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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.

American Society of Plastic Surgeons. Gender affirmation surgeries .

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

Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8 .  Int J Transgend Health . 2022;23(S1):S1-S260. doi:10.1080/26895269.2022.2100644 

Chou J, Kilmer LH, Campbell CA, DeGeorge BR, Stranix JY. Gender-affirming surgery improves mental health outcomes and decreases anti-depressant use in patients with gender dysphoria .  Plast Reconstr Surg Glob Open . 2023;11(6 Suppl):1. doi:10.1097/01.GOX.0000944280.62632.8c

Human Rights Campaign. Get the facts on gender-affirming care .

Human Rights Campaign. Transgender and non-binary people FAQ .

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877–84. doi:10.21037/tau.2016.09.04

Richards JE, Hawley RS. Chapter 8: Sex Determination: How Genes Determine a Developmental Choice . In: Richards JE, Hawley RS, eds. The Human Genome . 3rd ed. Academic Press; 2011: 273-298.

Randolph JF Jr. Gender-affirming hormone therapy for transgender females . Clin Obstet Gynecol . 2018;61(4):705-721. doi:10.1097/GRF.0000000000000396

Cocchetti C, Ristori J, Romani A, Maggi M, Fisher AD. Hormonal treatment strategies tailored to non-binary transgender individuals . J Clin Med . 2020;9(6):1609. doi:10.3390/jcm9061609

Van Boerum MS, Salibian AA, Bluebond-Langner R, Agarwal C. Chest and facial surgery for the transgender patient .  Transl Androl Urol . 2019;8(3):219-227. doi:10.21037/tau.2019.06.18

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes . Transl Androl Urol . 2019;8(3):248–53. doi:10.21037/tau.2019.06.12

Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases .  Front Endocrinol . 2021;12:760284. doi:10.3389/fendo.2021.760284

Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The surgical techniques and outcomes of secondary phalloplasty after metoidioplasty in transgender men: an international, multi-center case series .  The Journal of Sexual Medicine . 2019;16(11):1849-1859. doi:10.1016/j.jsxm.2019.07.027

Waterschoot M, Hoebeke P, Verla W, et al. Urethral complications after metoidioplasty for genital gender affirming surgery . J Sex Med . 2021;18(7):1271–9. doi:10.1016/j.jsxm.2020.06.023

Nikolavsky D, Hughes M, Zhao LC. Urologic complications after phalloplasty or metoidioplasty . Clin Plast Surg . 2018;45(3):425–35. doi:10.1016/j.cps.2018.03.013

Nota NM, den Heijer M, Gooren LJ. Evaluation and treatment of gender-dysphoric/gender incongruent adults . In: Feingold KR, Anawalt B, Boyce A, et al., eds.  Endotext . MDText.com, Inc.; 2000.

Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. The uterus in transgender men . Fertil Steril . 2021;116(4):931–5. doi:10.1016/j.fertnstert.2021.07.005

Miller TJ, Wilson SC, Massie JP, Morrison SD, Satterwhite T. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes . JPRAS Open . 2019;21:63-74. doi:10.1016/j.jpra.2019.03.003

Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals . Clin Plast Surg . 2018;45(3):369–80. doi:10.1016/j.cps.2018.03.010

De Boulle K, Furuyama N, Heydenrych I, et al. Considerations for the use of minimally invasive aesthetic procedures for facial remodeling in transgender individuals .  Clin Cosmet Investig Dermatol . 2021;14:513-525. doi:10.2147/CCID.S304032

Asokan A, Sudheendran MK. Gender affirming body contouring and physical transformation in transgender individuals .  Indian J Plast Surg . 2022;55(2):179-187. doi:10.1055/s-0042-1749099

Sturm A, Chaiet SR. Chondrolaryngoplasty-thyroid cartilage reduction . Facial Plast Surg Clin North Am . 2019;27(2):267–72. doi:10.1016/j.fsc.2019.01.005

Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery . Transl Androl Urol . 2019;8(3):191-208. doi:10.21037/tau.2019.06.19

Wangjiraniran B, Selvaggi G, Chokrungvaranont P, Jindarak S, Khobunsongserm S, Tiewtranon P. Male-to-female vaginoplasty: Preecha's surgical technique . J Plast Surg Hand Surg . 2015;49(3):153-9. doi:10.3109/2000656X.2014.967253

Okoye E, Saikali SW. Orchiectomy . In: StatPearls [Internet] . Treasure Island (FL): StatPearls Publishing; 2022.

