gender reassignment surgery complications

• Alzheimer's & Dementia
• Asthma & Allergies
• Atopic Dermatitis
• Breast Cancer
• Cardiovascular Health
• Environment & Sustainability
• Exercise & Fitness
• Headache & Migraine
• Health Equity
• HIV & AIDS
• Human Biology
• Men's Health
• Mental Health
• Multiple Sclerosis (MS)
• Parkinson's Disease
• Psoriatic Arthritis
• Sexual Health
• Ulcerative Colitis
• Women's Health
• Nutrition & Fitness
• Vitamins & Supplements
• At-Home Testing
• Men’s Health
• Women’s Health
• Latest News
• Medical Myths
• Honest Nutrition
• Through My Eyes
• New Normal Health
• 2023 in medicine
• Why exercise is key to living a long and healthy life
• What do we know about the gut microbiome in IBD?
• My podcast changed me
• Can 'biological race' explain disparities in health?
• Why Parkinson's research is zooming in on the gut
• Health Hubs
• Find a Doctor
• BMI Calculators and Charts
• Blood Pressure Chart: Ranges and Guide
• Breast Cancer: Self-Examination Guide
• Sleep Calculator
• RA Myths vs Facts
• Type 2 Diabetes: Managing Blood Sugar
• Ankylosing Spondylitis Pain: Fact or Fiction
• Our Editorial Process
• Content Integrity
• Conscious Language
• Health Conditions
• Health Products

Sex and sexual health tips for transgender women after gender-affirming surgery

Lower gender-affirming surgery for trans women will mean they need to wait until the surgical site heals before having sex. Using lubricant and taking additional steps to protect against contracting sexually transmitted infections (STIs) can also help during the healing process.

Three options for lower gender-affirming surgery for transgender women include:

• Orchidectomy : This involves the removal of the testes. It can be a stand-alone procedure or occur during a vaginoplasty.
• Vaginoplasty: This involves removing the penis, testicles, and scrotum and creating a vaginal canal and labia. The surgeon will also create a clitoris using a portion of the glans penis.
• Vulvoplasty: This creates a vulva, including the mons pubis, labia, clitoris, and urethral opening. People may opt for this surgery if they are uninterested in receptive vaginal sex or do not wish to maintain the dilation and aftercare regime necessary after vaginoplasty. People may also refer to this option as a minimal depth vaginoplasty.

This article discusses how long recovery can take and when people can have sex after gender-affirming surgery.

It also looks at what to expect during sex after surgery and tips for hygiene, contraception , and protection from infections.

When can a person have sex after surgery?

According to Johns Hopkins Medicine , people can have receptive intercourse or take part in any sexual activity 12 weeks after a vaginoplasty. Sexual activity before this may lead to delayed wound healing and complications.

After an orchidectomy, it may take 1–2 days for people to become fully mobile again. They may be able to return to work a few days to a week after surgery.

Full recovery from an orchidectomy may take 2–8 weeks . For a few weeks following surgery, people will not be able to carry out certain activities such as driving or heavy lifting. The area of surgery will need to fully heal before people can have sex.

A healthcare professional can advise people when it is safe for them to have sex after gender-affirming surgery.

Will it be possible to achieve orgasm?

Following surgery, it can take time for people to recover and start to experience orgasms.

When people undergo a vulvoplasty, the surgeon forms a clitoris from the head of the penis. This means most people will still be able to experience orgasms through clitoral stimulation.

Johns Hopkins Medicine states that people may experience clitoral sensation after a vaginoplasty, although it can vary for each individual. Nerve regeneration may begin around 3 weeks following surgery, but in some cases, it may take a year or more to regain sensation.

People may experience a shooting or tingling sensation as the nerves regenerate, which should decrease over time.

In a 2017 study , 84 participants had rectosigmoid vaginoplasty. A post-surgery interview found that 79 of the participants had had sexual intercourse, and 72 had experienced orgasm.

Some reported infrequent symptoms, such as pain after sex and vaginal spotting , but these improved within 6 months.

A 2016 study of 22 people who had undergone a vaginoplasty and clitoroplasty found that 86% of participants could experience orgasm after surgery.

In addition, research from 2017 involving 28 transgender women found that pressure and vibration provided the best results for genital sensitivity after gender-affirming surgery.

How will it affect libido?

Transgender women may experience a decrease in sex drive after gender-affirming surgery.

According to a 2020 article , people can stop taking anti- testosterone medication and may experience a decreased sex drive following an orchidectomy.

Hormone replacement therapy may help maintain a regular sex drive.

Vaginal depth and lubrication

Vaginal depth after a vaginoplasty can vary for each person and depend on the amount of skin in the genital area before surgery.

An average vaginal depth after a vaginoplasty is 4–6 inches . For comparison, the average depth of a cisgender female’s vagina measures from 3.5 to 5 inches .

In people who have a rectosigmoid vaginoplasty or colovaginoplasty, the vagina may have more depth.

The University of California, San Francisco Medical Centre notes that the most common vaginoplasty technique uses the penile inversion procedure. This does not create a vaginal mucosa. As a result, the vagina will not self-lubricate, and a person will need to use lubricants to undergo dilation or have penetrative sex.

Another vaginoplasty technique uses the colon or small bowel to line the vagina, which will result in a self-lubricating vagina. However, it is a far less common procedure that may lead to serious and possibly life threatening complications.

When using lubrication, people should use a water or silicone-based lube with latex condoms, as oil-based lubricants can damage latex.

Aftercare and dilation

After a vaginoplasty, people need to use a vaginal dilator to stretch the vaginal canal and keep it open. Following surgery, people may need to dilate twice each day for a minimum of 15 minutes. This helps prevent loss of vaginal depth and width.

A healthcare professional will provide instructions on how to safely and correctly use a dilator. Although people may experience some discomfort when they begin dilating, they should not experience any severe pain.

If people experience pain when dilating, they will need to stop and readjust the dilator and body position. People will also need to use lubrication during dilation.

An orchidectomy can cause testosterone levels to drop. A sudden drop in testosterone may lead to mood swings or low energy following surgery.

To help prevent this, people may want to discuss mild testosterone replacement options with a healthcare professional to allow a more gradual reduction in testosterone.

People may need to use plenty of lubricant to make sex feel more comfortable and prevent any tears. They may also find the rest of the genital area, including the anus, is more tender following surgery.

Contraception and STIs

According to the Terrence Higgins Trust , surgery can increase the risk of contracting STIs , as any unhealed skin can allow infections to pass more easily into the body.

If people have had a vaginoplasty that uses part of the colon, a mucus membrane will line the vagina, making it easier for STIs to pass through.

If people have had a vaginoplasty that uses penile and scrotal skin, the vagina is less susceptible to STIs, but any unhealed skin can still be a risk factor.

Dilation of the vagina can also cause bleeding, so it is important to use a condom for any sex following dilation.

Using a condom during sex can help protect from STIs. People can use an external condom over a penis or sex toy and an internal condom inside a vagina. An internal condom may not suit everyone, as using an internal condom will depend on vaginal depth.

People can also use a dental dam during oral-vaginal sex. Regular testing can help to prevent passing on or contracting STIs from a sexual partner.

If people have not had an orchidectomy or vasectomy, they will need to use contraception for any penetrative sex with a partner who is able to get pregnant and is not using contraception.

If people are taking estrogen or other hormone therapy, these will not provide enough contraceptive protection, so they will need to use other contraceptive methods.

Learn more about sexual health for transgender women here.

Hygiene tips

After a vaginoplasty, it is important to keep the genital area clean and free of infection .

People will need to keep the outside of the vagina dry. It may be useful to place an absorbent pad between the labia to soak up any excess moisture.

Once the genital area is allowed to get wet, people should use soap and water to gently wash the area. It is important to avoid scrubbing or allowing shower spray to reach the surgical site.

Johns Hopkins Medicine states that people will need to douche using a non-fragranced vaginal douche , beginning 8 days after surgery. Depending on how much vaginal discharge people have, douching may be required 1–2 times each week. More frequent douching may be necessary if there is a large amount of discharge.

Following an orchidectomy, people may experience some mild discomfort, bruising, and swelling around the area of surgery. Some bleeding may occur, although this is rare . People may need to apply topical antibiotics to prevent infection.

People will need to speak with a healthcare professional to check when they can bathe the area of surgery following an orchidectomy.

It can take time to heal, recover, and adjust to sex and intimacy after gender-affirming surgery.

If people are experiencing any physical or emotional issues regarding surgery, they can speak with a doctor, a mental health professional, or a sex therapist.

