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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

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Should gender reassignment surgery be preceded by a waiting period?

(Shutterstock Image)

Many surgeons require people who want to undergo gender reassignment surgery to live through a waiting period and to bring documentation from a therapist. 

It’s impossible to know exactly how many transgender people want to have surgery to change their bodies and align with the gender with which they identify. But it’s not a stretch to guess that they are having trouble getting the procedure covered by their insurance company, or that they simply can’t find a doctor to do the surgery.

Therapists Julia Gottlieb and Jasper Liem work at Philadelphia’s Mazzoni Center and spend a lot of time helping transgender people navigate the sometimes rocky shore of gender reassignment.

Most surgeons require, at minimum, a letter from a licensed therapist confirming that the person requesting gender reassignment surgery has sought counseling and been deemed able to have the procedure. Surgeons in some states require people to have lived in the gender they intend to transition to for as long as two years.

Unfair, says Gottlieb.

“I see this as another way to marginalize a population,” she says. “If you think about it, there are a lot of plastic surgeons out there that trust that if somebody’s coming into their office and they’re saying, ‘Hey, I have agency over my body, I know what decisions I want to make to medically change my body’—like breast augmentation or rhinoplasty—that those surgeons are saying, ‘We need you to prove who you actually say you are.'”

Lieb says this double standard can put those hoping to transition in a precarious position.

“For trans folks, a lot of times, it’s not realistic to have that one year of living in the gender you identify as,” agrees Liem. “So, in plenty of states—Virginia, for example—you can still get fired for being trans. So even though we do see a lot of progress, that doesn’t necessarily mean we’re safe to follow those protocols.”

When pressed how she would solve this issue, Gottlieb simply responds that people should be able to make choices about their bodies freely.

“I’m a firm believer that a person is their own best expert,” she says.

In our interview with Julia Gottlieb and Jasper Liem, they mention the 2015 U.S. Trans Survey . If you want to participate, you can find it here .

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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.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

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 gender and their assigned sex at birth.   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 their true gender.  

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 limit access to gender affirmative procedures.

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 their gender 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.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & 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 assigned female sexual characteristics and an increase in assigned 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 assigned male sexual characteristics and an increase in assigned 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  
• 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 for 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 a 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

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

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

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

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 transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people 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 tend to be 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 can be diagnosed with 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 precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

Transgender Health Program

Gender-affirming surgery.

OHSU surgeons are leaders in gender-diverse care. We provide specialized services tailored to the needs and goals of each patient. We offer:

• Specialists who do hundreds of surgeries a year.
• Plastic surgeons, urologists and other specialists who are leading experts in bottom surgery, top surgery and other gender-affirming options.
• Vocal surgery with a highly trained ear, nose and throat doctor.
• Peer volunteers who can provide support during visits.
• Welcoming care for every patient, every gender and every journey.

Our surgical services

We offer many gender-affirming surgery options for transgender and nonbinary patients, including options within the following types. We also welcome you to request a procedure that isn’t listed on our pages.

Top surgery:

• Gender-affirming mastectomy
• Gender-affirming breast augmentation

Bottom surgery:

• Phalloplasty and metoidioplasty , including vagina-preserving options
• Vaginoplasty and vulvoplasty , including penile-preserving options

Hysterectomy

Genitoplasty, oophorectomy, orchiectomy.

Bottom surgery options also include:

• Scrotectomy
• Scrotoplasty
• Urethroplasty
• Vaginectomy

Additional gender-affirming options:

• Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

• Steps to surgery
• WPATH standards of care
• The letter of support needed for some surgeries

For patients

Request services.

Please fill out an online form:

• I am seeking services for myself.
• I am seeking services for someone else.

Other questions and concerns

Contact us at:

• 503-494-7970
• [email protected]

Refer a patient

• Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
• Learn more on our  For Health Care Professionals  page.

At OHSU, our gynecologic surgeon, Dr. Lishiana Shaffer, specializes in hysterectomies (uterus and cervix removal; often combined with oophorectomy, or ovary removal) for gender-diverse patients. She does more than 150 a year.

We also offer a Transgender Gynecology Clinic with a gender-neutral space. Services include surgery. Referrals and appointments are made through the OHSU Center for Women's Health, though the space is not in the center. Call 503-418-4500 to request an appointment.

Some patients choose hysterectomy to:

• More closely align their bodies with their gender identity.
• With ovary removal, to remove a main source of the hormone estrogen.
• To end pain caused by testosterone therapy that shrinks the uterus.
• To end the need for some gynecologic exams, such Pap smears.

Preparation: We usually recommend a year of hormone therapy first, to shrink the uterus. We don’t require a year of social transition.

How hysterectomy is done

Most often, we use a minimally invasive laparoscope and small incisions in the belly. We usually recommend removing fallopian tubes as well, to greatly reduce the risk of ovarian cancer.

Most patients spend one night in the hospital. Recovery typically takes about two weeks. You’re encouraged to walk during that time but to avoid heavy lifting or strenuous exercise.

Considerations and risks

Hysterectomy is usually safe, and we have a low rate of complications. Risks can include blood clots, infection and scar tissue. Because of a possible link between hysterectomy and higher risk of cardiovascular disease, your doctors may recommend regular tests.

Removing the uterus also ends the ability to carry a child. OHSU fertility experts offer options such as egg freezing before treatment, and connecting patients with a surrogacy service.

OHSU offers genitoplasty to create a gender-neutral look in the groin area.

This surgery may include:

• Removing the penis (penectomy)
• Removing the testicles (orchiectomy)
• Reducing or removing the scrotum (scrotectomy)
• Shortening the urethra
• Removing the uterus (hysterectomy)
• Removing the vagina (vaginectomy)

The procedure takes several hours. Patients can expect to spend one to two nights in the hospital. Recovery typically takes six to eight weeks. Patients are asked to limit walking and to stick to light to moderate activity for four weeks. They should wait three months before bicycling or strenuous activity.

Genitoplasty cannot be reversed. Risks can include:

• Changes in sensation
• Dissatisfaction with the final look
• Healing problems

Removing the penis and testicles or the uterus also affects the ability to conceive a child. OHSU fertility experts offer options such as freezing eggs and connecting patients with a surrogacy service.

Having a gynecologic surgeon remove one or both ovaries is often done at the same time as a hysterectomy. We do nearly all these surgeries with a minimally invasive laparoscope and small incisions in the belly.

Most patients spend one night in the hospital and return to their regular routine in about two weeks.

The ovaries produce estrogen, which helps prevent bone loss and the thickening of arteries. After removal, a patient should be monitored long-term for the risk of osteoporosis and cardiovascular disease.

We encourage patients to keep at least one ovary to preserve fertility without egg freezing. This also preserves some hormone production, which can avoid early menopause.

At OHSU, expert urologists do orchiectomies (testicle removal). Patients may choose this option:

• To remove the body’s source of testosterone
• As part of a vaginoplasty or vulvoplasty (surgeries that create a vagina and/or vulva)
• To relieve dysphoria (some patients choose only this surgery)

Removing the testicles usually means a patient can stop taking a testosterone blocker. Patients may also be able to lower estrogen therapy.