Salgado CJ, Yu K, Lalama MJ. Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations . J Surg Case Rep . 2021;2021(12):rjab553. doi:10.1093/jscr/rjab553

American Society of Plastic Surgeons. What should I expect during my recovery after facial feminization surgery?

American Society of Plastic Surgeons. What should I expect during my recovery after transmasculine bottom surgery?

de Brouwer IJ, Elaut E, Becker-Hebly I, et al. Aftercare needs following gender-affirming surgeries: findings from the ENIGI multicenter European follow-up study .  The Journal of Sexual Medicine . 2021;18(11):1921-1932. doi:10.1016/j.jsxm.2021.08.005

American Society of Plastic Surgeons. What are the risks of transfeminine bottom surgery?

American Society of Plastic Surgeons. What are the risks of transmasculine top surgery?

Khusid E, Sturgis MR, Dorafshar AH, et al. Association between mental health conditions and postoperative complications after gender-affirming surgery .  JAMA Surg . 2022;157(12):1159-1162. doi:10.1001/jamasurg.2022.3917

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What Is Gender Affirmation Surgery?

Surgery to change the appearance of your body is a common choice for all kinds of people. There are many reasons that people might want to alter their appearance. For transgender or gender nonconforming people, making changes to their bodies is a way of affirming their identity.

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 decide to have surgery on their chest, genitals, or face. These surgeries are personal decisions, and each person makes their own choices about what is right for them.

Learn more about gender affirmation surgery and how it helps trans people.

What Does It Mean to Be Transgender or Nonbinary?

Transgender is a word to describe people whose gender identity or gender expression doesn't match the sex they were assigned at birth. Typically, parents and doctors assume a baby's gender based on the appearance of their genitals. But some people grow up and realize that their sense of who they are isn't aligned with how their bodies look. These people are considered transgender.

Trans people may identify as a different gender than what they were assigned at birth. For example, a child assigned male at birth may identify as female. Nonbinary people don't identify as either male or female. They may refer to themselves as "nonbinary" or "genderqueer."

There are many options for trans and nonbinary people to change their appearance so that how they look reflects who they are inside. Many trans people use clothing, hairstyles, or makeup to present a particular look. Some use hormone therapy to refine their secondary sex characteristics. Some people choose surgery that can change their bodies and faces permanently.

Facial Surgery

Facial plastic surgery is popular and accessible for all kinds of people in the U.S. It is not uncommon to have a nose job or a facelift . Cosmetic surgery is great for improving self-esteem and making people feel more like themselves. Trans people can use plastic surgery to adjust the shape of their faces to better reflect their gender identity.

Facial feminization. A person with a masculine face can have surgeries to make their face and neck look more feminine. These can be done in one procedure or through multiple operations. They might ask for:

• Forehead contouring
• Jaw reduction
• Chin surgery
• Hairline advancement
• Cheek augmentation
• Rhinoplasty
• Lip augmentation
• Adam's apple reduction

Facial masculinization. Someone with a feminine face can have surgery to make their face look more masculine. The doctor may do all the procedures at one time or plan multiple surgeries. Doctors usually offer:

• Forehead lengthening
• Jaw reshaping
• Chin contouring
• Adam's apple enhancement

Top Surgery

Breast surgeries are very common in America. The shorthand for breast surgeries is "top surgery." All kinds of people have operations on their breasts , and there are a lot of doctors who can do them. The surgeries that trans people have to change their chests are very similar to typical breast enhancement or breast removal operations.

Transfeminine. When a trans person wants a more feminine bustline, that's called transfeminine top surgery. It involves placing breast implants in a person's chest. It's the same operation that a doctor might do to enlarge someone's breasts or for breast reconstruction .

