many legal purposes. Though certain restrictions are still applicable (archived here ), that does not include required parental consent when it comes to health care (archived here ).

For gender-affirming care, however, "child" is not a blanket term for anyone under 18: People go through several developmental stages between birth and adulthood, and health care professionals consider that while deciding what is appropriate and medically necessary.

For example, the WPATH guidelines (archived here ) differentiates between children, pubescent youth and adults, as seen on page 67:

Unlike pubescent youth and adults, prepubescent gender diverse children are not eligible to access medical intervention (Pediatric Endocrine Society, 2020); therefore, when professional input is sought, it is most likely to be from an HCP [health care professional] specialized in psychosocial supports and gender development.

While WPATH suggests that there might be some benefits if vaginoplasty is performed before the age of 18, that appears to offer some flexibility -- not a blanket recommendation. At the same time, the organization still strongly advises against phalloplasty before that age.

The Minnesota Department Human Services (archived here ) prohibits one particular surgery -- phalloplasty -- before 18. In any case, the agency requires authorization for any other gender-affirming surgery, listing additional requirements for those younger than that age.

Trans youth and genital surgeries

Lead Stories was not able to locate any Minnesota-specific data about gender-affirming surgeries performed on people under 18, but available national statistics confirmed that genital surgeries in that age category are incredibly rare.

For example, a 2022 Reuters story (archived here ), citing an analysis of insurance claims for roughly 330 million U.S patients over five years, reported that:

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021.

A 2023 study (archived here ) published by the American Medical Association's JAMA Network Open, a peer-reviewed medical journal, read:

... breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

A 2024 article in JAMA Network Open (archived here ) found that among minors who had gender-affirming surgeries in 2019, 96.4 percent -- or 82 out of 85 cases -- were chest-related procedures, not genital surgeries.

Lead Stories contacted Minnesota Gov. Walz about the claim that is the target of this fact check. If we get a response, the article will be updated as appropriate.

About @BRICKinfo

The same account on X that posted the claim that is the focus of this fact check previously published a misleading statement about President Joe Biden before he dropped out of the presidential race. Lead Stories debunked it here .

Further reading

Lead Stories previously debunked false claims about transitions in toddlers here . Other Lead Stories fact checks concerning claims about transgender issues can be found here . Fact checks of claims about the 2024 U.S. presidential election are here .

Uliana Malashenko is a  New York-based freelance writer and fact checker. Read more about or contact Uliana Malashenko

Lead Stories is a fact checking website that is always looking for the latest false, misleading, deceptive or inaccurate stories, videos or images going viral on the internet. Spotted something? Let us know! .

Lead Stories is a:

• Verified signatory of the IFCN Code of Principles
• Facebook Third-Party Fact-Checking Partner
• Member of the #CoronavirusFacts Alliance

WhatsApp Tipline

Have a tip or a question? Chat with our friendly robots on WhatsApp!

Add our number +1 (404) 655-4223 , follow this link or scan the image below with your phone:

@leadstories

Subscribe to our newsletter

Please select all the ways you would like to hear from Lead Stories LLC:

You can unsubscribe at any time by clicking the link in the footer of our emails. For information about our privacy practices, please visit our website.

We use Mailchimp as our marketing platform. By clicking below to subscribe, you acknowledge that your information will be transferred to Mailchimp for processing. Learn more about Mailchimp's privacy practices here.

Fact Check: Image Of Kamala Harris' August 8, 2024 Detroit Rally Was NOT Digitally Altered

Fact Check: Kamala Harris' August 8, 2024, Detroit Rally Photo Is NOT AI-Generated; Airplane Engine and Fuselage Reflection Explained by Physics

Fact Check: Photo Does NOT Show Undamaged Ear In Immediate Weeks After Trump Shooting

Fact Check: Donald Trump Did NOT Owe Money To Bozeman Airport -- Plane Diversion Due To Mechanical Reasons

Fact Check: AP Did NOT Publish Fact Check On Fake Walz Horse Related Stomach Pumping Story

Fact Check: 113 Non-Citizens Did NOT Vote For President In DC June '2024 Presidential Primary'

Fact Check: Trump, Epstein Photos With 'Underage' Women NOT Authentic -- They're AI Generated

Most recent.

Fact Check: Satirical Claim Falsely Says Hope Walz Received $82,000 In Student Loan Forgiveness, Parents Worth $138 Million

Fact Check: Video Does NOT Show Tim Walz Enforcing '2020 COVID Lockdowns By Having Police Shoot Civilians With Paintball Guns' -- It Was Response To George Floyd Protests

Fact Check: Video Does NOT Show Authentic Jordan Peterson Promotion Of 'The Herbal Tablets' Book

Fact Check: Mel Gibson Did NOT Accuse Oprah Winfrey Of Selling Children

Fact Check: Photos Do NOT Genuinely Show 'Incredible Discovery' Of UFO In Egypt Desert

Fact Check: Teen Named 'Graci Mae Thompson' Is NOT Missing In Various Cities -- This Is Part Of Real Estate Scam

Fact Check: Trump DID Fly On Plane Previously Owned By Epstein -- Trump Campaign Says It Leased Plane Without Knowing Aircraft's History

Share your opinion, lead stories.

• Open access
• Published: 10 August 2024

Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran

• Elham Rahimpour 1 ,
• Elham Askary 1   nAff4 ,
• Shaghayegh Moradi Alamdarloo 1 ,
• Saeed Alborzi 2 &
• Tahereh Poordast 3  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  100 ( 2024 ) Cite this article

56 Accesses

6 Altmetric

Metrics details

Gender dysphoria, characterized by a misalignment between one’s gender identity and assigned sex, propels individuals towards medical interventions like gender reassignment surgery (GRS) to harmonize their bodies with their gender. This process aims to enhance overall quality of life (QoL), functioning, and body image. Recognizing the importance of cultivating a positive body image for transgender individuals navigating societal norms, this narrative highlights the ongoing debate surrounding QoL post-GRS. In response, our study is outlined, aiming to scrutinize QoL and self-image among transgender men post-GRS, offering valuable insights into societal perceptions and psychological well-being in this context.

This cross-sectional survey focused on transgender men aged 15 to 35 who underwent gender reassignment surgery (GRS) in 2018–2022 in Shiraz, Iran. Participants, after passing psychiatric evaluations, completed World Health Organization Quality of Life (WHOQOL-100) questionnaires pre- and at least one-year post-surgery. The scores of the Brief-WHOQOL questionnaire were evaluated in four domains of physical health, psychological health, social relationships, and environmental health.

