gender reassignment surgery steps

Stages of Gender Reassignment

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

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

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

Gender Dysphoria: Diagnosis and Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lots More Information

Author's note: stages of gender reassignment.

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

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

Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

Aggression
Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

Decreased antidepressant use
Decreased anxiety, depression, and suicidal ideation
Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

Both a man and a woman
Neither a man nor a woman
An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
Hysterectomy (uterus removal)
Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
Oophorectomy (ovary removal)
Phalloplasty (surgery to create a penis)
Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

Constructing a glans (head) to look more like a penis
Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals. Feminizing surgeries can include:

Breast augmentation
Facial feminization surgery
Penis removal (penectomy)
Scrotum removal (scrotectomy)
Testicle removal (orchiectomy)
Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
Vaginoplasty
Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

Gender nullification procedures
Penile preservation vaginoplasty
Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

Breast tissue removal
Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

Anesthesia risks
Hematoma, which is bad bruising
Poor incision healing

Complications from these procedures may be:

Acute kidney injury
Blood transfusion
Deep vein thrombosis, which is blood clot formation
Pulmonary embolism, blood vessel blockage for vessels going to the lung
Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
Surgical site infection
Urethral stricture or stenosis, which is when the urethra narrows
Urinary tract infection (UTI)
Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

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

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

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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Gender Confirmation Surgery

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

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

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

Available surgeries:

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

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

Sex Reassignment Surgeries (SRS)

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

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

Male-to-female sex reassignment surgery

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

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

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

Female-to-male sex reassignment

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

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

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

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 incisions for breast augmentation

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

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

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

Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

For those patients who choose to have gender-affirming surgery, the Mount Sinai Center for Transgender Medicine and Surgery can help. These procedures may also be referred to as gender reassignment or confirmation procedures. We are among the world’s leaders in this field, performing several hundred surgeries each year. We have no wait list. We will work with you to understand your goals. Then we develop personalized pre-surgery and surgery plans to meet your needs.

First, we ensure that you are healthy and have all surgery requirements in place. Our readiness team verifies your insurance and facilitates meetings with our team members. This takes place within several weeks of our first communication. If you are from outside New York City, we can usually arrange for you to see all team members over a two-day period. We can often schedule surgeries within months of the initial consultations.

We are informed by the guidelines from the World Professional Association of Transgender Health (WPATH) and the Endocrine Society. Our pre-surgery process is meant to provide all necessary pre-procedure care, and to satisfy your insurance company’s requirements. Typical standards require letters of recommendations from a health care provider. Many insurance companies require you to have, one letter for facial surgery, one for chest surgery, and two for genital surgery. Letters should come from a psychologist or psychiatrist working in the field of transgender health care. Our mental health professionals within our center can work with you and write your letters.

As our patient, you will meet with multiple members of our team. Often, you start with our social worker, who helps you navigate the process. You may meet with a primary care provider and a behavioral health specialist. We try to schedule appointments so you can complete more than one step in a single visit.

At your surgical consultation, you meet your surgeon, discuss your goals, and agree on a plan for your surgery. Your surgeon discusses necessary preparations, expected outcomes, risks, and recovery process. We also answer any questions you may have.

You may have to make physical preparations for your surgical procedure. We discuss this with you during your consultation. For instance, genital surgeries often require hair removal from the area where the surgery will be done. Some procedures may involve use of a tissue expander. In some cases, your surgeon may ask you to lose weight or quit smoking to lower your risk of complications. We set your surgery date based upon the preparations required.

We perform the following types of surgical procedures:

Trans-feminine (Male to Female) Surgeries
Trans-masculine (Female to Male) Surgeries

Please note, there might be additional steps needed as you prepare for surgery .

How Gender Reassignment Surgery Works (Infographic)

Infographics: How surgery can change the sex of an individual.

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

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

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

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

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

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

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

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

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

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

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

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A Pioneering Approach to Gender Affirming Surgery From a World Leader in the Field

Miroslav Djordjevic, MD, PhD, an internationally renowned surgeon and a leading authority on surgery for transgender individuals, is developing a procedure to match two patients undergoing transgender surgery—one male-to-female, the other female-to-male—and transfer the genitalia between these live donors in a one-stage procedure instead of discarding them as is done now.

For years, the main challenge associated with sex reassignment surgery (SRS) has been the ability to provide patients with genitalia that is not only fully functional but also aesthetically acceptable. Miroslav Djordjevic, MD, PhD , an internationally renowned surgeon and a leading authority on surgery for transgender individuals, believes he has the answer.

His idea is matching two patients undergoing transgender surgery—one male-to-female, the other female-to-male—and transferring the genitalia between these live donors in a one-stage procedure instead of discarding them as is done now.

“This will result in a huge improvement over what we currently offer patients,” says Dr. Djordjevic, who joined Mount Sinai Health System in June 2019 as a Professor of Urology at the Icahn School of Medicine at Mount Sinai and a urogenital reconstructive surgeon at the Mount Sinai Center for Transgender Medicine and Surgery . “We are striving to find a way to use all genital organs that are planned for removal in transition surgery to improve the lives of others who request this surgery and enable them to lead a normal life.”

Dr. Djordjevic says he is ready to proceed with transplantation now that he has developed the necessary special surgical techniques.

His confidence in this new approach is the result of nearly three decades of expertise and innovation in SRS and urogenital reconstructive surgery, which includes 600 male-to-female vaginoplasties, 900 female-to-male metoidioplasties, 300 female-to-male phalloplasties, and the co-development of a penile disassembly technique for epispadias repair. He also performed his first uterus transplant in 2017 and the second-ever testicular transplant in December 2019 at the Belgrade Center for Genital Reconstructive Surgery. Dr. Djordjevic is also a Professor of Urology and Surgery at the School of Medicine at the University of Belgrade in Serbia.