Last medically reviewed on October 27, 2021

• Sexual Health / STDs

How we reviewed this article:

• Can transgender women have orgasms after gender-reassignment surgery? (n.d.). https://issm.info/sexual-health-qa/can-transgender-women-have-orgasms-after-gender-reassignment-surgery
• FAQ: Vaginoplasty. (n.d.). https://www.hopkinsmedicine.org/center-transgender-health/services-appointments/faq/vaginoplasty
• Kim, S-K., et al . (2017). Is rectosigmoid vaginoplasty still useful? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300923/
• LeBreton, M., et al. (2016). Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women. https://www.jsm.jsexmed.org/article/S1743-6095(16)30859-1/fulltext
• Meltzer, T. (2016). Vaginoplasty procedures, complications and aftercare. https://transcare.ucsf.edu/guidelines/vaginoplasty
• Orchiectomy. (n.d.). https://transcare.ucsf.edu/orchiectomy
• Orchiectomy. (n.d.). https://www.transhub.org.au/orchiectomy
• Orchiectomy. (n.d.). http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/orchiectomy#Post--surgery
• Safer sex and sexual health for trans feminine people. (n.d.). https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/trans-people/trans-feminine/safer-sex
• Sigurjónsson, H., et al. (2017). Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery. https://www.jsm.jsexmed.org/article/S1743-6095(16)30857-8/fulltext
• Vaginoplasty / vulvoplasty. (n.d.). https://healthcare.utah.edu/transgender-health/gender-affirmation-surgery/vaginoplasty.php
• van der Sluis, W. B., et al . (2020). Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes. https://www.tandfonline.com/doi/full/10.1080/26895269.2020.1749921

Share this article

Latest news

• Keto diet may help lower cholesterol, toxic proteins in Alzheimer’s disease
• Zepbound and Mounjaro improve sleep apnea symptoms, Eli Lilly trial shows
• Scientists find that AFib may be more common in younger people than thought
• How quality sleep can reduce the risk of heart disease and stroke
• Carbon beads may help reduce liver disease, restore gut health

Related Coverage

There is no age limit on when a person can transition. Learn more about how to do so here.

Transgender is a term to refer to those who have a different gender identity than the one assigned to them at birth. Learn more here.

Estrogen hormone therapy can cause physical, sexual, reproductive, and emotional changes. Learn more about how it affects the body here.

• Patient Care & Health Information
• Tests & Procedures
• 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.

Products & Services

• A Book: Mayo Clinic Family Health Book, 5th Edition
• Available Sexual Health Solutions at Mayo Clinic Store
• Newsletter: Mayo Clinic Health Letter — Digital Edition

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.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

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.
• Doctors & Departments
• Care at Mayo Clinic

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

Make twice the impact

Your gift can go twice as far to advance cancer research and care!

You are using an outdated browser. Please upgrade your browser .

The Cultural Roadmap for City Girls Everywhere

“This Is So Hard:” Coping with Complications from Gender Affirmation Surgery

Two trans women and two trans men share their stories of post-op struggle and survival.

On one of the last days of 2016, Amy Hunter packed her bags for a flight from Michigan to Arizona with her spouse, to visit the in-laws and ring in the New Year.

She packed a few skirts, some light scarves, a blazer and a long, flowing sweater — nothing she would need at home this time of year. Except for the extra colostomy bags. She couldn’t leave home without them.

In fact, Hunter can’t travel far by plane or even by car without them. The 56-year-old transgender woman underwent gender confirmation surgery 8 years ago, and then spent two more agonizing years trying to fix something that had unexpectedly, horribly, gone wrong.

The surgery “ didn’t make me a woman,” Hunter told GO in a Facebook chat. “It was, for me, a necessary step toward removing the incongruities inherent to my gender.”

But that step forever changed her life, in ways she did not imagine.

Surgery is a risky but increasingly popular option to counter gender dysphoria, the feeling that one’s gender assigned at birth doesn’t correspond with the gender identity of that individual. Across America, doctors, hospitals and clinics that perform these transgender surgeries report a boom in demand, according to NBC News . It’s not clear if it’s because more trans people are coming out — the Williams Institute reported 1.4 million American adults now identity as trans — or if they are deciding to pursue surgery before President-elect Donald Trump and the Republican-led Congress make good on threats to scrap the Affordable Care Act.

Of course, not every trans person seeks or qualifies for surgery, often because of personal or financial reasons, their health, lack of insurance coverage, or out of fear of losing a job or their family’s support.

Those who do pursue transgender-related procedures have a range of options, beginning with hormone replacement therapy for both trans men and women. Then there is facial feminization, tracheal shaves, and breast augmentation for trans women, and double mastectomies for trans men. The surgeries that have been indelicately called “sex change operations” are the most complex procedures; a more common name is sex reassignment surgery, or SRS, and a more popular name within the trans community is gender confirmation surgery, or GCS. One more variation is Gender Affirmation Surgery. And since 2014, the U.S. Government’s Centers for Medicare and Medicaid Services have covered many, but not all, of these transgender-related procedures.

“Generally speaking, it is possible to obtain insurance coverage for gender-confirming surgeries in patients who meet WPATH guidelines for surgical transition,” said Dr. Jess Ting , Surgical Director and Assistant Professor of Surgery at the Icahn School of Medicine at Mount Sinai in New York City. WPATH is an acronym for the World Professional Association for Transgender Health. “Coverage varies from state to state.”

And while doctors say the vast majority of these transgender surgeries have successful outcomes, the risk is real, and historically, a taboo subject. But that’s changing as the surgeries themselves become more common.

“The demand for surgical transition has been growing over the last several decades,” Ting said. He couldn’t provide hard numbers, and internet searches typically churn out outdated data.

For example, statistics cited in the Surgery Encylopedia are more than a dozen years out of date, indicating that at the turn of the century, between 100 and 500 gender confirmation surgeries were performed a year in the U.S. The entry reported the worldwide number was two to five times larger, with many choosing to have their surgeries in Thailand. Since many of these operations are performed privately, the actual current number is difficult to estimate.

The U.S. Transgender Survey for 2015 by the National Center for Transgender Equality found 25 percent of the more than 27-thousand respondents reported undergoing some form of transition-related surgery, which comes to more than 6,750 operations. Also, 55 percent of respondents who hoped their health insurance would pay for transition-related surgery in the past year say they were denied coverage.

According to the Wall Street Journal , the transgender health program at Oregon Health & Science University had 180 transgender patients on a waiting list last summer, and Boston Medical Center’s Center for Transgender Medicine and Surgery had a waiting list with 200 transgender women awaiting vaginoplasty. That is the name of the irreversible operation in which a surgeon transforms parts of a penis and scrotum into a vagina, clitoris and labia. It is not, as so crudely put by the uninformed, the same as “cutting off your dick.” The male urethra is shortened to serve as a female urethra. The reverse is true for female to male patients. And in both cases, surgeons preserve nerve endings to maintain sensation.

At least, they try to preserve those nerve endings. Hannah Simpson, 32, was not so lucky. She lost all sensation and gained something that left her feeling that intimacy was impossible. The New York City writer and transgender advocate lives without a functioning clitoris.

“When I wake up in the morning and take off my pajamas to take a shower, I see this extra flap of tissue that my surgeon left and refused to address. It constantly reminds me this is not yet finished this is not a functional aesthetic representation of the female anatomy,” Simpson told GO in a phone interview.

“It reminds me it’s not done. It makes being flirtatious harder. It makes socializing harder, and just going out harder. Even waking up feels harder. I have to work through that every single day.”

“Complications are a possibility in any surgery, no matter how simple the surgery and GCS is most certainly not simple,” said Dr. Marci Bowers , an accomplished gender confirmation surgeon in San Francisco, who herself is trans. She spoke to GO via email.

“These surgeries include a wide variety of procedures with individual complication rates which correlate with the particular surgery in question and with the surgeon involved. Rates can vary from rare to as much as 30 percent in urethral lengthening procedures,” she wrote. “ Fortunately, with time, most incisional complications resolve themselves without intervention beyond local wound care. Unfortunately, genital surgery places great pressure on artistry with complexity of these procedures confounding all but the most precise of surgeons.”

Ting agreed, and put in a plug for the new program at his Manhattan hospital. “ Gender reassignment surgery is a complex, multi-step procedure which requires extensive training and expertise,” he said. “This is why, at the Mount Sinai Health System, we have created a multi-specialty center for transgender surgery where patients can receive the highest quality surgical care in a culturally-sensitive, high-volume, tertiary care center.”

Culturally insensitive folks, including far too many health care professionals, tend to ask transgender people, “have you had ‘the surgery?’” That question is frowned upon because being trans is “not about what’s between your legs, but what’s between your ears,” as Chaz Bono famously said.

Last month, Morehouse School of Medicine in Atlanta hosted a panel that brought together medical students and transgender advocates from the Human Rights Campaign, to help the students better understand trans people’s lives and health needs. 

But even within the transgender community, the subject of surgical complications is a topic that has too often been discussed only in hushed tones. Even today, it is typically limited to private social media groups and online chats, which attract large numbers.