A total of 60 individual who underwent GRS completed our questionnaire. The average age of the patients was 24.1 ± 3.8 years. Following GRS, the most increase was observed in the psychological factor (by 25.6%). The increase in score was statistically significant in all subgroups ( P  < 0.001) after operation. Urban living location had a significant association with higher increase in physical health ( P  < 0.010), psychological health ( P  = 0.005), and environmental health ( P  = 0.012) after GRS. In regards to physical health, the low socioeconomic group had a significantly less physical score improvement in QoL compared to the moderate group ( P  = 0.024) following GRS. In regards to environmental health, the high socioeconomic groups had significantly higher improvement in QoL compared to the low ( P  = 0.006) and moderate ( P  < 0.001) group after operation.

The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients hailing from low socioeconomic backgrounds and rural areas.

Gender dysphoria is a is described as a persistent and distressing misalignment between gender identity and the sex assigned at birth [ 1 ]. To alleviate the physical incongruence and distress associated with gender dysphoria, there is often a strong desire for medical and surgical interventions to align the body more closely with one’s experienced gender [ 2 ]. The prevalence of gender dysphoria seems to be increasing globally [ 3 , 4 , 5 ].

Transgender individuals often experience a sense of being trapped in the wrong gendered body and typically seek hormonal and surgical reassignment to align with their identified gender. Many desire the removal of the uterus and ovaries promptly to alleviate the stress of menstrual occurrences and reduce estrogen production, facilitating the effectiveness of exogenous androgen therapy [ 6 ].

Quality of life (QoL) is characterized as an “individuals’ perceptions of their position in life concerning their goals, expectations, standards, and concerns in the context of the culture and value systems in which they live.” This encompasses a broad concept influenced by factors such as physical health, psychological well-being, level of independence, social relationships, personal beliefs, and the connection to significant aspects of their environment. The intricate interplay of these elements contributes to the overall understanding of an individual’s quality of life. [ 7 , 8 , 9 , 10 ]

Gender reassignment surgery (GRS) is widely acknowledged for enabling transgender individuals to embrace their identified gender fully, marking it as the most effective treatment option [ 11 ]. Both GRS and hormonal treatment (HT) have demonstrated enhancements in quality of life (QoL), overall functioning, and body image perception. Despite variations in hormonal treatment dosages in some studies and the absence of standardized assessments for hormonal status, positive effects have been observed. Additionally, some experts suggest that GRS and HT might contribute to a reduction in the risk of suicidal attempts among transgender individuals [ 11 , 12 , 13 , 14 ].

Transgender individuals should have the opportunity to cultivate a positive body image [ 15 ]. For transgender people, body image serves as a means of self-expression and enables them to navigate their transgender identity in a world that often perceives gender in binary terms. This dynamic gives rise to a complex interplay of desire, authenticity, and the need to avoid societal stigma. Achieving a positive body image is crucial for trans people as it empowers them to assert their identity and cope with the challenges posed by societal norms and expectations. [ 16 ]

There exists a lack of consensus in the field regarding QoL, particularly post-gender reassignment surgery [ 17 ]. Some earlier studies indicate that transgender individuals exhibit lower QoL compared to the general population [ 17 , 18 , 19 ], while others report no significant differences in QoL or psychological functioning between transgender individuals and the general population [ 14 , 20 , 21 , 22 ]. Poor sexual life quality post-surgery can negatively impact psychological well-being, causing considerable distress [ 23 ]. Thus, this study seeks to assess the quality of life and self-image among transgender men following gender reassignment surgery (GRS), aiming to contribute valuable insights to the ongoing discourse in this area.

Homosexuality is banned in Iran, but gender reassignment (GR) has been religiously permitted since 1987 after the Iranian revolution. Iran stands as the sole Islamic nation endorsing and financially supporting GRS procedures. As per the Family Protection Law since 2012, any individual in Iran may submit their request for gender matching to the family court there. According to Ahmadzadeh’s study between 2002 and 2009, the annual application rate for transgender women was approximately 1 in 145,000, and for transgender men was around 1 in 136,000. In 2022, this figure was accompanied by a two-fold increase in requests by transgender men compared to transgender women, highlighting the increasing prevalence of gender reassignment in Iran. [ 24 , 25 ].

This study marks a significant milestone as it is the first of its kind conducted among Iranians, shedding light on the quality of life and self-image among transgender men post-GRS. It is noteworthy to mention that this research highlights the cultural and religious context that is still evolving, with acceptance by families being a recent development and societal integration still in progress. The strengths of this study lie in its comprehensive examination of various aspects related to transgender healthcare within an Iranian cultural framework, offering valuable insights into the experiences of transgender individuals in a society where such topics are relatively emerging.

Material and method

In this cross-sectional survey study, we included transgender men participants who underwent GRS between 2018 and 2022 (4 years) at Shahid Faghihi, Zeinabiyyeh, Peyvand, Ali-Asghar and Madar-kodak Hospitals, the five major hospitals affiliated with Shiraz University of Medical Sciences in Shiraz, Iran. GRS was performed among the participants through the laparoscopic hysterectomy and bilateral salpingo -oophrectomy method. All participants underwent a psychiatric evaluation to ensure the absence of severe psychiatric disorders, excluding any lifetime history of organic mental disorders, mental retardation, psychotic disorders, bipolar disorders, substance abuse, and severe Axis II psychopathology (cluster A personality disorder, antisocial personality disorder, and borderline personality disorder) according to the DSM-V [ 26 ].

Before undergoing surgery to remove the uterus and ovaries, individuals had already undergone mastectomy and were living with a man. A new birth certificate will be issued to them immediately following the hysterectomy. Patients often avoided discussing surgery related to external genitalia, despite it being a crucial aspect of the GRS. This could be due to the fact that, talking about genitalia in Iran is culturally sensitive, leading to reliance on non-verbal cues for sexual communication and seeking satisfaction in sexual roles.

The questionnaires were administered twice during the study period, once before the surgery and once at least one year after undergoing GRS. patients were contacted through a telephone survey, and after explaining the aim and details of the study, they provided verbal informed consent. All patients agreed to the participation in the study, sharing and publishing their information and questionnaires.

