gender reassignment surgery words

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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Taking Care of Ourselves & Each Other

Health & Well-Being

Glossary of Terms Related to Transgender Communities

Terminology frequently morphs within LGBTQIA communities, and a word that means one thing in one community may mean something else in another community. The terms used here are commonly used in the Stanford LGBTQIA community.

Basic Definitions

• Assigned Female At Birth (AFAB) or Female-Assigned-at-Birth (FAAB) : An individual assigned female at birth.
• Assigned Male At Birth (AMAB) or Male-Assigned-at-Birth (MAAB) : An individual assigned male at birth.
• Assigned Sex or Sex Assigned At Birth : The sex (typically M or F) that is assigned to a person based on external genitalia at birth.
• Cisgender, Cis : Someone whose gender identity corresponds with expectations based on the sex they were assigned at birth. For example, a person who was assigned female at birth and identifies as a woman is regarded as cisgender or as a cisgender woman.
• Gender-Affirming Surgery : Any surgical procedure that aims to increase a sense of congruence with one’s gender identity and physical body. Gender-affirming surgeries may include: chest reconstructive surgeries (e.g., double mastectomy, feminizing mammoplasty), genital reconstructive surgeries (e.g., orchiectomy, vaginoplasty, metoidioplasty, phalloplasty), facial feminization surgeries (e.g., tracheal shave, rhinoplasty, brow lift), or other procedures (e.g., vocal cord surgery). In California, surgery is not required to change one’s legal gender marker. Note: This term is preferred over the outdated term Sexual Reassignment Surgery (SRS). It is also preferred over the term gender confirmation surgery (GCS) because gender cannot be “confirmed” by having surgery. A person’s gender is to be respected regardless of surgical history/status or what kind of genitals they have or had. It is best to avoid terms such as “pre-op”, “non-op”, or “post-op,” as they reinforce the assumption all trans people want to or will have the opportunity to have surgery.
• Gender Dysphoria : Emotional distress related to the sense that one’s assigned sex is not in line with one’s gender identity. Gender Dysphoria is also a medical and mental health diagnosis that may warrant treatment in the form of gender-affirming medical interventions.
• Gender Expression : The ways in which a person outwardly expresses their gender, often through hair, makeup, clothing, and other aspects of appearance. Gender expression does not always correspond to gender identity.
• Gender Identity : The inherent feeling within an individual of what gender they are; a person may identify as a man, woman, neither, in-between, both, or fluidly moving between these two binary categories.
• Gender-Neutral Pronouns : Pronouns that a person may use when they do not fully identify with binary gender categories. Examples of gender-neutral pronouns include singular they/them/their, ey/em/eir, zie/hir/hirs, or no pronouns. It’s best to ask what pronouns are appropriate for them.
• Genderqueer : A gender identity that denotes someone who does not fully identify with the binary genders of male/man/masculine or female/woman/feminine. A genderqueer person may identify as neither a man nor a woman, in-between, both, fluidly moving between these two categories, or as a third/alternate gender. Related to the term  nonbinary , which has become more popular in the 2010’s.
• Intersex : A general term used for a variety of conditions in which a person is born with a physical characteristics (e.g., gonads, chromosomal makeup, external genitalia, internal reproductive or urinary organs) that do not fit typical medical or social definitions of female or male. Some people use the term DSD (Disorders of Sex Development) to describe intersex people, but this is not seen as affirming by intersex communities.
• Nonbinary : A gender identity that denotes someone who does not fully identify with the binary genders of male/man/masculine or female/woman/feminine. A nonbinary person may identify as neither a man nor a woman, in-between, both, fluidly moving between these two categories, or as a third/alternate gender. Related to the term  genderqueer , which was used more often prior to the 2010’s.
• Passing : Being perceived as cisgender or as a gender in line with one’s gender identity. This term is not considered affirming to many, as it implies that trans people are deceptive or are not truly the gender they say they are. Passing is important to some people (e.g., for safety reasons), but it is not the goal of every trans person.
• Queer : Used to describe non-normative identities (both sexual identities and gender identities) that might not easily be classified under other terminology (gay, lesbian, etc.). Queer can also be used as an umbrella term to describe LGBTQIA identities as a whole. In many communities, the term “queer” also has a political connotation that is connected to LGBTQIA activism. The term queer may be offensive to older LGBTQIA individuals, so it is best to use caution and only use this term when you know that someone uses it as an affirming term to describe themselves.
• Sexual Orientatio n: A way to describe a person’s romantic and/or sexual attractions to others. Sexual orientation may consist of attraction, behavior, and identity, and not all of these factors need to be aligned/consistent. For example, a person may have attractions towards trans women, be sexually active with cisgender men, and have an identity as heterosexual. Some labels to describe sexual orientation include: heterosexual, straight, lesbian, gay, bisexual, pansexual, queer, or fluid.
• Transgender man, trans man, trans masculine
• Transgender woman, trans woman, trans feminine
• Genderqueer
• Gender neutral
• It’s best to ask how a transgender person identifies. Be aware that the word “tranny” is considered offensive.
• Transgender Man, Trans Man, Trans Masculine : Someone who was female assigned at birth who identifies as a man or on the masculine spectrum. Note: The term FTM is no longer considered affirming.
• Transgender Woman, Trans Woman, Trans Feminine : Someone who was male assigned at birth who identifies as a woman or on the feminine spectrum. Note: The term MTF is no longer considered affirming.
• Transition : The process of shifting one’s gender identity and/or expression. Transition is a process that occurs over time, varies greatly among individuals, and may consist of physical/medical, emotional, social, and legal components. There is no uniform or set path for how a person transitions, if at all. Some transgender people consider themselves post-transition, and some no longer consider themselves to be transgender. Others feel that they are in a state of transition for the rest of their lives.
• Transsexual : A term that was commonly used before the term “transgender” came into more popular usage in the 1990’s. Some people still identify as transsexual, but this term is no longer considered affirming.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

