Coming to a Cleveland Clinic location? Hillcrest Cancer Center check-in changes Cole Eye entrance closing Visitation, mask requirements and COVID-19 information
Notice of Intelligent Business Solutions data event Learn more
Gender Affirmation (Confirmation) or Sex Reassignment Surgery
- Appointments & Access
What is sex reassignment surgery?
Sex reassignment surgery refers to procedures that help people transition to their self-identified gender. Today, many people prefer to use the terms gender affirmation or confirmation surgery.
Why is gender affirmation surgery done?
People may have surgery so that their physical body matches their gender identity. People who choose gender affirmation surgery do so because they experience gender dysphoria. Gender dysphoria is the distress that occurs when your sex assigned at birth does not match your gender identity.
What is the difference between transgender and nonbinary?
The term transgender describes someone whose gender identity is different than their sex assigned at birth. Gender nonbinary describes someone whose gender identity does not fit within traditional female or male categories. People in either of these categories may opt for gender affirmation medical treatment or surgery.
What are the types of transgender surgery?
Gender-affirming surgery gives transgender people a body that aligns with their gender. It may involve procedures on the face, chest or genitalia. Common transgender surgery options include:
- Facial reconstructive surgery to make facial features more masculine or feminine.
- Chest or “Top” surgery to remove breast tissue for a more masculine appearance or enhance breast size and shape for a more feminine appearance.
- Genital or “Bottom” surgery to transform and reconstruct the genitalia.
Is gender affirmation surgery the only treatment for gender dysphoria?
No. Surgery is just one option. Not everyone who is transgender or nonbinary chooses to have surgery. Depending on your age and preferences, you may choose:
- Hormone therapy to increase masculine or feminine characteristics, such as your amount of body hair or vocal tone.
- Puberty blockers to prevent you from going through puberty.
- Voice therapy to adjust your voice or tone or help with communication skills, such as introducing yourself with your pronouns.
People may also socially transition to their true gender with or without surgery. As part of social transitioning, you might:
- Adopt a new name.
- Choose different pronouns.
- Present as your gender identity by wearing different clothing or changing your hairstyle.
How common is gender affirmation surgery?
Surveys report that around 1 in 4 transgender and nonbinary people choose gender affirmation surgery.
Procedure Details
What happens before gender affirmation surgery.
Before surgery, you should work with a trusted healthcare provider. A healthcare provider can help you understand the risks and benefits of all surgery options.
Many insurance companies require you to submit specific documentation before they will cover a gender-affirming surgery. This documentation includes:
- Health records that show consistent gender dysphoria.
- Letter of support from a mental health provider, such as a social worker or psychiatrist.
What happens during transgender surgery?
What happens during surgery varies depending on the procedure. You may choose facial surgery, top surgery, bottom surgery or a combination of these operations.
Facial surgery may change your:
- Cheekbones: Many transgender women have injections to enhance the cheekbones.
- Chin: You may opt to soften or more prominently define your chin’s angles.
- Jaw: A surgeon may shave down your jawbone or use fillers to enhance your jaw.
- Nose: You may have a rhinoplasty , surgery to reshape the nose.
If you are a transgender woman (assigned male at birth or AMAB), other surgeries may include:
- Adam’s apple reduction.
- Placement of breast implants ( breast augmentation ).
- Removal of the penis and scrotum (penectomy and orchiectomy ).
- Construction of a vagina and labia ( feminizing genitoplasty ).
If you are a transgender man (assigned female at birth or AFAB), you may have surgeries that involve:
- Breast reduction or mastectomy .
- Removal of the ovaries and uterus ( oophorectomy and hysterectomy ).
- Construction of a penis and scrotum (metoidioplasty, phalloplasty and scrotoplasty).
What happens after gender affirmation surgery?
Recovery times vary based on what procedures or combination of procedures you have:
- Cheek and nose surgery: Swelling lasts for around two to four weeks.
- Chin and jaw surgery: Most swelling fades within two weeks. It may take up to four months for swelling to disappear.
- Chest surgery: Swelling and soreness last for one to two weeks. You will need to avoid vigorous activity for at least one month.
- Bottom surgery: Most people don’t resume usual activities until at least six weeks after surgery. You will need weekly follow-up with your healthcare provider for a few months. These visits ensure you are healing well.
It’s important to understand that, for most people, surgery is only one part of the transitioning process. After surgery, you should continue to work with a therapist or counselor. This professional can support you with social transitioning and your mental health.
Risks / Benefits
What are the benefits of gender affirmation surgery.
Research has shown that transgender individuals who choose gender-affirming surgery experience long-term mental health benefits. In one study, a person’s odds of needing mental health treatment declined by 8% each year after the gender-affirming procedure.
What are the risks or complications of gender affirmation surgery?
Different procedures carry different risks. For example, individuals who have bottom surgery may have changes to their sexual sensation, or trouble with bladder emptying. In general, significant complications are rare, as long as an experienced surgeon is performing the procedure.
With any surgery, there is a small risk of complications, including:
- Side effects of anesthesia .
Recovery and Outlook
What is the outlook for people who have gender affirmation surgery.
Most people who choose these surgeries experience an improvement in their quality of life. Depending on the procedure, 94% to 100% of people report being satisfied with their surgery results. In general, people who work with a mental health provider before surgery tend to experience more satisfaction with their treatment results.
When to Call the Doctor
When should i see my healthcare provider.
After surgery, you should see your healthcare provider if you experience:
- Bleeding for more than a few days after surgery.
- Pain that doesn’t go away after several weeks.
- Signs of infection, such as a wound that changes color or doesn’t heal.
A note from Cleveland Clinic
Gender affirmation procedures help people transition to their self-identified gender. Gender affirmation surgery may involve operations to change the face, chest or genitalia. You may choose to have one type of surgery or a combination of procedures. Before and after surgery, it’s important to work with a mental health provider. Research shows that having a trusted therapist makes you more likely to be satisfied with your surgery results.
Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy
More health news + info
Jump to content
Updated visitor guidelines
Other umhs sites.
- Michigan Medicine Gateway
- UofMHealth.org
- Medical School
- Find a Clinical Trial
Michigan Medicine
Federated search page form block, quick links.
- Patient Portal Login
- For Health Providers
- Maps & Directions
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.
- +31 75 647 63 72
- [email protected]
- Sexual Health Q&A
What is gender reassignment surgery?
Reviewed by the medical professionals of the ISSM’s Communication Committee
Gender reassignment surgery, sometimes called sex reassignment surgery, is performed to transition individuals with gender dysphoria to their desired gender.
People with gender dysphoria often feel that they were born in the wrong gender. A biological male may identify more as a female and vice versa.
- Surgery is typically the last step in the physical transition process, but it is not a decision to be made lightly.
- Many healthcare providers require patients to be formally diagnosed with gender dysphoria and undergo counseling to determine if they are truly ready to surgically transition.
- Patients usually undergo hormone therapy first. Hormones can suppress the secondary sex characteristics of the biological gender and make them appear more like their desired sex. For instance, women take androgens and start developing facial hair. Men take estrogens and anti-androgens to look more feminine.
- Surgeons may also require that patients live as their desired gender for at least one year. A man might dress as a woman traditionally does in the culture. Many men change their names and refer to themselves with female pronouns. Women transitioning to men would do the reverse.
Surgical transition may include several procedures.
- Males transitioning to females have their testicles and penis removed. The prostate gland may or may not be removed as well. Tissue from the penis is used to construct a vagina and clitoris. Labia – the “lips” surrounding the vagina – can be made from scrotal skin. The urethra (the tube from which urine leaves the body) is shortened.
- Many biological men also have facial feminization surgery to change the appearance of their lips, eyes, nose, or Adam’s apple.
- After surgery, patients use vaginal dilators to keep the new vagina open and flexible.
- Surgery for females transitioning to males is more complicated and expensive. The breasts, ovaries, and uterus are removed and the vagina is closed. A penis and scrotum may be made from other tissue. In some cases, a penile implant is used. The urethra is extended so that the patient can urinate while standing.