We utilized the Persian version of the WHOQOL-BREF questionnaire for the purpose of our study [ 27 , 28 ]. The WHOQOL-BREF is a 26-item tool with four domains: physical health (7 items), psychological health (6 items), social relationships (3 items), and environmental health (8 items), including QOL and general health items. Each item is rated on a five-point ordinal scale (1 to 5), and scores are linearly transformed to a 0–100 scale [ 29 , 30 ]. In the physical health domain, items assess mobility, daily activities, functional capacity, energy, pain, and sleep. The psychological domain covers self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory concentration, religion, and mental status. Social relationships involve personal relationships, social support, and sex life. The environmental health domain addresses financial resources, safety, health and social services, living physical environment, opportunities for skills and knowledge, recreation, general environment (noise, air pollution, etc.), and transportation. Cultural differences do not influence the importance of the domains. The scores ranged from 1 to 5 for each question, and ranged from 7 to 35 for physical health, 6 to 30 for psychological health, 3 to 15 for social relationships, and 8 to 40 for and environmental health (8 items).

The questionnaire has been translated and validated in Persian language [ 27 ]. Subjects rate each item on a Likert scale ranging from 1 to 4 or 1 to 5 [ 31 ]. We also added two extra questions of “Do you have any issues in your sexual life” and “To what extent are your sexual needs met?”. The answers consisted of “not at all/very poor/ very dissatisfied/ never as 0, not much/poor/ dissatisfied/seldom as 1, moderately/neither poor nor good/ neither satisfied nor dissatisfied/ quit often as 2, a great deal/good/ satisfied / very often as 3, and completely/very good/ very satisfied/ an extreme amount/ always as 4. Score calculation was performed according to the WHOQOL manual [ 28 ].

All analyses were performed using the Statistical Package for Social Science (SPSS v.27.0 software). Distribution was summarized through means and standard deviations (mean ± SD) or median and interquartile range (IQR). Descriptive statistics are reported as frequency and percentage (%). Wilcoxon signed test was applied to evaluate differences between the responses before and after surgery. Statistical significance was accepted at the two-tailed P  < 0.05 significance level.

A total of 60 transgender men individual who underwent GRS completed our questionnaire. The average age of the patients before operation was 24.1 (SD: 3.8; range: 13–31). Table  1 demonstrated the demographic features of the patients in our study. None of our participants were married.

The participants filled out the Brief-WHOQOL questionnaire at two phases of before operation and after operation. The median interval between the filling of questionnaire was 3 years. The descriptive frequency of the responses in our study is demonstrated in Table  2 .

As shown in Table  2 , and accounting for reverse scoring in several questions (F1.4, F11.3, F8.1, and Extra 1), the responses demonstrated overall improvement in all questions. The increase was significant in all questions following GRS ( P  < 0.05) except three questions: “Have you enough money to meet your needs?”, “How available to you is the information that you need in your day-to-day life?”, and “How satisfied are you with the support you get from your friends?”. The highest improvement was in the question “Are you able to accept your bodily appearance?” by 113%.

The scores were evaluated in four domains of physical health, psychological health, social relationships, and environmental health. Figure  1 demonstrates the average score of the participants before and after surgery. The most increase was observed in the psychological factor (by 25.6%), followed by physical health (19.1%), social relationships (13.2%), and environmental health (10.9%). The increase in score was statistically significant in all subgroups ( P  < 0.001).

Quality of life subsection score before and after surgery

When evaluating the amount of change in the subgroups, based on the participants demographic features, we observed no significant association with age, marital status, or educational level. Living location had a significant association with physical health ( P  < 0.010), psychological health ( P  = 0.005), and environmental health ( P  = 0.012), but not social relationships ( P  = 0.088), with urban residents demonstrating higher level of change. The socioeconomic status of the participants also had a significant association with physical health ( P  = 0.023) and environmental health ( P  < 0.001), but not psychological health ( P  = 0.596) or social relationships ( P  = 0.684). Based on the post-hoc test results, in regards to physical health, the low socioeconomic group had a significant lower physical score compared to the moderate group ( P  = 0.024), however, there was no significant difference between the moderate and high group ( P  = 1.000) or the low and high group ( P  = 0.070). In regards to environmental health, the high socioeconomic groups had significantly higher improvement compared to the low ( P  = 0.006) and moderate ( P  < 0.001) group.

A total of 60 transgender men who underwent GRS completed our questionnaire. The average age of the patients before operation was 24.1, which was lower to similar studies [ 20 , 32 ]. The majority of participants were educated, which is in accordance to a previous study by Cardoso da Silva et al. [ 32 ]. Most participants resided in urban areas (61.7%) and had a moderate (50%) or high (30%) socioeconomic status. Our results indicated an increase in QoL after GRS, which is line with previous reports [ 32 , 33 ]. Dhiordan et al. conducted a pre-post survey assessing GRS impact on transgender women in Brazil. Their findings revealed improvements in the psychological social relationships of the WHOQoL-BREF after stereotactic radiosurgery when comparing post-surgery results to pre-surgery evaluations [ 32 ]. We observed that the QoL significantly increased, both in overall scores and also in subgroups of physical, psychological, social, and environmental health. These changes were unrelated to patients age, marital status, and education, and more influenced by their socioeconomic status and living location. This demonstrates the importance of the environment and living situation and culture which can influence the individuals’ beliefs and QoL. The patients with a low socioeconomic status demonstrated the lowest change in their physical and environmental health factors. On the other hand, patients with high socioeconomic status demonstrated significant improvement in their environmental health. Also, urban living residents compared to rural residents showed significantly higher improvement in physical, psychological, and environmental health factors. Our study is the first of its kind conducted in Iran, offering a groundbreaking exploration into the quality of life and self-image of transgender men post-GRS within the Iranian context. By comprehensively examining various aspects of their experiences, this study fills a crucial gap in existing research and provides valuable insights into the challenges and successes faced by transgender individuals in Iran. Additionally, its thorough investigation contributes to the advancement of knowledge and understanding in both academic and clinical settings, paving the way for further research and improved support for transgender individuals in Iran and beyond.

In a more detailed evaluation of the responses, the increase in QoL was significant in all questions except three questions: “Have you enough money to meet your needs?”, “How available to you is the information that you need in your day-to-day life?”, and “How satisfied are you with the support you get from your friends?”. These questions represent the socioeconomic status, availability of information, and social support of the participants, respectively. The observable traits of transgender individuals, such as their voice and facial features, along with the behaviors of their friends and family, plays a crucial role in their post-surgery interactions within the community. Transgender women were identified to experience greater limitations and challenges in this regard [ 34 ]. Factors like disapproval from family and the community may expose transgender individuals to vulnerability, gradually influencing their QoL and potentially contributing to the onset of depression [ 35 ]. Rezaei et al. demonstrated that aspects such as family function, emotional fusion, behavior control, and emotional responsiveness can play a crucial role in facilitating the acceptance of their new sexual role among transgender individuals [ 36 ].

