Gender Affirmation Surgery

What is gender affirmation surgery?

Gender affirmation surgery includes several procedures that may help your body better align with your gender identity. Unlike sex assigned at birth (either male or female), gender identity is the way you understand your body and present yourself to others.

Gender affirmation surgery may be an option if your sex assigned at birth differs from your gender identity (gender incongruence). It may help if you experience psychological distress because of gender incongruence (gender dysphoria).

Why is gender affirmation surgery done?

Gender affirmation surgery may be a part of transitioning, or “coming out” to others (and yourself) if you’re transgender, nonbinary or gender diverse. Surgeries exist that:

• Enhance or lessen physical characteristics associated with being assigned male at birth (AMAB).
• Enhance or lessen physical characteristics associated with being assigned female at birth (AFAB).
• Change the way your genitals look.

Surgery is just one possible way to transition.

Nonsurgical gender-affirming options

There are nonsurgical gender-affirming medical options, too, including:

• Feminizing hormone therapy: Increases feminine characteristics, such as bigger breasts, rounded hips and a higher voice.
• Masculinizing hormone therapy: Increases masculine characteristics, such as facial hair, muscle mass and a lower voice.
• Puberty blockers: Delay the development of secondary sex characteristics that develop during puberty. Examples include changes in facial structure, breast growth and facial hair.
• Voice therapy: Teaches speaking and communication skills that allow you to express your gender.
• Laser hair removal: For removing facial or body hair.

Not every trans or gender-diverse person’s journey involves medical transitioning. Expressing your gender identity may also (or only) involve nonmedical changes, like:

• Choosing a new name.
• Using different pronouns (she/her, he/him, they/them, etc.).
• Changing your style (hairstyle, clothing, makeup, etc.).

What are the types of gender affirmation surgery?

Surgery types include:

• Facial reconstructive surgery to make facial features more masculine or feminine.
• Vocal surgery to change your voice pitch.
• Chest or “top” surgery to remove breast tissue for a more masculine appearance or enhance breast size and shape for a more feminine appearance.
• Genital or “bottom” surgery to transform and reconstruct your genitals.

Examples of gender-affirming surgery for people AFAB, such as for transgender men and transmasculine nonbinary people, include:

• Facial masculinization surgery: Reshapes the bones and tissues in your face to produce features such as a wider forehead, angular cheeks, a more pronounced jawline and an Adam’s apple.
• Masculinizing top surgery: Removes breast tissue to create a natural-looking flat (or flatter) chest.
• Hysterectomy: Removes the uterus. It may happen alongside surgery to remove your ovaries (oophorectomy).
• Vaginectomy: Removes the vagina. This may be an option if you don’t desire bottom surgery, like metoidioplasty or phalloplasty. These procedures often involve using vaginal tissue to reconstruct your genitals.
• Metoidioplasty: Uses the clitoris to form a penis. Before surgery, you’ll take testosterone to enlarge the clitoris to the size of a micropenis (a penis that’s less than about 2.57 inches long). This procedure usually happens alongside scrotoplasty.
• Phalloplasty: Uses a flap of skin from another part of your body to form an average-sized penis (about 5 to 6 inches). It usually happens alongside scrotoplasty.
• Scrotoplasty: Reshapes part of the labia majora (outer lips of the vulva) into a scrotum. Once you heal, you may choose to get silicone gel or saline implants that look and feel like testicles (testicular prosthesis).

Examples of gender-affirming surgery for people AMAB, such as transgender women and transfeminine nonbinary people, include:

• Facial feminization surgery: Reshapes the bones and tissues in your face to produce features such as a lower hairline, fuller cheeks, rounded jaw and smaller Adam’s apple.
• Feminizing top surgery: Adds saline or silicone implants (and sometimes fat tissue from elsewhere on your body) under your breast tissue to create rounded, fuller breasts.
• Orchiectomy: Removes the testicles. No longer having testicles reduces how much testosterone your body produces. This means you may need less feminizing hormone therapy. It may happen alongside surgery to remove the scrotum (scrotectomy).
• Penectomy: Removes the penis. This may be an option if you don’t want to preserve the tissue for feminizing surgeries, such as vaginoplasty or vulvoplasty.
• Vaginoplasty: Uses penile tissue and other genitalia to form a vaginal canal. Surgery may also involve constructing labia (labiaplasty) and a clitoris (clitoroplasty).
• Vulvoplasty: Constructs the parts of a vulva (including the mons, labia and clitoris) but not a vagina.

