Gender reassignment surgery: what is it, how it works, recovery, cost

Many transgender individuals choose to align their bodies with their true gender identities through gender reassignment surgery. These surgeries can help relieve psychological distress and are often considered medically necessary. Many surgeries are available, and treatment is individualized depending on a person’s goals and needs. 

How does gender reassignment surgery work, what are the side effects and complications, how much does it cost, and what recovery and results can you expect? Keep reading to find out. 

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Gender reassignment surgery—also called gender affirmation surgery, sex reassignment surgery, transgender surgery, and gender confirmation surgery—refers to several procedures that change the shape and function of a person’s genitalia (and potentially face and other features) to better align with their gender identity. 

Many people choose to have these surgeries to relieve years of inner struggle with a body that does not match who they are inside. It’s estimated that there are around 1.5 million people who identify as transgender in the US (likely more), and thankfully, these surgeries are becoming increasingly common. Around 9,000 transgender surgical procedures (and counting) are performed every year (Cohen, 2019; Mani, 2021). 

Surgery is often part of a several-step process of gender affirmation. This process can include social changes (living in the desired gender role, coming out as transgender to family and friends, and changing pronoun use), legal name change, and physical changes (including changed clothing, hairstyles, and medical interventions like hormone therapy and surgery). 

A transgender person can choose whichever combination of transition steps feels right for their goals and identity, including which (if any) surgical procedures are right for them. Not all transgender people need or want surgery, though many do.

There are a few overlapping categories of gender reassignment surgery: surgery for male to female (MTF) transition and surgery for female to male (FTM) transition.

• For FTM transitions, people may choose to have “top” surgery (chest surgery for breast removal and chest masculinization) and/or “bottom” surgery (female sex organ removal and penis creation surgery). 

• For MTF transitions, people may also choose to have “top” surgery (surgery to reshape the chest and place breast implants) and/or “bottom” surgery (male sex organ removal and vagina creation surgery) (WPATH, 2012).

There are multiple surgical techniques possible for each type of surgery, and a person can develop a unique care plan with their doctor.

Vaginoplasty is the surgical creation of a vagina for a transgender woman. It also generally includes removing the penis (penile dissection) and testicles (orchiectomy). 

How it works

There are three main surgical methods of creating a vagina (Chen, 2019): 

• Using genital skin

• Using skin from an area of the body other than the genitals

• Using a portion of the intestines 

Using genital skin (the skin of the penis) is the most common method. It’s called the “penile inversion” method and is widely reported to have excellent results. It also allows a woman and her surgeon to decide what vaginal depth is right for her. Depending on what feels right for her, she can choose to have a full-depth vagina that allows for full sexual penetration or a partial- or zero-depth vagina (Chen, 2019). 

Other surgeries, like a labiaplasty (creation of a labia), vulvoplasty (creation of a vulva), and clitoroplasty (creation of a clitoris) can be a part of a vaginoplasty procedure. The surgeon can use the head of the penis to create a clitoris and skin of the scrotum to create a labia and vulva, all of which can improve the sensation of the new vagina (Chen, 2019).

Before surgery, permanent hair removal from the penis and scrotum using laser hair removal or electrolysis is very important (if this tissue is going to be used to create the vagina). Hair removal helps prevent infection and issues with hair regrowth inside the new vagina. The surgery requires an inpatient hospital stay of roughly five days, allowing trained medical staff to keep a close eye on the early healing and wound draining (Pariser, 2019).

Risks & recovery

Risks and complications with vaginoplasty using the penile inversion technique are relatively low. Most complications—problems with wound healing, rectal injury, damage to the urethra, and significant tissue death requiring follow-up surgery—occur in fewer than 5% of patients (Pariser, 2019).