How orchiectomy is done

The surgeon makes an incision in the scrotum. The testicles and the spermatic cord, which supplies blood, are removed. Scrotal skin is removed only if the patient specifically requests it. The skin is used if the patient plans a vaginoplasty or vulvoplasty.

You will probably go home the same day. Patients can typically resume normal activities in a week or two.

Reducing testosterone production may increase the risk of bone loss and cardiovascular disease, so we recommend regular tests. Without prior fertility treatment, orchiectomy also ends the ability to produce children. Serious risks are uncommon but include bleeding, infection, nerve damage and scarring.

Adam’s apple reduction (laryngochrondoplasty)

Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins University.

Laryngochrondoplasty is also known as Adam’s apple reduction or a tracheal shave (though the trachea, or windpipe, is not affected).

A surgeon removes thyroid cartilage at the front of the throat to give your neck a smoother appearance. This procedure can often be combined with facial surgery.

Thin incision: At OHSU, this procedure can be done by an ear, nose and throat doctor (otolaryngologist) with detailed knowledge of the neck’s anatomy. The surgeon uses a thin incision, tucked into a neck line or fold. It can also be done by one of our plastic surgeons, typically with other facial surgery.

In an office or an operating room: Our team can do a laryngochrondoplasty in either setting, which may limit a patient’s out-of-pocket expenses.

OHSU also offers Adams’ apple enhancement surgery.

Many patients find that hormone therapy and speech therapy help them achieve a voice that reflects their identity. For others, vocal surgery can be added to raise the voice’s pitch.

Voice therapy: Patients have voice and communication therapy before we consider vocal surgery. Your surgeon and your speech therapist will assess your voice with tests such as videostroboscopy (allowing us to see how your vocal cords work) and acoustic voice analysis.

Effective surgery: We use a surgery called a Wendler glottoplasty. It’s done through the mouth under general anesthesia. The surgeon creates a small controlled scar between the two vocal cords, shortening them to increase tension and raise pitch. Unlike techniques that can lose effectiveness over time, this surgery offers permanent results.

Hormone therapy can bring out desired traits, but it can’t change the underlying structure or remove hair follicles. Our highly trained surgeons and other specialists offer options. Patients usually go home the same day or spend one night in a private room.

Face options:

• Browlift (done with the forehead)
• Cheek augmentation
• Chin surgery (genioplasty), including reductive, implants or bone-cut options
• Eyelid surgery
• Face-lift, neck lift
• Forehead lengthening
• Forehead reduction, including Type 3 sinus setback and orbital remodeling
• Hairline advancement (done with the forehead)
• Jawline contouring
• Lip lift and/or augmentation
• Lipofilling (transferring fat using liposuction and filling)
• Nose job (rhinoplasty)

Body options:

Hormone treatment may not result in fat distribution consistent with your gender. We offer liposuction and fat grafting to reshape areas of the body.

Transgender Australians waiting years for gender-affirming surgery, as Medicare bid looms

By Ashleigh Barraclough

Topic: Surgery

Navigating the health system added extra challenges to Abbie Clark's transition process. ( Supplied )

• In short: Only a handful of Australian surgeons offer certain gender-affirming procedures, meaning transgender people are waiting for years or seeking options overseas
• What's next? An application has been made to list gender-affirming surgeries as specific Medicare items, to help address high costs and low availability

For trans woman Abbie Clark, feelings of gender dysphoria have been coming and going since she was a kid.

She didn't initially know what it meant to be trans, but she knew she would rather be a woman than a man.

"When I wanted to transition, I didn't know where to go," the 30-year-old Ballarat woman said.

"I didn't know what service I needed to look at, I didn't know who I needed to talk to."

Abbie Clark underwent life-changing gender affirmation surgery in Melbourne last year. ( Supplied )

Ms Clark had surgery on Trans Day of Visibility last year, three years after starting hormone treatment and a year-and-a-half after her consultation with the surgeon.

Transgender Australians are spending years waiting for gender-affirming surgery, which is still required in some states to change birth certificate gender markers.

Gender-affirming surgery refers to a variety of procedures, including mastectomies, breast augmentation, facial feminisation and vocal chord surgery, as well as genital surgery.

Genital surgeries, such as vaginoplasty (creation of a vagina) and phalloplasty (creation of a penis), are known in the trans community as bottom surgeries.

Doctors in the field and trans people say there are only five Australian surgeons regularly performing these procedures. 

Ms Clark's out-of-pocket surgery costs were $25,000, which would have been much higher had she not had private health insurance, which covered around $15,000 in hospital expenses.

Abbie Clark feels relieved after having had surgery and changing her identification documents. ( ABC Ballarat: Laura Mayers )

Medicare contributed about $2,000 to the surgeon's fees.

"A lot of it's considered cosmetic. It's not, because in many cases, it is literally life-changing," Ms Clark said.

Now, for the first time, an application has been made to the commonwealth health department to list gender-affirming procedures on Medicare by the Australian Society of Plastic Surgeons. 

Trans people, surgeons and advocates argue a better system of public funding for the surgeries could cut costs for patients and hospitals, as well as address availability concerns.

Australia 'behind other countries' on gender-affirming care

The president of the Australian Society of Plastic Surgeons, Nicola Dean, said the society made the Medicare application to the Department of Health as part of a collaborative effort with trans organisations and other health professionals to improve access to the surgery.

Dr Dean said this could incentivise more surgeons to join the field and provide better data on how many surgeries were taking place in Australia.

"A lot of it goes on a bit under the radar," she said.

"I think Australia is really quite behind other countries."

Nicola Dean gender-affirming surgeries in Australia can't be properly tracked because they're not on Medicare. ( ABC News: David Frearson )

A Department of Health spokesperson confirmed it had received an application requesting the Medical Services Advisory Committee (MSAC) consider publicly funding gender-affirmation surgery and consultations under Medicare.

The department is currently considering if the request is suitable to be considered by MSAC.

A spokesperson said some Medicare rebates were already available "if the services are deemed by the treating practitioner to be clinically relevant to the care of their patient".

Surgeons have told the ABC the lack of specific Medicare item numbers for gender-affirming surgeries means costs are unpredictable and not transparent, and some procedures aren't covered.

In 2021, a petition to federal parliament for gender-affirming surgery to be included on Medicare gained nearly 150,000 signatures — the fifth most-signed petition on the Australian parliament website.

Surgeons inundated with hundreds of booking requests

Clinical guidelines written by the Royal Children's Hospital Melbourne and endorsed by the Australian Professional Association for Trans Health (AusPATH)  advise delaying genital surgery for trans people until adulthood . Surgeons spoken to by the ABC said they would only perform bottom surgeries for people over the age of 18.

Kieran Hart, a surgeon at ACT Urology in Canberra, said he had been swamped with requests for vaginoplasty and orchiectomy (removal of testicles) procedures. 

In Dr Hart's first year in 2018, he performed three gender-affirming surgeries. Last year, he did 60.

He has about 150 people booked in for surgery, and 100 for consultations. His waiting list has only recently reopened.

"There's been hundreds who have been trying to get consults while I closed the books for a while," he said.

Kieran Hart says demand for gender-affirmation surgeries is rising exponentially. ( Supplied )

The wait time is around two years, and about 90 per cent of his clients come from interstate.

He said private hospitals doing gender-affirming surgery "almost lose money" because the procedures were not listed on Medicare, meaning surgeons have to use different item numbers that   don't quite line up with the procedure.

