gender reassignment surgery for animals

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The Protojournalist

The 'sex change' operation for cats.

Linton Weeks

Like a circus parade, the cutting-edge pet stories just keep coming.

Plastic surgery for dogs. Designer kitties — poodle cats and jungle hybrids . Medicinal marijuana for ailing pets.

Can gender reassignment for pets be far behind? Actually, some veterinarians, like Christie Cornelius of Houston, do talk about "sex change" operations for cats.

The surgery, says Cornelius, of Last Wishes , is not a true "sex reassignment" because "it is not performed for the purpose of changing a cat's sex."

Ann Staub, a former vet and now keeper of the Pawsitively Pets blog, explains: The procedure — conducted on a male cat suffering from persistent urinary problems — is technically called a "perineal urethrostomy," but in her office and in other veterinary clinics, it's often referred to as a "sex change."

Because, Staub says, "it's easier to say and remember. Sometimes we have to humor ourselves at work, too."

Without getting too graphic, the operation involves removal of a tom's cathood, a shortening of the urethra and the creation of a new opening that is similar to a female cat's. "I don't know for sure," Staub says, "but this doesn't seem to have any effect on a cat's personality, as most of them are already neutered anyways."

Do owners ever decide to change their pets' gender for other reasons? Staub says she "can't imagine a veterinarian actually doing a 'sex change' surgery to an animal for cosmetic purposes, but I'm sure there's someone out there who's willing to make a buck."

After all, she adds, she has heard about people "using Botox on wrinkly dogs like Shar-Peis for medical reasons. I don't have any experience with that personally, though."

Hermaphrodite dog fully recovered after sex-change surgery

Vets operated on Jack Russell puppy Molly because she had testicles in place of ovaries and male and female external genitalia.

By Russell Hope, News Reporter

Tuesday 25 April 2017 18:37, UK

An "intersex" dog born with male and female genitals has made a full recovery after having rare gender reassignment surgery.

Molly, a Jack Russell puppy, was taken to a vet when her owners, Mary and Frank Finlay, noticed she would get excited before going to the toilet and squat to pee in their home, but lift her leg outside.

Vet Ross Allan discovered that, despite appearing to be completely female, she was a male pseudo hermaphrodite or "intersex" as it is more commonly known, with elements of both male and female external genitalia.

"Her particular anatomy meant that whilst Molly appeared to be a female, closer examination revealed elements of both male and female external genitalia, and unfortunately this was leading to significant genital discomfort," he said.

During "complex" surgery at the Pets'n'Vets Family's Roundhouse Hospital in Glasgow last June, Mr Allan found Molly had male internal sexual organs, with testicles in the place of ovaries within her abdomen.

He removed her pseudo male sexual organs and formed a functional urethral opening where the female genitalia would normally be found.

Mr Allan said Molly's condition is rare. He said: "She is certainly unique to me.

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"She was four months old when Mary and Frank first brought her in after they noticed her displaying quite masculine behaviour...rubbing herself against furniture, causing discomfort and abrasions to her skin.

"If left untreated, this risked her developing a long-term and debilitating condition.

"We decided that the very best solution for Molly was to proceed with definitive surgery to create an anatomical situation which would avoid ongoing issues or discomfort.

"The surgery was a great success and Molly is much more comfortable and happier as a result."

Mrs Finlay told BBC Scotland's Kaye Adams programme: "We've seen no change in her behaviour. She's still the same wee Molly and we wouldn't be without her, she's too precious."

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Cat’s life saved by ‘gender reassignment’ surgery

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A cat that was going to be put to sleep because of a bladder problem has made a miraculous recovery after undergoing radical ‘gender reassignment’ surgery.

Six-year-old Piglet was saved thanks to the skill of vet Sarah Bruce at Charter Vets in Congleton, Cheshire, who carried out a rare procedure to remove part of his genitals which allows him to urinate ‘like a female’.

The surgery was performed after a bladder stone was preventing Piglet from being able to pass water.

His owner Zoe Philpott said: ‘I noticed that Piglet’s bladder was really distended and he was trying his hardest to wee on his litter tray but nothing was happening.

‘At first, I took him to a different vets who thought he had cystitis and put a catheter in.

‘They thought bladder crystals were causing a blockage and that they had dislodged them, but 25 minutes after we got home, Piglet was struggling again.’

After his condition deteriorated, Zoe, who lives in Sandbach, Cheshire, took Piglet to Charter Vets where she learned that vet Sarah had come across the problem before.

The 48-year-old mum-of-three said: ‘Sarah said a stone was causing a blockage and they couldn’t remove it.

‘His penis was so swollen and Sarah asked me to consider whether to go ahead with a radical operation to remove it all together.’

Zoe agreed for Piglet to have the procedure.

Sarah, who has been a vet since 2011, said: ‘When Piglet came in, he had a bladder stone lodged at the end of his penis (the urethra).

‘We could either put him to sleep or perform radical surgery to remove part of the penis, where the stone was trapped, because we couldn’t flush it out.

‘The surgery involved making his anatomy more like a female, so now he wees like a girl.’

She added: ‘I think it’s worth raising awareness about the problems with passing stones because it’s quite common in male cats.

‘I’d urge owners to get them seen to straight away if they are having trouble urinating, as Mrs Philpott did in this case, because it can lead to more serious problems.’

Zoe, who hand-reared Piglet – given his name because of his likeness to the farm animal when he was a kitten – said: ‘Piglet has recovered so well from the surgery.

‘He’s regained all his weight and he’s back to his normal self, which is amazing.’

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Experience: my dog underwent gender reassignment surgery

Molly seemed like a perfectly normal female pup at first. It was only when she started taking walks outside that we noticed unusual behaviour

T he death of our collie Bonnie in 2006 hit my husband Frank and me so hard that it was almost a decade before we considered taking on another dog. But, late in 2015, my daughter mentioned that a friend of hers had a jack russell that was about to have pups. Familiar with female dogs, we decided that if there were any bitches in the litter we would take one. That’s how we ended up with Molly.

Picking her up involved a round trip of about 200 miles, but it was love at first sight. She was a tiny wee doggy, only 11in long and 6in high, and she weighed about a kilo and a half. She had delicate features – very feminine-looking.

We registered Molly at the local vet and made sure she had all her jabs. It was only when she started taking walks outside at about three months old that we noticed peculiarities in her behaviour.

Indoors, when Molly needed to pee, she would squat on her training mat as she had been taught, but when Frank took her out he noticed that she cocked her leg like a boy dog. We had spotted before that she had a tiny appendage between her back legs, but we thought little of it until we noticed that it sometimes seemed to cause her discomfort when she tried to sit down.

