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Preparing for Gender Affirmation Surgery: Ask the Experts

Preparing for your gender affirmation surgery can be daunting. To help provide some guidance for those considering gender affirmation procedures, our team from the  Johns Hopkins Center for Transgender and Gender Expansive Health (JHCTGEH) answered some questions about what to expect before and after your surgery.

What kind of care should I expect as a transgender individual?

What kind of care should I expect as a transgender individual? Before beginning the process, we recommend reading the World Professional Association for Transgender Health Standards Of Care (SOC). The standards were created by international agreement among health care clinicians and in collaboration with the transgender community. These SOC integrate the latest scientific research on transgender health, as well as the lived experience of the transgender community members. This collaboration is crucial so that doctors can best meet the unique health care needs of transgender and gender-diverse people. It is usually a favorable sign if the hospital you choose for your gender affirmation surgery follows or references these standards in their transgender care practices.

Can I still have children after gender affirmation surgery?

Many transgender individuals choose to undergo fertility preservation before their gender affirmation surgery if having biological children is part of their long-term goals. Discuss all your options, such as sperm banking and egg freezing, with your doctor so that you can create the best plan for future family building. JHCTGEH has fertility specialists on staff to meet with you and develop a plan that meets your goals.

Are there other ways I need to prepare?

It is very important to prepare mentally for your surgery. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts. These conversations and articles may be helpful; however, keep in mind that not everything you read will apply to your situation. If you have questions about whether something applies to your individual care, it is always best to talk to your doctor.

You will also want to think about your recovery plan post-surgery. Do you have friends or family who can help care for you in the days after your surgery? Having a support system is vital to your continued health both right after surgery and long term. Most centers have specific discharge instructions that you will receive after surgery. Ask if you can receive a copy of these instructions in advance so you can familiarize yourself with the information.

An initial intake interview via phone with a clinical specialist.

This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about, clarify what is required by your insurance company for surgery, and develop a plan for next steps. It will make your phone call more productive if you have these documents ready to discuss with the clinician:

Medications. Information about which prescriptions and over-the-counter medications you are currently taking.
Insurance. Call your insurance company and find out if your surgery is a “covered benefit" and what their requirements are for you to have surgery.
Medical Documents. Have at hand the name, address, and contact information for any clinician you see on a regular basis. This includes your primary care clinician, therapists or psychiatrists, and other health specialist you interact with such as a cardiologist or neurologist.

After the intake interview you will need to submit the following documents:

Pharmacy records and medical records documenting your hormone therapy, if applicable
Medical records from your primary physician.
Surgical readiness referral letters from mental health providers documenting their assessment and evaluation

An appointment with your surgeon. 

After your intake, and once you have all of your required documentation submitted you will be scheduled for a surgical consultation. These are in-person visits where you will get to meet the surgeon. typically include: The specialty nurse and social worker will meet with you first to conduct an assessment of your medical health status and readiness for major surgical procedures. Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey. Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

A preoperative anesthesia and medical evaluation. 

Two to four weeks before your surgery, you may be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

What can I expect after gender affirming surgery?

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs. Depending on your specific surgery and which organs you continue to have, you may need to follow up with a urologist or gynecologist for routine cancer screening. JHCTGEH has primary care clinicians as well as an OB/GYN and urologists on staff.

Among other changes, you may consider updating your name and identification. This list of  resources for transgender and gender diverse individuals can help you in this process.

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Transgender Health: What You Need to Know

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Gender Affirmation Surgeries

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Facial Masculinization Surgery

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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Tests & Procedures
Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

Removal of the testicles alone. This is called orchiectomy.
Removal of the penis, called penectomy.
Removal of the testicles.
Creation of a vagina, called vaginoplasty.
Creation of a clitoris, called clitoroplasty.
Creation of labia, called labioplasty.
Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
Tummy tuck, called abdominoplasty.
Buttock lift, called gluteal augmentation.
Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

Significant medical conditions that haven't been addressed.
Behavioral health conditions that haven't been addressed.
Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

Delayed wound healing
Fluid buildup beneath the skin, called seroma
Bruising, also called hematoma
Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
Urinary problems, such as incontinence
Pelvic floor problems
Permanent scarring
Loss of sexual pleasure or function
Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

Risks and benefits
Alternatives to surgery
Expectations and goals
Social and legal implications
Potential complications
Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