Continued psychotherapy is recommended for most patients as they adjust to their new bodies and lifestyles.
Not all people with gender dysphoria have surgery. Some feel comfortable living as the opposite gender without medical intervention. Others find that hormone therapy is sufficient for their personal needs.
- Sexual Orientation & LGBTQIA+ Health
- Transgender Health
- Gender-Affirming Surgery
- Transgender Psychological Counseling
Popular Men's Sexual Health Questions
What is the “normal” frequency of masturbation.
What is the “normal” frequency of sex?
Should men be concerned about watery semen? Does it affect their fertility?
- Sexual Health Topics
- Find a provider
- ISSM journals
- Upcoming Meetings
Members Only
Issm update.
- For providers
- Find a Provider
- Vision and Mission
- Bylaws Committee
- Communication Committee
- Consultation and Guidelines Committee
- Developing Countries Committee
- Education Committee
- Ethics Committee
- Finance & Audit Committee
- Grants & Prizes Committee
- History Committee
- Membership Committee
- Nominating Committee
- Publication Committee
- Scientific Committee
- Young Researchers Committee
- Young Trainees Committee
- Affiliated Societies
- Past Presidents
- Executive Office
Please note that Internet Explorer version 8.x is not supported as of January 1, 2016. Please refer to this page for more information.
Gender Reassignment Surgery
Gender reassignment surgery (GRS) refers to all surgical procedures that a patient wishes to undergo in an effort to become similar to the opposite gender.
From: Comprehensive Care of the Transgender Patient , 2020
Related terms:
- Sex Reassignment Surgery
- Transgender
- Transsexual
- Surgical Technique
- Gender Identity
- Bisexuality
- Testosterone
Reproductive Medicine
Karel Claes , ... Stan Monstrey , in Encyclopedia of Reproduction (Second Edition) , 2018
History of Transwomen Surgery
The development of modern gender reassignment surgery began in the twentieth century when, following rapid advances in the fields of endocrinology and plastic surgery after World War II, comprehensive medical and surgical treatments for transsexualism started to become available. In 1952, the Danish plastic surgeon Paul Fogh-Andersen initiated the modern era of sex reassignment surgery by using penile skin as a full thickness graft to line the neovagina of Christine Jörgenson ( Fogh-Andersen, 1956 ). In the United States, things began to change during the late 1950s, when several hundred transsexuals came under the care of Dr. Harry Benjamin, a compassionate endocrinologist who was the first physician to elucidate the nature of gender dysphoria ( Benjamin, 1964 ).
For the majority of transsexuals seeking surgery, the ‘Clinique du Parc’ in Casablanca was the place of last resort. There, Dr. Georges Burou (1910–1987), a French gynecologist, invented and applied the anteriorly pedicled penile skin flap inversion technique in 1956 ( Hage et al., 2007 ).
In 1966, surgeons at the Johns Hopkins Medical Center began performing a limited number of Male-to-Female (MtF) sex reassignment surgeries (SRS) at its new gender identity clinic. Shortly thereafter, hospitals at Stanford, Chicago and Colorado followed suit ( Laub and Fisk, 1974 ; Pandya and Stuteville, 1973 ).
The surgeons at Johns Hopkins initially used partial thickness skin grafts to line the neovaginal cavity, but later used penile skin, applied as a full thickness skin graft, much as the technique employed in Copenhagen. The posteriorly pedicled penile skin flap inversion technique for vaginoplasty — a variation of Burou’s method — was introduced by Edgerton and Bull at Johns Hopkins between 1968 and 1970 ( Edgerton and Bull, 1970 ). Beginning in 1967, the Chicago group used the anteriorly pedicled penile skin flap to line the vagina, and scrotal skin to form the labia ( Pandya and Stuteville, 1973 ).
In Europe, beginning in the 1970s, the University Hospital of the Free University of Amsterdam became the leading center for medical and surgical treatment of patients with severe gender dysphoria. By the end of the 20th century many centers of excellence employed a multidisciplinary approach for transsexual individuals, providing state of the art treatment, including surgical therapy, for both transwomen and transmen. With the recent increase in number of individuals seeking treatment for gender dysphoria, the quantity and the quality of the multidisciplinary teams has substantially increased worldwide with the largest number of vaginoplasties probably still being performed in Thailand.
Transgender, gender non-conformity and transvestism
John Bancroft MD FRCP FRCPE FRCPsych , in Human Sexuality and Its Problems (Third Edition) , 2009
Outcome of surgical gender reassignment
There have now been several reviews of the outcome of gender reassignment surgery ( Abramowitz 1986; Green & Fleming 1990; Pfafflin & Junge 1998; Carroll 1999 ) and their conclusions were summarized by Carroll (2007). Lawrence (2003) reported on 232 male-to-female surgical reassignments all carried out by one surgeon between 1994 and 2000. Using a 0–10 scale to rate happiness with result, 86% scored 8 or higher. None reported consistent regret about having the surgery, and any regret that was reported was about disappointment with the functional outcome of the genital reconstruction, rather than with the gender reassignment per se .
In spite of methodological limitations, there is overall consistency in the findings of improvement or a satisfactory outcome in 66% to 90% of cases, for both male-to-female and female-to-male reassignments. The greatest improvements were in self-satisfaction, interpersonal interaction and psychological well-being. The cosmetic results of the surgery were more variable, reflecting variability of skill among surgeons as well as improvements in relevant surgical techniques over the years. Sexual functioning is often impaired. Given the extent of overall satisfaction, this underlines the primary importance of gender identity over sexuality. Abramowitz (1986) found a poor outcome in around 8% of cases. Pfafflin & Junge (1998) reported that less than 2% regretted the surgery. In spite of the fact that the surgical possibilities for converting female genitalia to male are less than in the reverse direction, female to males showed a more positive psychosocial outcome than male to females ( Pfafflin & Junge 1998 ). Apart from it being generally easier for female-to-males to pass effectively in their chosen gender, they also tended to have less mental health problems pre-surgery.
Those whose transgender emerged from a previous phase of fetishistic transvestism or autogynephilia were more likely to regret reassignment or have more negative outcomes than those whose gender identity discordance was primary. The reasons for this are not established. Predictors of a poor outcome are personality problems of various kinds and a history of depression.
In general, these more recent reviews convey a more positive picture than those cited in the previous edition of this book, which was based on much more limited evidence. This may reflect more effective selection of suitable cases by referring clinicians as well as improvements in surgical techniques.
Overall, there is strong support for gender reassignment improving the mental health and quality of life for both male-to-female and female-to-male transgendered individuals. However, surgical reassignment is only part of the reassignment process, and careful selection of those who are recommended for surgical reassignment is important and will be considered more closely in the following section.
Case history-taking
Peter Conway Dip Phyt MNIMH MCPP Cert Ed , in The Consultation in Phytotherapy , 2011
This is usually obvious and doesn't need to be asked. However, transsexual (or transgender) people and people who have had gender reassignment surgery will usually prefer to be classed in their ‘target’ sex (i.e. the sex they perceive themselves as, or have undergone surgery to become, rather than the sex they were born as, which is known as the ‘assigned’ sex). To be respectful towards the patient and to avoid confusion, the practitioner can record the patient's target sex as their definitive sex and then in brackets show the ‘assigned-to-target’ sexes so that for a person who was born male but who self-identifies as a female, the note would be: Female (male-to-female). This can be alternatively written as: F (M2F).
Ervin Kocjancic , Valerio Iacovelli , in Encyclopedia of Reproduction (Second Edition) , 2018
Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery.
Gender reassignment surgery represents one of many therapies for transgender individuals with gender dysphoria and it can be pivotal in allowing individuals to become their true selves. Surgical procedures for the natal female subject being affirmed as a male subject can include genital reconstruction often paired with a combination of other hormonal and surgical interventions. This paper represents an evolution of surgical techniques, as well as a framework around which surgical therapies are based to allow for these transformations. While techniques will continue to advance, an understanding of the surgical principles is fundamental to this process.