How common is gender affirmation surgery?

Approximately 25% to 35% of trans and nonbinary people in the United States receive gender affirmation surgery. According to a 2023 study, the most common surgeries are top surgeries, followed by bottom surgeries and facial reconstruction surgeries.

How should I prepare for gender affirmation surgery?

You’ll work with healthcare providers to ensure you meet the criteria for gender-affirming surgery, according to the World Professional Association for Transgender Health (WPATH) standards of care. This organization promotes evidence-based care for transgender and gender-diverse people.

Many insurance companies require you to submit documentation related to WPATH criteria before they cover surgery costs.

Criteria include:

• Providing informed consent. You’ll need to demonstrate that you understand what’s involved. This includes what happens during surgery and how it’ll affect your life. These effects extend to your desire to have biological children. Many surgeries cause temporary or permanent infertility. Your provider will explain fertility preservation options, like freezing your eggs or sperm.
• A history of gender incongruence. You may need to produce health records demonstrating a history of gender incongruence (usually a year or more).
• A mental health evaluation. You may need a letter of support from a qualified mental health provider (therapist, psychiatrist or social worker). They’ll work with you to determine the safest and healthiest options for embodying your gender. If you have gender dysphoria, they can help diagnose and treat related conditions, like anxiety and depression.
• Hormone therapy. In some cases, you may need to be on hormone therapy before surgery. Depending on the procedure and desired outcomes, hormones can cause changes in your body that make surgery more effective.

To prepare for the procedure, your provider will review your medical history to ensure you’re in good physical health. They may perform various tests, including:

• A physical exam.
• Blood tests.
• Imaging tests.

What happens during gender affirmation surgery?

Your healthcare provider will walk you through what’ll happen during surgery. For many people, gender affirmation surgery is a combination of procedures. For example, you may have both an orchiectomy and a vaginoplasty, a hysterectomy and a phalloplasty, etc.

Regardless of the procedure, your surgeon will administer anesthesia so you don’t feel any pain. Depending on the surgery, your surgeon will:

• Remove or restructure organs or tissue.
• Construct new structures out of existing tissue.
• Insert implants or tissue grafts.

They may also place drains to remove fluid from wounds or a Foley catheter to help you pee.

Reach out to your provider if you have any questions about the specifics.

How long does gender-affirming surgery take?

Some procedures take place in a single day, while others require several surgeries spread out over time. For example, top surgery usually takes one day. But a phalloplasty is usually spread out over several surgeries.

Even if surgery only takes a day, you may need to return to your provider for additional changes (revision surgery) depending on how satisfied you are with the results. Choosing a healthcare provider with extensive experience performing a particular surgery will reduce the likelihood you’ll need a revision.

It’s essential to talk to your healthcare provider beforehand so you understand:

• How many surgeries you’ll need.
• How long (approximately) each surgery will last.
• When you should expect to see full results.

What types of healthcare providers make up a gender affirmation surgery team?

The following healthcare providers may make up your gender affirmation surgery team:

• Urologist.
• Gynecologist.
• Plastic surgeon.
• Otolaryngologist.
• Anesthesiologist.
• Speech-language pathologist (SLP).
• Physical/occupational therapists.
• Nurses, nurse practitioners, physician assistants.
• Trainees (residents and fellows).

What happens after gender affirmation surgery?