A review of your personal and family medical history
A physical exam
A review of your vaccinations
Screening tests for some conditions and diseases
Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

Gender identity
Gender dysphoria
Mental health concerns
Sexual health concerns
The impact of gender identity at work, at school, at home and in social settings
The role of social transitioning and hormone therapy before surgery
Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
Support from family, friends and caregivers
Your goals and expectations of treatment
Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

Moving the hairline to create a smaller forehead
Enlarging the lips and cheekbones with implants
Reshaping the jaw and chin
Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

Breast incisions for breast augmentation

Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

Placement of breast implants or tissue expanders

Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

Anatomy before and after penile inversion

Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

Anatomy before and after bowel flap procedure

Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

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

Vaginoplasty

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

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

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

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

Affiliations.

1 From the Department of Plastic and Reconstructive Surgery.
2 School of Medicine.
3 Department of Obstetrics and Gynecology.
4 Department of Urology.
5 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA.
PMID: 36149983
DOI: 10.1097/SAP.0000000000003233

Background: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

Methods: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

Results: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

Conclusion: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

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Conflict of interest statement

Conflicts of interest and sources of funding: none declared.

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ORIGINAL RESEARCH article

Male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

$\nGabriel Veber Moiss da Silva$

1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Why One Trans Woman Wants to Discuss Sex After Surgery

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A few years ago, as transgender issues leaped to the forefront of the cultural conversation, some famous and otherwise outspoken trans people were quick to steer the focus away from “the surgery.”

Many will remember the moment back in January 2014 when actress Laverne Cox schooled Katie Couric, after Couric ask an invasive question about her body. “The preoccupation with transition and surgery objectifies trans people,” Cox told Couric. “The reality of trans people’s lives is that so often we are targets of violence. We experience discrimination disproportionately to the rest of the community. Our unemployment rate is twice the national average [ . . . ] The homicide rate is highest among trans women. If we focus on transition, we don’t actually get to talk about those things.”

For the most part, people have respected that request. But according to my friend Nomi Ruiz, this has inadvertently created a taboo in the trans community: Nobody talks about sex. Nomi is a transgender singer and host of the podcast Allegedly NYC . “Right now there’s a lot of sensitivity around trans issues,” Nomi told me recently. “At times this makes it easier to communicate, but it also makes people afraid of offending someone, and prevents people from getting deeper into a conversation.” Nomi is concerned, in particular, about the lack of conversation around sex for women who have had sex reassignment surgery (SRS), and the real-life implications the operation can have on their sexual experience. “A lot of girls won’t even talk about it among themselves,” she said. “But I’d like to be someone who can open up this conversation.”

Now, I’m a cis person, and therefore have no personal insight to share on this seemingly off-limits subject. But I do know well that, when dealing with sexuality or any other sensitive topic, it is generally useful to hear the stories of people with experiences similar to your own, because it helps you to better understand your own experience and your own body. It helps you to not feel so fucking alone, basically. And I think Nomi’s concern poses a delicate question: Is it time for a nuanced discussion about sex and pleasure for trans women? Has the cultural conversation around trans culture progressed enough?

Over Chardonnay in Bushwick, Brooklyn, I sat down with Nomi to talk about sex. “I think a lot of people, when they think of trans females, they think ‘a girl with a penis,’” she said. “And if you’re post-op, they think you just had your penis cut off. There’s still this shock factor to having a sex change. People think, ‘Eww, that’s so horrible’ or ‘That’s so crazy .’”

According to Nomi, these misconceptions are common even within her own, progressive social scene. “Sometimes, if I’m dating a guy but I don’t want to sleep with him right away, he’s like, ‘Oh, because it doesn’t work.’ Or people think you can’t orgasm. They don’t realize the reality. But if they knew how beautiful and how natural the vagina really is, and how it’s so in tune with your mind and your body, I think people would start seeing it as sexy rather than as a science experiment. I mean, even I didn’t know the possibilities.”

Nomi said that as she was preparing for SRS, she wished there were more women talking about their experiences of sex after surgery, because she felt sort of in the dark. “There was this myth that you could never have another orgasm, that there’s no sensitivity, and that you could never enjoy sex again,” Nomi said. “So there was always that fear and that risk. But eventually I got to the point where I was like, ‘I don’t care. I’d rather not enjoy sex than live this way.’”