After a vaginoplasty, the surgeon will prescribe therapy using vaginal dilators. Dilators promote stretching of the vaginal tissue, prevent the vagina from narrowing, and enable comfortable penetrative sex. This therapy, along with vaginal cleansing or douching, will have to be continued for the rest of the woman’s life. This may sound onerous, but it is pretty simple and important for ensuring the vagina stays healthy and functional (Pariser, 2019).

Cost

Vaginoplasty procedures tend to cost tens of thousands of dollars. However, more and more insurance companies are offering coverage for transgender health services; 97% of US insurance companies cover vaginoplasty, although only 21% cover vulvoplasty (Cohen, 2019). It’s best to speak with your insurance and the hospital or surgical practice you are considering to get a realistic sense of what the cost of surgery could be under your plan.

Breast augmentation is a surgery that many transgender women choose as part of the MTF transition. Thankfully, this procedure is more available in the US than genital reconfiguration surgery, as breast implant surgery has been widely practiced for many years in cis-gendered women (Chen, 2019). Many transwomen report that breast augmentation dramatically improves their self-image and quality of life. For many transwomen, it’s the only surgery they choose to undergo (Bekeny, 2020).

How it works

Breast augmentation for gender reassignment surgery is very similar to breast augmentation or reconstruction in cisgendered individuals: implants filled with saline, silicone, or a person’s body fat are inserted either on top of or beneath the pectoral muscles of the chest (Fardo, 2021). You can discuss with your doctor which method of breast augmentation they prefer and which is right for you. 

The contours of the chest can also be reshaped to a more feminine form using fat grafting from the buttocks and hips. Surgeons also pay close attention to minimizing scarring and ensuring correct nipple position (Bekeny, 2020). 

It’s recommended (but not required) for transgender women to undergo a year of hormone therapy before having breast augmentation surgery; this helps the chest produce as much soft tissue as possible and enhances the appearance of the augmented breasts after surgery (WPATH, 2012). 

Risks & recovery

The risk of complications with breast augmentation is low, with only 1.8% of transgender patients experiencing bleeding, wound healing issues, infection, implant leakage, and reduced sensation in the breasts and nipples (Bekeny, 2020).

Cost

Breast augmentation costs around $6,000 out of pocket in the US (Schmitt, 2016). Generally speaking, it’s still considered a cosmetic procedure, but as of 2019, nearly a third of US insurance companies covered “chest feminization” procedures for people with gender dysphoria (Cohen, 2019). If you’re considering breast augmentation for MTF transition, it’s a good idea to check with your insurance company and healthcare provider to see whether it could be covered under your plan.

Breast reduction and removal (subcutaneous mastectomy), or FTM “top” surgery, is often chosen as the first surgical step by transgender men during their transition process. It’s shown to improve the quality of life for transgender men significantly, in aspects ranging from greater self-esteem and feelings of authenticity to better sexual enjoyment (van de Grift, 2019; WPATH, 2012).

How it works

Subcutaneous mastectomy involves removing breast tissue and excess skin, flattening the shape of the chest, and repositioning the nipples on the chest to a typical and aesthetically appealing position. Surgeons strive to minimize scarring (although some scarring is inevitable), maintain nipple sensation, and reduce nipple size to a more typically masculine size. Surgeons use several different techniques, but patient satisfaction rates are high across the board (Bustos, 2021). 

Risks & recovery

Risks of the procedure are similar to other major surgeries, including bleeding and infection. However, a 2018 systematic review found that only 6% of patients had experienced problematic bleeding (a hematoma) requiring follow-up surgery (Wilson, 2018). Top surgery is an outpatient procedure, and recovery typically takes 1–2 weeks.  

Cost

Breast removal and chest masculinization surgery can be expensive out-of-pocket. Fortunately, nearly all (98%) of US health insurance companies cover it (although only 20% cover nipple-areolar complex reconstruction, which is a surgery to improve the cosmetics of the nipple size and position on the chest) (Cohen, 2019). It’s best to check with your insurance company and healthcare provider to see what your plan covers.

