gender reassignment earnings

Does Starbucks Offer Employees Healthcare Plans Covering Gender Reassignment Surgery?

Quite a few u.s. companies that people might come across in their daily lives provide coverage to lgbtq+ employees for gender-affirming care., jordan liles, published feb. 29, 2024.

About this rating

Starbucks has provided employees coverage for gender reassignment surgery since 2013.

On Feb. 27, 2024, a Facebook user posted ( archived ) a photo of a Starbucks coffee cup that showed a small sticker that said "we're hiring" and that the company offers healthcare plans for employees ("partners") that include "coverage for gender reassignment surgery and more." The user remarked of the sticker, "Know this as you enjoy your next overpriced cup of Starbucks."

The oldest known post  ( archived ) of the picture appeared to be from July 2021, when it was posted by former Republican Texas State Rep. Jonathan Stickland . Stickland remarked of the photo, "Just wanted Starbucks fans to be aware. Lord help and forgive us." Stickland credited the picture to a person named Kevin Whitt. It's unclear where and when the photo was originally taken.

A reverse-image search of the photo showed that it had been posted in February 2024 by other users on X and Instagram . For example, one X user whose bio mentioned an "unvaxxed" vaccination status, Christian faith and "MAGA" political affiliation, posted  ( archived ) of the Starbucks cup photo, "I will drink McDonald's coffee before I will give Starbucks another cent of my money."

First, the truth of this matter was that Starbucks has provided its employees coverage for gender reassignment surgery since 2013, according to the company's own website . Starbucks expanded its coverage in 2018 "to include procedures that were previously considered cosmetic — including hair removal, facial feminization and hair transplants, among others," another page on the company's website said.

Second, in regard to the user on X who mentioned McDonald's as being their alternative to Starbucks, that user might be surprised to learn that the McDonald's website  also says it offers employees and their families "a variety of health and wellbeing programs," including coverage for "gender transition and affirming care," as well as access to "the queer and trans-led Included Health's LGBTQ+ Health care team."

Third, quite a few large companies that people in the U.S. might come across in their daily lives offer coverage for gender-affirming care  or have expressed support of programs that offer such care, including, for example  Amazon ,  Google  and Meta , as both Pink News and InHerSight.com  previously reported.

Further, in March 2022, The Texas Tribune reported that 60 corporations had published an open letter in a Sunday edition of Dallas Morning News calling on Gov. Greg Abbott "to 'abandon anti-LGBTQ+ efforts' after he authorized state investigations of families who allow transgender kids to receive gender-affirming care." The list of those corporations included Adobe, Apple, Capital One, IBM, IKEA, Intel, Macy's, Microsoft, PayPal, Pinterest, Yahoo, Yelp and The Walt Disney Company, among many others.

For further reading, we previously reported that accusations of Starbucks being "anti-Christmas" usually leave out one very big fact about the company's history.

"Addressing Misinformation: Access to Gender-Affirming Care for All Partners." One.Starbucks , 19 May 2023, https://one.starbucks.com/get-the-facts/access-to-gender-affirming-care/.

Barragán, James. "Apple, Google among Dozens of Corporations Condemning Texas' Order to Investigate Families of Trans Kids." The Texas Tribune , 11 Mar. 2022, https://www.texastribune.org/2022/03/11/apple-google-business-texas-trans-law/.

Cara Hutto. "27 Companies with Transgender Health Care Benefits." InHerSight , 27 July 2022, https://www.inhersight.com/blog/inclusive-benefits/transgender-health-care-benefits.

"Discrimination Is Bad for Business." Human Rights Campaign , 10 Mar. 2022, https://www.hrc.org/news/discrimination-is-bad-for-business.

"Google Careers Benefits." A Google Careers Project , https://googlerbenefits.withgoogle.com/.

"Health and Wellness: LGBTQ+ Support and Coverage." Meta Careers , https://www.metacareers.com/benefits.

Jarrett, Cosette. "Amazon's Benefits Helped This Employee Live Life on Her Own Terms." US About Amazon , 9 Mar. 2021, https://www.aboutamazon.com/news/workplace/an-opportunity-to-live-life-on-her-own-terms.

"Jonathan Stickland."  Ballotpedia , https://ballotpedia.org/Jonathan_Stickland.

"McDonald's LGBTQ+ Support and Livin' My Truth." McDonald's , https://www.mcdonalds.com/us/en-us/community/lgbtq-plus.html.

Mihalcik, Carrie. "Apple, Google, Other Tech Giants Urge Texas to Drop Anti-Transgender Legislation." CNET , 11 Mar. 2022, https://www.cnet.com/news/politics/apple-google-other-tech-giants-urge-texas-to-drop-anti-transgender-legislation/.

Niewiarowski, Erik. "5 Companies Going above and beyond to Support Trans and Non-Binary Employees." PinkNews | Latest Lesbian, Gay, Bi and Trans News | LGBTQ+ News , 15 Nov. 2023, https://www.thepinknews.com/2023/11/15/10-of-the-best-companies-for-trans-people/.

Peiper, Heidi. "Timeline: Starbucks History of LGBTQIA2+ Inclusion." Starbucks Stories & News , 16 May 2022, https://stories.starbucks.com/stories/2019/starbucks-pride-a-long-legacy-of-lgbtq-inclusion/.

"What Is Gender-Affirming Care? Your Questions Answered." AAMC , https://www.aamc.org/news/what-gender-affirming-care-your-questions-answered.

By Jordan Liles

Jordan Liles is a Senior Reporter who has been with Snopes since 2016.

Article Tags

• Today's news
• Reviews and deals
• Climate change
• 2024 election
• Newsletters
• Fall allergies
• Health news
• Mental health
• Sexual health
• Family health
• So mini ways
• Unapologetically
• Buying guides

Entertainment

• How to Watch
• My Portfolio
• Latest News
• Stock Market
• Biden Economy
• Stocks: Most Actives
• Stocks: Gainers
• Stocks: Losers
• Trending Tickers
• World Indices
• US Treasury Bonds Rates
• Top Mutual Funds
• Options: Highest Open Interest
• Options: Highest Implied Volatility
• Basic Materials
• Communication Services
• Consumer Cyclical
• Consumer Defensive
• Financial Services
• Industrials
• Real Estate
• Stock Comparison
• Advanced Chart
• Currency Converter
• Credit Cards
• Balance Transfer Cards
• Cash-back Cards
• Rewards Cards
• Travel Cards
• Credit Card Offers
• Best Free Checking
• Student Loans
• Personal Loans
• Car insurance
• Mortgage Refinancing
• Mortgage Calculator
• Morning Brief
• Market Domination
• Market Domination Overtime
• Asking for a Trend
• Opening Bid
• Stocks in Translation
• Lead This Way
• Good Buy or Goodbye?
• Financial Freestyle
• Capitol Gains
• Living Not So Fabulously
• Decoding Retirement
• Fantasy football
• Pro Pick 'Em
• College Pick 'Em
• Fantasy baseball
• Fantasy hockey
• Fantasy basketball
• Download the app
• Daily fantasy
• Scores and schedules
• GameChannel
• World Baseball Classic
• Premier League
• CONCACAF League
• Champions League
• Motorsports
• Horse racing

New on Yahoo

• Privacy Dashboard

Yahoo Finance

The Global Gender Reassignment Surgery Market is expected to grow by $ 209.07 million during 2021-2025, progressing at a CAGR of 8.41% during the forecast period

Global Gender Reassignment Surgery Market 2021-2025 The analyst has been monitoring the gender reassignment surgery market and it is poised to grow by $ 209. 07 million during 2021-2025, progressing at a CAGR of 8.

