gender reassignment surgery from male to female

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• Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Removal of the penis, called penectomy.
• Removal of the testicles.
• Creation of a vagina, called vaginoplasty.
• Creation of a clitoris, called clitoroplasty.
• Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Tummy tuck, called abdominoplasty.
• Buttock lift, called gluteal augmentation.
• Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

• Significant medical conditions that haven't been addressed.
• Behavioral health conditions that haven't been addressed.
• Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

• Delayed wound healing
• Fluid buildup beneath the skin, called seroma
• Bruising, also called hematoma
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Alternatives to surgery
• Expectations and goals
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• A review of your vaccinations
• Screening tests for some conditions and diseases
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
• Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

• Gender identity
• Gender dysphoria
• Mental health concerns
• Sexual health concerns
• The impact of gender identity at work, at school, at home and in social settings
• The role of social transitioning and hormone therapy before surgery
• Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
• Support from family, friends and caregivers
• Your goals and expectations of treatment
• Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead
• Enlarging the lips and cheekbones with implants
• Reshaping the jaw and chin
• Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

• Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

• Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

• Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

• Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

• Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
• Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
• It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
• In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon  will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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INTRODUCTION

This topic will review surgeries that are commonly performed as part of feminizing transition. Other topics related to the care of transgender persons include:

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

• 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
• 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Medindia » News » Research News » A Global Comparison: Best Countries for Gender Reassignment Surgery

A Global Comparison: Best Countries for Gender Reassignment Surgery

Purpose and Procedures

Chest surgery (top surgery) for ftm transitions:, phalloplasty for ftm transitions:, breast augmentation for mtf transitions:, facial feminization surgery (ffs) for mtf transitions:, vaginoplasty for mtf transitions:.

Turkey Emerges as a Budget-Friendly Destination

Latin america offers competitive prices.

Belgium: Affordable and Progressive in Europe

The u.s.: highest costs and legal challenges.

• What Is the Best Country for Gender Reassignment Surgery? - (https://healthnews.com/reports/what-is-the-best-country-for-gender-reassignment-surgery/)
• Expert Q&A: Gender Dysphoria - (https://www.psychiatry.org/patients-families/gender-dysphoria/expert-q-and-a)

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How Much Does Male-to-Female (MTF) Surgery Cost in 2024?

Medically reviewed by

Planning on conquering gender dysphoria through surgery but feeling worried about the cost? This comprehensive guide will clear up the financial fog and break down the costs of MTF gender-affirming surgery so you can focus on what truly matters— a journey to becoming your most authentic self.

Quick Overview:

• Average MTF top surgery cost: $5,000-$10,000.
• Average MTF bottom surgery cost: $10,000-$30,000.
• Average facial feminization surgery (FFS) costs: $20,000-$50,000.
• Average voice feminization surgery cost: $5,500-$9,000.
• The US and the UK: On the pricier side, with costs ranging from $10,000 to over $42,000 for some MTF gender-affirming surgeries.
• Thailand : Offers more affordable options, with costs ranging from $3,200 to $15,000 .
• Turkey : Known for cost-effective healthcare, with transgender surgeries costing between $2,500 and $13,000 .

Table of Contents

How much is male-to-female (mtf) gender reassignment surgery, how much does mtf top surgery cost, how much is mtf bottom surgery, how much does facial feminization surgery (ffs) cost, how much does voice feminization surgery cost, what factors affect mtf gender-affirming surgery cost.

• How Much Does Male-to-Female Transgender Surgery Cost Worldwide?

What is Included in the Male-to-Female Surgery Cost?

Does health insurance cover mtf surgery, additional costs of mtf gender-affirming surgeries.

Male-to-female (MTF) gender reassignment surgery involves various medical procedures that alter the physical characteristics of a person assigned male at birth to match their female gender identity. This can include breast augmentation, genital surgery, facial feminization surgery (FFS), and voice feminization surgery. 

Because of the variety and complexity of procedures, the total cost of MTF gender-affirming surgery can reach up to $140,500. However, the average cost typically falls between $5,000 and $30,000 . It all depends on the specific surgeries and results you are aiming for.

Below, you can compare costs for some standard MTF gender reassignment procedures:

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Male-to-female (MTF) top surgery, or chest feminization, is a procedure that enhances breast volume and shape to have a more traditionally feminine appearance. A surgeon places breast implants either behind the natural breast tissue or beneath the pectoral muscle. Each implant is carefully centered beneath the nipples to ensure a natural and symmetric appearance.

The cost of MTF top surgery ranges from $5,000 to $10,000 . The final price depends on the desired size, the type of implants, and the surgical technique.

Transgender people can choose between two types of implants:

• Saline implants are filled with sterile salt water. Due to the less expensive filling material, they can be up to 25% cheaper than their silicone counterparts. Saline implants also require smaller incisions because they are filled after being inserted.
• Silicone implants have a soft and natural feel. Although they are costlier, many find their texture more lifelike.

🤔 Learn more about what to expect from top surgery.

Male-to-female (MTF) bottom surgery encompasses a range of surgical procedures that align male genitalia with a transgender woman's gender identity. The average cost of transfeminine bottom surgery is around $25,000 .

• Orchiectomy: $2,000 to $8,000. This procedure involves the surgical removal of the testicles. This type of MTF bottom surgery is relatively simple and less invasive. It can be conducted alone or as part of a broader genital reconstruction.
• Vaginoplasty/Vulvoplasty: $10,000-$30,000. Vaginoplasty constructs a functional vagina, which includes a vaginal canal capable of intercourse and a depth that supports penetration. Vulvoplasty, or zero-depth vaginoplasty, creates the external genitalia (vulva) without a vaginal canal.

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Facial feminization surgery (FFS) is a subset of gender-affirming surgeries that soften facial features to reflect a more feminine appearance. FFS not only enhances aesthetic appeal but also offers profound psychological benefits. It can significantly alleviate gender dysphoria and boost self-confidence. For many, achieving a more traditionally feminine appearance and the ability to “pass” can also provide increased safety in a world where transphobia remains a genuine concern.

Out-of-pocket costs of FFS are quite variable and typically range from $20,000 to $50,000 , depending on which procedures you decide to have. 

Below is a breakdown of common FFS procedures and their average costs:

☝️Tip: While it's usually more cost-effective to have multiple FFS procedures done in a single operation, it's crucial not to overdo it. Sometimes, a single change can significantly enhance femininity. If your budget is limited, discuss with your doctor which procedures would most effectively soften your features and give you the most value for your money.

Voice feminization surgery is a specialized procedure that permanently raises the pitch of your voice, making it sound higher. Because certain voice qualities are traditionally associated with gender, trans women often seek this type of surgery as part of their medical male-to-female transition. The average cost for voice feminization surgery ranges from $5,500 to $9,000 .