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Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

Related Articles

• How Gender Identity Disorder Works
• Is gender just a matter of choice?
• What is transgender voice therapy?
• How fluid is gender?
• Why do girls wear pink and boys wear blue?

More Great Links

• DSM-5: Gender Dysphoria
• National Center for Transgender Equality
• The Williams Institute
• American Medical Student Association (AMSA). "Transgender Health Resources." 2014. (April 20, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
• American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." 2011. (July 1, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
• AP. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 20, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
• Belkin, Lisa. "Smoother Transitions." The New York Times. Sept. 4, 2008. (Aug. 1, 2011) http://www.nytimes.com/2008/09/04/fashion/04WORK.html
• Crane, Curtis. "The Total Guide to Penile Implants For Transsexual Men." Transhealth. May 2, 2014. (April 20, 2015) http://www.trans-health.com/2013/penile-implants-guide/
• Donaldson James, Susan. "Trans Chaz Bono Eyes Risky Surgery to Construct Penis." ABC News. Jan. 6, 2012. (April 20, 2015) http://abcnews.go.com/Health/transgender-chaz-bono-seeks-penis-genital-surgery-risky/story?id=15299871Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
• Glicksman, Eve. "Transgender today." Monitor on Psychology. Vol. 44, no. 4. Page 36. April 2013. (April 20, 2015) http://www.apa.org/monitor/2013/04/transgender.aspx
• Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape Medical News. May 20, 2013. (April 20, 2015) http://www.medscape.com/viewarticle/804432
• HealthResearchFunding.org (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 20, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
• International Foundation for Gender Education. "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 20, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
• Moskowitz, Clara. "High Suicide Risk, Prejudice Plague Transgender People." LiveScience. Nov. 18, 2010. (April 20, 2015) http://www.livescience.com/11208-high-suicide-risk-prejudice-plague-transgender-people.html
• Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. 2013. (April 20, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
• Public Religion Research Institute. "Survey: Strong Majorities of Americans Favor Rights and Legal Protections for Transgender People." Nov. 3, 2011. (April 20, 2015) http://publicreligion.org/research/2011/11/american-attitudes-towards-transgender-people/#.VSmlgfnF9bw
• Steinmetz, Katy. "Board Rules That Medicare Can Cover Gender Reassignment Surgery." Time. (April 20, 2015) http://time.com/2800307/medicare-gender-reassignment/
• The Philadelphia Center for Transgender Surgery. "Phalloplasty: Frequently Asked Questions." (April 20, 2015) http://www.thetransgendercenter.com/index.php/surgical-procedures/phalloplasty-faqs.html
• U.S. Office of Personnel Management. "Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace." 2015. (April 20, 2015) http://www.opm.gov/diversity/Transgender/Guidance.asp
• University of California, San Francisco - Department of Family and Community Medicine, Center of Excellence for Transgender Health. "Primary Care Protocol for Transgender Patient Care." April 2011. (April 20, 2015) http://transhealth.ucsf.edu/trans?page=protocol-hormones
• University of Miami - Miller School of Medicine, Department of Surgery, Plastic, Aesthetic and Reconstructive Surgery. "Transgender Reassignment." 2015. (April 20, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
• University of Michigan Health System. "Gender Affirming Surgery." (April 20, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
• World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
• World Professional Association for Transgender Health (WPATH). "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide." 2015. (April 20, 2015) http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947

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Preparing for Gender Affirmation Surgery: Ask the Experts

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Romy Smith, LMSW

Preparing for your gender affirmation surgery can be daunting. To help provide some guidance for those considering gender affirmation procedures, our team from the  Johns Hopkins Center for Transgender and Gender Expansive Health (JHCTGEH) answered some questions about what to expect before and after your surgery.

What kind of care should I expect as a transgender individual?