Facial feminization surgery
Jeffrey Weinzweig , Stephen B. Baker , in Aesthetic Surgery of the Facial Skeleton , 2022
Introduction
Almost 40 years ago, Dr. Douglas Ousterhout pioneered the field of facial feminization surgery (FFS) when, in 1982, Dr. Darrell Pratt, a plastic surgeon who performed gender reassignment surgery (GRS), conveyed the request of a male-to-female transgender patient who wished to have more feminine facial features as people still reacted to her as though she were a man despite her GRS. That request opened the door to a new world in which techniques of transforming the larger, more angular male features to smaller, softer, more feminine female features evolved and progressed with the goal of matching one’s external appearance with the internal perception of oneself.
Sociocultural and Individual Differences
James N. Butcher , ... Moshe Almagor , in Comprehensive Clinical Psychology , 1998
(i) Australia
In addition to rating the adequacy of the information provided in the narrative reports, raters estimated the percentage of statements they considered to be accurate descriptions of their patients ( Figure 1 ). Two-thirds (66%) of reports on Australian patients were rated as having 80–100% accuracy, while 87% were rated as having more than 60% accuracy. Only 2% were rated as having less than 20% accuracy. As noted above, a large number of patients in the study (46) were gender-dysphoric clients undergoing evaluation for possible gender reassignment surgery . It might be hypothesized that their inclusion may have lowered the overall adequacy and accuracy ratings because of possible attempts by these patients to present themselves in an overly positive manner. This was not the case. There was no significant difference between the ratings of gender-dysphoric and other patients on the symptomatic pattern (t(157) = −0.53), the interpersonal relations (t(157) = 1.14), the diagnostic considerations (t (156) = 1.79) and the treatment considerations (t (154)= 0.46) sections of the reports. With respect to the two other ratings, the reports on the gender-dysphoric patients were actually rated more positively than those of the other patients (validity considerations, t(165) = −2.84, p < 0.01; overall accuracy, t for unequal variances (110) = −2.15, p < 0.05).
Care of Transgender/Gender Nonconforming Youth
Stephen M. Rosenthal , Amy B. Wisniewski , in Sperling Pediatric Endocrinology (Fifth Edition) , 2021
Outcomes and Potential Adverse Effects
Limited outcomes data are available based on current treatment models. As noted earlier, one published study has thus far evaluated mental health in transgender adolescents/young adults before and after GnRH agonist treatment, following gender-affirming sex steroid treatment, and 1 year after “ gender reassignment surgery .” 64 At the completion of the observation period, GD was resolved, general psychological functioning had improved, and a sense of “wellbeing” was observed to be equal or greater to that found in age-matched controls. In addition, none of the 55 study participants regretted treatment. 64
Potential adverse effects of pubertal suppression with GnRH agonists in transgender youth, as recently reviewed, include impaired bone mineral density (BMD) and compromised fertility. In addition, there are unclear effects on brain development, body mass index (BMI), and body composition. 79
With respect to skeletal health, a 6-year longitudinal study (that spanned the period of pubertal suppression, gender-affirming sex hormone treatment, and gonadectomy), observed a significant decrease in lumbar spine areal BMD z-scores (relative to natal sex) in transgender females, with a similar decrease, following pubertal suppression in transgender males. 80 Potential study limitations, as acknowledged by the authors, included a relatively small number of study participants, relatively low doses of sex hormones, and lack of information regarding other factors that can influence BMD, including vitamin D status, dietary calcium intake, and weight-bearing exercise. 80 During pubertal suppression with GnRH agonists in early pubertal transgender adolescents, it is recommended to monitor vitamin D status and supplement if necessary, and to encourage adequate dietary calcium intake and weight-bearing exercise. 22 In a separate study, bone turnover markers and bone mineral apparent density (BMAD) z-scores decreased, following GnRH agonist treatment in younger transgender adolescents, whereas an increase in BMAD was observed after 2 years of gender-affirming sex hormone treatment, in both younger and older transgender adolescents. 81 A 22-year follow-up study of a gender dysphoric adolescent, treated initially with GnRH agonist and subsequently with gender-affirming sex hormones, found that BMD was in the normal range for both sexes when evaluated at 35 years of age. 82
A discussion about implications for fertility must precede any treatment of gender dysphoric adolescents with either GnRH agonists or gender-affirming sex hormones. Transgender adolescents may wish to preserve fertility, which will likely be compromised if puberty is suppressed at an early stage, and the individual subsequently transitions with gender-affirming sex hormones. In vitro maturation of human germ cells has not yet been achieved, although some families elect to freeze a section of prepubertal gonadal tissue for potential future use. 83 Cryopreservation of mature sperm or eggs is an option for late pubertal/ fully pubertal adolescents. However, recent reports indicate that even when provided with counseling regarding potential impact of sex hormone treatment on fertility and options for fertility preservation, only a small percentage of such adolescents opted to pursue fertility preservation. 84,85 Questionnaires to assess fertility and fertility preservation attitudes in transgender youth and their parents have been recently developed. 86,87
With respect to brain function, few studies have thus far evaluated potential adverse effects of GnRH agonists in transgender adolescents. When comparing small groups of GnRH agonist-treated versus untreated transgender adolescents (both male-to female and female-to male), there was no significant compromise of executive functioning, a developmental milestone typically achieved during puberty. 88 A 28-month longitudinal study in one transgender adolescent, undergoing treatment with GnRH agonist, showed lack of expected variation in white matter fractional anisotropy, a measure of brain maturation thought to normally occur during puberty, as well as a 9-point drop in operational memory testing after 22 months of pubertal suppression. 89 Given this relative lack of data, further longitudinal studies are needed to assess the impact of GnRH agonist treatment on brain development and function in transgender adolescents.
Studies assessing the impact of GnRH agonist treatment on BMI and body composition have also been carried out. Although variable results have been observed with respect to BMI, 80,90 an increase in fat percentage and a decrease in lean body mass percentage, after 1 year of treatment with GnRH agonist, have been reported in both transgender male and female adolescents. 90 In a separate study, significant weight gain was reported in one of 27 transgender adolescents treated with GnRH agonist, although this individual’s BMI was noted to be greater than the 85 th percentile before treatment. 91
A small number of short-term studies have thus far evaluated potential adverse effects of gender-affirming sex hormones in transgender adolescents. No change in blood pressure, BMI standard deviation score, lean body mass percentage, or fat percentage were observed in a study from the Netherlands of 28 transgender females treated for 1 to 3 years, primarily with gradually increasing doses of 17 β-estradiol. 92 In addition, no abnormalities were observed with liver enzymes or creatinine, and there was no change in hematocrit or hemoglobin A1c. Hyperprolactinemia was observed in one individual who had received high-dose ethinyl estradiol treatment to limit statural growth. 92
Two studies from the United States have assessed potential adverse effects of gender-affirming sex hormones in transgender adolescents and young adults. Following treatment with 17 β-estradiol in 44 transgender females, no abnormalities were seen in blood pressure, BMI, hemoglobin/hematocrit, lipids, renal and liver function studies, or in prolactin. 93 Following treatment with testosterone in 72 transgender males, there was an increase in BMI and in hemoglobin/hematocrit (supraphysiologic hematocrit levels were seen in 4% of the individuals) and a decrease in high-density lipoprotein cholesterol levels; no abnormalities were seen in blood pressure, renal and liver function studies, or in hemoglobin A1c. 93 A separate prospective study, after 21 to 31 months of treatment with gender-affirming hormones in 25 transfeminine and 34 transmasculine individuals, showed no clinically significant adverse effects in a variety of metabolic parameters. 94
Advances in Pediatrics
Marni E. Axelrad PhD , ... Lefkothea P. Karaviti MD, PhD , in Advances in Pediatrics , 2009
The decision to perform gender reassignment surgery has become more complex in recent years. Historically, the consensus was that ambiguous genitalia, left uncorrected, would cause the patient unnecessary psychological distress. Hence, an immediate decision was made concerning the child's sex, and surgery was performed accordingly. Today, however, genital surgery is 1 of the most controversial decisions in managing patients with DSDs [59] . Many researchers and advocate groups question the earlier approach and advocate postponing surgery until the patient can be involved in making the decision [60,61] . Numerous arguments have been posited to delay feminizing genital surgery in young children. One such argument is that many patients require further surgery in adolescence [62] ; another is that ablative surgery, such as clitoroplasty and clitorectomy, may impair later sexual function [63,64] . Some activist groups also argue strongly against performing surgery, charging that cosmetic genital surgery on infants with DSDs violates their human rights and subordinates the value of sexual pleasure or notions of heterosexual normality [65] , whereas others have challenged their position [66] .