“Through the procedures I have done, I have demonstrated to the world that it is possible to successfully perform uterine and penile transplantation,” says Dr. Djordjevic, who joined Mount Sinai from the Belgrade Center for Genital Reconstructive Surgery in Serbia, where he was one of the few urologists in the world whose scope of expertise encompassed treatment of all anomalies of the genital system regardless of sex or age.

Dr. Djordjevic joined Mount Sinai to develop his procedures, which would include finding the right pairing of donor and candidate and leading surgeons in performing concurrent transplant surgeries.

Although there have been five successful penile transplantations performed since the introduction of the procedure in 2006, Dr. Djordjevic notes that these cases involved trauma or removal of the penis due to oncological reasons. In all cases, patients had retained the corpora cavernosa and some degree of tissue, which facilitated transplantation.

His approach is novel in that it will not only involve transplantation of the entire penis with the corpora cavernosa and their crura but also determining the best position for fixation. He also expects to transplant a penis from a male to a female body.

“We are striving to find a way to use all genital organs that are planned for removal in transition surgery to improve the lives of others who request this surgery and enable them to lead a normal life.” -Miroslav Djordjevic, MD, PhD

“This is a far more complex procedure,” he explains. “I am continuing to refine my technique through cadaveric and micrometric study, and I plan to publish papers that detail the approach so that other surgeons can offer it to their patients.” For example, he plans to publish a cadaveric study in 2021 on penile transplantation.

If his technique proves successful, Dr. Djordjevic believes it will offer considerable advantages over existing modalities for creating male genitals, such as metoidioplasty or a full phalloplasty involving musculocutaneous latissimus dorsi (MLD). For one, penile transplantation with the corpora cavernosa would result in improved sexual function and sensation, and it would reduce the 50 percent risk of complications among patients who have undergone creation of the urethra from oral mucosa or surrounding material.

“Current surgical treatments do not enable us to provide a urethra with surrounding spongiosa as is present in normal penile anatomy,” Dr. Djordjevic says. “A penile transplant would enable the usage of existing urethra and corpora cavernosa, which promises an almost ideal solution for patients looking for male genitalia because there is a good channel for voiding and good erectile tissue for normal sexual function.”

Dr. Djordjevic says advances in therapeutics could address the risks involved in transplantation of reproductive organs, specifically the effects of postoperative immunosuppressant therapy among patients. But he has also developed strategies for mitigating risk in the meantime.

For example, he notes that the first successful organ transplantation was made possible by the fact that the patients involved were monozygotic twins. The testicular transplant he performed also involved monozygotic twins, and no immunosuppressive therapy was required.

Three decades of experience

male-to-female vaginoplasties performed

female-to-male metoidioplasties performed

female-to-male phalloplasties performed

“What I will be looking for is a possible genetic match between two candidates that would minimize the need to administer immunosuppressants, or a candidate who has undergone transplant surgery and is doing well on immunosuppressant therapy because the risk of rejection will be much lower,” he says.

To facilitate identification of candidates who match these criteria, Dr. Djordjevic envisions a worldwide network or registry of patients seeking SRS. In the meantime, he continues to develop his technique, optimistic that transplantation of genitalia will eventually become standard of care in the same way that hand and face transplants are becoming routine.

“Ultimately, I would like to see us reach the point where a patient is able to conceive and deliver a baby after transplantation of a uterus and ovaries, or has a functioning, anatomically acceptable penis with normal erection and voiding,” he says. “By pioneering these procedures, we are one step closer to enabling people to live the lives they want to live.”

Miroslav Djordjevic, MD, PhD

Professor of Urology and a urogenital reconstructive surgeon at the Mount Sinai Center for Transgender Medicine and Surgery

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What to know about female-to-male surgery

Female-to-male surgery is a type of gender-affirmation or gender-affirming surgery. There are multiple forms of gender-affirming surgery, including altering the genital region, known as “bottom” surgery.

There are multiple forms of gender-affirming surgery, including the removal of breasts — a mastectomy — and the altering of the genital region, known as “bottom” surgery.

Examples of bottom surgery include:

removal of the uterus called a hysterectomy
removal of the vagina, known as a vaginectomy
construction of a penis through metoidioplasty or phalloplasty

This article describes female-to-male gender-affirming surgeries. It also discusses recovery and what to expect from a transgender penis.

A doctor conversing with a patient, sat on a hospital bed

Before having female-to-male gender-affirming surgery, a person will often receive testosterone replacement therapy (TRT) .

They may then undergo one or more of the following types of procedures.

Chest restructuring or top surgery

A person in transition may wish to have a subcutaneous mastectomy to remove breast tissue. The surgeon will also make alterations to the appearance and position of the nipples. Many people refer to these procedures as “top surgery.”

Meanwhile, TRT will stimulate the growth of chest hair. A 2022 study notes that complications from gender-affirming mastectomy procedures are low, and satisfaction rates are incredibly high.

Removal of the uterus, ovaries, and fallopian tubes

A person may wish to undergo this type of surgery if they are uncomfortable having a uterus, ovaries, or fallopian tubes or if hormone therapy does not stop menstruation.

In a partial hysterectomy, a surgeon will remove only the uterus. In a total hysterectomy, they will also remove the cervix.

A bilateral salpingo-oophorectomy involves the removal of the right and left fallopian tubes and ovaries.

Metoidioplasty

A metoidioplasty is a method of constructing a new penis, or neopenis. Research from 2021 shows this procedure has a low risk of complication and a high satisfaction level. A metoidioplasty has positive cosmetic and functional outcomes.