We took Molly to the vet to get it looked at. After examining her, the vet said: “I’m going to have a senior colleague look at this,” and took Molly into a back room. I was reminded of Bonnie’s diagnosis with stomach cancer and feared the worst. When the vet came back and said she thought Molly could be a hermaphrodite, I didn’t realise what she meant; I started crying, assuming she was referring to another form of cancer. But she said: “No, it means Molly has male and female genitalia.” I was flabbergasted; I had never heard anything like it. But we were assured that Molly’s condition could be fixed, although we would have to wait until she was older and stronger.

In the meantime, Molly started to behave more like a male dog, mounting cushions and soft toys, although this often left her sore and unhappy. When she was six months old, we took her back to the vet, where a senior practitioner, Ross Allan , examined her. X-rays and other tests confirmed his suspicions – Molly was an intersex dog. In fact, she was most likely genetically male, meaning she was a male pseudohermaphrodite . She had a small vestigial penis within what looked like a female vulva and testicles inside her abdomen that hadn’t descended.

Molly’s condition was very rare. About one in 6,800 dogs born are pseudohermaphrodites. In 15 years of practice, Ross had never encountered another case, nor had any of his more senior colleagues. Sometimes no operation is needed, but Ross explained that Molly’s complications were likely to increase as she aged. Well-meaning friends had already suggested it might be kinder to have her put down, because she was often visibly distressed. The thought horrified us. However, Ross reassured us that an operation would make her life much easier.

The day she went into theatre was very stressful. Ross said: “Call me in the morning.” I didn’t sleep a wink that night, thinking about Molly and fearing the worst. But we were able to take her home the next day. Ross had removed the partly formed penis and testicles, which were at risk of becoming cancerous, and created an opening for Molly’s urethra so she could pee comfortably. She was exhausted the first day back and lay at the end of our bed, crying. When we spotted blood, we rushed her back to the vet, where she ended up spending a few more days being treated with drugs and antibiotics.

Twenty months on, she’s a cheeky little dog, full of character. She’s still unmistakably our Molly, whatever her genetic makeup. When our grandchildren visit, she jumps all over them and licks their ears; she’s clearly much happier than she was before the operation. She still loves her soft toys, too – just not in the same way.

As told to Chris Broughton

Do you have an experience to share? Email [email protected]

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Intersex pet dog undergoes gender reassignment surgery

Jack russell molly's owners became concerned when they say she started to behave like a male , article bookmarked.

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An intersex dog born with both male and female genitals has successfully recovered from a rare gender reassignment surgery.

Molly, a Jack Russell terrier puppy, was taken to the vet when her owners Frank and Mary Finlay noticed she was behaving strangely when going to the toilet, sometimes lifting her leg and other times squatting to pee.

The couple bought Molly in 2015 believing she was a female but became concerned about what they felt was increasingly male behaviour.

Upon examination by Glasgow vet Ross Allan, it appeared Molly had both female genitalia and male testicles - which had not descended - and a poorly-formed “vestigial” penis, BBC Scotland reports.

Mr Allan told the couple Molly’s hermaphrodite nature explained her genital discomfort.

Mr Allan told BBC Scotland's Kaye Adams Programme Molly’s condition was “extremely rare” and that neither him nor his colleagues had come across it before.

“In the literature there have been about 15 cases published in total. In 15 years of doing this job I have seen this in Molly and in no other dog at all," he said.

The vet operated on Molly, when she was six months old. He removed her male genitals and formed a functional urethral opening where the female genitalia would normally be found.

"She actually had the female external genitalia, as it were, but in the male formation,” said Mr Allan.

The vet said that without the operation, Molly’s problems would have exacerbated over time and could have developed into a debilitating condition.

Nearly a year on from the operation, he said Molly had made a full recovery and was happy in her home.

“Molly is Molly and she is happy and fit and healthy, that is the main thing,” said Mr Allan.

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How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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How Pose Is Changing Media Representation of Gender Confirmation Surgery

About a mile from my therapist’s office in Hollywood is a place called The Museum of Death. After a few months of passing by and hearing others talk about it, a friend and I decided to explore it together. We wanted to know what we were getting into before venturing out, so we did some research. Reviews of the museum on travel websites list one of the highlights as a TV that plays an endless loop of the infamous shock video “Traces of Death.” Several mentioned that even though the video shows people being eaten alive by animals, as well as real footage of murder and suicide, the hardest segment to watch is that of a “male-to-female sex change” operation.

This wasn’t the first time I’d read that there’s nothing more disgusting about trans women than the fact that we want to “chop our dicks off.” Trans surgeries are widely sensationalized and treated as punchlines across mainstream media. The ultimate insult to manhood is to, well, lose your “manhood” — so gender confirmation surgery is often treated as the worst thing a trans woman can do to herself. I never thought I would see positive discussion centered around a trans woman’s vagina on a popular TV show, but it happened on last night’s episode of Pose .

In the third episode of the season, written by Janet Mock and Our Lady J, we see Elektra Abundance (played with poise and power by Dominique Jackson) at a doctor’s appointment. While waiting to see her physician, Elektra sees a pamphlet on the wall about “sex reassignment surgery.” Not only do we get to see actual medical information a trans woman would have received in the 1980s, but we see detailed and graphic illustrations of the steps of vaginoplasty. We see a penis being turned into a vagina — and no one laughs, groans, or grimaces in disgust. We witness a trans woman learn what this surgical process may look like for her, while her knowledgeable doctor gives her life-saving information. The scene is meant to communicate that gender confirmation surgery is like any other operation: There may be blood and bone, but that’s par for the course.

I’ve been contemplating whether or not I want a vagina ever since I first researched these operations in high school. There are many reasons I haven’t had this surgery yet: it’s cost prohibitive, surgery is scary, and sometimes I like my current genitals. But one of the biggest reasons I haven’t had this operation is that I didn’t think I could ever feel comfortable having what I sadly sometimes think of as an “artificial” vagina. Movies and TV and bullies and trolls have taught me over and over again that a trans woman’s vagina is a cheap imitation of the “real thing,” and that no one could ever find it sexy, or even anything less than vomit-inducing. Even one of Ryan Murphy’s older shows perpetuated this narrative. I remember watching a Nip/Tuck scene in which Christian Troy pulls his hand out of Ava Moore’s vagina in disgust — because even though she could “pass,” her new vagina never would. I learned that the only thing worse than a woman with a penis was a woman with a surgically-created vagina.

Watching Elektra reading the SRS pamphlets in the doctor’s office, my heart beat faster and my breath caught in my throat. I dared not move. As soon as the scene ended, I decided to watch the episode again, because it felt so unbelievable to have seen this on TV. On my second time through, I sobbed. I’ve been waiting over a decade to see this topic broached respectfully in any form of media, and it made me more emotional than I anticipated. The scene allowed me to think about my own body, and the future of my body, in a whole new way. Could I actually get surgery and learn to love my vagina; to feel like it was normal? The possibility seems closer now than ever before.