🗣️How does it work? Your vocal cords determine the pitch of your voice based on their thickness and length. Typically, men and transgender individuals assigned male at birth (AMAB) have vocal cords that produce lower pitches compared to women and those assigned female at birth (AFAB). During this gender-affirming surgery, a laryngologist will permanently shorten, thin, or tighten your vocal cords to increase the pitch, helping your voice sound higher and more feminine.

Each male-to-female surgery is adapted to the patient’s needs, making each person’s experience and medical expenses unique. Here are some key elements that influence the overall cost:

• Type of gender-affirming surgery. Different MTF surgeries come with varying price tags depending on their complexity and the specific techniques used.
• Number of gender-affirming surgeries. Many patients choose to combine surgeries. For example, facial feminization surgery often involves multiple procedures—such as rhinoplasty, jaw reshaping, and a brow lift—all performed in one surgical session to maximize results and minimize recovery time. Additionally, revision surgeries may be necessary to refine the outcomes.
• Surgeon's experience. Highly experienced surgeons charge more for their services, but they also often offer a higher level of skill and potentially better outcomes.
• Geographic location. MTF gender-affirming surgery cost can vary significantly depending on where it's performed. For example, surgery costs might be higher in major cities than in smaller towns. Likewise, some countries offer more advantageous options. Countries like Turkey and Thailand offer lower MTF surgery costs due to lower living expenses, favorable currency exchange rates, and competitive medical tourism markets.
• Clinic fees. The choice of facility also influences the total cost. Private clinics might have different pricing structures compared to public hospitals. Some offer package deals for multiple procedures.
• Additional medical treatments. Additional procedures or treatments may sometimes be necessary, either before or after surgery, which can add to the total cost.

How Much Does Male-to-Female Transgender Surgery Cost Worldwide? 

Male-to-female transgender surgery costs vary significantly around the world, influenced by factors such as local economic conditions, healthcare infrastructure, and the prevalence of medical tourism. In countries like Thailand and Turkey , the costs for MTF procedures are often lower than average, making these countries popular destinations for affordable gender-affirming care.

Here’s a comparative table of average costs in the most popular countries for gender-affirming surgery:

Get a Free Personalized Quote

Understanding what is typically included in the quoted price of MTF surgery helps ensure that there are no unexpected expenses during your journey. 

The cost of male-to-female gender-affirming surgery usually covers:

• surgeon's fees;
• anesthesia fees;
• hospital costs (the use of the surgery room, hospital stay, and any necessary medical equipment);
• pre-operative consultations and necessary pre-surgery medical tests;

All-inclusive MTF surgery packages

It’s common for clinics, especially those in popular medical tourism destinations, to offer comprehensive sex reassignment surgery packages. These packages can provide a range of additional conveniences and necessities, simplifying the process for patients. 

Here’s what you might find included:

• several compatible gender-affirming surgeries in one trip (based on your preferences);
• airport-hotel-hospital transfers;
• accommodation in hotels near the clinic;
• compression underwear for post-surgery recovery;
• post-operative care.

Always compare what’s included to ensure you get the necessary services and the best value.

Get a Free Consultation

Yes, health insurance often covers certain types of male-to-female (MTF) transgender surgeries, but coverage can vary depending on the specific policy and the provider. A typical insurance plan will cover surgeries considered essential for gender affirmation, such as top and bottom surgeries. Health insurance plans usually deny coverage for gender-affirming procedures deemed cosmetic, such as facial feminization surgery (FFS) and voice feminization.

To qualify for health insurance coverage, transgender people usually need to follow the guidelines set by the World Professional Association for Transgender Health (WPATH). Common requirements include: 

• letters of readiness from mental health professionals;
• evidence of hormone replacement therapy for at least 1 year;

💰Struggling to fund your surgery with health insurance alone? Discover which organizations offer grants and other ways to fund gender-affirming surgeries here .

When planning for male-to-female (MTF) transgender surgery, it’s crucial to account for out-of-pocket costs. These extra expenses can significantly impact your overall budget. Here’s what to consider:

• Additional medications such as pain relief, antibiotics, and hormone therapy.
• Travel and accommodation for those traveling out of town or internationally for surgery.
• Secondary or revision surgeries if further procedures are needed for optimal results.
• Hair removal is often necessary as a preparatory step before certain gender-affirming surgeries like genital reconstruction. This process involves frequent sessions at $75-$100 per session.
• Hiring help at home if recovering alone, to assist with daily tasks during recovery.
• Therapy sessions , costing between $65 and $250, may be required to obtain referrals for surgery.
• Post-surgery items like compression garments, shower stools, waterproof bed sheets, cheap underwear, and sanitary towels.
• Factor in taking some time off work — about 6-8 weeks for bottom surgery recovery and 1-2 weeks for top surgery.
• Include a buffer for unexpected costs like extended hospital stays or emergency medical care.
• Male-to-female (MTF) gender reassignment surgery includes procedures like breast augmentation, genital reconstruction, facial feminization, and voice feminization.
• Total costs for MTF surgery can reach up to $140,500; average costs generally range from $5,000 to $30,000 , depending on the procedure.
• MTF top surgery typically costs $5,000 to $10,000; bottom surgery ranges from $10,000 to $30,000; facial feminization surgery costs between $20,000 and $50,000; and voice feminization surgery ranges from $5,000 to $9,000.
• MTF surgery is especially expensive in the US and the UK , where costs can reach $42,000 and more . Thailand and Turkey offer options that are up to 3 times more affordable .
• Insurance covers procedures like top and bottom surgeries per WPATH guidelines but does not usually provide for cosmetic procedures.
• Expect to budget for extra expenses such as medications, travel, accommodation, hair removal, home assistance, therapy sessions, and time off work for recovery.
• Forbes. (2022). How To Afford Transgender Surgery Expenses. https://www.forbes.com/advisor/personal-loans/transgender-surgery-cost/
• Business Insider. (2019). The staggering costs of being transgender in the US, where even patients with health insurance can face six-figure bills. https://www.businessinsider.com/transgender-medical-care-surgery-expensive-2019-6
• Healthline. (2023). Everything You Need to Know About Voice Feminization Surgery. https://www.healthline.com/health/voice-feminization-surgery

Ohio judge temporarily blocks ban on gender-affirming care for transgender minors

A Franklin County judge on Tuesday temporarily blocked an impending law that would restrict medical care for transgender minors in Ohio.

The decision came weeks after the American Civil Liberties Union filed a lawsuit challenging House Bill 68 on behalf of two transgender girls and their families. The measure prevents doctors from prescribing hormones, puberty blockers or gender reassignment surgery before patients turn 18.

Attorneys contend the law violates the state Constitution , which gives Ohioans the right to choose their health care.

"Today's ruling is a victory for transgender Ohioans and their families," said Harper Seldin, staff attorney for the ACLU. "Ohio's ban is an openly discriminatory breach of the rights of transgender youth and their parents alike and presents a real danger to the same young people it claims to protect."

House Bill 68 was set to take effect April 24 after House and Senate Republicans  voted to override  Gov. Mike DeWine's veto. Proponents of the bill contend it will protect children, but critics say decisions about transition care should be left to families and their medical providers.