This procedure involves changing the clitoris into a penis. A person will receive hormone therapy before the surgery to enlarge the clitoris for this purpose. During the procedure, the surgeon also removes the vagina in a vaginectomy.

In addition, they lengthen the urethra and position it through the neopenis. To achieve the lengthening, the surgeon uses tissues from the cheek, labia minora, or other parts of the vagina. The aim of this is to allow the person to urinate while standing.

An advantage of metoidioplasty is that the neopenis may become erect due to the erectile abilities of clitoral tissue.

Phalloplasty

A phalloplasty uses grafted skin — usually from the arm, thigh, back, or abdomen — to form a neopenis. Compared with a metoidioplasty, a phalloplasty results in a larger penis. However, this neopenis cannot become erect on its own.

After a period of recovery, a person can have a penile implant. This can allow them to get and maintain erections and have penetrative sex.

Disadvantages of a phalloplasty include the number of surgical visits and revisions that may be necessary, as well as the cost, which is typically higher than that of a metoidioplasty.

Scrotoplasty

A person may decide to have a scrotoplasty — creating a scrotum — alongside a metoidioplasty or phalloplasty.

In a scrotoplasty, a surgeon hollows out and repositions the labia majora to form a scrotum and inserts silicone testicular implants.

The recovery time from female-to-male surgery varies, depending on the type of procedure and factors such as the person’s overall health and lifestyle choices. For example, smoking slows down recovery and increases the risk of complications following surgery.

Following gender-affirming surgery, most people need to stay in the hospital for at least a couple of days.

After leaving the hospital, the person must rest and limit strenuous activity.

Complications

As with any surgery, all gender-affirming surgeries carry a risk of:

reactions to anesthesia

Some complications of a metoidioplasty or phalloplasty include :

Urethral fistula: A tunneled connection that forms between the urethra and another part of the body.
Urethral stricture: A narrowing that causes a blockage of urine flow within the urethra.

A person who has had a phalloplasty may experience scarring in the area where the surgeon has taken the graft or a skin graft failure.

What to expect

A person who undergoes a metoidioplasty may have erections and enjoy more sensation in their neopenis. However, the penis will be relatively small in size. A neopenis that results from a phalloplasty is usually larger, though it may be less sensitive. To have erections, a person will need a penile implant.

These procedures can improve a person’s quality of life, and most people report high levels of satisfaction.

A 2018 study found that 94–100% of participants who had undergone gender-affirming surgery reported satisfaction with the surgical results, with the variance depending on the type of procedure.

The 6% of people who reported dissatisfaction or regret did so due to preoperative psychological symptoms or complications following the procedures.

The outlook for female-to-male surgery depends on the type of surgery, the person’s health, and other factors. Most people report satisfaction following the procedure.

It is important to work closely with a qualified plastic surgeon, urologist, gynecologist , and mental health professional to ensure the best outcome.

It is also essential to follow recovery guidelines and attend all follow-up appointments.

There are several types of gender-affirming surgeries that a person can help a person during a transition.

These procedures broadly fall into top or bottom surgery. Top surgery is a colloquial term for chest restructuring procedures, while bottom surgery refers to operations changing genitalia. There are multiple forms of both surgeries and can include the removal of breast tissue and the creation of a penis.

Last medically reviewed on July 12, 2023

Cosmetic Medicine / Plastic Surgery
Sexual Health / STDs

How we reviewed this article:

Bordas N, et al. (2021). Metoidioplasty: Surgical options and outcomes in 813 cases. https://www.frontiersin.org/articles/10.3389/fendo.2021.760284/full
Carbonnel M, et al. (2021). The uterus in transgender men. https://www.sciencedirect.com/science/article/pii/S0015028221005811
General surgery — possible complications. (n.d.). https://stanfordhealthcare.org/medical-treatments/g/general-surgery/complications.html
Purohit RS, et al. (2022). Penile prosthesis in transgender men after phalloplasty. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9398527/
Tang A, et al. (2022). Gender-affirming mastectomy trends and surgical outcomes in adolescents. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9555285/
van de Grift TC, et al. (2018). Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study. https://www.ncbi.nlm.nih.gov/pubmed/28471328
World Health Organization. (2020). Smoking greatly increases risk of complications after surgery [Press release]. https://www.who.int/news/item/20-01-2020-smoking-greatly-increases-risk-of-complications-after-surgery

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Female to Male Gender Reassignment Surgery (FTM GRS)

Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia composed of the penis and scrotum.

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Female gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.

Apart from genital surgery, the patient would seek other procedures to allow them to live as males smoothly such as breast amputation, facial surgery, body surgery, etc.

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is very complicated and only a handful of surgeons are able to perform this procedure. It is a multi-staged procedure, the first stage is the removal of the uterus, ovary, and vagina. The duration of the procedure is 2-3 hours. The second and later stages are penis and scrotum reconstruction which is at least 6 months later. There are several techniques for penile reconstruction depending on the type of tissue such as skin/fat of the forearm, skin/fat of the thigh, or adjacent tissue around the clitoris. This second stage of surgical time is between 3-5 hours. A penile prosthesis can be incorporated simultaneously or at a later stage. The scrotal prosthesis is also implanted later.

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-7 days for each stage depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.

Additional Information

What are the risks.

The most frequent complication of FTM GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis and fistula, unsightly scar, etc. The revision procedure is scar revision, hair transplant, or tattooing to camouflage unsightly scars.

What is the recovery process?

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patients return to their normal lives but not having to do physical exercise during the first 2 months after surgery. The patient will have a urinary catheter continuously for several weeks to avoid a urinary fistula. If the patient has a penile prosthesis, it would need at least 6 months before sexual intimacy.

What are the results?

With good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a male role completely and happily either on their own or with their female or male partners.