There’s a lot of power in being told that your body isn’t wrong, and the importance of the ways media portrays trans surgeries cannot be overstated. By hiring Janet Mock and Our Lady J to write for his latest show, Murphy has helped trans women gain the representation we’ve been hoping for. This is what it looks like for artists to grow with the times; to learn and make their art even better because of it. Pose is what trans people need to see. It’s what cis people need to see. This is how the culture around trans bodies changes for the better — by showing us that these surgeries are completely normal for trans women to desire and to get, and not the grotesque crime against nature so many want us to think they are.

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

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

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

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

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

Transitioning

Transitioning may involve:

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

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

Reasons for Undergoing Surgery

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

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

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

Steps Required Before Surgery

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

Steps may include:

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

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

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

Hormone Therapy & Transitioning

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

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

Effects of Testosterone

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

Bodily changes can include:

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

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

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

Changes to the body can include:

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

When Are the Hormonal Therapy Effects Noticed?

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

Timeline of Surgical Process

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

Transfeminine Surgeries

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

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

Top surgery includes:

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

Bottom surgery includes:

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

Transmasculine Surgeries

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

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

Top surgery includes :

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

Complications and Side Effects

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

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

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

Cost of Gender Confirmation Surgery

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

Quality of Life After Surgery

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

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

A Word From Verywell

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

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

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

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

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

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

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

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

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

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

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

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

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

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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

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MTF Gender Confirmation: Genital Construction

The specifics, the takeaway.

Download the app

As part of a transgender individual’s transition, genital reassignment surgery alters male genitalia into female genitalia.

Written By: Erin Storm, PA-C

Published: October 07, 2021

Last updated: February 18, 2022

• Procedure Overview
• Ideal Candidate
• Side Effects
• Average Cost

thumbs-up Pros

• Can Help Complete A Gender Affirmation Journey

thumbs-down Cons

• Potentially Cost Prohibitive

Invasiveness Score

Invasiveness is graded based on factors such as anesthesia practices, incisions, and recovery notes common to this procedure.

Average Recovery

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Surgical Procedure

$ 7000 - $ 24000

What is a male to female (MTF) gender reassignment surgery?

Male to female (MTF) gender reassignment surgery is also known as sex reassignment surgery (SRS), genital construction, and generally as Gender Confirmation Surgery. These procedures are used to remove and alter male genitalia into traditional female genitalia. Plastic surgeons will remove the scrotum, perform a penile inversion to create the neovagina, remove and alter penile erectile tissue to form the clitoral tissue of the clitoris, and construct labia usually from scrotal tissue. The prostate gland is left intact. These procedures create fully functional female genitalia in transgender patients.

Typically gender reassignment surgery is performed as a last step in a transgender individuals transition journey. Guidelines from The World Professional Association for Transgender Health (WPATH) state candidates must have letters of recommendation from their mental health provider and physician, have been living full time as a woman for one year, and have completed one year of hormonal therapy to be eligible.

Information on facial feminization surgeries, top surgeries (like a breast construction), and other male to female gender affirming surgeries as part of a gender transition for transwomen can be found in our comprehensive guide to MTF gender affirmation solutions .

What concerns does a MTF gender reassignment surgery treat?

• Transfeminine Bottom Surgery & Genital Construction : Male to female gender reassignment surgery creates female genitalia that are aesthetically authentic and functional. A vaginoplasty, penectomy, orchiectomy (testicle removal), clitoroplasty, and labiaplasty are typically performed.

Who is the ideal candidate for a MTF gender reassignment surgery?

The ideal candidate for MTF gender reassignment surgery is a transgender women seeking to complete her physical embodiment of her gender identity. This reconstructive genital surgery creates functioning female genitalia.

MTF gender reassignment surgery is not recommended for those who have not been on hormone therapy for one year, have not been living full time as a woman for one year, do not have letters of recommendation from their mental health provider and physician, children under the age of 18, and those with certain chronic medical conditions.

What is the average recovery associated with a MTF gender reassignment surgery?

Most patients experience four to six weeks of recovery time following a MTF gender reassignment surgery. Patients can expect bruising, swelling, and tenderness following the procedure. A urinary catheter is placed for one week and vaginal packing as well which may cause a sensation of fullness. Vaginal dilation is a component of the procedure and the patient will be advised on how to complete this progressive dilation at home over the course of a few weeks.

What are the potential side effects of a MTF gender reassignment surgery?

Possible side effects following a MTF gender reassignment surgery include bleeding, swelling, bruising, site infection, altered sensation, difficulty urinating, difficulty with sexual function, prolonged edema, and complications from anesthesia or the procedure.

What can someone expect from the results of a MTF gender reassignment surgery?

The results of MTF gender reassignment surgery are permanent. This procedure creates functional female genitalia and removes all male genitalia. The prostate gland is left intact which is important for transgender individuals ongoing healthcare and preventative screenings.

What is the average cost of a MTF gender reassignment surgery?

What to expect.

A MTF Gender Reassignment Surgery creates female genitalia. Here is a quick guide for what to expect before, during, and after a MTF Gender Reassignment Surgery:

Before Surgery

• Prophylactic antibiotics or antivirals may be prescribed
• Stop taking blood thinning medications two weeks prior to surgery. Blood thinners may include, Advil, Tylenol, Aspirin, and prescription anticoagulants
• Stop smoking four weeks prior to the procedure and continue cessation for four weeks post op
• No alcohol two days prior to the procedure
• Do not eat or drink six hours before

During Surgery

• General anesthesia
• A penile inversion is performed to create the vaginal canal
• The scrotum is removed
• Skin grafts are used to create the labia and vulva
• Erectile tissue is removed from the new vaginal walls, and erectile tissue from the head of the penis is used to create the clitoris
• ​The urethra is shortened

Immediately After Treatment

• Swelling, bruising, and tenderness

1 - 30 After Treatment & Beyond

• Resume most activities after a few days
• Swelling typically resolves within a few weeks
• Avoid strenuous activity for two to four weeks
• Remove urinary catheter and vaginal packing after one week
• Continue progressive vaginal dilation

Result Notes

• Results are permanent
• Proper aftercare will ensure optimal results

Gender confirmation surgeries for transgender individuals are an important component of transgender health and in creating an embodied gender identity. Gender reassignment surgery allows transgender women who feel it is a part of their transition to more fully embrace their gender identity.

To learn more about our content creation practices,  visit our Editorial Process page .

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AEDIT uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

• American Society of Plastic Surgeons Gender Confirmation Surgeries plasticsurgery.org
• Karel E Y Claes Chest Surgery for Transgender and Gender Nonconforming Individuals PubMed.gov ; 2018-07-02

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MTF Gender Confirmation Solutions

MTF Gender Confirmation: Facial Feminization

Adam’s Apple Reduction

MTF Gender Confirmation: Transfeminine Top & Bottom Surgeries

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Learn More About MTF Gender Confirmation: Genital Construction in The AEDITION

Gender Transitioning And Skincare: Taking Care Of Your Changing Face

Side effects of hormone therapy often show up on the skin in the form of acne, pigmentation, and uneven skin texture. Here’s what you need to know about the most common skin concerns and treatment options.