Genital reconstruction for the transgendered individual
Marta R. Bizic , ... Miroslav L. Djordjevic , in Journal of Pediatric Urology , 2017
Metoidioplasty
Metoidioplasty is a technically demanding and challenging surgical procedure used in female transsexuals who want gender reassignment surgery without a complex, multistaged surgical creation, of an adult-size phallus [3,10] . The native female urethra is lengthened to reach the tip of the glans, as in males, allowing voiding while standing, and the scrotum is created from the labia majora with two inserted testicular prostheses.
A new type of genital reconstruction in female transgenders using the hormonally enlarged clitoris was first reported by Durfee and Rowland [11] . The term metoidioplasty was introduced later by Laub et al. [12] deriving from Greek words “meta” meaning “toward” and “oidion” meaning “male genitalia”. They defined the procedure as a creation of a small neophallus, insufficient for penetrative sexual intercourse but with the ability of voiding while standing in the majority of subjects operated on and reported good results in the appearance of external genitalia, with a more male-like configuration. In their series, as the urethral plate remained intact, the neophallus was usually small and curved [13] . Hage [14] introduced refinements into modified metoidioplasty characterized by urethral lengthening. Urethroplasty was based on using both the labia minora and the urethral plate, which was divided at the level of the female urethral opening [14] . Since the course of dissection was from proximal to distal, there was a risk of compromising the vascularization of the mobilized urethral plate, resulting in a high complication rate in long term follow-up. Finally, he concluded that an average of 2.6 surgical procedures per patient was needed for a successful outcome of the surgery [15] .
Metoidioplasty is performed as a one-stage procedure in our center together with the removal of female reproductive organs and vaginectomy, as well as urethroplasty and scrotoplasty with implantation of testicular prostheses. The first results showed a high success rate in esthetic and functional points in the majority of patients [16] . Since the main complications were related to urethral reconstruction, we continued searching for a better solution resulting in improved Belgrade metoidioplasty. The technique is based on clitoral lengthening by dissection of the clitoral ligaments dorsally and the short urethral plate ventrally. Bulbar urethral reconstruction is performed using part of the anterior vaginal wall and the proximal part of the urethral plate. To avoid the described complications following tubularized urethroplasty, a buccal mucosa graft is used as the dorsal half of the neourethra. A well-vascularized recipient site provides a good blood supply and prevents contraction of the graft. Covering of the buccal mucosa graft is performed using either a longitudinal dorsal clitoral skin flap or a flap harvested from the inner surface of the labia minora. In both approaches, well-vascularized tissue completely covers all suture lines, preventing fistula formation. A longitudinal island skin flap is harvested from dorsal clitoral skin and buttonholed ventrally, to join with the dorsal buccal mucosa. This approach is similar to the urethral reconstruction in severe hypospadias with ventral curvature, where the urethra is reconstructed using a buccal mucosa graft and island skin flap originating from dorsal penile skin [17] . This technique usually leaves the remaining clitoral skin insufficient for neophallic shaft reconstruction. Also, the length of the flap is related to the available hairless dorsal skin that could prove insufficient for complete urethral lengthening. On the other hand, the labia minora are always available for flap creation. They are hairless and elastic, with a very good blood supply. This abundant blood supply to the labia minora enables the creation of a very long, vascularized labia minora skin flap for urethral reconstruction leaving the other labia intact and useful for neophallic shaft reconstruction. Reconstruction is completed with scrotal reconstruction and insertion of testicular implants ( Fig. 1 ). Overall satisfaction is noted in most patients, as male genitalia appearance and voiding while standing are achieved after a one-stage surgery. Urethral fistula and stricture occurred in only 7.72% and 2.89%, respectively. The length of the neophallus ranged from 4 to 10 cm, which was not adequate for penetration during sexual intercourse, and total phalloplasty could be subsequently added depending on the patient's sexual preferences [18,19] .
Figure 1 . Male-like appearance of genitalia is achieved one year after one-stage metoidioplasty.
An Update on the Surgical Treatment for Transgender Patients
Britt Colebunders MD , ... Stan Monstrey MD, PhD , in Sexual Medicine Reviews , 2017
As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options.
To review current gender reassignment surgical techniques and update the clinician.
A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery .
Main Outcome Measures
Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap.
Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures.
Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap.
- Reconstructive Procedures
Gender Affirmation Surgeries Transgender-Specific Facial, Top and Bottom Procedures
What surgical options are available to transgender and gender non-conforming patients? Gender affirmation surgeries, also known as gender confirmation surgeries, are performed by a multispecialty team that typically includes board-certified plastic surgeons. The goal is to give transgender individuals the physical appearance and functional abilities of the gender they know themselves to be. Listed below are many of the available procedures for transwomen (MTF) and transmen (FTM) to aid in their journey.
Facial Feminization Surgery
Transfeminine top surgery, transfeminine bottom surgery, facial masculinization surgery, transmasculine top surgery, transmasculine bottom surgery, on the blog.
Facial feminization surgery is a combination of procedures designed to soften the facial features and feminize the face. There are many procedures that are available to feminize the face.
- Facial feminization surgery improves gender dysphoria in trans women Josef Hadeed, MD, FACS
- The impact of COVID-19 on gender dysphoria patients Cristiane Ueno, MD
On The Vlog
Facial feminization surgery is always tailored to the individual, but as ASPS member Justine Lee, MD, PhD, explains there are general characteristics such as hairline, brow bones, cheeks and jawline that many patients note and plastic surgeons plan for.
- Gender Affirmation Top Surgery with Dr. Julie Hansen
Find Your Surgeon
Patient care center, before & after photos.
Video Gallery
3d animations, patient safety.
An official website of the United States government
The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.
The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
- Publications
- Account settings
- Advanced Search
- Journal List
- Dtsch Arztebl Int
- v.111(47); 2014 Nov
Satisfaction With Male-to-Female Gender Reassignment Surgery
Jochen hess.
1 Department of Urology at the University Hospital Essen
Roberto Rossi Neto
2 Clinica Urologia, General Hospital Ernesto Simoes Filho, Salvador, Brasilien
Herbert Rübben
Wolfgang senf.
3 Department of Psychosomatic Medicine and Psychotherapy, University of Essen
The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery.
254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital’s Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction.
119 (46.9%) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1–7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now.
The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.
Culturally, gender is considered an obvious, unambiguous dichotomy. The term “gender identity” denotes the consistency of one’s emotional and cognitive experience of one’s own gender and the objective manifestations of a particular gender. In gender identity disorder, one’s own anatomical sex is objectively perceived but is felt to be alien, whereas the term “gender incongruence” refers to a difference between an individual’s gender identity and prevailing cultural norms. Finally, gender dysphoria is the suffering that results. The treatment guidelines of the World Professional Association of Transgender Health (WPATH) state that gender identity need not coincide with anatomical sex as determined at birth. Transgender identity should therefore be considered neither negative nor pathological ( 1 ). Unfortunately, gender incongruence often leads to discrimination against the affected individual, which can favor the development of psychological complaints such as anxiety disorders and depression ( 2 – 4 ). While some transgender individuals are able to realize their gender identity without surgery, for many gender reassignment surgery is an essential, medically necessary step in the treatment of their gender dysphoria ( 5 ). Research conducted to date has shown that gender reassignment surgery has a positive effect on subjective wellbeing and sexual function ( 2 , 6 , 7 ). The surgical procedure (penile inversion with sensitive clitoroplasty) is described in eBox 1 .