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Transgender health care must be paid for by state insurance, says an appeals court

Selena Simmons-Duffin

Cases about transgender people and their rights have been working their way through the court system for years. Here, people demonstrate in favor of trans rights in front of the Supreme Court in 2019. Manuel Balce Ceneta/AP hide caption

A federal appeals court ruled on Monday that state health insurance plans must provide coverage for gender-affirming care in North Carolina and West Virginia. Trans advocates say it's a huge victory, especially since bills restricting the rights of transgender people have been on the rise in state legislatures.

The 4th Circuit Court of Appeals in Richmond, Va., issued its decision about two cases. One was brought by North Carolina state employees and their dependents who are transgender and were unable to get coverage for gender-affirming care.

The other lawsuit came from West Virginians who are transgender and on Medicaid. They could get coverage for some treatments — like hormones — but not for surgery.

These cases were heard last fall by the 4th circuit en banc — that is, all the judges on that appeals court heard the argument.

In oral arguments, the judges asked about mastectomies, as an example. Those are covered for patients with breast cancer, but they were not covered by the health insurance plans for transgender patients.

In an 8-6 decision, the majority of the 4th circuit decided that these patients were entitled to health insurance coverage for their care. Judge Roger Gregory, writing the majority opinion, called the denial of coverage "obviously discriminatory."

West Virginia Attorney General Patrick Morrisey had defended his state's decision not to cover gender-affirming surgeries in Medicaid. Morrisey responded to the loss in a statement, saying: "Decisions like this one, from a court dominated by Obama- and Biden-appointees, cannot stand: we'll take this up to the Supreme Court and win."

Supporters of Missouri's ban on gender-affirming care for minors gather on the floor of the statehouse in Jefferson City in March 2023. Charlie Riedel/AP hide caption

Supporters of Missouri's ban on gender-affirming care for minors gather on the floor of the statehouse in Jefferson City in March 2023.

In a statement, North Carolina State Treasurer Dale Folwell called the ruling "unabashed judicial activism."

The 4th circuit has seven judges appointed by Republican presidents and eight judges appointed by Democratic presidents.

"We're absolutely thrilled that the court ruled that discriminatory treatment just has no place under the law," says Tara Borelli , senior counsel with Lambda Legal, who argued the case for the plaintiffs.

The policies in question have already changed, Borelli notes. Both state health programs have had to cover transgender health care since lower federal district courts ruled in favor of the patients in 2022, she says.

Now that the appeals court has issued its decision, Borelli says it sets an important precedent and other states across the country should pay close attention.

Missouri to restrict gender-affirming care for trans adults this week

Lawyers for North Carolina and West Virginia had argued that the coverage denials were based on saving taxpayer money, not bias.

Borelli noted that an appeal to the Supreme Court will cost more taxpayer dollars.

The Supreme Court's recent actions on transgender issues are mixed.

Earlier this month, the justices allowed Idaho's ban on gender-affirming care for minors to take effect.

But it has declined to hear other cases about to transgender students' access to bathrooms and participation in school sports. Court-watchers read that as a reluctance to step into the fray.

Meanwhile, on Friday the Biden administration issued a regulation strengthening protections against discrimination for transgender patients across the country. That regulation applies to any health care — not just care related to their gender — so a trans person with a broken arm can't be mistreated in the E.R., for example.

A group of Republican-led states have pledged to challenge the rule in court.

transgender care
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Court says state health-care plans can’t exclude gender-affirming surgery

A federal appellate court in Richmond became the first in the country to rule that state health-care plans must pay for gender-affirming surgeries, a major win for transgender rights amid a nationwide wave of anti-trans activism and legislation.

The decision came from a set of cases out of North Carolina and West Virginia, where state officials argued that their policies were based on cost concerns rather than bias. The U.S. Court of Appeals for the 4th Circuit rejected that argument, saying the plans were discriminating against trans people in need of treatment.

Judge Roger L. Gregory, an appointee of President Bill Clinton, wrote for the majority that the restrictions were “obviously discriminatory” based on both sex and gender.

“In this case, discriminating on the basis of diagnosis is discriminating on the basis of gender identity and sex,” Gregory wrote, because “gender dysphoria is so intimately related to transgender status as to be virtually indistinguishable from it.”

The majority ruled that West Virginia’s policy also violated the Affordable Care Act’s anti-discrimination provision, a finding that has broad implications for other states’ Medicaid programs.

It’s the second ruling in favor of trans rights this month from the 4th Circuit, a once-conservative court that has become a trailblazer in the realm of transgender rights. The court was the first to say trans students had a right to use the bathrooms that align with their gender identity and the first to recognize gender dysphoria as a protected disability. Earlier this month, the court said a federally funded middle school could not ban a trans 13-year-old from playing on the girls’ track and field team.

The decision will be appealed to the Supreme Court, which recently allowed Idaho to enforce a ban on gender-affirming care for minors. West Virginia Attorney General Patrick Morrisey, who is running for governor, said in a statement Monday that he would “take this up to the Supreme Court and win.”

But the conservative-led Supreme Court has been reluctant to engage on these issues, letting multiple 4th Circuit rulings in favor of transgender rights stand. The court also generally waits until there is disagreement between circuit courts before getting involved.

All of these rulings split the 4th Circuit court down ideological lines, with judges appointed by Democrats joining the majority opinion and those appointed by Republicans dissenting. In the lead dissent from the ruling Monday, Judge Jay Richardson, a Trump appointee, wrote that there was no role for the federal court in policing what treatments health-care plans decide to cover.

The majority opinion, Richardson wrote, “treats these cases as new fronts upon which this conflict must be waged. But not every battle is part of a larger war. In the majority’s haste to champion plaintiffs’ cause, today’s result oversteps the bounds of the law.”

