Gender Affirmation Surgery

Overview 

Gender affirmation surgery involves various procedures that can help align your physical body with your gender identity. While sex is assigned at birth as male or female, gender identity refers to how you perceive and express yourself. For individuals whose gender identity differs from their assigned sex at birth (gender incongruence), these surgeries may offer relief from the psychological distress known as gender dysphoria. 

Types 

Gender affirmation surgery has two main approaches: surgical and nonsurgical. 

Nonsurgical gender-affirming options: 

• Feminizing hormone therapy: Increases feminine characteristics like breast development, rounded hips, and a higher voice. 
• Masculinizing hormone therapy: Promotes masculine traits such as facial hair growth, increased muscle mass, and a lower voice. 
• Puberty blockers: Delay puberty and the development of secondary sex characteristics, like breast growth, facial hair, and changes in facial structure. 
• Voice therapy: Teaches speech and communication techniques that align with your gender identity. 
• Laser hair removal: Permanently removes unwanted facial or body hair. 

Surgical gender-affirming options 

For people assigned female at birth (AFAB) (transgender men and transmasculine nonbinary people): 

• Facial masculinization surgery: Alters facial features by reshaping bones and tissues, creating a more masculine appearance (e.g., wider forehead, angular cheeks, pronounced jawline, Adam’s apple). 
• Masculinizing top surgery: Removes breast tissue to create a flatter chest. 
• Hysterectomy: Removal of the uterus. It is often performed alongside an oophorectomy (removal of the ovaries). 
• Vaginectomy: Removal of the vagina, which may be performed without additional bottom surgery like metoidioplasty or phalloplasty. 
• Metoidioplasty: Uses an enlarged clitoris, grown through testosterone therapy, to create a micropenis. It is often performed along with scrotoplasty. 
• Phalloplasty: Constructs a penis using a flap of skin from another body part, typically alongside scrotoplasty. 
• Scrotoplasty: Reshapes the labia majora into a scrotum. Silicone or saline testicular implants can be added later. 

For people assigned male at birth (AMAB) (transgender women and transfeminine nonbinary people) 

• Facial feminization surgery: Modifies the face by reshaping bones and tissues to create a more feminine appearance (e.g., fuller cheeks, rounded jaw, smaller Adam’s apple, lower hairline). 
• Feminizing top surgery: Enhances the chest by placing saline or silicone implants, sometimes combined with fat tissue transfer, to create fuller breasts. 
• Orchiectomy: Removal of the testicles, which reduces testosterone production and may lessen the need for feminizing hormone therapy. It can also be paired with scrotectomy (removal of the scrotum). 
• Penectomy: Removes the penis. This procedure may be performed without preserving tissue for future surgeries like vaginoplasty. 
• Vaginoplasty: Uses penile and other genital tissue to construct a vaginal canal, often including labia (labiaplasty) and clitoris (clitoroplasty) formation. 
• Vulvoplasty: Constructs external genitalia like the mons, labia, and clitoris, without creating a vaginal canal.

Reasons for undergoing the procedure  

Gender affirmation surgery is one of several options available for transgender, nonbinary, or gender diverse individuals who are transitioning or affirming their gender identity. This surgery can involve altering physical characteristics typically associated with being assigned male at birth (AMAB) or assigned female at birth (AFAB), such as modifying the appearance of the genitals.

Risk  

Generally, significant complications are rare if an experienced healthcare professional performs the surgery. However, as with any medical procedure, common complications may include:  

• Infection  
• Adverse effects from anesthesia  
• Bleeding 

Different gender-affirming procedures come with various risks. For instance, bottom surgery can affect sexual sensation or cause bladder issues.  

Before the procedure  

To prepare for gender-affirming surgery, healthcare providers review the patient’s medical history and conduct tests such as physical exams, blood tests, and imaging. The patient collaborates with healthcare professionals to meet the standards set by the World Professional Association for Transgender Health (WPATH), which promotes evidence-based care.

WPATH criteria include:  

• Giving informed consent: One must provide informed consent, showing they understand the surgery, its impact on their life, and potential infertility. Healthcare providers will discuss fertility preservation options like egg or sperm freezing.  
• History of gender incongruence: Health records demonstrating a history of gender incongruence, typically for a year or more will need to be presented.  
• Mental assessment: This evaluation helps assess one’s mental well-being and address conditions like gender dysphoria, anxiety, or depression. This will often require a letter of support from a qualified mental health provider, such as a therapist, psychiatrist, or social worker.  
• Hormone therapy: Hormones can alter the body in ways that increase the effectiveness of surgery, depending on the process and intended results. This may be recommended before the surgery.

Many insurance companies require documentation showing that the patient meets WPATH criteria before covering the surgery costs.  

During the procedure  

Some gender affirmation surgeries can be completed in a single day, while others, like phalloplasty, may require multiple procedures over time. Even after a one-day surgery, follow-up visits might be necessary for revisions if the results aren’t as expected. It’s crucial to choose a healthcare provider with extensive experience in the specific surgery to minimize the need for revisions. The provider will detail the procedure and address any questions you might have.

Gender affirmation surgeries typically combine multiple procedures. Generally, these may be done during the surgeries:  

• Anesthesia is administered to ensure pain-free surgery  
• Organs or tissues are removed or reshaped  
• New structures are created using existing tissue  
• Implants or tissue grafts are inserted as needed  
• Drains may be used to remove fluids from wounds  
• A Foley catheter may be inserted to assist with urination  

After the procedure  

Healing after surgery requires special attention. It’s important to reach out to friends or family for help during recovery.  

• Wound and drain care 
  • Follow medical advice: Clean your wounds carefully and monitor for signs of infection. 
  • Care for catheters and drains: Ensure you understand the proper procedures for maintenance and cleanliness. 

• Compression garments 
  • Use as directed: Wearing compression bandages or garments can help reduce swelling and speed up healing. 

• Medication management 
  • Take your medication: Follow your provider’s prescription plan, and seek help if managing pain becomes difficult. 

• Avoid reaching and straining 
  • Prepare your space: Before surgery, organize your home to minimize the need for reaching or straining, preventing potential injury post-op. 

• Healthy eating habits 
  • Discuss with your provider: Plan a nutritious diet that will support your healing process. 

• Routine adjustments 
  • Modify daily activities: Stick to sponge baths until cleared for regular showers and limit physical exercise. Some activities, including sexual activity, may need to be postponed until full recovery—follow your provider’s guidance.