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Gender Surgery Amsterdam

We help transgender people from all over the world. We offer several surgical services for those who are in their transitional phase and search for high-quality personalized care. Read more .

Surgery for transmen

Surgery for transwomen

Why choose us.

• Academic level of experience Yet welcoming and easy to talk to
• Latest knowledge By ungoing education and training
• Gender sensitive team Compassion for every person

Our experienced specialists are happy to help you

If you wish to transition by having surgery, expert care is needed. Accessing health care can however be challenging for transgender people. Our practioners are experienced to work with people who might not (yet) feel comfortable with their body. We offer state of the art surgical services and aim for high quality of life. First read our conditions to apply .

Surgical and demographic trends in genital gender-affirming surgery in transgender women: 40 years of experience in Amsterdam

Affiliations.

• 1 Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• 2 Centre of Expertise on Gender Dysphoria, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• 3 Department of Endocrinology, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• 4 Department of Medical Psychology, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• 5 Department of Gynaecology and Obstetrics, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• 6 Department of Epidemiology and Data Science, Amsterdam UMC, location VUMC, Amsterdam, The Netherlands.
• PMID: 34291277
• PMCID: PMC10364763
• DOI: 10.1093/bjs/znab213

This was a single-centre, retrospective study of transgender women undergoing genital gender-affirming surgery. A chart study was conducted, recording individual demographics, all genital surgical procedures, and surgical techniques. Procedure incidence, techniques employed, and demographic variations over the years were analysed.

• Middle Aged
• Netherlands
• Penis / surgery
• Retrospective Studies
• Sex Reassignment Surgery / methods*
• Sex Reassignment Surgery / statistics & numerical data
• Transgender Persons*
• Vagina / surgery
• Young Adult

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What Is Gender Affirmation Surgery?

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

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

Why Is Gender Affirmation Surgery Performed?

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

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

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

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

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

Transgender vs Nonbinary

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

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

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

Hormone Therapy

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

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

Types of hormone therapy include:

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

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

Masculinizing Surgeries

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

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

Top Surgery

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

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

Metoidioplasty

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

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

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

Phalloplasty

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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

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

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

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

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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

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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.

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WORLD LEADER IN GENDER REASSIGNMENT SURGERY

The most advanced clinic in Europe

Gender reassignment surgery, what is gender reassignment surgery.

Gender reassignment surgery, confirmation surgery or sex reassignment surgery means a variety of procedures that allow people transition to their self-identified gender. These surgical treatments modify a physical person’s appearance and sexual characteristics to approach their identified gender.

The most common treatments are feminization surgeries are vaginoplasty, breast augmentation or facial aesthetic procedures. In the cases FTM, phalloplasty, breast reduction or facial masculinization operations are the most demanded surgeries.

Our gender affirming treatments and procedures

We offer a wide range of gender confirmation procedures to help our patients to achieve the results they are looking for, supporting and providing professional advice throughout the transformation process.

Feminisation surgery

MTF Vaginoplasty

Facial feminization

BREAST AUGMENTATION

MTF body surgery

FEMINIZING VOICE SURGERY

AESTHETIC MEDICINE

Masculinisation surgery.

Phalloplasty

Metoidioplasty

FTM top surgery

FTM Hysterectomy

Body Masculinization

OTHER MASCULINIZATION SURGERIES

Before and after gender-affirming surgery results.

Knowing the results of some sex reassignment surgeries could be helpful to make a decision and to have an idea about what to expect.

Dr. Ivan Mañero, a reference

Dr. Ivan Mañero, reconstructive and aesthetic plastic surgeon, is an international leader in gender affirmation surgery (ies) for trans people. He has been performing and perfecting gender reassignment surgeries for more than two decades, both inside and outside our borders.

His professionalism has led him to be internationally known and sought after, participating and moderating events in conferences. From the beginning of his professional career, he has always advocated for specialized and sensitive care for trans people. However, in the beginning, he had to deal with other peers who did not understand why a specialist like him cared about this matter.

A pioneer in unique surgical techniques for gender reassignment, Dr. Ivan Mañero has collaborated with various administrations to ensure that this type of a surgeries re included within the public health service in Spain. . In order to be able to offer greater and better care to trans people who require it.

The IM GENDER team, led by Dr Ivan Mañero, is a leading international reference in sex reassignment surgery and genital reassignment surgery.

World leader in gender reassignment surgery

The IM GENDER Gender Unit opened its doors over twenty years ago and has become an international benchmark in Gender Reassignment Surgery. IM GENDER has cared for more than 3,000 trans people who have decided to carry out some treatment or surgical procedure at the Unit, whether genital affirmation surgery – vaginoplasty, phalloplasty, metoidioplasty -, body surgery – mastectomy, breast augmentation, feminizing liposculpture, among others -, facial surgery – facial feminization, thyroplasty, masculinization of features, etc.- or other plastic surgery procedures.

IM GENDER offers all the advantages of IM CLINIC, a pioneering clinic for its concept of understanding healthcare in a global and personalized way. Our clinic confers differentiating characteristics that allow us to offer a high quality of care.

At IM GENDER you will find a clear commitment to the most cutting-edge and reliable technology, with technologically cutting-edge operating rooms and the most innovative equipment in the sector. All this, added to a medical team expert in gender surgery with more than two decades of experience led by Dr. Ivan Mañero, the most recognized plastic surgeon specialized in gender reassignment surgery in Europe and even internationally. In addition, Dr. Mañero was a pioneer in unique/specific surgical techniques for genital affirmation, such as vaginoplasty with graft.