New York, Dec. 13, 2021 (GLOBE NEWSWIRE) -- Reportlinker.com announces the release of the report "Global Gender Reassignment Surgery Market 2021-2025" - https://www.reportlinker.com/p06190006/?utm_source=GNW 41% during the forecast period. Our report on the gender reassignment surgery market provides a holistic analysis, market size and forecast, trends, growth drivers, and challenges, as well as vendor analysis covering around 25 vendors. The report offers an up-to-date analysis regarding the current global market scenario, latest trends and drivers, and the overall market environment. The market is driven by increase in number of people opting for sex-change surgeries globally and favorable government policies in the US. In addition, increase in number of people opting for sex-change surgeries globally is anticipated to boost the growth of the market as well. The gender reassignment surgery market analysis includes the gender transition segment and geographic landscape. The gender reassignment surgery market is segmented as below: By Gender Transition • Male to female • Female to male By Geographic • North America • Europe • Asia • ROW This study identifies the increasing gender reassignment surgical centersas one of the prime reasons driving the gender reassignment surgery market growth during the next few years. The analyst presents a detailed picture of the market by the way of study, synthesis, and summation of data from multiple sources by an analysis of key parameters. Our report on gender reassignment surgery market covers the following areas: • Gender reassignment surgery market sizing • Gender reassignment surgery market forecast • Gender reassignment surgery market industry analysis This robust vendor analysis is designed to help clients improve their market position, and in line with this, this report provides a detailed analysis of several leading gender reassignment surgery market vendors that include Boston Medical Center, Bupa, Cleveland Clinic, CNY Cosmetic & Reconstructive Surgery, Moein Surgical Arts, Mount Sinai Centre for Transgender Medicine and Surgery (CTMS), Phuket International Aesthetic Centre (PIAC), Rumer Cosmetic Surgery, Sava Perovic Foundation Surgery, and Transgender Surgery Institute. Also, the gender reassignment surgery market analysis report includes information on upcoming trends and challenges that will influence market growth. This is to help companies strategize and leverage all forthcoming growth opportunities. The study was conducted using an objective combination of primary and secondary information including inputs from key participants in the industry. The report contains a comprehensive market and vendor landscape in addition to an analysis of the key vendors. The analyst presents a detailed picture of the market by the way of study, synthesis, and summation of data from multiple sources by an analysis of key parameters such as profit, pricing, competition, and promotions. It presents various market facets by identifying the key industry influencers. The data presented is comprehensive, reliable, and a result of extensive research - both primary and secondary. Technavio’s market research reports provide a complete competitive landscape and an in-depth vendor selection methodology and analysis using qualitative and quantitative research to forecast the accurate market growth. Read the full report: https://www.reportlinker.com/p06190006/?utm_source=GNW About Reportlinker ReportLinker is an award-winning market research solution. Reportlinker finds and organizes the latest industry data so you get all the market research you need - instantly, in one place. __________________________

CONTACT: Clare: [email protected] US: (339)-368-6001 Intl: +1 339-368-6001

Recommended Stories

Putting numbers on the rise in children seeking gender care

By ROBIN RESPAUT and CHAD TERHUNE

Filed Oct. 6, 2022, 11 a.m. GMT

Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.

As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.

Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.

Diagnoses of youths with gender dysphoria surge

In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.

Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.

Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.

These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.

For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.

Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.

This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.

By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.

Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.

The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.

After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.

At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.

Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.

Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.

Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.

The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.

The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.

A note on the data

Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.

To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.

For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.

Youth in Transition

By Robin Respaut and Chad Terhune

Photo editing: Corrine Perkins

Art direction: John Emerson

Edited by Michele Gershberg and John Blanton

• Follow Reuters Investigates

Other Reuters investigations

Credit Cards

Financial planning.

• Cheapest Car Insurance
• Cheapest Full Coverage Car Insurance
• Car Insurance Cost Calculator
• Best Car Insurance
• Compare Car Insurance Costs
• Average Cost of Car Insurance
• Best Term Life Insurance
• Best Whole Life Insurance
• Best Life Insurance Companies
• Best Universal Life Insurance
• Best Life Insurance for Seniors
• Compare Quotes
• Best Auto and Home Insurance Bundle
• Homeowners Insurance
• Renters Insurance
• Health Insurance
• Pet Insurance
• Small Business Insurance

Insurance Guidance

• Conventional Mortgages
• Jumbo Loans
• Best HELOC Loans and Rates
• Get a HELOC With Bad Credit
• Pay Off Your Mortgage With a HELOC
• Pros and Cons of HELOCs
• The HELOC Approval Process
• Mortgage Payment Calculator
• Reverse Mortgage Calculator
• FHA vs. Conventional Loan Calculator
• Private Mortgage Insurance Calculator
• Debt-to-Income Ratio Calculator

Mortgage Guidance

• Best Balance Transfer Credit Cards
• Best Cash Back Credit Cards
• Best Travel Rewards Credit Cards
• Best Airline Credit Cards
• Best Credit Cards for Excellent Credit
• Best Business Credit Cards
• Best American Express Cards
• Best Capital One Credit Cards
• Best Chase Credit Cards
• Best Citi Credit Cards
• Best Bank of America Credit Cards
• Cash Back Calculator
• Pros and Cons of Balance Transfers
• Practical Guide for Improving Credit Fast
• Average Credit Score by Age
• Credit Cards For Bad Debt
• Credit Card Glossary

Recent Credit Card Reviews & Comparisons

• Best Personal Loans of 2024
• Best Personal Loans for Excellent Credit
• Best Personal Loans for Good Credit
• Best Personal Loans for Bad Credit
• Best Same-Day Approval Loans
• Best Personal Loans for Debt Consolidation
• Best Private Student Loans
• Best Student Loans for Bad Credit
• Best Student Loans for International Students
• Best Low-Interest Student Loans
• Best Student Loans Without a Co-Signer
• Personal Loan Calculator
• Auto Loan Calculator
• Student Loan Calculator
• How to Calculate Loan Payments
• Can You Get a Personal Loan With Bad Credit?

Loans Guidance

• Compound Interest Calculator
• Cost of Living Calculator
• Financial Literacy Handbook
• Guide to Retirement Planning
• Ultimate Guide to Budgeting
• Understanding Types of Debt
• How to Pay Down Student Loan Debt
• How to Start Saving & Investing
• Should You Rent or Buy a House
• How to Pay for College
• Guide to Buying a Car
• Guide to Negotiating Salary
• Safest Cities in America
• Top Cities for Job Seekers
• Most & Least Tax-Friendly States
• Most Dangerous Days for DUIs

Financing & Support for Gender Confirmation Surgery

Laura Dorwart

Laura Dorwart is a writer living in Oberlin, Ohio, with her family. She has bylines at VICE, The New York Times, The Guardian and many others. She has a Ph.D. from UCSD, an MFA in nonfiction writing from Antioch University Los Angeles and experience in UX writing and copywriting for brands such as KeyBank. Follow her work at www.lauradorwart.com.

Patrick McHugh

Chief Creative Officer and Cofounder at Euphoria.LGBT

Patrick McHugh is the Chief Creative Officer and Cofounder of Euphoria.LGBT, a health-tech company building technology for the transgender community to alleviate the great pains associated with gender transition. A communications, research and design specialist, McHugh leads the research and content-writing efforts for Solace and Bliss.

Quality Verified

MoneyGeek is dedicated to providing trustworthy information to help you make informed financial decisions. Each article is edited, fact-checked and reviewed by industry professionals to ensure quality and accuracy.

Updated: December 5, 2023

Featured Experts:

President at Total Engagement Consulting by Kimer

Stan Kimer is a nationally recognized consultant and speaker on all areas of workplace diversity with a deep expertise in LGBT (Lesbian, Gay, Bisexual, Transgender) diversity and unconscious bias. For four years, Stan served as IBM’s corporate global LGBT diversity manager, including establishing IBM’s procedures for supporting transgender employees and assisting with case management of employees undergoing gender transition while in the workplace. Since retiring from IBM, Stan has trained or spoken in over 125 venues reaching over 7,500 professionals. He is a certified Out and Equal Workplace Advocates Building Bridges trainer and a certified Training Management Corp / Berlitz Cultural Competency Trainer / Practitioner. Within the transgender arena, Stan has provided training to client employee and HR teams, and has assisted with case management of several gender transitions in the workplace.

Richard Kosinski

Co-founder and Partner at Brio Benefits Consulting

In 2004, Richard Kosinski founded Brio Benefits Consulting with longtime colleague, Jason Pastano because they believed that the traditional insurance/employee benefits broker model was broken. Together they built a fast-growing, proactive, out-of-the-box thinking employee benefits consultancy to replace the industry's conventional, sell-policies-come-back-in-a-year-with higher-premiums processes with a collaborative, personalized blueprint process to ensure employers deliver the benefits employees need and appreciate.

Robbi Katherine Anthony

CEO and Founder at Euphoria.LGBT

Robbi Katherine Anthony (RKA) is the founder and CEO of Euphoria.LGBT, a public benefit corporation that builds technology for the transgender community to alleviate the great pains associated with gender transition. RKA is a front-end developer and serial entrepreneur whose lived experiences as a woman in tech, who happens to be transgender, deeply inform the products she builds. The self-described “relentless optimist” is part of Go Magazine’s 100 Women We Love Class of 2020, a former TEDx Speaker and a Stylus Changemaker. RKA has also sat on panels for Healthtech4Medicaid and the Yale Women's Mental Health Conference.

• Options and Average Costs

What Health Insurance Can Cover

• Ways to Navigate Health Insurance

Financing Options and Support

• Organizations Making a Change
• Expert Insight
• Additional Healthcare Resources

Advertising & Editorial Disclosure

Between 1.4 million and 1.65 million adults in the U.S. identify as transgender, according to the Williams Institute at UCLA's School of Law. For many transgender and gender non-conforming individuals, medical transition is a significant and empowering part of their journey. Transition may include hormonal treatment and/or surgery known as gender confirmation surgery or gender affirmation surgery.