But Dr Hart said seeing the outcomes for trans women made it some of the most rewarding work a surgeon could do.

"It's just quite remarkable how resilient they are, but also what difference you make to their happiness and mental health," he said.

Advocates point to numerous studies which back the mental health benefits of gender-affirming surgeries for adults.

In a 2014 peer-reviewed study of 188 trans Australians, the 42.5 per cent of respondents who had undergone gender-affirming surgery reported higher levels of physical and mental health than those who had not had surgery . The difficulties in accessing surgery in Australia mean post-surgery survey sample sizes tend to be small.

A peer-reviewed analysis of the 2015 US Transgender Survey , which had 27,715 respondents, found the 13 per cent who had undergone gender-affirming surgeries in the preceding two years experienced a 42 per cent reduction in psychological distress and a 44 per cent reduction in suicidal ideation, compared to those who desired surgery but had not had it.

Not all trans people wish to undergo surgery, and for many of those who do, it is not financially viable — with nearly all surgeries taking place in the private system due to state government policy settings on elective surgery.

For trans men, getting a phalloplasty in Australia is even more difficult, with only two surgeons offering the procedure.

One is Brisbane-based Dr Hans Goossen, whose new patients might expect to wait six to 12 months for an initial consultation.

After completing surgical training in urology and reconstruction, he spent two years overseas learning the skills to do gender-affirming surgeries.

"It's still a relatively new field in Australia," he said.

"Until recently, most patients had to travel overseas."

Bottom surgeries for trans men include metoidioplasty and phalloplasty.

An insured patient might expect to pay $80,000 out-of-pocket, for what is a complicated and lengthy series of three or more operations. This includes costs associated with the surgery, anaesthetic, hospital stay, preparation and recovery.

"I understand people's frustration with the fact that it's currently not available in the public hospital system, and that it costs a lot of money and it's therefore not affordable for everyone," he said.

Dr Goossen wants to see federal or state governments fund a certain amount of surgeries per year, like in New Zealand , reducing the need for patients to spend tens of thousands of dollars on the procedures.

Another surgeon, David Caminer, started regularly performing phalloplasty and vaginoplasty procedures this year at his practices in Sydney and Wollongong.

Dr Caminer said even if the procedures ended up being listed on Medicare, patient costs would still be high due to Medicare not keeping up with inflation.

"The only way to get it cheaper, or for nothing, is to do it through the public hospitals," he said.

He said some private hospitals were religious, and did not permit gender-affirming surgeries to be performed or taught there.

"They won't allow you to do it, because it's not really keeping with their religious belief," he said.

After a religious hospital told Dr Caminer he could not perform a phalloplasty on a patient there, he's struggled to find another hospital with an intensive care unit to do the procedure. The patient has pre-existing health conditions so would require close monitoring.

"There's not that many intensive care units in the private sector," he said.

"It's taking me a lot of time and effort, we're still trying."

Official training and support needed, surgeons say

To address the surgeon shortage, Dr Hart said the relevant medical societies and colleges could do more to introduce trainees to gender dysphoria theory and basic gender-affirming procedures.

"The College of Surgeons, we don't have a formalised training pathway for it at this point in time," he said.

"It's not really recognised in the curriculums for the Urological Society or the plastic surgeons' society."

A spokesperson the Royal Australasian College of Surgeons (RACS) said gender-affirming surgery was complex and required multidisciplinary consultation.

"While RACS supports the training of gender-affirmation surgery, it is important to note that the limited number of cases and the highly specialised nature of this field requires specific focus for a limited number of surgeons," they said.

Trans advocates say reforms are needed to make gender-affirming surgery a viable option for more people. ( AP: Frank Franklin )

Dr Dean from the Australian Society of Plastic Surgeons said in conjunction with RACS, her organisation provided plastic and reconstructive surgery training which was applicable to gender-affirming surgery, but there should be funding to send surgeons overseas to learn.

"We do have the basics of how to do the genital surgery, but it does need expertise to be built up," she said.

"And I think that it will take quite some time for people to learn off the few Australian surgeons that are doing this surgery."

Thailand a better option for some trans Australians

About one in five patients access their superannuation to pay for surgery at Dr Hart's clinic, he said.

Sav Zwickl, a director with AusPATH, said this could put a financial strain on trans people.

"They spend years saving for surgery, and there's often no option but to access their super and, of course, that has long-term implications down the road for their financial situation," the researcher, who is trans and non-binary, said.

Sav Zwickl says trans people struggle with employment discrimination and so often access their super early to pay for surgery. ( Supplied )

Dr Zwickl said many trans people went to Thailand for surgery, where surgeons were generally "very skilled and experienced in performing gender-affirming surgeries".

"That's a case of a lack of surgeons [in Australia], but also some procedures that people are looking for are not available in Australia at all," they said.

Anne *  went to Thailand for her bottom surgery in 2012, after being quoted $30,000 for surgery in Australia.

"Surgery in Thailand was a lot more affordable than what it was in Australia," she said.

"Thailand has been performing these surgeries over there for thousands of trans women for decades."

To fund the surgery and overseas trip, she spent more than two years living in financial hardship.

Without surgery, she wouldn't have been able to change her gender marker on her Queensland birth certificate, a requirement that only changed in June.

"I wanted to make sure that all my legal documentation was consistent," she said.

"Without having a birth certificate and official documentation, you're always having to explain yourself."

New South Wales and Western Australia are the only states still requiring gender diverse people to undergo medical procedures to update their birth certificate gender marker.

In WA, a "gender reassignment board" judges applications by trans people to change their gender, although the state is in the process of repealing these laws.

Surgery and the approval of a panel is required to legally change gender in NSW, but a spokesperson for the attorney-general said during the election campaign, Labor had committed to reviewing the legislation in consultation with trans and gender diverse communities.

The spokesperson said work had not yet started on reviewing the legislation.

Post surgery and legal recognition, life's a bit easier

Anne said she had no regrets about her decision to get surgery.

"It stopped the gender dysphoria, the thoughts of self-harm and suicide that I was experiencing," she said.

It's not lost on her that many trans people struggle to access surgery, but she's grateful to have a body she feels more at home in.

"I finally felt complete," Anne said. 

Ms Clark can breathe a sigh of relief having overcome the hurdles of surgery.

"I've honestly never been happier, now that it's finally all sorted," she said.

"I occasionally catch places where I've forgotten to change my name, but by and large, it's so simple now."

*Name has been changed.

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Center for Transgender Health

• Surgical Care

Gender-affirmation Surgery

The gender surgeons at the Brigham and Women's Center for Transgender Health have extensive expertise performing advanced gender-affirming surgery. Our team uses the latest medical technology to ensure optimal outcomes. This includes virtual surgical planning tools, custom implant design and tissue engineering.

As leaders in research as well as clinical care, our surgeons provide innovative treatment options designed to meet every patient's individual needs and goals. We have the experience and skills to perform even the most complex gender surgery, including complicated revision surgery.

Customized Surgical Treatment

We work with patients to create a treatment plan designed to meet their gender surgery objectives rather than provide one-size-fits-all solutions.