Transmasculine. Transmasculine top surgery is when a person wants a more masculine chest shape. It is similar to a mastectomy . The doctor removes the breast tissue to flatten the whole chest. The doctor can also contour the skin and reposition the nipples to look more like a typical man's chest.

Bottom Surgery

For people who want to change their genitals, some operations can do that. That is sometimes called bottom surgery. Those are complicated procedures that require doctors with a lot of experience with trans surgeries.

Transmasculine bottom surgery. Some transmasculine people want to remove their uterus and ovaries. They can choose to have a hysterectomy to do that. This reduces the level of female hormones in their bodies and stops their menstrual cycles.

If a person wants to change their external genitals, they can ask for surgery to alter the vaginal opening. A surgeon can also construct a penis for them. There are several techniques for doing this.

Metoidioplasty uses the clitoris and surrounding skin to create a phallus that can become erect and pass urine. A phalloplasty requires grafting skin from another part of the body into the genital region to create a phallus. People can also have surgery to make a scrotum with implants that mimic testicles. ‌

Transfeminine bottom surgery. People who want to reduce the level of male hormones in their bodies may choose to have their testicles removed. This is called an orchiectomy and can be done as an outpatient operation.

Vaginoplasty is an operation to construct a vagina . Doctors use the tissue from the penis and invert it into a person's pelvic area. The follow-up after a vaginoplasty involves using dilators to prevent the new vaginal opening from closing back up.

How Much Does Gender Affirmation Surgery Cost?

Some medical insurance companies will cover some or most parts of your gender-affirming surgery. But many might have certain "exclusions" listed in the plan. They might use language like "services related to sex change" or "sex reassignment surgery." These limitations may vary by state. It's best to reach out to your insurance company by phone or email to confirm the coverage or exclusions.

If your company does cover some costs, they may need a few documents before they approve it.

This can include:

• A gender dysphoria diagnosis in your health records. It's a term used to describe the feeling you have when the sex you're assigned at birth does not match with your gender identity. A doctor can provide a note if it's necessary.
• A letter of support from a mental health professional such as a social worker, psychiatrist , or a therapist.

Gender affirmation surgery can be very expensive. It's best to check with your insurance company to see what type of coverage you have.

If you're planning to pay out-of-pocket, prices may vary depending on the various specialists involved in your case. This can include surgeons, primary care doctors, anesthesiologists, psychiatrists, social workers, and counselors. The procedure costs also vary, and the total bill will include a number of charges, including hospital stay, anesthesia, counseling sessions, medications, and the procedures you elect to have.

Whether you choose facial, top, or bottom or a combination of these procedures, the total bill after your hospital stay can cost anywhere from $5,400 for chin surgery to well over $100,000 for multiple procedures.

Recovery and Mental Health After Gender Affirmation Surgery

Your recovery time may vary. It will depend on the type of surgery you have. But swelling can last anywhere from 2 weeks for facial surgery to up to 4 months or more if you opted for bottom surgery.

Talk to your doctor about when you can get back to your normal day-to-day routine. But in the meantime, make sure to go to your regular follow-up appointments with your doctor. This will help them make sure you're healing well post-surgery.

Most trans and nonbinary people who get gender affirmation surgery report that it improves their overall quality of life. In fact, over 94% of people who opt for surgery say they are satisfied with the results.

Folks who have mental health support before surgery tend to do better, too. One study found that after gender affirmation surgery, a person's need for mental health treatment went down by 8%.

Not all trans and nonbinary people choose to have gender affirmation surgery, or they may only have some of the procedures available. If you are considering surgery, speak with your primary care doctor to discuss what operations might be best for you.

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

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

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

Gender Dysphoria: Diagnosis and Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lots More Information

Author's note: stages of gender reassignment.

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

Related Articles

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

More Great Links

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

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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.

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Understanding Insurance Requirements for Gender Affirmation Surgery

• Type of Surgeries
• Barriers to Access
• WPATH Standards

Restrictions to Coverage

Getting started, what you can do.