The entire human team that makes up IM GENDER, from Patient Care to medical, health professionals, psychologists and physiotherapists, are trained in health care based on human rights, respect and privacy of all patients. Our goal is to offer all the necessary information before, during and after the surgery through close treatment and personalized attention.

YEARS OF EXPERIENCE

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THEIR EXPERIENCE COULD BE YOURS

Meet IM GENDER’s true stars and learn about their personal experiences, from preoperative consultations to postoperative follow-up care. Discover how our comprehensive approach to gender-affirming surgery, (ies) coupled with our psychological support and family guidance, has made a difference in their lives.

At IM GENDER, we understand that every patient’s journey is unique, and we are committed to providing personalised care that caters to individual needs. Our testimonials are a testament to our dedication to patient satisfaction, and we are proud to share the stories of our satisfied clients with you.

We invite you to explore our website and learn more about our services, team, and testimonials. Our team is available to answer any questions or concerns you may have and to help you start your journey towards gender affirmation.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

American Society of Plastic Surgeons. Gender confirmation surgeries .

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

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

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13.1 The ethics of gender reassignment surgery

• Published: August 2021
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Transgender issues are very much in the news at present. There has been discussion about both gender dysphoria in general but, more specifically, the practical, psychological, and financial implications of carrying out gender reassignment surgery. In the United Kingdom, this extends to a debate on whether it is justifiable to carry out these procedures within an already hard-pressed National Health Service. This chapter discusses the nature, history, and background of both gender dysphoria and gender reassignment surgery and whether such procedures are justifiable in terms of outcomes and patient satisfaction; and also whether these are legitimate procedures to carry out within the National Health Service.

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• Ann Transl Med
• v.9(7); 2021 Apr

Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies

Sasha karan narayan.

1 Department of Surgery, Oregon Health and Science University, Portland, OR, USA;

Rayisa Hontscharuk

2 Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA;

Sara Danker

3 Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA;

Jess Guerriero

4 Transgender Health Program, Oregon Health & Science University, Portland, OR, USA;

Angela Carter

5 Primary Care, Equi Institute, Portland, OR, USA;

Gaines Blasdel

6 NYU Langone Health, New York, NY, USA;

Rachel Bluebond-Langner

Randi ettner.

7 University of Minnesota, Minneapolis, MN, USA;

8 Callen-Lorde Community Health Center, New York, NY, USA;

Loren Schechter

9 The University of Illinois at Chicago, Chicago, IL, USA;

10 Rush University Medical Center, Chicago, IL, USA;

11 The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA;

Jens Urs Berli

12 Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA

Associated Data

The article’s supplementary files as

A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons’ experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.

This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review.

The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2–0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons’ experience with patient regret and request for reversal was consistent with the existing literature.

Conclusions

In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Introduction

Over the past several years, there has been sustained growth in institutional and social support for transgender and gender non-conforming (TGNC) care, including gender-affirming surgery (GAS) ( 1 ). The American Society of Plastic Surgeons (ASPS) estimates that in 2016, no less than 3,200 gender-affirming surgeries were performed by ASPS surgeons. This represents a 20% increase over 2015 ( 2 ) and may be partially attributable to an increase in third party coverage ( 3 , 4 ). A rare, but consequential, risk of GAS is post-operative regret that could lead to requests for surgical reversal. As the number of patients seeking surgery increases, the absolute number of patients who experience regret is also likely to increase. While access to gender-affirming health care has expanded, these gains are under continued threat by various independent organizations, religious, and political groups that are questioning the legitimacy of this aspect of healthcare despite an ever-growing body of scientific literature supporting the medical necessity of many surgical and non-surgical affirming interventions. It is therefore not surprising that studies on regret and surgical reversal are scarce compared to studies on satisfaction and patient-reported outcomes. The transgender community rightfully fears that studies on this topic can be miscited to undermine the right to access to healthcare.

The goal of this study is to assist patients, professionals, and policy makers regarding this important, albeit rare, occurrence. We do so by addressing the following:

• The current literature regarding the etiology of regret following gender-affirming surgery;
• The experience of surgeons regarding requests for surgical reversal.

Based on these results, the authors propose a classification system for both type and etiology of regret.

It is important to acknowledge that the authors identify along the gender spectrum and are experts in the field of transgender health (mental health, primary care, and surgery). We hope to facilitate discussion regarding this multifaceted and complex topic to provide a stepping-stone for future scientific discussion and guideline development. Our ultimate goal is to reduce the possibility of regret and provide clinical support to patients suffering from the sequelae of regret. We present the following article in accordance with the SURGE reporting checklist (available at http://dx.doi.org/10.21037/atm-20-6204 ).

A 16-question survey (see Table S1 ) was developed and uploaded to the online survey platform SurveyMonkey (SurveyMonkey, Inc., San Mateo, CA, USA). This anonymous survey was e-mailed by the senior author to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. There were no incentives offered for completing this survey. One reminder e-mail was sent after the initial invitation.