“In the trans community, there is a very active online community where there is an open exchange of information on where to have surgery, what the complications are, and who the practitioners are,” Ting said. “Discussions of postop care and complications are common in these online venues.”

Of the three surgeons who agreed to speak to GO , not one will proceed with the operation unless a patient agrees to sign a form that they are aware that complications are possible. “ Outcomes —including potential complications — are part of every discussion with prospective patients,” Ting said.

“Complications do occur, however.  Obtaining long-term outcomes data, including complications, is one of our goals. There is no current registry process for transgender surgery and outcomes, and it is our hope to establish a multi-institutional longitudinal outcomes registry.  Similar to cardiac and transplant programs, a future scenario where publicly or voluntarily reported outcomes data are available to prospective patients would be desirable.”

If a database is created, it will come too late for Hunter, who is the transgender advocacy consultant for the American Civil Liberties Union in Michigan. She’s known she was not male since the age of four.

Instead of the vagina she had always longed for, Hunter has what she called a “fibrous lump between my legs and a colostomy bag.” Everything she read online and in an information packet, everything her surgeon told her, led her to believe the chances of complications were at best remote.

“Almost as an afterthought, she said we needed to go over ‘this stuff.’ We got to that last, not worth mentioning but still possible, worst-case scenario thing,” Hunter said. “Of course, it needed to be brought up but in almost four hundred surgeries ‘it had only happened just once, so we don’t worry about it.’ I didn’t.”

That’s a decision that has haunted Hunter, Simpson, and two trans men who also shared their stories of surgical complications.

“Why did I do this?”

Ryan is a transgender man who said he’s always felt like he’s a guy, and rejected the label lesbian when he was younger. He spoke with GO by phone, and although he asked we not use his real name or identify his home state, he’s made no secret of his struggle on social media, like Hunter and others who’ve encountered complications after his “bottom surgery.” That is a phrase many in the transgender community use to refer to the specific operation that female to male trans people undergo, a phalloplasty, in which tissue from an arm is used to create a phallus that allows a trans man to urinate in the same way he would if he had been born that way.

Ryan said although he had done his homework, he still had doubts prior to being operated on by a world-famous surgeon in Illinois. While Hunter chose to not name her surgeon, Ryan decided others might benefit from knowing about his experience with that surgeon, who declined to be interviewed or offer a comment on the record. He is medical director at a Chicago clinic for transgender men and women.

“I wondered, ‘Am I doing the right thing?’” Ryan said. “There’s this huge potential for complications.” And so there were.

“I started having urinary complications almost immediately, less than a week,” said Ryan, who developed a stricture, which is an abnormal narrowing of the urethra, the tube that carries urine out of the body from the bladder.

There were also problems of a far more basic nature during his recovery.

“My disappointment is that I don’t feel like the communication from my surgeon was there at all,” Ryan said. “I felt abandoned. There was no help. Thank goodness for this one amazing nurse practitioner. She was a godsend who was always available, because [the surgeon] certainly was not.”

“I found him in a private, secret group I was in,” on Facebook, said Ryan. “I really liked his work.”

Ryan had turned to the surgeon in spring of 2016 only after “a horrible, horrible experience” with the office staff of a male surgeon in San Francisco, a doctor he decided to not name. “They blew me off, it took six months to get back to me, they wouldn’t answer the phone, and they wouldn’t return phone calls. I even emailed the doctor several times,” said Ryan, who heard from friends there had been a major snafu in which several scheduled surgeries were canceled en masse in the midst of the doctor’s move to the Midwest. Ryan finally gave up after nine months and made a consultation appointment with the Chicago surgeon.

“I felt really good about my consultation in April,” Ryan said. “There were far fewer people who had negative experiences with him; in fact, people I talked to had really good experiences. I looked at his results and they were hands down the best I had seen.”

Following his radial forearm flap phalloplasty on May 31, the doctor required he lay prone for six days, forced to maintain nothing more upright than a 30-degree angle.

“[The surgeon] would come in, he’d take one quick look,” Ryan said of the days following his operation. “He’d be in the room for less than two minutes at a time, he’d go, “Hmm. Looks good,” and he’d walk out. “And I had pus and infection concerns for almost the whole first month after surgery,” which was the first of two he spent in the hospital. But he said his surgeon seemed nonplussed.

“He even examined Gary in the shower,” said Ryan.

Gary talked with GO by phone. He teamed up with Ryan for this odyssey and underwent the same procedure with that same surgeon. Like Ryan, he is trans, and also asked that we use a pseudonym for legal reasons. From late May until mid-July, he was by Ryan’s side, except for that one morning in the shower.

“Seeing that Gary wasn’t in his bed, [the surgeon] went and examined him in the shower,” Ryan explained. Gary picked up the story: “He walked in on me, in the shower.” He said the doctor pulled back the shower curtain, and asked him, “Can I take a peek?”

“ I was like, ‘Um… I’m showering, but okay,’” Gary recalled with laughter. “The R.N. standing behind him just gave me a look of horror when he asked that.”

“We have this joke now that when you pull back the shower curtain we expect [the surgeon] to be standing there,” Ryan said, reminiscing about the classic film, Psycho. “It was the talk of the floor for days.”

Gary had the same complaint about their doctor as Ryan:  “We were just so frustrated by our aftercare, specifically the lack of communication. For example, I emailed [the surgeon], asking, ‘there seems to be an area underneath my scrotum that is opening up, is that normal?’”

Anyone reading that kind of message would no doubt be alarmed at that development, but Gary said the doctor’s response was disappointing: “Put gauze on it.”

“I was like, ‘Are you kidding me with this?” Gary said. “ I never questioned whether I should have had the surgery but I thought to myself, ‘this is so hard. Why did I do this?’ When I questioned whether it was worth it, each time I would think to myself, ‘you know what? It’s going to be worth it. It’s just hard right now. It’s a hard road. You’ll get to the point of being okay.’ I admit, I expected it to be 100 percent happiness, when I had visions of what recovery would be. It turned out to be more of a mixed bag.”

“I got really depressed and shut down. I gave up on myself.”

Like Gary and Ryan, Hunter spent her recovery seeking new surgeons, and she underwent several reconstruction surgeries to repair a rectovaginal fistula that had resulted from a slight tear in her colon. A fistula is a hole between the vagina and the rectum that in women who are assigned female at birth is typically a complication of childbirth, and allows stool to flow through that hole into the vagina.

Hunter said a surgical tool called a retractor caused her tear, during what she described as “an otherwise flawless procedure” by a leading surgeon in this field whom she chose to not name here. But as it happens, those attempts to fix what went wrong backfired horribly, leaving her not with an approximation of what every woman has, but with something that left very much to be desired.

“Unfortunately, all of the efforts at repair failed,” she said. “I got really depressed and shut down. I gave up on myself.”

“Those two years of multiple procedures after GCS were rough. That many surgeries, the general anesthesia and the pain meds take an extraordinary toll on your body and emotional health.  One surgery made the problem worse having severed some critical muscle tissue. I have a permanent colostomy and no vaginal canal. But, and it’s a big but, I have been able to use my experience to help others, including some physicians, understanding the need for integrated post-op care.  I was fairly depressed for awhile and it was really difficult to get off the opioids, but eventually, life became pretty routine again. I was unable to do much physical work for those two plus years, and I left my previous profession as a lighting designer and went into advocacy and politics.  Ironically, I guess, my difficulties nudged me to take seriously what I already knew was a moral imperative, and live it. Living with a colostomy becomes routine but takes some adjusting. I learned to give myself more time in the morning and to let, ahem, things move, before I get in the car for a long commute or on an airplane.”

Speaking of planes, Hunter said because of her colostomy bag, “I ALWAYS get pulled out by security for an “anomaly” and tested for explosive residue by TSA.

She learned to not see herself as lacking anything: “It wasn’t so much having something, as clearing away that which blocked me from my authenticity as a woman.”

“I am a woman, and that is unequivocal now,” declared Simpson, who shared a similar fate to Hunter’s, but has all but given up hope after a frustrating series of surgeries that made things worse, not better.

“A woman who does not have functional female anatomy.”

“One surgeon finally washed his hands of me, saying, ‘Well, you did this to yourself.’”

Simpson had her bottom surgery in Philadelphia and has chosen to not name her surgeon. As is typical, the success of the surgery — or lack thereof — was not apparent at first. Recalling her recovery in July 2014, she said the sensation of the cuffs that surrounded her calf muscles, constantly pulsating to circulate her blood flow, “that was more painful than the recovery from the surgery itself.”

But a far different pain was soon evident. Before sending her home, the packing was removed and she was instructed on vaginal self-care, such as dilation and abstinence from sex for three months.

“I looked at it and saw some marked asymmetry, even from the first day. One side was very swollen and firm, and the other side was a lot softer; still swollen but there was a difference in texture,” said Simpson, who at the time was in her second year of medical school, studying to be a doctor.