Phalloplasty is one method of surgically creating a penis, often part of FTM transition (it’s also done to reconstruct the penis after traumatic injury in cisgender men). There are several options and stages of this process, and your provider can tailor a care plan to your individual goals.

How it works

In phalloplasty, a new penis is created out of a person’s own skin and tissue. It’s surgically attached to the pelvis and can also be connected to the urethra so that the person can urinate standing up if they would like (Heston, 2019). 

There are two main phalloplasty techniques. The radial forearm free flap, or RFFF method, uses a flap of skin from the forearm to create the new penis. The anterolateral thigh, or ALT method, uses a flap of skin from the person’s thigh.

There are pros and cons to both of these methods. The RFFF method is usually preferred because the skin of the forearm is thin and sensitive—more similar to genital skin. This skin also has a good supply of nerves and blood vessels (so there is better blood flow and tactile sensation in the penis). The phalloplasty can usually be completed in only one or two surgeries with the RFFF method. However, it does leave a large and identifiable forearm scar, which some people don’t want (Van Caenegem, 2013).

In this case, the ALT method may be an option. Since it uses skin from the thigh, the “donor site” scar is easier to conceal. It can also create a larger penis with slightly firmer tissue, which some people may prefer. However, the thigh's nerve and blood vessel supply are not as abundant as the forearm. There is often a lot of fatty tissue, so the penis can have less tactile sensitivity and usually requires follow-up surgery to decrease its size. More follow-up surgeries are necessary with the ALT method than the RFFF method (Chen, 2019).

Phalloplasty usually involves removal of some or all of the female sex organs, including the vagina (called a vaginectomy), uterus (a hysterectomy), and ovaries (an oophorectomy). A patient may also have a phalloplasty without removing these organs. If you choose a hysterectomy or oophorectomy, it must usually be completed before the surgery to allow your body time to recover before the phalloplasty (Carter, 2020). 

Follow-up surgeries are often done to create a scrotum, correct issues with the urethra, improve penis aesthetics and create a glans (head of the penis), or place prosthetics that enable erections and sexual function (Chen, 2019).

Risks & recovery

Recovery from phalloplasty takes up to 12 weeks. There’s usually a five-day hospital stay, where your healthcare team will closely monitor you to watch for complications and to make sure the new penis has good blood flow. 

Recovery at home takes 4–12 weeks, with weekly home visits from a healthcare provider for the first month or two. You’ll have a catheter in the urethra for the first week, then a catheter above the pubic bone for three weeks until you begin urinating normally. For at least the first month, you should limit big movements and all physical strain, even excessive walking and lifting. It’s also important to avoid bending deeply at the waist or putting pressure on the new penis (Carter, 2020).

Phalloplasty carries a significant risk of complications, although most patients are still pleased with the results of their surgery and would choose to do it again (Papadopulos, 2021). Most patients have minor complications immediately following surgery (things like pain, bleeding, skin issues, and UTIs), and about a third of patients experience a significant complication and need corrective surgery. These include strictures and fistulas (abnormal narrowing or holes) in the urethra, tissue death of the new penis, wound breakdown, and lack of sensation (Ascha, 2018; Santucci, 2018).

Cost

Phalloplasties tend to cost several tens of thousands of dollars when paid for out of pocket. However, thanks to the Affordable Care Act and increasing awareness of transgender health needs, 95% of US insurance companies cover phalloplasty, and 60% cover penile prosthesis (Baker, 2017; Cohen, 2019). It’s a good idea to speak with your insurance company and the hospital or surgical practice you are considering to get a realistic sense of what the cost could be.

Metoidioplasty is another method of surgically creating a penis and is only done in a person with female anatomy (so, unlike phalloplasty, it isn’t a method of penis reconstruction used in cisgendered men).

How it works

In a metoidioplasty, a small penis is built using tissue from a person’s clitoris. During the surgery, the clitoris is “released” and extended outward. Other genital tissue from the person’s labia is used to build up a penis. Patients often opt for scrotoplasty as well, in which a small scrotal pouch is created from the labia. The procedure is completed in a single surgery unless the person has a complication or wants a later surgery for testicular implants (Chen, 2019). 