You’ll need to take extra care of yourself as you heal. This may mean asking friends or family to help during recovery. After surgery, you’ll need to:

• Care for wounds, catheters and drains. Follow your healthcare provider’s guidance on how to wash your wounds and monitor for infection. Make sure you understand how to care for catheters and drains if you have them.
• Wear compression garments. You may need to wear compression bandages or garments to reduce swelling, so wounds heal faster.
• Take medicines as prescribed. This includes reaching out to your healthcare provider if you need help managing pain.
• Avoid reaching or straining. Before surgery, rearrange your living space so you don’t have to strain to reach objects you need. This can prevent injuries once you return home.
• Monitor your eating patterns. Discuss nutritious food options that will facilitate healing with your healthcare provider.
• Adjust your routine. For example, you may need to stick with sponge baths for a while and limit exercise. You may need to avoid certain sexual activities until you’ve healed completely. Follow your provider’s instructions.

What are the benefits of gender affirmation surgery?

Gender affirmation surgery may help in those areas where your gender feels out of sync with your body. Surgery can enable you to become more satisfied with your:

• Appearance, including changes in the way your face, chest or genitals look.
• Gender expression, including how you look, sound and do routine things (like peeing standing up or sitting down).
• Sexual function, including engaging in sexual activities in ways that align with your gender.

What are the risks or complications of gender affirmation surgery?

Different procedures carry different risks. For example, individuals who have bottom surgery may have changes to their sexual sensation or trouble with bladder emptying. In general, significant complications are rare, as long as an experienced surgeon performs the procedure.

With any surgery, there’s a small risk of complications, including:

• Bleeding.
• Infection.
• Side effects of anesthesia.

What is the recovery time?

Recovery times vary based on what procedures or combination of procedures you have:

• Cheek and nose surgery: Swelling lasts for around two to four weeks.
• Chin and jaw surgery: Most swelling fades within two weeks. It may take up to four months for swelling to disappear.
• Chest surgery: Swelling and soreness last for one to two weeks. You’ll need to avoid vigorous activity for at least one month.
• Bottom surgery: Most people don’t resume usual activities until at least six weeks after surgery. You’ll need weekly follow-up visits with your healthcare provider for a few months. These visits ensure you’re healing well.

After surgery, it’s a good idea to continue seeing a mental health professional with a background in transgender care. They can support you as you adjust to life after surgery.

What is the outlook for people who have gender affirmation surgery?

Research consistently shows that people who choose gender affirmation surgery experience reduced gender incongruence and improved quality of life. Depending on the procedure, 94% to 100% of people report satisfaction with their surgery results.

Gender-affirming surgery provides long-term mental health benefits, too. Studies consistently show that gender affirmation surgery reduces gender dysphoria and related conditions, like anxiety and depression.

What is the regret rate for gender-affirming surgery?

Very few people who have gender-affirming surgery regret their decision. Research tracking the outcomes following gender affirmation surgeries shows that among people who opt for gender-affirming surgery, only 1% regret having the procedure.

When should I see my healthcare provider?

Attend all follow-up visits to ensure you’re healing. Reach out to your provider if you notice signs of a complication, including:

• Bleeding for more than a few days after surgery.
• Pain that doesn’t go away after several weeks or intense pain.
• Signs of infection, such as a wound that changes color or doesn’t heal.

Also, talk to your surgeon about routine aftercare. Depending on your anatomy, you may need regular visits with a gynecologist or a urologist. You may need routine checks for conditions like breast cancer, cervical cancer or prostate cancer. It’s essential to understand how surgery affects your care plan moving forward.

What’s the difference between gender affirmation surgery and gender (sex) reassignment surgery?

Gender reassignment is an outdated term for gender affirmation surgery. The new language, “gender affirmation,” is more accurate in terms of what the surgery does (and doesn’t) do. No surgery can reassign your gender — who you know yourself to be. Instead, gender-affirming surgery changes your physical body so that it better aligns with how you understand (and wish to express) your gender.

A note from Cleveland Clinic

All gender-affirming surgeries are major procedures. There are several steps involved and healthcare providers you’ll likely meet with, including your primary care provider, a mental health specialist and a surgeon. Assembling the right care team makes all the difference when it comes to your surgery results and your care experience.

Research the providers you choose carefully. Pick a mental health professional with expertise in treating transgender and gender-diverse people. Find a surgeon with several years of experience performing the surgery you want. Ask about their track record of achieving positive results. This may be one of the most important procedures of your life. Choose a team that can deliver the best possible care.