Respondents were asked to describe their practices, including: country of practice, years in practice, a range estimate of the total number of TGNC patients surgically treated, and the number of TGNC patients seen in consultation who expressed regret and a desire to reverse or remove the gendered aspects of a previous gender-affirming surgery. We limited the questions to breast and genital procedures only. Facial surgery was excluded as there are no associated WPATH criteria, so there is less standardization of patient selection for surgery. Thus, we did not feel that those patients should be pooled with those who were subject to WPATH criteria in our calculation for prevalence of regret. We did not define the term “regret” in order to capture a wide range of responses. Respondents were asked about their patients’ gender-identification, the patient’s surgical transition history, and the patient’s reasons for requesting reversal surgery. If the respondents had experience with patients seeking reversal surgery, the number of such interventions were queried to include: the initial gender-affirming procedure and the patients’ reason(s) for requesting reversal procedures. The respondents were also asked about the number of reversal procedures they had performed, and what requirements, if any, they would/did have prior to performing such procedures. Finally, respondents were asked whether they believed that the WPATH Standards of Care 8 should address this topic.

Statistical analysis

Response rate was calculated from the total number of respondents as compared to the number of unique survey invitations sent. Responses to the survey were analyzed using descriptive statistics. When survey questions offered ranges, (i.e., estimating the number of patients surgically treated), the minimum and maximum values of each of the selected answers were independently summed to report a more comprehensible view of the data. Partially completed surveys were identified individually and accounted for in analysis. Any missing or incomplete data items from the survey were excluded from the results with the denominator adjusted accordingly.

Narrative literature review

A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret and satisfaction. Terms included (regret) and (transgender) and (surgery) or (satisfaction) and (transgender) and (surgery). These terms included their permutations according to the PubMed search methodology. Original research and review studies whose abstracts addressed the following topics were included for full-text review: gender-affirming surgery, sex reassignment, patient satisfaction, detransition, regret. A total of 163 abstracts were reviewed and a total of 21 articles were closely read for the relevant discussion of regret and satisfaction.

Ethical statement

This study was approved by the Oregon Health & Science Institutional Review Board #17450 and was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Survey results

Of the 154 surgeons who received the survey between December 2017 and February 2018, 46 (30%) surgeons completed the survey. The survey, including its results, can be found in Table S1 . Thirty respondents (65%) were in practice for greater than 10 years, and most (67%) practice in the United States, followed by Europe (22%). The respondents treated between 18,125 and 27,325 TGNC or gender non-conforming (TGNC) patients. Most of the respondents (72%) surgically treated over 100 TGNC patients (see Figure 1 ). Of the 46 respondents, 61% of respondents encountered either at least one patient with regret regarding their surgical transition or a patient who sought a reversal procedure—irrespective of whether their initial surgery was performed by the respondent or another surgeon. Twelve respondents (26%) encountered one patient with regret, and the remaining 12 (26%) encountered two or more patients with regret. One respondent indicated that they encountered between 10 and 20 patients who regretted their surgical gender transition. No respondent encountered more than 20 such patients (see Figure 2 ). This amounted to a total of 62 patients with regret regarding surgical transition, or a 0.2% to 0.3% rate of regret. Of these 62 patients, 13 (21%) involved chest/breast surgery and 45 (73%) involved genital surgery (see Table 1 ).

Distribution of transgender surgery experiences among respondents.

Number of transgender patients encountered who expressed regret.

Totals do not add to 100 due to incomplete responses.

Of the 62 patients who sought surgical reversal procedures, at the time of their initial gender-affirming surgery, 19 patients identified as trans-men, 37 identified as trans women, and 6 identified as non-binary. The reasons for pursuing surgical reversal were provided for 46 patients (74%) and included: change in gender identity or misdiagnosis (26 patients, 42%), rejection or alienation from family or social support (9 patients, 15%), and difficulty in romantic relationships (7 patients, 11%). In some patients, surgical complications or social factors were cited as a reason for regret and request for reversal of genital surgery—no change in the patient’s gender identity was elucidated (see Table 2 , etiologies of regret). Of the 37 trans-women seeking reversal procedures, complaints at the time of secondary surgical consultation included: vaginal stenosis (7 patients), rectovaginal fistulae (2 patients), and chronic genital pain (3 patients). Of the 19 trans-men seeking reversal procedures, complaints at the time of secondary surgical consultation included: urethral fistulae (2 patients) and urethral stricture (1 patient). A total of 36 reversal procedures were reported, with supplemental qualitative descriptions provided for only 23 procedures. The distribution of the 23 reversal procedures is found in Table 1 .

Totals exceed 100 as respondents could select multiple options.

Most respondents (91%) indicated that new mental health evaluations would be required prior to performing surgical reversal procedures. Eighty-eight percent of respondents indicated that WPATH SOC 8 should include a chapter on reversal procedures (see Figure 3 ).

Respondent’s requirements to proceed with surgical reversal.

Literature review

Overall, the incidence of regret following gender-affirming surgery has been reported to be consistently very low ( 5 - 26 ). Wiepjes et al. ( 27 ) reported an overall incidence of surgical regret in the literature in transgender men as <1% and transgender women as <2%. Landen et al. comment that outcomes following gender-affirming surgery have improved due to preoperative patient assessment, more restrictive inclusion criteria, improved surgical techniques, and attention to postoperative psychosocial guidance ( 28 ). Although retrospective, the Wiepjes et al. study is the largest series to date and included 6,793 patients over 43 years. In this study, only 14 patients were classified as regretful, and only 10 of these patients pursued procedures consistent with intent to detransition. Perhaps most importantly, the Amsterdam team categorized regret into three main subtypes: “ social regret , true regret , and feeling non - binary ”.