Surgical procedure for penile inversion vaginoplasty
- Open the scrotum.
- Remove both testicles, including the spermatic cord, from the superficial inguinal ring.
- Make a circular cut around the skin of the shaft of the penis under the glans and prepare the skin of the shaft of the penis as far as the base of the penis.
- Separate the urethra from the erectile tissue.
- Separate the neurovascular bundle from the erectile tissue.
- Perform bilateral resection of the erectile tissue.
- Create a space for the neovagina between the rectum and urethra or prostate (the prostate is left intact).
- Invert the skin of the shaft of the penis and close the distal end.
- Insert a placeholder into the neovagina (= the inverted skin of the shaft of the penis).
- Create passages for the neoclitoris (former glans penis) and urethra and then fix in place.
- Inject fibrin glue into the neovagina.
- Position the neovagina, including the placeholder.
- Adjust the labia majora.
- During a second operation six to eight weeks after the first, the vaginal entrance is constructed and minor plastic corrections are made if necessary.
Surgery lasts an average of approximately 3.5 hours. Preservation of the neurovascular bundle results in a sensitive clitoroplasty. The most common complications in short-term postoperative recovery include superficial wound healing problems around the external sutures. In the medium and long term there is a risk of loss of depth ( 23 , 24 , 30 , e15 , e23 , e25 ) or breadth ( 24 , 30 , e11 , e19 , e25 ) of the neovagina in particular. These problems usually result from inconsistent dilatation ( e27 ).
No official figures are available on the prevalence of transgender or gender-nonconforming individuals, and it is very difficult to arrive at a realistic estimate. There is no central reporting register in Germany. Furthermore, figures for those who seek medical help for gender dysphoria would in any case give only an imprecise idea of the true prevalence. The global prevalence of transgender individuals has been estimated at approximately 1 per 11 900 to 1 per 45 000 for male-to-female individuals and approximately 1 per 30 400 to 1 per 200 000 for female-to-male individuals ( 1 ). Weitze and Osburg estimate prevalence in Germany at 1 per 42 000 ( 8 ). In contrast, De Cuypere et al. ( 9 ) suppose a prevalence of 1 per 12 900 for Belgium. Biosnich et al. ( 10 ) estimate prevalence among US veterans at 1 per 4366. This compares to an estimated prevalence of 1 per 23 255 in the general population. Even if percentages of transgender individuals in different parts of the world are comparable, it is highly likely that cultural differences will lead to differing behavior and expression of gender identity, resulting in differing levels of gender dysphoria ( 1 ). The ratio of male-to-female to female-to-male transgender individuals varies greatly. Although it was given as approximately 3:1 by van Kesteren ( 11 ), it is 2.3:1 according to Weitze and Osburg ( 8 ) and 1.4:1 according to Dhejne ( 3 ). Garrels ( 12 ) found a gradual decrease in the difference between the two figures in Germany, with the ratio decreasing from 3.5:1 (in the 1950s and 60s) to 1.2:1 (1995 to 1998) ( Table 1 ).
MTF: male-to-female; FTM: female-to-male
Criteria for diagnosis
Transsexualism is primarily a problem of gender identity (transidentity) or gender role (transgenderism) rather than of sexuality ( 13 ). In Germany, it is diagnosed according to ICD-10 (10 th revision of the International Statistical Classification of Diseases and Related Health Problems).
Criteria for diagnosis include the following:
- Feeling of unease or not belonging to biological gender
- Desire to live and be accepted as a member of the opposite sex
- Presence of this desire for at least two years persistently
- Wish for hormonal treatment and surgery
- Not a symptom of another mental disorder
- Not associated with intersex, genetic, or gender chromosomal abnormalities.
Psychological aspects of transsexualism
According to Senf, no disruption to an individual’s identity is comparable in scale to the development of transsexualism ( 14 ). Transsexualism is a dynamic, biopsychosocial process which those affected cannot escape. An affected individual gradually becomes aware that he or she is living in the wrong body. The feeling of belonging to the opposite sex is experienced as an unchangeable, unequivocal identity ( 14 , 15 ). The individual therefore strives to change his or her inner identity. This change is associated with a change in psychosocial role, and in most cases with hormonal and/or surgical reassignment of the body to the desired gender ( 14 ). Coping with the development of transsexualism poses enormous challenges to those affected and often leads to a considerable psychological burden. In some cases this results in mental illness. Transsexualism itself need not lead to a mental disorder ( 14 ). Psychotherapeutic support is beneficial and is a major part of standard treatment and the examination of transsexual individuals in Germany ( 15 ).
This study aimed to evaluate the effect of male-to-female gender reassignment surgery on the satisfaction of transgender patients.
Data collection
Retrospective inquiry involved consecutive inclusion of 254 patients who had undergone male-to-female gender reassignment surgery involving penile inversion vaginoplasty at Essen University Hospital’s Department of Urology between 2004 and 2010. All patients received a questionnaire ( eBox 2 ) by post, with a franked return envelope. The questions were contained within a follow-up questionnaire developed by Essen University Hospital’s Department of Urology ( 16 ). Because the process was anonymized, patients who had not sent back the questionnaire could not be contacted. The diagnosis of “transidentity” had been made previously following specialized medical examination and in accordance with ICD-10.
Questionnaire
1. How satisfied are you with your outward appearance?
A) Very satisfied
B) Satisfied
C) Dissatisfied
D) Very dissatisfied
2. How satisfied were you with the gender reassignment surgery process?
C) Mostly satisfied
D) Dissatisfied
E) Very dissatisfied
3. How satisfied are you with the aesthetic outcome of your surgery?
4. How satisfied are you with the functional outcome of your surgery?
5. How satisfied are you with your life now, on a scale from 1 (very dissatisfied) to 10 (very satisfied)?
6. How do you see yourself today?
A) As a woman
B) More female than male
C) More male than female
D) As a man
7. Do you feel accepted as a woman by society?
A) Yes, completely
D) No/Not sure
8. Has your life become easier since surgery?
B) Somewhat easier
C) Somewhat harder
9. Have your expectations of life as a woman been fulfilled?
C) Mostly not
D) Not at all
10. How easy is it for you to achieve orgasm?
A) Very easy
B) Usually easy
C) Rarely easy
D) Never achieve orgasm
11. If you compare your orgasm earlier as a man and now as a woman, what is your orgasm like now?
A) More intense
B) Equally/Roughly equally intense
C) Less intense
Statistical evaluation was performed using SPSS (Statistical Package for the Social Sciences, 17.0). Correlation analyses were performed using SAS (Statistical Analysis System, 9.1 for Windows). The distribution of categorical and ordinal data was described using absolute and relative frequencies. Fisher’s exact test was used to compare categorical and ordinal variables in independent samples. The Mann–Whitney U-test was used to compare satisfaction scale distribution of two independent samples. This nonparametric test was used in preference to the t -test because the Shapiro–Wilk test indicated that distribution was not normal. Spearman’s correlation analysis was performed.
A total of 119 completed questionnaires were returned, all of which were included in the evaluation. This represents a response rate of 46.9%. Because the questionnaires were anonymous, no data on patients’ ages could be obtained. The average age of a comparable cohort of patients at Essen University Hospital’s Department of Urology between 1995 and 2008 ( 17 ) was 36.7 years (16 to 68 years). The median time since surgery was 5.05 years (standard deviation: 1.6 years; range: 1 to 7 years). Not all patients had completed the questionnaire in full, so for some questions the total number of responses is not 119.
Following surgery, 63 of 103 patients (61.2%) were satisfied with their outward appearance as women, and a further 27 (26.2%) were very satisfied ( Figure 1 ). 45.5% ( n = 50) were very satisfied with the gender reassignment surgery process, 30% ( n = 33) satisfied, 22.7% ( n = 25) mostly satisfied, and 1.8% ( n = 2) dissatisfied. Figure 2 shows the high rates of subjective satisfaction with the aesthetic outcome of surgery. Overall, approximately three-quarters (70 of 94 responses) reported that they were satisfied or very satisfied. A further 21 (22.3%) were mostly satisfied. Figures for satisfaction with the functional outcome of surgery were similar ( Figure 3 ). A total of 67 of 93 respondents (72%) were satisfied or very satisfied. A further 18 patients (19.4%) were mostly satisfied. Table 2 compares the rates of subjective satisfaction with aesthetic and functional outcome with other studies.