Many transgender individuals go through the process of transition — which includes legal, psychological, social and medical experiences — to resolve gender incongruence between their internal sense of self and external anatomy. Gender identity refers to an individual's experienced gender and sense of self.

Not all transgender people want to undergo gender confirmation surgery. But for those who do, the process can help to alleviate gender dysphoria . Gender confirmation surgery also doesn’t change or “reassign” one’s gender or sex. Instead, it allows transgender and gender non-conforming people to change their bodies to reflect their gender identity more accurately.

While hormonal treatment and/or surgery is a deeply important step for many trans and gender non-conforming people, it can also be expensive. Learn more about the average costs of medical transition care options and find resources and ways to help fund procedures.

Medical Transition Care Options and Average Costs

Medical transition care options are diverse in terms of procedures, costs and outcomes. Each transgender person, along with their medical provider, should choose the options that make the most sense in terms of budget and desired results.

The main two medical transition care options are hormonal transition and gender confirmation surgery. Here’s a breakdown of the average costs of each kind of gender-confirming healthcare treatment.

Hormonal Transition

Average Cost: $20–350/month

The majority of transgender individuals who seek out medical transition choose to undergo hormonal transition, also known as hormone therapy. Because of its relative affordability and accessibility, hormone therapy can be a particularly effective option for those experiencing gender dysphoria or looking for an alternative to surgery. Hormone therapy can help trans men and women, as well as nonbinary and gender non-conforming individuals, achieve significant physical changes.

Patients who undergo masculinizing hormone therapy often take testosterone. Testosterone therapy can affect a patient’s fat distribution, facial characteristics, vocal cords, hair growth patterns, libido, menstrual cycles and more. Testosterone typically comes in the form of injections (approximately $80 per month), patches ($300 per month), and gels ($300–350 per month) .

Patients who go through feminizing hormone therapy often take estrogen or testosterone blockers such as spironolactone and/or progesterone. Like testosterone therapy, this can affect a patient’s voice, facial appearance, libido, fertility, emotions and fat distribution. It can also promote breast development. On average, oral estrogen costs about $20 per month, while estrogen injections can cost up to $200 per month and spironolactone up to $20 per month.

Gender Confirmation Surgeries

Average Cost: $5,000–$50,000

Gender confirmation surgery for transgender patients refers to reconstructive surgeries to bring patients' bodies into conformity with their experienced gender. Surgeries might include reconstruction of the chest and/or face. Depending on the type of surgery, patients may have a recovery period from about two weeks to several months after their initial hospitalization.

Like all surgeries, these procedures come with potential risks. But patients who seek out board-certified surgeons and follow all pre- and post-op guidelines are usually satisfied with their results.

Here are some of the most common gender confirmation surgeries that transgender and gender non-conforming patients seek out.

Types of Surgeries for Trans Men

For trans patients, gender confirmation surgery might include removing breast tissue and reconstructing the chest, facial masculinization surgery (FMS) to make their facial features appear more masculine, removing and reconstructing the external genitalia, and removing internal reproductive organs.

Here are the most common forms of gender confirmation surgery for trans men and nonbinary patients.

Average Cost: $10,000–$50,000

Here is what FMS surgery may include:

• Thyroid cartilage enhancement: An “Adam’s apple” is made using a small incision in the chin area and an implant in the throat region.
• Cheek augmentation: Small incisions inside the mouth allow the surgeon to place implants in the cheek to create a more angular appearance.
• Forehead lengthening or augmentation: Forehead lengthening and augmentation procedures involve lengthening the area between the eyes and scalp, and sometimes placing an implant, to create a more masculine, angular forehead.
• Jaw and chin augmentation: Jaw and chin reshaping and implants can help to widen the face and contour the jawline for more masculine facial proportions.
• Nose reshaping: Rhinoplasty can help to widen the nose and masculinize the facial proportions.

Surgery procedures could include:

• Facial masculinization surgery (FMS): FMS may include thyroid cartilage enhancement, cheek augmentation, forehead lengthening or augmentation, jaw and chin augmentation and nose reshaping.
• Periareolar procedure: The areolas and nipples are resized and repositioned during this surgery. Two circular incisions around the areolas allow the surgeon to remove the “ring” of chest tissue.
• Keyhole procedure: The keyhole procedure involves just one semi-circular incision below each of the nipples. Keyhole top surgery also allows most patients to keep the sensation in their nipple area.
• Double incision: In double incision top surgery, the surgeon makes two incisions at the top and bottom of the pectoral muscles. The nipples and areolas are removed and replaced with nipple grafts.
• Inverted-T top surgery: Inverted-T top surgery involves horizontal and vertical incisions and the removal of chest tissue but not nipples. Sensation is retained for most patients.
• Metoidioplasty: Metoidioplasty involves releasing the clitoris from the ligament attached to it and repositioning it to create a penis. With this procedure, patients can also choose to undergo urethral lengthening and remove vaginal tissue.
• Phalloplasty: Surgeons use skin grafts from other parts of the body (usually the thigh or forearm) to create a penis. A vaginectomy, or the closing of the opening in the front of the pelvis, as well as scrotoplasty, which creates a scrotum, can be included in some phalloplasty procedures. This is the most expensive of bottom surgery options for trans men, with price tags up to $150,000 in some cases.
• Hysterectomy: A hysterectomy includes the removal of the uterus and ovaries.

Types of Surgeries for Trans Women

Around half of trans patients choose to undergo breast augmentation, facial feminization surgery (FFS) (which involves a variety of procedures that make facial features appear more feminine) and the removal or reconstruction of genitalia.

Average Cost: $20,000–$50,000

Facial feminization surgery (FFS) may include:

• Genioplasty: Genioplasty uses surgical incisions inside the mouth to contour the chin for a softer, rounder shape.
• Cheek augmentation: Implants, fat transfers or fillers can soften the face to create a more feminine look.
• Brow lift: A brow lift raises the eyebrows for a shorter forehead, softer look, and enlarged appearance of the eyes.
• Tracheal shave: The neck bump created by thyroid cartilage is reduced in a tracheal shave.
• Lip lift or augmentation: Lip augmentation can be achieved with implants and fillers. A lip lift emphasizes the upper lip.

Here are some of the most common gender confirmation surgeries for trans women:

• Facial feminization surgery (FFS): This surgery may include genioplasty, cheek augmentation, brow lifts, tracheal shave and lip lift or augmentation.
• Breast augmentation/augmentation mammoplasty: Breast augmentation is one of the most common gender confirmation surgeries for trans women and nonbinary patients. It might involve saline or silicone implants or even fat transfers from other parts of the body.
• Vaginoplasty: In vaginoplasty, a surgeon uses skin grafts from another part of the body (usually the scrotum or abdomen) to create a vaginal canal. The surgeon also uses existing genital tissue to create a clitoris. This allows most patients to have penetrative intercourse.
• Orchiectomy: An orchiectomy is often a transfeminine patient ’s first gender affirmation surgery. It involves the removal of the testicles.
• Vulvoplasty: A vulvoplasty involves the external part of the vagina rather than the vaginal canal. Skin from the patient’s genitalia is used to create a vaginal opening, the inner and outer labia, a clitoris and an opening that allows the patient to urinate.

Additional Alternatives

Some trans women undergo voice feminizing therapy to adapt their voice to their gender identity. In voice feminizing therapy, vocal cords are surgically altered to raise the patient’s vocal pitch.

Some trans patients might also choose to undergo gender confirmation surgery in the form of body contouring procedures. These might include liposuction or abdominoplasty as well as implants in the calves, buttocks or other areas.

In the U.S., it is illegal for most public and private health insurance providers to discriminate against transgender patients or deny them transition-related care. However, trans patients may still face financial and logistical barriers. Here’s what you should know about health insurance coverage and gender confirmation surgery.

Type of Barriers

Transgender patients still sometimes face health disparities and barriers to medical care, including transition-related medical care. These are some of the obstacles that trans and gender non-conforming people might face when trying to access healthcare and insurance coverage.

• Differences in state-by-state health insurance coverage: Each U.S. state has different policies regarding health insurance and trans-related care. Some U.S. states legally require health insurance providers to cover transition-related care while others do not.
• Difficulty accessing up-to-date and accurate insurance information: The language in health insurance plan summaries can be out-of-date or vague. This can lead to discriminatory denials of care.
• Discrimination and stigma: Discrimination against the LGBTQ community remains widespread, and transgender people may face health disparities and stigma in the context of medical care as a result, as well as other financial challenges . A 2015 study by the National Center for Transgender Equality revealed that about one-third of transgender patients said they were denied medical care or harassed by a medical provider.
• Lack of training and cultural competency among health providers: Some healthcare providers haven’t had adequate training in healthcare for transgender patients, which can lead them to make questionable decisions.

Additional Insurance Considerations

Transgender patients might also have questions about Medicaid coverage and Medicare coverage for gender confirmation surgery and other transition-related care. Both Medicare and Medicaid are prohibited from denying coverage of trans-related care if it is medically necessary.