The suit in Ohio mirrors efforts in other states to challenge laws that restrict gender-affirming care for minors. A federal judge struck down a  similar policy in Arkansas , arguing it violates the constitutional rights of transgender youth and their families. The state is appealing that decision.

“This is just the first page of the book,” Attorney General Dave Yost said Monday. “We will fight vigorously to defend this properly enacted statute, which protects our children from irrevocable adult decisions. I am confident that this law will be upheld.”

What does House Bill 68 do?

House Bill 68 allows Ohioans younger than 18 who already receiving hormones or puberty blockers to continue, as long as doctors determine stopping the prescription would cause harm. Critics say that's not enough to protect current patients because health care providers could be wary of legal consequences.

The legislation does not ban talk therapy, but it requires mental health providers to get permission from at least one parent or guardian to diagnose and treat gender dysphoria.

The bill also bans transgender girls and women from playing on female sports teams in high school and college. It doesn't specify how schools would verify an athlete's gender if it's called into question. Players and their families can sue if they believe they lost an opportunity because of a transgender athlete.

The lawsuit doesn't specifically challenge the athlete ban. But it argues that House Bill 68 flouts the constitution's single-subject rule, which requires legislation to address only one topic. House Republicans introduced separate bills on gender-affirming care and transgender athletes before  combining them into one .

In Tuesday's decision, Franklin County Judge Michael Holbrook indicated that the law could be tossed out because of a single-subject violation.

"It is not lost upon this Court that the General Assembly was unable to pass the (Saving Ohio Adolescents from Experimentation) portion of the Act separately, and it was only upon logrolling in the Saving Women’s Sports provisions that it was able to pass," Holbrook wrote.

Panel clears ban on gender reassignment surgery for minors

Tuesday's decision came one day after a legislative panel cleared the way for an administrative rule that will ban gender reassignment surgery for minors. Ohio health care providers say they do not perform that procedure on patients under 18.

The rule will take effect May 3.

The measure was among several that DeWine proposed to regulate gender-affirming care after he vetoed House Bill 68. In testimony for Monday's meeting, opponents argued that the rules overstep the administration's authority and conflict with federal law.

"The proposed administrative rule changes are based on biased definitions, ignore well-established best practices and restrict countless patients’ access to gender-affirming care," said Mallory Golski, civic engagement and advocacy manager for Kaleidoscope Youth Center.

DeWine's other proposals are still working their way through the rulemaking process. That includes a requirement for transgender minors to undergo at least six months of counseling before further treatment occurs. Another rule would require providers to report non-identifying data on gender dysphoria diagnoses and treatment.

Haley BeMiller is a reporter for the USA TODAY Network Ohio Bureau, which serves the Columbus Dispatch, Cincinnati Enquirer, Akron Beacon Journal and 18 other affiliated news organizations across Ohio.

Transgender inclusion? World’s major religions take varying stances

The Vatican has issued a  new document  rejecting the concept of changing one’s biological sex — a setback for transgender people who had hoped Pope Francis might be setting the stage for a more welcoming approach from the Catholic Church.

Around the world, major religions have diverse approaches to gender identity, and the inclusion or exclusion of transgender people. Some examples:

Christianity

The Catholic Church’s disapproving stance toward gender transition is shared by some other denominations. For example, the Southern Baptist Convention — the largest Protestant denomination in the United States — adopted a resolution in 2014 stating that “God’s design was the creation of two distinct and complementary sexes, male and female.” It asserts that gender identity “is determined by biological sex, not by one’s self-perception”

However, numerous mainline Protestant denominations welcome trans people as members and as clergy. The Evangelical Lutheran Church in America elected an openly transgender man as a bishop in 2021.

In Islam, there isn’t a single central religious authority and policies can vary in different regions.

Abbas Shouman, secretary-general of Al-Azhar’s Council of Senior Scholars in Cairo, said that “for us ... sex conversion is completely rejected.”

“It is God who has determined the ... sex of the fetus and intervening to change that is a change of God’s creation, which is completely rejected,” Shouman added.

In Iran, the Shiite theocracy’s founder, Ayatollah Ruhollah Khomeini,  issued a religious decree,  or fatwa, decades ago, opening the way for official support for gender transition surgery.

In Hindu society in South Asia, while traditional roles were and are still prescribed for men and women, people of non-binary gender expression have been recognized for millennia and played important roles in holy texts. Third gender people have been revered throughout South Asian history with many rising to significant positions of power under Hindu and Muslim rulers. One survey in 2014 estimated that around 3 million third gender people live in India alone.

Sanskrit, the ancient language of Hindu scriptures, has the vocabulary to describe three genders — masculine, feminine and gender-neutral.

The most common group of third gender people in India are known as the “hijras.” While some choose to undergo gender reassignment surgery, others are born intersex. Most consider themselves neither male or female.

Some Hindus believe third gender people have special powers and the ability to bless or curse, which has led to stereotyping causing the community to be feared and marginalized. Many live in poverty without proper access to healthcare, housing and employment.

In 2014, India, Nepal and Bangladesh, which is a Muslim-majority country, officially recognized third gender people as citizens deserving of equal rights. The Supreme Court of India stated that “it is the right of every human being to choose their gender,” and that recognition of the group “is not a social or medical issue, but a human rights issue.”

Buddhism has traditionally adhered to binary gender roles, particularly in its monastic traditions where men and women are segregated and assigned specific roles.

These beliefs remain strong in the Theravada tradition, as seen in the attempt of the Thai Sangha Council, the governing Buddhist body in Thailand, to ban ordinations of transgender people. More recently, the Theravada tradition has somewhat eased restrictions against gender nonconforming people by ordaining them in their sex recorded at birth.

However, the Mahayana, and Vajrayana schools of Buddhism have allowed more exceptions while the Jodo Shinshu sect has been even more inclusive in ordaining transgender monks both in Japan and North America. In Tibetan Buddhism, Tashi Choedup, an openly queer monk, was ordained after their teacher refrained from asking about their gender identity as prescribed by Buddhist doctrine. Many Buddhist denominations, particularly in the West, are intentionally inclusive of transgender people in their sanghas or gatherings.

Reform Judaism is accepting of transgender people and allows for the ordination of trans rabbis. According to David J. Meyer, who served for many years as a rabbi in Marblehead, Massachusetts, Jewish traditional wisdom allowed possibilities of gender identity and expression that differed from those typically associated with the sex assigned at birth.

“Our mystical texts, the Kabbalah, address the notion of transitioning from one gender to another,” he wrote on a Reform-affiliated website.

It’s different, for the most part, in Orthodox Judaism. “Most transgender people will find Orthodox communities extremely difficult to navigate,” says the Human Rights Campaign, a major U.S. LGBTQ-rights advocacy group.

“Transgender people are further constrained by Orthodox Judaism’s emphasis on binary gender and strict separation between men and women,” the HRC says. “For example, a transgender person who has not medically transitioned poses a challenge for a rabbi who must decide whether that person will sit with men or women during worship.”

