A Comprehensive Guide to Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on April 15, 2024.

Gender-affirming surgery is an umbrella term for a series of surgical procedures that help transgender, non-binary and gender non-confirming individuals alleviate their gender dysphoria and promote a sense of congruence between their physical body and gender identity. Below we outline the different types of gender-affirming surgeries that are documented in the World Professional Association for Transgender Health’s (WPATH) Standards of Care 8 (SOC8) alongside important cost, insurance, and recovery information often solicited by patients.

At the Gender Confirmation Center (GCC), we believe that medically necessary gender-affirming surgical care should be made available to patients of diverse gender identities and body types with differing BMIs. If you are interested in making an individualized surgical plan to meet your unique needs, you can schedule a virtual or in-person consultation with one of our board-certified surgeons today.

Types of Gender-Affirming Surgeries

There are several types of gender-affirming surgeries available, each designed to help patients feel more congruence between their body and their gender identity. We highly recommend that patients seek out board-certified surgeons with hospital privileges and extensive experience in gender-affirming surgical care.

Top Surgery

Top surgery refers to procedures that modify the chest area. In our practice, top surgery usually refers to chest reconstructions or breast reductions, both involving the removal of breast tissue. Patients can also modify the nipples through a free nipple graft to adjust the size, shape and placement of their nipples or remove the nipple completely. In addition, nerve preservation techniques can also be performed to prevent the loss of heightened, erotic sensation in the nipples.

Another type of top surgery procedure is a breast augmentation. In general, implants yield better results than fat transfers when a large increase in volume is desired and existing skin is relatively tight. Patients can choose between silicone and saline breast implants, their size and placement, as well as the location of their breast implant scars.

Bottom Surgery

Bottom surgeries are gender-affirming procedures performed to reconstruct external genitalia or remove internal reproductive organs. Bottom surgery can involve the construction of structures that do not currently exist on the patient’s body (like a vaginal canal, vulva or penis).

Fertility planning considerations and/or preoperative hair removal may be required for some procedures.

  • Vaginoplasty and vulvoplasty: This procedure involves the creation of a vaginal canal using tissue from the penis, scrotum or parts of the intestine. Patients who undergo a vaginoplasty will need to dilate for the rest of their lives to maintain the patency of the vaginal canal and preserve sexual function. Patients will need to undergo laser hair removal of their scrotum and/or penis prior to undergoing a vaginoplasty.
    • Zero-depth vaginoplasty or vulvoplasty: This involves the creation of a vulva and clitoris without the creation of a vaginal canal for penetrative sex.
    • Penile-preserving vaginoplasty: This involves the creation of a vulva, clitoris, and vaginal canal by reconstructing penile and scrotal tissues.
    • Labiaplasty and revisions: Dr. Ley is well-renowned for her expertise in bottom surgery revisions. These procedures allow for corrections to the size, shape and/or symmetry of their labia minora, labia majora and/or clitoral hood.
  • Orchiectomy: This procedure involves the removal of the testicles. Patients interested in a vaginoplasty or vulvoplasty should have their scrotal tissue preserved for the construction of the labia. An orchiectomy can take place up to 8 weeks before their vaginoplasty or vulvoplasty procedure.
  • Metoidioplasty: A metoidioplasty involves releasing erectile tissue (clitoris), from restraining structures, allowing it to move into a more forward and elevated position. This is typically less complex to perform and maintains more sensation compared to a phalloplasty procedure, but results in a smaller penis. Patients can opt for a urethral lengthening procedure the ability to urinate standing up is a priority.
  • Phalloplasty: This surgery involves the creation of a penis using a tissue flap from the patient’s groin, outer thigh, or forearm. This allows the possibility of creating a larger penis that enables penetrative sex and the ability to urinate while standing. The risk of not having full, erotic sensation in the new penis may differ based on the type of phalloplasty performed.
  • Hysterectomy, vaginectomy, scrotoplasty and more: Prior to, simultaneously or independent from other bottom surgery procedures, patients can have their vaginal canal, uterus and/or one or both of their ovaries removed. Dr. Ley only requires a vaginectomy or removal of the vaginal canal in the case of a urethral lengthening (to allow patients to urinate standing up) to prevent urinary complications. Additionally, Dr. Ley offers the possibility of constructing a scrotum, inserting testicular implants, and other procedures to help patients feel more aligned with their genitals.

Facial Feminization Surgery and Facial Masculinization Surgery

Gender-affirming facial surgery encompasses a broad set of procedures that seek to alter different features of the face to help patients feel more congruence between their appearance and their gender. Facial feminization surgery (FFS) involves procedures that soften facial features to give the face a more conventionally feminine appearance. Facial masculinization surgery (FMS) typically creates a more angular, and conventionally masculine appearance. Patients can choose between any of the following procedures: hairline advancement, brow bone reduction, brow bone augmentation, eyebrow lift, rhinoplasty (nose reconstruction), cheek augmentation, lip augmentation, Adam’s apple reduction/augmentation, or jaw and chin contouring or augmentation.

Body Contouring Surgery

Gender-affirming body contouring can include a variety of liposuction, fat grafting, or silicone implant procedures to alter the shape and appearance of the body. It may be helpful to learn about the common effects of androgenic and estrogenic puberties on body shapes to determine their surgical goals for Body Masculinization Surgery (BMS) or Body Feminization Surgery (BFS). Procedures can include masculinizing liposuction, feminizing liposuction, fat transfer procedures such as a Brazilian Butt Lift (BBL), or silicone pectoral implants.