Nomi had SRS five years ago, in her mid-20s. “The conversation with my doctor beforehand was hilarious, because it’s sort of customized,” Nomi said. “She asked me: What are you looking to achieve? Like, are you a lesbian, are you interested in being penetrated? Is it more important to focus on the nerve endings in your clit, or do you want a lot of depth? Or do you want both? I was like, ‘I want it all. Go for gold.’”

Like any major surgery, there is a lengthy recovery period. “I was in bed for a month, and after that, there’s a dilation process,” Nomi said. “They give you four dilators, with a ruler on them. You’re basically fucking yourself: You slowly increase the size, so that you keep the depth and width you’ve achieved.” This process takes six months. “And then you have to dilate once a week for the rest of your life, unless you’re having sex,” Nomi continued. “So now when I’m not having sex, it’s kinda sad, because you’re really reminded of it. You’re like, ‘Oh, God, I have to dilate now because I’m not getting laid. Fuck.’”

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(It’s important to note here that Nomi’s experience is not every trans woman’s experience. The process of altering one’s birth sex is complex, happens over a long period of time, and does not always involve surgery. SRS is only one small part of transition, and not all transgender people choose to, or can afford to, undergo surgery. Though it’s sort of strange to think of SRS as a privilege, there are many transgender people who want SRS but do not have access to it. For this and other reasons, sex change and post-op are outdated terms, and are used in this article only in direct quotations.)

At first, Nomi said, she was hesitant to jump into being sexually active: “I didn’t want to give my vagina to every guy, because I was like, ‘Duh, it’s brand-new!’” When she did start having sex, it felt kind of weird for a while. “I was really self-conscious, because I was blaming all of the awkward sex on my neo-vagina,” Nomi said. “I was like, Maybe it’s not working. It’s not like other girls’ vaginas. It’s not right. I’m not getting pleasure.” The first time she got head, it basically felt like nothing, so she called up her BFF, a cis girl, in a panic. “I was like, ‘Girl, is it normal to just feel like you’re rubbing on a carpet when a guy is eating you out?!’ She was like, ‘Oh, girl, yeah, sometimes it’s a fucking nightmare.’”

Nomi was faced with a harsh reality: A lot of guys just aren’t that great with their tongue. “I realized he just wasn’t good at it,” Nomi said. “But then, when I met a guy who was good at it, I was like, ‘Oh, duh, okay, it really depends. It’s not like jerking off a penis.’ When I had better lovers, things changed. It took meeting the right guy, slowly fingering me, seeing how I reacted. You need someone to help you enjoy your body, not someone who just wants to fuck you.”

As she continued to explore her body, sex became better than she ever imagined. “When I was turned on, I would get really wet, and I was shocked, because I’d never heard a [trans] girl say that her vagina got wet,” she said. “I didn’t realize that it would be this beautiful, natural part of me. I was like, ‘Holy shit, this is beyond what I thought my sex life could be.’” She paused for dramatic effect. “But I still love anal sex. The best sex is if we do both. But I learned that you can’t go back and forth, because I got a UTI from that. I was like, ‘Fuck, this is what having a vagina is like?!’ My friend was cracking up, like, ‘Girl, you wanted a pussy.’ I was like, ‘This is too real.’”

Other changes Nomi noticed were more mental than physical. “Before [SRS], sex was almost violent,” she said. “It was like shooting a gun, like I’ve got to get rid of this. But now I really have to be present and be into the person in order for my body to react. Like, my vagina will basically reject a penis if I’m not into the sex. But if I am into it, it gets really open and moist. I feel sex is more attached to my brain now. And I can keep having more sex after I orgasm, whereas before, after I came, I was like, ‘I’m done, thanks.’”

In other words, Nomi’s experience became an almost clichéd account of sex as a woman—i.e., often, reaching orgasm can feel like an epic psychological journey that requires laser focus. You have to be in the right headspace, with the right atmosphere. You know, candles or whatever. And Nomi isn’t the only trans woman I’ve heard say this. On YouTube, there’s a small community of transgender women who talk about sex (among other issues), and many of them echo this sentiment. In one particularly funny video, posted by vlogger Danica Lee, she talks about how having an orgasm post-SRS is just more work —she can be sooo close, but then she’ll remember a bill she has to pay, and she’ll have to start over from scratch. Been there.