Rabbi Avi Shafran, spokesman for the Orthodox Jewish organization Agudath Israel of America, wrote a blog post last year after appearing on an Israeli television panel to discuss transgender-related issues.

“There can be no denying that there are people who are deeply conflicted about their gender identities. They deserve to be safe from harm and, facing challenges the rest of us don’t, deserve empathy and compassion,” Shafran wrote. “But the Torah and its extension, halacha, or Jewish religious law, are unequivocal about the fact that being born in a male body requires living the life of a man, and being born female entails living as a woman.”

“In Judaism, each gender has its particular life-role to play,” he added. “The bodies God gave us are indications of what we are and what we are not, and of how He wants us to live our lives.”

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• v.25(3); 2011 Aug

Aesthetic and Functional Genital and Perineal Surgery: Male

Sex reassignment surgery in the female-to-male transsexual, stan j. monstrey.

1 Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium

Peter Ceulemans

Piet hoebeke.

2 Department of Urology, Ghent University Hospital, Gent, Belgium

In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy (endoscopically assisted). The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap (or an alternative). After about one year, penile (erection) prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reassignment surgery procedures that can be performed in a female-to-male transsexual.

Transsexual patients have the absolute conviction of being born in the wrong body and this severe identity problem results in a lot of suffering from early childhood on. Although the exact etiology of transsexualism is still not fully understood, it is most probably a result of a combination of various biological and psychological factors. As to the treatment, it is universally agreed that the only real therapeutic option consists of “adjusting the body to the mind” (or gender reassignment) because trying to “adjust the mind to the body” with psychotherapy has been shown to alleviate the severe suffering of these patients. Gender reassignment usually consists of a diagnostic phase (mostly supported by a mental health professional), followed by hormonal therapy (through an endocrinologist), a real-life experience, and at the end the gender reassignment surgery itself.

As to the criteria of readiness and eligibility for these surgical interventions, it is universally recommended to adhere to the Standards of Care (SOC) of the WPATH (World Professional association of Transgender Health) 1 . It is usually advised to stop all hormonal therapy 2 to 3 weeks preoperatively.

The two major sex reassignment surgery (SRS) interventions in the female-to-male transsexual patients that will be addressed here are (1) the subcutaneous mastectomy (SCM), often combined with a hysterectomy/ ovariectomy; and (2) the actual genital transformation consisting of vaginectomy, reconstruction of the fixed part of the urethra (if isolated, metoidioplasty), scrotoplasty and phalloplasty. At a later stage, a testicular prostheses and/or erection prosthesis can be inserted.

SUBCUTANEOUS MASTECTOMY

General principles.

Because hormonal treatment has little influence on breast size, the first (and, arguably, most important) surgery performed in the female-to-male (FTM) transsexual is the creation of a male chest by means of a SCM. This procedure allows the patient to live more easily in the male role 2 , 3 , 4 , 5 and thereby facilitates the “real-life experience,” a prerequisite for genital surgery.

The goal of the SCM in a FTM transsexual patient is to create an aesthetically pleasing male chest, which includes removal of breast tissue and excess skin, reduction and proper positioning of the nipple and areola, obliteration of the inframammary fold, and minimization of chest-wall scars. 4 , 5 Many different techniques have been described to achieve these goals and most authors agree that skin excess , not breast volume, is the factor that should determine the appropriate SCM technique. 2 , 3 , 4 , 5 Recently, the importance of the skin elasticity has also been demonstrated and it is important to realize that in this patient population, poor skin quality can be exacerbated when the patient has engaged in years of “breast binding” (Fig. 1 ). 6

(A,B) Result of long-term “breast binding.”

In the largest series to date, Monstrey et al 6 described an algorithm of five different techniques to perform an aesthetically satisfactory SCM (Fig. 2 ). Preoperative parameters to be evaluated include breast volume, degree of excess skin, nipple-areola complex (NAC) size and position, and skin elasticity.

Algorithm for choosing appropriate subcutaneous mastectomy technique.

Regardless of the technique, it is extremely important to preserve all subcutaneous fat when dissecting the glandular tissue from the flaps. This ensures thick flaps that produce a pleasing contour. Liposuction is only occasionally indicated laterally, or to attain complete symmetry at the end of the procedure. Postoperatively, a circumferential elastic bandage is placed around the chest wall and maintained for a total of 4 to 6 weeks.

The semicircular technique (Fig. 3 ) is essentially the same procedure as that described by Webster in 1946 7 for gynecomastia. It is useful for individuals with smaller breasts and elastic skin. A sufficient amount of glandular tissue should be left in situ beneath the NAC to avoid a depression. The particular advantage of this technique is the small and well-concealed scar which is confined to (the lower half of) the nipple-areola complex. The major drawback is the small window through which to work, making excision of breast tissue and hemostasis more challenging.

Semicircular technique. (A) Incisions and scar; (B) preoperative; (C) postoperative.

In cases of smaller breasts with large prominent nipples, the transareolar technique (Fig. 4 ) is used. This is similar to the procedure described by Pitanguy in 1966 8 and allows for subtotal resection and immediate reduction of the nipple. The resulting scar traverses the areola horizontally and passes around the upper aspect of the nipple.

Transareolar technique. (A,B) Incisions and scar; (C) preoperative; (D) postoperative.

The concentric circular technique (Fig. 5 ) is similar to that described by Davidson in 1979. 9 It is used for breasts with a medium-sized skin envelope (B cup), or in the case of smaller breasts with poor skin elasticity. The resulting scar will be confined to the circumference of the areola. The concentric incision can be drawn as a circle or ellipse, enabling deepithelialization of a calculated amount of skin in the vertical or horizontal direction. 4 , 5 Access is gained via an incision in the inferior aspect of the outer circle leaving a wide pedicle for the NAC. A purse-string suture is placed and set to the desired areolar diameter (usually 25–30 mm). The advantage of this technique is that it allows for reduction and/or repositioning of the areola, where required, and for the removal of excess skin.

Concentric circular technique. (A) incisions; (B) preoperative; (C) postoperative.

The extended concentric circular technique (Fig. 6 ) is similar to the concentric circular technique, but includes one or two additional triangular excisions of skin and subcutaneous tissue lateral and/ or medial. This technique is useful for correcting skin excess and wrinkling produced by large differences between the inner and outer circles. The resulting scars will be around the areola, with horizontal extensions onto the breast skin, depending on the degree of excess skin.

Extended concentric circular technique. (A) Incisions and scar; (B) preoperative preoperative; (C) postoperative.