What kind of care should I expect as a transgender individual? Before beginning the process, we recommend reading the World Professional Association for Transgender Health Standards Of Care (SOC). The standards were created by international agreement among health care clinicians and in collaboration with the transgender community. These SOC integrate the latest scientific research on transgender health, as well as the lived experience of the transgender community members. This collaboration is crucial so that doctors can best meet the unique health care needs of transgender and gender-diverse people. It is usually a favorable sign if the hospital you choose for your gender affirmation surgery follows or references these standards in their transgender care practices.

Can I still have children after gender affirmation surgery?

Many transgender individuals choose to undergo fertility preservation before their gender affirmation surgery if having biological children is part of their long-term goals. Discuss all your options, such as sperm banking and egg freezing, with your doctor so that you can create the best plan for future family building. JHCTGEH has fertility specialists on staff to meet with you and develop a plan that meets your goals.

Are there other ways I need to prepare?

It is very important to prepare mentally for your surgery. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts. These conversations and articles may be helpful; however, keep in mind that not everything you read will apply to your situation. If you have questions about whether something applies to your individual care, it is always best to talk to your doctor.

You will also want to think about your recovery plan post-surgery. Do you have friends or family who can help care for you in the days after your surgery? Having a support system is vital to your continued health both right after surgery and long term. Most centers have specific discharge instructions that you will receive after surgery. Ask if you can receive a copy of these instructions in advance so you can familiarize yourself with the information.

An initial intake interview via phone with a clinical specialist.

This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about, clarify what is required by your insurance company for surgery, and develop a plan for next steps. It will make your phone call more productive if you have these documents ready to discuss with the clinician:

• Medications. Information about which prescriptions and over-the-counter medications you are currently taking.
• Insurance. Call your insurance company and find out if your surgery is a “covered benefit" and what their requirements are for you to have surgery.
• Medical Documents. Have at hand the name, address, and contact information for any clinician you see on a regular basis. This includes your primary care clinician, therapists or psychiatrists, and other health specialist you interact with such as a cardiologist or neurologist.

After the intake interview you will need to submit the following documents:

• Pharmacy records and medical records documenting your hormone therapy, if applicable
• Medical records from your primary physician.
• Surgical readiness referral letters from mental health providers documenting their assessment and evaluation

An appointment with your surgeon. 

After your intake, and once you have all of your required documentation submitted you will be scheduled for a surgical consultation. These are in-person visits where you will get to meet the surgeon.  typically include: The specialty nurse and social worker will meet with you first to conduct an assessment of your medical health status and readiness for major surgical procedures. Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey. Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

A preoperative anesthesia and medical evaluation. 

Two to four weeks before your surgery, you may be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

What can I expect after gender affirming surgery?

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs. Depending on your specific surgery and which organs you continue to have, you may need to follow up with a urologist or gynecologist for routine cancer screening. JHCTGEH has primary care clinicians as well as an OB/GYN and urologists on staff.

Among other changes, you may consider updating your name and identification. This list of  resources for transgender and gender diverse individuals can help you in this process.

The Center for Transgender and Gender Expansive Health Team at Johns Hopkins

Embracing diversity and inclusion, the Center for Transgender and Gender Expansive Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.

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In the Operating Room During Gender Reassignment Surgery

Behind the scenes with identical twin Emmie Smith during her medical transition.

Before August 30, 2016, getting stitches at age seven was the most time Emmie Smith had ever spent in a hospital.

That morning, she swapped her plaid shirt and jean shorts for a gown, tucked her hair into a cap, and prepared for surgery to conform her anatomy to the gender she already identified with: woman. In the operating room with her was National Geographic photographer Lynn Johnson. She and Emmie hoped they could demystify the procedure by documenting it, close-up and unflinching. “It was stressful and scary at times, but it almost created a mission other than just recovery,” Emmie says. “We were making something together.”

It had been a year and a half since Emmie had first come out as a transgender woman on Facebook. Telling her family and friends had been an enormous relief. “I’m not sure I could have taken another few years of being closeted,” she says.

Still, it was a challenging time for her family. Her mother, Reverend Kate Malin, is a prominent figure in their Massachusetts town, and her identical twin sons Caleb and Walker were familiar fixtures at her Episcopal church. A month after Walker came out as Emmie, Malin stepped out from behind her pulpit and walked into the aisle. Halfway through her sermon she decided it was time to address the change in her family.

“As most of you know, Bruce and I have three children,” she began. “Caleb and Walker, who are 17, and 13-year-old Owen. Walker’s new name is Emerson, and she prefers Emmie or Em. She’s wearing feminine clothing and makeup and will likely continue to move in the direction of a more feminized body.”

Follow Emmie's transition in pictures

Kate nervously revealed her struggle to the attentive New England crowd. “I feel broken much of the time,” she confessed. “I’ve wanted to run away, and I’ve prayed for this child that I would gladly die for, guilty for how much I miss the person I thought was Walker and everything I thought might be.”