One of the most popular trans vloggers is A Girl for All Seasons , also known as Charlie, a British race-car driver with a dry sense of humor. In one of her most-watched videos , viewed more than 50,000 times, Charlie compares sex before and after SRS. “When you have sex as a guy, you pretty much know you’re going to climax, and that’s cool,” Charlie says in the video. “But as a woman, I find it quite difficult to reach that point. It’s like, sure, intimacy and being with somebody and having that experience is nice. But it’s very strange to suddenly make love to somebody and not climax, thinking, is this all sex is ever going to be now? It’s nice, but it’s kind of a bit shit.”

After binge-watching Charlie’s channel, I called her up to ask about this. She laughed. “Cis girls will probably be like, ‘Yeah, welcome to having sex with a guy as a woman,’” she said. But of course, this is not the only challenge that transgender women face when it comes to sex. “It’s strange, because after SRS, you’re having to relearn your entire body: how it works, what you’re going to enjoy, and what things are going to hurt. When you’ve had sex so many times in your life, and suddenly you’re doing it and you’re a complete novice, it’s a crazy experience. You know how it all works, but everything’s different.” (Another trans woman, @sugarpunk_xoxo on Twitter, described this to me: “During sex, it felt like my brain was remapping my body.”)

For a while, Charlie was worried she was never going to enjoy sex again. “I never felt that at ease,” she said. “I don’t think any of the guys I slept with actually gave me an orgasm, which sucks.” But like Nomi, eventually she met the right sexual partner, and after enough personal experimentation, she was able to relax and feel pleasure. “I definitely enjoy sex now,” she said, adding that climaxing is every bit as good and intense as it ever was. “You just have to figure it out as you go along, and feel your way through things.”

Talking openly with Nomi and Charlie, I realized that, even in the trans community, there is a binary of “normal” and “abnormal” that needs to be broken. To this point, Nomi referenced a recent Instagram post by musician Dev Hynes that accompanied the release of his new album, Freetown Sound. The post featured a note, handwritten by Hynes, that read: “My album is for everyone told they’re not black enough, too black, too queer, not queer the right way.”

“When you’re post-op, some people will say, ‘You’re just trying to be a woman. You’re not trans enough ,’” Nomi said. “But that doesn’t take away my experiences, or the way people look at me or talk about me. It doesn’t make me any different than you. Trans is beautiful and, within that, post-op is also beautiful. To this day, every time I am intimate with someone, I’m exploring more and learning new things about my body.”

Karley Sciortino writes the blog Slutever .

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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 ).

An external file that holds a picture, illustration, etc.
Object name is atm-09-07-605-f1.jpg

Distribution of transgender surgery experiences among respondents.

An external file that holds a picture, illustration, etc.
Object name is atm-09-07-605-f2.jpg

Number of transgender patients encountered who expressed regret.

Results regarding regret and reversal	N	%
Total regretful patients encountered	62	100.0
Type of procedure patient sought to reverse
Chest surgery	13	21.0
Genital surgery	45	72.6
Reversal procedures performed
Reversal of mastectomy	0	0
Reversal of breast augmentation	6	9.7
Reversal of phalloplasty	16	25.8
Reversal of vaginoplasty	1	1.6
Regretful patients encountered, per surgeon respondent
0	18	39.1
1	12	26.1
2	6	13.0
3	1	2.2
4	3	6.5
5	0	0.00
5–10	1	2.2
10–20	1	2.2
>20	0	0.0

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 .

Regret type	Reason cited by surgeon	N	%
–	Reason unknown or no response	16	25.8
True gender-related regret	Change in gender identity	22	35.5
	Misdiagnosis	4	6.5
	Total	26	41.9
Social regret	Fear for safety due to societal judgment	1	1.6
	Difficulty in marriage or romantic/sexual relationships	7	11.3
	Rejection or alienation from family, emotional, or social supports	9	14.5
	Problems associated with employment or professional life	1	1.6
	Spiritual or religious conflict or pressure	5	8.1
	Total	23	37.1
Medical regret	Concern for health	1	1.6
	Complications due to surgery	1	1.6
	Change in sexual response	1	1.6
	Desired pregnancy	1	1.6
	Missed their natal genitals	1	1.6
	Total	5	8.1

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 ).