Engaging in a range of social activities due to gender reassignment has been observed to enhance the sociability and activity levels of transgender individuals, fostering stronger social connections and helping them overcome social isolation. This enhancement in social relationships has the potential to elevate their overall QoL [ 37 , 38 ].

A notable aspect of focus in this study is sexual activity, which showed improvement after GRS through the two additional questions we provided. This finding has also been supported in previous studies [ 32 ]. One potential explanation for this observation could be linked to a heightened sense of personal fulfillment post-surgery and an enhanced acceptance of one’s body. This is also evident in our study, which the highest improvement was in the question “Are you able to accept your bodily appearance?” by 113%. Bartolucci et al. [ 23 ] asserted that GRS serves as a cornerstone for individuals with gender dysphoria, not only addressing their gender dysphoria but also leading to an enhancement in sexual satisfaction.

This study has various limitations, notably the short-term evaluation period post-GRS, the varying recovery times of patients after surgery, and the diverse levels of QoL among individuals. Consequently, we underscore the importance of conducting additional follow-up trials to comprehensively assess satisfaction with GRS.

Our study stands as one of the initial reports to assess the outcomes of surgical interventions in transgender individuals in Iran. Additionally, it adds value to the limited body of literature by employing the WHOQOL-BRIEF instrument both before and after GRS. The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients from low socioeconomic backgrounds and rural areas. Therefore, an increase in targeted support and resources for individuals from these demographics is warranted.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request and with permission of the Research Ethics Committee of the Shiraz University of Medical Sciences.

World Health Organization. International Classification of Diseases-ICD. 2009.

Association AP. Diagnostic and statistical manual of mental disorders (DSM-5 ® ): Am. J. Psychiatr. Pub; 2013.

Book   Google Scholar  

Judge C, O’Donovan C, Callaghan G, Gaoatswe G, O’Shea D. Gender dysphoria–prevalence and co-morbidities in an Irish adult population. Front Endocrinol. 2014;5:87.

Article   Google Scholar  

Chen M, Fuqua J, Eugster EA. Characteristics of referrals for gender dysphoria over a 13-year period. J Adolesc Health. 2016;58(3):369–71.

Article   PubMed   PubMed Central   Google Scholar  

Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807–15.

Article   PubMed   CAS   Google Scholar  

Gilbert DA, Winslow BH, Gilbert DM, Jordan GH, Horton CE. Transsexual surgery in the genetic female. Clin Plast Surg. 1988;15(3):471–87.

Oort FJ. Using structural equation modeling to detect response shifts and true change. Qual Life Res. 2005;14(3):587–98.

Article   PubMed   Google Scholar  

Oort FJ, Visser MR, Sprangers MA. An application of structural equation modeling to detect response shifts and true change in quality of life data from cancer patients undergoing invasive surgery. Qual Life Res. 2005;14(3):599–609.

Shahriarirad R, Erfani A, Ranjbar K, Bazrafshan A, Mirahmadizadeh A. The mental health impact of COVID-19 outbreak: a Nationwide Survey in Iran. Int J Ment Health Syst. 2021;15(1):19.

Keramati MR, Yazd SMM, Omidi M, Keshvari A, Shahriarirad S, Shahriarirad R, et al. Translation, cross-cultural adaptation, and psychometric evaluation of the Persian (Farsi) version of the QoLAF (quality of life in patients with anal fistula) questionnaire. PLoS ONE. 2023;18(4):e0277170.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Cohen-Kettenis PT, Gooren LJ. Transsexualism: a review of etiology, diagnosis and treatment. J Psychosom Res. 1999;46(4):315–33.

Gooren LJ, Giltay EJ, Bunck MC. Long-term treatment of transsexuals with cross-sex hormones: extensive personal experience. J Clin Endocrinol Metab. 2008;93(1):19–25.

Johansson A, Sundbom E, Hojerback T, Bodlund O. A five-year follow-up study of Swedish adults with gender identity disorder. Arch Sex Behav. 2010;39(6):1429–37.

De Cuypere G, Elaut E, Heylens G, Van Maele G, Selvaggi G, T’Sjoen G, et al. Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies. 2006;15(2):126–33.

Wolfradt U, Neumann K. Depersonalization, self-esteem and body image in male-to-female transsexuals compared to male and female controls. Arch Sex Behav. 2001;30(3):301–10.

Fraser L. Depth psychotherapy with transgender people. Sex Relatsh Ther. 2009;24(2):126–42.

Kuhn A, Bodmer C, Stadlmayr W, Kuhn P, Mueller MD, Birkhauser M. Quality of life 15 years after sex reassignment surgery for transsexualism. Fertil Steril. 2009;92(5):1685–9. e3.

Davey A, Bouman WP, Arcelus J, Meyer C. Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls. J Sex Med. 2014;11(12):2976–85.

Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Qual Life Res. 2006;15(9):1447–57.

Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8(12):3379–88.

Weyers S, Elaut E, De Sutter P, Gerris J, T’Sjoen G, Heylens G, et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med. 2009;6(3):752–60.

Castellano E, Crespi C, Dell’Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest. 2015;38(12):1373–81.

Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender‐dysphoric adults before genital sex reassignment surgery. J Sex Med. 2015;12(1):180–8.

Ahmadzad-Asl M, Jalali A-H, Alavi K, Naserbakht M, Taban M, Mohseninia-Omrani K, et al. The epidemiology of transsexualism in Iran. J Gay Lesbian Ment Health. 2010;15(1):83–93.

Talaei A, Hedjazi A, Badieyan Moosavi N, Dadgarmoghaddam M, Lotfinejad N, Khorashad BS. The epidemiology of gender dysphoria in Iran: the first nationwide study. Arch Sex Behav. 2022;51(4):1881–9.

First MB. DSM-5 ® handbook of differential diagnosis. American Psychiatric Pub; 2013.

Nejat S, Montazeri A, Holakouie Naieni K, Mohammad K, Majdzadeh S. The World Health Organization quality of life (WHOQOL-BREF) questionnaire: translation and validation study of the Iranian version. J School Public Health Inst Public Health Res. 2006;4(4):1–12.

Google Scholar  

World Health Organization. WHOQOL: Measuring Quality of Life [cited 2024 March]. https://www.who.int/tools/whoqol/whoqol-bref

Skevington SM, Tucker C. Designing response scales for cross-cultural use in health care: data from the development of the UK WHOQOL. Br J Med Psychol. 1999;72(Pt 1):51–61.