Many of the reviewed studies aimed to identify various variables or risk factors that may identify patients that are at risk or that may predict future postoperative regret.

Earlier studies focused on patient characteristics and identified several variables that were associated with regret in their patient populations. These variables include psychological variables ( 11 , 22 , 23 ), such as previous history of depression ( 15 , 26 ), character pathology ( 26 ) or personality disorder ( 5 , 15 ), history of psychotic disorder ( 15 , 28 ), overactive temperament ( 26 ), negative self-image ( 26 ) or other psychopathology ( 15 , 19 , 26 ), as well as various social or familial factors that include history of family trauma ( 19 , 29 ), poor family support ( 5 , 11 , 15 , 28 ), belonging to a non-core group ( 28 ), previous marriage ( 15 , 19 ), and biological parenthood ( 15 , 19 ). Landen et al. identified poor family support as the most important variable predicting future postoperative regret in transgender men and women undergoing gender-affirming surgery in Sweden between 1972–1992 ( 28 ). Defined as subsequent application for reversal surgery, the authors found that 3.8% of their study population regretted their surgery. Other factors previously associated with regret include: sexual orientation ( 5 , 7 , 15 , 19 ), impaired postoperative sexual function [most notably in transgender women; ( 29 )], previous military service ( 29 ), a physically strenuous job ( 29 ), history of criminality ( 5 ), age at time of surgery and transition [>30 year increased risk; ( 5 , 6 , 11 , 15 , 19 , 29 )], asexual or hyposexual status preoperatively ( 15 , 29 ), too much or too little ambivalence regarding prospect of surgery ( 29 ), and/or an absence of gender nonconformity in childhood ( 15 ).

Studies examining transgender women have identified postoperative sexual function to be a significant factor contributing to possible surgical regret ( 15 , 29 ). A literature review by Hadj-Moussa et al. ( 11 ) (2018) identified poor sexual function as a factor that may contribute to postoperative regret in transgender women after vaginoplasty. Lindemalm et al. ( 29 ) (1986) previously reported a rate of 30% regret in their study examining 13 transgender women in Sweden after vaginoplasty. This rate of regret is the highest reported and appears to be an outlier. In their patient population, they found that only one third had a surgically-created vagina capable of sexual intercourse. This was consistent with patient-reported poor postoperative sexual function and highlights the importance of discussing sexual function following vaginoplasty. Similarly, Lawrence et al. ( 15 ) (2003) found that occasional regret was reported in 6% of transgender women after vaginoplasty, with 8 of the 15 regretful patients identifying disappointing physical and functional outcomes after their surgery. These findings are consistent with literature reviews that have found that regret is related to unsatisfactory surgical outcomes and poor postoperative function ( 19 , 30 ).

Transgender men have been found to manifest more favorable psychosocial outcomes following surgery and are less likely to report post-surgical regret ( 26 ). These findings highlight the importance of surgical results, and their influence on surgical regret. Despite this difference between transgender men and women, overall regret continues to remain low.

While the rate of surgical regret is low, many patients can suffer from many forms of “minor regret” after surgery. Although this could skew the outcomes data ( 30 ), this is considered temporary and can be overcome with counseling. As such, this should not be calculated in assessments of true regret ( 30 ). Alternatively, lasting regret is attributed to gender dysphoria and is explicitly expressed through patient postoperative behaviors ( 30 ). Factors that have been found to contribute to “minor regret” after gender-affirming surgery include postsurgical factors such as pain during and after surgery, surgical complications, poor surgical results, loss of partners, loss of job, conflict with family, and disappointments that various expectations linked to surgery were not fulfilled ( 19 ). Previous reviews further underline the importance of following the contemporaneous WPATH Standards of Care. This is especially important regarding patient education pertaining to surgical expectations and outcomes ( 11 , 26 ). Patient education programs are thought to identify those individuals who would most benefit from surgery ( 20 ). Other issues reported to decrease postoperative regret include appropriate preoperative diagnosis ( 19 , 20 , 26 ), consistent administration of hormone therapy ( 15 ), adequate psychotherapy ( 15 ), and the extent to which a patient undergoes a preoperative “real-life test” living in their desired gender role ( 15 , 19 , 20 , 26 ).

As compared to the volume of literature regarding postoperative satisfaction following gender-affirming surgery, the literature on regret is still relatively small. However, the literature (and anecdotal surgeon reports) consistently shows low rates of regret. We juxtaposed these findings to the surgeons’ experience with patients seeking reversal surgery or verbalizing regret. We found a rate of regret between 0.2–0.3%. This is consistent with the most recent data from Wiepjes et al. who reported rates of regret of 0.3% for trans-masculine and 0.6% for trans-feminine patients ( 27 ). The question of prevalence seems relatively well-answered by the current literature.

