Here's what it's like to undergo male-to-female or female-to-male surgery.

By Karen Pallarito
August 03, 2020
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Transgender surgery goes by a constellation of names. People call it gender reassignment, realignment, or confirmation surgery; masculinization or feminization surgery; male-to-female or female-to-male surgery; or even sex reassignment surgery. Increasingly, as medicine breaks out of a gender-binary box, more inclusive and culturally appropriate descriptors, such as “gender-affirmation surgery” and “gender-affirming care,” are catching on.

Having surgery to change one or more sex characteristics—breasts/chest, genitalia, or facial features, for example—is a highly personal decision. But to say it’s a “choice” misses the mark, explains Steph DeNormand (they/them), Trans Health Program Manager at Fenway Health in Boston. It’s a matter of survival; it’s “can I be the person that I know I am?” they tell Health.

Whether you are  supporting someone who’s transitioning, or you're on your own journey to align your body with your sense of self, it’s important to know what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications. We spoke with surgeons and trans health professionals from to find out more about this expanding category of care.

Before transgender surgery: what to consider

“What I always tell patients is if you don’t have dysphoria about a body part, [then] don’t have surgery,” Christopher McClung, MD, a urologist with OhioHealth in Columbus, Ohio, tells Health. Dysphoria refers to the distress that trans people may experience when their gender identity doesn’t match their sex assigned at birth. In some cases, surgery may be medically necessary to treat the dysphoria, according to the World Professional Association for Transgender Health (WPATH), which publishes evidence-based standards for the care of transsexual, transgender, and gender non-conforming people.

Hormone therapy is another option for treating gender dysphoria, and it can be helpful either as a stand-alone therapy or in combination with other treatments. Hormone therapy is also recommended before most surgeries; they induce many of the physical changes that masculinize or feminize the body.

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

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

While these are guidelines, every person’s treatment is individualized, so “there’s not one linear path,” Julie Thompson, a physician assistant and medical director of trans health at Boston’s Fenway Health, tells Health.

What are masculinizing surgeries, and how do they work?

The process of masculinizing often includes “top surgery” to remove breast tissue. ”I think a lot of trans men in general will just get top surgery and stop there,” depending on the level of dysphoria, says Dr. McClung. Others opt for “bottom surgery” to reconstruct the pelvic area.

Hormone therapy, which is required before most surgeries, produces obvious changes in appearance. “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, tells Health.

Some trans men elect to do metoidioplasty—also called a meta—which involves lengthening the clitoris, extending the urethra (the tube through which urine passes), and making a scrotum. Some patients may request a variation called a simple release (or simple meta) “to stretch the clitoris out and doing nothing else,” observes Dr. McClung.

Other trans men opt for phalloplasty to give them a phallic structure with sensation. 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, tells Health. Those structures are then reconnected under an operative microscope using very fine sutures—“thinner than our hair,” he says. That surgery alone can take 6 to 8 hours, he adds.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, says Dr. Kim. Due to possible urinary complications after phalloplasty, such as urinary fistulas or strictures, some people prefer to skip that step, especially if urinating through the penis while standing is not a priority, he explains. Patients who want to have penetrative sex must have prosthesis implant surgery, too.

As for removal of the uterus and ovaries, it depends. Patients may want a hysterectomy to address their dysphoria, says Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

What do feminizing surgeries involve?

Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

As for bottom surgery, there are a variety of feminizing procedures from which to choose. “You could do an orchiectomy alone, which is just removal of the testicles,” says Dr. McClung. “You could do an orchiectomy and scrotectomy [removal of the scrotum],” he says, Other options include vulvoplasty (to create external genitalia without a vagina) or a full vaginoplasty (creating a vulva and vaginal canal).

Dr. Wittenberg notes that patients may undergo six to 12 months of electrolysis or laser hair removal prior to surgery to remove pubic hair from 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 out and inverted into a created cavity, explains Dr. Kim. Vaginoplasty may be done in one or two stages, says Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until patients see results.

Wound healing difficulties are a common complication. Vaginoplasty patients must use a dilator to maintain the vaginal cavity’s depth and width, which places stress on the surgical site, says Dr. Kim. “So you have two competing goals,” he says, one of trying to heal wounds and the other trying to keep the vaginal cavity “as deep and wide as possible,” he adds. If wounds become infected, antibiotics may be necessary or even another operation to clean out the infection.

A growing number minimal-depth vaginoplasties are being performed in response to patients wanting feminine genitalia but not willing to risk complications or the hassle of dilating. “Recently, we’re finding out that from a patient’s perspective the external appearance of the vulva is just as important as the vaginal cavity,” says Dr. Kim.

Other surgeries that may be options

People who are agender or asexual may opt for nullification, meaning the removal of all sex organs. The external genitalia are removed, leaving an opening for urine to pass.

Some gender non-conforming patients assigned male at birth want a vagina but also want to preserve their penis, says Dr. Wittenberg. This is called a penile preservation vaginoplasty, or “phalgina,” as one of her patients coined it. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Alternatively, a patient assigned female at birth can undergo phalloplasty and retain the vaginal opening.

What doctors wish their patients knew before surgery

All in all, the entire transition process—living as your preferred gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, doctors say. By the time they finally have a surgical consult, patients tend to be focused on doing the surgery as quickly as possible, says Dr. Wittenberg.

Yet it’s important to proceed with the utmost care. Dr. McClung wishes patients had a better idea of the potential risks. Complication rates related to vaginoplasties, phalloplasties, and other procedures can be as high as 25%, he says. “I always tell my patients, ‘Look, I want the same thing as you: I want a cosmetically and functionally perfect set of genitals that is going to make you happy,’” he says. But the procedures need to be done in the safest way possible to avoid complications.

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