A Guide To Non-Surgical Facial Feminization

Facial feminization procedures have been gaining popularity among men hoping to look more approachable or transition to female as well as among women hoping to have a more feminine appearance.

Finding The Right Plastic Surgeon, Dermatologist, Or Cosmetic Dentist

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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

Nature Reviews Urology volume  8 ,  pages 274–282 ( 2011 ) Cite this article

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This article has been updated

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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Principles and outcomes of gender-affirming vaginoplasty

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

The effect of early puberty suppression on treatment options and outcomes in transgender patients

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• GENDER REVOLUTION

In the Operating Room During Gender Reassignment Surgery

Behind the scenes with identical twin Emmie Smith during her medical transition.

Before August 30, 2016, getting stitches at age seven was the most time Emmie Smith had ever spent in a hospital.

That morning, she swapped her plaid shirt and jean shorts for a gown, tucked her hair into a cap, and prepared for surgery to conform her anatomy to the gender she already identified with: woman. In the operating room with her was National Geographic photographer Lynn Johnson. She and Emmie hoped they could demystify the procedure by documenting it, close-up and unflinching. “It was stressful and scary at times, but it almost created a mission other than just recovery,” Emmie says. “We were making something together.”

It had been a year and a half since Emmie had first come out as a transgender woman on Facebook. Telling her family and friends had been an enormous relief. “I’m not sure I could have taken another few years of being closeted,” she says.

Still, it was a challenging time for her family. Her mother, Reverend Kate Malin, is a prominent figure in their Massachusetts town, and her identical twin sons Caleb and Walker were familiar fixtures at her Episcopal church. A month after Walker came out as Emmie, Malin stepped out from behind her pulpit and walked into the aisle. Halfway through her sermon she decided it was time to address the change in her family.

“As most of you know, Bruce and I have three children,” she began. “Caleb and Walker, who are 17, and 13-year-old Owen. Walker’s new name is Emerson, and she prefers Emmie or Em. She’s wearing feminine clothing and makeup and will likely continue to move in the direction of a more feminized body.”

Follow Emmie's transition in pictures

Kate nervously revealed her struggle to the attentive New England crowd. “I feel broken much of the time,” she confessed. “I’ve wanted to run away, and I’ve prayed for this child that I would gladly die for, guilty for how much I miss the person I thought was Walker and everything I thought might be.”

After the sermon, the congregation engulfed her in a hug. Then they moved to offer words of support to the sandy-haired 17-year-old sitting in the pews. In the first of many awkward mistakes the family would later laugh about, it was Caleb—Emmie’s identical twin.

After that sermon, a “new normal” set in. On a Saturday night soon after, they had their first “out” outing. Kate took Emmie—whose hair was still short and chest was flat—to buy a prom dress at David’s Bridal. She feared someone would point or laugh, but the crowds of brides and bridesmaids in the dressing room offered only compliments.

Though she hadn’t initially considered surgery, after a couple of months Emmie had grown frustrated by the tucking and taping required to fit into women’s clothes. That fall, her senior year of high school, she decided to do it.

But waking up after the operation, Emmie felt none of the immediate relief she’d expected. In the recovery room her earbuds played a soothing loop of Bon Iver and Simon and Garfunkel, but it didn’t drown out her disappointment and fear. In retrospect, she thought, hadn’t life before been OK?

It wasn’t until months later, when she was home and could walk and sit again, that Emmie knew she’d made the right choice. “If you’re not living freely that’s time wasted, and I felt my time was wasted pretending to be a boy,” she says. “It was the best decision in my life.”

Now, halfway through a gap year, she’s applying to college theater programs. It’s strange, she says, knowing that her future classmates may watch Johnson’s film and learn the most intimate details of her life. She’s hopeful that her participation will evolve the public’s understanding of gender reassignment surgery. “It’s not science fiction or mythology,” Emmie says. “It’s what happens to women just trying to be at peace with themselves and their bodies.”

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• v.116(15); 2019 Apr

Quality of Life Following Male-To-Female Sex Reassignment Surgery

Géraldine weinforth.

1 Department of Plastic Surgery and Hand Surgery, Universitätsspital Zürich

Richard Fakin

Pietro giovanoli, david garcia nuñez.

2 Department of Plastic, Reconstructive & Aesthetic Surgery and Hand Surgery, Center for Gender Variance, Universitätsspital Basel

Associated Data

Additional points regarding the study method

We conducted a systematic key word guided literature search of four databases (PubMed, EMBASE, Web of Science, PsycINFO) in March 2017 in order to identify the current medical literature relating to our research question. Among the search terms we used were “transsexualism”, “reassignment surgery”, and “quality of life” ( etable 1 ). The article search was adapted to the technical requirements (for example, the option of using MeSH terms) of each database and undertaken by GW and DGN independently, supported by the recommendations summarized in the PRISMA statement ( 16 ).

Inclusion criteria

We included only articles that focused on the topic of the quality of life of trans women who had had sex reassignment surgery, independently of the studies’ population sizes and publication dates. GW, RF, and DGN operationalized the search terms by using an iterative process following the PICO method ( e1 ) ( etable 1 ) and a search string was created with these ( eTabelle 2 ) . The search for publications intentionally identified only studies reported in English or German.

Exclusion criteria

Studies that did not exclusively focus on trans persons (for example, LGBT [= lesbian, gay, bisexual, and transgender] studies) or that did not evaluate quality of life by using a standardized questionnaire were not considered. Furthermore, this review did not include review articles, published dissertations, nor congress presentations/commentaries. Studies of trans persons who were under age were excluded too.

Screening process

During the study selection process we excluded according to the mentioned criteria those studies that were not able to contribute to answering our research question ( figure ). Furthermore, we searched the reference lists of all selected articles in order to be able to include further studies that were not found in the databases. This yielded four additional studies that met the inclusion criteria. In a parallel and independent process, DGN checked the results of this search. In cases where discrepancies were found, a solution pertaining to the inclusion of the relevant study was found by consensus.

Study analysis

After the study selection process we viewed full-text articles and collated important key study data ( table 1 ). According to the definitions in the PICO scheme ( e1 ) we collated all relevant parameters from the individual studies in further full-text reviews. The first author extracted the data, and DGN checked these in a second, independent process. All included articles are non-randomized studies of evidence level III ( e2 ). Some studies ( 17 – 21 ) reported on the quality of life of trans women as well as trans men. In these cases we ensured that the data evaluation for trans women was done separately or the ratio M–F/F–M was in favor of trans women. Where information was lacking or lack of clarity existed in individual studies, we contacted the authors. Table 2 shows the quality characteristics of the included studies.

