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. It is also known as sex reassignment surgery, gender confirmation surgery, and several other names.

Professional medical organizations have established Standards of Care, which apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

Feminization surgeries are surgeries that result in anatomy that is typically gendered female, such as vaginoplasty, vulvoplasty and breast augmentation, while masculinization surgeries are those that result in anatomy that is typically gendered male, such as phalloplasty and breast reduction.

In addition to gender-affirming surgery, patients may need to follow a lifelong course of masculinizing or feminizing hormone replacement therapy.

Sweden became the first country in the world to allow transgender people to change their legal gender after "reassignment surgery" and provide free hormone treatment in 1972. Singapore followed soon after in 1973, being the first in Asia.

Terminology
Gender-affirming surgery is known by numerous other names, including gender-affirmation surgery, sex reassignment surgery, gender reassignment surgery, and gender confirmation surgery. It is also sometimes called a sex change, though this term is usually considered offensive. Top surgery and bottom surgery refer to surgeries on the chest and genitals respectively.

Some transgender people who desire medical assistance to transition from one sex to another identify as "transsexual".

Trans women and others assigned male at birth may undergo one or more feminizing procedures which result in anatomy that is typically gendered female. These include genital surgeries such as penectomy (removal of the penis), orchiectomy (removal of the testicles), vaginoplasty (construction of a vagina), vulvoplasty (construction of a vulva), as well as breast augmentation, tracheal shave (reduction of the Adam's apple), facial feminization surgery, and voice feminization surgery among others.

Trans men and others assigned female at birth seeking surgery may undergo one or more masculinizing procedures, which include chest reconstruction, breast reduction, hysterectomy (removal of the uterus), oophorectomy (removal of the ovaries). A penis can be constructed through metoidioplasty or phalloplasty, and a scrotum through scrotoplasty.

As knowledge of non-binary genders expands in the medical community, more surgeons are willing to tailor operations to individual needs. Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Gender nullification is the removal of all external genitalia except the urethral opening, typically pursued by people assigned male at birth.

Gender-affirming surgery can also refer to operations pursued by cisgender people, such as mammaplasty, penile implant, or testicular implants following orchiectomy.

Gender-affirming surgery is often sensationalized and misrepresented by anti-trans activists through terminology such as genital-mutilation surgery.

Genital surgery
For trans women, genital reconstruction usually involves the surgical construction of a vagina, by means of penile inversion or the sigmoid colon neovagina technique; or, more recently, non-penile inversion techniques that make use of scrotal tissue to construct the vaginal canal. For trans men, genital reconstruction may involve construction of a penis through either phalloplasty or metoidioplasty.

Non-binary people often pursue genital surgeries, including the same operations as binary trans people of the same sex assignment, as well as bigenital or gender nullification surgeries. Bigenital operations include androgynoplasty, a procedure that retains the penis, or vagina-preserving phalloplasty.

Genital surgery may also involve other medically necessary ancillary procedures, such as orchiectomy, penectomy, mastectomy or vaginectomy. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistulas (abnormal connections between the neovagina and the rectum) can occur in about 1–3% of patients. These require additional surgery to correct and are often fixed by colorectal surgeons.

Other surgeries


As underscored by WPATH, a medically assisted transition from one gender to another may entail any of a variety of non-genital surgical procedures which change primary and/or secondary sex characteristics, any of which are considered "gender-affirming surgery" when undertaken to affirm a person's gender identity. For trans men, these may include mastectomy (removal of the breasts) and chest reconstruction (the shaping of a male-contoured chest), or hysterectomy and bilateral salpingo-oophorectomy (removal of ovaries and fallopian tubes). For some trans women, facial feminization surgery, hair implants, and breast augmentation are also aesthetic components of their surgical treatment.

Scope and procedures
The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery - or bottom surgery (the latter is named in contrast to top surgery, which is surgery to the breasts; bottom surgery does not refer to surgery on the buttocks in this context). However, the meaning of "sex reassignment surgery" has been clarified by the medical subspecialty organization, the World Professional Association for Transgender Health (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for "gender dysphoria" or "transsexualism". According to WPATH, medically necessary sex reassignment surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation ... including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient ...)... and certain facial plastic reconstruction." In addition, other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair electrolysis.

Voice feminizing surgery is a procedure in which the overall pitch range of the patients voice is reduced.

Adam's apple reduction surgery (chondrolaryngoplasty) or tracheal shaving is a procedure in which the most prominent part of the thyroid cartilage is reduced.

There is also Adam's apple enhancement therapy, in which cartilage is used to bring out the Adam's apple in female to male patients.