The Veterans Health Administration (VHA) provides some coverage for transition-related medical care to transgender veterans . However, there is still an exclusion when it comes to coverage of gender confirmation surgery.

If you have insurance through your employer, you might be able to save up for your out-of-pocket surgery costs with a non-taxed Flexible Spending Account (FSA).

Ways to Navigate Health Insurance for Gender-Confirming Surgeries

It can be challenging to navigate health insurance coverage for gender confirmation surgery, but it’s not impossible. It’s important to know your rights as a patient when interacting with providers and finding the best health insurance plan for your needs. Here are some tips to keep in mind.

Stay informed

Remember that your health insurance plan should cover your transition-related care. Make sure that you read your insurance provider’s member handbook. Ask for the medical policy and any specific documents about eligibility for trans-related medical care to determine if you qualify.

Find a plan with no exclusions

Look for a health insurance plan that doesn’t have exclusions for either all transition-related care or specific kinds of treatments. You can often find this information in the medical policy.

Ask your current or potential employer about coverage

If you’re in the negotiation phase of a job interview, don’t be afraid to ask your potential employer about transition-related health coverage. If your current company or school doesn’t cover transition-related care, you might want to advocate for coverage.

Understand informed consent vs. WPATH standards

Before choosing a plan and care provider, find out about your potential provider’s ethical approach. An informed consent model of care allows you to make your own transition-related decisions after being informed of the risks by a physician. The WPATH standards of care might require additional steps, such as letters of support from therapists and other providers.

Look into pre-authorization

You'll need to see your primary care physician before requesting pre-authorization for surgery. It is also known as prior authorization. You might need to gather documents such as letters from medical providers before applying. Depending on the plan you selected, your primary care physician can provide you with a referral. Keep in mind that the referral or pre-authorization may not guarantee the surgery or other procedures will be authorized. National Center for Transgender Equality addresses common health coverage questions related to pre-authorization that may be helpful. It may be a good idea to speak with your health coverage provider directly.

Appeal denials

If you are denied coverage for a transition-related procedure, do not be afraid to appeal your insurance provider’s decision. Some exclusions might be prohibited or deemed discriminatory.

Outside of partial or full health insurance coverage, there are several other options for financing gender confirmation surgery, such as loans, lines of credit, grants and scholarships and fundraising.

There are several different personal loans you can use to fund your transition-related care.

• Bank or credit union loans: To qualify for a loan from a bank or credit union, you’ll need a good credit score and history.
• Family loans: If a family member can extend you a personal loan, consider creating a promissory note so that you have a repayment schedule in writing.
• Online loans: If your credit history is less than ideal, an online personal loan could be a good option.

Grants and Scholarships

Several organizations offer grants and scholarships to cover some or all of the costs associated with gender-confirming surgeries. These can help you avoid or offset any potential medical debt .

• The Jim Collins Foundation : The Jim Collins Foundation is dedicated to funding gender-confirming surgeries for trans people who need them. Grants are awarded on an annual basis.
• Genderbands Transition Grants : Genderbands offers transition grants to offset the expense of gender confirmation surgery for trans and nonbinary recipients.
• Rizi Xavier Timane Trans Surgery Grant : Rizi Xavier Timane, DSW, established a grant program to aid in the costs of gender-confirming surgeries for trans and nonbinary individuals.
• TransMission : The Loft LGBTQ+ Community Center’s TransMission is a small scholarship fund that helps trans and nonbinary recipients with medical, surgical and legal expenses.
• Stealth Bros & Co. Surgery Support Fund : The Stealth Bros & Co. Support Fund offers financial aid to trans men and transmasculine people for surgery, hormone therapy and related expenses.
• Black Transmen, Inc. Surgery Scholarship : Black trans men in the U.S. who have already been approved for surgery by a surgeon can apply for up to $1,000 in financial assistance.
• Point of Pride : Point of Pride offers scholarship-like funding for gender-confirming surgeries on an annual basis with a competitive application process each November.

Fundraising

Many people may raise funds for their gender confirmation surgery. For example, some throw parties with suggested donation amounts so friends, family and other supporters come together. Others raise money for their procedures by selling original art and letting would-be buyers know that they’re supporting a good cause.

Line of Credit

A home equity line of credit (HELOC) is one option if you own your home. With a HELOC, you can borrow against your home’s appraised value and repay it over time.

Certain surgeons partner with medical financing companies to help gender confirmation surgery patients make payments over time. You may want to check your credit score with a free report . Other surgeons allow patients to make smaller payments in installments.

Advocacy Organizations Making a Change

Many LGBTQ advocacy organizations are making a difference in the lives of transgender and gender non-conforming people every day. Here are just a few of the LGBTQ charities , nonprofits and other organizations making positive changes.

• The Sylvia Rivera Law Project : In addition to impact litigation advocacy, the Sylvia Rivera Law Project offers legal services and resources to aid people in their journey toward gender self-determination.
• Transgender Legal Defense & Education Fund : The Transgender Legal Defense & Education Fund is a nonprofit that fights for trans rights and against discrimination. The organization’s Trans Health Project helps transgender people access trans-confirming health insurance.
• Transgender Law Center : The Transgender Law Center is a trans-led advocacy organization that offers educational materials and other resources around healthcare, immigration, incarceration and employment.
• National Center for Transgender Equality : The National Center for Transgender Equality offers educational materials, self-help guides and other resources for the trans community.
• SPARTA : SPARTA is a nonprofit organization dedicated to transgender, nonbinary and gender non-conforming people serving in the U.S. military.

Expert Insight on Financing Gender Confirming Surgery

• What steps should trans, nonbinary and gender non-conforming employees take when navigating health insurance coverage for gender confirmation surgery?
• What are some other factors that employees should consider in terms of transition-related care and employer-provided health insurance?
• What are the most important forms of support a trans or nonbinary person can get from their employer?
• What are some of the most common financial barriers faced by trans, nonbinary and gender non-conforming patients when seeking transition-related care, including gender affirmation surgery?
• What are the steps a transitioning individual might take to financially prepare for gender affirmation surgery?

Additional Resources for Trans-Related Healthcare and Support

If you are a transgender or gender non-conforming patient seeking funding or support for your gender confirmation surgery, various resources can help. Here are some of the best resources available for trans people, loved ones and allies who want to know more about gender confirmation surgery.

• National Center for Transgender Equality's Know Your Rights : The National Center for Transgender Equality regularly updates its guide to existing and expanding legal protections for trans people in the U.S.
• HealthCare.gov's Transgender Health Care : The website helps explain what to know about applying for Marketplace health insurance coverage as a trans or gender non-conforming patient.
• HRC's Corporate Equality Index : Human Rights Campaign (HRC) publishes an annual guide to workplace policies and benefits for LGBTQ employees, including a list of companies that offer trans-inclusive benefits.
• Transgender Law Center's Transgender Health Benefits Guide : The Transgender Law Center offers a guide to healthcare advocacy for trans and gender non-conforming patients, including advice on what to do if you face discriminatory denials of care.
• Out2Enroll : Out2Enroll helps members of the LGBTQ community find and enroll in health insurance plans.
• Trans-Health.com's Trans Health Clinics : The clinics in this list specialize in transition-related and trans-confirming care and mental health support.

Social Support

• Transbucket : Initially started in 2009, Transbucket is an online resource and peer-to-peer support group exclusively dedicated to trans participants, primarily discussing gender confirming surgeries and medical transition.
• Gender Spectrum : Gender Spectrum hosts online support groups for trans, nonbinary and gender non-conforming youth, as well as parents and educators.
• Sam & Devorah Foundation for Trans Youth : The Sam & Devorah Foundation for Trans Youth connects members of the trans community with mentors who can offer emotional support and advice as well as empowerment and "building the confidence and skills critical for self-agency and leadership."

Mental Health Support

• The Trevor Project : The Trevor Project provides a number of resources, including suicide prevention and crisis intervention services, to LGBTQ people under 25.
• Trans Lifeline : The Trans Lifeline is a hotline offering peer-to-peer support services for trans callers, as well as their family, friends and allies.
• The Tribe, LGBTribe : The LGBTribe offers mental health support and wellness tools to LGBTQ participants.