Richardson said what mattered is that trans patients have the same coverage of the same conditions as others. For example, he said, a trans patient with uterine cancer could get a hysterectomy under these plans.

“The different coverage accorded to treatments for different diagnoses is … based on medical judgment of biological reality,” he wrote. “States can reasonably decide that certain gender-dysphoria services are not cost-justified, in part because they question the services’ medical efficacy and necessity.”

Other states have banned hormonal treatment and surgery for trans minors; some have restricted care for transgender adults as well. Multiple other states have similar laws against insurance coverage for transition-related treatment. The Biden administration has moved to protect trans Americans through federal regulations, including guidelines released Monday that treat misuse of pronouns or refusal to let transgender employees use their preferred bathroom as workplace harassment.

In West Virginia, transgender Medicaid users challenged the state’s program, which since 2004 has by law banned “transsexual surgeries.” In North Carolina, state employees challenged their coverage, which in 2018 excluded surgical treatment of gender dysphoria — the clinical diagnosis of a disconnect between a person’s gender and birth sex.

Both states insisted that there was no bias in their coverage limitations, only cost concerns. Trans patients, they argued, were entitled to the same health treatments as everyone else but not specialized care.

“There is no service that is covered for a cisgendered person that is not covered for a transgender person meeting the same criteria,” Caleb David, an attorney for West Virginia, told judges on the appellate court during the oral argument. David added that the state had decided to provide psychiatric and hormonal treatment for gender dysphoria — just not surgery.

Advocates for trans patients said there was no medical justification for drawing the line there, when the state would cover such procedures for other conditions. They also said the financial explanation was suspect because so few people get gender-affirming surgery. It’s “a drop in the bucket,” Lambda Legal attorney Tara Borelli said during oral arguments. But even if the cost was significant, she argued, the cost of public health insurance “has to be a shared burden. It can’t be shunted onto the backs of a vulnerable minority group.”

The court agreed, saying cost-cutting could not justify covering the same treatments for health concerns other than gender dysphoria. For example, Gregory noted that under these plans, “cisgender people do receive coverage for certain gender-affirming surgeries,” including breast reconstruction for cancer patients after a mastectomy.

North Carolina began covering gender-affirming care in 2017 and stopped the following year, when Republican Dale Folwell became state treasurer. Julia McKeown, a professor at North Carolina State University, accepted her job in 2016, a few years into fully transitioning after a lifetime of “being adamant about what my gender was” but being limited in expressing it. She spent months preparing for surgery, only to be forced to cover the full cost along with all other treatment.

“It’s like having the rug pulled out from under you,” she said. “In some ways it’s worse than going in and knowing it was going to be denied.” She cut into her retirement savings rather than delay the surgery, calling herself “fortunate” to be able to do so.

McKeown grew up in a rural town in Florida and spent years pretending to be a man for fear of social and professional exclusion. Joining the lawsuit meant exposing herself to hate mail from strangers.

“In an ideal world, I would have loved to just move on with my life” after the surgery, she said. “At the same time, I feel a moral obligation to help those who can’t speak up for themselves, and for those who risk being fired or who have dependents on the state health-care plan who need access to treatment.”

Twenty-one Republican-led states asked the court to rule against the plaintiffs, focusing on disagreement over what physical interventions should be available to trans youth. But most major medical plans and the federal government cover gender transition treatment, which has been endorsed by mainstream medical associations. Studies indicate very few people who transition regret doing so or seek to reverse the changes, including those who start treatment in their teens.

Seventeen Democratic-led states and the District of Columbia urged the court to rule for the coverage, saying their “experience demonstrates that protecting access to gender-affirming care improves health outcomes for our transgender residents at little cost.”

An earlier version of this story reported that the contested insurance plans covered mastectomies for cancer patients but not for trans women. The plans covered mastectomies for all cancer patients, but did not cover the procedure for trans men who wanted their breasts removed to treat gender dysphoria.

Neuman Awarded Federal Grant to Study Patient-Surgeon Interactions on Low-Value Procedures

What happens during a conversation between a patient with cancer and their surgeon when the patient is interested in a procedure for which the surgeon knows there is little value? This is the very question that Division of Surgical Oncology Associate Professor Dr. Heather Neuman plans to answer with a new two-year, $412,000 Exploratory/Developmental Research Grant Award (R21) from the National Cancer Institute.

According to Neuman, there are two specific breast cancer procedures that have limited clinical benefit and could potentially cause harm: sentinel lymph node biopsies (SLN) for women who are 70+ years old and contralateral prophylactic mastectomy (CPM, a surgery to remove the healthy breast in a person who has had the other breast with cancer removed).

“These procedures have no impact on overall survival and can in fact have a negative impact on a patient’s psychosocial, physical, and financial outcomes, yet many patients request them to minimize future cancer risk and reduce anxiety,” said Neuman. “How patients and their surgeons are having conversations about these low-value procedures could tell us a lot about how we can better support patient decision-making while also helping patients understand why these operations may not be right for them.”

Neuman and her team plan to analyze data from 594 previously audio-recorded initial consultation appointments between patients newly diagnosed with breast cancer and their surgeon. The research team plans to evaluate the extent to which surgeons use elements of shared decision-making in these conversations and how this impacts SLN or CPM decisions. They also plan to look for patterns in these interactions that may be associated with decisions to not perform SLM or CPM. Finally, they will develop a low-value care conversation tool that surgeons can use to guide discussions with patients, with the goal of testing the effectiveness of the conversation guide in a future study.

“Conversations about low-value procedures can be really challenging,” explained Neuman. “Learning more about them and ultimately improving how they can successfully happen has the potential to reduce both patient harm and healthcare costs for the more than 1.6 million people who are diagnosed with cancer every year.”