“I was told, ‘The tissues could be swollen at different levels, it’s hard to predict. Give it time to heal. This particular surgeon wanted to keep everything open as opposed to compression garments,” Simpson said. And when she reported the asymmetry had increased, she said the surgeon scolded her for wearing Depends post-op, claiming the tightness may have exacerbated the swelling. “I said I don’t think that’s the case because a number of other surgeons use compression dressing in their protocols, and I didn’t have that pair of Depends on for very long — we’re talking ten minutes — and I even ripped them to make them wider, didn’t wear them all the way up and replaced them with a bigger pair the next day.”

“I’m watching it heal and I’m watching it necrose,” — which means the tissue on one side of her vulva was dying — ”and I know what is happening, because I’m a medical student and it becomes clear within the first few weeks that I’m going to need a revision, a labiaplasty. I was told it’s just going to fill in on its own, and no it wasn’t. I had follow-ups, first a week, then a month, then three months. And each time the asymmetry is persisting and it looks like shit. And I’m also having issues with the vaginal canal itself as well as the vulva. One surgeon, then another, and yet another look at me, and they won’t do anything. One finally washes his hands of me, telling me, ‘You did this to yourself.’”

While Simpson’s and Hunter’s cases are said to be rare exceptions, both women expressed no regrets in terms of choosing to have their surgeries, even in spite of the complications.

Simpson — who has no need for a colostomy bag — did find a use for them: as a prop in a successful Twitter campaign to fight North Carolina’s House Bill 2. She attracted support from transgender author Jennifer Finney Boylan, activist Brynn Tannehill, supermodel Geena Rocero and more, with the tagline: “Legislating peeing is legislating being!”

As part of her activism tour around the world in 2016, Simpson also visited Ryan and Gary in Chicago last summer, at the beginning of their seemingly endless recovery.

“I feel like I lost three and a half months of my life.”

Gary agreed that he wasn’t sorry he had the operation, but there was an enormous amount of frustration, and he endured it for more than three months.

Imaging from a tiny camera that was inserted into his bladder in July revealed Gary had a urinary fistula. “While it was explained to me these are common, it’s been so, so hard to deal with these catheters.”

Not one. Two.

“If I were to go into a locker room now,” he said in August 2016,” there wouldn’t be any concern aesthetically, but someone would surely wonder, ‘Oh, why does that guy have two catheters?’”

One was a penile catheter, known also as a Foley, which was inserted into his penis; the second or pubic catheter was inserted near Gary’s stomach and acted as a fail-safe in case of complications once the Foley was removed.

“It’s been frustrating that here I am, three months later and I still can’t pee standing up. I was supposed to get the catheters pulled a month ago but they say I’m not healed enough,” Gary said, exasperated, last August. “I usually don’t cry, but I’ve broken down three times. It’s a mixture of frustration anger, annoyance. It’s a pain in the ass. It’s not painful per se, it’s just annoying. I feel like I lost three months of my life”

By mid-September, that problem was resolved, and both Gary and Ryan said they are glad to have made a joint decision to ditch that doctor, leave Chicago and find another surgeon.

“We felt like our complications were not being addressed,” said Gary, who had the fistula; Ryan had the stricture that he felt wasn’t adequately treated.   “We have different body anatomy and yet we have the same complications. We feel, honestly, that [our surgeon] didn’t give us his best, ‘A’ game. I’ve never had a health issue all my life and to be in a hospital 31 days, that’s saying something.”

Ryan and Gary are members of the same group on Facebook where trans men can share their concerns, both pre- and post-op. Gary found it invaluable.

“By discussing with other trans men I realized, I’m not alone, and there are lots of guys with urinary complications,” Gary said. “And even though this recovery has been really challenging, it is ‘normal.’”

The surgeon they chose for the “fix” was Dr. Dmitriy Nikolavsky in Syracuse, N.Y., who is fast developing a reputation in the transgender community.

“I found a niche, for fixes,” Nikolavsky told GO in a phone interview. He said he doesn’t do gender affirmation surgeries, at least not right now. “The original surgeries are much more difficult,” said Nikolavsky, who said he always consults the surgeons before he begins work on one of their patients. “I compliment them. They are doing the impossible.”

Nikolavsky said he was stunned to find a terrible shortage of research to guide him as he learned his technique, which he said was not more difficult than the same kinds of surgeries on men assigned male at birth, and women assigned female at birth. He did concede, “nobody knows the ‘correct’ procedure, given that there are only three papers in the world addressing this topic, two from the 1990s and a more recent paper from Belgium.

“But no matter what you do, in some complications, you have very little success,” Nikolavsky said.

While acknowledging many of his transgender patients express shock and disbelief at their complications, Nikolavsky said most of the cases he encounters are, “in the grand scheme of things, tiny setbacks, minor problems after a complex surgery,” that he has developed a skill in resolving, including in the case of both Ryan and Gary, who drove eleven hours from Chicago to Syracuse last summer to find their “fixer.” Both men are living authentically now, tubes out, back at work, and they pee standing up, just like any other guys.

Their friend Simpson hasn’t stood up to urinate for years, but one of her complications is that the flow of her urine skews forward instead of downward, yet another problem that sets her apart from cisgender (not transgender) women. Still, she said, peeing was the least of her concerns.

Three months after her surgery, she asked her surgeon what the plan was for having sex, a major reason she chose to have the operation in the first place. She is the oldest of four children, a snarky Jew from New Jersey who boasts that she used the money she had socked away from her bar mitzvah — the Jewish ritual in which a boy becomes a man — to become the woman she always felt she was. “I want to be able to use my vagina, and I don’t feel like I’m going to be able to have sex, which is typically three months.”

“A pear is not an apple.”

The surgeon’s response stunned her: “’If you were in a relationship that would be one thing. You just want to have sex for the sake of having sex.’ And all I could think was, ‘Excuse me, mommy?’ She should have no say in how I’m using this vagina.”

Simpson wanted a second opinion on getting a revision, but most surgeons she consulted at this point told her the same thing: let it heal, see if it improves on its own. It didn’t.

Ultimately, a surgeon in California did perform a revision in 2015, which Simpson said left her looking butchered, and feeling damaged beyond the point at which she worries if she ever experienced sensation during intercourse.

“A number of things are wrong: I do not have a clitoris, which makes it really hard to achieve stimulation leading to an orgasm. I do not have symmetric and complete labia on either side of my vagina,” Simpson said. “And I have tremendous scarring in the vaginal canal that needs to be addressed, shaved down, in order to have comfortable penetration. I also have excess urethral tissue that was just left out. It’s an angry inch, just sticking out from the top of my vulva. And I lost the nerve endings that were attached to the tip of my penis, and those nerves are still leading toward where they were, but something needs to be attached to them to restore sensitivity. You can string power lines to a house but if you knock out all the light switches, what’s the point?”

Simpson is hoping she might find help as more doctors do more procedures to repair complications, and has appealed to Dr. Nikolavsky among others around the country and the world for help. “I cannot be the only one person this has happened to, let alone the last person.” She believes there might be a solution in the breakthrough work being done on male soldiers who survive bombings and require genital reconstruction. Simpson also actively supports the cause of women who have been tortured through genital mutilation, something with which she closely identifies. “I’m cognizant of the significant difference between my surgery and the experience of women worldwide who are subjected to this horror, but I can see in the aftermath a parallel, and I can’t help but identify with their plight.”

Friends, especially those who are pre-op transgender women, have tried to convince Simpson to move on, to concede that she’s lucky to at least have had access to surgery, even if it did not end well. Those appeals do not help, Simpson said.

“’It has to be better than not having a penis,’ they’ll say. And I’ll say, ‘No, actually there’s something worse than having a penis, and that’s a nonfunctional, not aesthetically accurate vagina.’”

Or they will tell her that somewhere out there is someone who will love her for who she is, not what she looks like below the belt.

“They’ll say, ‘you’ll find a partner who understands.’ And my response is, the standard for surgery is, I did it for me, I didn’t do it for anyone else. It shouldn’t be about my partner when I’m uncomfortable with the result I have. And then they’ll say, ‘vaginas come in all shapes and sizes.’ But when you’re outside the natural range, that doesn’t work. Apples come in all shapes and sizes. A pear is not an apple.”

Some of the toughest conversations have been with her very supportive mother, who’s told Simpson, “I support you for being a woman. What more can I do?”

“And I say, ‘nothing,’ and that alienates them because they want to do something,” she said. “ But the hardest part is the physicians that you look to, some try to be honest, they’re primary care doctors, they say, ‘We don’t have a clue about this, you’re on your own.  I felt like I already died. I already died. Now I was just in limbo in between when my life as a spirit ended and when my physicality ended, and that I wasn’t exactly pushing to die but I wasn’t living either. Thank God my family was supporting me.”