We use the most advanced technology to provide natural-looking results with the best possible functionality. Our surgeons use the latest in 3D technology, tissue engineering and biomedical engineering to create customized surgical approaches tailored for each patient’s anatomy and goals. This allows us to provide the best possible outcome.

Before surgery, we work with you by guiding you through the process of establishing surgical readiness with physical and mental health evaluations.

No matter what kind of treatment you seek, our surgeons are here for you. We provide a spectrum of gender-affirming surgical treatments, including the following:

• Top surgery : Eliminating or enhancing the shape, size and appearance of the chest through mastectomy or augmentation
• Vaginoplasty : Constructing a vagina and external female genitalia using penile or other tissue
• Phalloplasty: Constructing a penis and urethra using tissue from a donor site
• Metoidioplasty : Constructing a penis using existing genital tissue
• Facial gender surgery (facial feminization/facial masculinization): Using various surgical techniques and reconstruction procedures, including contouring, augmentation and implantation, to reshape the bones and soft tissues of the face
• Orchiectomy: Removal of the testes
• Hysterectomy/oophorectomy: Removing the uterus and/or ovaries
• Vocal cord surgery : Changing the tone or pitch of the voice through modification of the vocal cords
• Revision surgery: Repair or correction of complications after gender-affirming surgeries performed at other institutions

Contact the Center for Transgender Health

To schedule an appointment with a physician in the Center for Transgender Health, please contact our patient coordinator at: 617-732-5303 or email us at: [email protected] .

If you are a physician seeking to refer a patient to the Center for Transgender Health, please call 617-732-5303 . To contact one of our physicians with a question, patient referral or second opinion, you may also email: [email protected] .

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• Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Removal of the penis, called penectomy.
• Removal of the testicles.
• Creation of a vagina, called vaginoplasty.
• Creation of a clitoris, called clitoroplasty.
• Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Tummy tuck, called abdominoplasty.
• Buttock lift, called gluteal augmentation.
• Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

• Significant medical conditions that haven't been addressed.
• Behavioral health conditions that haven't been addressed.
• Any condition that limits your ability to give your informed consent.

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

• Delayed wound healing
• Fluid buildup beneath the skin, called seroma
• Bruising, also called hematoma
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Alternatives to surgery
• Expectations and goals
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• A review of your vaccinations
• Screening tests for some conditions and diseases
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
• Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

• Gender identity
• Gender dysphoria
• Mental health concerns
• Sexual health concerns
• The impact of gender identity at work, at school, at home and in social settings
• The role of social transitioning and hormone therapy before surgery
• Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
• Support from family, friends and caregivers
• Your goals and expectations of treatment
• Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead
• Enlarging the lips and cheekbones with implants
• Reshaping the jaw and chin
• Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

• Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

• Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

• Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

• Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other 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. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That 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, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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Gender-Affirming Surgery (Top Surgery)

Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as “top surgery" and "bottom surgery.” Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their appearance to align with their internal identity. If, after a consultation with our doctors, you decide to pursue top surgery, we work toward a positive outcome that improves your physical, emotional, and psychological well-being.

What You Should Know About Gender-Affirming Surgery

Choosing to pursue gender-affirming surgery is an individual, personal decision. You’ll want to consider how it will change your quality of life and how it will help you achieve your goals.

Gender Dysphoria One important step is understanding how much you are affected by gender dysphoria, a diagnosis that the American Psychiatric Association defines as a conflict between your physical or assigned gender and the gender with which you identify. 

Candidates for Top Surgery To be a candidate for top surgery, you must:

• Be 18 or older
• Be in good health without illness or a condition that can increase your risk of surgical complications
• Have a BMI under 35
• Provide a clearance letter from your mental health or primary care provider stating you have gender dysphoria and you have been living in your assigned gender for at least 12 months

Top Surgery Costs Some private insurance plans will cover transgender surgery when it is used to address a diagnosis of gender dysphoria. Check with your insurance plan to determine your coverage.

Understanding Which Top Surgery Is Right for You There are several approaches to transgender surgery. We will review these with you during your initial consultation and make a recommendation based on your physical exam and medical history.

You May Have Scars Your surgeon will use the natural contours of your breasts to minimize scarring as much as possible. In some cases, depending on your breast size and weight, a small bunching of tissue may result in scars known as “dog ears” following mastectomy. These can be corrected later with revision surgery.

Understand the Risks Top surgery carries the same risks as other standard surgeries. These include the risk of bleeding and infection and risks associated with general anesthesia. Your doctor will discuss these risks with you if surgery is recommended.

Initial Consultation and Tests

Consultation and Exam Your first step will be an in-person consultation. Our providers spend time meeting with you, evaluating your anatomy, answering your questions, and determining if this surgery will help you achieve your goals.

Your surgeon will review your family history, general health status, lifestyle habits such as smoking, previous operations, any medications you may be taking, and conditions that can put you at risk for surgery.

Measurements, Photographs, Tests Your breasts will be measured and assessed for size and shape, and photographs may be taken for your medical record. Before treatment is recommended, you will also undergo one or more of the following tests.

• Blood tests may be necessary to evaluate your hormone levels. Pre-surgical testing also requires several blood tests to assess your liver and kidney function and to determine if you have a previously undetected infection, blood disorder, or anemia.
• A mammogram may be performed to look for any underlying breast abnormalities. Additional imaging, including ultrasound and MRI, may also be requested.

Recommending Treatment Based on these findings, your surgeon will recommend an approach to surgery. She will discuss the expected outcome, potential risks and complications, and your post-operation recovery. Alternatively, your surgeon may recommend that you lose weight, quit smoking, or discontinue medication before surgery to ensure you experience the best possible outcome.

If You Take Hormone Therapy Some gender-affirming hormone therapy , such as testosterone, can be continued if you pursue transgender surgery. Others, such as anti-estrogen therapy, may be stopped. Your surgeon will explain what you need to do to prepare for surgery.

Top Surgeries

Chest reconstruction - mastectomy, breast reduction.

We use different approaches to remove breast tissue and contour breasts to appear more masculine. The right approach depends on your anatomy and the size of your breasts. Techniques for medium to large breasts include nipple-sparing, double incision, buttonhole, and inverted-T incision. Keyhole and peri-areolar techniques may be used for smaller breasts or for those with good skin elasticity. Your surgeon will discuss your options with you after your physical exam and consultation.

Breast Augmentation

There are also many different approaches to breast augmentation, including the use of implants and fat grafting. We can also combine breast augmentation with body contouring, liposuction, and neurotoxin injections such as Botox injections and dermal fillers.

The Procedure Length

On average, top surgery takes about two to three hours and is performed under general anesthesia in an outpatient ambulatory surgery center. In some case, an overnight stay may be required. Sometimes a second procedure is needed to further tighten skin and achieve optimal cosmetic results.

Your chest will be wrapped in bandages, and a compression chest vest or surgical bra will be worn after the procedure. Drains will be required after mastectomy but not after breast augmentation. Initial recovery takes about one week. It may take three to six months for all swelling to subside and scars to fade.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 10 pediatric specialties by U.S. News & World Report for 2024–2025.

Why Choose Duke

You'll Work With a Plastic Surgeon Experienced in Gender Affirmation Surgery Our plastic surgeon has worked with many individuals seeking gender confirmation surgery. She is fellowship trained in body contouring, which means she has completed additional training in procedures that improve the body shape. Our surgeon is also a member of the World Professional Association for Transgender Health (WPATH), a nonprofit organization working to standardize and improve transgender care.

