Transgender Surgery: Everything You Need to Know

Transgender surgery goes by a constellation of names. People call it gender-affirming surgery; 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. Older terms such as gender- or sex-reassignment surgery and male-to-female or female-to-male surgery have fallen out of favor.

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, explained 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?" DeNormand told 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 to find out more about this expanding category of care.

What To Consider Before Transgender Surgery

First, it is important to note that an individual does not need surgery to transition. Many transgender people do not undergo surgery. If they do, it is usually only one part of their transition.

"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, told 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). The organization publishes evidence-based standards for the care of transsexual, transgender, gender non-conforming, genderqueer, gender diverse, and nonbinary individuals.

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, when people 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 work to 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.

Research shows that cross-sex hormone therapy has positive physical and psychological effects on transitioning individuals.

Hormone therapy is used either as a stand-alone therapy or in combination with other treatments. It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. 

It is typically recommended before gender-affirming surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Mental Health Counseling

There's also psychotherapy. People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender-conforming 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, 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, told Health.

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.

"I think a lot of trans men, in general, will just get top surgery and stop there," depending on the level of dysphoria, said Dr. McClung. Others opt for bottom surgery to reconstruct the pelvic area.

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.

Prior to 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

Some people may request a variation called a simple release (or simple meta) "to stretch the clitoris out and do nothing else," said Dr. McClung.

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 contains eggs and produces 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 and 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 out 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.

Wound healing difficulties are a common complication. People undergoing vaginoplasty must use a dilator to maintain the vaginal cavity's depth and width, which places stress on the surgical site, said Dr. Kim.

"So you have two competing goals," said Dr. Kim, one of trying to heal wounds and the other trying to keep the vaginal cavity "as deep and wide as possible," he added. If wounds become infected, antibiotics may be necessary, or even another operation to clean out the infection.

A growing number of minimal-depth vaginoplasties are being performed in response to those wanting feminine genitalia but are 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," said Dr. Kim.

Penectomy

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 nowadays. 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.

"You could do an orchiectomy alone, which is just removal of the testicles," said Dr. McClung. "You could do an orchiectomy and scrotectomy [removal of the scrotum]," said Dr. McClung.

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
• Hysterectomy (uterus removal)
• Nipple and areola augmentation or removal
• Oophorectomy (ovary removal)
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple

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.

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.

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.

What Doctors Wish People Knew Before Surgery

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.

By the time they finally have a surgical consult, people tend to be focused on doing the surgery as quickly as possible, said Dr. Wittenberg.

Yet it's important to proceed with the utmost care. Dr. McClung wished people had a better idea of the potential risks.

A 6-year study of 7,905 transgender people who had gender-affirming surgeries found about 5.8% had complications, and that phalloplasty had the highest rate of complications.

"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,'" said Dr. McClung. But the procedures must be done in the safest way possible to avoid complications.

A Quick Review

Transgender surgeries help to reduce or resolve gender dysphoria in transsexual, transgender, and gender non-conforming people. It is a highly personalized process that looks different for each person and can often take several months or years. Psychotherapy and hormone therapy are typically required prior to surgical planning. 

Gender-affirming procedures often involve multiple surgeries. Feminizing or masculinizing top surgery involves adding, removing, or reshaping breasts, areoles, and nipples.

Masculinizing bottom surgeries may involve procedures to remove the uterus (hysterectomy) and ovaries (oophorectomy) and create a phallic structure by either phalloplasty or a procedure to lengthen the clitoris (metoidioplasty). Some trans men also have a procedure to extend the urethra, which allows them to urinate in a standing position.

Feminizing bottom surgeries can include penis removal or inversion, testicle and scrotum removal (orchiectomy and scrotectomy), and creating a vagina and vulva (vaginoplasty) or vulva without a vaginal canal (vulvoplasty).

Gender nullification surgery is often used for people who identify as agender, asexual, or non-binary. This involves removing external genitalia to create a smooth transition from the abdomen to the groin. 

Gender-affirming procedures can also involve plastic surgery to modify facial features for a more masculine, feminine, or non-binary appearance. In addition, vocal cord and voice-box modifications are sometimes used to change the voice pitch and reduce the size of the Adam’s apple.