The free nipple graft technique (Fig. 7 ) has been proposed by several authors for patients with large and ptotic breasts. 2 , 3 , 10 , 11 , 12 It consists of harvesting the NAC as a full-thickness skin graft; amputating the breast; and grafting the NAC onto its new location on the chest wall. Our preference is to place the incision horizontally 1 to 2 cm above the inframammary fold, and then to move upwards laterally below the lateral border of the pectoralis major muscle. The placement of the NAC usually corresponds to the 4th or 5th intercostal space. Clinical judgment is most important, however, and we always sit the patient up intraoperatively to check final nipple position. The advantages of the free nipple graft technique are easy chest contouring, excellent exposure and more rapid resection of tissue, as well as nipple reduction, areola resizing, and repositioning. The disadvantages are the long residual scars, NAC pigmentary and sensory changes, and the possibility of incomplete graft take.

Free nipple graft technique. (A) Incisions and scar; (B) preoperative; (C) postoperative.

Complications

Postoperative complications include hematoma (most frequent, despite drains and compression bandages), (partial) nipple necrosis, and abscess formation. This underscores the importance of achieving good hemostasis intraoperatively. Smaller hematomas and seromas can be evacuated through puncture, but for larger collections surgical evacuation is required.

Another not infrequent complication consists of skin slough of the NAC, which can be left to heal by conservative means. The exceptional cases of partial or total nipple necrosis may require a secondary nipple reconstruction. Even in the patients without complications, ~25% required an additional procedure to improve the aesthetic results. The likelihood of an additional aesthetic correction should be discussed with the patient in advance. 13 Tattoo of the areola may be performed for depigmentation.

The recommendations of the authors are summarized in their algorithm (Fig. 2 ), which clearly demonstrates that a larger skin envelope and a less elastic skin will require progressively a longer-incision technique. The FTM transsexual patients are rightfully becoming a patient population that is better informed and more demanding as to the aesthetic outcomes.

Finally, it is important to note that there have been reports of breast cancer after bilateral SCM in this population 14 , 15 , 16 because in most patients the preserved NAC and the always incomplete glandular resection leave behind tissue at risk of malignant transformation.

PHALLOPLASTY

In performing a phalloplasty for a FTM transsexual, the surgeon should reconstruct an aesthetically appealing neophallus, with erogenous and tactile sensation, which enables the patient to void while standing and have sexual intercourse like a natural male, in a one-stage procedure. 17 , 18 The reconstructive procedure should also provide a normal scrotum, be predictably reproducible without functional loss in the donor area, and leave the patient with minimal scarring or disfigurement.

Despite the multitude of flaps that have been employed and described (often as Case Reports), the radial forearm is universally considered the gold standard in penile reconstruction. 17 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28

In the largest series to date (almost 300 patients), Monstrey et al 29 recently described the technical aspects of radial forearm phalloplasty and the extent to which this technique, in their hands approximates the criteria for ideal penile reconstruction.

For the genitoperineal transformation (vaginectomy, urethral reconstruction, scrotoplasty, phalloplasty), two surgical teams operate at the same time with the patient first placed in a gynecological (lithotomy) position. In the perineal area, a urologist may perform a vaginectomy, and lengthen the urethra with mucosa between the minor labiae. The vaginectomy is a mucosal colpectomy in which the mucosal lining of the vaginal cavity is removed. After excision, a pelvic floor reconstruction is always performed to prevent possible diseases such as cystocele and rectocele. This reconstruction of the fixed part of the urethra is combined with a scrotal reconstruction by means of two transposition flaps of the greater labia resulting in a very natural looking bifid scrotum.

Simultaneously, the plastic surgeon dissects the free vascularized flap of the forearm. The creation of a phallus with a tube-in-a-tube technique is performed with the flap still attached to the forearm by its vascular pedicle (Fig. 8A ). This is commonly performed on the ulnar aspect of the skin island. A small skin flap and a skin graft are used to create a corona and simulate the glans of the penis (Fig. 8B ).

(A–D) Phallic reconstruction with the radial forearm flap: creation of a tube (urethra) within a tube (penis).

Once the urethra is lengthened and the acceptor (recipient) vessels are dissected in the groin area, the patient is put into a supine position. The free flap can be transferred to the pubic area after the urethral anastomosis: the radial artery is microsurgically connected to the common femoral artery in an end-to-side fashion and the venous anastomosis is performed between the cephalic vein and the greater saphenous vein (Fig. 8C ). One forearm nerve is connected to the ilioinguinal nerve for protective sensation and the other nerve of the arm is anastomosed to one of the dorsal clitoral nerves for erogenous sensation. The clitoris is usually denuded and buried underneath the penis, thus keeping the possibility to be stimulated during sexual intercourse with the neophallus.

In the first 50 patients of this series, the defect on the forearm was covered with full-thickness skin grafts taken from the groin area. In subsequent patients, the defect was covered with split-thickness skin grafts harvested from the medial and anterior thigh (Fig. 8D ).

All patients received a suprapubic urinary diversion postoperatively.

The patients remain in bed during a one-week postoperative period, after which the transurethral catheter is removed. At that time, the suprapubic catheter was clamped, and voiding was begun. Effective voiding might not be observed for several days. Before removal of the suprapubic catheter, a cystography with voiding urethrography was performed.

The average hospital stay for the phalloplasty procedure was 2½ weeks.

Tattooing of the glans should be performed after a 2- to 3-month period, before sensation returns to the penis.

Implantation of the testicular prostheses should be performed after 6 months, but it is typically done in combination with the implantation of a penile erection prosthesis. Before these procedures are undertaken, sensation must be returned to the tip of the penis. This usually does not occur for at least a year.

The Ideal Goals of Penile Reconstruction in FTM Surgery

What can be achieved with this radial forearm flap technique as to the ideal requisites for penile reconstruction?

A ONE-STAGE PROCEDURE

In 1993, Hage 20 stated that a complete penile reconstruction with erection prosthesis never can be performed in one single operation. Monstrey et al, 29 early in their series and to reduce the number of surgeries, performed a (sort of) all-in-one procedure that included a SCM and a complete genitoperineal transformation. However, later in their series they performed the SCM first most often in combination with a total hysterectomy and ovariectomy.

The reason for this change in protocol was that lengthy operations (>8 hours) resulted in considerable blood loss and increased operative risk. 30 Moreover, an aesthetic SCM is not to be considered as an easy operation and should not be performed “quickly” before the major phalloplasty operation.

AN AESTHETIC PHALLUS

Phallic construction has become predictable enough to refine its aesthetic goals, which includes the use of a technique that can be replicated with minimal complications. In this respect, the radial forearm flap has several advantages: the flap is thin and pliable allowing the construction of a normal sized, tube-within-a-tube penis; the flap is easy to dissect and is predictably well vascularized making it safe to perform an (aesthetic) glansplasty at the distal end of the flap. The final cosmetic outcome of a radial forearm phalloplasty is a subjective determination, but the ability of most patients to shower with other men or to go to the sauna is the usual cosmetic barometer (Fig. 9A-C ).

(A–C) Late postoperative results of radial forearm phalloplasties.

The potential aesthetic drawbacks of the radial forearm flap are the need for a rigidity prosthesis and possibly some volume loss over time.