History
Nero had Sporus castrated, and during their marriage, Nero had Sporus appear in public as his wife wearing the regalia that was customary for Roman empresses.

Reports of people seeking gender-confirming surgery (vaginoplasty) go back to the 2nd century, such as the Roman Emperor Elagabalus. In the Byzantine Empire "reconstructive" surgeries on intersex people were performed at least from the seventh century on, in Alexandria possibly as early as the 2nd century. Paul of Aegina (c. 625 – c. 690), quoting Leonidas (Alexandria, 2nd – 3rd centuries), describes in section LXIX (On Hermaphrodites) of his sixth book four types of intersex and how to "cure" three of them by surgically removing the "useless parts". In the next section (LXX, On Extirpation of the Nympha and Cauda Pudendi) he deals with clitoromegaly and how to remove the enlarged clitoris. The first modern gender-confirming surgery was performed in the 20th century.

20th century
In the US in 1917, Alan L. Hart, an American tuberculosis specialist, became one of the first trans men to undergo hysterectomy and gonadectomy as treatment of what is now called gender dysphoria.

Dora Richter is the first known trans woman to undergo complete male-to-female genital surgery. She was one of several transgender people in the care of sexologist Magnus Hirschfeld at Berlin's Institute for Sexual Research. In 1922, Richter underwent orchiectomy. In early 1931, a penectomy, followed in June by vaginoplasty.

Between 1930 and 1931, Lili Elbe underwent four sex reassignment surgeries, including orchiectomy, an ovarian transplant, and penectomy. In June 1931, she underwent her fourth surgery, including an experimental uterine transplant and vaginoplasty, which she hoped would allow her to give birth. However, her body rejected the transplanted uterus, and she died of post-operative complications in September, at age 48.

A previous sex reassignment surgery (SRS) patient was Magnus Hirschfeld's housekeeper, but their name has not been discovered.

Elmer Belt may have been the first U.S. surgeon to perform gender affirmation surgery, in about 1950.

In 1951, Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male SRS, producing a technique that has become a modern standard, called phalloplasty. Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

In 1971, Roberto Farina performed Brazil's first male-to-female gender-affirming surgery.

In 1984, Jalma Jurado developed a new surgical technique, which he used in surgeries for more than 500 transgender women in Brazil and from around the world.

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by the doctors Lebovic and Laub. Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head. Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "cis-appearing" penis in multiple stages.

21st century
On 12 June 2003, the European Court of Human Rights ruled in favor of Carola van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as van Kück vs Germany.

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".

some European countries require forced sterilization for the legal recognition of sex reassignment. , Japan also requires an individual to undergo sterilization to change their legal sex.

The early history of sex reassignment surgery in transgender people has been reviewed by various authors.

Prevalence
The prevalence of transgender-related surgeries is difficult to measure and likely underestimated. In 2015, the largest survey of transgender people in the United States reported that 25% of respondents reported having undergone such a surgery.

Medical considerations
Some transgender persons present with health conditions including diabetes, asthma, and HIV, which can lead to complications with future therapy and pharmacological management. Typical SRS procedures involve complex medication regimens, including sex hormone therapy, throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including endocrinologists, whom the surgeon may consult when determining if the patient is physically fit for surgery. Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.

People with HIV or hepatitis C may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.

Fertility is also a factor considered in SRS, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.

Gender dysphoric children
Sex reassignment surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it. Preferred treatments for children include puberty blockers, which are thought to have some reversible physical changes, and sex hormones, which reduce the need for future surgery. Medical protocols typically require long-term mental health counseling to verify persistent and genuine gender dysphoria before any intervention, and consent of a parent or guardian or court order is legally required in most jurisdictions.

Intersex children and cases of trauma
Infants born with intersex conditions might undergo interventions at or close to birth. This is controversial because of the human rights implications.

There can be negative outcomes (including PTSD and suicide) that occur when the surgically assigned gender does not match the individual's gender identity, which will be realized by the individual only later in life. Milton Diamond at the John A. Burns School of Medicine, University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.

Standards of care
Sex reassignment surgery can be difficult to obtain due to financial barriers, insurance coverage, and lack of providers. An increasing number of surgeons are now training to perform such surgeries. In many regions, an individual's pursuit of SRS is often governed, or at least guided, by documents called Standards of Care for the Health of Transgender and Gender Diverse People (SOC). The most widespread SOC in this field is published and frequently revised by the World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the United States and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of psychological evaluation and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly referred to as the real life test (RLT)) before sex reassignment surgeries are covered by insurance.

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.

Many surgeons require two letters of recommendation for sex reassignment surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as gender dysphoria), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.