“Right now I’m taking it one day at a time,” she continued. “I’m doing lots of things to distract myself, like staffing trips to Israel, writing, traveling, because I know if I go back to something like medical school I will fall back into depression. I am traumatized every time I wake up, get naked, take a shower, use the bathroom. Just looking at it, it’s a trauma. And it’s a continuous one that I carry around with me. It is connected to me. It is me. I cannot remove it from myself and I cannot remove myself from it. And that is devastating.”

Simpson said her only regret is her choice of surgeons and can accept that. “What I can’t accept is being shrugged off. I am a woman who has a right to a functional anatomy. Any woman, cisgender or transgender, would feel that way. What are we going to do about that?”

She’s still waiting for that question to be answered.

You Might Also Like...

The unexpected lesson about transgender friendship i learned at a sushi bar, new york repeals discriminatory ‘walking while trans’ law, ‘clarice’ addresses ‘complicated legacy’ of buffalo bill, says actress jen richards, what do you think, leave a reply.

Your email address will not be published. Required fields are marked *

• Wonder Women
• Celesbian Culture
• Sex & Dating
• Arts & Entertainment
• Event Photos

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Review Article
• Published: 02 June 2020

Urethral complications after gender reassignment surgery: a systematic review

• N. Nassiri 1 ,
• M. Maas   ORCID: orcid.org/0000-0001-9677-9917 1 ,
• M. Basin 1 ,
• G. E. Cacciamani 1 &
• L. R. Doumanian 1  

International Journal of Impotence Research volume  33 ,  pages 793–800 ( 2021 ) Cite this article

1053 Accesses

21 Citations

55 Altmetric

Metrics details

• Health care
• Medical research

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms ((“Transsexualism”[Mesh])) AND (“Sex Reassignment Surgery”[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19–54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

This is a preview of subscription content, access via your institution

Access options

Subscribe to this journal

Receive 8 print issues and online access

$259.00 per year

only $32.38 per issue

Buy this article

• Purchase on Springer Link
• Instant access to full article PDF

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

Surgical repair of urethral complications after metoidioplasty for genital gender affirming surgery

Nicolaas Lumen, Mieke Waterschoot, … Piet Hoebeke

Erectile device insertion following phalloplasty in transgender and non-binary individuals assigned female at birth: a narrative review

Giovanni Chiriaco, Aisling Looney, … Wai Gin Lee

Impact of minimally invasive surgical procedures for Male Lower Urinary Tract Symptoms due to benign prostatic hyperplasia on ejaculatory function: a systematic review

Luca Gemma, Alessio Pecoraro, … Mauro Gacci

Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8:274–82. https://doi.org/10.1038/nrurol.2011.46 .

Article   PubMed   Google Scholar  

Santucci RA. Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence. Clin Anat 2018;31:187–90. https://doi.org/10.1002/ca.23021 .

Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097. https://doi.org/10.1371/journal.pmed.1000097 .

Article   PubMed   PubMed Central   Google Scholar  

Oxford Center of Evidence-Based Medicine. Levels of Evidence. https://www.cebm.net/2016/05/ocebm-levels-of-evidence/ . Published 2011. Accessed September 22, 2019.

Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47:398–402. https://doi.org/10.1016/j.eururo.2004.10.008 .

Weyers S, Selvaggi G, Monstrey S, et al. Two-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals. Gynecol Surg. 2006;3:190–4. https://doi.org/10.1007/s10397-006-0203-3 .

Article   Google Scholar  

Schaff J. Enlarged range of free flaps for phalloplasty in transsexual reassignment surgery. Int J Transgenderism. 2007;10:39–45. https://doi.org/10.1300/J485v10n01_06 .

Takamatsu A, Harashina T. Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:318–25. https://doi.org/10.1016/j.bjps.2008.11.038 .

Article   CAS   PubMed   Google Scholar  

Kim S-K, Lee K-C, Kwon Y-S, Cha B-H. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:309–17. https://doi.org/10.1016/j.bjps.2007.11.011 .

Zhang Y-F, Liu C-Y, Qu C-Y, et al. Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals? World J Urol. 2015;33:2115–23. https://doi.org/10.1007/s00345-015-1562-z .

Fang R-H, Kao Y-S, Ma S, Lin J-T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217–22. https://doi.org/10.1054/bjps.1998.3027 .

Dabernig J, Chan LKW, Schaff J. Phalloplasty with free (septocutaneous) fibular flap sine fibula. J Urol 2006;176:2085–8. https://doi.org/10.1016/j.juro.2006.07.036 .

Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6:1306–13. https://doi.org/10.1111/j.1743-6109.2008.01065.x .

Garaffa G, Christopher NA, Ralph DJ. Total phallic construction in female to male transsexuals. Curr Urol 2009;3:146–55. https://doi.org/10.1159/000253373 .

Kim S-K, Moon J-B, Heo J, Kwon Y-S, Lee K-C. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64:759–64. https://doi.org/10.1097/SAP.0b013e3181a5b719 .

Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8:3379–88. https://doi.org/10.1111/j.1743-6109.2011.02348.x .

Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;10:1431–8. https://doi.org/10.1111/jsm.12108 .

van der Sluis WB, Smit JM, Pigot GLS, et al. Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. Microsurgery 2017;37:917–23. https://doi.org/10.1002/micr.30190 .

Stojanovic B, Bizic M, Bencic M, et al. One-stage gender-confirmation surgery as a viable surgical procedure for female-to-male transsexuals. J Sex Med. 2017;14:741–6. https://doi.org/10.1016/j.jsxm.2017.03.256 .

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. Colpectomy significantly reduces the risk of urethral fistula formation after urethral lengthening in transgender men undergoing genital gender affirming surgery. J Urol 2018;200:1315–21. https://doi.org/10.1016/j.juro.2018.07.037 .

Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol 2018;199:206–14. https://doi.org/10.1016/j.juro.2017.07.084 .

Wirthmann AE, Majenka P, Kaufmann MC, et al. Phalloplasty in female-to-male transsexuals by Gottlieb and Levine’s free radial forearm flap technique-A long-term single-center experience over more than two decades. J Reconstr Microsurg. 2018;34:235–41. https://doi.org/10.1055/s-0037-1608656 .

Namba Y, Watanabe T, Kimata Y. Flap combination phalloplasty in female-to-male transsexuals. J Sex Med. 2019;16:934–41. https://doi.org/10.1016/j.jsxm.2019.02.010 .

D’Arpa S, Claes K, Lumen N, et al. Urethral reconstruction in anterolateral thigh flap phalloplasty: a 93-case experience. Plast Reconstr Surg. 2019;143:382e–392e. https://doi.org/10.1097/PRS.0000000000005278 .

Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019. https://doi.org/10.1016/j.jsxm.2019.03.263 .

Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44:611–4. https://doi.org/10.1016/S0302-2838(03)00356-7 .

Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol 2010;57:715–22. https://doi.org/10.1016/j.eururo.2009.05.018 .

Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch Sex Behav. 2006;35:717–27. https://doi.org/10.1007/s10508-006-9104-9 .

Rossi Neto R, Hintz F, Krege S, Rübben H, vom Dorp F. Gender reassignment surgery - a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38:97–107. https://doi.org/10.1590/S1677-55382012000100014 .

Amend B, Seibold J, Toomey P, Stenzl A, Sievert K-D. Surgical reconstruction for male-to-female sex reassignment. Eur Urol 2013;64:141–9. https://doi.org/10.1016/j.eururo.2012.12.030 .

Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. 2015;12:1837–45. https://doi.org/10.1111/jsm.12936 .

van der Sluis WB, Bouman M-B, de Boer NKH, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med. 2016;13:702–10. https://doi.org/10.1016/j.jsxm.2016.01.008 .

Kuzon WMJ, Gast KM, Buncamper ME, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg. 2016;138:999–1007. https://doi.org/10.1097/PRS.0000000000002684 .

Article   CAS   Google Scholar  

Ives GC, Fein LA, Finch L, et al. Evaluation of BMI as a risk factor for complications following gender-affirming penile inversion vaginoplasty. Plast Reconstr Surg Glob Open. 2019;7:e2097 https://doi.org/10.1097/GOX.0000000000002097 .

Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int. 2007;100:607–13. https://doi.org/10.1111/j.1464-410X.2007.07017.x .

Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 2001;88:396–402. https://doi.org/10.1046/j.1464-410X.2001.02323.x .

World Professional Association for Transgender Health. Standards of Care—WPATH. https://www.wpath.org/publications/soc . Accessed September 25, 2019.

Morrison SD, Chen ML, Crane CN. An overview of female-to-male gender-confirming surgery. Nat Rev Urol. 2017;14:486–500. https://doi.org/10.1038/nrurol.2017.64 .

Jun MS, Santucci RA. Urethral stricture after phalloplasty. Transl Androl Urol. 2019;8:266–72. https://doi.org/10.21037/tau.2019.05.08 .

Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg. 2017;140:551e–558e. https://doi.org/10.1097/PRS.0000000000003697 .