TACTILE AND EROGENOUS SENSATION

Of the various flaps used for penile reconstruction, the radial forearm flap has the greatest sensitivity. 1 Selvaggi and Monstrey et al. always connect one antebrachial nerve to the ilioinguinal nerve for protective sensation and the other forearm nerve with one dorsal clitoral nerve. The denuded clitoris was always placed directly below the phallic shaft. Later manipulation of the neophallus allows for stimulation of the still-innervated clitoris. After one year, all patients had regained tactile sensitivity in their penis, which is an absolute requirement for safe insertion of an erection prosthesis. 31

In a long-term follow-up study on postoperative sexual and physical health, more than 80% of the patients reported improvement in sexual satisfaction and greater ease in reaching orgasm (100% in practicing postoperative FTM transsexuals). 32

VOIDING WHILE STANDING

For biological males as well as for FTM transsexuals undergoing a phalloplasty, the ability to void while standing is a high priority. 33 Unfortunately, the reported incidences of urological complications, such as urethrocutaneous fistulas, stenoses, strictures, and hairy urethras are extremely high in all series of phalloplasties, as high as 80%. 34 For this reason, certain (well-intentioned) surgeons have even stopped reconstructing a complete neo-urethra. 35 , 36

In their series of radial forearm phalloplasties, Hoebeke and Monstrey still reported a urological complication rate of 41% (119/287), but the majority of these early fistulas closed spontaneously and ultimately all patients were able to void through the newly reconstructed penis. 37 Because it is unknown how the new urethra—a 16-cm skin tube—will affect bladder function in the long term, lifelong urologic follow-up was strongly recommended for all these patients.

MINIMAL MORBIDITY

Complications following phalloplasty include the general complications attendant to any surgical intervention such as minor wound healing problems in the groin area or a few patients with a (minor) pulmonary embolism despite adequate prevention (interrupting hormonal therapy, fractioned heparin subcutaneously, elastic stockings). A vaginectomy is usually considered a particularly difficult operation with a high risk of postoperative bleeding, but in their series no major bleedings were seen. 30 Two early patients displayed symptoms of nerve compression in the lower leg, but after reducing the length of the gynecological positioning to under 2 hours, this complication never occurred again. Apart from the urinary fistulas and/or stenoses, most complications of the radial forearm phalloplasty are related to the free tissue transfer. The total flap failure in their series was very low (<1%, 2/287) despite a somewhat higher anastomotic revision rate (12% or 34/287). About 7 (3%) of the patients demonstrated some degree of skin slough or partial flap necrosis. This was more often the case in smokers, in those who insisted on a large-sized penis requiring a larger flap, and also in patients having undergone anastomotic revision.

With smoking being a significant risk factor, under our current policy, we no longer operate on patients who fail to quit smoking one year prior to their surgery.

NO FUNCTIONAL LOSS AND MINIMAL SCARRING IN THE DONOR AREA

The major drawback of the radial forearm flap has always been the unattractive donor site scar on the forearm (Fig. 10 ). Selvaggi et al conducted a long-term follow-up study 38 of 125 radial forearm phalloplasties to assess the degree of functional loss and aesthetic impairment after harvesting such a large forearm flap. An increased donor site morbidity was expected, but the early and late complications did not differ from the rates reported in the literature for the smaller flaps as used in head and neck reconstruction. 38 No major or long-term problems (such as functional limitation, nerve injury, chronic pain/edema, or cold intolerance) were identified. Finally, with regard to the aesthetic outcome of the donor site, they found that the patients were very accepting of the donor site scar, viewing it as a worthwhile trade-off for the creation of a phallus (Fig. 10 ). 38 Suprafascial flap dissection, full thickness skin grafts, and the use of dermal substitutes may contribute to a better forearm scar.

(A,B) Aspect of the donor site after a phalloplasty with a radial forearm flap.

NORMAL SCROTUM

For the FTM patient, the goal of creating natural-appearing genitals also applies to the scrotum. As the labia majora are the embryological counterpart of the scrotum, many previous scrotoplasty techniques left the hair-bearing labia majora in situ, with midline closure and prosthetic implant filling, or brought the scrotum in front of the legs using a V-Y plasty. These techniques were aesthetically unappealing and reminiscent of the female genitalia. Selvaggi in 2009 reported on a novel scrotoplasty technique, which combines a V-Y plasty with a 90-degree turning of the labial flaps resulting in an anterior transposition of labial skin (Fig. 11 ). The excellent aesthetic outcome of this male-looking (anteriorly located) scrotum, the functional advantage of fewer urological complications and the easier implantation of testicular prostheses make this the technique of choice. 39

Reconstruction of a lateral looking scrotum with two transposition flaps: (A) before and (B) after implantation of testicular prostheses.

SEXUAL INTERCOURSE

In a radial forearm phalloplasty, the insertion of erection prosthesis is required to engage in sexual intercourse. In the past, attempts have been made to use bone or cartilage, but no good long-term results are described. The rigid and semirigid prostheses seem to have a high perforation rate and therefore were never used in our patients. Hoebeke, in the largest series to date on erection prostheses after penile reconstruction, only used the hydraulic systems available for impotent men. A recent long-term follow-up study showed an explantation rate of 44% in 130 patients, mainly due to malpositioning, technical failure, or infection. Still, more than 80% of the patients were able to have normal sexual intercourse with penetration. 37 In another study, it was demonstrated that patients with an erection prosthesis were more able to attain their sexual expectations than those without prosthesis (Fig. 12 ). 32

(A,B) Phalloplasty after implantation of an erection prosthesis.

A major concern regarding erectile prostheses is long-term follow-up. These devices were developed for impotent (older) men who have a shorter life expectancy and who are sexually less active than the mostly younger FTM patients.

Alternative Phalloplasty Techniques

Metaidoioplasty.

A metoidioplasty uses the (hypertrophied) clitoris to reconstruct the microphallus in a way comparable to the correction of chordee and lengthening of a urethra in cases of severe hypospadias. Eichner 40 prefers to call this intervention “the clitoris penoid.” In metoidioplasty, the clitoral hood is lifted and the suspensory ligament of the clitoris is detached from the pubic bone, allowing the clitoris to extend out further. An embryonic urethral plate is divided from the underside of the clitoris to permit outward extension and a visible erection. Then the urethra is advanced to the tip of the new penis. The technique is very similar to the reconstruction of the horizontal part of the urethra in a normal phalloplasty procedure. During the same procedure, a scrotal reconstruction, with a transposition flap of the labia majora (as previously described) is performed combined with a vaginectomy.

FTM patients interested in this procedure should be informed preoperatively that voiding while standing cannot be guaranteed, and that sexual intercourse will not be possible (Fig. 13 ).

Results of a metoidioplasty procedure.

The major advantage of metoidioplasty is the complete lack of scarring outside the genital area. Another advantage is that its cost is substantially lower than that of phalloplasty. Complications of this procedure also include urethral obstruction and/or urethral fistula.