The prevalence of persons who are born with primary and secondary male sexual characteristics but feel that they are female (trans women) is ca. 5.48 per 100 000 males in Germany. In this article, we provide a detailed overview of the currently available data on quality of life after male-to-female sex reassignment surgery.

This review is based on publications retrieved by a systematic literature search that was carried out in the PubMed, EMBASE, Web of Science, and PsycINFO databases in March 2017.

The 13 articles (11 quantitative and 2 mixed quantitative/qualitative studies) that were found to be suitable for inclusion in this review contained information on 1101 study participants. The number of trans women in each study ranged from 3 to 247. Their mean age was 39.9 years (range: 18–76). Seven different questionnaires were used to assess postoperative quality of life. The findings of the studies permit the conclusion that sex reassignment surgery beneficially affects emotional well-being, sexuality, and quality of life in general. In other categories (e.g., “freedom from pain”, “fitness”, and “energy”), some of the studies revealed worsening after the operation. All of the studies were judged to be at moderate to high risk of bias. The drop-out rates, insofar as they were given, ranged from 12% to 77% (median: 56%).

Current studies indicate that quality of life improves after sex reassignment surgery. The available studies are heterogeneous in design. In the future, prospective studies with standardized methods of assessing quality of life and with longer follow-up times would be desirable.

The term “gender incongruence” (GI) describes the situation in which a person does not identify with the gender they were assigned at birth on the basis of physical sexual characteristics and that they consequently experience “a marked and persistent incongruence between. .. experienced gender and the assigned sex” ( 1 ). The term trans women describes persons with congenital primary and secondary male sexual characteristics (assigned male at birth) who feel/identify as women. Trans men are persons who feel/identify as men but who have primary and secondary female sexual characteristics (assigned female at birth). Persons who fully identify with the sex/gender they were assigned at birth are known as cis women and cis men.

A data analysis from 2000 showed a prevalence in Germany of 4.26 trans persons/100 000 population (5.48 trans women/100 000 of the male population and 3.12 trans men/100 000 of the female population) ( 2 ). We are not aware of any more recent data for Germany.

If persons with gender incongruence develop clinically relevant biopsychosocial suffering, they have gender dysphoria (GD), according to the DSM-5 classification ( 3 ). For many trans persons, physical transition is the best option for alleviating the symptoms of gender dysphoria ( 4 ). Sex/gender reassignment hormone treatment as well as surgery have a central role in this setting ( 5 ). The latter comprise surgical procedures involving the genitals (sex reassignment surgery) ( box ), the breasts, and the face and vocal cords, as well as hair epilation ( 6 ).

Principle of male-to-female sex reassignment surgery

• Bilateral orchiectomy
• Preparation of the glans (head) of the penis with the complete neurovascular bundle
• Preparation of the urethra
• Subtotal resection of the cavernous bodies (corpora cavernosa) and the corpus spongiosum of the penis
• Preparation of the neovaginal space in the perineal area between rectum and urethra/bladder
• Penile inversion vaginoplasty (pedicle flap from the skin of the penal shaft: gold standard)
• If required, use of free split-thickness skin grafts
• In selected cases, this is the primary indication—for example, in trans women with penoscrotal hypoplasia or at the patient’s wish (for better natural secretion).
• This procedure can also be used as a secondary intervention in patients after unsatisfactory penile inversion vaginoplasty.
• Construction of a neo-clitoris from the glans (head) of the penis
• Construction of a urethral neo-meatus after urethral shortening as required
• Construction of labia from the remaining scrotal skin, possibly also labia minora

A US study showed that from 2000 to 2011, the rate of surgical sex reassignment measures among trans persons rose from 72% to 83.9% ( 7 ). These data move the question of the effectiveness of such operations increasingly into the focus of clinical attention and awareness ( 8 – 11 ).

In the context of evidence-based medicine, the consensus is now that the success of medical procedures should not be studied merely in terms of objective results (survival and complication rates, measurements of functionality, etc), but that patients’ personal wellbeing should be included in assessing the success of any procedure ( 12 , 13 ). Review articles to date have shown that sex reassignment hormone treatment has a positive effect on the quality of life of trans persons ( 14 , 15 ). By contrast, an overall assessment of quality of life after sex reassignment surgery is so far lacking. In this article we will attempt to provide a review of current studies, and on this basis we will investigate the question of quality of life after sex reassignment surgery.

For the review to be as representative as possible, this article deals with trans women only, whose incidence is notably higher than that of trans men (0.41 male to female/100 000 total male population in Germany and 0.26 female to male/100 000 total female population in Germany) ( 2 ).

We conducted as systematic literature search in PubMed, EMBASE, Web of Science, and PsycINFO in March 2017. GW and DGN independently undertook the article search on the basis of the recommendations summarized in the PRISMA statement ( 16 ). Details of the methods are described in the eMethods section.

We included only articles on the subject of the quality of life of trans women after sex reassignment surgery. GW, RF, and DGN operationalized ( etable 1 ) the search terms in an iterative process according to the PICO method ( e1 ) and set out a search string ( etable 2 ).

* Key words used in accordance with the PI(C)O method

* Catch phrases and key words used in the literature search

Among others, we excluded studies that did not focus exclusively on trans persons or that didn’t collect data on quality of life by using a standardized questionnaire. We also excluded studies in underage trans people.

The Figure shows the study selection process.

Flow chart illustrating the study selection process

All included articles are non-randomized studies with an evidence level of III ( e2 ). In the case of studies that reported on the quality of life of trans women as well as trans men ( 17 – 21 ) we ensured that the data for trans women were evaluated separately or that the ratio of M–F/F–M favored trans women. Table 1 shows further key study data; Table 2 shows the quality characteristics of the studies.

* 1 Numbers of study participants after removal of dropouts ( table 2 ); exception: Lindqvist et al. ( 23 ), see Table 2

* 2 M–F, male-to-female; F–M, female to male, sex reassignment surgery

* 1 M–F male to female; F–M female to male, reassignment surgery

* 2 Prospective study design

* 3 Of originally 190 participants, n = 160 (84.21%) completed the questionnaire preoperatively and n = 47 (24.73%) postoperatively

* 4 Out of a total of 190 study participants, n = 146 (76.84%) completed the questionnaire preoperatively, n = 108 (56.84%) 1 year postoperatively, n = 64 (33.68%) 3 years postoperatively, and n = 43 (22,63%) 5 years postoperatively. Most of the 190 participants completed the questionnaire at least at two follow-up points.

The studies made use of the following instruments:

• 6 studies used the Short Form 36 Health Survey (SF-36) ( 18 , 20 , 22 – 25 );
• 2 studies used the World Health Organization’s Quality of Life 100 questionnaire (WHOQOL-100) ( 17 , 26 );
• 2 studies used the Subjective Happiness Scale (SHS) in combination with the Satisfaction with Life Scale (SWLS) and the Cantrils Ladder of Life Scale (CLLS) ( 27 , 28 );
• 2 studies used the FLZ questionnaire ( Fragebogen zur Lebenszufriedenheit ) ( 21 , 29 ); and
• 1 study used the King’s Health Questionnaire (KHQ) ( 19 ).