CDC describes first known cases of HIV transmitted via 'vampire facial' injections

Three women were likely infected with HIV while receiving so-called vampire facials at a New Mexico spa, marking the first known HIV cases transmitted via cosmetic injections, the Centers for Disease Control and Prevention said in a report Thursday.

The first HIV case linked to the VIP Spa in Albuquerque was discovered in 2018 and prompted the New Mexico Department of Health to offer free testing to anyone who got injections at the facility. The department said at the time that the spa was shut down after its investigators "identified practices that could potentially spread blood-borne infections."

The most recent case was a former client of the spa who tested positive for HIV last year, according to the health department —which led it to reopen the prior investigation.

Now, the CDC report provides new detail about the affected clients and the spa's practices.

The first case was a middle-aged woman who tested positive for HIV in 2018, the CDC said. She had no history of injectable drug use, recent blood transfusions or recent sexual contact with someone with HIV — but she did report getting a vampire facial.

Close up of dermapen tool - device equipped with fine, sterile needles to create tiny punctures in skin.

The second two were also middle-aged women who had gotten vampire facials in 2018. One was diagnosed with the earliest stage of HIV in 2019, and the other in 2023, when she was hospitalized with severe symptoms.

The CDC said the spa did not have appropriate licenses to operate and was not using proper safety measures.

A joint investigation by the CDC and New Mexico Department of Health found a rack of unlabeled tubes of blood on a kitchen counter at the spa, as well as in the kitchen refrigerator, next to food and injectables like lidocaine. The investigators also discovered unwrapped syringes in drawers, on counters and discarded in trash cans.

The spa’s owner pleaded guilty in 2022 to five felony counts of practicing medicine without a license, the health department said last year. NBC affiliate KOB of Albuquerque reported in 2022 that the owner was sentenced to 3 ½ years in prison.

CDC and health department investigators ultimately determined that 59 spa clients may have been exposed to HIV. Of those, 20 had received vampire facials, a procedure also known as platelet-rich plasma microneedling. It involves drawing someone’s blood, separating out the plasma, then injecting the plasma into the face using tiny needles. The rest of the clients had gotten other injection services like botox, the CDC report said.

People get vampire facials to plump up sagging skin and reduce the appearance of acne scars or wrinkles, but according to the American Academy of Dermatology, there’s little evidence to support those claims . The AAD says the facials appear to be safe as long as blood is handled properly.

In addition to the three spa clients who contracted HIV, the CDC identified a woman who got multiple vampire facials there in 2018 and had tested positive for HIV two years earlier. However, the investigators said the original source of the HIV contamination at the spa remains unknown.

HIV is transmitted via contact with bodily fluids from an infected person, including blood and semen, which is why it is most often contracted through sex or the sharing of needles. HIV attacks the immune system, and if left untreated, it can lead to AIDS. People with AIDS have a severely damaged immune system, making them susceptible to various infections and serious illnesses.

The CDC said in its report that spa facilities offering cosmetic injections should require proper infection control practices to prevent the transmission of HIV and other blood-borne pathogens.

The risks of cosmetic injections have also gained attention recently because of an ongoing CDC investigation into counterfeit and mishandled Botox injections .

The agency has identified 22 women who experienced bad reactions from the injections , including slurred speech, trouble breathing and blurry vision. Eleven hospitalizations had been reported as of last week.

Six patients were treated with botulism antitoxin because of concerns that the toxin in the injection could have spread beyond the site where it was administered.

Aria Bendix is the breaking health reporter for NBC News Digital.

CDC says it's identified 1st documented cases of HIV transmitted through cosmetic needles

A LBUQUERQUE, N.M. (AP) — Three women who were diagnosed with HIV after getting “vampire facial” procedures at an unlicensed New Mexico medical spa are believed to be the first documented cases of people contracting the virus through a cosmetic procedure using needles, federal health officials said.

The Centers for Disease Control and Prevention said in its Morbidity and Mortality Report last week that an investigation into the clinic from 2018 through 2023 showed it apparently reused disposable equipment intended for one-time use.

Although HIV transmission from contaminated blood through unsterile injection is a well-known risk, the report said this is the first documentation of probable infections involving cosmetic services.

Many popular cosmetic treatments are delivered with needles, such as Botox to iron out wrinkles and fillers to plump lips. A “vampire facial,” or platelet-rich plasma microneedling procedure, involves drawing a client's own blood, separating its components, then using tiny needles to inject plasma into the face to rejuvenate the skin. Tattoos also require needles.

The New Mexico Department of Health began investigating the spa in the summer of 2018 after it was notified that a woman in her 40s had tested positive for HIV even though she had no known risk factors. The woman reported exposure to needles through the procedure at the clinic that spring.

The spa closed in fall 2018 after the investigation was launched, and its owner was prosecuted for practicing medicine without a license.

The report said the investigation showed how important it is to require infection control practices at businesses that offer cosmetic procedures involving needles.

It also noted that the investigation was slowed by poor record keeping and said businesses providing such services should keep better records in case clients need to be contacted later.

FILE - This electron microscope image made available by the U.S. National Institutes of Health shows a human T cell, in blue, under attack by HIV, in yellow, the virus that causes AIDS. Three women who were diagnosed with HIV after getting “vampire facial” procedures at an unlicensed New Mexico medical spa are the first believed to have contracted the virus through a cosmetic procedure using needles, according to federal health officials. (Seth Pincus, Elizabeth Fischer, Austin Athman/National Institute of Allergy and Infectious Diseases/NIH via AP, File)

Second Patient Receives Gene-Edited Pig Kidney Transplant in Breakthrough Surgery

The woman, 54-year-old Lisa Pisano, also received a mechanical heart pump implant days earlier, making her the first person to undergo both procedures

Will Sullivan

Daily Correspondent

Surgeons in blue scrubs gathered around a patient on an operating table

Lisa Pisano, a 54-year-old woman from New Jersey, has become the second living person to receive a transplant of a gene-edited pig kidney. Doctors also implanted a mechanical heart pump, making Pisano the first person to receive both a heart pump and an organ transplant, according to a statement from NYU Langone Health, where the procedure was performed.