Duke Health Is Committed to the LGBTQ+ Community Duke Health values diversity and has taken many steps to show its commitment to eliminating discrimination, promoting equality, and standing beside our lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital are recognized as LGBTQ+ Healthcare Equality Leaders by the Human Rights Campaign Foundation for perfect scores across areas of patient-centered care, support services, and inclusive health insurance policies for LGBTQ+ patients.

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Expert Commentary

What the research says about hormones and surgery for transgender youth

Researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of gender-affirming medical treatment for transgender youth.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by Chloe Reichel, The Journalist's Resource August 7, 2019

This <a target="_blank" href="https://journalistsresource.org/politics-and-government/gender-confirmation-surgery-transgender-youth-research/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

In the interest of examining this important news topic through a research lens, Journalist’s Resource collaborated on this story with The Burlington Free Press,  where it first appeared .  This piece is part of the newspaper’s series of stories about transgender youth  in the state.

As Vermont regulators consider changes to Medicaid that would expand access to gender confirmation surgery for transgender youth, researchers and physicians point to a growing body of peer-reviewed academic scholarship in support of the new proposal.

Among other changes,  the proposed rules would eliminate the requirement that transgender individuals on Medicaid must wait until the age of 21  to receive surgery. Individuals over the age of 18 and minors — with informed parental consent — would be eligible.

Such changes are in line with current thinking among academics and physicians in the field. It’s still a fledgling field, as Marci Bowers, a California-based gynecologist and surgeon who specializes in gender confirmation and serves as a professorial lecturer at the Icahn School of Medicine at Mount Sinai points out.

“Kids are coming out very young. A generation ago, they were driven into the closet,” Bowers said. “It’s only these last 20 years or so where instead of that happening, people are getting professional help.”

How common are gender confirmation surgeries in the U.S.?

Estimates suggest that in the U.S., between 2000 and 2014, 10.9% of inpatient visits for transgender people involved gender confirmation surgery. This figure comes from  an analysis of inpatient visits for a nationally representative sample that includes, but is not limited to, transgender patients, which was published in 2018 in the medical journal JAMA Surgery . Over the study period, the number of patients who sought gender confirmation surgery increased annually.

Further, the percentage of gender confirmation surgeries that are “genital surgeries” — commonly referred to as bottom surgeries — has increased over time. Between 2000 and 2005, 72% of gender confirmation surgeries were bottom surgeries; from 2006 to 2011, that number increased to 84%. And the number of patients insured by Medicare or Medicaid seeking these procedures increased threefold between 2012-2013 and 2014.

As societal acceptance of gender diversity has grown, medical thinking has changed, too, Bowers notes.

“At least in the academic circles, in the medical circles, we realize that yes, it’s valid, that yes, kids do better after treatment, yes, surgery is appropriate, and why wait till 21?” Bowers said. “That’s really completely arbitrary. In fact, it’s probably cruel.”

“Most of the research is on older patients,” Elizabeth Boskey, a social worker at the Center for Gender Surgery at Boston Children’s Hospital and co-author of several research papers on gender confirmation gender-affirming surgery in youth, notes. “But there is evidence in the literature about just overall improved health, reduced anxiety, increased ability to function, for individuals after they have these gender-affirming surgeries.”

What does research say about treatment of transgender youth?

A  review of the latest research on gender-affirming hormones and surgery in transgender youth , published in a June 2019 edition of The Lancet Diabetes & Endocrinology , supports Bowers’ assertions that gender confirmation surgery benefits adolescents, though it does not go as far as to recommend specific age guidelines.

“Several preliminary studies have shown benefits of gender-affirming surgery in adolescents, particularly regarding bilateral mastectomy in transgender adolescent males, but there is a scarcity of literature to guide clinical practice for surgical vaginoplasty in transgender adolescent females,” the authors write. “The optimal age and developmental stage for initiating [cross sex hormones] and performing gender-affirming surgeries remains to be clarified.”

The  World Professional Association for Transgender Health  (WPATH), a leading organization for transgender health worldwide whose membership consists of physicians and educators, publishes Standards of Care and Ethical Guidelines for the treatment of transgender patients.

Though WPATH’s Standards of Care was last updated in 2011 and is under revision, even the current standards suggest that individuals at the age of majority in a given country (for the United States, that’s 18) who have lived for at least 12 months in accordance with their gender identity should be eligible for genital surgery, and that chest surgeries can be done earlier.

“I think it’s important to recognize for all of these standards of care, these are flexible guidelines,” says Loren Schechter, director of the  Center for Gender Confirmation Surgery  at  Weiss Memorial Hospital , clinical professor of surgery at the University of Illinois at Chicago, and co-lead for the revision of the WPATH standards of care surgery chapter for adolescents and adults. “It is not necessarily uncommon that we will currently perform bottom surgeries under the legal age of majority now.”

Schechter also indicated that the revision of the standards will likely include lowered age guidelines.

One reason to give transgender youth access to surgery

Schechter maintains that there are many reasons why minors should be eligible to receive gender confirmation surgery.

“One of them is that post-operative care in a supportive environment is very important,” Schechter said. “So, for example, for those individuals going off to college, the ability to recuperate while at home in a supportive environment and parents during that post-operative period is quite important. Trying to have your post-operative care in a dorm room after surgery is it is not necessarily an ideal scenario.”

This reasoning was echoed in a  paper published in the Journal of Sexual Medicine in April 2017 . For the study, researchers asked 20 WPATH-affiliated surgeons practicing in the U.S. about whether and why they performed genital surgery on transgender female minors.

Respondents noted the beneficial recovery environment some minor patients may have.

“Some surgeons viewed timing the procedure before college attendance as a harm reduction measure: Younger patients who have the support of their families, support of their parents, and can have the operation while they are still at home, as opposed to being alone at school or at work, anecdotally tend to do much better than someone who is alone and doesn’t have appropriate support.”

Others suggest that receiving surgery as a minor might allow the patient to “fully socially transition” in their next phase, such as in college.

Who is ready for surgery? Considerations beyond age

Physicians involved in the study also noted that while the number of minors requesting information about genital surgery had increased, psychological maturity is their main criteria for approval.

As one interviewed surgeon put it, “Age is arbitrary. The true measures of how well a patient will do are based on maturity, discipline and support.”

Eleven of the 20 surgeons interviewed had performed such surgeries. Minors ranged in age from 15 to “a day before 18.” About two-thirds of surgeons interviewed believe that such decisions should be made on a case-by-case basis rather than in strict adherence with current WPATH guidelines, which advises to wait until 18 in the U.S.

Boskey, who works for the Center for Gender Surgery at Boston Children’s Hospital, notes: “Just setting the age guidelines in place doesn’t remove the need to appropriately assess whether the surgery is something that should be happening,” she said.

“They’re going to need to make certain that the patient is appropriate for that surgery, that they are being diagnosed with gender dysphoria, that they are taking hormones as appropriate, that they are living in their affirmed gender, that they are aware of all of the life-changing nature of these surgeries,” she said. “These are surgeries that require pretty intense assessment to make certain that they’re appropriate. But that needs to come from the clinical side, rather than the insurance side.”

