Preparation and Procedures Involved in Gender Reassignment Surgery

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If you or a loved one are considering gender confirmation 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 confirmation surgery, historically known as sex reassignment surgery (SRS) and gender reassignment surgery (GRS), is performed to transition individuals with gender dysphoria to their identified gender.

Historically, the term transsexual was used to describe an individual who had undergone some form of medical or surgical treatment for gender reassignment. These can be when a transgender woman transitions from male-to-female or when a transgender man transitions from female-to-male.

The Difference Between Transgender and Transsexual

Transgender refers to individuals whose gender identity differs from the one assigned at birth. The gender assigned is usually based on the appearance of the external genitalia. Transgender people may or may not have undergone sex reassignment surgery. Transgender people have been recorded since ancient times.

Transsexual refers to individuals who seek or have undergone surgery or medical treatment to change the appearance of their birth genitalia as a means of reducing their gender dysphoria.

Reasons Why a Person Undergoes Surgery

Many transgender people experience a marked incongruence between their experienced gender and their assigned gender. The American Psychiatric Association (APA) has identified this as gender dysphoria. Gender dysphoria may cause people to experience major upset and impairment on social and personal levels. For these individuals, gender role changing, hormone therapy, and gender confirmation surgery permit their outside appearance to match what they feel internally.

Transitioning to Another Gender

Transitioning to another gender may involve:

  • Dressing and living in a gender role that is congruent with their gender identity without surgery.
  • Taking sex hormones and/or surgically removing or modifying genitals and reproductive organs.

Steps Required Before Gender-Affirming Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in these types of operations, there are other steps which must be accomplished before surgery is performed. Necessary steps may include:

  • A 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.
  • A clear and consistent documentation of gender dysphoria.
  • A "real life" test: The individual must take on the role of the desired sex in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

The Role of Hormone Therapy in Transitioning

For transgender individuals desiring surgery, hormone therapy (HT), also called hormone replacement therapy (HRT), involves taking estrogen for a male to female transition or testosterone for a female to male transition. Hormone therapy may be used before, during, and after the surgical transition to another gender.

The purpose of hormone therapy is to change the physical appearance into that of the desired gender.

The Effects of Testosterone on Females

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

Bodily changes 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 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

The Effects of Estrogen on Males

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

Changes to the body 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

Behavioral changes include:

  • Decreased sex drive
  • Mood swings

When Are the Effects of Hormone Therapy 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 satisfactorily transitioned. This is especially true of breast development.

How Long Does the Surgery Process Take?

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after the first 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.

Surgeries Involved in Transitioning From a Male to a Female

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 which may be considered 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 to become more feminine appearing.
  • Chin reduction: Female chin structure is often more delicate, so chin reduction may be performed.
  • Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.
  • Lips: A lift lip may be done.
  • Creation of female 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 (feminizing genitoplasty)

Surgeries Are Involved in Transitioning From a Female to a Male

As with male to female transitions, surgery involves top surgery and bottom surgery.

Top surgery includes:

  • Subcutaneous mastectomy/breast reduction surgery

Bottom surgery includes:

  • Removal of the uterus and ovaries
  • Creation of a penis and scrotum (masculinizing genitoplasty)

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 transgender women. There is also the potentially increased risk of breast cancer, and even without hormones we know that males can also develop breast cancer. Testosterone use in transgender men 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.

How Much Does Gender Confirmation Surgery Cost?

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. It is somewhat more expensive to transition from male to female than from female to male. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery both for people who transition from female to male and those who transition from male to female. 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 confirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person clearly has a diagnosis of gender dysphoria. After this is complete, hormonal treatment is begun with testosterone for those transitioning from female to male and estrogen for those transitioning from male to female. 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 a precise estimate is difficult due to many variables including possible complications and the number and extent of surgeries selected. Finding a surgeon who focuses on gender confirmation surgery alone and has performed many of these procedures is a plus.

For those who follow through with these preparation steps, hormone treatment, and surgeries, quality of life appears to be good, and many people state that they would undergo gender affirmation surgery again.

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