It is always possible to perform a regular phalloplasty (e.g., with a radial forearm flap) at a later stage, and with substantially less risk of complications and operation time.

FIBULA FLAP

There have been several reports on penile reconstruction with the fibular flap based on the peroneal artery and the peroneal vein. 27 , 41 , 42 It consists of a piece of fibula that is vascularized by its periosteal blood supply and connected through perforating (septal) vessels to an overlying skin island at the lateral site of the lower leg. The advantage of the fibular flap is that it makes sexual intercourse possible without a penile prosthesis. The disadvantages are a pointed deformity to the distal part of the penis when the extra skin can glide around the end of fibular bone, and that a permanently erected phallus is impractical.

Many authors seem to agree that the fibular osteocutaneous flap is an optimal solution for penile reconstruction in a natal male. 42

NEW SURGICAL DEVELOPMENTS: THE PERFORATOR FLAPS

Perforator flaps are considered the ultimate form of tissue transfer. Donor site morbidity is reduced to an absolute minimum, and the usually large vascular pedicles provide an additional range of motion or an easier vascular anastomosis. At present, the most promising perforator flap for penile reconstruction is the anterolateral thigh (ALT) flap. This flap is a skin flap based on a perforator from the descending branch of the lateral circumflex femoral artery, which is a branch from the femoral artery. It can be used both as a free flap 43 and as a pedicled flap 44 then avoiding the problems related to microsurgical free flap transfer. The problem related to this flap is the (usually) thick layer of subcutaneous fat making it difficult to reconstruct the urethra as a vascularized tube within a tube. This flap might be more indicated for phallic reconstruction in the so-called boys without a penis, like in cases of vesical exstrophy (Fig. 14 ). However, in the future, this flap may become an interesting alternative to the radial forearm flap, particularly as a pedicled flap. If a solution could be found for a well-vascularized urethra, use of the ALT flap could be an attractive alternative to the radial forearm phalloplasty. The donor site is less conspicuous, and secondary corrections at that site are easier to make. Other perforator flaps include the thoracodorsal perforator artery flap (TAP) and the deep inferior epigastric perforator artery flap (DIEP). The latter might be an especially good solution for FTM patients who have been pregnant in the past. Using the perforator flap as a pedicled flap can be very attractive, both financially and technically.

Penile reconstruction with a pedicled anterolateral thigh flap. (A) Preoperative and (B) postoperative results.

The Importance of a Multidisciplinary Approach

Gender reassignment, particularly reassignment surgery, requires close cooperation between the different surgical specialties. In phalloplasty, the collaboration between the plastic surgeon, the urologist, and the gynecologist is essential. 45 The actual penile reconstruction is typically performed by the plastic and reconstructive surgeon, and the contribution of the gynecologist, who performs a hysterectomy and a BSO (preferably through a minimal endoscopic access in combination with SCM), should not be underestimated.

However, in the long term, the urologist's role may be the most important for patients who have undergone penile reconstruction, especially because the complication rate is rather high, particularly with regard to the number of urinary fistulas and urinary stenoses. The urologist also reconstructs the fixed part of the urethra. He or she is likely the best choice for implantation and follow-up of the penile and/or testicular prostheses. They must also address later sequelae, including stone formation. Moreover, the surgical complexity of adding an elongated conduit (skin-tube urethra) to a biological female bladder, and the long-term effects of evacuating urine through this skin tube, demand lifelong urological follow-up.

Therefore, professionals who unite to create a gender reassignment program should be aware of the necessity of a strong alliance between the plastic surgeon, the urologist, mental health professional and the gynecologist. In turn, the surgeons must commit to the extended care of this unique population, which, by definition, will protract well into the future.

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Transgender inclusion? World’s major religions take varying stances on policies toward trans people

FILE - Laxmi Narayan Tripathi, leader of the “Kinnar Akhara,” a monastic order of the transgender community, meets with followers at the Kumbh Mela festival in Pragraj, India, Feb. 5, 2019. The Kumbh Mela is a series of ritual baths by Hindu holy men, and other pilgrims that dates back to at least medieval times. The Vatican has issued a new document rejecting the concept of changing one’s biological sex – a setback for transgender people who had hoped Pope Francis might be setting the stage for a more welcoming approach from the Catholic Church. Around the world, major religions have diverse approaches to gender identity, and the inclusion or exclusion of transgender people. (AP Photo/Channi Anand, File)

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The Vatican has issued a new document rejecting the concept of changing one’s biological sex – a setback for transgender people who had hoped Pope Francis might be setting the stage for a more welcoming approach from the Catholic Church.

Around the world, major religions have diverse approaches to gender identity, and the inclusion or exclusion of transgender people. Some examples:

Christianity

The Catholic Church’s disapproving stance toward gender transition is shared by some other denominations. For example, the Southern Baptist Convention – the largest Protestant denomination in the United States – adopted a resolution in 2014 stating that “God’s design was the creation of two distinct and complementary sexes, male and female.” It asserts that gender identity “is determined by biological sex, not by one’s self-perception”

However, numerous mainline Protestant denominations welcome trans people as members and as clergy. The Evangelical Lutheran Church in America elected an openly transgender man as a bishop in 2021.

In Islam, there isn’t a single central religious authority and policies can vary in different regions.

Abbas Shouman, secretary-general of Al-Azhar’s Council of Senior Scholars in Cairo, said that “for us, ... sex conversion is completely rejected.”

“It is God who has determined the ... sex of the fetus and intervening to change that is a change of God’s creation, which is completely rejected,” Shouman added.

In Iran, the Shiite theocracy’s founder, Ayatollah Ruhollah Khomeini, issued a religious decree, or fatwa, decades ago, opening the way for official support for gender transition surgery.

In Hindu society in South Asia, while traditional roles were and are still prescribed for men and women, people of non-binary gender expression have been recognized for millennia and played important roles in holy texts. Third gender people have been revered throughout South Asian history with many rising to significant positions of power under Hindu and Muslim rulers. One survey in 2014 estimated that around 3 million third gender people live in India alone.

Sanskrit, the ancient language of Hindu scriptures, has the vocabulary to describe three genders – masculine, feminine and gender-neutral.

The most common group of third gender people in India are known as the “hijras.” While some choose to undergo gender reassignment surgery, others are born intersex. Most consider themselves neither male or female.

Some Hindus believe third gender people have special powers and the ability to bless or curse, which has led to stereotyping causing the community to be feared and marginalized. Many live in poverty without proper access to healthcare, housing and employment.

In 2014, India, Nepal and Bangladesh, which is a Muslim-majority country, officially recognized third gender people as citizens deserving of equal rights. The Supreme Court of India stated that “it is the right of every human being to choose their gender,” and that recognition of the group “is not a social or medical issue, but a human rights issue.”

Buddhism has traditionally adhered to binary gender roles, particularly in its monastic traditions where men and women are segregated and assigned specific roles.

