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If you have any medical questions or concerns, please talk to your healthcare provider. The articles on Health Guide are underpinned by peer-reviewed research and information drawn from medical societies and governmental agencies. However, they are not a substitute for professional medical advice, diagnosis, or treatment.
It is estimated that roughly one and a half million Americans identify as transgender, experiencing conflict between the bodies they were born with and the gender with which they identify (Cohen, 2019).
Fortunately, there are many different ways to manage this condition, including social, medical, and surgical changes. Transgender individuals may choose none, some, or all of these options to achieve an external look that aligns with how they feel inside (El-Hadi, 2018).
One treatment that can help transgender individuals improve their quality of life is gender reassignment surgery, sometimes called bottom surgery.
What is bottom surgery?
Bottom surgery refers to the plastic surgical procedures performed on the genitals to give the look—and in some cases, functionality—that matches their gender identity. Not every transgender person wants to undergo bottom surgery, but it can significantly improve self-esteem and quality of life for those who do.
You may also hear bottom surgery called:
- Gender affirmation surgery
- Genital reconstructive surgery
- Gender confirmation surgery
Having genitalia that matches your gender identity can help relieve feelings of gender dysphoria. After gender reassignment surgery, transgender people often report feeling more comfortable with their sex partners, in healthcare settings, swimming pools, or the gym (WPATH, 2012).
The World Professional Association for Transgender Health recommends the following criteria for anyone seeking bottom surgery (WPATH, 2012):
- Persistent, well-documented gender dysphoria
- Capacity to make a fully informed decision and to consent for treatment
- Age of adulthood in their location
- If significant medical or mental health concerns are present, they must be well-controlled.
- 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones aren’t appropriate for that individual)
- 12 continuous months of living in a gender role congruent with their gender identity
Although not a requirement, it is recommended that anyone considering bottom surgery also have regular visits with a mental health professional (WPATH, 2012).
What types of bottom surgery are there?
If you have been taking hormones, living in your desired gender role, and feeling emotionally prepared, you may choose to undergo bottom surgery as your final step in transitioning (Hohman, 2021; Garg, 2021).
There are several types of bottom surgery available. You and your plastic surgeon will choose the right procedures based on your needs, preferences, and goals (Hohman, 2021; Garg, 2021).
Female to male (FTM) bottom surgery
Bottom surgery for trans men involves a hysterectomy to remove the uterus (and often the ovaries). Then there are two main choices for genital reconstruction: metoidioplasty or phalloplasty.
Metoidioplasty is when the surgeon releases the clitoris from the ligaments that attach it inside the body. They then add tissue to increase the length and girth. Your surgeon may also lengthen the urethra to allow you to urinate while standing. This is the more common procedure chosen by FTM people since it is less expensive and can be completed in a single surgery (Garg, 2021; Schechter, 2016).
Phalloplasty represents the most complete genital transformation for FTM individuals. This surgery takes place over multiple stages and uses skin grafts from other sites on the body, plus an implanted penile prosthesis to create an aesthetically pleasing and functional penis. Since it is so complex, there is an increased risk of complications, including scarring and trouble passing urine, but most people who undergo this procedure are satisfied with the results (Schechter, 2016).
Male to female (MTF) bottom surgery
Several surgical procedures are available to transgender women, including removal of the penis, scrotum, and testicles (orchiectomy). The latter removes the primary source of testosterone from the body (Garg, 2021; Schechter, 2016).
Depending on your individual goals, a surgeon then creates new structures (such as a new mons pubis, labia, clitoris, and possibly a vaginal canal) through a “vaginoplasty” procedure. These new structures will be feminine appearing, have sensation, and be functional for sexual intercourse if desired (Schechter, 2016).
People who don’t want vaginal penetration or have medical issues may opt for a zero-depth vaginoplasty, also known as a vulvoplasty. This would give the outward appearance of a vulva but without an internal vaginal canal (Li, 2021).
How much is bottom surgery?
The exact cost of your bottom surgery will depend on factors such as your location, the procedures performed, and your insurance plan coverage. You may need to document special criteria before your insurance covers your surgery. Your healthcare provider can help you estimate these charges and navigate insurance coverage.
The total cost for your bottom surgery will include charges for the surgeon, the anesthesiologist, and the hospital stay. You may also have to pay for medications and supplies to care for your surgical wounds while you recover.
What is bottom surgery recovery like?
Bottom surgical procedures are considered major surgery, and it will take some time for your body to heal afterward. The amount of recovery time you need depends on the type of surgery you had.
MTF bottom surgery recovery
For transgender men, you will typically stay in the hospital for 1–2 days following your surgery. Your new vagina will be packed with gauze, then covered with a larger dressing over the genitals to prevent swelling and bruising. You will be on bed rest and have a urinary catheter before you’re able to go home. When you go home from the hospital, you’ll take certain medications to prevent infection and relieve pain. You’ll likely follow up with your surgeon about a week after surgery (Schechter, 2016; Li, 2021).