Harper A, Power M. WHOQOL user manual. World Health Organization Edinburgh; 1999.

Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932;140:44–53.

Cardoso da Silva D, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. J Sex Med. 2016;13(6):988–93.

Eftekhar Ardebili M, Janani L, Khazaei Z, Moradi Y, Baradaran HR. Quality of life in people with transsexuality after surgery: a systematic review and meta-analysis. Health Qual Life Outcomes. 2020;18(1):264.

Michel A, Ansseau M, Legros J-J, Pitchot W, Mormont C. The transsexual: what about the future? Eur Psychiatry. 2002;17(6):353–62.

Nuttbrock L, Hwahng S, Bockting W, Rosenblum A, Mason M, Macri M, et al. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J Sex Res. 2010;47(1):12–23.

Rezaei M, A Vahedian A. A. Comparison of depression, anxiety, stress and quality of life in dormitories students of Tarbiat Modares University. 2007.

Blanchard R. Typology of male-to-female transsexualism. Arch Sex Behav. 1985;14(3):247–61.

Rakic Z, Starcevic V, Maric J, Kelin K. The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes. Arch Sex Behav. 1996;25:515–25.

Download references

Acknowledgements

None to declare.

Author information

Elham Askary

Present address: Obstetrics and Gynecology Office, Shahid Faghihi Hospital, Zand Avenue, Shiraz, 7134844119, Iran

Authors and Affiliations

Department of Obstetrics and Gynecology, School of Medicine, Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Elham Rahimpour, Elham Askary & Shaghayegh Moradi Alamdarloo

Department of Obstetrics and Gynecology, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Saeed Alborzi

Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Tahereh Poordast

You can also search for this author in PubMed   Google Scholar

Contributions

T P, E A, E R, Sh M and S A designed the study. E R collected the data; E R analyzed the data; E A and E R interpreted the results; E A, Sh M and T P conceived and designed the study. E A, E R and Sh M wrote the manuscript. All authors discussed the results and revised the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Elham Askary .

Ethics declarations

Ethics approval.

The study was approved by our Institutional Review Board (Ethical Code: IR.SUMS.MED.REC.1401.499). Permission to carry out the study and access patient records was sought from the respective university administrators, and the study was conducted in compliance in accordance with the relevant guidelines and regulations and the Declaration of Helsinki and was also approved by the ethics committee of the university.

Consent for publication

Not applicable.

Consent to participate

Written informed consent for participation was obtained from the patients..

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Rahimpour, E., Askary, E., Alamdarloo, S.M. et al. Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran. Child Adolesc Psychiatry Ment Health 18 , 100 (2024). https://doi.org/10.1186/s13034-024-00794-0

Download citation

Received : 18 May 2024

Accepted : 05 August 2024

Published : 10 August 2024

DOI : https://doi.org/10.1186/s13034-024-00794-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Gender reassignment surgery
• Gender dysphoria
• Quality of life

Child and Adolescent Psychiatry and Mental Health

ISSN: 1753-2000

• Submission enquiries: [email protected]

• Share full article

Advertisement

Supported by

Lydia Polgreen

The Strange Report Fueling the War on Trans Kids

By Lydia Polgreen

Opinion Columnist

I n its upcoming term, the Supreme Court will once again hear a case that involves a highly contentious question that lies at the heart of personal liberty: Who should decide what medical care a person receives? Should it be patients and their families, supported by doctors and other clinicians, using guidelines developed by the leading experts in the field based on the most current scientific knowledge and treatment practice? Or does the Constitution permit lawmakers to place themselves, and courts, in the middle of some of the most complex and intimate decisions people will make in their lives?

The case, United States v. Skrmetti , has been brought by the Biden administration to challenge a ban in Tennessee on gender-affirming care for adolescents that all major American medical organizations support. Tennessee is one of some two dozen states that have passed laws limiting gender-affirming care for young people. The appeal argues that these bans are an unconstitutional form of sex discrimination: They forbid long-used treatments for transgender adolescents that are also given to children who are not transgender for different reasons.

The Tennessee law, called the Protecting Children From Gender Mutilation Act, prohibits the use of puberty-blocking medications for transgender adolescents, for example, but permits them for children who go into puberty at an early age. It bans the use of sex hormones like testosterone in transgender adolescents but allows it for other health issues, such as for children assigned male at birth. It bans gender-affirming surgeries for transgender adolescents — such surgeries are extremely rare — but allows similar surgical procedures that affirm the sex a child is assigned at birth, even on infants who are intersex.

The Supreme Court ruled in 2020 — somewhat surprisingly given its conservative majority — that differential treatment of transgender and gay people is impermissible under civil rights law. “It is impossible,” Justice Neil Gorsuch wrote in his decision in that landmark employment discrimination case, “to discriminate against a person for being homosexual or transgender without discriminating against that individual based on sex.” Lawyers seeking to overturn gender-affirming-care bans will urge the court to follow the logic of that ruling and declare the Tennessee law and others like it unconstitutional.

Lawyers arguing in favor of these bans have taken a sharply different approach. In a striking echo of the arguments used to challenge medical abortion, they have asserted , against the consensus of the mainstream medical science, that the standard treatments for transgender children are not based in evidence and represent a grave risk to the health and well-being of young people.

This argument has been floating around conservative circles in the United States for some time, and some European government health care systems have embraced it, too, with some limiting access to gender-affirming care for young people, citing doubts about the evidence supporting it. The argument has been supercharged in recent months by an unlikely ally on the other side of the Atlantic Ocean: the British pediatrician Hilary Cass.

We are having trouble retrieving the article content.

Please enable JavaScript in your browser settings.

Thank you for your patience while we verify access. If you are in Reader mode please exit and  log into  your Times account, or  subscribe  for all of The Times.

Thank you for your patience while we verify access.

Already a subscriber?  Log in .

Want all of The Times?  Subscribe .

• The Magazine
• City Journal
• Contributors
• Manhattan Institute
• Email Alerts

A Consensus No Longer

The American Society of Plastic Surgeons becomes the first major medical association to challenge the consensus of medical groups over “gender-affirming care” for minors.

The main justification for “gender-affirming care” for minors in the United States has been that “all major U.S. medical associations” support it. Critics of this supposed consensus have argued that it is not grounded in high-quality research or decades of honest and robust deliberation among clinicians with different viewpoints and experiences. Instead, it is the result of a small number of ideologically driven doctor-association members in LGBT-focused committees, who exploit their colleagues' trust. Physicians presenting different viewpoints are silenced or kept away from decision-making circles, ensuring the appearance of unanimity.