Insurance coverage for orchiectomy, genitoplasty, and other types of gender-affirmation surgery is largely governed by standards issued by the World Professional Association for Transgender Health (WPATH). Many health insurance providers use these guidelines to direct which procedures are medically necessary. However, not every insurer—or state—does.

Because acceptance of WPATH guidelines can vary, it can sometimes be hard to determine which procedures are covered by your health plan and whether gender affirmation is even affordable.

This article describes the types of surgeries pursued by transgender or gender-nonconforming people as a part of gender affirmation and the barriers they face. It also explains the WPATH standards of care for each type of surgery, how insurance companies use them to determine eligibility, and what restrictions are imposed by providers or states.

Gender-affirmation surgery is the preferred term but gender-confirmation surgery and gender-alignment surgery can also be used. Outdated terms like "sex reassignment" or "sex change" should not be used.

Gender affirmation reflects the process a person goes through when they begin to live as their authentic gender rather than the gender assigned to them a birth.

Medical or surgical procedures are only one facet of gender affirmation.

Types of Gender-Affirmation Surgery

Not all transgender, non-binary , and genderqueer individuals want surgery to align their bodies to their gender identity. Some people are content with social or other medical transition options .

Others want one or more surgeries, including those referred to as " top surgery ” (occurring above the waist) and "bottom surgery" (occurring below the waist).

An extensive national survey of transgender people found that:

• 66% of transgender women either had or wanted  vaginoplasty or labiaplasty .
• 51% of transgender women either had or wanted breast augmentation.
• 50% of transgender women either had or wanted facial feminization (surgery to make a face appear more feminine).
• 37% of transgender women either had or wanted a tracheal shave (removal of the Adam’s apple).
• 58% of transgender women either had or wanted orchiectomy (removal of the testicles).
• 22% of transgender men either had or wanted phalloplasty (the creation of a penis).
• 27% of transgender men either had or wanted metoidioplasty (surgery that uses existing genitalia to create a penis).
• 97% of transgender men either had or wanted chest reconstruction or mastectomy (removal of the breasts).
• 71% of transgender men either had or wanted a hysterectomy (removal of the uterus).

Common Barriers to Gender-Affirmation Surgery

Cost, surgeon availability, and a process referred to "gatekeeping" are three major hurdles commonly faced by people undergoing gender affirmation.

Cost is one of the primary reasons people have limited access to gender-affirmation surgeries. Historically, most public or private insurance companies have not covered these procedures. Fortunately, that is changing.

Some public and private insurance companies cover some or all gender-affirmation surgery options. But that coverage often comes with many hoops that people need to jump through. It is also not available to all people in all states.

Surgeon Availability

Another major factor limiting access to surgery is the small number of surgeons trained to perform them. These surgeons, particularly very experienced ones, are often booked months or years in advance.

In addition, many don’t take insurance. Fortunately, as insurance coverage for gender-affirmation surgeries has increased, so too has physician interest in training. Today, there are many hospitals across the country that routinely perform vaginoplasty and accept insurance to pay for them.

"Gatekeeping"

Another barrier is a process called “gatekeeping" currently endorsed by WPATH. Gatekeeping involves undergoing a significant therapy or psychiatric assessment before they are allowed to transition medically.

It is a process that attracted considerable debate given that this level of scrutiny is not required for other major surgeries. It ultimately places the decision in the hands of a psychiatrist who can determine if a person is mentally "fit" to pursue treatment.

Discrimination and Stigma

In addition to barriers like cost and surgeon availability/competency, there is also a long history of discrimination and stigma limiting transgender patients’ access to care.

Insurance and the WPATH Standards

When determining eligibility for gender-affirming surgery coverage, many insurers turn to the WPATH Standards of Care to inform their eligibility guidelines. These are also known as the WPATH criteria or WPATH requirements.

WPATH updates its guidelines every five to 10 years. These standards of care help define which treatments are medically necessary and under which conditions they should be authorized. The standards have become less restrictive over time, reflecting the growing recognition of gender diversity in society.

The standards of care are broadly described as follows:

Standards for Top Surgery

“Top surgery” refers to gender-affirmation surgery of the breast or chest. For transmasculine people, this surgery is called chest reconstruction. For transfeminine people, it is breast augmentation.