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Object name is atm-09-07-605-f3.jpg

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 type	Definition	Potential etiology	Percent citing this in request for reversal
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	Misdiagnosis, insufficient exploration of gender identity, barriers to access for non-binary transition	42%
Social regret	Refers to one’s desire to return to their sex assigned at birth so as to ease the repercussions of transitioning on their societal life	Feeling unsafe in public, loss of partnership, religious conflict, inability to partake in one’s community, encountering professional barriers	37%
Medical regret	Includes regret originating from a direct outcome of a surgery or an irreversible consequence thereof	Medical complications, dissatisfaction with functional outcome, pre-operative decision making (e.g., inadequate/incomplete counseling, change in life goals)	8%

Term	Definitions
Gender fluidity	An inclusive term describing gender along a spectrum rather than a binary construct. A gender fluid individual may identify differently at various time points in their lives
Continued transition	Treatments following initial gender-affirming procedure(s) that may relate to an evolving gender identity or request further surgical consolidation of their identity. Continued transition need not be accompanied by regret for previous transition
Detransition	A change in gender role and/or the cessation of medical transition. This term should only be utilized for those who self-identify with this experience, rather than to describe the process of surgical reversal
Retransition	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
Fleeting ambivalence	A short term or temporary regret, often related to societal stigma or medical complications in the post-operative period

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.

FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media claims only 1% of people regret their gender-affirmation surgery.

View this post on Instagram A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

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Biden ‘gender reassignment’ surgery mandate blocked

By Peter Pinedo

Houston, Texas, Sep 3, 2024 / 16:45 pm

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender reassignment” surgeries or face a range of penalties including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” Paxton said.

Jennifer Carr Allmon, executive director of the Texas Catholic Conference of Bishops, told CNA that the Texas bishops are “grateful” for the nationwide stay.

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Allmon said that gender transition surgeries are “not authentic health care” because these procedures “interrupt natural developmental processes and can result in infertility and other serious health risks, especially for children, all of which may be irreversible.”

“Health care providers must be free to refuse to perform these harmful interventions without risk of penalty,” she said. “The Texas Catholic Conference of Bishops advocates for health care that is oriented toward honoring the dignity of each person while respecting the religious liberty and conscience rights of medical professionals.”

The Biden administration will likely appeal the ruling to the Fifth Circuit Appellate Court.

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Trump repeats false claims that children are undergoing transgender surgery during the school day

Former President Donald Trump repeated his false claim that children are undergoing transition-related surgery during their school day, worsening fears among some conservatives that educators are pushing children to become transgender and aiding transitions without parental awareness.

“Can you imagine you’re a parent and your son leaves the house and you say, ‘Jimmy, I love you so much, go have a good day in school,’ and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?” Trump said Saturday at a campaign rally in Wisconsin, a vital swing state.

Trump made similar remarks — saying children were returning home from school after having had surgical procedures — the previous weekend at an event hosted by Moms for Liberty, a parent activist group that has gained outsized influence in conservative politics in recent years.

Asked by one of the group’s co-founders how he would address the “explosion in the number of children who identify as transgender,” Trump said: “Your kid goes to school and comes home a few days later with an operation. The school decides what’s going to happen with your child.”

There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure elsewhere.

About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare . In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers . Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

A spokesperson for Trump’s campaign did not substantiate his claims and pointed NBC News to reports about parents’ being left in the dark about their children’s gender transitions at school.

“President Trump will ensure all Americans are treated equally under the law regardless of race, gender or sexual orientation,” said the spokesperson, Karoline Leavitt.

Kate King, president of the National Association of School Nurses, said that even when it comes to administering over-the-counter medication such as Advil or Tylenol, school nurses need explicit permission from a physician and a parent.

“There is no way that anyone is doing surgery in a classroom in schools,” she said when she was asked about Trump’s remarks.

Trump’s claims stand out even amid years of allegations by conservative politicians and right-wing media pundits that teachers, Democratic lawmakers and LGBTQ adults are “grooming” or “indoctrinating” children to become gay or transgender.

The practice of labeling LGBTQ people, particularly gay men and trans women, as “groomers” and “pedophiles” of children had been relegated to the margins for decades, but the tropes resurfaced during the heated debate over Florida’s so-called Don’t Say Gay law, which Gov. Ron DeSantis signed in March 2022. The law limits the instruction of sexual orientation and gender identity in school and has been replicated in states across the country.