After the sermon, the congregation engulfed her in a hug. Then they moved to offer words of support to the sandy-haired 17-year-old sitting in the pews. In the first of many awkward mistakes the family would later laugh about, it was Caleb—Emmie’s identical twin.

After that sermon, a “new normal” set in. On a Saturday night soon after, they had their first “out” outing. Kate took Emmie—whose hair was still short and chest was flat—to buy a prom dress at David’s Bridal. She feared someone would point or laugh, but the crowds of brides and bridesmaids in the dressing room offered only compliments.

Though she hadn’t initially considered surgery, after a couple of months Emmie had grown frustrated by the tucking and taping required to fit into women’s clothes. That fall, her senior year of high school, she decided to do it.

But waking up after the operation, Emmie felt none of the immediate relief she’d expected. In the recovery room her earbuds played a soothing loop of Bon Iver and Simon and Garfunkel, but it didn’t drown out her disappointment and fear. In retrospect, she thought, hadn’t life before been OK?

It wasn’t until months later, when she was home and could walk and sit again, that Emmie knew she’d made the right choice. “If you’re not living freely that’s time wasted, and I felt my time was wasted pretending to be a boy,” she says. “It was the best decision in my life.”

Now, halfway through a gap year, she’s applying to college theater programs. It’s strange, she says, knowing that her future classmates may watch Johnson’s film and learn the most intimate details of her life. She’s hopeful that her participation will evolve the public’s understanding of gender reassignment surgery. “It’s not science fiction or mythology,” Emmie says. “It’s what happens to women just trying to be at peace with themselves and their bodies.”

For Hungry Minds

Related topics, you may also like.

Meet the 5 iconic women being honored on new quarters in 2024

Source page for gender identity map.

How science is helping us understand gender

Redefining gender.

The Legality of Gender Change

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Demystifying and Navigating Your Options: Gender Reassignment Surgery

Medically reviewed by Paul Gonzales on March 25, 2024.

Previously, the term gender reassignment surgery (GRS) referred to genital reconstruction bottom surgeries like vaginoplasty, vulvoplasty, phalloplasty, or metoidioplasty. Individuals who look up this term on a search engine do so looking for information on gender-affirming procedures generally for transgender, non-binary and gender non-conforming people. This detailed guide breaks down everything you need to know about these procedures, their costs, their eligibility requirements, the potential benefits and risks and more. If you are interested in undergoing any gender-affirming or “gender reassignment” surgery, you can schedule a free, virtual consultation with one of our surgeons.

At the Gender Confirmation Center (GCC), we generally avoid using terminology like GRS in a clinical setting out of the recognition that for the vast majority of our patients, surgeries do not “reassign” anyone’s gender. Rather, surgery can help individuals experience greater alignment with their bodies and greater gender euphoria as a result.

Types of Gender “Reassignment” Surgeries: “Female to Male (FTM)”

Female to Male (FTM) is outdated terminology that the GCC does not use in our clinical practice. This abbreviation leaves out the experiences of many trans masculine and non-binary patients who do not identify with being labeled as a “woman becoming a man.” 

In the past, “FTM gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial estrogenic puberty or procedures that reconstruct a patient’s genitals. We still receive various inquiries about which “FTM” procedures we offer, so below you can find a list of surgeries that have typically been placed under this label. 

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients “into men,” but to help them feel more comfortable, affirmed, and/or aligned with their bodies.

Chest Surgery or Top Surgery

“FTM” top surgery is an antiquated term that refers to gender-affirming chest reconstruction and/or breast reduction. Practices who use this acronym sometimes have limited experience meeting the unique needs of non-binary patients seeking top surgery . Patients who would like to remove their chest tissue to have a flatter chest can choose from a variety of incision options to reach their desired results around chest tightness, contour and/or scar shape. 

Not all patients who pursue top surgery want flat chests. Whether you would like to opt for a breast reduction or a chest reconstruction with some volume left behind, the button buttonhole incision is the most commonly pursued type.

Top surgery patients who would like to maintain an erotic or a high level of sensation in their nipples can ask their surgeon about nerve-preservation techniques . Inversely, many patients who get top surgery choose to have their nipples removed .

Genital Reconstruction or Bottom Surgery

While the following bottom surgery procedures are traditionally put under the “FTM” category, we recognize that not all patients who pursue these procedures identify as men nor are they looking to “masculinize” their genitals.

Two procedures can be used to reconstruct a penis or “neophallus”: metoidioplasty and phalloplasty. Metoidioplasty or “meta” releases the ligaments around the erectile tissue (called a clitoris or penis) to extend it to about 2-4 inches in length. A phalloplasty uses a donor flap (usually from the forearm or thigh) to construct a penis of 4 inches in length or more (depending on availability of tissue). Both procedures can be specialized to allow a patient to maintain erotic sensation in their genitals (nerve preservation) and/or urinate standing up (urethroplasty).