Salgado CJ, Nugent AG, Moody AM, Chim H, Paz AM, Chen H-C. Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula. J Plast Reconstr Aesthet Surg. 2016;69:1551–7. https://doi.org/10.1016/j.bjps.2016.05.011 .

Cocci A, Frediani D, Cacciamani GE, et al. Systematic review of studies reporting perioperative and functional outcomes following male-to- female gender assignment surgery (MtoF GAS): a call for standardization in data reporting. Minerva Urol Nefrol. 2019. https://doi.org/10.23736/S0393-2249.19.03407-6 .

Download references

There was no funding source for this study. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Author information

Authors and affiliations.

Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA

N. Nassiri, M. Maas, M. Basin, G. E. Cacciamani & L. R. Doumanian

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to L. R. Doumanian .

Ethics declarations

Conflict of interest.

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Prisma 2009 checklist, rights and permissions.

Reprints and permissions

About this article

Cite this article.

Nassiri, N., Maas, M., Basin, M. et al. Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res 33 , 793–800 (2021). https://doi.org/10.1038/s41443-020-0304-y

Download citation

Received : 15 February 2020

Revised : 20 April 2020

Accepted : 05 May 2020

Published : 02 June 2020

Issue Date : December 2021

DOI : https://doi.org/10.1038/s41443-020-0304-y

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Phalloplasty and metoidioplasty: a systematic review of sensation, orgasm, and penetrative intercourse.

• Elad Fraiman
• Kelly Chambers
• Shubham Gupta

Current Sexual Health Reports (2023)

Imaging in Gender Affirmation Surgery

• Omar Hassan
• Priyanka Jha

Current Urology Reports (2021)

Geschlechtsangleichung von Frau zu Mann

• S. Morgenstern

Der Urologe (2020)

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Reference Manager
• Simple TEXT file

People also looked at

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.

1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-non-conforming people, version 7. Int J Transgend. (2012) 13:165–232. doi: 10.1080/15532739.2011.700873

CrossRef Full Text | Google Scholar

2. Massie JP, Morrison SD, Maasdam JV, Satterwhite T. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast Reconstruct Surg. (2018) 141:911–921. doi: 10.1097/PRS.0000000000004427

PubMed Abstract | CrossRef Full Text | Google Scholar

3. Pan S, Honig SC. Gender-affirming surgery: current concepts. Curr Urol Rep . (2018) 19:62. doi: 10.1007/s11934-018-0809-9

4. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int . (2007) 100:607–13. doi: 10.1111/j.1464-410X.2007.07017.x

5. Rossi NR, Hintz F, Krege S, Rübben H, Vom DF, Hess J. Gender reassignment surgery – a 13 year review of surgical outcomes. Eur Urol Suppl . (2013) 12:e559. doi: 10.1016/S1569-9056(13)61042-8

6. Silva RUM, Abreu FJS, Silva GMV, Santos JVQV, Batezini NSS, Silva Neto B, et al. Step by step male to female transsexual surgery. Int Braz J Urol. (2018) 44:407–8. doi: 10.1590/s1677-5538.ibju.2017.0044

7. Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. Transgender surgery in Denmark from 1994 to 2015: 20-year follow-up study. J Sex Med. (2016) 13:720–5. doi: 10.1016/j.jsxm.2016.01.012

8. Perovic SV, Stanojevic DS, Djordjevic MLJ. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. (2001) 86:843–50. doi: 10.1046/j.1464-410x.2000.00934.x

9. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. (2001) 88:396–402. doi: 10.1046/j.1464-410X.2001.02323.x

10. Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol International. (2010) 84:330–3. doi: 10.1159/000288238

11. Reed H. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin PlasticSurg. (2011) 25:163–74. doi: 10.1055/s-0031-1281486

12. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. (2015) 12:1837–45. doi: 10.1111/jsm.12936

13. Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open. (2015) 6:69–73. doi: 10.1016/j.jpra.2015.09.003

14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol. (2018) 199:760–5. doi: 10.1016/j.juro.2017.10.013

15. Dy GW, Sun J, Granieri MA, Zhao LC. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. (2018) 19:36. doi: 10.1007/s11934-018-0795-y

16. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. (2013) 64:141–9. doi: 10.1016/j.eururo.2012.12.030

17. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med . (2015) 12:1499–512. doi: 10.1111/jsm.12868

18. Hadj-Moussa M, Ohl DA, Kuzon WM. Feminizing genital gender-confirmation surgery. Sex Med Rev. (2018) 6:457–68.e2. doi: 10.1016/j.sxmr.2017.11.005

19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

20. Hess J, Rossi NR, Panic L, Rubben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DtschArztebl Int. (2014) 111:795–801. doi: 10.3238/arztebl.2014.0795

21. Silva DC, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals. J Sex Med. (2016) 13:988–93. doi: 10.1016/j.jsxm.2016.03.370

22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

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

Jazz Jennings's Doctors Revealed Her Gender Confirmation Complications Were 'Severe'

"I think in hindsight we would have never sent you home from the hospital."

• In a clip from the new season of I Am Jazz , Jazz Jennings's doctors are sharing new details about her gender confirmation surgery complications and ongoing transition.
• The teen reality star and LGBTQ+ activist underwent her first gender confirmation surgery in 2018 and had to have a follow-up procedure due to complications.
• Marci Bowers, MD, says, "it turned out tougher than any of us imagined. I think in hindsight we would have never sent you home from the hospital."

In the episode clip, Jazz's doctors, Marci Bowers, MD, and Jess Ting, MD, speak to Jazz and her family about the previous surgeries. Bowers admits Jazz “has had a very difficult surgical course,” in the show. “She had a very incredible first surgery—it went seemingly very well, but there were problems. And that prompted a second surgery, which I was not a part of, unfortunately.”

“Taking Jazz on as a patient for surgery, we knew it was going to be a one-of-a-kind surgery,” Ting explained in the clip. “We don’t have the experience of having said we’ve done 50 of these. I was just not expecting her to have a complication as severe as what she did have.”

“This has been a real journey, hasn’t it? We knew it would be tough—it turned out tougher than any of us imagined,” Bowers tells Jazz's family. “I think in hindsight we would have never sent you home from the hospital. You know, easy to say now. When I wasn’t here when you had problems and had to go back, I can’t tell you how stressful that was.”

It hasn't been easy for Jazz, either. She shared a bit of what she's gone through on Instagram. Jazz opened up in the caption: "As portrayed in this teaser, the past year has been extremely challenging. I have experienced some of my highest highs and lowest lows... Although it continues to be difficult to cope with the hurdles life throws my way, I have been actively working every day to get better and improve my mental health."

Jazz went through her initial gender confirmation surgery in June 2018 . Doctors had to use a new technique because she started using hormones at such a young age. Since she hadn’t developed enough tissue to construct a vagina, Jazz's doctors used tissue from her stomach lining.

Jazz experienced complications and had to return for a follow-up procedure . “There was just an unfortunate event and setback where things did come apart, and there was a complication,” she told the outlet. “I had to come back in for another procedure, but it was just all part of the journey. The good thing though is that it was only cosmetic and external so it wasn’t too dramatic.”

Jazz came out as transgender at age 5 and has been sharing her transition in the TLC series I Am Jazz and on her Youtube channel. FYI: Gender confirmation surgery gives “transgender individuals the physical appearance and functional abilities of the gender they know themselves to be,” according to the American Society of Plastic Surgeons (ASPS).

The new season of I Am Jazz premieres on TLC Tuesday Jan. 28 at 9:00 pm EST.

Jennifer Nied is the fitness editor at Women’s Health and has more than 10 years of experience in health and wellness journalism. She’s always out exploring—sweat-testing workouts and gear, hiking, snowboarding, running, and more—with her husband, daughter, and dog. 

What To Know About Celine Dion’s Health Status

'My Itchy Rash Turned Out To Be Plaque Psoriasis'

What Is TikTok’s Dangerous ‘Blackout Challenge’?

Olivia Munn's Luminal B Breast Cancer Diagnosis

Olivia Munn Is In Medically-Induced Menopause

8 Potential Reasons Why Your Period Came Early

19 Reasons for Unexplained Weight Loss

All About Gypsy Rose Blanchard's Rhinoplasty

Kourtney Kardashian Drank Breast Milk For Immunity

'LiB's Jessica Vestal's 8-Lb. Weight Loss

Does Intermittent Fasting Increase Heart Attacks?

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Plast Reconstr Surg Glob Open
• v.6(4); 2018 Apr

Trends in Gender-affirming Surgery in Insured Patients in the United States

From the Department of Surgery, Division of Plastic Surgery, University of Michigan, Ann Arbor, Mich.

Graham C. Ives

Emily c. sluiter, jennifer f. waljee, tsung-hung yao, hsou mei hu, william m. kuzon.