Perhaps the most striking finding is the heterogeneity of etiologies and risk factors associated with regret. Within this context, establishing consistent definitions for both regret and its underlying etiology is essential. Furthermore, as our understanding of gender identity evolves, our definitions and understanding become more precise. We highlight the Wiepjes et al. classification as an example of how narrower definitions may preclude an understanding of evolving gender theory. This predominantly single-institution study included 6,793 individuals, and the authors classified regret into three subtypes: social regret, true regret, and feeling non-binary. They categorized patients as either trans-female or trans-male. Conversely, in the 2015 US Transgender Survey, 35% of the nearly 28,000 respondents reported a non-binary identification ( 31 ). The classification by Wiepjes et al. is important in that it recognizes that individuals may not regret “transitioning”, but rather regret specific aspects of their medical treatment. More specifically, if these individuals request a reversal procedure, they are not necessarily requesting a “reversal” of their gender identity. However, the Wiepjes et al. study does not elaborate on this topic.

Case example: a trans-masculine, non-binary individual after testosterone therapy and chest masculinization regrets having secondary sex characteristics from hormonal therapy but is highly satisfied following chest masculinization. This should be considered true gender-related regret as the individual desires, at least in part, to return to the phenotype of the sex assigned at birth (e.g., hair removal). However, the etiology regarding this type of regret can be varied. For example, the etiology may include: insufficient exploration of the individual’s gender identity [by the individual and/or mental health professional (misdiagnosis)], lack of knowledge of professionals regarding surgical options for non-binary individuals, insurance carrier mandate to undergo hormonal therapy prior to chest masculinization (healthcare stigma), etc.

Based on the reviewed literature and our consensus expert opinion, we propose the following classification of regret, examples of etiology pertaining to regret ( Table 3 ), and an overview of associated terminology regarding regret ( Table 4 ).

Regret is a general term that describes an emotional state wherein a previous decision now feels incorrect. This can be temporary (fleeting ambivalence) or permanent. Permanent regret can be divided into three forms: true gender-related regret, social regret, and medical regret.

True gender-related regret involves a person having undergone a transition in gender whether by social, medical, or surgical means, indicating a formal change in gender identity, who then desires to return to their assigned sex at birth or a different gender identity. True gender-related regret differs from other types of regret in that it implies a misdiagnosis or misinterpretation of gender incongruence at the time of transition. Based on the case example, true gender-related regret need not be related to all medical treatments, but instead may be focused on specific treatments for which the individual seeks reversal. True gender-related regret constituted 42% of the requests for surgical reversal in our study. Etiology may include: misdiagnosis, insufficient exploration of gender identity, or barriers to access for options to transition to non-binary gender expression.

Social regret refers to one’s desire to return to their sex assigned at birth to alleviate the repercussions of transitioning on their social life. The etiologies can vary widely and include feeling unsafe in public, losing partnership, feeling unable to partake in one’s community, and encountering professional barriers. An additional reason identified in this study included religious conflict, mentioned in 9% of individuals. Social regret was cited in 37.1% of the requests for surgical reversal.

Medical regret includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof. This area is particularly important for the medical community as it is preventable and may increase as access to care expands. Medical regret can be further subdivided into regret secondary to medical complications, long-term functional outcomes (i.e., sexual), and preoperative decision-making.

Medical regret due to inadequate preoperative decision-making is directly related to a medical intervention, but it is not due to a change in gender identity, medical complication, functional outcome, or social stigma. Examples include choosing a simple-release metoidioplasty rather than a phalloplasty or regretting gonadal sterilization later in life ( 32 ). In these situations, individuals may not have appreciated the long-term implications at the time they underwent the procedure, may have received incomplete or inaccurate counseling, may have had a change in life goals, or may have not had access to technologies that are currently available. This form of regret may be mitigated by employing a multidisciplinary approach which includes discussions beyond surgical risks (i.e., fertility preservation, sexuality, etc.) ( 33 , 34 ). Medical regret was cited in 8% of requests for reversal, however 24% of patients were separately noted to have experienced post-operative complications.

Associated definitions

Gender fluidity is an inclusive term describing gender along a spectrum rather than a binary construct. When applied to identity, gender fluidity, sometimes called “genderqueer” ( 35 , 36 ) describes an individual who remains flexible regarding their identity and may identify differently at different times in their lives. Surgeons should work collaboratively with their mental health colleagues to help the patient understand the impact of surgery and how surgery may influence/affect future life goals. Non-identified gender fluidity can be one etiology for true gender-related regret.

Continued transition medically recognizes the concept of gender fluidity and the gender spectrum. This patient seeks additional medical treatment following their initial gender-affirming procedure(s) and may express an evolving gender identity or request further surgical consolidation of their identity. The patient need not express regret over their initial transition. An example is a patient assigned male-at-birth who takes feminizing hormones and undergoes breast augmentation. Subsequently, the patient returns to the surgeon indicating they identify as non-binary and requests implant removal. With decreased stigmatization of non-binary gender identity and ability to access non-binary affirming surgical options, this type of regret may be less common in the future.

Detransition refers to a change in gender role and/or the cessation of medical transition (e.g., hormonal treatment). This term has been used controversially and disparagingly with regards to surgical transition and fails to honor the spectrum of reasons why patients may undergo reversal surgery. However, some patients utilize this term to self-identify and to describe their experiences. This term should not be used to describe the process of surgical reversal.

Retransition is a phenomenon where a patient, following surgical reversal procedures, later feels that this reversal was wrong and seeks to re-affirm their previously expressed gender identity. A reason for retransition may include a change in societal structure that has provided a safer environment for transition. The need to distinguish continued transition from retransition results from a clash between increasing societal perception of a gender spectrum and the Western culture’s binary gender construct ( 35 ).