How satisfied are you with your outward appearance? (103 responses)
How satisfied are you with the aesthetic outcome of your surgery? (94 responses)
How satisfied are you with the functional outcome of your surgery? (93 responses)
*1 Functional satisfaction includes satisfaction with depth and breadth of the neovagina and satisfaction with penetration or intercourse
*2 Aesthetic satisfaction includes satisfaction with appearance of external genitalia
In order to gather information on patients’ general satisfaction with their lives, they were asked to place themselves on a Likert scale ranging from 1 (“very dissatisfied”) to 10 (“very satisfied”). Of the total of 102 respondents, 7 (6.9 percent) selected scores from 1 to 3 (2 × 1, 1 × 2, 4 × 3) and 39 (38.2%) scores from 4 to 7 (4 × 4, 16 × 5, 8 × 6, 11 × 7). 56 patients (54.9%) placed themselves in the top third (32 × 8, 13 × 9, 11 × 10). 88 of 103 participants (85.4%) felt completely female following surgery, and 11 (10.7%) mostly female ( Figure 4 ). 69 of 102 women (67.6%) saw themselves as fully accepted as women by society, 25 (24.5%) mostly, and 6 (5.9%) rarely. Two women (2.0%) were not sure of their answer to this question. Of 95 respondents, 65 (68.4%) answered with a clear “Yes” that their life had become easier since surgery. 14 (14.7%) found life somewhat easier, 9 (9.5%) somewhat harder, and 7 (7.4%) harder. Expectations of life as a woman were completely fulfilled for 51 of 102 (50.0%) women, and mostly for 41 (40.2%). The expectations of 6 (5.9%) patients were mostly not fulfilled, and those of 4 (3.9%) were not fulfilled at all.
How do you see yourself today? (103 responses)
There was a correlation between self-perception as a woman (“How do you see yourself today?”) and perceived acceptance by society ( r = 0.495; p <0.01). There was also a correlation between self-perception and answers to whether life had become easier since surgery ( r = 0.375; p <0.01) and whether expectations of life as a woman had been fulfilled ( r = 0.419; p <0.01). Patients who saw themselves completely as women reported higher scores for current satisfaction with their lives than patients who only saw themselves as more female than male ( r = 0.347; p <0.01).
Patients were asked how easy they found it to achieve orgasm. A total of 91 participants answered this question: 75 (82.4%) reported that they could achieve orgasm. Of these, 19 (20.9%) still achieved orgasm very easily, 39 (42.9%) usually easily, and 17 (18.7%) rarely easily. Participants were also asked to compare their experience of orgasm before and after surgery (more intense/the same/less intense). Over half of those who answered this question (43 of 77, 55.8%) experienced more intense orgasm postoperatively, and 16 patients (20.8%) experienced the same intensity.
According to Sohn et al. ( 18 ), subjective satisfaction rates of 80% can be expected following gender reassignment surgery. Löwenberg ( 19 ) reported 92% general satisfaction with the outcome of gender reassignment surgery. The study by Imbimbo et al. ( 20 ) found a similarly high satisfaction rate (94%); however, subjective assessment of general satisfaction and the question of whether or not patients regretted the decision to undergo gender reassignment surgery were queried in one combined question. It is likely that most patients do not actually regret their decision to undergo surgery, even though general postoperative satisfaction is limited. Löwenberg’s figures also show this ( 19 ): 69% of those asked were satisfied with their overall life situation, but 96% would opt for surgery again. In the authors’ own study population, general satisfaction with surgery was achieved in 87.4% of patients. Regardless of surgical results, over half of patients (54.9%) were in the top third (“completely satisfied”) and a further 38.2% in the middle third (“fairly satisfied”) of the general life satisfaction scale.
A retrospective survey performed by Happich ( 21 ) found more than 90% satisfaction with gender reassignment. Sexual experience following surgery is a very important factor in satisfaction with gender reassignment. It depends essentially on the functionality of the neovagina. Figures for satisfaction with functional outcome range from 56% to 84% ( 16 , 19 , 20 , 22 , 23 ). In the authors’ population, satisfaction with function was 72% (“very satisfied” and “satisfied”) or 91.4% (including also “mostly satisfied”). According to Happich ( 21 ), satisfaction with sexual experience is positively correlated with satisfaction with outcome of surgery. Other studies ( 16 , 23 – 25 ) have also found surgical outcome to be one of the essential factors in postoperative satisfaction. Löwenberg ( 19 ) also found a correlation between satisfaction with surgery and satisfaction with aesthetic appearance of the external genitalia. In our study, almost all patients (98.2%) were satisfied with the gender reassignment surgery process ( n = 50, 45.5% “very satisfied”; n = 33, 30% “satisfied”; n = 25, 22.7% “mostly satisfied”).
The Imbimbo et al. working group ( 20 ) reported 78% satisfaction with aesthetic appearance of the neogenitalia (36% “very satisfied,” 32% “satisfied,” 10% “mostly satisfied”). Happich found 82.1% satisfaction with outcome of surgery (46 of 56 patients). Of these, 33.9% of patients reported high satisfaction and 48.2% good to medium satisfaction ( 21 ). A similar value was obtained in the survey by Hepp et al. ( 22 ). Löwenberg ( 19 ) found higher values (94%) for satisfaction with aesthetic outcome of surgery. This population included 106 male-to-female transgender individuals who underwent surgery at Essen University Hospital’s Department of Urology between 1997 and 2003. In the population described here (254 patients, 2004 to 2010) satisfaction with aesthetic outcome was still higher (96.8%).
Orgasm was possible for 82.4% of study participants. The ability to achieve orgasm was lower than in an earlier study population ( 16 ). Figures in the literature vary widely (29% to 100%) and sometimes include small case numbers ( Table 3 ). Overall, the figures for this study match those of comparable studies of a similar size. Finally, it is not clear why more than half the participants experienced orgasm more intensely following surgery than preoperatively. One possible explanation is that postoperatively patients were able to experience orgasm in a body that matched their perception.
Limitations
The response rate of less than 50% must be mentioned as a shortcoming of this study. This may have led to a bias in the results. If all patients who did not take part in the survey were dissatisfied, up to 50.1% and 54.6% would be dissatisfied with aesthetic or functional outcome respectively. According to Eicher, the suicide rate in transgender individuals following successful surgery is no higher than in the general population ( 26 ), so suicide is a very unlikely reason for nonparticipation. Contacting transfemale patients for long-term follow-up after successful surgery is generally difficult (2, 3, 22, 23, 25, 27, 28). This may be because a patient has moved since successful surgery, for example, ( 21 ). Postoperative contact is particularly difficult in countries such as Germany which have no central registers. Response rates to surveys in retrospective research are between 19% ( 28 ) and 79% ( 29 ). Goddard et al. obtained a response rate of 30% in a retrospective survey following gender reassignment surgery ( 30 ). A follow-up survey performed by Löwenberg et al. had a similar response rate, 49% ( 19 ). It is also possible that the positive results of our survey represent patients’ wish for social desirability rather than the real situation. However, this cannot be verified retrospectively.
Taking into account the limitations mentioned above, the high rates of subjective satisfaction with outward female appearance and with aesthetic and functional outcome of surgery indicate that the study participants benefited from gender reassignment surgery.
Key Messages
- At the core of the transsexual experience lies the awareness that one is a member of a realistically perceived anatomical sex (matching of genotype and phenotype), but a subjective feeling of belonging to the other gender.
- Change to the gender inwardly identified with is associated with a change in psychosocial role and in most cases with hormonal and surgical reassignment of the body to the desired gender.
- Although transsexualism itself is not a mental disorder, it can favor the development of mental problems.
- Transsexualism is a dynamic, biopsychosocial process which affected individuals cannot escape.