Pisano had been suffering from heart failure and end-stage kidney disease and was on dialysis before the surgery. Because of her medical conditions, she was ineligible for heart and kidney transplants from human donors. The Food and Drug Administration approved the experimental procedure through a “compassionate use” program for patients with serious or immediately life-threatening conditions.

The NYU team said Wednesday that Pisano is recovering well, according to Lauran Neergaard of the Associated Press (AP).

“I feel fantastic,” Pisano said from the hospital during a Wednesday press conference over Zoom, per Wired ’s Emily Mullin. “When this opportunity came, I said, ‘I’m gonna take advantage of it.’”

While Pisano hasn’t shown signs of rejecting the transplant so far, the critical point for that may not come until a month after surgery, Robert Montgomery , who led the procedure and is the director of NYU Langone’s transplant institute, tells Scientific American ’s Tanya Lewis.

Montgomery tells NPR ’s Rob Stein that Pisano will probably need to recover in the hospital for several months. He can’t predict how much time the procedure will buy for her.

“We’re optimistic that she’ll be able to go home and spend time with her children and grandchildren and live a comfortable life,” he says to NPR.

Patients with conditions like Pisano’s aren’t candidates for typical transplants, in part because their odds of survival are low, and there are not currently enough organs available to meet the vast need. More than 100,000 people are on the national transplant waiting list —with the majority in need of a kidney—and 17 people die every day waiting for a transplant in the U.S. Of the nearly 808,000 people in the country with end-stage kidney disease, only about 27,000 received a transplant last year, per NYU’s statement.

Scientists hope pig organs could combat this shortage and help more people get transplants. The NYU team has previously experimented with transplanting gene-edited pig organs into brain-dead patients with the consent of their families. They have also twice transplanted pig hearts into deceased human patients.

Two living patients who were experiencing heart failure have received pig heart transplants . The first lived for two months following the procedure, and the second died after six weeks .

Last month, a patient at Massachusetts General Hospital received the first pig kidney transplant . He was discharged from the hospital in early April and continued to recover at home .

“I do think it’s incredibly exciting we now have a second genetically edited pig kidney that’s been put into a living person,” Jayme Locke , a transplantation surgeon at the University of Alabama at Birmingham, who previously transplanted pig kidneys into brain-dead patients, says to Scientific American .

Pisano received the heart pump implant first, on April 4. She would have lived for only days or weeks without the device, according to NYU. She then received the gene-edited pig kidney in a second procedure on April 12.

“Without the possibility of a kidney transplant, she would not have been eligible as a candidate for [a heart pump] due to the high mortality in patients on dialysis with heart pumps,” Nader Moazami , an NYU cardiac surgeon who performed the heart pump surgery, says in the statement.

The pig kidney was genetically altered to disrupt the production of a sugar called alpha-gal. In previous studies, the researchers had shown that making this edit prevented the recipient’s immune system from rejecting the transplant. The team also attached a pig thymus gland to the tissue to reduce the likelihood of rejection.

Some experts question the ethics of such experiments.

“I think there are worries about conducting these experiments in this way, where we are finding the most desperate patients who have no other options,” L. Syd Johnson , a bioethicist at SUNY Upstate Medical University, tells NPR. “Maybe those patients will benefit. Maybe they believe they will benefit and that the risks are worthwhile for them. But I do worry about whether or not we are taking advantage of particularly vulnerable and desperate patients in conducting these experiments.”

Doctors say this transplant, as well as the one last month, will provide key information about the safety and effectiveness of the procedure.

“Like with any other transplant, in the early days, we want to make sure that we have control of the immune system and that there aren’t early rejections,” Locke tells Scientific American . “If this works, that’s incredibly positive.”

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Will Sullivan | | READ MORE

Will Sullivan is a science writer based in Washington, D.C. His work has appeared in Inside Science and NOVA Next .