Fleeting ambivalence (considered short-term regret) over one’s transition is common, especially if the patient experiences initial surgical complications or loss of their support communities. The normal grief experienced as a result of trauma should not be pathologized, and the patient should be encouraged to trust in their long-standing gender identification. Some patients may desire a change in gender identify as a result of feeling unsafe due to severe social stigma. Knowing this, healthcare teams should counsel patients regarding the implications of transitioning within a given societal structure prior to surgery. This may include discussions regarding the effect of transitioning on relationships, careers, personal safety in public, sexuality, etc. These discussions are often facilitated by the patient’s mental health professional and/or primary care provider.

Special considerations

We recognize that regret and surgical reversal are complex, multifaceted phenomena without an easy treatment path. While both regret and requests for surgical reversal are rare, the need for guideline development is critical in providing high-quality care for this patient population, regardless of prevalence.

A concern expressed by both providers and patients is that discussions regarding regret and surgical reversal may be used to restrict access to affirming care. The authors believe that research including feelings of grief and regret will not only help individuals who experience severe forms of regret but will also help to refine surgical indications and procedures to minimize this already rare occurrence. Finally, and perhaps most importantly, failure to study regret and surgical reversal procedures will allow these topics to be left up to interpretation and may not reflect the actual experience of patients.

Limitations

The literature review was not performed systematically and as such is subject to selection bias. Our survey involved a survey of gender surgeons but did not include other medical or mental health professionals who may evaluate patients requesting surgical reversal. In addition, the study findings are limited by its design. Because survey studies are prone to recall bias, response bias, and selection bias, they are not well-suited for calculating the prevalence of a particular condition. For example, 89% of the respondents practice in the United States and Europe. This leaves significant areas of the world underrepresented and so does not represent the experiences or desires of all international surgeons. Furthermore, the survey was distributed in English only, as it was circulated to surgeons who attended conferences in the United States. Most notably, patients may have sought consultation from multiple surgeons resulting in an overestimation of the prevalence of regret. Conversely, patients seeking surgical reversal may not have had access to additional surgical care, causing an underestimate in the prevalence of regret. While our study findings are strengthened by external validation from other studies, the true prevalence of regret remains an estimate.

Regret after gender-affirming surgery was found to be rare, both in the literature as well as in our survey of surgeons’ experiences with this topic. Regret can be classified as true gender-related regret, social regret and medical regret from complications, function, pre-intervention decision making. Guidelines in transgender health should include both preventive strategies as well as treatment guidelines if regret occurs. Future studies and scientific discourse are encouraged on this important topic.

Supplementary

Acknowledgments.

The authors acknowledge the many surgeons who were surveyed in this work, and the community members who thusly contributed to the survey results.

This research was orally presented by Dr. Sasha Narayan at the Philadelphia Trans Wellness Conference (PTWC) August 2018 in Philadelphia, PA and at the World Professional Association for Transgender Health (WPATH) International Conference, November 2018 in Buenos Aires, Argentina. This research was orally presented by Dr. Sara Danker at Plastic Surgery, The Meeting (PSTM), October 2018 in Chicago, IL.

Funding : None.

Ethical Statement : The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was approved by the Oregon Health & Science Institutional Review Board #17450. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Subjects were physicians and so gave consent through their participation in the survey. The patients who were captured in the study were not individually consented for this research as the IRB felt it to be unnecessary given the degree of separation of the study and lack of identifiers. None of the study outcomes affect future management of the patients’ care.

Provenance and Peer Review : This article was commissioned by the Guest Editors (Drs. Oscar J. Manrique, John A Persing, and Xiaona Lu) for the series “Transgender Surgery” published in Annals of Translational Medicine . The article has undergone external peer review.

Reporting Checklist : The authors have completed the SURGE reporting checklist. Available at http://dx.doi.org/10.21037/atm-20-6204

Data Sharing Statement : Available at http://dx.doi.org/10.21037/atm-20-6204

Conflicts of Interest : All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/atm-20-6204 ). The series “Transgender Surgery” was commissioned by the editorial office without any funding or sponsorship. Dr. RBL reports that he serves on the standards of care committee of WPATH. No financial reward. Dr. AR reports that he serves as board member for World Professional Association for Transgender Health. This is an uncompensated position. Dr. LS reports other from Elsevier Publishing, other from Springer Publishing, outside the submitted work; and he serves on the board of WPATH (world professional association for transgender health), this is an unpaid position. Dr. JUB reports that he serves on the standards of care committee of the World professional association of transgender health. No financial reward associated with this. The authors have no other conflicts of interest to declare.

The Gender Affirming (Genital) Surgery Service

On this page, about the service, new referrals to the service, the waiting list, referring for masculinising or feminising gender affirming genital surgery, gender affirming (genital) surgery service forms and support documents, revision surgery, national travel assistance .

The Service has been funded with $2.99 million approved in Budget 2019 over four years for the delivery of up to 14 surgeries per year.

The Service is provided through a contractual agreement between Health New Zealand | Te Whatu Ora, and a private provider of gender affirming genital surgery in Aotearoa New Zealand. 

The scope of the Service is gender affirming genital surgery for transgender people. 