- The high rates of subjective satisfaction with outward female appearance and with aesthetic and functional outcome of surgery indicate that study participants benefited from gender reassignment surgery.
Acknowledgments
Translated from the original German by Caroline Devitt, M.A.
Conflict of interest statement
Dr. Hess has received reimbursement of conference fees and travel expenses from AMS American Medical Systems.
The other authors declare that no conflict of interest exists.
- Advice and guidance
- Our projects
- Our research
- Publications library
- Legal case search
- Legal responses
- Legal casework
- Inquiries and investigations
- What are human rights?
- The Human Rights Act
- Exercising your human rights
- Our human rights work
- Equality Act 2010
- Know your rights
- Protected characteristics
- Equality Act FAQs
- Corporate reporting
- Equality Act
Gender reassignment discrimination
- Your rights under the Equality Act 2010
- Age discrimination
- Disability discrimination
- Marriage and civil partnership discrimination
- Pregnancy and maternity discrimination
- Race discrimination
- Religion or belief discrimination
- Sex discrimination
- Sexual orientation discrimination
Human Rights in Action
What is on this page?
What is gender reassignment discrimination, what the equality act says about gender reassignment discrimination, different types of gender reassignment discrimination, circumstances when being treated differently due to gender reassignment is lawful, who is this page for.
- individuals using a service
- any organisation using a service
- public sector
Which countries is it relevant to?
Great Britain
On this page we have used plain English to help explain legal terms. This does not change the meaning of the law.
The Equality Act 2010 uses the term ‘transsexual’ for individuals who have the protected characteristic of gender reassignment. We recognise that some people consider this term outdated, so we have used the term ‘trans’ to refer to a person who has the protected characteristic of gender reassignment. However, we note that some people who identify as trans may not fall within the legal definition.
This page is subject to updates due to the evolving nature of some of the issues highlighted.
This is when you are treated differently because you are trans in one of the situations covered by the Equality Act . The treatment could be a one-off action or as a result of a rule or policy. It doesn’t have to be intentional to be unlawful.
There are some circumstances when being treated differently due to being trans is lawful. These are explained below.
See more videos like this in the equality law: discrimination explained playlist on YouTube (opens in new window) .
The Equality Act 2010 says that you must not be discriminated against because of gender reassignment.
In the Equality Act, gender reassignment means proposing to undergo, undergoing or having undergone a process to reassign your sex.
To be protected from gender reassignment discrimination, you do not need to have undergone any medical treatment or surgery to change from your birth sex to your preferred gender.
You can be at any stage in the transition process, from proposing to reassign your sex, undergoing a process of reassignment, or having completed it. It does not matter whether or not you have applied for or obtained a Gender Recognition Certificate, which is the document that confirms the change of a person's legal sex.
For example, a person who was born female and decides to spend the rest of their life as a man, and a person who was born male and has been living as a woman for some time and obtained a Gender Recognition Certificate, both have the protected characteristic of gender reassignment.
There are four types of gender reassignment discrimination.
Direct discrimination
This happens when someone treats you worse than another person in a similar situation because you are trans. For example:
- you inform your employer that you intend to spend the rest of your life living as the opposite sex. If your employer alters your role against your wishes to avoid you having contact with clients, this would be direct gender reassignment discrimination.
The Equality Act says that you must not be directly discriminated against because:
- you have the protected characteristic of gender reassignment. A wide range of people identify as trans. However, you are not protected under the Equality Act unless you have proposed, started or completed a process to change your sex.
- someone thinks you have the protected characteristic of gender reassignment. For example, because you occasionally cross-dress or do not conform to gender stereotypes (this is known as discrimination by perception).
- you are connected to a person who has the protected characteristic of gender reassignment, or someone wrongly thought to have this protected characteristic (this is known as discrimination by association).
Absences from work
If you are absent from work because of your gender reassignment, your employer cannot treat you worse than you would be treated if you were absent:
- due to an illness or injury. For example, your employer cannot pay you less than you would have received if you were off sick.
- due to some other reason. However, in this case it is only discrimination if your employer is acting unreasonably. For example, if your employer would agree to a request for time off for someone to attend their child’s graduation ceremony, then it may be unreasonable to refuse you time off for part of a gender reassignment process. This would include, for example, time off for counselling.
Indirect discrimination
This happens when an organisation has a particular policy or way of working that puts people with the protected characteristic of gender reassignment at a disadvantage.
Sometimes indirect gender reassignment discrimination can be permitted if the organisation or employer is able to show that there is a good reason for the discrimination. This is known as objective justification . For example:
- An employer has a practice of starting induction sessions for new staff with an ice-breaker designed to introduce everyone in the room to each other. Each worker is required to provide a picture of themselves as a toddler. One worker is a trans woman who does not wish her colleagues to know that she was brought up as a boy, so she does not bring her photo and is criticised by the employer in front of the group for not joining in. The same approach is taken for all new staff, but it puts people with the protected characteristic of gender reassignment at a particular disadvantage. This would be unlawful indirect discrimination unless the employer could show that the practice was justified.
Harassment is when someone makes you feel humiliated, offended or degraded for reasons related to gender reassignment. For example:
- a person who has undergone male-to-female gender reassignment is having a drink in a pub with friends and the landlord keeps calling her ‘sir’ or ‘he’ when serving drinks, despite her complaining about it.
Harassment can never be justified. However, if an organisation or employer can show it did everything it could to prevent people who work for it from harassing you, you will not be able to make a claim for harassment against the organisation, only against the harasser.
Victimisation
This is when you are treated badly because you have made a complaint of gender reassignment discrimination under the Equality Act. It can also occur if you are supporting someone who has made a complaint of gender reassignment discrimination. For example:
- a person proposing to undergo gender reassignment is being harassed by a colleague at work. He makes a complaint about the way his colleague is treating him and is sacked.
A difference in treatment may sometimes be lawful. This will be the case where the circumstances fall under one of the exceptions in the Equality Act that allow organisations to provide different treatment or services on the basis of gender reassignment. For example:
- competitive sports: a sports organisation restricts participation because of gender reassignment. For example, the organisers of a women’s triathlon event decide to exclude a trans woman with a Gender Recognition Certificate as they think her strength or stamina gives her an unfair advantage. However, the organisers would need to be able to show that this was necessary to make the event fair or safe for everyone.
- a service provider provides single-sex services. The Equality Act allows a lawfully established separate or single-sex service provider to prevent, limit or modify people’s access on the basis of gender reassignment in some circumstances. However, limiting or modifying access to, or excluding a trans person from, the separate or single-sex service of the gender in which they present will be unlawful if you cannot show such action is a proportionate means of achieving a legitimate aim. This applies whether or not the person has a Gender Recognition Certificate.
Updated: 23 Feb 2023
- Removed paragraph on language recommendations made by Women and Equalities Committee (WEC) in 2016
- Removed the term ‘transsexual’ as per WEC 2016 recommendations
- Added paragraph explaining use of plain English in the guidance
- Removed a paragraph on intersex people not being explicitly protected from discrimination by the Equality Act
Last updated: 23 Feb 2023
Further information
If you think you might have been treated unfairly and want further advice, you can contact the Equality Advisory and Support Service .
Phone: 0808 800 0082 Textphone: 0808 800 0084
You can email using the contact form on the EASS website .
Also available through the website are BSL interpretation, web chat services and a contact us form.
Post: FREEPOST EASS HELPLINE FPN6521
Opening hours:
9am to 7pm Monday to Friday 10am to 2pm Saturday closed on Sundays and Bank Holidays
Alternatively, you can visit our advice and guidance page .
- University of California, San Francisco
- Search UCSF
- UCSF Medical Center
- For Providers
- UCSF Transgender Care & Treatment Guidelines
Overview of gender-affirming treatments and procedures
Supporting evidence for providing gender-affirming treatments and procedures.