At the Republican National Convention in July, at least a dozen speakers — including DeSantis and Rep. Marjorie Taylor Greene, R-Ga. — mentioned gender identity or sexuality negatively in their speeches, according to an NBC News analysis. DeSantis, for example, alleged that Democrats want to “impose gender ideology” on kindergartners.

Nearly 70% of public K-12 teachers who have been teaching for more than one year said topics related to sexual orientation and gender identity “rarely or never” come up in their classrooms, according to a recent poll from the Pew Research Center. Half of all teachers polled, including 62% of elementary school teachers, said elementary school students should not learn about gender identity in school.

Trump vowed last year that if he is re-elected he would abolish gender-affirming care for minors, which he equated to “child abuse” and “child sexual mutilation.” This year, Trump also said he would roll back Title IX protections for transgender students “on day one” of his potential second presidential administration.

His campaign website says he would, if he is re-elected, cut federal funding for schools that push “gender ideology on our children” and “keep men out of women’s sports.”

More broadly, Trump has promised to eliminate the Education Department, claiming that doing so would give states more authority over education.

During his first administration, Trump barred trans people from enlisting in the military — which he has vowed to do again if he is re-elected — and rolled back several antidiscrimination protections for LGBTQ people.

For more from NBC Out, sign up for our weekly newsletter.

Matt Lavietes is a reporter for NBC Out.

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Steve-O Canceled Plan to Get Breast Implants for a Comedy Prank After Talking to a Transgender Person He Met on Surgery Day: ‘It’s Not All Fun and Games’

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“I knew what my motivation was, I knew what my intention was, and it wasn’t to be hurtful to anybody,” Steve-O said. “I was just trying to get laughs. I had done a bunch of workshop shows to test out material, and I had a number of trans people come to me after the shows to voice support for [the stunt]. And I think some people would’ve been okay with it, and some people wouldn’t have. It would’ve been a mixed bag.”

The clerk fell in the latter category and said that “the part where I deliberately went out to trick people into thinking that I was a woman and then fooling them, and then kind of celebrating the idea of hate towards [trans people] — that was a [bad] thing.”

That’s when Steve-O opted not to go through with his plan to get breast implants as “framed like that, I thought about it in a way that I hadn’t before, where you know, wow, maybe it’s not all fun and games. Especially the pranks.”

Steve-O originally announced in July his plan to get breast implants. The “Jackass” favorite will be performing “The Super Dummy Tour” in theaters around the U.S. this fall. Head over to Consequence’s website to read his interview in its entirety.