These beliefs remain strong in the Theravada tradition, as seen in the attempt of the Thai Sangha Council, the governing Buddhist body in Thailand, to ban ordinations of transgender people. More recently, the Theravada tradition has somewhat eased restrictions against gender nonconforming people by ordaining them in their sex recorded at birth.

However, the Mahayana, and Vajrayana schools of Buddhism have allowed more exceptions while the Jodo Shinshu sect has been even more inclusive in ordaining transgender monks both in Japan and North America. In Tibetan Buddhism, Tashi Choedup, an openly queer monk, was ordained after their teacher refrained from asking about their gender identity as prescribed by Buddhist doctrine. Many Buddhist denominations, particularly in the West, are intentionally inclusive of transgender people in their sanghas or gatherings.

Reform Judaism is accepting of transgender people and allows for the ordination of trans rabbis. According to David J. Meyer, who served for many years as a rabbi in Marblehead, Massachusetts, Jewish traditional wisdom allowed possibilities of gender identity and expression that differed from those typically associated with the sex assigned at birth.

“Our mystical texts, the Kabbalah, address the notion of transitioning from one gender to another,” he wrote on a Reform-affiliated website.

It’s different, for the most part, in Orthodox Judaism. “Most transgender people will find Orthodox communities extremely difficult to navigate,” says the Human Rights Campaign, a major U.S. LGBTQ-rights advocacy group.

“Transgender people are further constrained by Orthodox Judaism’s emphasis on binary gender and strict separation between men and women,” the HRC says. “For example, a transgender person who has not medically transitioned poses a challenge for a rabbi who must decide whether that person will sit with men or women during worship.”

Rabbi Avi Shafran, spokesman for the Orthodox Jewish organization Agudath Israel of America, wrote a blog post last year after appearing on an Israeli television panel to discuss transgender-related issues.

“There can be no denying that there are people who are deeply conflicted about their gender identities. They deserve to be safe from harm and, facing challenges the rest of us don’t, deserve empathy and compassion,” Shafran wrote. “But the Torah and its extension, halacha, or Jewish religious law, are unequivocal about the fact that being born in a male body requires living the life of a man, and being born female entails living as a woman.”

“In Judaism, each gender has its particular life-role to play,” he added. “The bodies God gave us are indications of what we are and what we are not, and of how He wants us to live our lives.”

Associated Press religion coverage receives support through the AP’s collaboration with The Conversation US, with funding from Lilly Endowment Inc. The AP is solely responsible for this content.

Ontario resident who wants both a vagina and penis wins public funding for unique surgery

A court has ruled Ontario must pay for a penis-sparing vaginoplasty for a person who identifies as neither fully female nor fully male

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Ontario has been ordered to pay for surgery for a resident who is seeking to have a vagina constructed while leaving their penis intact.

Denying the procedure would infringe on the person’s Charter-protected right to security of the person, an Ontario court said in its ruling.

The unanimous decision by a three-member panel of judges of Ontario’s Divisional Court could expand access to a novel “bottom surgery” for people who identify as non-binary, meaning neither fully male nor fully female.

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The Ontario resident, identified in court documents as K.S., has been locked in a legal battle with the Ontario Health Insurance Plan since 2022, when OHIP denied a funding request to have a penile preserving vaginoplasty performed at a clinic in Austin, Texas.

The surgery, which is not available anywhere in Canada, involves creating a vaginal canal, or opening, without removing the penis.

K.S., 33, was born male but identifies as female dominant and uses a feminine name.

OHIP denied her request for funding, arguing that the procedure is not included on its list of sex-reassignment procedures, and is therefore not an insured service.

K.S. appealed OHIP’s decision to Ontario’s Health Services Appeal and Review Board, arguing that forcing her to have her penis removed would invalidate her identity and be akin to an illegal act of conversion therapy.

She also worried about the risk of complications and urinary incontinence from the urological rerouting, and the risk of orgasm dysfunction. She argued the procedure she is seeking abroad is like standard vaginoplasties performed in Ontario, but without the additional procedure, namely, the penectomy.

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The appeal board overturned OHIP’s decision, ruling that a vaginoplasty is among the genital surgeries listed for public coverage and need not inherently include removal of the penis. The board therefore ruled the procedure eligible for public funding.

OHIP appealed the board’s decision to the Divisional Court, arguing the review board erred in finding a penis-sparing vaginoplasty is specifically listed as an insured service, and that it failed to consider that the unorthodox procedure is considered an experimental procedure in Ontario, and, therefore, not eligible for funding.

Just because vaginoplasty is listed as an insured service doesn’t mean any type of vaginoplasty qualifies, OHIP argued in court.

The court disagreed. Vaginoplasty and penectomy are listed as discrete, separate services on Ontario’s list of surgeries eligible for funding, the court said. “The fact that most people who have a vaginoplasty have it done in a way that also involves a penectomy” doesn’t change the provision. If the province had intended for only one type of vaginoplasty to be insured (vaginoplasty with penis removal) it should have drafted the list differently, the court said.

The court said the appeal board’s conclusion was also consistent with standards of care developed by the World Professional Association for Transgender Health (WPATH) — an influential group whose guidelines for gender-affirming care for children and youth were found to lack “developmental rigour”  in a sweeping review released this week.

The WPATH standards “expressly refer to vaginoplasty without penectomy as a surgical option for some non-binary people,” Justice Breese Davies wrote in the court ruling.

While the court said it didn’t need to address Charter arguments, if there was any ambiguity concerning what should or should not be covered, the review board’s interpretation was also consistent with Charter values of equality and security of the person, the court added.

“The Charter-protected right to security of the person safeguards individual dignity and autonomy,” Davies wrote. Requiring a transgender or non-binary person born male “to remove their penis to receive state funding for a vaginoplasty would be inconsistent with the values of equality and security of the person.”

“Such an interpretation would force transgender, non-binary people like K.S. to choose between having a surgery (penectomy) they do not want, and which does not align with their gender expression to get state funding, on the one hand, and not having gender affirming surgery at all, on the other,” Davies wrote.

“Such a choice would reinforce their disadvantaged position and would not promote their dignity and autonomy.”

OHIP’s appeal was dismissed, and the province ordered to pay K.S. $20,000 to cover legal costs.

“This is a significant win for the transgender and non-binary communities,” K.S.’s lawyer, John McIntyre, told CTV News Toronto.

“We hope that OHIP decides to accept the decision of the court rather than seeking leave to appeal so that K.S. can move forward with her surgery she has been trying to get for years now.”

“K.S. is very happy with this unanimous decision,” McIntyre said in an email to the National Post. “The Divisional Court determined the existing language of the Health Insurance Act and the Schedule of Benefits clearly provided coverage for the procedure she sought.”

In earlier reports, National Post was told that gender-affirming surgeries at the Texas clinic range from US$10,000 to $70,000, depending on what is done.

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I'm a professional hair stylist, and this is my favourite heat protection spray

Heat styling can cause severe damage to hair, which is why heat protection spray is beneficial.

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