None of the questionnaires constitutes an investigative tool that is specifically tailored to trans persons. Table 3 shows the result scales. Table 2 shows the confounding variables and, as far as it is possible to assess this, the risk of bias.

*For the studies referenced in parentheses, it was not possible to calculate effect sizes

Quality of life

The SF-36 and WHOQOL-100 are validated, reliable and disease–non-specific instruments for measuring health-related quality of life ( 30 , 31 ). They can be used to gain information on the individual health status and allow for observing disease-related stresses over time. The questionnaires collect data on numerous aspects of daily life, which in their totality reflect quality of life. They are used internationally and therefore make cross-cultural studies an option ( 32 ).

Studies that used the SF-36 to answer the question of postoperative quality of life ( 18 , 20 , 22 – 25 ) observed after sex reassignment surgery an improvement in “social functioning”, “physical” and “emotional role functioning”, “general health perceptions”, “vitality”, and “mental health” (p = 0.025 to p >0.05). In two of these studies ( 22 , 24 ), “mental health” in trans women after sex reassignment surgery did not differ significantly from the standard sample. This explains the formally non-significant result. Ainsworth and Spiegel ( 22 ) showed that trans women without surgical intervention when compared indirectly with cis women from the SF-36 standard sample reported significantly poorer “mental health” (39.5 vs 48.9; p <0.05). Lindqvist et al. ( 23 ) and Weyers et al. ( 24 ) found an improvement in “self-perceived health” in the first postoperative year (p <0.05 and p <0.009), which deteriorated later but did not fall as low as its original score (p <0.0001). Furthermore, the studies concluded that “physical pain” increased postoperatively and “physical functioning” decreased; the postoperative follow-up periods varied between 3 months ( 18 ) and 5 years ( 23 ). According to Lindqvist et al. ( 23 ), “physical pain” in trans women five years postoperatively was comparable to that in the standard population (72.5 vs 72.7; SD 26.5).

Studies that used the WHOQOL-100 came up with the following results: Cardoso da Silva et al. ( 26 ) observed postoperatively an increase in “sexual activity” (p = 0.000) compared with the preoperative evaluation (prospective study design). Furthermore they found a postoperative improvement in the “psychological domain” (p = 0.041) and “social relationships” (p = 0.007), but a deterioration in “physical health” (p = 0.002) and “independence” (p = 0.031). Accordingly, deteriorations were seen in the areas of “energy” and “fatigue”, “sleep”, “negative feelings”, “mobility”, and “activities of daily living” (p <0.05). Castellano et al. ( 17 ) found after sex reassignment surgery for the group of trans women compared with the group of cis women no significant differences relating to “sexual activity” (65.85 vs 66.28; p >0.05), “body image” (64.64 vs 65.47; p >0.05), and the “quality of life score” (67.87 vs 69.49; p >0.05).

Quality of life and urinary incontinence

The King’s Health Questionnaire (KHQ) is a validated questionnaire for evaluating the impact of urinary incontinence on quality of life ( 33 ), a topic of central importance for trans persons ( 34 ). This questionnaire interrogates the quality of life domains always in association with urinary incontinence as the main problem. Kuhn et al. ( 19 ) showed that “general health” in trans persons was experienced as poorer to a relevant extent (Cohen’s d = 4.126; p = 0.019), and “physical” (d = -7.972; p <0.0001) and “personal limitations” (d = -7.016; p <0.001) were experienced to a greater extent. In contrast to this, trans persons felt less limited in terms of “role limitation” (d = 3.311; p = 0.046). For “emotions”, “sleep”, “incontinence”, and “symptom severity”, the differences to the control group did not reach significance. The control group consisted of cis women who had undergone abdominopelvic surgery. The evaluation of the visual analogue scale (VAS) showed a lower (d = 14.136; p <0.0001) degree of general life satisfaction in the group of trans persons.

Life satisfaction

The SHS ( 35 ), SWLS ( 36 ), and CLLS ( 37 ) are validated and internationally used visual analogue scales to evaluate life satisfaction. The SHS evaluates individual happiness and associated physical, mental, and social wellbeing ( 35 ). The SWLS was used as a short-form scale in the cited studies (also known as L-1) and included only the question on general life satisfaction ( 36 ). The CLLS evaluates emotional wellbeing associated with life satisfaction as well as subjective health ( 37 ).

Studies that used the SHS, SWLS, and CLLS ( 27 , 28 ) to evaluate postoperative life satisfaction reported a high degree of “subjective happiness” (5.6; SD 1.4 and 5.9; SD 0.6), of “satisfaction with life“ (27.7; SD 5.8 and 27.1; SD 2.1) and “subjective wellbeing” (8.0 [range: 4–10] and 7.9; SD 0.7) in trans women after intestinal vaginoplasty. The studies cited earlier differ with regard to the following items: Bouman et al. ( 27 ) studied a population of young trans women (mean age: 19.1 years) with penoscrotal hypoplasia after primary laparoscopic intestinal vaginoplasty. The study participants had received puberty blockers during their transition therapy, which resulted in penoscrotal hypoplasia and made penile inversion vaginoplasty ( box ) impossible. Van der Sluis et al. ( 28 ) studied an older population (mean age: 58 years) of trans women after secondary intestinal vaginoplasty—that is, patients who required secondary intestinal reconstruction owing to vaginal stenosis or insufficient vaginal length after penile inversion vaginoplasty. The postoperative follow-up period varied between 1–7.5 years ( 27 ) and 17.2–34.3 years ( 28 ). In spite of the different patient populations, these studies found that sex reassignment surgery had a positive effect on life satisfaction.

The FLZ is a validated multidimensional questionnaire for evaluating individual general life satisfaction ( 38 ). It is used in life quality and rehabilitation research and enables the recording of changes if administered repeatedly. It is available in a German language version only; for this reason, its results apply only to German speaking populations.

Studies that used the FLZ questionnaire ( 21 , 29 ) found that the postoperative life satisfaction of trans women in terms of “health” does not differ from that of the general population. Additionally, Papadopoulos et al. ( 29 ) found no differences for “friends”, “hobbies”, “income”, “work”, and “relationship.” A subanalysis of the module “health” found postoperatively in both studies a relevant decrease in “fitness” (d = 0.521; p <0.001) and “energy” (d = 0.494; p <0.003). Zimmerman et al. ( 21 ) additionally found a significant decrease in “ability to relax/equilibrium” (p = 0.002), “fearlessness/absence of anxiety” (p = 0.015), and “absence of discomfort/pain” (p = 0.037). Both studies ( 21 , 29 ) were retrospective surveys that were undertaken once only in a time period between 6 months and 58 months postoperatively. Papadopoulos et al. ( 29 ) included only subjects into the study who did not require any further corrective surgery after sex reassignment surgery or who had already undergone a second procedure for the purpose of minor corrections.

