Gender Affirmation Surgery

Overview

Gender affirmation surgery is an option for people experiencing a discrepancy between their sex assigned at birth and their gender identity, particularly if it leads to psychological distress. These surgeries can include facial surgery, top surgery, and bottom surgery.

Unlike the sex assigned at birth, gender identity reflects a person’s internal understanding of their body, such as how they perceive and present themselves. Various procedures under the gender affirmation surgery can help individuals’ bodies better align with their gender identity.

Many individuals who undergo gender affirmation surgery report high satisfaction with their appearance and bodily function, as well as an improved quality of life.

Types

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

• Surgical approaches: This include facial reconstruction to create more masculine or feminine features, voice surgery to alter pitch, “top” or chest surgery to remove or enhance breast tissue for a desired appearance, and “bottom” or genital surgery to reshape and reconstruct the genital area.
  • Gender-affirming surgery for transgender men and transmasculine nonbinary people include:
    • Scrotoplasty: This involves reshaping part of the labia majora into a scrotum, which can be followed by the option of getting silicone gel or saline implants for testicular prosthesis.
    • Metoidioplasty: Often combined with scrotoplasty, this procedure uses testosterone to enlarge the clitoris to the size of a micropenis, which is then used to form a penis.
    • Phalloplasty: Often performed alongside scrotoplasty, this procedure utilizes skin from another body part to create an average-sized penis, typically around 5 to 6 inches.
    • Hysterectomy: Often performed with removal of the ovaries, this procedure is done to remove the uterus.
    • Vaginectomy: Vaginal tissue is frequently used in these surgeries to restore the genitals. This procedure involves removal of the vagina.
    • Facial masculinization surgery: Broader forehead, angular cheeks, a stronger jawline, and the formation of an Adam’s apple is the result of this procedure. In general, it alters facial bones and tissues to achieve specific features.
    • Masculinizing top surgery: To achieve a flat or flatter chest appearance that aligns with masculine characteristics, the breast tissue is removed.
  • Gender-affirming surgery for transgender women and transfeminine nonbinary people include:
    • Penectomy: If people do not need the tissue for feminizing surgeries, this procedure, which involves penis removal, is an option.
    • Vaginoplasty: Labia (labiaplasty) and a clitoris (clitoroplasty) may be constructed during this surgery. Penile tissue and other genitalia are used in this procedure.
    • Vulvoplasty: This procedure constructs the external parts of a vulva, such as the mons, labia, and clitoris, but not a vaginal canal.
    • Orchiectomy: This procedure can be done in conjunction with a scrotectomy. Orchiectomy decreases testosterone production and may reduce the need for feminizing hormone therapy. The procedure entails removal of the testicles.
    • Facial feminization surgery: To achieve a lower hairline, fuller cheeks, a rounded jaw, and a smaller Adam’s apple, this procedure modifies facial bones and tissues.
    • Feminizing top surgery: This enhances breast size and shape by inserting saline or silicone implants, and occasionally fat tissue from other parts of the body, under the existing breast tissue.
  • Nonsurgical gender-affirming options include:
    • Voice therapy: To express gender, individuals modify their speech
    • Laser hair removal: Unwanted facial or body hair is removed during this treatment.
    • Puberty blockers: Puberty-related changes, such as breast growth and facial hair are delayed by this treatment.
    • Feminizing hormone therapy: Feminine traits like larger breasts and rounded hips are enhanced by this therapy.
    • Masculinizing hormone therapy: Masculine traits like facial hair and muscle mass are enhanced by this treatment.

Reasons for undergoing the procedure

Gender affirmation surgery can enhance or reduce physical traits associated with being assigned male or female at birth and can also alter the appearance of genitals.

Surgery is just one option for transitioning for transgender, nonbinary, or gender diverse individuals.

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

After gender affirmation surgery it is important to take prescribed medications, including pain management as directed. Compression garments might also be necessary to reduce swelling and promote faster healing.

Other essential steps to follow may include:

• Care for wounds, catheters, and drains as instructed by the healthcare provider
• Adjust daily routines as advised, including bathing, sexual activities and exercise restrictions
• Avoid straining or reaching to prevent injury
• Monitor diet to support healing, such as nutritious food choices

Outcome

Follow-up care is important after gender affirmation surgery. Regular visits may be required to monitor conditions like breast cancer, cervical cancer, or prostate cancer, depending on one’s anatomy.

It is also important to look out for potential complications. If any of the following is experienced, seek medical attention immediately:

• Excessive bleeding beyond a few days post-surgery
• Persistent or severe pain after several weeks
• Symptoms of infection, like changes in wound appearance or delayed healing

Maintaining ongoing appointments with a mental health specialist experienced in transgender healthcare post-surgery is recommended. They can provide valuable support during the adjustment period.

Recovery period is different for every procedure:

• Chest surgery: Strenuous activities should be avoided for at least a month. Swelling and discomfort usually last one to two weeks.
• Bottom surgery: Weekly follow-up appointments for several months are recommended to monitor recovery progress. In most cases, normal activities may be resumed after at least six weeks post-surgery.
• Cheek and nose surgery: For about two to four weeks post-surgery, swelling is expected.
• Chin and jaw surgery: It can take up to four months for the swelling to fully subside, but it starts to go down in two weeks.

Gender affirmation surgery reliably alleviates gender incongruence and improves quality of life for individuals, with satisfaction rates ranging from 94% to 100%, depending on the type of surgery.

Key benefits include:

• Improved appearance: Surgery helps align the body more closely with the individual’s gender identity, enhancing satisfaction with changes to the face, chest, or genitals.
• Enhanced gender expression: It supports alignment with gender expression, affecting how individuals present themselves and perform daily activities such as urination.
• Better sexual function: The surgery positively impacts sexual activities, allowing individuals to engage in ways that better reflect their gender identity.
• Better mental health: Gender-affirming surgery offers significant long-term mental health benefits. Research consistently indicates that it reduces gender dysphoria, anxiety, and depression associated with gender incongruence.