The WPATH criteria for top surgery include:

• Persistent, well-documented gender dysphoria (distress caused by the difference between a person’s gender and the gender they were assigned at birth)
• The ability to make an informed decision and consent to treatment
• Any significant medical or mental health conditions are “reasonably well controlled”

Standards for Hormone Therapy

It is important to note that hormone therapy is not required for these surgeries. However, a year of hormone therapy is recommended  for transgender women because it allows them to get the maximum possible breast growth without surgery, which improves surgical outcomes.

For transgender men, there is no hormone requirement or recommendation. That’s because some transmasculine people are only dysphoric about their chests. Therefore, they do not want or need testosterone treatment.

There are also several physical and psychological reasons people choose to undergo top surgery without hormone use. That said, people who are taking testosterone and are very active may wish to wait a year for surgery because testosterone and exercise can significantly reshape the chest. Therefore, waiting a year may result in a more aesthetic outcome.

Standards for Orchiectomy, Hysterectomy, and Ovariectomy

These surgeries involve the removal of the testicles (orchiectomy), uterus (hysterectomy), or ovaries (ovariectomy).

WPATH criteria for these surgeries include:

• Persistent, well-documented gender dysphoria
• Any significant medical or mental health conditions are “well controlled”
• At least 12 continuous months of appropriate hormone therapy, unless there are reasons someone can’t or won’t take hormones. The purpose of this guideline is so that people can experience reversible hormone changes before they undergo irreversible ones.

Surgeries to remove the gonads (testes, ovaries) and the uterus may be performed independently. They may also be performed alongside other gender-affirmation surgeries.

Removing the gonads alone can lower the amount of cross-sex hormone therapy required to get results. In addition, removing the uterus or cervix eliminates the need to screen those organs. That’s important because those screening exams can cause dysphoria and discomfort in many transgender men.

Standards for Vaginoplasty, Phalloplasty, and Metoidioplasty

This group of surgeries constructs a vagina (vaginoplasty) or penis (phalloplasty, metoidioplasty). These procedures make a person’s genitalia more in line with their gender identity.

• Any significant medical or mental health conditions are “well controlled”
• Appropriate hormone therapy for 12 continuous months, unless there are reasons why someone can’t or won’t take hormones
• Living in a gender role that is consistent with their gender identity for 12 continuous months

The requirement for a year of living in a gender role is because it gives people time to adjust to their desired gender. In addition, doctors widely believe that a year is a sufficient time for that adjustment before undergoing a complicated, expensive, and irreversible surgery.

Aftercare for these surgeries can be emotionally intense and difficult. For example, following vaginoplasty , consistent vaginal dilation is required to maintain depth and girth and avoid complications. These requirements can sometimes be challenging for people with a history of sexual trauma.

Aftercare Recommendations

Due to these surgeries’ physical and emotional intensity, experts recommend that those considering them have regular visits with a mental or medical health professional.

Standards for Facial Feminization Surgery

There are no formal guidelines for facial feminization surgery. In addition, it has historically been tough to get this procedure covered by insurance due to a lack of research on the benefits.

However, some individuals have been able to have it successfully covered by arguing that it is as medically necessary as genital surgery and has equally positive effects on quality of life.

Standards for Children and Adolescents

WPATH guidelines for children and adolescents include criteria for fully reversible interventions ( puberty blockers that pause puberty, for example) or partially reversible ones (hormones, for example). However, they do not recommend irreversible (surgical) interventions until the age of majority in their given country.

One exception is chest surgery for transmasculine adolescents. WPATH criteria suggest this could be carried out before adulthood, after ample time of living in their gender role, and after being on testosterone treatment for one year.

Despite the increasing uptake of WPATH guidelines by insurers, not every organization embraces them or applies them in the same way. Even WPATH notes that “the criteria put forth in this document... are clinical guidelines. Individual health professionals and programs may modify them.” And many times, they do.

Generally speaking, private insurance companies are more likely to offer coverage for some or all procedures than government agencies like Medicaid and Medicare. Even so, eligibility requirements can vary as can copayment and coinsurance costs.