As the U.K.’s Cass Review pointed out, the World Professional Association for Transgender Health (WPATH) and the U.S. Endocrine Society were especially important in forging this consensus, and they did so by citing each other’s statements, rather than conducting a scientific appraisal of the evidence. The “circularity” of this approach, says Cass in her report to England’s National Health Service , “may explain why there has been an apparent consensus on key areas of practice despite the evidence being poor.”

Perhaps because it has never really depended on evidence, this doctor-group consensus has shown remarkable resilience in the face of major system shocks, including several whistleblowers , revelations from court documents that WPATH manipulated scientific evidence reviews , the Cass Review, a bipartisan commitment in the U.K. to roll back pediatric medical transition, and a growing international call for a developmentally informed approach that prioritizes psychotherapy over hormones and surgeries.

But the U.S. consensus now appears to have its first big fracture. In July, the American Society of Plastic Surgeons, a major medical association representing 11,000 members and over 90 percent of the field in the U.S. and Canada, told me that it “has not endorsed any organization’s practice recommendations for the treatment of adolescents with gender dysphoria.” ASPS acknowledged that there is “considerable uncertainty as to the long-term efficacy for the use of chest and genital surgical interventions” and that “the existing evidence base is viewed as low quality/low certainty.”  

Calling the evidence for youth gender transition “low quality” is not, as some gender clinicians say, a “scary buzzword” intended to “confus[e] non-experts.” In evidence-based medicine, “low quality” evidence means something very specific : that the true effect of an intervention is likely to be markedly different from the results reported in studies. As one expert in evidence-based medicine put it , low quality “doesn’t just mean something esoteric about study design, it means there’s uncertainty about whether the long-term benefits outweigh the harms.” As evidence for those harms —which include infertility , sexual dysfunction , and the agony of regret —continues to mount and ethical concerns  get  harder to ignore , European countries are increasingly prioritizing psychotherapy and reclassifying endocrine and surgical approaches as experimental.

Aware that WPATH suppressed systematic reviews of evidence while developing its latest “standards of care,” ASPS says that it “is reviewing and prioritizing several initiatives that best support evidence-based gender surgical care to provide guidance to plastic surgeons.” I also asked ASPS whether plastic surgeons share responsibility for determining the medical necessity of gender surgeries for minors. ASPS responded that surgeons are “members of the multidisciplinary care team” and as such “have a responsibility to provide comprehensive patient education and maintain a robust and evidence-based informed consent process, so patients and their families can set realistic expectations in the shared decision-making process.”

Sheila Nazarian, a plastic surgeon who practices in Beverly Hills, California, told me that colleagues in her field are increasingly expressing concern about the use of hormones and surgeries to help minors who experience distress associated with their sex. Many, however, fear that voicing these concerns will bring professional and social blowback. “It’s a real problem when colleagues are afraid to debate any medical treatment or procedure, and especially when minors are the patients,” Nazarian says. “I have been following the international debate on youth gender medicine for some time now and know we [in the U.S.] are far behind in recognizing the lack of evidence for long-term benefits, something that our European colleagues have done.”

One obstacle to having productive discussions, Nazarian said, is the partisan divide over youth gender medicine, which leads physicians to believe that disagreement with the “gender-affirming” approach is driven by political or ideological considerations. This perception is understandable, given that the debate is in fact polarized along partisan lines, though it has become less so in the last two years as a number of Democrats in state legislatures have voted in favor of (or abstained from voting against) age restriction laws. It’s possible that advocates of “gender-affirming” interventions see benefit in the partisan framing, as it may deter liberal doctors from examining the issue in greater depth and speaking up when they detect problems.

Regardless of why the issue is polarized in the U.S., the growing international consensus against the “gender affirming” approach for minors is anything but partisan. In Finland and Sweden, for instance, left-leaning governments implemented restrictions following systematic reviews of evidence by independent health-care quality agencies. In the U.K., the NHS-commissioned independent review of the Gender Identity Development Service, led by Hilary Cass, prompted the Tory government to ban puberty blockers, a move subsequently endorsed by the new Labour government.

The U.S. is one of the few Western countries where minors can receive gender surgeries, according to a new report . Teens under 18 cannot undergo double mastectomy in Belgium, Finland, Germany, Luxemburg, Sweden, the U.K., and three Canadian provinces. Countries that allow these procedures typically do so only in “rare cases,” after age 16, and with parental consent. In the U.S., WPATH Standards of Care, Version 8 , widely followed and endorsed by the Biden administration , specifies no age minimums for gender surgeries, with the exception of phalloplasty (but even that can be performed if “significant, compelling reasons” exist to do so). In June, unsealed court documents revealed that WPATH eliminated age minimums for political reasons, and under pressure from U.S. Assistant Secretary for Health Rachel Levine, a transgender woman.

An estimate of U.S. “gender-affirming” double mastectomies published in 2023 in the Journal of the American Medical Association reported 3,125 cases of “breast or chest procedures” in patients ages 12 to 18 between 2016 to 2020. The study did not differentiate between 18-year-olds and minors. A new analysis by the Manhattan Institute, using a more up-to-date all-payer national insurance database from 2017 to 2023, found evidence of 5,288 to 6,294 “gender-affirming” double mastectomies for girls under age 18. This includes 50 to 179 girls who were 12.5 or younger at the time of their procedure. (“Top surgery” on 12-year-old girls has been reported in the medical literature.)

Two caveats should be mentioned. First, 2023 data are incomplete, making it premature to conclude that a dip occurred that year, relative to previous years. Second, even the liberal estimates are an undercount, as the data are limited by two constraints: the procedures had to be covered by insurance, and patients had to have a preexisting diagnosis of gender dysphoria. The out-of-pocket costs of “top surgery” can be as low as $3,000 , a sum many middle-class families can afford. Further, if it is true, as is being alleged , that gender clinicians are using false diagnostic and procedural codes for insurance billing, these cases would not show up in our data.

A growing trend in gender medicine is “nonbinary” mastectomies, a procedure that some patients seek in order to appear neither male nor female. According to our data, a minimum of 1,873 such procedures (conservative estimate) were performed on girls under age 18 in the U.S. between 2017 and 2023. The number of procedures grew from 70 in 2017 to 470 in 2023—an almost seven-fold rise. Plastic surgeons who perform these procedures leverage the existing billing code for breast reduction (“19318–Unilateral reduction mammaplasty”), a practice some might argue amounts to insurance fraud.

