Purpose of Transgender Surgery

Transgender surgery is known by many names. What used to be called sex reassignment surgery is now more often referred to as gender affirmation surgery or gender confirmation surgery. This reflects a growing understanding of the differences between sex and gender.

It also reflects an understanding that sex and gender are complex, and the purpose of transgender surgery is to address gender dysphoria or achieve gender euphoria. In other words, the purpose of transgender surgery is to help people live happily in their affirmed gender—not to achieve an externally-driven goal.

Diagnosis Related to Transgender Surgery

Transgender surgery is used to help people resolve gender dysphoria or achieve gender euphoria. Considered medically necessary, many transgender surgery options are covered by insurance. However, what specific surgeries are covered varies from state to state and plan to plan.

Accessing transgender surgery usually requires a diagnosis of gender dysphoria or gender identity disorder. This diagnosis may also appear as "transsexualism," depending on the coding system used. A diagnosis of gender dysphoria may come from a medical or mental health provider.

There is substantial controversy over whether being transgender should be a diagnosable condition, but applying a diagnosis can make it easier to access care.

Transgender surgery is almost never the first step in an individual's gender transition. Most individuals will first engage in social and/or medical transition. Social transition is when a person lives in their affirmed gender, often changing their gender expression, name, and preferred pronouns.

Medical transition can involve the use of puberty blockers or gender affirming hormone therapy. Furthermore, not all transgender people are interested in transgender surgery or other medical treatment to address their gender.

Criteria

The World Professional Association of Transgender Health (WPATH) Standards of Care are the documents most often used to determine eligibility for various types of transgender surgery. Specific eligibility criteria vary for different types of surgery, and different surgeons may also have their own criteria.

The WPATH Standards of Care version 7 lays out eligibility criteria for several different types of surgery.

Transgender Top Surgery

Criteria for top surgery are:

• Persistent gender dysphoria
• Capacity to consent for treatment
• Age of majority
• Significant medical and mental health conditions must be well controlled
• One referral letter from a behavioral health provider
• Hormone treatment is recommended but not required for feminizing breast augmentation. If someone is using gender-affirming hormone therapy, they are recommended to be on it for 12 months. It is not a criteria for masculinizing chest surgery.

Bottom Surgeries

Criteria for phalloplasty, metoidioplasty, vaginoplasty, and other bottom surgeries are:

• Persistent gender dysphoria
• Capacity to consent for treatment
• Age of majority
• Significant medical and mental health conditions must be well controlled
• Two referral letters from behavioral health providers
• 12 months of continuous hormone therapy, unless hormones are not clinically indicated for the person or they are unable or unwilling to take hormones
• 12 months of living in a gender role congruent with their gender identity. (Note: This requirement is not in place for gender affirming hysterectomy or orchiectomy.)

Facial Feminization Surgery

The WPATH SOC does not establish formal criteria for facial feminization surgery. These surgeries are only rarely covered by insurance, even though they can profoundly affect people's lives.

Tests and Labs

No tests or labs are required for transgender surgery, in general. However, specific surgeries may require tests. Also, people may be required to undergo tests related to any underlying health conditions.

Currently, to access most gender-affirming surgeries, patients must present referral letters from both a medical provider and a mental health provider. (Two mental health letters are sometimes required for genital surgeries). These letters address concerns that surgeons may not have the skills to assess gender dysphoria appropriately.

However, they are often considered a form of gatekeeping as these types of requirements can make it difficult for transgender people to access affirming care. For instance, having a medical and mental health provider will create additional costs that can impede a transgender person from pursuing an affirmation surgery.

A Word From Verywell

Transgender surgeries are medically necessary procedures that can make an enormous difference in the ability of gender-diverse individuals to live comfortably in their bodies and function successfully in the world.

Not all transgender people want surgery, but those who do often struggle to access it. In addition to insurance coverage issues, there is a shortage of surgeons trained to provide these surgeries. Patients may also have to travel long distances to receive care, which can make follow-up difficult.

The good news is that since federal insurance guidelines require gender-affirming surgery coverage, more and more providers have been interested in offering these services to transgender patients.

The bad news is not all providers offering this care have been appropriately trained, and transgender surgery is not yet a standard residency training component, even in plastic surgery. When considering transgender surgery, you should always ask potential surgeons about their training and experience with any procedure.

Ethical surgeons will be up-front about providing this information. It is also reasonable to ask to see pictures of outcomes from previous surgeries. Ideally, surgeons should be able to show results from individuals with a range of body types so that patients can get an idea of what they can realistically expect.

It can also help join online communities and Facebook groups commonly utilized by transgender individuals to learn more about surgical experiences, resources, recommended surgeons, and more.