Medicaid is the U.S. government health coverage program for low-income people, jointly funded by the federal government and states. Of the estimated 1.4 million transgender adults living in the United States, approximately 152,000 have Medicaid coverage, according to the Kaiser Family Foundation.

Many state Medicaid programs cover aspects of gender-affirming health services. But only two states—Maine and Illinois—cover all five WPATH standards of care as of October 2022 (hormone therapy, surgery, fertility assistance, voice and communication therapy, primary care, and behavioral intervention).

Current Medicaid Coverage Status

In terms of gender-affirming surgery, 23 states provide coverage for adults, while nine states (Alabama, Arizona, Florida, Hawaii, Iowa, Kansas, Missouri, Texas, and Wyoming) currently deny coverage. The remaining states either have no policies in place or offer no reporting of coverage.

Medicare is federal health insurance for people 65 or older and some younger people with disabilities. Original Medicare (Part A and Part B) will cover gender-affirmation surgery when it is considered medically necessary. Prior to 2014, no coverage was offered.

The challenge with accessing surgery is that Medicare has no national precedent for approving or denying coverage. As such, approval or denial is based largely on precedents within your state and is conducted on a case-by-case basis.

This suggests that approval may be more difficult in states that deny coverage to Medicaid recipients given that Medicare is administered by a central agency called the Centers for Medicare & Medicaid Services (CMS).

As a general guideline, the CMS states that the following is needed for you to be an eligible candidate for gender-affirmation surgery:

• Have a diagnosis of gender dysphoria
• Provide proof of counseling
• Provide evidence of hormone therapy (for transgender women)

If coverage is denied, there is an appeal process you can undergo to overturn the denial.

Private Insurance

Most private insurance companies in the United States will offer coverage for some—but not necessarily all—gender-affirming surgeries.

According to the Transgender Legal Defense & Education Fund (TLDEF), many of the larger insurers offer coverage for a comprehensive array of surgeries, including providers like:

• Blue Cross/Blue Shield
• UnitedHealthcare

Others have different standards in different states (such as AmeriHealth) or only offer coverage for specific surgeries like facial feminization surgery (Prestige and AmeriHealth New Hampshire).

Though coverage of gender-affirmation surgery is increasing, many private insurers still require you to meet extensive criteria before approval is granted. By way of example, to get approval for breast augmentation, a transgender woman would need to provide a company like Aetna:

• A signed letter from a qualified mental health professional stating their readiness for physical treatment as well as their capacity to consent to a specific treatment
• Documentation of marked and sustained gender dysphoria
• Documentation that other possible causes of gender dysphoria have been excluded
• The completion of six to 12 months of hormone therapy
• A risk assessment of breast cancer screening by a qualified healthcare provider

Even if approval is granted, copayment, coinsurance, and out-of-pocket costs can vary, often considerably.

Out-of-Pocket Costs

According to a 2022 study from Oregon Health & Science University, a transgender person who underwent "bottom" surgery from 2007 to 2019 paid an average of $1,781 out of pocket.

With that said, 50% had to leave their state due to the restriction or unavailability of gender-affirmation surgery and ended up paying an average of $2,645 out of pocket, not including travel or living expenses.

Showing that a person has “persistent, well-documented gender dysphoria” usually requires a letter from a mental health provider. This letter usually states that the person meets the criteria for gender dysphoria, including the length of time that has been true.

This letter often also contains a narrative of the person’s gender history in detail. In addition, the letter should state how long the provider has been working with the person.

Well or Reasonably Controlled

It is important to note that some standards require that medical and mental health problems be well controlled, while others only require them to be reasonably well controlled. Documentation of this is also usually in a letter from the relevant healthcare provider.

This letter should contain information about the history of the condition, how it is controlled, and the length of the clinician’s relationship with the person. Ideally, the phrases “well controlled” or “reasonably well controlled” are used in the letter as appropriate.

Using terminology referenced in the WPTH criteria makes it easier for providers and insurance companies to determine that the conditions of the standards of care have been met.