Supplemental Digital Content is available in the text.

Background:

An estimated 0.6% of the U.S. population identifies as transgender and an increasing number of patients are presenting for gender-related medical and surgical services. Utilization of health care services, especially surgical services, by transgender patients is poorly understood beyond survey-based studies. In this article, our aim is 2-fold; first, we intend to demonstrate the utilization of datasets generated by insurance claims data as a means of analyzing gender-related health services, and second, we use this modality to provide basic demographic, utilization, and outcomes data about the insured transgender population.

The Truven MarketScan Database, containing data from 2009 to 2015, was utilized, and a sample set was created using the Gender Identity Disorder diagnosis code. Basic demographic information and utilization of gender-affirming procedures was tabulated.

We identified 7,905 transgender patients, 1,047 of which underwent surgical procedures from 2009 to 2015. Our demographic results were consistent with previous survey-based studies, suggesting transgender patients are on average young adults (average age = 29.8), and geographically diverse. The most common procedure from 2009 to 2015 was mastectomy. Complications of all gender-affirming procedures was 5.8%, with the highest rate of complications occurring with phalloplasty. There was a marked year-by-year increase in utilization of surgical services.

Conclusion:

Transgender care and gender confirming surgery are an increasing component of health care in the United States. The data contained in existing databases can provide demographic, utilization, and outcomes data relevant to providers caring for the transgender patient population.

INTRODUCTION

Identifying as transgender can have varying meanings to different individuals, but is generally understood to describe discordance between one’s biologic sex assigned at birth and the gender with which one identifies. An estimated 0.6% of the U.S. population identifies as transgender or gender-nonconforming. 1 Transgender patients face many unique health risks, including an increased risk of suicide, mental health issues, and HIV compared with those in the general population. 2 , 3 In addition, trans patients are less likely to be insured 2 , 3 and often find health insurance coverage for transgender medical care to be lacking. The paucity of insurance coverage for hormone therapy and gender-affirming surgery, even among those who are able to secure health insurance, contributes to a high financial burden. Of the respondents in the 2015 U.S. Transgender Survey, 55% of patients who sought surgery and 25% of those on hormones reported difficulty obtaining insurance coverage for these services. 3 In addition to cost, transgender patients report delaying health care for urgent needs and preventative care due to discrimination and disrespect from providers. 3

Although there are financial and social barriers to health care access for transgender patients in the United States, the need for medical and surgical gender-related care is increasing. The 2015 US Transgender Survey reported in a sample of over 27,000 transgender and gender-nonconforming Americans, 25% had undergone 1 or more gender-affirming surgeries. 3 Beyond large survey studies such as the U.S. Transgender Survey, there has been little investigation into the utilization of gender-related health services over time, which is a particularly pertinent area of investigation, given both increasing visibility of transgender issues and the ongoing debate regarding health care reform in the United States.

We aim to shed light on basic demographics and trends in utilization of gender-affirming surgeries through the use of insurance claims data available on the Truven MarketScan Database, and provide a model for future investigation into gender-related health care utilizing this study modality. The Truven MarketScan Database is composed of health information from a large cohort of patients with employer-sponsored health insurance between 2009 and 2015. Demographics, types of surgical procedures performed, and utilization over time will be described and information not easily elicited in survey-based studies such as the rates of major complications.

Data Source

The Truven MarketScan Database, which includes inpatient and outpatient claims from prescriptions, procedures, and laboratory results from over 122 million unique individuals beginning in 1999, was analyzed. 4 Specifically, the MarketScan Commercial Claims and Encounters Database, which collects information on several million patients annually from 2009 to 2015, was used. 4 These data are collected from over 150 employers and 20 health plans. 4 The database is deidentified, and information about providers and select demographic information is withheld from the database to protect patient privacy.

Database Analysis

A dataset was initially created by pulling patients in the MarketScan Commercial Claims and Encounters Database with the International Code of Diseases, 9th Edition (ICD-9) diagnosis code for Gender Identity Disorder (GID, 302.85) within the 2009–2015 date range (Fig. ​ (Fig.1). 1 ). Patient information collected included age at diagnosis, date of diagnosis within the database range, gender marker, employment status, and location ( see pdf, Supplemental Digital Content 1 , which displays table of variables provided for all patients with GID ICD-9 code, http://links.lww.com/PRSGO/A762 ). Gender marker was not included in the analysis, given the ability to change gender marker on insurance plans, and is not necessarily reflective of one’s biologic sex or gender. To isolate patients within this dataset who underwent gender-affirming surgery, patients with ICD-9 and Current Procedural Terminology, 4th Edition (CPT-4) codes associated with mastectomy, breast augmentation, vaginoplasty, free flaps (for phalloplasty), urethroplasty, orchiectomy, and hysterectomy from 2009 to 2015 in the GID dataset were pulled (Fig. ​ (Fig.1). 1 ). The date of the first instance of any code listed for each procedure was used as the date of surgery. Patients who had more than 1 surgery were only counted once in the analysis for demographic information. As there are no universal CPT codes for phalloplasty, ICD-9 procedure codes for construction of penis, the CPT code for male-to-female intersex surgery, and CPT codes for free flap were used to represent a phalloplasty in this dataset. Free flaps associated with trauma based on ICD-9 diagnosis codes were excluded. Similarly, ICD-9 procedure codes for vaginal construction, the CPT code for female-to-male intersex surgery, and any CPT code related to operations on the vagina were assumed to represent vaginoplasty in this dataset ( see pdf, Supplemental Digital Content 2 , which displays ICD-9 and CPT-4 codes utilized to determine patient procedures, http://links.lww.com/PRSGO/A763 ; see pdf, Supplemental Digital Content 3 , which displays table of variables provided for GID patients who underwent gender-affirming surgery, http://links.lww.com/PRSGO/A764 ). All cases of possible phalloplasty and vaginoplasty were reviewed manually and, in cases of discrepant or incomplete data, a final determination of whether to include a procedure in a particular category was made based on the associated ICD-9 diagnosis codes. All other procedures were identified by their respective ICD-9 and CPT procedure codes. We did not use the ICD-9 procedure code for “sex transformation operation NEC” (645) due to its ambiguity and lack of gender-specificity, and the majority of patients in the dataset also had encounters with the CPT codes associated with genital surgery noted above. From the patients who underwent gender-affirming surgery, information about date of operation, length of stay, and venous thromboembolism (VTE) was collected ( Supplemental Digital Content 3 ). Paired t tests were utilized to provide descriptive analysis.

Outline of dataset creation and isolation of surgical variables.

Transgender Patient Demographics in the MarketScan Database

A total of 7,905 transgender patients in the Truven MarketScan Commercial Claims and Encounters Database were identified using the GID diagnosis code. The first diagnosis in the dataset is recorded on January 2, 2009, and the last is October 20, 2015 (Fig. ​ (Fig.2 2 ).

Number of GID diagnoses from 2009 to 2015.

Age, Income, Employment Status, and Location

The average age of transgender patients within the database was 29.8, and the largest number of transgender patients was in the young adult age range (Fig. ​ (Fig.3). 3 ). The largest income bracket represented in this dataset earned greater than $70,000 a year (50% of patients with available income information), with only 4 patients earning less than $40,000 a year (Table ​ (Table1). 1 ). Of the patients where employment data were available, 90% were listed as full-time employees (Table ​ (Table2), 2 ), but a variety of employment statuses, including retirees, unemployed, and those relying on COBRA Consolidated Omnibus Budget Reconciliation Act (COBRA) were represented in the dataset. Patients from 49 states were represented in the sample—with the largest number of patients residing in New York, California, and Texas, with 765, 1,285, and 457 patients, respectively. There were no patients from Hawaii in the dataset.

Income of Patients with GID Diagnosis and Patients who Underwent a Gender-affirming Procedure

Employment Status of Patients with GID Diagnosis and Patients who Underwent a Gender-affirming Procedure

Age distribution of patients at first GID diagnosis in the MarketScan Database.

Insured Patients Undergoing Gender-affirming Surgery

A total of 1,047 patients, or 13.2% of the sample, underwent 1 or more gender-affirming surgeries from 2009 to 2015, with the number of patients undergoing surgeries increasing over the sample period (Fig. ​ (Fig.4). 4 ). There were a total of 401 mastectomies, 62 breast augmentations, 60 phalloplasties, 193 vaginoplasties, 189 hysterectomies, and 93 orchiectomies in the sample. Mastectomy was the most common procedure represented within the sample, accounting for 11.7% of all procedures. Phalloplasty was the least common procedure, accounting for 5.7% of all surgical cases.

Number of gender-affirming surgeries by year.

The average age for any procedure was 29.5. The youngest subset of patients were those undergoing mastectomy, with an average age of 28.1, and those undergoing breast augmentation were the oldest, with an average age of 42.4. With the exception of mastectomy, the average age of patients undergoing all individual procedures were older than the average age of patients with the GID diagnosis in the dataset (Table ​ (Table3). 3 ). The youngest patient undergoing gender-affirming surgery in the sample was age 14 at the time of mastectomy and the oldest patient was 76 at the time of vaginoplasty.