When speaking to the public, American gender clinicians have a tendency vastly to understate or even deny the existence of gender surgeries on minors. For example, in 2023, Marci Bowers, a plastic surgeon and president of WPATH, told CBS News that “Surgery really is not done under the age of 18, except in severe cases . . . And even that is rare, I think the estimates are something like 57 surgeries under the age of 18 were done for trans individuals.” (Bowers, a genital surgery specialist, may have been thinking about genital surgery on minors, of which at least 56 were performed between 2019 and 2021, according to a Reuters report .)

At an April 2023 hearing before the Texas Senate Committee on Health and Human Services, Cody Miller Pyke, a physician and gender medicine advocate, said that “children under the age of eighteen in this country do not have gender reassignment surgery. There isn’t a single case.” Texas Pediatric Society president Louis Appel testified that “surgeries are not part of the standard of care.” This was seven months after WPATH published its Standards of Care, Version 8 , which includes gender surgeries with no age minimums.

Due to the nature of their work, plastic surgeons are increasingly finding themselves in the hot seat of gender medicine lawsuits. Almost two dozen lawsuits by detransitioners against clinics and clinicians are currently underway, and at least seven of the defendants in these cases are ASPS members. One, Winnie Tong, performed a double mastectomy on Kayla Lovdahl in 2017, when she was only 13. Lovdahl is now suing Kaiser Permanente and Tong, who claim that they were following WPATH’s Standards of Care, Version 7 —a guideline so poor in its quality that it does not meet Kaiser’s own explicitly stated criteria for what makes a clinical guideline trustworthy.

Whether detransitioners like Lovdahl will win in court depends largely on how the courts understand the standard of care—a medical-legal term—at the time defendants performed the surgeries. WPATH calls its recommendations “standards of care,” likely because it recognizes—or hopes—that judges will look to these recommendations when determining what the standard of care was and whether the defendants deviated from it. But the unsealed court documents from the lawsuit challenging Alabama’s age restriction law revealed that WPATH wrote its current standards of care explicitly with a view to eventual litigation, even consulting an ACLU lawyer in the process. The ACLU has regularly cited WPATH’s standards of care in its legal briefings to argue that its legal position is grounded in medical science—a claim that seems, at the least, to represent circular reasoning.

If surgeons who perform double mastectomy or vaginoplasty on teenagers lose in court, the judgment will show up on their board of medicine examiner website and on their license. Malpractice premiums in this area are already rising , and some insurers outright exclude under-18 gender-transition procedures from their coverage policies. California, where Chloe Cole and Kayla Lovdahl are suing Kaiser Permanente, limits punitive damages to nine times the total amount of special and general damages awarded. This could bring the total awarded to each plaintiff to as high as $18 million, according to an attorney familiar with the case. 

Kevin Keller, a lawyer who specializes in health-care-related tort litigation, told me that medical malpractice is actually the lesser worry for clinicians here. Plaintiffs can also allege “intentional acts,” a category of behaviors including fraud that are typically excluded under medical malpractice insurance policies. In her lawsuit against Eric T. Emerson—an ASPS member—and his clinic, Piedmont Plastic Surgery and Dermatology in North Carolina, Prisha Mosley, a former patient, alleges that Emerson “misled and deceived [her] into thinking that surgery on her healthy breasts would benefit her and that she needed this surgery.” Juries can award massive damages for such tort claims, and these will be borne directly by the surgeon and the clinic. “Juries can easily award plaintiffs like Mosley $10 million or more,” Keller said. “And that’s money that doctors and clinics will have to pay out of pocket.”

A key question for these lawsuits is the degree to which surgeons are responsible for determining the medical necessity of the procedures that they are asked to perform. According to Mosley’s complaint, for instance, Emerson, the surgeon, “noted” her “history of anxiety and anorexia nervosa and family history of depression” but did not see any of these issues as red flags and did not “form an evidence-based, independent judgment” about the medical necessity of mastectomy in her case.

Existing guidelines like the ones issued by WPATH and the Endocrine Society envision surgeons as part of a “multidisciplinary” team that includes mental-health professionals. Though WPATH recommends that surgeons have special training in “gender-affirming care,” it is unclear whether surgeons can second-guess the appropriateness of surgery (except if there are physical contraindications) once a patient has been “affirmed” and given the all-clear by a mental-health professional. Doing so would constitute “gatekeeping,” which is seen in the gender medicine community as “non-affirming” and harmful. “Treatment” is oriented around “the child’s sense of reality and feeling of who they are,” says Jason Rafferty , who wrote the American Academy of Pediatrics’ statement on “gender-affirming care” at the very beginning of his medical career and who is now being sued by two former patients .  

Kayla Lovdahl, the young woman currently suing Kaiser Permanente, was approved for surgery after an “affirming” psychologist conducted a single 75-minute evaluation and determined that she was “transgender,” according to her legal complaint . Five weeks later, Lovdahl, still only 12, met with the plastic surgeon, Winnie Tong, who concluded after a 30-minute evaluation that she fulfilled criteria for a double mastectomy. The procedure was performed four months later, just after Lovdahl turned 13.

In July, the Pennsylvania Psychological Association, a branch of the American Psychological Association, forbade any mention of the Cass Review on its professional listserv. Doing so, the leadership suggested, could cause “harm” to colleagues with “very different points of view based on their varied life experiences.” This is but one of many examples of how the mental health profession has abdicated its role in ensuring that young people with mental health challenges are provided evidence-based care. It is likely a matter of time before judges come to appreciate how this area of medicine operates and refuse to let surgeons off the hook when they assert that they were relying on mental health professionals to determine medical necessity.

Gender clinics across the country have adopted letter-of-support and letter-of-medical-necessity templates to ensure that adolescents seeking surgery get approval, with few hiccups. The message these templates implicitly send to therapists, who are the first and arguably most important gatekeepers, is that gender surgery for minors is a standard procedure rather than an extreme departure requiring strong evidence.

The gender clinic at Seattle Children’s Hospital is an example of a major clinic that offers mental-health professionals a template to use for writing letters of support for surgery. The template contains language designed to bypass any concern that the candidate fits the profile of “rapid onset gender dysphoria” (ROGD), the most common adolescent presentation and the one that prompted the course reversal in Europe. The template effectively instructs the referring therapist to attest that the ROGD presentation is really just a teen who has always known he or she was transgender but only disclosed that information to his or her parents during adolescence. This common anti-ROGD refrain is based on highly dubious research .

Nazarian, the Beverly Hills surgeon, told me that surgeons in her professional network who perform gender surgeries typically defer to mental-health professionals and endocrinologists to determine for them whether minors should receive procedures like double mastectomy. That approach, she believes, is misguided, and reduces surgeons to mechanics.