Of note, mental health conditions are not a contraindication for gender affirmation surgeries. In fact, these procedures can help resolve symptoms in many transgender people and others with gender dysphoria. Symptom relief is true not just for anxiety and depression but for more severe conditions such as psychosis.

Getting insurance coverage for gender confirmation surgery can be a frustrating process. However, it can help to prepare a copy of the WPATH guidelines and any relevant research papers to support your goals. That’s particularly true if they include surgeries other than those listed above.

In addition, it may be a good idea to reach out to your local LGBT health center for assistance. Many health centers are now hiring transgender patient navigators who have extensive experience with the insurance process. They can be a great resource.

Local and national LGBTQ-focused legal organizations often have helplines or access hours where people can seek information.

Gender-affirmation surgery refers to various surgeries that allow people to align their bodies with their gender. WPATH guidelines offer criteria for determining whether someone is a good candidate for gender-affirmation surgery.

Not all insurance offers coverage for gender-affirmation surgery, but some do. First, however, you need to provide the proper documentation to show that you meet specific surgery criteria. This documentation is usually in a letter written by your physician or mental health clinician.

Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. Prospective quality-of-life outcomes after facial feminization surgery: an international multicenter study . Plast Reconstr Surg . 2020;145(6):1499-1509. doi:10.1097/PRS.0000000000006837

National Center for Transgender Equality. The report of the 2015 U.S. transgender survey .

World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th version .

Kaiser Family Foundation. Update on Medicaid coverage of gender-affirming health services .

CMS.gov. Gender dysphoria and gender reassignment surgery .

Transgender Legal Defense & Education Fund. Health insurance medical policies: gender dysphoria / gender reassignment .

Aetna. Gender-affirming surgery .

Downing J, Holt SK, Cunetta M, Gore JL, Dy GW. Spending and out-of-pocket costs for genital gender-affirming surgery in the US . JAMA Surg.  2022;157(9):799-806. doi:10.1001/jamasurg.2022.2606

Meijer JH, Eeckhout GM, van Vlerken RH, de Vries AL. Gender dysphoria and co-existing psychosis: review and four case examples of successful gender affirmative treatment . LGBT Health . 2017;4(2):106-114. doi:10.1089/lgbt.2016.0133

By Elizabeth Boskey, PhD Boskey has a doctorate in biophysics and master's degrees in public health and social work, with expertise in transgender and sexual health.

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Vaginoplasty for Gender Affirmation

Featured Experts:

Fan Liang, M.D.

Andrew Jason Cohen, M.D.

Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

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 feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

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Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

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Federal judge rules transgender Indiana inmate can receive gender-affirming surgery

A federal judge on Tuesday issued an order that will require the Indiana Department of Corrections to provide a transgender inmate with gender-affirming surgery.

Richard Young, a judge for the U.S. District Court in the Southern District of Indiana , granted a preliminary injunction in the ACLU of Indiana's case representing a transgender inmate serving a murder sentence in a male state prison, concluding that "gender-confirming surgery is a medically necessary treatment option for some individuals with gender dysphoria," according to the ruling.

The inmate, who goes by Autumn Cordellioné, sued the state of Indiana last yea r after the IDOC denied her gender-affirming surgery. The Indiana Legislature banned transgender surgery in prisons in 2023.

The ACLU cheered Tuesday's ruling, with legal director Ken Falk calling it a "significant victory for transgender individuals in Indiana's prisons."

"Denying evidence-based medical care to incarcerated people simply because they are transgender is unconstitutional," Falk said in a statement.

An Indiana Department of Corrections spokesperson said the agency does not comment on pending litigation. The Indiana Attorney General's Office didn't immediately reply to IndyStar's request for comment.

But the IDOC argued in court that there is a "disagreement as to whether there is widespread medical consensus that gender-affirming surgery is a 'safe and effective court of treatment.'"

Indiana lawmakers move bill banning state-provided gender-affirming surgery in prison

However, the court noted that "extensive research from the past three decades" establishes gender-affirming surgeries to be "safe, therapeutic and effective," and that groups including The National Commission on Correctional Health Care said gender-affirming surgery "should be provided when determined to be medically necessary for transgender prisoners."