Voice Feminization Surgery

Voice modification surgery, also known as voice feminization surgery or voice masculinization surgery, alters the vocal cords and other structures in the throat to help individuals achieve a voice that aligns with their gender identity. Procedures like a Wendler’s Glottoplasty can help raise the pitch of the voice to create a more feminine tone by removing layers of vocal cord tissue. Vocal therapy is needed before and after surgery, not just for rehabilitation purposes, but also to help adjust resonance and tone. You can learn more about gender-affirming vocal therapy and surgical treatments from trusted providers like San Francisco Voice and Swallow.

Considerations for Gender-Affirming Surgery

Undergoing gender-affirming surgery is a deeply personal decision that requires careful consideration and preparation. It’s important to consult with qualified healthcare professionals, such as mental health providers and surgeons with expertise in gender-affirming care, to ensure that the procedures align with your goals and expectations.

Eligibility and Readiness

Most healthcare providers follow the WPATH Standards of Care, which outline criteria for eligibility and readiness for gender affirming surgeries. These criteria typically include:

  • Persistent and well-documented gender dysphoria
  • Capacity to make a fully informed decision and consent to treatment
  • Clearance from a mental health professional experienced in treating gender dysphoria

At the GCC, we use an informed-consent model that ensures adults capable of making informed decisions are eligible for surgery. That said, patients who plan on using health insurance to cover their surgery need a letter of support from their therapist which is required for the insurance approval process. You can read more about the requirements for this process here.

Additional Eligibility Requirements: Age, Gender and BMI

Aside from support letters from a mental health provider, several other gatekeeping or discriminatory protocols can get in the way of a patient accessing medically necessary gender-affirming care. Historically, there have been extra barriers to access for patients who are non-binary, those with higher BMIs, and those who pursue transitional care at a later age. The GCC is one of the only practices that operate on patients with BMIs above 30, and also has specialized protocols for patients with disabilities, adolescents and seniors. For more specific information about these eligibility requirements, click here.

Costs and Insurance Coverage

The costs of gender-affirming procedures can vary depending on the unique, surgical plan you and your surgeon come up with. Many insurance companies recognize these kinds of surgeries as medically necessary, and therefore provide full or partial coverage for them. For more information on costs and insurance coverage, click here.

Preparation for Surgical Gender Affirmation

Beyond eligibility requirements, there are various other preparations patients need to address before undergoing gender-affirming surgery. These may include:

  • Undergoing laser hair removal prior to certain bottom surgery procedures
  • Looking into your fertility preservation options prior to certain bottom surgery procedures
  • Stopping any laser hair removal on your face at least 6 weeks prior to FFS
  • Requesting time off work for surgery and recovery
  • Booking travel and lodging if you are coming in from out-of-town
  • Completing necessary lab work and getting your medications from the pharmacy
  • Refraining from smoking any substance at least 3 weeks before and after surgery
  • Refraining from drinking alcohol at least 1 week before and after surgery
  • Getting a care team together of friends, loved ones and/or professionals to take care of you post-op

Recovery from Gender-Affirming Surgery

Just like preparing for surgery, recovery involves both physical and emotional processes. Emotionally, it is very common for patients to experience temporary feelings of depression and even regret in the postoperative period due to pain, inflammation and changes in mobility during recovery. As healing progresses and the results of surgery become more apparent, patients who undergo gender-affirming surgeries report significantly high levels of satisfaction. For this reason, we highly encourage patients to include supportive loved ones and/or a mental health professional as a part of their surgical recovery plan.

In terms of physical recovery, most patients will be advised to follow a low-sodium diet two weeks after surgery to reduce the formation of excessive swelling. Likewise, if surgery leaves any visible incisions, patients should follow incision and scar care protocols such as moisturizing incisions, scar massages, and minimizing sun exposure for at least a year after surgery.

You can find more specific recovery guidelines in the following articles:

FAQs

Q: Is gender affirming surgery covered by insurance?

Many insurance plans cover gender affirming surgeries. However, coverage and requirements vary by plan and state. It’s essential to check with your insurance provider for specific details on coverage, pre-authorization requirements, and any exclusions or limitations. For more information, click here.

Q: What is the recovery process like for gender affirming surgeries?

The recovery process differs depending on the specific procedure(s) performed. Generally, it involves some downtime, pain management, and follow-up appointments. Your surgeon will provide detailed recovery instructions and timelines. It’s important to follow these instructions carefully to ensure proper healing and minimize the risk of complications.

Q: Are there any risks associated with gender affirming surgeries?

As with any surgical procedure, there are potential risks and complications associated with gender affirming surgeries. These can include bleeding, infection, scarring, and adverse reactions to anesthesia. Your surgeon can discuss specific risks or complications, as well as steps to minimize these and ensure the best possible outcome. For more information on how you can minimize surgical risks, click here.

Q: How long does it take to recover from a vaginoplasty?

The recovery process for a vaginoplasty can take at least 3 months, which is when patients can begin to have penetrative sex. Initial healing typically takes 4-6 weeks, during which time you may experience discomfort, swelling, bruising, and the need for dilation to maintain the vaginal depth and width. Dilation is a life-long commitment to maintain the vaginal canal opening after surgery. However, it can take 6 months to a year for swelling to resolve so that final results are visible. For more in-depth information on vaginoplasty recovery, click here.

Q: Can gender affirming surgeries be reversed?

Depending on the surgery, some procedures can be reversed. For example, implants can be removed after a breast augmentation. However, attempting to reverse the outcomes of any surgery can be complex and may not restore function pre-operatively (i.e. inability to chest feed after mastectomy). Additionally, procedures that alter reproductive organs like an orchiectomy (removal of the testicles), hysterectomy (removal of the uterus) or oophorectomy (removal of one or more ovaries) are irreversible. For this reason, we recommend that our patients look into their fertility preservation options prior to undergoing said procedures.