Associated procedures include the removal of the uterus (hysterectomy), the removal of the vaginal canal (vaginectomy), the construction of a scrotum (scrotoplasty), the insertion of penile/testicular implants, and more.

Body Masculinization Surgery (BMS)

Body Masculinization Surgery (BMS) refers to a series of body contouring procedures. Most often, BMS involves liposuction of one or more of the following areas: abdomen, flanks, hips, thighs, buttocks, or arms. BMS can also involve removing unwanted, excess skin from fat loss or liposuction. Occasionally, some patients may opt for silicone pectoral implants alongside or after their top surgery results.

Facial Masculinization Surgery (FMS)

Facial Masculinization Surgery (FMS) refers to a series of procedures that patients can choose from to give their face a more angular, conventionally masculine appearance. In the bottom third of the face, the chin, jaw, or laryngeal prominence (aka Adam’s apple) can be augmented or increased in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be augmented.

Types of Gender “Reassignment” Surgeries: “Male to Female (MTF)”

Male to Female (MTF) is outdated terminology that we do not use in our clinical practice. This abbreviation leaves out the experiences of many trans feminine and non-binary patients who do not identify with being labeled as a “man becoming a woman.”

In the past, “MTF gender confirmation surgery” was used to describe surgical procedures that reverse the effects of an initial androgenic (testosterone-dominant) puberty and/or reconstruct a patient’s genitals. As a practice, we still get asked by prospective patients about the “MTF” procedures we offer, which is why we have compiled a guide of surgeries that have typically been placed under this category.

Please note that patients can seek out any of these procedures regardless of their gender identity. The goal of our practice is not to make our patients turn “into women,” but to help them feel greater gender congruence with their bodies.

Breast Augmentation or “MTF” Top Surgery

Typically, for trans feminine and non-binary patients who prefer to have more volume on their chest, breast augmentation with saline or silicone implants allows for greater success in their desired outcomes. Fat grafting procedures limit the amount of volume transferred to the chest based on available body fat that can be safely removed.

Genital Reconstruction or Bottom Surgeries

The most common surgeries that are placed under this category are vaginoplasty and vulvoplasty (also called zero-depth vaginoplasty) procedures. The most common vaginoplasty uses a penile-inversion technique to reconstruct a vaginal canal. However, a penile-preserving vaginoplasty is also another option for patients. Lifelong dilation after this procedure is necessary to maintain the depth of the canal so that it can be used for penetrative sex. Labiaplasty revisions are sometimes sought out by patients wishing to adjust the size, shape and symmetry of their labia and/or clitoral hood.

Before a vaginoplasty, patients may opt to remove the testicles ( orchiectomy ). Patients of varying gender identities undergo orchiectomies for many reasons, such as chronic pain or to simplify their hormone therapy.  For patients who plan to have a vaginoplasty in the future, it’s best to consider the timing of an orchiectomy procedure since scrotal tissue can be used to construct the labia.

Facial Feminization Surgery (FFS)

FFS refers to a series of procedures that a patient can choose from to give their face a softer, more conventionally feminine appearance. In the bottom third of the face, the laryngeal prominence (or Adam’s apple), chin, or jaw can be reduced in size. In the middle third of the face, the appearance of the nose and/or cheeks can be altered. In the top third of the face, the hairline’s position can be changed and the forehead can be reduced.

Body Feminization Surgery (BFS)

BFS encompasses a series of body contouring procedures. Most often, BFS involves removal of fat through liposuction of one or more of the following areas: the thighs, the abdomen/waist, or the arms. The fat removed from these areas of the body can be transferred to the buttocks and/or hip areas and is commonly referred to as a Brazilian butt lift (BBL). BFS can also involve removing unwanted excess skin from fat loss or liposuction, a procedure often referred to as a tummy tuck or abdominoplasty.

Evaluating Candidacy for Gender Affirmation Surgery

Strict guidelines evaluate patient readiness for life-altering GRS procedures.

Informed consent

The GCC follows an informed consent model for surgery because it gives patients autonomy over their health. Under this model, adults can consent to procedures if they have received adequate education about their risks, advantages, and potential effects on their health given their unique medical history. Historically, TGD people have had a difficult time accessing quality gender-affirming health care in part because of gatekeeping and discrimination based on requirements set by insurance companies. For example, letters from medical and mental health providers are a part of these requirements. We recognize that therapists and other healthcare providers are invaluable sources of support for patients undergoing a medical gender transition. 

Health factors

We recommend our patients get medical clearance from their primary care provider (PCP) before surgery. If you have medical conditions that may affect your surgery, we can work with your PCP or specialist to ensure a safe recovery. Patients should inform their surgeons of any cardiovascular or respiratory issues, history of anorexia, diabetes, or use of immunosuppressant medications.