The Service is able to provide the following surgical techniques:

• Vaginoplasty 
• Minimal Depth Vaginoplasty 
• Metoidioplasty with or without urethral lengthening 
• Phalloplasty with or without urethral lengthening  

Referrals for other gender affirming surgeries and referrals for people with an intersex variation should be sent to the person’s local hospital network, in accordance with locally agreed pathways.

Further information on the Service can be found at Delivering health services to transgender people.

Referrals to the waiting list need to be made by a hospital specialist unless a hospital network has agreed to allow general practitioners to make referrals on their behalf. The districts where authorised GPs can make referrals on behalf are Wellington and Christchurch only.

People referred to the Service and accepted, will be placed on the waiting list for a first specialist assessment (FSA).

Read the monthly update  on current referrals and the waiting list for a first specialist assessment.

To be considered for a first specialist assessment a person must be at least 18 years of age, and medically fit to have an anaesthetic and complex surgery.

It is important that a person on the waiting list maintain a healthy Body Mass Index (BMI), be a non-smoker (including nicotine-based vapes), ensure that any physical and/or mental health conditions are managed and stable and that their contact details with us remain up to date and are correct. 

To be considered a non-smoker, people must be 12 weeks+ completely nicotine free. We require people to be nicotine free when progressing through the pre-surgical pathway.  

We require people referred for surgery to maintain a healthy BMI. This is for patient safety and the best possible surgical outcome. International evidence shows a significant risk of complications with these highly complex surgeries, when a patient has a high BMI.

You can find out more about Body Mass Index (BMI) and how to calculate BMI here:

The Service is currently accepting new patients on to the wait list for a first specialist assessment (FSA) with a BMI less than 35, with the expectation that patients with a BMI between 30 and 35 will be working with their general practitioners (GP) on a healthy weight management programme while they are waiting to be offered an FSA with the surgeon. 

This gives patients the opportunity to reduce their weight to a BMI of 30 or less, in a managed and safe way over time, while they wait for their FSA with the surgeon.

We encourage people with a BMI between 30-35 to speak with their general practitioner about weight loss management programmes and to ask about their eligibility for a Green Prescription .

Please note: Patients on the waiting list will not be offered surgery unless their BMI is below 30. People who have a BMI of under 30 which makes them  more likely to progress to surgery and had their GP complete and return the GP Completed Health and Wellbeing form (confirming their current health status meets surgery criteria) will be offered an FSA as soon as the service provider is able to do so. There may be some delays in providing an FSA to people whose BMI is currently between 30-35.

Any referral sent directly to the Service’s contracted provider will not be eligible for the publicly-funded Service. Only referrals that are forwarded to the Service by the HNZ wait list coordinator, will be accepted.

The waiting list is a list for a first specialist assessment (FSA) with the surgeon. It is not a waiting list for surgery.

The number of people on the waiting list is constantly changing as new referrals are received, and the waiting list is updated following the validation of referrals. Some people cannot be contacted, advise they no longer require surgery, or need to address health issues before they are ready for a first specialist assessment or surgery.

Therefore, attributing a ‘number’ to a referral on the waitlist does not depict the specific order that a patient may be considered for a first specialist assessment, or the length of time someone may be on the waiting list.

The preparation time for surgery can be lengthy as patients may require weight loss, readiness assessment and/or hair removal prior to proceeding to surgery.

There is no reimbursement available to patients who pay for hair removal prior to their first specialist assessment. After the patient has been seen by the Service at the FSA, then the Service will arrange for hair removal procedures and readiness assessments, if these are still required

Given the number of people on the waiting list, we ask those who have had a referral accepted to notify us promptly by email [email protected] if their contact details or circumstances change.

We also encourage people to complete the Patient Completed Gender Affirming Genital Surgery Annual Review form (pdf, 184kb) annually and return it to us at [email protected] to ensure that we have their correct, up to date contact details and relevant information.

It is important that we have up to date contact information available because if we cannot make contact, patients will be removed from the wait list. Contact information includes a current email address, contact phone number, your home address and your usual GP's details.

Health NZ sends completed referrals with updated health information to the Service provider. Following the review of the submitted referral either:

• Te Whatu Ora Health NZ will contact a patient if the Service requires additional health information before considering them for a first specialist assessment or
• the Service will contact the patient directly with the offer of an appointment for a first specialist assessment.
• it is important that patients on the wait list and progressing through the pre-surgical pathways promptly provide any information requested by Te Whatu Ora or the Service. Failure to do so will affect their ability to be reviewed with considered for an FSA and/or their waiting list status. 
• New Zealand citizens are eligible to receive publicly funded services while they live in New Zealand, but are not entitled to publicly funded care while residing overseas.

It is very helpful if during your annual check in with your GP, you ask them to fill in the GP Completed Gender Affirming Genital Surgery Health and Well-Being Form (pdf, 273kb ) and have them send it through to us at [email protected] .

Gender affirming genital surgery can be publicly funded and provided in New Zealand in the private sector. 

People who have been referred for gender affirming genital surgery are on a waiting list for a first specialist assessment (FSA) to see a surgeon and discuss their surgery options.

There is currently a long waiting list for an FSA. From 1 July 2022, Te Whatu Ora Health New Zealand (HNZ) is managing the waiting list for an FSA.

