Feminizing surgery encompasses procedures that alter your appearance to promote the matching of your body with your gender identity (gender congruence). Feminizing surgery includes many options, such as "top" surgery to increase the size of your breasts (breast augmentation). "Bottom" surgery can involve removal of your testicles (orchiectomy) or the removal of your testicles and penis and the creation of a vagina, labia and clitoris (vaginoplasty). You might also consider facial procedures or body-contouring procedures to create a more feminine appearance.
People who seek feminizing surgery, also called gender-affirming surgery, often do so as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth or sex-related physical characteristics (gender dysphoria).
Feminizing surgery isn't for all transgender women. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Prior to some types of surgery, you might be required to get recommendations from behavioral health providers, live as a female and be on feminizing hormone therapy for a specific period of time. Certain surgeries will alter your fertility and your sexual sensations, in addition to how you feel about your body.
Your doctor, as well as people who have had these surgeries, can help you weigh the risks and benefits.
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Why it's done
People who seek feminizing surgery experience discomfort or distress because their gender identity differs from their sex assigned at birth or sex-related physical characteristics (gender dysphoria).
For some transgender women, feminizing surgery is a natural step — and important to their sense of self. However, many don't choose to have surgery. Transgender people relate to their bodies differently and need to make individual choices that best suit their needs..
Feminizing surgeries are typically deferred until adulthood. Options include:.
- Surgical removal of the testicles (orchiectomy) alone
- Vaginoplasty, a procedure that includes the following
- Surgical removal of the penis (penectomy)
- Surgical removal of the testicles (orchiectomy)
- Surgical creation of a vagina using penile or colon tissue (vaginoplasty)
- Surgical creation of a clitoris (clitoroplasty)
- Surgical creation of labia (labioplasty)
- Surgery to increase breast size through implants, the placement of tissue expanders under breast tissue or the transplantation of fat from other parts of the body into the breast (top surgery for transgender women)
- Plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are altered to create a more feminine appearance (facial feminization surgery)
- Body-contouring procedures, such as a tummy tuck (abdominoplasty), buttock lift (gluteal augmentation) and a surgical procedure that uses a suction technique to remove fat from specific areas of the body (liposuction)
- Therapy and surgery to raise the voice pitch (voice feminizing therapy and surgery)
- Surgery to reduce the thyroid cartilage or Adam's apple (tracheal shave)
- A procedure to remove hair follicles from the back and side of the head and transplant them to balding areas (scalp hair transplant)
- A procedure that uses a laser to remove unwanted hair (laser hair removal) or a procedure that involves inserting a tiny needle into each hair follicle, emitting a pulse of electric current to damage and eventually destroy the follicle (electrolysis)
Feminizing surgery isn't for all trans women. Your doctor might recommend against these surgeries if you have:
- Unmanaged behavioral health conditions
- Uncontrolled significant health conditions
- Any condition that limits your ability to give your informed consent
Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and an adverse reaction to anesthesia. Other complications might include:
- Delayed wound healing
- Fluid accumulation beneath the skin (seroma)
- A solid swelling of clotted blood within your tissues (hematoma)
- Changes in skin sensation such as persistent pain, tingling, reduced sensation or numbness
- Damaged or dead body tissue (tissue necrosis) in the vagina and labia
- A blood clot in a deep vein (deep vein thrombosis) or a blood clot in a lung (pulmonary embolism)
- An abnormal connection between two body parts (fistula), such as between the bladder or bowel into the vagina
- Urinary problems, such as incontinence
- Pelvic floor dysfunction
- Permanent scarring
- Loss of sexual pleasure and functioning
- Worsening of an underlying behavioral health problem
Certain types of feminizing surgery can harm or end your fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your doctor about freezing your sperm (sperm cryopreservation) before moving forward.
How you prepare
Before feminizing surgery, you'll meet with your surgeon. Consult a surgeon who is board certified and experienced in the procedures you desire. Your surgeon will describe your options and potential results. The surgeon will provide information on the anesthesia, the location of the operation and the kind of follow-up procedures that you might need. Follow your doctor's specific instructions on preparing for your procedures, including guidelines on eating and drinking, adjusting current medications, and quitting smoking.
Although giving your informed consent after discussing the procedure’s risks and benefits is an acceptable standard of care, most surgeons will require you to meet certain criteria before having a feminizing surgery. To start, your surgeon will evaluate your health to rule out or address any medical conditions that might affect or contraindicate treatment. The evaluation might include:
- A review of your personal and family medical history
- A physical exam, including an assessment of your internal reproductive organs
- Lab tests measuring your lipids, blood sugar, blood count, liver enzymes, electrolytes and the hormone prolactin
- A review of your immunizations
- Age- and sex-appropriate screenings
- Identification and management of tobacco use, drug abuse, alcohol abuse, HIV and other sexually transmitted infections
- Discussion about sperm freezing (sperm cryopreservation)
A behavioral health evaluation by a provider with expertise in transgender health is also required. The evaluation might assess:
- Your gender identity and gender dysphoria
- The impact of your gender identity at work, school, home and social environments, including issues related to discrimination, relationship abuse and minority stress
- Mood or other mental health concerns
- Sexual health concerns
- Risk-taking behaviors, including substance use and use of nonmedical-grade silicone injections or unapproved hormone therapy or supplements
- Protective factors such as social support from family, friends and peers
- Your goals, risks and expectations of treatment and your future care plans
In addition, before having non-genital feminizing surgery, you’ll be required to have one letter of support from a behavioral health provider with expertise in transgender health. The letter must confirm that you meet the World Professional Association of Transgender Health (WPATH) standards of care criteria for surgery, including:
- Having the ability to make fully informed decisions and to consent to treatment
- Be managing any major medical or mental health problems
Before having genital surgery, you'll be required to obtain two letters of support, each from a behavioral health provider with expertise in transgender health. The letters must confirm that you meet the WPATH standards of care criteria, including:
- Undergoing hormone therapy as appropriate to your gender goals for at least 12 months, unless you have a medical contraindication or you're otherwise unable or unwilling to take hormones
- Living in a gender role that matches your gender identity for at least 12 continuous months
Since feminizing surgery might cause irreversible physical changes, you must give informed consent after thoroughly discussing:
- Risks and benefits
- Alternatives to surgery
- Expectations and goals
- Social and legal implications
- Potential complications
- Impact on sexual function and fertility
Health insurance coverage for feminizing surgical procedures is variable.