Different surgeons may consider a patient’s Body Mass Index (BMI) as part of their eligibility for surgery. You can read more about our requirements and recommendations around BMI here .

We require all our patients to stop smoking or consuming any form of nicotine for at least 3 weeks before and 3 weeks after surgery, as this can lead to significant problems with delayed wound healing. Please do not drink alcohol for at least 1 week before and 1 week after surgery or until prescription pain medications are discontinued.

Insurance requirements

Patients who wish to have their insurance cover their gender affirming surgery need to fulfill certain requirements. You will need to get a letter of support from a mental health professional to confirm that the procedure is medically necessary. If the surgeon is outside of your insurance’s in-network providers, you will need to get a referral letter from your primary care provider (PCP). Additionally, some insurance companies may require that a patient undergo gender-affirming hormone therapy to cover surgery.

Hormone Therapy Considerations

At GCC, we do not require our patients to undergo hormone therapy to access medically necessary, gender-affirming surgeries. That said, undergoing hormones before surgery can help some patients improve the appearance of post-op results.

• Facial surgery: It may take up to 1.5 years on hormone therapy before soft tissue changes can appear on the face so patients should consider waiting to undergo facial surgery until these changes have settled.
• Bottom surgery: Maximal bottom growth may take up to 2 years for patients on a standard dose of testosterone so patients should consider undergoing metoidioplasty until maximal growth is achieved for optimal outcomes.
• Breast augmentation: Maximal breast growth may take up to 1.5 to 2 years for patients on a standard dose of estrogen so patients should consider undergoing breast augmentation until maximal growth is achieved.
• Body contouring: It may take up to 1.5 years on hormone therapy before the fat redistribution process settles so patients should consider waiting until then before undergoing liposuction or fat grafting procedures.

When it comes to age and eligibility for surgery, we are typically asked about 2 populations: adolescents and seniors. The World Professional Association for Transgender Health (WPATH) has outlined in their Standards of Care (SOC), Version 8 , the need for the involvement of caregivers/parents and mental health professionals in the informed consent process for adolescents. If these protocols are followed, the only type of gender-affirming surgery that an adolescent can undergo is top surgery.

As long they are in good health and cleared for surgery, senior patients are eligible for surgery regardless of their age and can achieve good aesthetic outcomes. It’s important to consider what accommodations are necessary to support post-op recovery. You can read more about our eligibility standards here .

Weighing GRS Benefits Against Complications

The decision to undergo “gender reassignment surgery” is a highly personal one. Understanding both the pros and cons provides critical insight.

How GRS Can Transform Lives

The WPATH’s SOC 8 reviews the medical research literature around the long-term effects of gender-affirming surgery on trans and non-binary patients. Gender-affirming procedures report greater satisfaction and lower regret rates compared to similar cosmetic and reconstructive procedures performed in cisgender patients.

• Improved mental health
• Improved body-image, etc.
• Enhanced quality of life

Rates of anxiety, depression, and suicide risk all tend to decrease substantially following surgery for those who need it, which is why these procedures are considered medically necessary for many patients.

Risk Factors and Long-Term Effects

All surgeries carry risks of complications. Generally speaking, patients who optimize their health prior to surgery (e.g., do not smoke tobacco) and manage any pre-existing medical conditions can greatly reduce their risk for complications. Undergoing surgery with a board-certified surgeon who has hospital access privileges can help ensure the integrity of your surgical process. If you have specific questions about surgical complications and how to prevent them, you can consult our content library on this question.

Navigating Emotions

Surgery not only takes a physical, but also an emotional toll on the body. Experiencing pain, inflammation, discomfort and limitations on physical activity occasionally mat result in temporary postoperative depression. Likewise, having to wait weeks or months to have a sense of what your final results from surgery will look like can give some patients temporary feelings of regret during recovery. For this reason, we highly encourage patients to tap into their support networks of friends, (chosen) family and/or mental health professionals during this time. To learn more about the emotional recovery process, click here .

Conclusion: Is Gender Reassignment Surgery the Right Choice?

While gender-affirming surgery has been proven to be positively life-changing for many trans and non-binary individuals. Whether you seek surgery or not, we remain dedicated to your health, empowerment, and right to be your authentic self.

More Articles

Understanding the cost of double incision top surgery: a comprehensive guide, gatekeeping vs. empowerment: accessing gender affirming care, treating gender dysphoria in adolescents, sign up for instructions to get a virtual consultation.

The virtual consultation will be billed to your insurance company. We will accept the insurance reimbursement as payment in full.

Dr. Scott Mosser Suite 1010, 450 Sutter St San Francisco, CA 94108 Phone: (415) 780-1515 Fax: ( 628) 867-6510

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gender reassignment

Definition of gender reassignment

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than making changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

Word History

1969, in the meaning defined at sense 2

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Dictionary Entries Near gender reassignment

genderqueer

gender reassignment surgery

Cite this Entry

“Gender reassignment.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment. Accessed 12 May. 2024.