Will trans youth regret surgery? What the research says

Research supports the benefits of early interventions.

A 2018 study published in JAMA Pediatrics of 136 transmasculine youth and young adults between the ages of 13 and 25 receiving care at Children’s Hospital of Los Angeles finds that, on average,  chest dysphoria, or distress caused by one’s chest, was significantly higher among participants who had not received chest reconstruction surgery as compared with those who did .

Serious complications among the surgery group were rare, and only one of the 68 patients who received surgery reported experiencing regret sometimes, with the other 67 reporting no regret over the procedure. The time that had elapsed between surgery and the survey ranged from less than 1 year to 5 years.

“Given these findings,” the authors conclude, “professional guidelines and clinical practice should consider patients for chest surgery based on individual need rather than chronologic age.”

Those who study the impact of early access to gender confirming surgeries often point to research from the Netherlands, home to one of the earliest comprehensive gender clinics.

“[T]hey’ve probably got the most data on transgender, gender non-conforming adolescents, who have been followed longitudinally, prospectively in the most rigorous way — that data indicates that people do well with early access and early interventions,” Schechter says. “By early, I mean late adolescence — we’re not, of course, talking about operating on children.”

Adolescents who were the first 22 people to receive gender confirming surgery at the clinic in the Netherlands  showed after surgery that they no longer experienced distress over their gender, according to a 1997 publication in the Journal of the American Academy of Child & Adolescent Psychiatry .

The study also showed that the 22 adolescents scored within the normal range for a number of psychological measures.

Further, the authors note, “Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.”

A follow-up study, published four years later, of another group of 20 adolescents receiving surgery after the first group of 22  confirmed the initial findings .

Another, later study in the Netherlands focused on the outcomes of  55 transgender young adults  who received gender confirmation surgery between 2004 and 2011. The participants all “were generally satisfied with their physical appearance and none regretted treatment.”

Moreover, gender dysphoria was alleviated, mental health improved, and well-being among those studied was similar to or better than their peers in the general population.

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Chloe Reichel

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Age restriction lifted for gender-affirming surgery in new international guidelines

'Will result in the need for parental consent before doctors would likely perform surgeries'

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• Release Date: September 16, 2022

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Kristin Samuelson

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• Expert can speak to transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage, how the U.S. gender regulations compare to other countries, more

CHICAGO --- The World Professional Association for Transgender Health (WPATH) today today announced  its updated Standards of Care and Ethical Guidelines for health professionals. Among the updates is a new suggestion to lift the age restriction for youth seeking gender-affirming surgical treatment, in comparison to previous suggestion of surgery at 17 or older. 

Alithia Zamantakis (she/her), a member of the Institute of Sexual & Gender Minority Health at Northwestern University Feinberg School of Medicine, is available to speak to media about the new guidelines. Contact Kristin Samuelson at [email protected] to schedule an interview.

“Lifting the age restriction will greatly increase access to care for transgender adolescents, but will also result in the need for parental consent for surgeries before doctors would likely perform them,” said Zamantakis, a postdoctoral fellow at Northwestern, who has researched trans youth and resilience. “Additionally, changes in age restriction are not likely to change much in practice in states like Alabama, Arkansas, Texas and Arizona, where gender-affirming care for youth is currently banned.”

Zamantakis also can speak about transgender peoples’ right to bodily autonomy, how guidelines affect insurance coverage and how U.S. gender regulations compare to other countries.

Guidelines are thorough but WPATH ‘still has work to do’

“The systematic reviews conducted as part of the development of the standards of care are fantastic syntheses of the literature on gender-affirming care that should inform doctors' work,” Zamantakis said. “They are used by numerous providers and insurance companies to determine who gets access to care and who does not.

“However, WPATH still has work to do to ensure its standards of care are representative of the needs and experiences of all non-cisgender people and that the standards of care are used to ensure that individuals receive adequate care rather than to gatekeep who gets access to care. WPATH largely has been run by white and/or cisgender individuals. It has only had three transgender presidents thus far, with Marci Bower soon to be the second trans woman president.

“Future iterations of the standards of care must include more stakeholders per committee, greater representation of transgender experts and stakeholders of color, and greater representation of experts and stakeholders outside the U.S.”

Transgender individuals’ right to bodily autonomy

“WPATH does not recommend prior hormone replacement therapy or ‘presenting’ as one's gender for a certain period of time for surgery for nonbinary people, yet it still does for transgender women and men,” Zamantakis said. “The reality is that neither should be requirements for accessing care for people of any gender.

“The recommendation of requiring documentation of persistent gender incongruence is meant to prevent regret. However, it's important to ask who ultimately has the authority to determine whether individuals have the right to make decisions about their bodily autonomy that they may or may not regret? Cisgender women undergo breast augmentation regularly, which is not an entirely reversible procedure, yet they are not required to have proof of documented incongruence. It is assumed that if they regret the surgery, they will learn to cope with the regret or will have an additional surgery. Transgender individuals also deserve the right to bodily autonomy and ultimately to regret the decisions they make if they later do not align with how they experience themselves.” 

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Gender Affirmation Surgeries

Featured Expert:

Fan Liang, M.D.

Surgeries are not required for gender affirmation, but many patients choose to undergo one or more surgical procedures. Talk with your doctor to discuss what surgical options may be right for you. The following is an overview of gender affirmation surgeries.

• Penile construction (phalloplasty/metoidioplasty) : This surgical procedure can include removal of the vagina (vaginectomy), reconstruction of the urethra and penile reconstruction. Surgeons may use either vaginal tissue or tissue from another part of the body to construct the penis.
• Vaginal construction (vaginoplasty) : This surgical procedure is a multistage process during which surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina, the clitoris (clitoroplasty) and the labia (labiaplasty).
• Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.
• Facial gender surgery can include a variety of procedures to create more feminine features , like reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. 
• Facial gender surgery can also include a series of procedures to create more masculine features , such as forehead lengthening and augmentation; cheek augmentation;  reshaping the nose  and chin;  jaw augmentation ; and thyroid cartilage enhancement to construct an Adam’s apple.
• Hysterectomy : This surgical procedure includes the removal of the uterus and ovaries (oophorectomy). There are options for oocyte storage and fertility preservation that you may want to discuss with your doctor. 
• Some people may combine this procedure with a scrotectomy , which is surgery to remove all or part of the scrotum. For others, the skin of the scrotum can be used in vulvoplasty or vaginoplasty ― the surgical construction of a vulva or vagina.
• The procedure reduces testosterone production and may eliminate the need for continuing therapy with estrogen and androgen-suppressing medications. Your health care practitioner will discuss options such as sperm freezing before orchiectomy that can preserve your ability to become a biological parent.

Recovery After Gender Affirmation Surgeries

Recovery time from a gender affirmation surgery or procedure varies, depending on the procedure. Talk to your doctor about what you can expect.

Treatment Caring for Transgender Patients

Fearing discrimination and hostility, transgender people are often reluctant to seek care. Discover how Paula Neira, Program Director of LGBTQ+ Equity and Education, Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, is working to ensure that all patients — regardless of gender identity — are treated with dignity and respect.