New referrals for gender affirming genital surgery can be made by the person’s transgender health professional (this is normally an endocrinologist or a sexual health physician) or for those living in the Wellington and Christchurch districts only, this may be done by their general practitioner (GP). 

To be considered for surgical assessment, patients need to:

• meet the eligibility criteria set out in the version 7 Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, published by The World Professional Association for Transgender Health (WPATH) - Version 7 is to be used when assessing patients and not version 8. 
• be  eligible for publicly funded surgery in New Zealand  
• be physically and mentally fit to undertake a complex surgical procedure. This includes being a non-smoker, having a BMI under 35 and good mental health and social support.

Referrals should be made on the Gender Affirming (Genital) Surgery Service referral form (available below), with relevant physical, social and mental health history/clinical reports attached.

Send referrals to:  [email protected] .

Referrals for gender affirming (genital) surgery must be completed by hospital specialist or an authorised GP (see above for more details) .

• Referral form – Gender Affirming Genital Surgery (PDF, 213 KB)

People on the waiting list are encouraged to complete the annual review form and to send it to Te Whatu Ora - Health New Zealand every twelve months.

• Patient Completed Gender Affirming Genital Surgery – Annual Review Form (PDF, 206 KB) 

People who are on the waiting list for an FSA and have received an appointment date for an FSA will be sent the health and well-being questionnaire form which must be completed by the patient’s GP.

• GP Completed Gender Affirming Genital Surgery – Health and Well-Being Questionnaire Form (PDF, 280 KB) 

This resource is for people wanting to know more about phalloplasty surgery and what is involved.  

• What is Phalloplasty? (PDF, 196 KB)

This resource is for people wanting to know more about phalloplasty without urethral lengthening surgery and what is involved. 

• What is Phalloplasty without Urethral Lengthening (PDF, 168 KB)

This resource focuses on helping patients with answering frequently asked questions regarding phalloplasty surgery.

• FAQs Phalloplasty (Frequently Asked Questions) (PDF, 205 KB)

This resource is for people wanting to know more about vaginoplasty surgery and what is involved. 

• What is Vaginoplasty? (PDF, 217 KB) 

This resource is for people wanting to know more about minimal depth vaginoplasty and what is involved. 

• What is Minimal Depth Vaginoplasty? (PDF, 169 KB)

This resource focuses on helping patients with answering frequently asked questions regarding vaginoplasty surgery. 

• FAQs Vaginoplasty (frequently asked questions) (PDF, 156 KB)

This resource is for people wanting to know more about metoidioplasty and what is involved. 

• What is Metoidioplasty? (PDF, 219 KB)

This resource focuses on helping patients with answering frequently asked questions regarding metoidioplasty surgery. 

• FAQs Metoidioplasty (PDF, 269 KB)

This resource will help patients choose a caregiver and support people to make the post-surgery recovery process easier.

• Choosing Your Caregiver and Support People ( PDF, 205 KB)

This resource focuses on helping the patient’s caregiver and support people through the post-surgery recovery process with different ways on how to support the patient.

• FAQ Sheet for Caregivers and Main Support People (PDF 174 KB)

Email any questions regarding gender affirming (genital) surgery to: [email protected] .

The focus of the Ministry-funded service is to improve access to gender affirming genital reconstruction for transgender people who have not previously been able to have this surgery.

People who have had or are considering self-funding genital reconstruction surgery in New Zealand or overseas should be aware that the Service will not routinely accept referrals for elective revisions of past surgeries. If you are considering self-funding genital reconstruction surgery overseas, please click on the following link and consider the information provided https://www.safetravel.govt.nz/news/medical-tourism

People who have or are considering self-funding surgery are advised that their local hospital network is responsible for treating emergency or urgent complications from surgery. Non-emergency / non-urgent complications or sub-optimal outcomes from self-funded surgeries should be referred to the surgical team who provided the patient’s surgery or their GP. 

The Service will not reimburse the cost of surgery to patients on the waiting list for publicly funded surgery, who choose to self-fund private surgery in New Zealand or overseas.

A patient offered a first specialist assessment who needs to travel a long distance for the appointment may be eligible for financial assistance under the National Travel Assistance (NTA) Scheme.

A patient may be eligible for the NTA if they can answer yes to one of these questions:

• Do you travel more than 350 km one way per visit for an adult, or
• Will you visit a specialist 22 or more times in two months, or
• Will you visit a specialist six or more times in six months, and travel more than 50 km one way per visit for an adult, or
• Are you a Community Services Card holder and travel more than 80 km one way per visit for an adult? 

The Service will assist patients register for NTA. Eligibility for NTA is decided by a patient’s local hospital network, after the hospital network has received a copy of the NTA registration form and appointment letter from Health NZ.

If Health NZ does not approve financial assistance for travel and post operative accommodation under the NTA Scheme, travel and post operative accommodation until medically discharged to return home may be an additional expense for the patient. Patients will be advised whether they are eligible for NTA well in advance of their appointment.

For more information on NTA, please click the link here:

https://www.tewhatuora.govt.nz/our-health-system/hospitals-and-specialist-services/national-travel-assistance/

State health plans must cover gender-affirming surgery, US appeals court rules

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Reporting By Brendan Pierson in New York, Editing by Alexia Garamfalvi and Bill Berkrot

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Brendan Pierson reports on product liability litigation and on all areas of health care law. He can be reached at [email protected].

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