You also might consider talking to others who've had feminizing surgery. They can help you shape your expectations of what can be achieved and help prepare you for the recovery process, scarring and possible changes in sexual sensations. They might also have insight on what personal and social problems you might experience during treatment.
What you can expect
Facial feminization surgery
Facial feminization surgery includes a broad range of procedures to change masculine facial features into feminine features. You might have your hairline moved to create a smaller forehead, have your lips and cheekbones augmented with implants, or have your jaw and chin reshaped and resized. If you have bone reduced, you might need skin-tightening surgery.
These surgeries are typically outpatient, requiring no hospital stay. Recovery time for most of these procedures is about two weeks, though recovering from jaw procedures will take longer.
A tracheal shave is a procedure to minimize your thyroid cartilage or Adam's apple. During the procedure, a small incision will be made under your chin, in the shadow of your neck or in a skin fold to conceal the scar. Your surgeon will then reduce and reshape the cartilage. This is typically an outpatient procedure, requiring no hospital stay.
Top surgery for transgender women
Breast augmentation incisions
As part of top surgery for transgender women, your surgeon will make incisions around the areola, near the armpit or in the crease under the breast.
Placement of breast implants or tissue expanders
During top surgery for transgender women your surgeon will place the implants under breast tissue. If feminizing hormones haven't made your breasts large enough, you might need an initial surgery to have devices called tissue expanders placed in front of your chest muscles.
While the use of estrogen will stimulate breast growth, many people aren't satisfied with this growth alone. Top surgery for transgender women is a surgical procedure to increase your breast size that might involve implants, fat grafting or both.
Your surgeon will make incisions around the areola, near the armpit or in the crease under the breast. Next, your surgeon will place the silicone or saline implants under breast tissue. Alternatively, you could have fat, muscles or tissue from other parts of your body transplanted into your breasts.
If feminizing hormones haven't made your breasts large enough, you might need an initial surgery to have devices called tissue expanders placed in front of your chest muscles. You'll visit your doctor every few weeks to have a small amount of saline injected into the tissue expanders. This will slowly stretch your chest skin and other tissues to make room for the implants. When your skin has been sufficiently stretched, you'll have another surgery to remove the expanders and place your implants.
Anatomy before and after penile inversion
During a penile inversion your surgeon will make an incision in the area between your rectum and your urethra and prostate. This forms a tunnel that becomes your new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, penis or both. If you don't have enough penile or scrotal skin, your surgeon might take skin from your thighs, abdomen or another area of your body and use it for the new vagina as well.
Anatomy before and after bowel flap procedure
Your surgeon might do a bowel flap procedure if you don't have enough tissue or skin in your penis or scrotum. Your surgeon will move a segment of your colon or small bowel to form your new vagina. The segment is called a bowel flap or conduit. Your surgeon will reconnect the remaining parts of your colon.
Orchiectomy is a surgery to remove your testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers, such as spironolactone (Aldactone), and reduce the amount of estrogen needed to achieve and maintain your desired appearance.
This type of surgery is typically done on an outpatient basis. You will be given a local anesthetic, in which you're awake and only your testicular area is numbed, or you will be placed under general anesthesia, in which you're asleep for the surgery. To remove your testicles, your surgeon will make an incision in your scrotum and extract the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty, though some prefer to have orchiectomy alone without further genital surgery.
Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. In some techniques these are also used to create the labia (labiaplasty). To surgically create a clitoris (clitoroplasty), the tip (glans) of the penis and the nerves that supply it are used. Alternatively, skin can be taken from another area of the body or tissue from the colon to create the vagina. The testicles also are removed during the course of the surgery.
Some surgeons use a technique requiring electrolysis or laser hair removal in your penile and scrotal areas to provide hair-free tissue for the procedure. The process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.
After vaginoplasty, you'll have a tube (catheter) placed in your urethra to collect urine. You will need to be closely monitored either in the hospital or an associated care center for about a week after surgery. Recovery can take up to two months. Your doctor will provide instructions about when it's OK to begin sexual activity with your new vagina. You'll be given a set of vaginal dilators of increasing sizes that you'll insert in your vagina at time intervals to maintain, lengthen and stretch the size of your vagina. You will need to dilate on a regular basis indefinitely.
Keep in mind that because the prostate gland isn't removed during surgery, you will need to follow age-appropriate recommendations for prostate cancer screening. You might also develop urinary obstructive symptoms from benign enlargement of the prostate.
Research suggests that gender-confirming surgery can have a positive impact on your well-being and sexual function.
Long-term postoperative care and follow-up after surgical treatment for gender dysphoria also have been linked with good outcomes. Before you have surgery, talk to your surgeon, hormone-prescribing doctor — if you're taking hormones — and your behavioral health provider about what ongoing treatment you'll need.
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