Feminizing surgery

Overview

Feminizing surgery encompasses procedures that alter your appearance to promote the matching of your body with your gender identity (gender congruence). Feminizing surgery includes many options, such as "top" surgery to increase the size of your breasts (breast augmentation) and "bottom" surgery to remove your testicles (orchiectomy) and create a vagina (vaginoplasty). You might also consider facial procedures or body-contouring procedures to create a more feminine appearance.

Feminizing surgery, also called gender-affirming surgery, is often chosen as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria).

Feminizing surgery isn't for all transgender women. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Prior to some types of surgery, you might be required to obtain recommendations from mental health providers, live as a female and be on feminizing hormone therapy for a specific period of time. Certain surgeries will alter your fertility and your sexual sensations, in addition to how you feel about your body.

Your doctor, as well as people who have had these surgeries, can help you weigh the risks and benefits.

Why it's done

People who seek feminizing surgery experience distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria).

For some trans women (male to female), feminizing surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs.

Feminizing surgeries are typically deferred until adulthood. Options include:

• A surgical procedure to increase your breast size (breast augmentation) through implants or the transplantation of fat from other parts of the body into the breast
• Plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are altered to create a more feminine appearance (facial feminization surgery)
• Body-contouring procedures, such as a tummy tuck (abdominoplasty), buttock lift (gluteal augmentation) and a surgical procedure that uses a suction technique to remove fat from specific areas of the body (liposuction)
• Surgery to raise the pitch of your voice (voice feminization)
• Surgery to minimize the thyroid cartilage or Adam's apple (tracheal shave)
• A procedure to remove hair follicles from the back and side of the head and transplant them to balding areas (hair-transplant surgery)
• A procedure that uses a laser — an intense, pulsating beam of light — to remove unwanted hair (laser hair removal) or a procedure that involves inserting a tiny needle into each hair follicle, emitting a pulse of electric current to damage and eventually destroy the follicle (electrolysis)
• A procedure that uses a laser to improve the appearance of your skin or treat minor facial flaws by removing layers of skin (laser resurfacing)
• Silicone injections to enhance your hips, buttocks, breasts, lips, cheekbones and other body parts
• Genital surgery to remove your testicles (orchiectomy), create a vagina using penile or colon tissue (vaginoplasty), create a vulva (vulvoplasty), create a clitoris (clitoroplasty), and create labia (labiaplasty)

Feminizing surgery isn't for all trans women. Your doctor might recommend against these surgeries if you have:

• Unmanaged mental health conditions
• Significant health conditions, such as heart or kidney disease, a bleeding disorder, or a history of blood clots in a deep vein (deep vein thrombosis) or in a lung (venous thromboembolism)
• Any condition that limits your ability to give your informed consent

Risks

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and an adverse reaction to anesthesia. Other complications might include:

• Poor wound healing, such as along an incision line
• Fluid accumulation beneath the skin (seroma)
• A solid swelling of clotted blood within your tissues (hematoma)
• Changes in skin sensation such as persistent pain, tingling, reduced sensation or numbness
• Damaged or dead body tissue (tissue necrosis) in the vagina and labia
• A blood clot in a deep vein (deep vein thrombosis) or a blood clot in a lung (pulmonary embolism)
• An abnormal connection between two body parts (fistula), such as between the bladder or bowel into the vagina
• Dissatisfaction with appearance after surgery
• Loss of sexual pleasure and functioning, including the persistent inability to achieve orgasm despite responding to sexual stimulation (anorgasmia)

Your fertility

Certain types of feminizing surgery can harm or end your fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your doctor about freezing your sperm (sperm cryopreservation) before moving forward.

How you prepare

Before feminizing surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in the procedures you desire. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that might be necessary. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.

In addition, before you can have certain feminizing surgeries, you'll be required to meet certain criteria. To start, your surgeon will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:

• A review of your personal and family medical history
• A physical exam, including an assessment of your internal reproductive organs
• Lab tests measuring your lipids, blood sugar, blood count, liver enzymes, electrolytes and the hormone prolactin
• A review of your immunizations
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
• Discussion about sperm freezing (sperm cryopreservation)

Although giving your informed consent after a discussion about the risks and benefits of the procedure is an acceptable standard of care, most surgeons will require a mental health evaluation by a provider with expertise in transgender health. The evaluation might assess:

• Your gender identity and dysphoria
• The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
• Mood or other mental health concerns
• Sexual health concerns
• Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
• Protective factors such as social support from family, friends and peers
• Your goals, risks and expectations of treatment and your future care plans

Before having facial feminization surgery, it's recommended that you talk to a mental health provider, who can help you make a fully informed decision about the timing and implications of the procedures in the context of your transition.

Before having breast augmentation, also called breast feminization, you'll be required to obtain one letter of support from a mental health provider competent in transgender health. He or she will determine that you meet the World Professional Association of Transgender Health (WPATH) standards of care criteria. The criteria state that you must:

• Have persistent, well-documented gender dysphoria
• Have the capacity to make a fully informed decision and to consent to treatment
• Be of legal age to make health care decisions in your country (age of majority or age 18 in the U.S.)
• Be managing any significant medical or mental health concerns
• Undergo hormone therapy as appropriate to your gender goals for a minimum of 12 months prior to breast augmentation surgery, unless you have a medical contraindication, or you're otherwise unable or unwilling to take hormones

The purpose of hormone therapy prior to breast augmentation is to maximize breast growth in order to help you obtain better results.