Many medical professionals and numerous professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents. However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.

Insurance
A growing number of public and commercial health insurance plans in the United States now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and hysterectomy (FTM). For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:
 * a written initial assessment by a qualified licensed mental health professional
 * persistent, well-documented gender dysphoria
 * months of prior physician-supervised hormone therapy

In June 2008, the American Medical Association (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician." Other organizations have issued similar statements, including WPATH, the American Psychological Association, and the National Association of Social Workers.

In 2017, the United States Defense Health Agency for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who is a transgender woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.

Quality of life
Clinical research on long-term quality-of-life outcomes following surgery is limited and confounded by various factors, including small sample sizes, and baseline rates of mental health issues and suicide among transgender people compared to the general population.

A 2020 meta-analysis found "evidence of low quality" that gender-affirming surgery, particularly chest reconstruction for trans men, improves quality of life. A 2024 systematic review found that genital surgeries significantly improved depression and dissociation, with "mixed results" for other mental health outcomes.

A secondary analysis of the U.S. Transgender Survey found that gender-affirming surgery was significantly associated with lower rates of psychological distress, smoking, and suicidal ideation, compared to rates among respondents who desired surgery but had not undergone it. This was the largest controlled study on the subject to date (N=19,960), although the design of the survey and self-reported responses introduced some limitations and possible response bias.

A 2021 review found that less than 1% of 7,928 patients regretted gender-affirming surgery.

Psychological and social consequences
A 2009 review in the International Journal of Transgenderism found that from 1998 onward, studies have shown that "the whole process of gender reassignment is effective in relieving gender dysphoria and that its positive results greatly outweighed any negative consequences", but noted methodological issues in many studies, particularly older ones. A 2010 meta-analysis in Clinical Endocrinology noted the lack of randomization and control groups and reliance of self-reporting in the studies it reviewed, reaching the conclusion "Very low quality evidence suggests that hormonal therapies given to individuals with GID as a part of sex reassignment are likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."

Smith et al. (2001) found that among 20 patients, anxiety, depression and hostility levels were lower after sex reassignment surgery. Wierckx et al. (2011), in a study of 49 trans men, found them in good self-perceived physical and mental health. Dhejne et al. (2011), in a study following 324 transgender people who received sex reassignment surgery from 1973 to 2003, found that they "have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population", concluding that "sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism". Lawrence (2003), in a study of 232 trans women who underwent surgery between 1994 and 2000, found "None reported outright regret and only a few expressed even occasional regret."

Risk categories for post-operative regret include being older, having characterised personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice and stigmatising behaviours. The rejection faced by transgender people is much more severe than what is experienced by lesbian, gay, and bisexual individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.

Sexuality
Looking specifically at transsexual people's genital sensitivities, both trans men and trans women are capable of maintaining their genital sensitivities after SRS. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexual individuals to avoid unnecessary harm or injuries to the genitals, allowing trans men to obtain an erection by inserting a penile implant after phalloplasty, the ability for transsexual people to experience erogenous and tactile sensitivity in their reconstructed genitals is one of the essential objectives surgeons want to achieve in SRS. Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasms after phalloplasty is to preserve both the clitoris hood and the clitoris underneath the reconstructed phallus.

Erogenous sensitivity is measured by the capabilities to reach orgasms in genital sexual activities, like masturbation and intercourse. Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities, implying the possibilities to maintain or even enhance genital sensitivity after SRS.

The majority of the transsexual individuals have reported enjoying better sex lives and improved sexual satisfaction after sex reassignment surgery. The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics. Before undergoing SRS, transsexual patients possessed unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone SRS are more satisfied with their bodies and experienced less stress when participating in sexual activity.

Most of the individuals have reported that they have experienced sexual excitement during sexual activity, including masturbation. The ability to obtain orgasms is positively associated with sexual satisfaction. Frequency and intensity of orgasms are substantially different among trans men and trans women. Almost all female-to-male individuals have revealed an increase in sexual excitement and are capable of achieving orgasms through sexual activity with a partner or via masturbation, whereas only 85% of the male-to-female individuals are able to achieve orgasms after SRS. A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male transgender individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female individuals have been encountering longer and more gentle feelings.

The rates of masturbation have also changed after sex reassignment surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies exhibited in most transsexual individuals and 78% of them were able to reach orgasm by masturbation after SRS. A study showed that there were differences in masturbation frequencies between trans men and trans women, in which female-to-male individuals masturbated more often than male to female The possible reasons for the differences in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels). When comparing transgender with cisgender individuals of the same gender, trans women had a similar sexual satisfaction to cis women, but trans men had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.