About Laura Dorwart

• American Psychiatric Association . " What Is Gender Dysphoria ." Accessed May 27, 2021 .
• CostHelper . " How Much Does Sex Reassignment Surgery Cost ." Accessed May 30, 2021 .
• Current Opinion in Endocrinology, Diabetes and Obesity . " Barriers to Health Care for Transgender Individuals ." Accessed May 28, 2021 .
• European Association of Urology . " First accurate data showing that male to female transgender surgery can lead to a better life ." Accessed May 19, 2023 .
• First Report Managed Care . " Transgender Patients: Calculating the Actual Cost ." Accessed May 30, 2021 .
• Gender Confirmation Center . " Techniques, Incisions, & Surgery Options Facial For Feminization Surgery ." Accessed May 30, 2021 .
• Grand View Research . " U.S. Sex Reassignment Surgery Market Size, Share & Trends Analysis Report by Gender Transition ." Accessed May 29, 2021 .
• Jones, Jeffrey M. Gallup . " LGBT Identification Rises to 5.6% in Latest U.S. Estimate ." Accessed June 1, 2021 .
• Mount Sinai Center for Transgender Medicine and Surgery . " Trans-masculine (Female to Male) Surgeries ." Accessed May 30, 2021 .
• National Center for Transgender Equality . " U.S. Trans Survey ." Accessed May 26, 2021 .
• Planned Parenthood . " Sex and Gender Identity ." Accessed May 25, 2021 .
• The International Center for Transgender Care . " Facial Masculinization Surgery ." Accessed May 30, 2021 .
• UCSF Transgender Care . " Information on Estrogen Hormone Therapy ." Accessed May 29, 2021 .
• UCSF Transgender Care . " Information on Testosterone Hormone Therapy ." Accessed May 29, 2021 .
• University of Utah Healthcare . " Transfeminine Bottom Surgery ." Accessed May 30, 2021 .
• Williams Institute at UCLA School of Law . " How Many Adults Identify as Transgender in the United States ." Accessed May 27, 2021 .
• Car Insurance
• Home Insurance
• Rental Insurance
• Life Insurance
• Refinancing
• Conventional Loan
• Business Credit Cards
• Student Credit Cards
• Balance Transfer Cards
• Credit Cards with Rewards
• Travel Credit Cards
• Cash Back Credit Cards

Find a Surgeon

Search by U.S. State, Procedure and Insurance Search by Country and Procedure Browse the Global Surgeon Maps

Gender Surgeons in United States

Learn about Surgeons in the U.S. who offer Male to Female (MTF) and Female to Male (FTM) procedures, also known as Gender Confirmation Surgery (GCS), Sex Reassignment Surgery (SRS) or Gender Reassignment Surgery (GRS).

Dr. Bauback Safa

Dr. Safa is an internationally renowned Reconstructive Microsurgeon and the Medical Director of the San Francisco Transgender Institute. He and his team have performed more than 700 Phalloplasty surgeries since 2012, making him one of the most experienced Phalloplasty surgeons in the world.

Dr. Scott Mosser

Dr. Mosser is an award-winning surgeon in San Francisco who has been helping transgender and non-binary patients for more than 13 years. He is board-certified by the American Board of Plastic Surgeons, co-founder of the American Society of Gender Surgeons (ASGS), Founder of the Gender Institute at Saint Francis Memorial Hospital, a member of WPATH, and co-chair of the Surgery and Beyond professional conference. Dr. Mosser is California’s FTN / FTM Top Surgery and Breast Augmentation expert.

Dr. Kriya Gishen

Dr. Kriya is an ivy-league trained plastic and craniofacial surgeon in Beverly Hills who specializes in Facial Feminization Surgery. Dr. Kriya is fellowship-trained in craniofacial surgery which gives her the knowledge and experience needed to perform reconstructive facial surgery with a high degree of skill and finesse. She is known not only for her surgical mastery but also for her deeply personal manner with her patients. In addition to Facial Feminization, Dr. Kriya is also highly proficient in Body Sculpting and Breast Augmentation.

Dr. Shareef Jandali

Dr. Jandali is a board-certified plastic surgeon in Connecticut who specializes in chest and breast surgery procedures. Dr. Jandali has earned a reputation for his advanced surgical skills, consistent results and personal approach to every patient. His expertise in the complex techniques used for gynecomastia surgery and breast reconstruction served as a solid foundation for becoming proficient in gender-affirming Top Surgery. Dr. Jandali further customizes these techniques based on each patient’s unique chest anatomy and surgery goals. He and his staff look forward to welcoming you to a transformative experience at Jandali Plastic Surgery.

Dr. Shahin Javaheri

Dr. Javaheri is a double board-certified plastic and reconstructive surgeon in San Francisco who specializes in facial, breast and body contouring procedures. With 27 years of experience, Dr. Javaheri has earned a reputation for his surgical skill, artistic touch and attention to detail. His work with transgender patients has focused on Facial and Body Feminization, Facial and Body Masculinization, Breast Augmentation, Body Sculpting and utilizing 3D technology to create patient-specific implants.

Dr. Tony Mangubat

Dr. Mangubat is a board-certified cosmetic surgeon in the Seattle area who has been performing gender-affirming for over twenty years. Dr. Mangubat specializes in Top Surgery, Breast Augmentation and Body Sculpting, Gender Confirming Facial Surgery and Hair Grafting. Dr. Mangubat’s excellent surgical skills, experience and dedication to transgender health have made him the most sought after surgeon for transgender surgery in the Pacific Northwest.

Dr. Lena Weinman

Dr. Weinman is the newest Cosmetic Surgeon to join Dr. Tony Mangubat’s practice, La Belle Vie Cosmetic Surgery, in Seattle, Washington. Dr. Weinman has a unique background that combines training in Obstetrics and Gynecology, non-surgical cosmetic treatments and cosmetic surgery. She has a long history of women’s health advocacy and is thrilled to extend her practice to the transgender and non-binary communities in providing gender-affirming surgical care. Dr. Weinman performs Top Surgery, Breast Augmentation and Body Sculpting.

Dr. Hope Sherie

Dr. Hope Sherie is a board-certified surgeon who has extensive training in transgender surgery procedures, including FTM Top Surgery and Orchiectomy. She is well-known for popularizing the Buttonhole Top Surgery method. Dr. Sherie is pleased to offer the highest level of surgical care at her practice in Charlotte, North Carolina.

Dr. Paul Mittermiller

Dr. Mittermiller is a board-certified craniofacial plastic surgeon in Los Angeles who specializes in gender-affirming facial surgery. He is one of few plastic surgeons in the U.S. with specialty training in craniofacial and Facial Feminization Surgery (FFS). Dr. Mittermiller has been actively involved in research to advance the field of facial surgery, and his published peer-reviewed research has gained recognition from prestigious journals including Plastic and Reconstructive Surgery . Dr. Mittermiller joined Align Surgical Associates in 2023 and practices at their Los Angeles location.

Dr. Breanna Jedrzejewski

Dr. Jedrzejewski is a plastic and reconstructive surgeon who serves the transgender, non-binary and gender-nonconforming community exclusively. Dr. Jedrzejewski’s commitment to research in advancing gender-affirming care is backed by a lifelong dedication to social justice. She seeks to understand the challenges marginalized communities experience accessing healthcare and to be a part of the change in improving that access. Dr. Jedrzejewski is highly trained and specializes in the full array of gender-affirming procedures, from facial and chest surgeries to genital reconstruction. She joined Align Surgical Associates in 2023 and works out of their San Francisco location.

Dr. Mark Youssef

Dr. Youssef is a top Cosmetic Surgeon in the greater Los Angeles area and Director of the Transgender Surgery Institute of Southern California. For trans men, women and gender-nonconforming clients in Los Angeles, Santa Monica, San Diego and elsewhere in Southern California, Dr. Youssef offers Top Surgery, Breast Augmentation and Facial Feminization Surgery.

Dr. John L. Whitehead

Dr. Whitehead is a board-certified surgeon and gender surgery specialist at Restore Medical Center, the only practice in Miami that is 100% dedicated to gender-affirming surgery. Dr. Whitehead was trained in the art of gender reassignment surgery by Dr. Harold Reed, the now-retired urologist who performed gender surgeries for decades in Miami. Dr. Whitehead is proud to honor the legacy of Dr. Reed and to serve the needs of the transgender community. He performs gender-affirming Vaginoplasty, as well as Top Surgery and Hysterectomy.

Dr. Christopher McClung

Dr. McClung is a board-certified urologist in Columbus, Ohio who specializes in gender-affirming genital surgery. His path to becoming a Gender Surgeon started with providing surgical solutions for complex urinary complications in patients who had bottom surgery elsewhere. In 2017, Dr. McClung started offering primary gender-affirming surgeries, including Vaginoplasty and Phalloplasty, and his practice is now fully dedicated to providing this care.

Dr. Daniel Medalie

Dr. Medalie is a board certified plastic and reconstructive surgeon who has been performing Gender Surgery procedures since 1996. Based in the Cleveland area, Dr. Medalie offers Top Surgery and Metoidioplasty for transmasculine people, and Breast Augmentation and Tracheal Shave for transfeminine people. His vast experience and consistently natural-looking results, along with his trans-friendly staff, have made Dr. Medalie’s Cleveland Plastic Surgery a popular choice.