Two prospective studies documented postoperatively a notable improvement in quality of life ( 23 , 26 ). Four studies found that the life quality of trans women after sex reassignment surgery was no different from that of cis women ( 17 , 20 , 22 , 24 ). Sex reassignment surgery has also been shown to have a positive effect on life satisfaction ( 27 , 28 )—the exception was urinary incontinence, in which case life satisfaction dropped ( 19 ). Lindqvist et al. ( 23 ) and Weyers et al. ( 24 ) observed an improvement in self-perceived health in the first postoperative year, which then drops, albeit not all the way down to its original level. This is consistent with the honeymoon phase described by De Cuypere et al. ( 39 ), which has been described as a euphoric period in the first year after surgery. Several studies ( 18 , 20 – 25 ) showed that physical pain increased after surgery and physical functioning deteriorated. This is easily explained by the surgery itself, however; the postoperative follow-up periods in these studies varied between 3 months ( 18 ) and 5 years ( 23 ).

Altogether the study results imply that sex reassignment surgery has an overall positive effect on partial aspects, such as mental health, sexuality, life satisfaction, and quality of life.

These results were confirmed by Barone et al. ( 40 ) and Murad et al. ( 15 ) in their review articles, which were published in 2017 and 2010, respectively. Barone et al. ( 40 ) in a systematic review evaluated patient reported results after sex reassignment surgery; among others, regarding life satisfaction. Murad et al. ( 15 ) in a meta-analysis focused on quality of life and psychosocial health after hormone therapy (main aspect) and sex reassignment surgery. In sum, both studies found improvements in quality of life and life satisfaction after sex reassignment surgery, and an improvement at the psychosocial level. Hess et al. ( 11 ) concluded that the study participants benefited from sex reassignment surgery—they too found high rates of satisfaction postoperatively in Germany.

As sex reassignment surgery often constitutes the final step of sex reassignment measures, hormone therapy as well as accompanying psychotherapy may have had a confounding effect. Not all studies adjusted for confounding factors. A lack of randomization and control or the use of a matched control group ( 17 , 19 ) in the studies also introduced methodological bias ( table 2 ). Furthermore, the high dropout rates of 12% ( 17 ) to 77% ( 23 ) (median: 56%), which are mainly due to non-respondents, should be assessed critically. In our experience, however, the patient population of trans women is often reticent and is not interested in study participation because of personal reasons (“to not be reminded of that time”). Other authors have shared this observation ( 18 , 24 ), which may also explain the occasionally high dropout rates. There is also the possibility that dissatisfied patients were among the dropouts. Owing to socioeconomic and clinical conditions, the studies from Croatia ( 18 ) and China ( 25 ) need to be evaluated separately. On the one hand, the authors of both studies draw attention to the public’s lack of awareness and understanding (and the associated psychological stress for trans women) in these countries, and, on the other hand, statutory sickness funds did not cover the costs of all treatments, which were therefore accessible to only few patients. This explains the notably lower participant numbers of 3 ( 18 ) and 4 ( 25 ) male-to-female transitions after sex reassignment surgery. None of the included studies reported potential suicide rates.

The strength of this review lies in the fact that we included only studies that used standardized questionnaires. Tests (such as the SF-36 or WHOQOL-100) represent validated and reliable measuring instruments, for some of which reference standard populations exist, and they enable international and intercultural comparison. Furthermore, standardized questionnaires have the advantage of a high degree of objectivity in terms of conducting, evaluating, and interpreting studies.

The available study data show that sex reassignment surgery has a positive effect on partial aspects—such as mental health/wellbeing, sexuality, and life satisfaction—as well as on quality of life overall.

It should be noted that the studies are almost exclusively retrospective analyses of mostly uncontrolled and small cohorts, for which no valid or specific measuring instruments are available to date. Because of the high dropout and non-response rates, the current data should be interpreted with caution.

In spite of the essentially positive results, the data are not satisfactory at this point in time. Due to the studies’ limited follow-up times, no conclusions can be drawn as yet about the long term consequences of such procedures. Furthermore, many studies did not use standardized questionnaires and/or scores, which makes comparisons between individual studies difficult.

Key messages

• Trans persons suffer from the tension between their biologically characterized body and their experienced sex/gender.
• Undergoing medical and/or social transition seems for many trans persons the best possible solution for alleviating their gender dysphoria symptoms.
• Results from studies imply that sex reassignment surgery on the one hand has positive effects in terms of partial aspects of quality of life, such as mental health, sexuality, and life satisfaction, and, on the other hand, on quality of life overall.
• Because of the studies’ high dropout rates (12–77%; median 56%), the results should be interpreted with caution.
• The studies did not include information on potential suicide rates.

Supplementary Material

Acknowledgments.

Translated from the original German by Birte Twisselmann, PhD.

Conflict of interest statement

The authors declare that no conflict of interest exists.

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Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

Related Articles

• How Gender Identity Disorder Works
• Is gender just a matter of choice?
• What is transgender voice therapy?
• How fluid is gender?
• Why do girls wear pink and boys wear blue?