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Male to Female Surgery: Breast augmentation Facial feminisation Vaginoplasty Vulvoplasty

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Biden ‘Gender-Reassignment’ Surgery Mandate Blocked

The ruling expands an earlier court decision that blocked the mandate for hospitals in Texas and Montana to all hospitals.

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender-reassignment” surgeries or face a range of penalties, including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” said Paxton.

The Biden administration will likely appeal the ruling to the 5th Circuit Appellate Court.

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The pro-life referendum would allow the current law to stay in place. However, the pro-abortion referendum would substantially expand abortion. Nebraska is one of 10 states where abortion will be on the ballot this fall.

Shroud Gets Scientific Nod/ What’s Causing The Birth Dearth?

The Shroud of Turin got another significant nod from scientists. What do recent studies say about the shroud, believed by Christians to be the burial cloth of Jesus? Alyssa Murphy brings us a report. Then Peter Laffin provides analysis on the presidential debate. And finally, we turn to a growing problem in the US: a birth dearth. Why aren’t we having enough children to replace our population? Daniel Payne and Jonathan Liedl cover this story.

‘God’s Not Dead 4’: Does God Still Have a Place in American Politics?

The movie is a plea to invite God back into the public square.

Why I’ll Never Remove My Scapular Again, The Only Way to Remove a Demon, and More Great Links!

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The Holy Name of Mary Is Our Weapon and Shield

The Sept. 12 feast of the Holy Name of Mary reminds us of its stirring history and, above all, the reason why her name is a most powerful prayer.

Satan’s Protection, An Oxford Professor Gave a Public Lecture About Belief in God, and More Great Links!

‘the incorruptibles’: who are these mysterious saints, there is no shame in being catholic, post-debate explainer: the truth about late-term abortions in the united states, pope francis: us presidential election a choice between ‘the lesser evil’, ryan anderson: the pro-life movement needs to shift to promoting chastity and marriage, opus dei prelate asks prayers for new statutes and to share ‘the fire of the lord’, marian montreal: a city of mary and the saints, march for life announces ‘longtime marcher’ as new president, subscription options.

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Trump repeats false claims that children are undergoing transgender surgery during the school day

Former President Donald Trump repeated his false claim that children are undergoing transition-related surgery during their school day, worsening fears among some conservatives that educators are pushing children to become transgender and aiding transitions without parental awareness.

“Can you imagine you’re a parent and your son leaves the house and you say, ‘Jimmy, I love you so much, go have a good day in school,’ and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?” Trump said Saturday at a campaign rally in Wisconsin, a vital swing state. 

Trump made similar remarks — saying children were returning home from school after having had surgical procedures — the previous weekend at an event hosted by Moms for Liberty, a parent activist group that has gained outsized influence in conservative politics in recent years.

Asked by one of the group’s co-founders how he would address the “explosion in the number of children who identify as transgender,” Trump said: “Your kid goes to school and comes home a few days later with an operation. The school decides what’s going to happen with your child.”

There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure elsewhere. 

About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare . In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers . Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

A spokesperson for Trump’s campaign did not substantiate his claims and pointed NBC News to reports about parents’ being left in the dark about their children’s gender transitions at school. 

“President Trump will ensure all Americans are treated equally under the law regardless of race, gender or sexual orientation,” said the spokesperson, Karoline Leavitt.

Kate King, president of the National Association of School Nurses, said that even when it comes to administering over-the-counter medication such as Advil or Tylenol, school nurses need explicit permission from a physician and a parent.

“There is no way that anyone is doing surgery in a classroom in schools,” she said when she was asked about Trump’s remarks.

Trump’s claims stand out even amid years of allegations by conservative politicians and right-wing media pundits that teachers, Democratic lawmakers and LGBTQ adults are “grooming” or “indoctrinating” children to become gay or transgender. 

The practice of labeling LGBTQ people, particularly gay men and trans women, as “groomers” and “pedophiles” of children had been relegated to the margins for decades, but the tropes resurfaced during the heated debate over Florida’s so-called Don’t Say Gay law, which Gov. Ron DeSantis signed in March 2022. The law limits the instruction of sexual orientation and gender identity in school and has been replicated in states across the country.

At the Republican National Convention in July, at least a dozen speakers — including DeSantis and Rep. Marjorie Taylor Greene, R-Ga. — mentioned gender identity or sexuality negatively in their speeches, according to an NBC News analysis. DeSantis, for example, alleged that Democrats want to “impose gender ideology” on kindergartners.

Nearly 70% of public K-12 teachers who have been teaching for more than one year said topics related to sexual orientation and gender identity “rarely or never” come up in their classrooms, according to a recent poll from the Pew Research Center. Half of all teachers polled, including 62% of elementary school teachers, said elementary school students should not learn about gender identity in school.

Trump vowed last year that if he is re-elected he would abolish gender-affirming care for minors, which he equated to “child abuse” and “child sexual mutilation.” This year, Trump also said he would roll back Title IX protections for transgender students “on day one” of his potential second presidential administration.

His campaign website says he would, if he is re-elected, cut federal funding for schools that push “gender ideology on our children” and “keep men out of women’s sports.”

More broadly, Trump has promised to eliminate the Education Department, claiming that doing so would give states more authority over education.

During his first administration, Trump barred trans people from enlisting in the military — which he has vowed to do again if he is re-elected — and rolled back several antidiscrimination protections for LGBTQ people. 

For more from NBC Out, sign up for our weekly newsletter.

Matt Lavietes is a reporter for NBC Out.

Harvey Weinstein rushed to emergency heart surgery in New York ahead of court date

Sept. 9 (UPI) -- Ex-Hollywood film producer Harvey Weinstein , waiting on his second sex crimes trial, had emergency heart surgery on Monday at New York's Bellevue Hospital, his representatives confirmed.

The Hollywood mogul was rushed to Bellevue Sunday night after experiencing chest pains, Weinstein representatives Craig Rothfeld and Juda Engelmayer told ABC News in first reporting it. Advertisement

Weinstein, 72, was taken from his prison facility at Rikers Island to Bellevue also after reports of telling his attorney over the weekend "how ill he was," Weinstein lawyer Arthur Aidala told The Post .

• Harvey Weinstein to stay in N.Y. prison pending retrial on sex charges
• Fall trial looms as Harvey Weinstein faces new sexual assault allegations

"We can confirm that Mr. Weinstein had a procedure and surgery on his heart today however cannot comment any further than that," they added.

Aidala noted that Rothfield, Weinstein's private "jail consultant," reportedly worked with officials to see Weinstein taken to Bellevue.

"Luckily, they heeded our emergency calls," said Aidala.

In their statement, Engelmayer and Rothfield expressed gratitude to the city's Department of Corrections and Rikers Island for acting quickly.

"As we have extensively stated before, Mr. Weinstein suffers a plethora of significant health issues that need ongoing treatment," they continued. Advertisement

Weinstein was due back in court on Thursday, where he previously has been seen in a wheelchair, for a pre-trial hearing in Manhattan Supreme Court as prosecutors show evidence to a grand jury and work to secure for Weinstein a new indictment on related sex crime charges.

More than 80 women have accused the Oscar-winning producer of sexual assault or harassment while he has maintained that any alleged sexual encounter was consensual.

Weinstein, who was in Bellevue Hospital in Manhattan last month for health issues, is facing a retrial scheduled for Nov. 12 after the state Court of Appeals overturned his rape and sexual assault conviction from 2020.