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COMMENTS

Gender Affirmation Surgery: What Happens, Benefits & Recovery
Depending on the procedure, 94% to 100% of people report satisfaction with their surgery results. Gender-affirming surgery provides long-term mental health benefits, too. Studies consistently show that gender affirmation surgery reduces gender dysphoria and related conditions, like anxiety and depression.
Stages of Gender Reassignment
WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. ... and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though ...
Preparing for Gender Affirmation Surgery: Ask the Experts
410-955-5000 Maryland. 855-695-4872 Outside of Maryland. +1-410-502-7683 International. To help provide guidance for those considering gender affirmation surgery, two experts from the Johns Hopkins Center for Transgender Health answer questions about what to expect before and after your surgery.
Gender Confirmation Surgery
The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed. A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019. Insurance Coverage for Sex Reassignment Surgery.
Gender Affirmation Surgeries: Common Questions and Answers
Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender. A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery. The term "transexual" was previously used by the medical community to describe people ...
Vaginoplasty for Gender Affirmation
Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum. During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a ...
Phalloplasty for Gender Affirmation
Featured Expert: Fan Liang, M.D. Phalloplasty is surgery for masculinizing gender affirmation. Phalloplasty is a multistaged process that may include a variety of procedures, including: Creating the penis. Lengthening the urethra so you are able to stand to urinate. Creating the tip (glans) of the penis. Creating the scrotum.
Gender Affirmation Surgery: A Guide
A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person ...
Gender Confirmation Surgery
Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected]. We will assist you in obtaining what you need to qualify for surgery. University of Michigan Comprehensive Gender Services Program brings ...
Gender-affirming surgery (male-to-female)
Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.. Often used to refer to vaginoplasty, sex reassignment surgery can also more broadly refer to other gender-affirming ...
Feminizing surgery
Overview. 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.
Gender Affirming Surgery: Before and After Photos
Facial Feminizations. Facial feminization surgery (FFS) involves several surgeries that can be done to feminize the facial features. These procedures include but are not limited to: rhinoplasty, forehead contouring, jaw angle reduction, chin width reduction, lowering the hairline, hair transplantation, cheek augmentation, lip augmentation and upper lip shortening.
Overview of gender-affirming treatments and procedures
Supporting evidence for providing gender-affirming treatments and procedures. Transgender people may seek any one of a number of gender-affirming interventions, including hormone therapy, surgery, facial hair removal, interventions for the modification of speech and communication, and behavioral adaptations such as genital tucking or packing, or chest binding.
Transgender Surgeries & Gender Affirmation
Gender Affirming Surgeries. For those patients who choose to have gender-affirming surgery, the Mount Sinai Center for Transgender Medicine and Surgery can help. These procedures may also be referred to as gender reassignment or confirmation procedures. We are among the world's leaders in this field, performing several hundred surgeries each ...
Surgery for Transgender People: Learn About Gender Affirmation
A trans person can choose from multiple procedures to make their appearance match their self-identified gender identity. Doctors refer to this as gender "affirmation" surgery. Trans people might ...
How Gender Reassignment Surgery Works (Infographic)
Here's how gender reassignment works: Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina. An incision ...
Gender-affirming surgery
Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals.
A Pioneering Approach to Gender Affirming Surgery From a World Leader
His confidence in this new approach is the result of nearly three decades of expertise and innovation in SRS and urogenital reconstructive surgery, which includes 600 male-to-female vaginoplasties, 900 female-to-male metoidioplasties, 300 female-to-male phalloplasties, and the co-development of a penile disassembly technique for epispadias repair.
How does female-to-male surgery work?
Top surgery is a colloquial term for chest restructuring procedures, while bottom surgery refers to operations changing genitalia. ... Medicare pays for gender reassignment surgeries and hormone ...
Gender Affirmation Surgeries
Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people. Facial gender surgery: While hormone replacement therapy can help achieve gender affirming changes to the face, surgery may help. Facial gender surgery can include a variety ...
Feminizing Bottom Surgery: Purpose, Procedures & Recovery
Feminizing bottom surgery is a gender-affirming procedure that reconstructs male reproductive organs into parts of a vulva and vagina. 800.223.2273; 100 Years of Cleveland Clinic; ... For many people, surgery is only one step in the process. A therapist or counselor can help discuss potential causes of stress to your mental health. This may ...
Female to Male Gender Reassignment Surgery (FTM GRS)
Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia ...
Transgender health care must be paid for by state insurance, says ...
The federal appeals court in Richmond, Va., ruled in favor of transgender patients on Monday. The case was brought by Medicaid recipients in West Virginia and state employees in North Carolina.
Court says state health-care plans can't exclude gender-affirming surgery
A federal appellate court in Richmond became the first in the country to rule that state health-care plans must pay for gender-affirming surgeries, a major win for transgender rights amid a ...
Same-sex couples face up to 15 years in prison in Iraq's LGBTQ ...
Transgender individuals and doctors who perform gender reassignment surgery face up to three years in prison under the new law, though it excludes cases of medical intervention to "treat birth ...
Trump's Lead Attorney Christopher Kise to Undergo Surgery ...
D onald Trump's legal battles face a new challenge as Christopher Kise, one of his high-profile defense attorneys, is scheduled for planned surgery, leading to a temporary departure from his ...
Neuman Awarded Federal Grant to Study Patient-Surgeon Interactions on
According to Neuman, there are two specific breast cancer procedures that have limited clinical benefit and could potentially cause harm: sentinel lymph node biopsies (SLN) for women who are 70+ years old and contralateral prophylactic mastectomy (CPM, a surgery to remove the healthy breast in a person who has had the other breast with cancer ...
CDC describes cases of HIV transmitted via 'vampire facial' cosmetic
Three women likely got HIV while receiving "vampire facials" at a New Mexico spa — the first known cases transmitted via cosmetic injections, a CDC report says.
CDC says it's identified 1st documented cases of HIV transmitted ...
ALBUQUERQUE, N.M. (AP) — Three women who were diagnosed with HIV after getting "vampire facial" procedures at an unlicensed New Mexico medical spa are believed to be the first documented ...
Second Patient Receives Gene-Edited Pig Kidney Transplant in
Lisa Pisano, a 54-year-old woman from New Jersey, has become the second living person to receive a transplant of a gene-edited pig kidney. Doctors also implanted a mechanical heart pump, making ...

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Why it's done

How you prepare

Evaluation for surgery

Other considerations

What you can expect

Tracheal shave

Top surgery

Genital surgery

Orchiectomy

Vaginoplasty

Dilation after gender-affirming surgery

Clinical trials

Mayo Clinic Press

Make twice the impact

Center for Transgender Medicine and Surgery

How Gender Reassignment Surgery Works (Infographic)

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What to know about female-to-male surgery

Chest restructuring or top surgery

Removal of the uterus, ovaries, and fallopian tubes

Metoidioplasty

Phalloplasty

Scrotoplasty

Complications

What to expect

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Female to Male Gender Reassignment Surgery (FTM GRS)