As with a phalloplasty, a person can choose to reconstruct the urethra to try and enable urination while standing. However, the success of this can vary depending on how large the penis is; sometimes, they are too small to realistically enable urination while standing (Chen, 2019). Surgeons usually recommend that a person undergo masculinizing hormone therapy for at least a year before surgery, as this helps enlarge the clitoris as much as possible (Jolly, 2021).

Because they use clitoral tissue (rather than tissue from a donor site elsewhere on the body), the ability to have spontaneous sexual blood flow usually enables the man to have erections. However, because the penis created in a metoidioplasty is small, it’s not a guarantee that he’ll be able to penetrate a partner during sex (though most people can) (Jolly, 2021; van de Grift, 2019).

Risks & recovery

The risks of metoidioplasty are much lower than with a phalloplasty since it’s a less complex surgery. There are also no donor sites that need to heal, and reconstruction with the urethra tends to be less complicated because the penis shaft is shorter (Chen, 2019). 

Metoidioplasty patients are usually discharged on the same day or watched overnight; the surgery rarely requires a long hospital stay. Recovery lasts for several weeks, and the patient is encouraged to walk gently but often. Some swelling of the penis and drainage is to be expected.

The main complications to watch out for are issues with urination. Fortunately, although about 25% of patients experience urethral complications, most of these resolve on their own and don’t require follow-up surgery (Chen, 2019). 

Cost

Metoidioplasty procedures tend to cost ten thousand dollars or more out-of-pocket (though typically less than phalloplasty because the surgery is less complicated). Fortunately, 93% of US health insurance companies cover metoidioplasty. You can speak with your insurance company and the hospital or surgical practice you are considering to get a realistic sense of costs.

Before undergoing any surgery, it’s important to understand what to expect fully. With gender reassignment surgery, in particular, there are many considerations since it’s such a complex set of procedures with so many emotional, physical, and social implications. Here are some key things to be aware of as you embark on this journey: 

Setting goals and expectations

Having a candid, honest talk with your healthcare provider about what you want from surgery and your risk tolerance can help increase the likelihood of having a satisfying and successful experience. Your provider can help make sure you have a good support system and realistic expectations about things like sensation, orgasm, and sexual pleasure. When these open discussions happen, rates of post-surgery disappointment are extremely low—a 2021 systematic review of nearly 8,000 patients found the rate of regret to be only 1% (Bustos, 2021; Garg, 2021). 

Fertility

It’s also important to discuss fertility with your doctor ahead of time. If there’s a chance you may want the option of having biological children but still want to have sex organ removal during your surgery, you can consider fertility preservation options (like freezing your sperm or egg freezing) (Garg, 2021; WPATH, 2012).

Access to care providers

Gender-affirming surgery is becoming increasingly common, but unfortunately, few providers around the country have the skills and sensitivity to manage transgender care (Mani, 2021). If you have to travel out of town to seek gender-affirming surgery, it can be a good idea to try to find any care providers in your local area who specialize in transgender health issues to help guide your follow-up care if need be.

Hidden costs

Hidden costs are another major issue for transgender individuals seeking to transition with surgery. Certain hormone treatments, sperm and embryo freezing, and surgeries can be prohibitively expensive if insurance does not cover any part of the cost. Distance from trained providers can also be an issue; few surgeons are experienced in gender reassignment surgery, so seeing them can be costly and time-intensive (WPATH, 2012).

Gender reassignment surgery can be complex and overwhelming. There is a lot of information out there and many options to consider. But by taking it one step at a time and seeking support from family, friends, and community support groups, it can be an invaluable step in helping a transgender person live in a way that is true to who they are. 

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Current version

February 10, 2022

Written by

Nancy LaChance, BSN, RN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.