Dr. Heidi Wittenberg

Dr. Wittenberg is a highly experienced urogynecologist and reconstructive pelvic surgeon in San Francisco who works exclusively with trans and non-binary patients. Dr. Wittenberg is the Director of MoZaic Care, which specializes in gender affirming genital and pelvic surgeries, a Founder Surgeon and Co-Director of the first SRC accredited Center of Excellence in Gender Confirmation Surgery at Greenbrae Surgery Center, and the Medical Director of the Gender Institute at Saint Francis Memorial Hospital.

Dr. Toby Meltzer

Dr. Meltzer is a plastic and reconstructive surgeon who has been performing gender-affirming procedures since the early ’90s. Dr. Meltzer is widely recognized as one of the leading surgeons in the field of Gender Surgery, having completed over 4000 surgeries. He currently performs approximately 200 genital reconstruction surgery cases per year in Scottsdale, Arizona.

Dr. Charles Garramone

Dr. Garramone is one of the most experienced Top Surgery surgeons in the world, having performed thousands of Top Surgery procedures since 2005. With Dr. Garramone, you won’t have to worry about what your Top Surgery results will look like. His FTM Top Surgery technique is sought after by thousands of patients for its consistent and predictable results.

Dr. Mang Chen

Dr. Chen is a highly experienced Reconstructive Urologist in San Francisco who specializes in bottom surgery procedures for transmasculine individuals. He has performed hundreds of Phalloplasty, Metoidioplasty and related procedures, and has deep expertise in urological repair surgeries.

Dr. Loren Schechter

Dr. Schechter is one of the country’s foremost experts on transgender surgery. He is the Medical Director of the Gender Affirmation Surgery Program at Rush University Medical Center in Chicago. Dr. Schechter has been performing gender-affirming surgeries for more than 20 years. Since 2013, he has performed approximately 100-150 gender-affirming procedures every year. He offers the full spectrum of gender-affirming procedures.

Dr. Andrew Watt

Dr. Watt is a Reconstructive Microsurgeon at the Buncke Clinic, widely considered to be the birthplace of microsurgery. He is a highly accomplished Phalloplasty surgeon, having performed hundreds of microvascular Phalloplasty and related procedures with his team in San Francisco.

Dr. Adam Bonnington

Dr. Bonnington is a highly skilled obstetrician-gynecologist in San Francisco who is passionate about working with underrepresented patient populations and has a particular interest in caring for transgender and gender expansive individuals. Dr. Bonnington joined MoZaic Care as a Surgical Associate in 2020 and performs Vaginoplasty, Orchiectomy and Hysterectomy.

Dr. Walter Lin

Dr. Lin is a fellowship-trained Plastic Surgeon at the Buncke Clinic in San Francisco. Dr. Lin has a sub-specialization in reconstructive microsurgery and is dedicated to the advancement of care in microsurgical reconstruction of the extremities, breast, and lymphatic systems. His experience in these areas has contributed to his exceptional skills in gender-affirming Top Surgery and Breast Augmentation.

Dr. Angela Rodriguez

Dr. Rodriguez is a board-certified plastic surgeon in San Francisco who is dedicated full time to providing surgical care for transgender patients. Dr. Rodriguez had 14 years of craniofacial, aesthetic and pediatric plastic surgery experience before becoming a Gender Surgeon. She has a special interest in Facial Feminization and is also highly proficient in Vaginoplasty and Top Surgery.

Dr. Daniel Crane

Dr. Crane is a plastic surgeon who joined Dr. Drew Schnitt’s Inspire Aesthetics in 2022, expanding access to gender-affirming surgical care in South Florida. After completing a highly specialized aesthetic surgery fellowship where he performed countless breast, body contouring and facial surgeries, Dr. Crane worked with Dr. Schnitt to refine his skills with Top Surgery and Facial Feminization. His broad training in plastic and aesthetic surgery provides him with the knowledge and experience to help you achieve your transition goals.

Masks Strongly Recommended but Not Required in Maryland

Respiratory viruses continue to circulate in Maryland, so masking remains strongly recommended when you visit Johns Hopkins Medicine clinical locations in Maryland. To protect your loved one, please do not visit if you are sick or have a COVID-19 positive test result. Get more resources on masking and COVID-19 precautions .

• Vaccines  
• Masking Guidelines
• Visitor Guidelines  

Vaginoplasty for Gender Affirmation

Featured Experts:

Fan Liang, M.D.

Andrew Jason Cohen, M.D.

Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

1 of 4 in series. Enlarged image .

2 of 4 in series. Enlarged image .

3 of 4 in series. Enlarged image .

4 of 4 in series. Enlarged image .

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

Find a Doctor

Specializing In:

• Gender Affirmation Surgery
• Transgender Health

Find a Treatment Center

• Center for Transgender and Gender Expansive Health
• Plastic and Reconstructive Surgery

Find Additional Treatment Centers at:

• Howard County Medical Center
• Sibley Memorial Hospital
• Suburban Hospital

Request an Appointment

Phalloplasty for Gender Affirmation

Top Surgery

Facial Masculinization Surgery

Related Topics

• LGBTQ Health
• Gender Affirmation

• Today's news
• Reviews and deals
• Climate change
• 2024 election
• Newsletters
• Fall allergies
• Health news
• Mental health
• Sexual health
• Family health
• So mini ways
• Unapologetically
• Buying guides

Entertainment

• How to Watch
• My watchlist
• Stock market
• Biden economy
• Personal finance
• Stocks: most active
• Stocks: gainers
• Stocks: losers
• Trending tickers
• World indices
• US Treasury bonds
• Top mutual funds
• Highest open interest
• Highest implied volatility
• Currency converter
• Basic materials
• Communication services
• Consumer cyclical
• Consumer defensive
• Financial services
• Industrials
• Real estate
• Mutual funds
• Credit cards
• Balance transfer cards
• Cash back cards
• Rewards cards
• Travel cards
• Online checking
• High-yield savings
• Money market
• Home equity loan
• Personal loans
• Student loans
• Options pit
• Fantasy football
• Pro Pick 'Em
• College Pick 'Em
• Fantasy baseball
• Fantasy hockey
• Fantasy basketball
• Download the app
• Daily fantasy
• Scores and schedules
• GameChannel
• World Baseball Classic
• Premier League
• CONCACAF League
• Champions League
• Motorsports
• Horse racing

New on Yahoo

• Privacy Dashboard

Fact Check: Trump Falsely Claimed Kids Go to School and Come Back with 'Sex-Change Operations'

Children in the U.S. have gone to school and returned home having received gender-affirming surgeries.

During the final stretch of former U.S. President Donald Trump's presidential campaign in 2024, a claim that attempts to tap into transphobia and U.S. parents' fears over what happens in schools without their knowledge or approval emerged as a recurring talking point.

On multiple occasions, Trump alleged — without citing evidence — that children have gone to school and returned home later having received gender-affirming surgeries, or that school officials somehow "changed the sex" of children.

For instance, while speaking to a crowd in Tucson, Arizona, on Sept. 12, 2024, Trump spoke of what he called "transgender insanity" occurring in the U.S., and then said, "Can you imagine your child goes to school and they don't even call you, and they change the sex of your child?"

The crowd's negative reaction suggested they believed he had described a documented scenario.

Trump: Can you imagine your child goes to school and they don't even call you and they change the sex of your child. pic.twitter.com/yuBORGBwY8 — Acyn (@Acyn) September 12, 2024

However, we uncovered no evidence of children going to school to receive any sort of sex-change operation or gender-affirming surgery. For this reason, and another we'll mention shortly, we rated this claim as "False."

Before the remark on Arizona, on Sept. 9, Trump said during a Wisconsin campaign rally, " 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?"

In an article that also debunked the assertion, NBC News reported:

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.

Days before the Wisconsin speech, on Aug. 30, Trump uttered the same claim in slightly different words during a discussion with Tiffany Justice, co-founder of the conservative organization Moms for Liberty.

Justice brought up the subject of children identifying as transgender, telling Trump, "There's been an explosion in the number of children who identify as transgender, and children are being taught that they were born in the wrong body. It's an incredibly abusive message to send. So let's talk a little bit about some of the things that you might be able to do as president."

Trump answered, "Well, you can do everything. President has such power. It does. It has such power."

Moments later, he added, "But the transgender thing is incredible. Think of it. 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. And you know, many of these childs [sic] 15 years later say, 'What the hell happened? Who did this to me?' They say, 'Who did this to me?' It's incredible."

Readers can watch these remarks in this video from the LiveNOW from Fox YouTube channel beginning at the 38:11 mark:

There's No Evidence of Children Receiving Gender-Affirming Surgeries at School

CNN extensively reported on this claim about children supposedly going to school and receiving gender-affirming surgeries, as well as other statements Trump made during the discussion with Justice. The article featured interviews with medical professionals who refuted the idea of childrens' surgeries being secretly carried out by or with the involvement of schools.