He was convicted of assaulting his former production assistant, Miriam Haley, in 2006 and raping Jessica Mann, an aspiring actress, in 2013.

In April, the court threw out the guilty verdicts and his 23-year sentence based on testimony provided by three women about uncharged instances of sexual violence.

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'Emilia Pérez' Review: Three Great Performances Lead Jacques Audiard’s Ambitious but Flawed Netflix Melodrama | TIFF 2024

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Jacques Audiard has never made two films alike, with each new endeavor a completely new exploration of entirely new genres and experiences. From making one of the greatest crime dramas of the 21st century with A Prophet , creating a Western dramedy in The Sisters Brothers , or a unique take on the romantic drama with Rust and Bone , Audiard always makes sure each film is unlike what you’ve seen from him before. While Audiard usually seems to latch onto a specific new genre and try to master it, his latest, Emilia Pérez , is arguably his most ambitious film so far, one that refuses to fit into a particular box, a musical drug cartel drama with a transgender affirmation story, all blended with a melodramatic telenovela style. No one would ever say Audiard isn’t daring, and Emilia Pérez is certainly a strong example of this, yet despite three strong female lead performances—including one of the best of the year— it's a film that bites off more than it can effectively chew.

What Is 'Emilia Pérez' About?

Rita ( Zoe Saldaña ) is a lawyer for a major law firm, yet is under-appreciated in her job, assisting her teammates while not getting any of the credit. After a mysterious phone call one day, she is kidnapped and brought to meet a Mexican cartel leader, Juan “Manitas” Del Monte ( Karla Sofia Gascón ) who needs her help. Manitas wants to leave the country and have sex reassignment surgery, a desire had since childhood. Manitas wants Rita to find the best place to do this major life change quickly and effectively, but also have Manitas’ wife, Jessi Del Monte ( Selena Gomez ), and their children set up for a life without their father and husband. But even after Rita succeeds at helping Manitas become Emilia Pérez (also played by Gascón) and moving Jessi’s family to Switzerland, Rita, Emilia, and Jessi are intertwined in ways they never expected.

Audiard wisely centers this film around these three fantastic female performances , each of which is daring and surprising in its own way. Despite finding massive success at the box office, we’ve never seen Saldaña so free and playful as we do here, with many of the bigger, bombastic musical numbers centered around her. Her opening number sets up the wild shifts in styles that Audiard is going for, and some of the broader songs allow her to really strap in and have a blast. One sequence has Saldaña’s Rita singing in a plastic surgery office to a song called “La Vaginoplastia,” while another has her gyrating and mocking throwing money at rich people. With these three stories intersecting, Saldaña has the most opportunities to let loose and embrace the over-the-top nature of Audiard’s vision fully , and it’s a delight to see Saldaña get a role like this that she can truly sink her teeth into.

The same can be said about Selena Gomez’s Jessi , which gives the actress one of her most mature performances yet, as she’s thrown into a role at extremes. Jessi begins as Manitas’ wife, then goes to mourning her husband, followed by changing her life’s situation, then potentially falling for another man with a questionable background ( Édgar Ramírez as Gustavo Brun). Gomez may not get quite the same amount of attention that the other two actresses receive, yet she makes the most of this rich role in the moments we do focus on her.

Karla Sofia Gascón Gives a Star-Making Performance in 'Emilia Pérez'

But the real standout here is Gascón in a remarkable performance of discovery, struggle, and becoming who Manitas was always meant to be. Even though Emilia Pérez is playing with melodrama and grand ideas—especially in her segments of the film—Gascón always grounds the role of the title character with strength, reserve, and subtle power over everything. As Manitas, Gascón is an intimidating figure who gets what they want, and when the transformation to Emilia Pérez is complete, we still feel the power they hold, even though the character is trying to distance themselves from their cartel past. Again, Gascón is thrown into many larger-than-life situations and story beats, but excels at all of them. We know the pain that this character can inflict, but we also see the love and care Pérez has in this new phase of her life. Especially when Gascón interacts with her children in the film as Emilia, the film finds a touching emotional core that centers this often wild story into something real and heartbreaking. Gascón plants this film into very honest emotions and concepts, and gives a commanding performance that will go down as one of the year’s best.

'Emilia Pérez' Might Be Too Ambitious For Its Own Good

And yet, it’s the overabundance of ideas within Audiard’s latest that holds this film back , attempting to do a lot, and spreading itself too thin. Emilia Pérez is the first film Audiard has written on his own, a story which began as a four-act opera libretto, and was loosely based on the 2018 novel “Écoute” from Boris Razon . It’s impossible not to admire how daring Audiard’s story is, with a narrative that will shift and evolve into something else every 15 minutes or so. But because of that, Emilia Pérez can sometimes feel more like a genre deconstruction and attempt to flow so many different types of films together in a way that never quite becomes cohesive. As previously stated, Audiard has always tried something new with each subsequent film, but with Emilia Pérez , it’s like he wants to try that same level of ambitious genre-hopping every few minutes.

This, unfortunately, mostly hurts the musical side of the film. There are large stretches of Emilia Pérez that are without songs, almost as if Audiard has forgotten he’s attempting a musical. When the film is a musical, songs often stop and start without leaving much of an impact, and sadly, the songs by Camille and score by Clément Ducol are mostly forgettable. There are some exceptions, as with the emotional “Papa,” in which Pérez’s son sings to her about his deceased father, and the staging of the musical sequences are always impressive. But when they’re done extremely well and the songs are hitting just right, it only highlights how often the musical elements seem almost like an afterthought. For a film so daring and inventive, it’s disappointing that the musical aspect of Emilia Pérez never soars to meet this film’s ambitions.

As an always exciting auteur who has deserved more attention for decades, Emilia Pérez is an excellent calling card for Audiard, a film that truly spotlights everything he’s capable of doing as a remarkable director. Audiard has also thrived at getting incredible performances out of actors, such as Tahar Rahim ’s breakthrough in A Prophet , one of Marion Cotillard ’s finest achievements in Rust and Bone , and Antonythasan Jesuthasan ’s powerful performance in the Palme d’Or-winning Dheepan , and he continues this trend with this brilliant trio of Saldaña, Gomez, and Gascón, each of which should deservedly receive attention come award season. But Audiard’s attempt to pack this story with so many directions and ideas doesn’t always coalesce into a satisfying whole, exploring the absurdities of melodrama and Mexican telenovelas effectively, but cramming to many other styles in as well. Emilia Pérez is doing a lot and often doing it quite well, but not all of these pieces fit together as well as they should.

Emilia Perez

Emilia Pérez boasts a remarkable trifecta of performances, but Jacques Audiard's ambitious project tries to do a bit too much.

• Karla Sofia Gascón gives a star-making performance that should make a splash in award season.
• Zoe Saldaña and Selena Gomez get to flex acting muscles they never have before.
• Jacques Audiard gets to embrace his penchant for trying out new genres.
• But Audiard's playfulness means some parts of the film aren't as effective as others.
• The musical moments are well-shot, but the songs themselves are mostly unmemorable.

Emilia Pérez screened at the Toronto International Film Festival. It's available to stream on Netflix in the U.S. starting November 13.

WATCH ON NETFLIX

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