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Before & After Procedures
See the before and after procedures done by Dr. Gary J. Alter. (310) 275-5566 . Search for: MEET DR. ALTER. Published Works; FEMALE GENITAL SURGERY. ... MALE TO FEMALE GENDER CONFIRMATION SURGERY; MALE-TO-FEMALE SEX REASSIGNMENT REVISIONS; GENDER CONFIRMATION BREAST AUGMENTATIONS; FEMALE-TO-MALE CHEST CONTOURING; FEMALE TO MALE METAIDOIOPLASTY ...
Vaginoplasty for Gender Affirmation
Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum. During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a ...
Preparing for Gender Affirmation Surgery: Ask the Experts
Request an Appointment. 844-546-5645 United States. +1-410-502-7683 International. To help provide guidance for those considering gender affirmation surgery, two experts from the Johns Hopkins Center for Transgender Health answer questions about what to expect before and after your surgery.
Dilation after gender-affirming surgery
Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life. Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each ...
Gender Affirmation Surgeries: Common Questions and Answers
Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender. A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery. The term "transexual" was previously used by the medical community to describe people ...
Feminizing surgery
Overview. Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation.
Gender Confirmation (Formerly Reassignment) Surgery: Procedures
Today, many transgender people prefer to use the term "gender confirmation surgery," because when we say something like gender "reassignment" or "sex change," it implies that a person ...
Vaginoplasty procedures, complications and aftercare
Great care is taken to limit the external scars from a vaginoplasty by locating the incisions appropriately and with meticulous closure. Typical depth is 15 cm (6 inches), with a range of 12-16cm (5-6.5 inches); in comparison, typical vaginal depth in non-transgender females is between 9-12cm (3.5 to 5 inches).
Vaginoplasty Before and After Photos
Dr. Christopher Salgado - Miami, Florida. Dr. Christopher Salgado is a board-certified plastic surgeon in Florida who has deep expertise in Gender Affirming Surgery. In practice for more than 20 years, Dr. Salgado performs the full spectrum of male-to-female surgery, giving patients the opportunity to experience a continuity of care throughout ...
Long-term Outcomes After Gender-Affirming Surgery: 40-Year ...
Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret. ... Sex Reassignment Surgery* Transgender Persons* / psychology Transsexualism* / psychology ...
Regret after Gender-affirmation Surgery: A Systematic Review and Meta
Regret after GAS may result from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery. 15 Poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors ...
Gender-affirming surgery (male-to-female)
Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.. Often used to refer to vaginoplasty, sex reassignment surgery can also more broadly refer to other gender-affirming ...
Gender-affirming surgery
Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals.
Male-to-Female Gender-Affirming Surgery: 20-Year Review of ...
Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open. (2015) 6:69-73. doi: 10.1016/j.jpra.2015.09.003. CrossRef Full Text | Google Scholar. 14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al ...
MTF Vaginoplasty Gallery
MTF Vaginoplasty. In male-to-female sex reassignment, the trans woman may choose to undergo vaginoplasty - the inversion of the penis to create a vagina - as part of her physical transition. This procedure can result in a fully sensate neovagina. Dr. MacPhee performs this reconstructive procedure by disassembling the penis and utilizing the ...
Trans Women Open Up About Sex After Surgery
Nomi said that as she was preparing for SRS, she wished there were more women talking about their experiences of sex after surgery, because she felt sort of in the dark. "There was this myth ...
Sexuality after Male-to-Female Gender Affirmation Surgery
Abstract. Male-to-Female (MtF) gender affirmation surgery (GAS) comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all 254 MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of ...
Guiding the conversation—types of regret after gender-affirming surgery
Pfäfflin F, Junge A. Sex Reassignment. Thirty Years of International Follow-up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961-1991. Symposion Publishing in the Book Section of The International Journal of Transgenderism, 1998. [Google Scholar]
FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1
The source used is "Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence" from the National Library of Medicine (NLM). ... "Factors predictive of regret in sex reassignment," found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures ...
Biden 'gender reassignment' surgery mandate blocked
Biden 'gender reassignment' surgery mandate blocked. Image credit: ADragan/Shutterstock. By Peter Pinedo. Houston, Texas, Sep 3, 2024 / 16:45 pm.
Trump repeats false claims that children are undergoing transgender
There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure ...
Steve-O Cancels Plan to Get Breast Implants for Comedy Sketch
Latest; Steve-O Canceled Plan to Get Breast Implants for a Comedy Prank After Talking to a Transgender Person He Met on Surgery Day: 'It's Not All Fun and Games' 16 hours ago James McAvoy ...

Dr. Alter’s Before and After IMAGE GALLERY

LABIAPLASTY (Labia Minora Reduction)

CLITORAL HOOD REDUCTION WITH/WITHOUT CLITOROPEXY

LABIA MAJORA REMODELING

COMBINATION FEMALE GENITAL SURGERIES

REVISION OF BOTCHED LABIAPLASTIES

CLITORIS REDUCTION

PUBIC LIPOSUCTION

PUBIC MONS LIFT

INTERSEX & COMPLEX FEMALE RECONSTRUCTION

BURIED/HIDDEN PENIS CORRECTIVE SURGERY – ADULT

MALE TO FEMALE GENDER CONFIRMATION SURGERY

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Botched Labiaplasty? There’s Still Hope

Why You Should Choose a Specialist for your Labiaplasty

5 Labiaplasty Benefits You Should Know About

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Preparing for Gender Affirmation Surgery: Ask the Experts

What kind of care should I expect as a transgender individual?

Can I still have children after gender affirmation surgery?

Are there other ways I need to prepare?

An initial intake interview via phone with a clinical specialist.

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A preoperative anesthesia and medical evaluation.

What can I expect after gender affirming surgery?

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ORIGINAL RESEARCH article

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Postoperative Care and Follow-Up

An appointment with your surgeon. 

A preoperative anesthesia and medical evaluation. 