List of Procedures by Average Age

Income, Employment Status, and Location

Fifty-nine percentage of individuals, undergoing gender-affirming procedures earned greater than $70,000 a year (Table ​ (Table1). 1 ). Like the greater sample, the majority of patients who underwent gender-affirming surgery were employed full time (n = 557, 90% of patients with employment information; Table ​ Table2). 2 ). Surgical patients were located in 45 states and were not present in Montana, Wyoming, North Dakota, Alaska, and Hawaii. California had the largest number of surgical patients (n = 211).

Complications

VTE, hematoma, seroma, wound infection, and wound dehiscence were recorded as complications and found in patients who underwent gender-affirming surgery. In total, 62 complications (5.8% of all procedures) were recorded in the sample, with the most common being wound infection (n = 16; Table ​ Table4, 4 , Fig. ​ Fig.5). 5 ). With the exception of mastectomy and breast augmentation where hematoma and hemorrhage were the most common complications respectively, wound infection was the most common complication among all groups undergoing gender-affirming surgery. The rate of complications was the highest in phalloplasty at 0.22 and lowest in orchiectomy at 0.4 (Table ​ (Table4). 4 ). There were a total of 4 incidences of VTE in the sample set, 2 following mastectomy and 1 following hysterectomy and vaginoplasty. The rate of VTE in all procedures was 0.003.

Complications by Procedure Type and Rates (in Parentheses)

Complications by procedure.

This article is intended to describe both the demographics of the transgender population in the Unites States and trends in gender-affirming surgery utilizing an insurance claims database. Our results suggest the majority of patients who have a GID diagnosis are young adults with an average age of 29.8. Although the age of transgender patients in the MarketScan dataset were consistent with previous survey-based demographic results, 6 the economic demographics in our sample were skewed toward higher-earning employed patients. Previous survey-based studies report a 35% full-time employment rate among trans individuals with 76% of respondents earning $50,000 or less. 3 Given the use of commercial and employee-based insurance plans and the absence of Medicaid within the MarketScan database, these differences in demographics are expected compared with large, survey-based studies of the general population.

Unlike questionnaire-based studies, the use of insurance claims data allowed for the survey of specific gender-affirming surgeries and associated complication rates. In total, 13.2% of trans patients within the sample underwent gender-affirming procedures from 2009 to 2015, with an increasing number of patients seeking surgical interventions annually. Mastectomy was the most common gender-affirming surgical procedure within the sample. The demographics of patients undergoing gender-affirming surgery were consistent with those in the general transgender population in the MarketScan Database.

The use of a large database also allows for the analysis of surgical complications and outcomes. Of the patients who underwent gender-affirming surgery, 5.9% had complications, with the most common being wound infection. Phalloplasty had the highest rate of complication among gender-affirming procedures, which is consistent with the clinical experience of the authors and their institution. The rate of VTE among the study population was 0.003, which is less than the estimated VTE rate associated with other plastic surgery procedures of 0.5–2%. 8 Complication rates within the Marketscan database were significantly lower than those reported from single-center studies in gender mastectomy, 9 , 10 and systematic reviews in vaginoplasty 11 , 12 and phalloplasty. 13 This may represent variation in coding practices leading to an underestimation of complications. Many minor complications may also be treated conservatively and not be captured by diagnosis codes.

Most importantly, our results suggest that the number of patients presenting for gender-related medical and surgical care is on the rise. Because the incidence of gender dysphoria is likely stable, these increasing numbers reflect increasing access to gender-related health services, given social and political shifts. This increase in the number of patients with a GID diagnosis and those seeking medical and surgical intervention is in part thought to be the result of section 1557 of the Affordable Care Act, which bans gender discrimination in health care coverage and was previously interpreted to include transition-related care for transgender patients until December 2016. 7 This possible effect is observed in the increase in patients with the GID diagnosis and number of gender-affirming surgeries in the MarketScan dataset from 2009. With an increasing number of transgender patients presenting for care, an understanding and partnership with the transgender community at both the patient and population level is paramount.

There are multiple limitations to this study stemming from the MarketScan database. The first is the use of the formal diagnosis of GID. Patients who identify as transgender or gender-nonconforming may either not feel comfortable sharing this information with their provider, or may not agree with the concept of the transgender identity as medicalized disorder. The MarketScan database does not capture individuals on Medicaid, and only includes Medicare Advantage plans, which skews both the income and employment of the sample. The data also do not account for individuals who chose to pay for visits and procedures out of pocket. Another major limitation is the variety of CPT and ICD-9 codes that are utilized to bill for gender-affirming procedures, specifically phalloplasty and vaginoplasty. This was controlled for by both utilizing a large number of codes, including those that are nonspecific such as “free-flap,” and manually confirming diagnosis by using other associated ICD-9 and CPT codes within a clinical encounter. We have attempted to capture all patients in the dataset by utilizing a broad range of billing codes ( Supplemental Digital Content 2 ), but this collection may underestimate the number of surgeries in this dataset. The utilization of an insurance database may underestimate complication rates, given conservative management of minor complications and limitations, given coding variation as mentioned above. MarketScan also does not include information about conditions present on admission, which may also skew estimated complication rates; however, our chosen complications in this analysis are acute in nature rather than chronic sequelae. The study only encompasses a 6-year period and does not allow for long-term follow-up.

This study is the first use of a large, commercially available insurance database to examine the transgender patient population and the use of surgical gender-related services. This article is intended to be a first step into a research modality that could be utilized to study multiple areas of gender-related care, including trends in hormone prescribing patterns, rates of chronic illness in transgender patients, and outcomes of surgical and medical transgender care.

CONCLUSIONS

This study is the first use of a large, commercial database to examine demographics of insured transgender patients and trends in gender-related surgical care. Our results suggest that the number of patients interacting with health care system and those pursuing gender-affirming surgeries has steadily increased over the intended study period. Mastectomy was the most common procedure performed over the 2009–2015 period, and the rates of complication were the highest with phalloplasty. Although there are limitations, such as skewed income and employment status compared with previously surveyed transgender patient populations, database-based studies can be utilized to provide a powerful tool to observe and analyze transgender health trends and outcomes.

Supplementary Material

Published online 16 April 2018.

Ms. Lane and Mr. Ives contributed equally to this work.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

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.

• Expert Q&A: Gender Dysphoria - (https://www.psychiatry.org/patients-families/gender-dysphoria/expert-q-and-a)

• Consult Online Doctor
• Take Telemedicine course
• Health Centers
• Health Tools
• Health info by Speciality
• Know Your Body
• Health and Wellness
• Web Stories
• Health Tips
• Nutrition Facts
• Lifestyle & Wellness
• Beauty Tips
• Diet & Nutrition
• Home Remedies
• Obesity & Weight Loss
• Complementary Medicine
• Special Reports
• Press Releases
• Health Guide
• Health articles
• Health Quiz
• Health Facts
• Travel Health
• Medicine and Movies
• Symptom Articles
• Diabetes Tools
• Pediatric Calculators
• Men's Health
• Women's Health
• Height Weight Tools
• Cardiac Tools
• Pharma Tools
• Wellness Interactive Tools
• Drug Information
• Drugs by Condition
• Drug Price List - Brand Names
• Drug Interaction with Food
• Drug Price List - Generic Names
• Drugs - Side Effects
• Drug Videos
• Drug Database
• Doctor Directory
• Diagnostic Lab Directory
• Hospital Directory
• Pharmacy or Chemist
• Medical Equipment Suppliers
• Pharma Directory
• Emergency Services
• PG Education
• Family Medicine
• Other Resources
• Medical Aphorism
• Health Acts in India
• Health Quotations
• Medical Conference
• Amazing Body Facts
• Health poll
• Editorial Team
• Exclusive Interviews
• In the News
• Partners & Affiliates
• Advertise With Us
• हिन्दी
• français
• Español
• 中文

Urethral complications after gender reassignment surgery: a systematic review

Affiliations.

• 1 Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
• 2 Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA. [email protected].
• PMID: 32488213
• DOI: 10.1038/s41443-020-0304-y

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms (("Transsexualism"[Mesh])) AND ("Sex Reassignment Surgery"[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19-54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

© 2020. The Author(s), under exclusive licence to Springer Nature Limited.

Publication types

• Systematic Review
• Sex Reassignment Surgery* / adverse effects
• Transsexualism* / surgery
• Urethra / surgery

Tuesday, April 23, 2024

Tax payer funded gender reassignment surgeries prompt questions about military readiness.

• by: Tracy Beanz

Read our latest news on any of these social networks!

Get the latest news delivered daily!

We will send you breaking news right to your inbox

Recent Articles