For example, Dr. Meredithe McNamara , an assistant professor of pediatrics specializing in adolescent medicine at the Yale School of Medicine, told CNN, "Of course everything in this statement is false," in reference to Trump's remark about children going to school and supposedly coming home "a few days later with an operation." By email, we asked McNamara whether she had ever seen evidence of even one such surgery occurring inside a U.S. school. She answered, "No, I absolutely have not."

In CNN's reporting, the network also said Justice responded to its correspondence, saying in part, "Are kids getting surgery in school? No they're not." CNN further reported that Trump's campaign shared no evidence of any such activity occurring inside schools.

Snopes contacted other professionals in the field of pediatrics and the Trump campaign, but we did not yet receive responses.

We reached out to Moms for Liberty by email to ask further questions. In response, we received several statements, including one scolding CNN for not including part of the organization's correspondence that detailed five court cases involving lawsuits about schools assisting students in "socially transitioning" from one gender to another. To be clear, none of the five cases involved children undergoing medical operations inside of schools.

Trump Tied Olympic Athletes' Genders into the Claim

On at least two speaking occasions, Trump connected the false claim about surgeries taking place inside schools with references to Algerian female boxer Imane Khelif and Taiwanese female boxer Lin Yu-ting — who were accused of transitioning from male to female to cheat and win gold medals at the 2024 Paris Olympics. However, as we previously reported , Khelif was assigned female at birth, meaning she has always lived as a woman. Yahoo Sports published the same about Lin.

For further reading, we previously reported about a false rumor claiming 2024 Democratic vice-presidential nominee and Minnesota Gov. Tim Walz signed a bill allowing "gender reassignment surgery for children" in his state.

"About." Moms for Liberty , https://www.momsforliberty.org/about/ .

Baker, Katie J. M. "When Students Change Gender Identity, and Parents Don't Know." The New York Times , 22 Jan. 2023, https://www.nytimes.com/2023/01/22/us/gender-identity-students-parents.html .

Beacham, Greg. "Boxer Lin Yu-Ting Wins Gold, Following Imane Khelif to Conclude an Olympics Filled with Scrutiny." The Associated Press , 10 Aug. 2024, https://apnews.com/article/olympics-2024-boxing-lin-khelif-28d3e1a46ed8fe5c1aa6cd612e2561ca .

Dale, Daniel. "Fact Check: Trump Falsely Claims Schools Are Secretly Sending Children for Gender-Affirming Surgeries | CNN Politics." CNN , 4 Sept. 2024, https://www.cnn.com/2024/09/04/politics/donald-trump-fact-check-children-gender-affirming-surgery/index.html .

"FULL REMARKS: Trump Attends Moms for Liberty 2024 Summit." YouTube , LiveNOW from FOX, 30 Aug. 2024, https://www.youtube.com/watch?v=86clTu93p50 .

"Imane Khelif's Olympic Gold Inspires Algerian Girls to Take up Boxing." The Associated Press , 5 Sept. 2024, https://apnews.com/article/algeria-boxing-imane-khelif-567f5ea9f008642010e6cf8fef7245c4 .

"IOC 'saddened by Abuse' of 2 Boxers over Gender." ESPN.com , 1 Aug. 2024, https://www.espn.com/olympics/story/_/id/40702393/ioc-saddened-abuse-two-boxers-gender-paris-olympics .

Kasprak, Alex. "Olympic Boxer Imane Khelif Is Neither Trans Nor Male." Snopes , 6 Aug. 2024, https://www.snopes.com//news/2024/08/05/imane-khelif-not-trans/ .

Leicester, John. "IOC Calls Tests That Sparked Vitriol Targeting Boxers Imane Khelif and Lin Yu-Ting Impossibly Flawed." The Associated Press , 4 Aug. 2024, https://apnews.com/article/olympics-2024-imane-khelif-lin-yuting-boxing-13e9529195585404c7b03c96f97dd634 .

Rascouët-Paz, Anna. "Walz Didn't Sign Bill Permitting 'Gender Reassignment Surgery for Children.'" Snopes , 12 Aug. 2024, https://www.snopes.com//fact-check/walz-gender-reassignment-surgery-children/ .

The Associated Press. "Moms for Liberty Fully Embraces Trump and Widens Role in National Politics as Election Nears." KNSI , 3 Sept. 2024, https://knsiradio.com/2024/09/03/moms-for-liberty-fully-embraces-trump-and-widens-role-in-national-politics-as-election-nears-2/ .

"Transgender Surgeries & Gender Affirmation." Mount Sinai Health System , https://www.mountsinai.org/locations/center-transgender-medicine-surgery/care/surgery .

Wetzel, Dan. "Lin Yu-Ting, Boxer Embroiled in Gender Controversy, Wins Olympic Gold Medal in 57kg Women's Final." Yahoo Sports , 10 Aug. 2024, https://sports.yahoo.com/lin-yu-ting-boxer-embroiled-in-gender-controversy-wins-olympic-gold-medal-in-57kg-womens-final-194703156.html .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

Affiliations.

• 1 From the Department of Plastic and Reconstructive Surgery.
• 2 School of Medicine.
• 3 Department of Obstetrics and Gynecology.
• 4 Department of Urology.
• 5 Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, VA.
• PMID: 36149983
• DOI: 10.1097/SAP.0000000000003233

Background: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

Methods: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

Results: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

Conclusion: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest and sources of funding: none declared.

Similar articles

• Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Robinson IS, et al. J Sex Med. 2021 Apr;18(4):800-811. doi: 10.1016/j.jsxm.2021.01.183. Epub 2021 Mar 1. J Sex Med. 2021. PMID: 33663938
• Prospective Evaluation of Psychosocial Changes After Chest Reconstruction in Transmasculine and Non-Binary Youth. Boskey ER, Jolly D, Kant JD, Ganor O. Boskey ER, et al. J Adolesc Health. 2023 Sep;73(3):503-509. doi: 10.1016/j.jadohealth.2023.04.029. Epub 2023 Jun 5. J Adolesc Health. 2023. PMID: 37278674
• Partial Regret After Gender Affirmation Surgery of a 35-Year-Old Taiwanese Transgender Woman. Shen WV, Shen BH. Shen WV, et al. Arch Sex Behav. 2023 Apr;52(3):1345-1351. doi: 10.1007/s10508-022-02442-0. Epub 2022 Oct 17. Arch Sex Behav. 2023. PMID: 36253559
• Current Concepts in Feminizing Gender Surgery. Safa B, Lin WC, Salim AM, Deschamps-Braly JC, Poh MM. Safa B, et al. Plast Reconstr Surg. 2019 May;143(5):1081e-1091e. doi: 10.1097/PRS.0000000000005595. Plast Reconstr Surg. 2019. PMID: 31033837 Review.
• Gender Affirmation Surgery, Transfeminine. Elyaguov J, Schardein JN, Sterling J, Nikolavsky D. Elyaguov J, et al. Urol Clin North Am. 2022 Aug;49(3):437-451. doi: 10.1016/j.ucl.2022.05.001. Epub 2022 Jun 29. Urol Clin North Am. 2022. PMID: 35931435 Review.
• Endocrine, gender dysphoria, and sexual function benefits of gender-affirming bilateral orchiectomy: patient outcomes and surgical technique. Stelmar J, Victor R, Yuan N, Smith SM, Mallavarapu S, Sandhu S, Garcia MM. Stelmar J, et al. Sex Med. 2024 Aug 29;12(4):qfae048. doi: 10.1093/sexmed/qfae048. eCollection 2024 Aug. Sex Med. 2024. PMID: 39211910 Free PMC article.
• Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Straub JJ, Paul KK, Bothwell LG, Deshazo SJ, Golovko G, Miller MS, Jehle DV. Straub JJ, et al. Cureus. 2024 Apr 2;16(4):e57472. doi: 10.7759/cureus.57472. eCollection 2024 Apr. Cureus. 2024. PMID: 38699117 Free PMC article.
• Pain mechanisms in the transgender individual: a review. Anger JT, Case LK, Baranowski AP, Berger A, Craft RM, Damitz LA, Gabriel R, Harrison T, Kaptein K, Lee S, Murphy AZ, Said E, Smith SA, Thomas DA, Valdés Hernández MDC, Trasvina V, Wesselmann U, Yaksh TL. Anger JT, et al. Front Pain Res (Lausanne). 2024 Mar 27;5:1241015. doi: 10.3389/fpain.2024.1241015. eCollection 2024. Front Pain Res (Lausanne). 2024. PMID: 38601924 Free PMC article. Review.
• Do we urologists know enough about gender minorities with prostate cancer? Javaroni V. Javaroni V. Int Braz J Urol. 2024 Jan-Feb;50(1):87-94. doi: 10.1590/S1677-5538.IBJU.2023.9914. Int Braz J Urol. 2024. PMID: 38166225 Free PMC article. No abstract available.
• Knowledge, Attitudes, and Beliefs of Medical Students Toward Transgender Healthcare: A Community-Driven Initiative. Sengupta T, Soni T, Bolock AM, Heisey SA, Kuchinski EC, Piper BJ, Joyce JM, Carbe CJ. Sengupta T, et al. Cureus. 2023 Dec 5;15(12):e49992. doi: 10.7759/cureus.49992. eCollection 2023 Dec. Cureus. 2023. PMID: 38058529 Free PMC article.
• Edgerton MT Jr., Langman MW, Schmidt JS, et al. Psychological considerations of gender reassignment surgery. Clin Plast Surg . 1982;9:355–366.
• Van de Grift TC, Elaut E, Cerwenka SC, et al. Surgical satisfaction, quality of life, and their association after gender-affirming surgery: a follow-up study. J Sex Marital Ther . 2018;44:138–148.
• Van de Grift TC, Pigot GLS, Kreukels BPC, et al. Transmen's experienced sexuality and genital gender-affirming surgery: findings from a clinical follow-up study. J Sex Marital Ther . 2019;45:201–205.
• Tucker RP, Testa RJ, Simpson TL, et al. Hormone therapy, gender affirmation surgery, and their association with recent suicidal ideation and depression symptoms in transgender veterans. Psychol Med . 2018;48:2329–2336.
• Van der Sluis WB, Bouman MB, de Boer NK, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med . 2016;13:702–710.
• Search in MeSH

LinkOut - more resources

Full text sources.