Medical Definition

Medical definition of gender reassignment.

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than makes changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

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The Gender Reassignment Controversy

When people opt for surgery, are they satisfied with the outcome.

Posted March 16, 2018 | Reviewed by Ekua Hagan

In an age of increasing gender fluidity, it is surprising that so many find it difficult to accept the gender of their birth and take the drastic step of changing it through surgery. What are their motives? Are they satisfied with the outcome?

Gender may be the most important dimension of human variation, whether that is either desirable, or inevitable. In every society, male and female children are raised differently and acquire different expectations, and aspirations, for their work lives, emotional experiences, and leisure pursuits.

These differences may be shaped by how children are raised but gender reassignment, even early in life, is difficult, and problematic. Reassignment in adulthood is even more difficult.

Such efforts are of interest not just for medical reasons but also for the light they shed on gender differences.

The first effort at reassignment, by John Money, involved David Reimer whose penis was accidentally damaged at eight months due to a botched circumcision.

The Money Perspective

Money believed that while children are mostly born with unambiguous genitalia, their gender identity is neutral. He felt that which gender a child identifies with is determined primarily by how parents treat it and that parental views are shaped by the appearance of the genitals.

Accordingly, Money advised the parents to have the child surgically altered to resemble a female and raise it as “Brenda.” For many years, Money claimed that the reassignment had been a complete success. Such was his influence as a well-known Johns Hopkins gender researcher that his views came to be widely accepted by scholars and the general public.

Unfortunately for Brenda, the outcome was far from happy. When he was 14, Reimer began the process of reassignment to being a male. As an adult, he married a woman but depression and drug abuse ensued, culminating in suicide at the age of 38 (1).

Money's ideas about gender identity were forcefully challenged by Paul McHugh (2), a leading psychiatrist at the same institution as Money. The brunt of this challenge came from an analysis of gender reassignment cases in terms of both motivation and outcomes.

Adult Reassignment Surgery Motivation

Why do people (predominantly men) seek surgical reassignment (as a woman)? In a controversial take, McHugh argued that there are two main motives.

In one category fall homosexual men who are morally uncomfortable about their orientation and see reassignment as a way of solving the problem. If they are actually women, sexual interactions with men get redefined as heterosexual.

McHugh argued that many of the others seeking reassignment are cross-dressers. These are heterosexual men who derive sexual pleasure from wearing women's clothing. According to McHugh, surgery is the logical extreme of identifying with a female identity through cross-dressing.

If his thesis is correct, McHugh denies that reassignment surgery is ever either medically necessary or ethically defensible. He feels that the surgeon is merely cooperating with delusional thinking. It is analogous to providing liposuction treatment for an anorexic who is extremely slender but believes themselves to be overweight.

To bolster his case, McHugh looked at the clinical outcomes for gender reassignment surgeries.

Adult Reassignment Results

Anecdotally, the first hurdle for reassignment is how the result is perceived by others. This problem is familiar to anyone who looked at Dustin Hoffman's depiction of a woman ( Tootsie ). Diligent as the actor was in his preparation, his character looked masculine.

For male-to-female transsexuals, the toughest audience to convince is women. As McHugh reported, one of his female colleagues said: “Gals know gals, and that's a guy.”

According to McHugh, although transsexuals did not regret their surgery, there were little or no psychological benefits:

“They had much the same problems with relationships, work, and emotions, as before. The hope that they would emerge now from their emotional difficulties to flourish psychologically had not been fulfilled (2)”.

Thanks to McHugh's influence, gender reassignment surgeries were halted at Johns Hopkins. The surgeries were resumed, however, and are now carried out in many hospitals here and around the world.

What changed? One likely influence was the rise of the gay rights movement that now includes transgender people under its umbrella and has made many political strides in work and family.

McHugh's views are associated with the religious right-wing that has lost ground in this area.

Transgender surgery is now covered by medical insurance reflecting more positive views of the psychological benefits.

Aspirational Surgery

Why do people who are born as males want to be women? Why do females want to be men? There seems to be no easy biological explanation for the transgender phenomenon (2).

Transgender people commonly report a lifelong sense that they feel different from their biological category and express satisfaction after surgery (now called gender affirmation) that permits them to be who they really are.

The motivation for surgical change is thus aspirational rather than medical, as is true of most cosmetic surgery also. Following surgery, patients report lower gender dysphoria and improved sexual relationships (3).

All surgeries have potential costs, however. According to a Swedish study of 324 patients (3, 41 percent of whom were born female) surgery was associated with “considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

1 Blumberg, M. S. (2005). Basic instinct: The genesis of behavior. New York: Thunder's Mouth Press.

2 McHugh, P. R. (1995). Witches, multiple personalities, and other psychiatric artifacts. Nature Medicine, 1, 110-114.

3 Dhejne, S., Lichtenstein, P., Boman, M., et al. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study of Sweden . Plos One.