“We are not highly trained technicians,” Nazarian told me. “We are physicians with responsibility for the health and well-being of our patients. We can get input from other clinicians, but ultimately the responsibility for determining medical readiness lies with us. That means that we have to examine all the data and studies available to us. Furthermore, you can’t help people by ignoring the reasons they want to go under the knife. With every patient, I exercise discretion as a professional and determine whether the procedure they are seeking is in their ultimate best interest.” The idea that surgeons should defer heavily to the prior assessments of clinicians struck Nazarian as wrong. “You can’t outsource your professional judgement to other clinicians. It’s your responsibility as the last in a chain of treatment to ensure you are doing what is best for the patient now and in the long term.”

Editor’s note: This article has been corrected to remove reference to a template mistakenly attributed to Caitlin Thornbrugh.

Leor Sapir is a fellow at the Manhattan Institute.

Photo by Jessica Rinaldi/The Boston Globe via Getty Images

City Journal is a publication of the Manhattan Institute for Policy Research (MI), a leading free-market think tank. Are you interested in supporting the magazine? As a 501(c)(3) nonprofit, donations in support of MI and City Journal are fully tax-deductible as provided by law (EIN #13-2912529).

Further Reading

Copyright © 2024 Manhattan Institute for Policy Research, Inc. All rights reserved.

• Eye on the News
• From the Magazine
• Books and Culture
• Privacy Policy
• Terms of Use

EIN #13-2912529

Ohio judge rules ban on health care for transgender minors can take effect, appeal expected

A Franklin County judge ruled Tuesday that Ohio's ban on gender-affirming care for transgender minors can take effect immediately.

Franklin County Court of Common Pleas Judge Michael Holbrook rescinded an earlier restraining order temporarily blocking the law , which also bans transgender girls from participating in female sports. The American Civil Liberties Union of Ohio plans to appeal the decision.

Holbrook, a Republican, ruled that Ohio's new ban doesn't violate the Ohio Constitution's health care freedom amendment or an Ohio law requiring legislation be limited to a single subject.

"The court finds the health care ban reasonably limits parents' rights to make decisions about their children's medical care consistent with the state’s deeply rooted legitimate interest in the regulation of medical profession and medical treatments," Holbrook wrote in his order.

The Ohio law prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery for patients under 18.

The American Civil Liberties Union of Ohio sued the state on behalf of two Ohio transgender girls and their families, saying the law violates their right to choose their health care under the Ohio Constitution. Holbrook  temporarily blocked the law  in April.

The ACLU of Ohio argued that puberty blockers and hormone therapy are safe and effective approaches for treating gender dysphoria. Gender dysphoria refers to the distress a person feels when their gender identity does not match their assigned sex. 

The Ohio Attorney General's Office argued that gender dysphoria should be addressed solely through mental health interventions.

Ohio Attorney General Dave Yost applauded Holbrook's decision. 

"This case has always been about the legislature’s authority to enact a law to protect our children from making irreversible medical and surgical decisions about their bodies," Yost spokeswoman Bethany McCorkle said. "The law doesn’t say 'no' forever; it simply says 'not now’ while the child is still growing."

Freda Levenson, legal director at the ACLU of Ohio, called the decision devastating and a genuine setback.

“This loss is not just devastating for our brave clients, but for the many transgender youth and their families across the state who require this critical, life-saving health care," she said in a statement. "While this decision by the court is a genuine setback, it is not the end of the road in our fight to secure the constitutional rights of transgender youth, as well as  all Ohioans’ right to bodily autonomy."

Read the decision here:

Ruling on transgender healthcare bill by Jessie Balmert on Scribd

Erin Glynn is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

• Sports Betting
• Sports Entertainment

Recommended

Transgender golfer lectures rivals about complaining as she makes lpga push.

Hailey Davidson, a transgender golfer who nearly qualified for the U.S. Women’s Open earlier this year, took a shot at athletes who complain about competing against trans athletes.

Davidson, who was banned from the NXXT Women’s Pro Tour in March as the organization changed its eligibility standards earlier in the year, made the remark on Instagram.

“I will never understand athletes who blame a transgender competitor on their own athletic failures,” Davidson wrote seemingly out of the blue. “If you don’t take accountability for your failures then you will never actually be good enough to make it.”

Davidson posted a video Monday practicing pitch shots to the green as prep work began for Q School, which begins later this month. It could be an avenue for Davidson to qualify for the LPGA Tour.

“3 shots in the hole out of 15 total isn’t too bad,” she captioned the post with qualifiers starting at the end of the August. “I’m super excited for Q School coming up soon, especially after not playing last year.”

The LPGA has an inclusion policy for transgender athletes who undergo surgery after male puberty, which states that transgender athletes have an “avenue to membership and opportunity to participate in events, and in an effort to assure fair competition for all members and participants.”

“An applicant for membership or entry into a tournament that has undergone gender reassignment from male to female after puberty must identify herself during the application/entry process and provide proof of gender in accordance with this Policy,” the LPGA Tour says. “Failure to provide proof of gender when gender has been reassigned, and to comply with the process and procedures set forth in this Policy, may result in disqualification from eligibility for membership and/or entry into a tournament.

“If there is a genuine question as to the eligibility of any applicant, including via sponsor exemptions or qualifiers, the LPGA shall have the right, within its sole discretion, to require such athlete to substantiate her transitioned status in accordance with this Policy.”

The transgender athlete must have “undergone gender reassignment surgery prior to submitting an application for membership or entering the tournament.”

“The applicant must have undergone, for at least one (1) year, appropriate hormonal therapy and maintained testosterone levels in a verifiable manner sufficient to minimize or negate gender-related advantages in sport competitions, as determined by LPGA in consultation with its medical advisor(s), and demonstrate that she is ready, willing and able to continue to maintain such levels for so long as she continues to compete in tournaments,” the LPGA Tour says.

“For the avoidance of doubt, applicants transitioning to male who either declare their gender identity to be male or commence hormone treatment for such purpose will not be eligible for membership or entry into a tournament.”

The transgender athletes would also need medical documentation, including all notes from gender reassignment, hospital records pertaining to the surgery, records relating to follow-up treatment, lab results on testosterone levels, and “an executed Authorization for Release of Medical Information waiver form allowing LPGA medical advisor(s) to contact all treating physicians if deemed necessary.”

Davidson was named  the first alternate  for the U.S. Women’s Open in May but never got the chance to compete at the major.

Advertisement