• Ovid Technologies, Inc.
• Wolters Kluwer
• MedlinePlus Health Information

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Transgenderism, Sex Reassignment Surgery and Employees’ Job-Satisfaction

• First Online: 26 April 2016

Cite this chapter

• Nick Drydakis 2 , 3  

5049 Accesses

10 Citations

2 Altmetric

The current study examines the association between sex reassignment surgery (i.e., genital reconstruction surgery) and job satisfaction. For a period of 3 years (2012–2014), 23 biological male employees and 17 biological female employees who underwent sex reassignment surgery were periodically interviewed in the city of London (UK). By collecting longitudinal quantitative data before and after their sex reassignment surgery, associations between masculinity, femininity, pre- and post-sex reassignment surgery, life satisfaction and job satisfaction were analyzed. Utilizing random effect models the estimations suggest that, for both male to female, and female to male groups, sex reassignment surgery entails job satisfaction adjustments. In addition, interaction effects suggest that, with sex reassignment surgery life satisfaction, femininity for males to females, and masculinity for females to males can positively impact on transgender employees’ job satisfaction. We suggest that if sex reassignment surgery is correlated with better mental health, improved body and mental satisfaction in relation to gender identity, and more commitment to work due to better psychology, then job satisfaction might be positively affected by sex reassignment surgery since these factors are perceived to have a direct impact on the happiness individuals receive from their jobs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or eBook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Exploring Job Satisfaction by Sexual Orientation, Gender, and Marital Status

Sexual orientation and job satisfaction: survey-based evidence from sweden.

Personal Endorsement of Ambivalent Sexism and Career Success: an Investigation of Differential Mechanisms

Archer, J., & Lloyd, B. (2002). Sex and gender . Cambridge: Cambridge University Press.

Book   Google Scholar  

Bem, S. L. (1981). Bem sex role inventory: Professional manual . Palo Alto, CA: Consulting Psychologists Press.

Google Scholar  

Bowling, A. (2004). Measuring health (3rd ed.). Maidenhead: Open University Press.

Bowling, N. A., Eschleman, K. J., & Wang, Q. (2010). A meta-analytic examination of the relationship between job satisfaction and subjective well-being. Journal of Occupational and Organizational Psychology, 83 , 915–934.

Article   Google Scholar  

Colton Meier, S. L., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The effects of hormonal gender affirmation treatment on mental health in female-to-male transsexuals. Journal of Gay and Lesbian Mental Health, 15 , 281–299.

Davis, S. A., & Meier, C. B. (2014). Effects of testosterone treatment and chest reconstruction surgery on mental health and sexuality in female-to-male transgender people. International Journal of Sexual Health, 26 , 113–128.

Drydakis, N. (2015). Effect of sexual orientation on job satisfaction: Evidence from Greece. Industrial Relations: A Journal of Economy and Society, 54 , 162–187.

Grant, J. M., Mottet, L. A., Justin, T., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey . Washington, DC: The National Center for Transgender Equality and National Gay and Lesbian Task Force.

Law, C. L., Martinez, L. R., Ruggs, E. N., Hebl, M. R., & Akers, E. (2011). Trans-parency in the workplace: How the experiences of transsexual employees can be improved. Journal of Vocational Behavior, 79 , 710–723.

Leppel, K. (2014). Does job satisfaction vary with sexual orientation? Industrial Relations: A Journal of Economy and Society, 53 , 169–198.

Likert, R. (1932). A technique for the measurement of attitudes. Archives of Psychology, 140 , 1–55.

Locke, E. A. (1976). The nature and causes of job satisfaction. In M. D. Dunnette (Ed.), Handbook of industrial and organisational psychology . Chicago: Rand McNally.

Locke, E. A. (1984). Job satisfaction. In M. Gruneberg & T. Wall (Eds.), Social psychology and organizational behaviour (pp. 92–117). London: Willey.

McNeil, J., Bailey, L., Ellis, S., Morton, J., & Regan, M. (2012). Trans mental health study 2012 . Edinburgh: The Scottish Transgender Alliance.

Meads, D. M., McKenna, S. P., & Doward, L. C. (2006). Assessing the cross-cultural comparability of the Centre for Epidemiologic Studies Depression Scale (CES-D). Value in Health, 9 , A324–A324.

Morton, J. (2008). Transgender experiences in Scotland . Edinburgh: Scottish Transgender Alliance.

National Archives. (1999). The sex discrimination (gender reassignment) regulations 1999 . Norwich: National Archives.

Ozkan, T., & Lajunen, T. (2005). Masculinity, femininity, and the BEM sex role inventory in Turkey. Sex Roles, 52 , 103–110.

Robbins, S. (1993). Organizational behaviour: Concepts, controversies, and applications . New Jersey: Prentice Hall.

Saari, L. M., & Judge, T. A. (2004). Employee attitudes and job satisfaction. Human Resource Management, 43 , 395–407.

Schilt, K., & Wiswall, M. (2008). Before and after: Gender transitions, human capital, and workplace experiences. The B.E. Journal of Economic Analysis and Policy, 8 , 1–28.

Whittle, S., Turner, L., Al-Alami, M., Rundall, E., & Thom, B. (2007). Engendered penalties: Transgender and transsexual people’s experiences of inequality and discrimination . London: The Equalities Review.

Xiumei, Y., Meifang, W., & Qing, Z. (2012). Effects of gender stereotypes on spontaneous trait inferences and the moderating role of gender schematicity: Evidence from Chinese undergraduates. Social Cognition, 30 , 220–231.

Download references

Author information

Authors and affiliations.

Department of Economics and International Business, Lord Ashcroft International Business School, Anglia Ruskin University, Cambridge, UK

Nick Drydakis

Institute for the Study of Labor, IZA, Forschungsinstitut zur Zukunft der Arbeit GmbH, Bonn, Germany

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Nick Drydakis .

Editor information

Editors and affiliations.

Dept of Mgmt, Vienna Univ of Economics & Business, Vienna, Austria

Thomas Köllen

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Drydakis, N. (2016). Transgenderism, Sex Reassignment Surgery and Employees’ Job-Satisfaction. In: Köllen, T. (eds) Sexual Orientation and Transgender Issues in Organizations. Springer, Cham. https://doi.org/10.1007/978-3-319-29623-4_5

Download citation

DOI : https://doi.org/10.1007/978-3-319-29623-4_5

Published : 26 April 2016

Publisher Name : Springer, Cham

Print ISBN : 978-3-319-29621-0

Online ISBN : 978-3-319-29623-4

eBook Packages : Business and Management Business and Management (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• JAMA Network
• PMC10448302

National Estimates of Gender-Affirming Surgery in the US

Jason d. wright.

1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York

Yukio Suzuki

Koji matsuo.

2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Dawn L. Hershman

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

Associated Data

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

This cohort study examines trends in inpatient and outpatient gender-affirming surgical procedures in the US and explores the temporal trends in the types of procedures across age groups.

What are the temporal trends in gender-affirming surgery (GAS) in the US?

In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants

This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures

Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance

Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Introduction

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 , 3 , 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 , 3 , 4 , 5 , 6 , 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

Data Sources

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

Patients and Procedures

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

Statistical Analysis

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

Abbreviations: GAS, gender-affirming surgery; NA, not available; NOS, not otherwise specified.

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

Abbreviations: GAS, gender-affirming surgery; NOS, not otherwise specified.

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

Limitations

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

Conclusions

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Supplement 1.

eTable. ICD-10 and CPT Codes of Gender-Affirming Surgery

Supplement 2.

Data Sharing Statement

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

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