Nigel Barber, Ph.D., is an evolutionary psychologist as well as the author of Why Parents Matter and The Science of Romance , among other books.

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Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

The 14th Amendment to the Constitution is truly a magical amendment. It was used to justify attempts to kick Donald Trump off the 2024 ballot. Through the decades, judges who want to play at social engineering have used it frequently to justify questionable law. 

It's even been invoked to bypass Congress to raise the debt limit.

Now, the Fourth Circuit Court of Appeals has decided that the amendment's "equal protection" clause means that state Medicaid programs have to cover gender reassignment surgeries.

The appeals court ruled that West Virginia's Medicaid rules on mastectomies are unconstitutional because they violate the "equal protection standard" by not covering mastectomies for gender dysphoria.

Yes, really.

The ruling also includes a North Carolina Medicaid case that the state government won't cover "sex changes." The Fourth Circuit nullified the state ban on gender change surgeries, citing the 14th Amendment’s guarantee of “equal protection of the laws.”

This was a court looking for an excuse to make law.

Judge Roger Gregory who wrote the majority opinion in Kadel v. Folwell (8-6) asked, “Is removing a patient’s breasts to treat cancer the same procedure as removing a patient’s breasts to treat gender dysphoria?” He continued, “There is no case law to ground this discussion nor obvious first principles.”

Wall Street Journal:

He is undeterred, and he concludes that gender dysphoria and transgender status are intertwined, so that such insurance exclusions are nothing more than a proxy for discriminating against gender identity. Then he goes further, finding that West Virginia’s and North Carolina’s policies also unconstitutionally discriminate based on sex. How so? Imagine, Judge Gregory says, an unidentified patient seeking a vaginoplasty. Is this a biological female with a rare birth defect? Is it a transgender patient? “By virtue of the fact that they are seeking a vaginoplasty, we know that they were born without a vagina,” he writes. “But we do not know what sex they were assigned at birth. Without that information, we cannot say whether the Plan or Program will cover the surgery.” Ergo, sex discrimination.

Gregory gets even nuttier.

The differences in coverage "is rooted in a gender stereotype: the assumption that people who have been assigned female at birth are supposed to have breasts, and that people assigned male at birth are not."

It's not a "gender stereotype." It's a biological fact. 

"No doubt, the majority of those assigned female at birth have breasts, and the majority of those assigned male at birth do not. But we cannot mistake what is for what must be.”

Not just a "majority." It's a universal biological fact with a tiny number of exceptions.

Treating different things differently doesn’t violate the 14th Amendment’s Equal Protection Clause, and jurists aren’t supposed to ignore the obvious. Writing in dissent at the Fourth Circuit, Judge Julius Richardson struggles to contain his exasperation. “The states,” he says, “have chosen to cover alterations of a person’s breasts or genitalia only if the person experiences physical injury, disease, or (in West Virginia) congenital absence of genitalia.” That determination does not turn on the patient’s sex or gender. “Christopher Fain—one of the plaintiffs below—received coverage for a hysterectomy based on a diagnosis unrelated to Fain’s transgender status,” the dissent says. Likewise, males with gynecomastia qualify for surgery coverage in West Virginia only “if they have physical symptoms, like breast pain,” meaning that isn’t a procedure done merely “to affirm a patient’s biological sex.”

The ruling that opened this can of worms was Bostock v. Clayton County, a case that "held that Title VII of the Civil Rights Act of 1964 protects employees against discrimination because of  sexuality or gender identity." Now, as a dissenting judge in Kadel v. Folwell,  Judge J. Harvie Wilkinson III is saying that this ruling could be a Roe v Wade  ruling for the transgender community.

“This is imperial judging at its least defensible,” he says, “What plaintiffs propose is nothing less than to use the Constitution to establish a nationwide mandate that States pay for emerging gender dysphoria treatments.”

He's not wrong. But getting the ruling past this Supreme Court would be a stretch. 

Rick Moran has been writing for PJ Media for 18 years. His work has appeared in dozens of media outlets including the Washington Times  and ABC News. He was an editor at American Thinker for 14 years. His own blog is Right Wing Nut House . For media inquiries, please contact [email protected] .

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Gender bender: gujarat official to oversee lok sabha ballot as a woman post gender reassignment.

A Gujarat government official, Nilesh Maheta, will oversee Tuesday's Lok Sabha ballot as a woman, Bijal Maheta, after undergoing gender reassignment surgery in 2020. Maheta's journey reflects years of struggle with her gender identity, dating back to her school days, and culminating in her decision to transition in 2012. The Transgender Persons (Protection of Rights) Act 2020 provided her with legal protection, reassuring her decision. Despite facing challenges, Maheta feels supported by her colleagues and is excited about her new role, symbolizing a step towards inclusivity and acceptance.

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