More Great Links

• DSM-5: Gender Dysphoria
• National Center for Transgender Equality
• The Williams Institute
• American Medical Student Association (AMSA). "Transgender Health Resources." 2014. (April 20, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
• American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." 2011. (July 1, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
• AP. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 20, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
• Belkin, Lisa. "Smoother Transitions." The New York Times. Sept. 4, 2008. (Aug. 1, 2011) http://www.nytimes.com/2008/09/04/fashion/04WORK.html
• Crane, Curtis. "The Total Guide to Penile Implants For Transsexual Men." Transhealth. May 2, 2014. (April 20, 2015) http://www.trans-health.com/2013/penile-implants-guide/
• Donaldson James, Susan. "Trans Chaz Bono Eyes Risky Surgery to Construct Penis." ABC News. Jan. 6, 2012. (April 20, 2015) http://abcnews.go.com/Health/transgender-chaz-bono-seeks-penis-genital-surgery-risky/story?id=15299871Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
• Glicksman, Eve. "Transgender today." Monitor on Psychology. Vol. 44, no. 4. Page 36. April 2013. (April 20, 2015) http://www.apa.org/monitor/2013/04/transgender.aspx
• Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape Medical News. May 20, 2013. (April 20, 2015) http://www.medscape.com/viewarticle/804432
• HealthResearchFunding.org (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 20, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
• International Foundation for Gender Education. "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 20, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
• Moskowitz, Clara. "High Suicide Risk, Prejudice Plague Transgender People." LiveScience. Nov. 18, 2010. (April 20, 2015) http://www.livescience.com/11208-high-suicide-risk-prejudice-plague-transgender-people.html
• Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. 2013. (April 20, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
• Public Religion Research Institute. "Survey: Strong Majorities of Americans Favor Rights and Legal Protections for Transgender People." Nov. 3, 2011. (April 20, 2015) http://publicreligion.org/research/2011/11/american-attitudes-towards-transgender-people/#.VSmlgfnF9bw
• Steinmetz, Katy. "Board Rules That Medicare Can Cover Gender Reassignment Surgery." Time. (April 20, 2015) http://time.com/2800307/medicare-gender-reassignment/
• The Philadelphia Center for Transgender Surgery. "Phalloplasty: Frequently Asked Questions." (April 20, 2015) http://www.thetransgendercenter.com/index.php/surgical-procedures/phalloplasty-faqs.html
• U.S. Office of Personnel Management. "Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace." 2015. (April 20, 2015) http://www.opm.gov/diversity/Transgender/Guidance.asp
• University of California, San Francisco - Department of Family and Community Medicine, Center of Excellence for Transgender Health. "Primary Care Protocol for Transgender Patient Care." April 2011. (April 20, 2015) http://transhealth.ucsf.edu/trans?page=protocol-hormones
• University of Miami - Miller School of Medicine, Department of Surgery, Plastic, Aesthetic and Reconstructive Surgery. "Transgender Reassignment." 2015. (April 20, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
• University of Michigan Health System. "Gender Affirming Surgery." (April 20, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
• World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
• World Professional Association for Transgender Health (WPATH). "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide." 2015. (April 20, 2015) http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947

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ISAPS Olympiad Word Congress 2025, Singapore: submit your abstract by October 18, 2024

Female to Male Gender Reassignment Surgery (FTM GRS)

Female-to-male gender reassignment surgery (FTM GRS) is a complex and irreversible genital surgery for female transsexual who is diagnosed with gender identity disorder and has a strong desire to live as male. The procedure is to remove all female genital organs including the uterus, ovaries, and vagina with the construction of male genitalia composed of the penis and scrotum.  

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Female gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as males smoothly such as breast amputation, facial surgery, body surgery, etc.  

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is very complicated and only a handful of surgeons are able to perform this procedure. It is a multi-staged procedure, the first stage is the removal of the uterus, ovary, and vagina. The duration of the procedure is 2-3 hours. The second and later stages are penis and scrotum reconstruction which is at least 6 months later. There are several techniques for penile reconstruction depending on the type of tissue such as skin/fat of the forearm, skin/fat of the thigh, or adjacent tissue around the clitoris. This second stage of surgical time is between 3-5 hours. A penile prosthesis can be incorporated simultaneously or at a later stage. The scrotal prosthesis is also implanted later.  

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-7 days for each stage depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What are the risks.

The most frequent complication of FTM GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis and fistula, unsightly scar, etc. The revision procedure is scar revision, hair transplant, or tattooing to camouflage unsightly scars.   

What is the recovery process?

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patients return to their normal lives but not having to do physical exercise during the first 2 months after surgery. The patient will have a urinary catheter continuously for several weeks to avoid a urinary fistula. If the patient has a penile prosthesis, it would need at least 6 months before sexual intimacy.  

What are the results?

With good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a male role completely and happily either on their own or with their female or male partners.  

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House GOP probes Biden admin over push to loosen transgender surgery guidelines for minors

by JACKSON WALKER | The National Desk

WASHINGTON (TND) — The House Oversight Committee on Tuesday announced it has launched a probe into the Department of Health and Human Services over its push to remove age restrictions for a variety of transgender procedures.

Documents released in June show that when the World Professional Association for Transgender Health (WPATH) was updating its guidelines, officials within the Department of Health and Human Services (HHS) feared a minimum age requirement for breast removals, genital surgeries and other procedures could invite political backlash. Emails included in the documents reveal Assistant Secretary for Health Rachel Levine, a transgender woman, advocated for WPATH to remove proposed age limits from the guidelines.

In one included email, Levine's then-chief of staff Sarah Boateng said both the assistant secretary and the Biden administration as a whole worried the inclusion of "specific ages" would affect access to health care for transgender youth. Boateng now serves as HHS's principal deputy assistant secretary for health.

Rep. Lisa McClain, R-Mich., wrote to Secretary of Health and Human Services Xavier Becerra to press for answers. She noted the House Oversight Committee is concerned the department "inappropriately applied pressure for changes to international pediatric medical standards."

“Considering the Biden administration’s recently concocted defense that ‘the Administration does not support surgery for minors,’ it is alarming that HHS would advocate for these policies in its communications with WPATH,” the letter reads . “The reality that WPATH caved to make changes to child patient care recommendations based on blatant political motivations is a stain on the credibility of WPATH and its guidelines.”

READ MORE | Detransitioner sues Planned Parenthood, other doctors over hormone therapy, breast removal

The representative closed the letter by calling for a slew of documents from HHS leaders and communications with WPATH. She included a deadline of Sept. 10.

A spokesperson for HHS did not respond to a request for comment from The National Desk (TND) Tuesday.

Former President Donald Trump’s campaign indicated last week he would call to instate felonies for doctors who perform surgeries on minors without parental consent. Prepared rally remarks of Trump also touched on introducing the death penalty for child rapists and the return of “stop and frisk” policing.

Follow Jackson Walker on X at @_jlwalker_ for the latest trending national news. Have a news tip? Send it to [email protected].

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Gender reassignment and the role of the laboratory in monitoring gender-affirming hormone therapy.

1. Introduction

3. gender development, genesis of gender incongruence, 4. guidelines for gaht, 4.1. adolescent gi, 4.2. adult gi, 5. laboratory tests in transgender afab/amab individuals, 5.1. red blood cell indices, 5.2. renal function, 5.3. liver enzymes, 5.4. lipids, 5.5. cardiac biomarkers, 5.6. reproductive hormones, 5.7. ferritin, 5.8. prostate specific antigen.

5.9. Laboratory Test Reference Intervals for Transgender Population

6. electronic medical record systems (emr), 7. gaht and other laboratory markers, 7.1. risk of venous thromboembolism in amab people, 7.2. hyperprolactinemia, 7.3. other sex hormone dependent tumours, 7.4. bone mineral density, 8. gaht, vascular health and cardiovascular disease, and impact of aging in transgender adults, 9. conclusions, 10. future directions, conflicts of interest.

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Ramasamy, I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. J. Clin. Med. 2024 , 13 , 5134. https://doi.org/10.3390/jcm13175134

Ramasamy I. Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy. Journal of Clinical Medicine . 2024; 13(17):5134. https://doi.org/10.3390/jcm13175134

Ramasamy, Indra. 2024. "Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy" Journal of Clinical Medicine 13, no. 17: 5134. https://doi.org/10.3390/jcm13175134

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