Before having orchiectomy, you'll be required to obtain two letters of support, each from a mental health provider competent in transgender health. They will determine that you meet the WPATH standards of care criteria. The criteria state that you must:

• Have persistent, well-documented gender dysphoria
• Have the capacity to make a fully informed decision and to consent to treatment
• Be of legal age to make health care decisions in your country (age of majority or age 18 in the U.S.)
• Be managing any significant medical or mental health concerns
• Undergo hormone therapy as appropriate to your gender goals for a minimum of 12 months prior to orchiectomy, unless you have a medical contraindication, or you're otherwise unable or unwilling to take hormones

The aim of hormone therapy prior to orchiectomy is primarily to introduce a period of reversible testosterone suppression before you undergo irreversible surgical intervention. These criteria don't apply to people who are having these procedures for medical indications other than gender dysphoria.

Before having vaginoplasty, you'll be required to obtain two letters of support, each from a mental health provider competent in transgender health. They will determine that you meet the WPATH standards of care criteria. The criteria state that you must:

• Have persistent, well-documented gender dysphoria
• Have the capacity to make a fully informed decision and to consent to treatment
• Be legally considered an adult in your country (age of majority)
• Be managing any significant medical or mental health concerns
• Undergo hormone therapy as appropriate to your gender goals for a minimum of 12 months prior to vaginoplasty, unless you have a medical contraindication, or you're otherwise unable or unwilling to take hormones
• Live in a gender role congruent with your gender identity for 12 continuous months prior to vaginoplasty

Consent

Since feminizing surgery might cause irreversible physical changes, you must give informed consent after thoroughly discussing:

• Risks
• Benefits
• Cost
• Alternatives
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility
• Procedure irreversibility

Health insurance might not cover surgical procedures considered cosmetic for the general population, even though these procedures might be essential to alleviating your gender dysphoria.

You might consider talking to others who've had feminizing surgery before taking this step. They can help you shape your expectations of what can be achieved and help prepare you for the recovery process, scarring and possible changes in sexual sensations. They might also have insight on what personal and social problems you might experience during treatment.

What you can expect

Facial feminization surgery

These plastic surgery techniques alter your jaw, chin, cheeks, forehead, nose or areas surrounding the eyes, ears or lips to create a more feminine appearance. You might have your hairline moved to create a smaller forehead, have your lips and cheekbones augmented with implants, or have your jaw and chin reshaped and resized. If you have bone reduced, you might need skin-tightening surgery.

These surgeries are typically outpatient, requiring no hospital stay. Recovery time for most of these procedures is about two weeks, though recovering from jaw procedures will take longer.

Tracheal shave

A tracheal shave is a procedure to minimize your thyroid cartilage or Adam's apple. During the procedure, a small incision will be made under your chin, in the shadow of your neck or in a skin fold to conceal the scar. Your surgeon will then reduce and reshape the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Breast augmentation

While the use of estrogen will stimulate breast growth, many people aren't satisfied with this growth alone. Breast augmentation is a surgical procedure to increase your breast size. Feminizing breast surgery might involve implants, fat grafting or both.

Your surgeon will make incisions around the areola, near the armpit or just below the breast. Next, your surgeon will place the silicone or saline implants either in front of or behind the pectoral muscles. Alternatively, you could have fat, muscles or tissue from other parts of your body transplanted into your breasts.

If feminizing hormones haven't made your breasts large enough, you might need an initial surgery to have devices called tissue expanders placed in front of your chest muscles. You'll need to visit your doctor every few weeks to have a small amount of saline injected into the tissue expanders. This will slowly stretch your chest skin and other tissues to make room for the implants. When your skin has been sufficiently stretched, you'll have another surgery to remove the expanders and place your implants.

Genital surgery

Orchiectomy

Orchiectomy is a surgery to remove your testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers, such as spironolactone (Aldactone), and reduce the amount of estrogen needed to achieve and maintain your desired appearance.

This type of surgery is typically done on an outpatient basis. You will be given a local anesthetic, in which you're awake and only your testicular area is numbed, or you will be placed under general anesthesia, in which you're asleep for the surgery. To remove your testicles, your surgeon will make an incision in your scrotum and extract the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty, though some prefer to have orchiectomy alone without further genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. In some techniques these are also used to create the labia (labiaplasty). To surgically create a clitoris (clitoroplasty), the tip (glans) of the penis and the nerves that supply it are used. Alternatively, skin can be taken from another area of the body or tissue from the colon to create the vagina. The testicles also are removed during the course of the surgery.

Some surgeons use a technique requiring electrolysis or laser hair removal in your penile and scrotal areas to provide hair-free tissue for the procedure. The process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, you'll have a tube (catheter) placed in your urethra to collect urine. You will need to be closely monitored either in the hospital or an associated care center for about a week after surgery. Recovery can take up to two months. Your doctor will provide instructions about when it's OK to begin sexual activity with your new vagina. You'll be given a set of vaginal dilators of increasing sizes that you'll insert in your vagina at time intervals to maintain, lengthen and stretch the size of your vagina. You will need to dilate on a regular basis indefinitely.

Keep in mind that because the prostate gland isn't removed during surgery, you will need to follow age-appropriate recommendations for prostate cancer screening. You might also develop urinary obstructive symptoms from benign enlargement of the prostate.

Results

Research suggests that gender-confirming surgery can have a positive impact on your well-being and sexual function.

Long-term postoperative care and follow-up after surgical treatment for gender dysphoria also have been linked with good outcomes. Before you have surgery, talk to your surgeon, hormone-prescribing doctor — if you're taking hormones — and your mental health provider about what ongoing treatment you'll need.