Federal prisoners, along with state prisoners in Illinois, Washington, Idaho, California and Massachusetts are allowed to receive such surgeries.

"The assessment process for the appropriateness of surgery is the same as the process for those who are not incarcerated," according to the decision.

Before the law banning the use of state and federal money on such surgeries took effect in July 2023, the IDOC had a policy that allowed transgender inmates surgical interventions after a review of mental health professionals and a "Gender Dysphoria Review Committee."

Two other IDOC inmates had been approved for gender-affirming surgery under that policy. The IDOC now allows social transitioning and hormonal therapy.

The person at the center of the case, Cordellioné, has attempted suicide and self-harm on multiple occasions due to her gender dysphoria, according to the court, and sought out gender-affirming surgery from IDOC in 2022. The court found her case "credible," according to the ruling.

"The IDOC's denial of surgery to her because of the challenged statute denies her effective and necessary treatment for her serious medical need and represents deliberate indifference to her serious medical need," according to the judge.

The ruling also found Indiana's legislation violates both Cordellioné's Eighth Amendment right against cruel and unusual punishment and the Equal Protection clause of the Fourteenth Amendment.

However, the ruling is "narrowly drawn," according to the court," and "extends no further than necessary to correct the violation of Ms. Cordellioné's constitutional rights."

Hayleigh Colombo is the senior government accountability reporter at IndyStar. She can be reached at [email protected].

Georgian parliament approves bill to curb LGBTQ rights

TBILISI, Georgia — Georgian lawmakers on Tuesday approved the third and final reading of a law on “family values and the protection of minors” that would impose sweeping curbs on LGBTQ rights.

The bill would provide a legal basis for authorities to outlaw Pride events and public displays of the LGBT rainbow flag, and to impose censorship of films and books.

Leaders of the governing Georgian Dream party say it is needed to safeguard traditional moral standards in Georgia, whose deeply conservative Orthodox Church is highly influential.

Activists say the measure is aimed at boosting conservative support for the government ahead of a parliamentary election on Oct. 26 in Georgia, a country that has ambitions to join the European Union but which Western governments fear is now tilting back towards Russia.

Tamara Jakeli, director of campaign group Tbilisi Pride, said the bill, which also restates an existing ban on same-sex marriage and bans gender reassignment surgery, would likely force her organization to close its doors.

“This law is the most terrible thing to happen to the LGBT community in Georgia,” Jakeli, 28, told Reuters. “We will most likely have to shut down. There is no way for us to continue functioning.”

Georgian President Salome Zourabichvili, a critic of Georgian Dream whose powers are mostly ceremonial, has indicated that she will block the bill. But Georgian Dream and its allies have enough seats in parliament to override her veto.

LGBT rights are a fraught topic in Georgia, where polls show broad disapproval of same-sex relationships, and the constitution bans same-sex marriage. Participants in Tbilisi’s annual Pride marches have come under physical attack by anti-LGBT protesters in recent years.

The issue has become more prominent ahead of October’s election, where Georgian Dream is seeking a fourth term in office and is campaigning heavily against LGBT rights.

The ruling party, whose top candidate for the election is billionaire ex-prime minister Bidzina Ivanishvili, has deepened ties with neighboring Russia as relations with Western countries have soured.

Earlier this year, it passed a law on “foreign agents” that the European and U.S. critics said is authoritarian and Russian-inspired. Its passage sparked some of the largest protests Georgia has seen since independence from the Soviet Union in 1991.

Opinion polls show the party, which in 2014 passed a law banning anti-LGBT discrimination before later pivoting to more conservative positions, remains Georgia’s most popular, though it has lost ground since 2020, when it won a narrow majority in parliament.

In one ruling party advert aired on Georgian television, Pride director Jakeli’s face is shown alongside the words: “No to moral degradation.”

Jakeli said that the bill could only be stopped if Georgian Dream were to lose power in October, though she noted that the country’s opposition parties are not overtly supportive of LGBT rights.

“The only way we can survive in this country and have any progress on LGBT rights is for us to go in great numbers to the elections and vote for change,” she said.