Once your provider removes the gauze packing, they’ll show you how to begin to dilate your neovagina daily to widen the canal and allow for penetration (if so desired). You’ll continue to visit your surgeon regularly to track your progress. Vaginal intercourse may begin 6–8 weeks after surgery (Schechter, 2016; Li, 2021).
FTM bottom surgery recovery
For trans women, your postoperative care will depend on the surgical procedures performed. Some procedures are performed in multiple stages, so you may have more than one surgery. You will likely be on antibiotics to prevent infection after each stage. You’ll also have a stent placed to keep your new urethra open while it heals and a separate tube for urine to leave your body during this time (Djordjevic, 2018).
You may have a wound on your arm or thigh where tissue was taken for a skin graft. Your provider will give you directions on keeping this area clean and dry while it heals (Schechter, 2016).
After about 10 days, the stent will be removed. The urine tube will remain in for another three weeks and then be removed as well. After that, your provider will give you directions on using a vacuum device and using a class of medication called phosphodiesterase type-5 inhibitors (PDE5 inhibitors), such as Viagra (generic name sildenafil; see Important Safety Information) or Cialis (generic name tadalafil; see Important Safety Information), for at least six months to prevent your new penis from retracting back into the body (Djordjevic, 2018).
Talking to your healthcare provider
Bottom surgeries are typically complex and require the services of a specialized plastic surgeon. This type of care isn’t usually available outside major cities in many regions. You can ask friends for recommendations or search online to find the closest surgery center near you that performs bottom surgeries (Hohman, 2021).
You will most likely need to consult with specialists from multiple disciplines, such as transgender medicine, mental health, and plastic surgery. This team will support you, helping you create a plan and navigate insurance coverage (Hohman, 2021).
You should discuss the following with your surgeon (Hohman, 2021):
- Your goals for surgery
- Reasonable expectations for results
- What to expect before, during, and after surgery
- The risks of general anesthesia and the planned procedure(s)
- How to avoid surgical complications
Having bottom surgery will affect your ability to have biological children. Your care team can help you explore possibilities to preserve your fertility by freezing sperm or freezing eggs before surgery if that’s something you desire (Garg, 2021).
Bottom surgery can help you move forward in life with a body aligned with your self-image. Having supportive healthcare providers can help ensure you get the results you want.
- Cohen, W. A., Sangalang, A. M., Dalena, M. M., Ayyala, H. S., & Keith, J. D. (2019). Navigating insurance policies in the United States for gender-affirming surgery. Plastic and Reconstructive Surgery. Global Open, 7(12), e2564. doi: 10.1097/GOX.0000000000002564. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7288898/
- Djordjevic, M. L. (2018). Novel surgical techniques in female to male gender confirming surgery. Translational Andrology and Urology, 7(4), 628–638. doi: 10.21037/tau.2018.03.17. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6127556/
- El-Hadi, H., Stone, J., Temple-Oberle, C., & Harrop, A. R. (2018). Gender-affirming surgery for transgender individuals: perceived satisfaction and barriers to care. Plastic Surgery (Oakville, Ont.), 26(4), 263–268. doi: 10.1177/2292550318767437. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6236505/
- Garg, G., Elshimy, G., & Marwaha, R. (2021). Gender dysphoria. [Updated Jul 20, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 31, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK532313/
- Hohman, M. H. & Teixeira, J. (2021). Transgender surgery of the head and neck. [Updated Oct 18, 2021]. In: StatPearls [Internet]. Retrieved on Jan. 31, 2022 from https://www.ncbi.nlm.nih.gov/books/NBK568729/
- Leis, S.-a. (2022). Male to female price list. The Philadelphia Center for Transgender Surgery. Retrieved on Jan. 31, 2022 from http://www.thetransgendercenter.com/index.php/maletofemale1/mtf-price-list.html
- Leis, S.-b. (2022). Female to male price list. The Philadelphia Center for Transgender Surgery. Retrieved on Jan. 31, 2022 from http://www.thetransgendercenter.com/index.php/femaletomale1/ftm-price-list.html
- Li, J. S., Crane, C. N., & Santucci, R. A. (2021). Vaginoplasty tips and tricks. International Brazilian Journal of Urology: Official Journal of the Brazilian Society of Urology, 47(2), 263–273. doi: 10.1590/S1677-5538.IBJU.2020.0338. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7857744/
- Schechter, L. S. (2016). Gender Confirmation surgery: an update for the primary care provider. Transgender Health, 1(1), 32–40. doi: 10.1089/trgh.2015.0006. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685250/
- WPATH. (2012). Standards of care for the health of transsexual, transgender, and gender- nonconforming people, version 7. World Professional Association for Transgender Health. Retrieved from https://www.wpath.org/publications/soc
Dr. Steve Silvestro is a board-certified pediatrician and Manager, Medical Content & Education at Ro.