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.

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Overview

Gender affirmation 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 affirmation. These can be when a transgender woman, man, or nonbinary person choose affirmative medical intervention.

The term is no longer accepted by many members of the community because it presents a medicalized view of being transgender. "Transsexual" has also been weaponized as a slur against transgender people. While some older people identify with this term, cisgender people should never use it unless referring to someone who explicitly identifies as “transsexual.”

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 experienced gender and their assigned gender. 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 what they feel internally.

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 gatekeep gender affirmative procedures.

Necessary 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 the desired sex 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.

One reason a transgender person would want surgery without having dysphoria is to be at less risk for transphobic violence. Requiring trans people to conduct a “real-life” test without allowing them the protection of passing is transphobic and extremely dangerous.

Hormone Therapy in 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 traditionally female sexual characteristics and an increase in traditionally 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 traditionally male sexual characteristics and an increase in traditionally 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

Behavioral changes include:

  • 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 of 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 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.

Transfeminine Surgeries

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

As with transfeminine, surgery involves top surgery and bottom surgery.

Top surgery includes :

  • subcutaneous mastectomy/breast reduction surgery.

Bottom surgery includes:

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 potential of increased risk of breast cancer (even without hormones, cisgender men can 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.

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 are 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 clearly has a diagnosis of 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 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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Article Sources
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