Transgender people may seek any one of a number of gender-affirming interventions, including hormone therapy, surgery, facial hair removal, interventions for the modification of speech and communication, and behavioral adaptations such as genital tucking or packing, or chest binding. All of these procedures have been defined as medically necessary by the World Professional Association for Transgender Health.[1] Lower quality research has found improvements in a range of psychosocial measures after gender-affirming treatments such as hormones or surgery.[2-5] Sevelius' Model of Gender Affirmation describes the ways in which denial of access to gender affirmation is associated with high risk behaviors and increased rates of HIV infection.[6] Conversely, not all transgender people seek all interventions, and some may seek none. In contrast to past practices in which a set pathway involved a requirement of psychological assessment → hormones → genital surgery, the current standard of care is to allow each transgender person to seek only those interventions which they desire to affirm their own gender identity.[7]
Medical interventions
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people. Such treatment allows the acquisition of secondary sex characteristics more aligned with an individual's gender identity.
Surgical interventions
A wide range of gender-affirming surgeries are available to transgender people. These include surgeries specific to gender affirmation, as well as procedures commonly performed in non-transgender populations.
Surgeries specific to transgender populations:
- Feminizing vaginoplasty
- Masculinizing phalloplasty / scrotoplasty
- Metoidioplasty (clitoral release/enlargement, may include urethral lengthening
- Masculinizing chest surgery ("top" surgery)
- Facial feminization procedures
- Reduction thyrochondroplasty (tracheal cartilage shave)
- Voice surgery
Surgeries not specific to transgender populations:
- Augmentation mammoplasty
- Hysterectomy / oophorectomy
- Orchiectomy
- Vaginectomy
Other interventions:
Other interventions include:
- Facial hair removal
- Voice modification
- Genital tucking and packing, and chest binding
- WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide WPATH . Transgender Health Information Program. [cited 2014 Jan 21].
- Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology. 2012 May;37(5):662-70.
- Meier SLC, Fitzgerald KM, Pardo ST, Babcock J. The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. J Gay Lesbian Ment Health. 2011;15(3):281-99.
- Newfield E, Hart S, Dibble S, Kohler L. Female-to-male transgender quality of life. Qual Life Res. 2006 Jun 7;15(9):1447-57.
- White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender Health. 2016 Jan 13;1(1):21-31.
- Sevelius JM. Gender Affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013 Jun 1;68(11-12):675-89.
- Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgenderism. 2012;13(4):165-232.
Medical Referral Disclaimer
The CoE is unable to respond to individual patient requests for medical guidance. If you need medical advice, please contact your local primary care provider. If you need clarification, seek a second opinion locally or have your provider contact us for more information.
COVID-19 Updates
Masks are required inside all of our care facilities . We are vaccinating all eligible patients. Learn more:
Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus
Find more COVID-19 testing locations on Maryland.gov .
Popular Searches
- new strain of coronavirus
- coronavirus vaccine
- coronavirus
- medical records
- insurance accepted
- telemedicine
Gender Affirmation: Do I Need Surgery?
- Share on Facebook
- Share on Twitter
- Share on Linkedin
- Share on Pinterest
- Share via Email
- Print this Page
Featured Expert:
Fan Liang, M.D.
There is no one-size-fits-all approach for the gender affirmation process. Perhaps you don’t want to undergo surgery right now because it’s too expensive or your family is not on board. Maybe you don’t see surgery as being a part of your transition process at all.
Gender affirmation is an individualized journey. Doing your own research and talking to experts will help you decide which options are best for you.
Dr. Fan Liang, the current medical director of Johns Hopkins Center for Transgender Health , stresses that while surgery can be a part of the transition process for many, it’s not for everyone. "Each patient needs to consider their personal goals and decide whether surgical options will improve their quality of life and lessen their gender dysphoria," she adds.
Dr. Liang shares insights into the many choices available to patients who wish to use nonsurgical options to express their gender identity. “It’s very possible that surgery is not in the transition plan for someone in the gender affirmation process. There are several nonsurgical services that may help transgender patients achieve their transition goals.
Hormone Treatment
Hormone therapy can help you achieve more masculine or feminine characteristics. Commonly prescribed by a primary care provider or endocrinologist, hormone treatments can be part of a presurgical plan or a stand-alone service.
These medications work to more closely align outward secondary sexual characteristics, such as enlarged breasts, body fat distribution or facial hair, with someone’s gender identity.
For transgender women or transfeminine nonbinary individuals, the hormones administered include estrogens and antiandrogens. For transgender men or transmasculine nonbinary individuals, hormones administered include androgens such as testosterone. Always talk to your doctor about your options and any possible side effects before beginning hormone treatment.
Dermatology
As part of the gender affirmation process, you can choose to undergo permanent hair removal for both aesthetic reasons and as preparation for some surgeries. Laser and electrolysis are the recommended methods.
- During electrolysis, your dermatologist may use chemical or heat energy to destroy hair follicles and tweezers to remove the hair. Possible side effects of the treatment are pain, swelling or redness.
- Laser hair removal uses infrared light to destroy hair follicles. Laser hair removal can cover a larger area more quickly than electrolysis. Possible side effects include skin irritation and redness. Some hair could be resistant to the laser treatment or grow back, although it is usually finer and lighter. Laser is not an option for every skin and hair type (for example, gray hair and/or fair hair).
Voice Therapy
Voice therapy with a laryngologist may help you achieve a way of speaking that more closely matches your gender identity. During an initial consultation, you will be comprehensively evaluated, including screening for the presence of any physical problems with your voice, such as vocal cord nodules. Depending on your desired outcome, a voice therapist who specializes in gender affirmation can help you with the following:
- Habitual speaking pitch
- Resonance (the way sound is shaped to produce a vocal quality)
- Inflection/prosody (the melodic ups and downs of the voice)
- Rate of speech
- Volume/intensity
- Articulation (how speech sounds are produced)
- Pragmatics (social rules of communication)
- Nonverbal communication
“As you consider your options, remember that the journey is your own,” says Liang. Knowing what is available, talking to other people who have transitioned and meeting with transgender health care experts can help you make an informed decision on which procedures, if any, are right for you.
The Center for Transgender Health Team at Johns Hopkins
Embracing diversity and inclusion, the Center for Transgender Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.
Specializing In:
- Transgender Health
- Gender Affirmation Surgery
At Another Johns Hopkins Member Hospital:
- Howard County General Hospital
- Sibley Memorial Hospital
- Suburban Hospital
- The Center for Transgender Health
Find Additional Treatment Centers at:
Request an Appointment
Transgender Health: What You Need to Know
Gender Affirmation Nonsurgical Services
Gender Affirmation Surgeries
Related Topics
IMAGES
VIDEO
COMMENTS
The appropriate words are most dependent upon the type of relationship that exists between the person and the patient. Close family members gain comfort from simple expressions of love, but friends or co-workers thrive on supportive words.
Gender discrimination is the unfair or unequal treatment of people based on their gender or sexual orientation: gender discrimination occurs against homosexuals, heterosexuals and transgenders, and may be initiated by men or women.
We are vaccinating all eligible patients. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus | Email Alerts Find more COVID-19 testing locations on Maryland.gov. Popular Searches Th...
Gender affirmation surgeries help people transition to their self-identified gender. Many transgender people choose top surgery
Gender Confirmation Surgery · Available surgeries: · Sex Reassignment Surgeries (SRS) · Male-to-female sex reassignment surgery · Female-to-male sex reassignment.
Gender-affirming surgery (GAS) is a surgical procedure, or series of procedures, that alters a transgender or transsexual person's physical appearance and
Gender reassignment surgery, sometimes called sex reassignment surgery, is performed to transition individuals with gender dysphoria to
Gender reassignment surgery (GRS) refers to all surgical procedures that a patient wishes to undergo in an effort to become similar to the opposite gender.
Gender affirmation surgeries, also known as gender confirmation surgeries, give transgender individuals the physical appearance and functional abilities of
Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made
Research conducted to date has shown that gender reassignment surgery has a
This is when you are treated differently because you are trans in one of the situations covered by the Equality Act. The treatment could be a one-off action or
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people. Such treatment allows the acquisition of
will improve their quality of life and lessen their gender dysphoria," she adds.