gender reassignment surgery timeline

Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

Lots More Information

Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

Decreased antidepressant use
Decreased anxiety, depression, and suicidal ideation
Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

Both a man and a woman
Neither a man nor a woman
An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
Hysterectomy (uterus removal)
Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
Oophorectomy (ovary removal)
Phalloplasty (surgery to create a penis)
Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

Constructing a glans (head) to look more like a penis
Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals. Feminizing surgeries can include:

Breast augmentation
Facial feminization surgery
Penis removal (penectomy)
Scrotum removal (scrotectomy)
Testicle removal (orchiectomy)
Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
Vaginoplasty
Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

Gender nullification procedures
Penile preservation vaginoplasty
Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

Breast tissue removal
Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

Anesthesia risks
Hematoma, which is bad bruising
Poor incision healing

Complications from these procedures may be:

Acute kidney injury
Blood transfusion
Deep vein thrombosis, which is blood clot formation
Pulmonary embolism, blood vessel blockage for vessels going to the lung
Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
Surgical site infection
Urethral stricture or stenosis, which is when the urethra narrows
Urinary tract infection (UTI)
Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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American Society of Plastic Surgeons. What are the risks of transfeminine bottom surgery?

American Society of Plastic Surgeons. What are the risks of transmasculine top surgery?

Khusid E, Sturgis MR, Dorafshar AH, et al. Association between mental health conditions and postoperative complications after gender-affirming surgery . JAMA Surg . 2022;157(12):1159-1162. doi:10.1001/jamasurg.2022.3917

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Feminizing hormone therapy

Feminizing hormone therapy typically is used by transgender women and nonbinary people to produce physical changes in the body that are caused by female hormones during puberty. Those changes are called secondary sex characteristics. This hormone therapy helps better align the body with a person's gender identity. Feminizing hormone therapy also is called gender-affirming hormone therapy.

Feminizing hormone therapy involves taking medicine to block the action of the hormone testosterone. It also includes taking the hormone estrogen. Estrogen lowers the amount of testosterone the body makes. It also triggers the development of feminine secondary sex characteristics. Feminizing hormone therapy can be done alone or along with feminizing surgery.

Not everybody chooses to have feminizing hormone therapy. It can affect fertility and sexual function, and it might lead to health problems. Talk with your health care provider about the risks and benefits for you.

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Why it's done

Feminizing hormone therapy is used to change the body's hormone levels. Those hormone changes trigger physical changes that help better align the body with a person's gender identity.

In some cases, people seeking feminizing hormone therapy experience discomfort or distress because their gender identity differs from their sex assigned at birth or from their sex-related physical characteristics. This condition is called gender dysphoria.

Feminizing hormone therapy can:

Improve psychological and social well-being.
Ease psychological and emotional distress related to gender.
Improve satisfaction with sex.
Improve quality of life.

Your health care provider might advise against feminizing hormone therapy if you:

Have a hormone-sensitive cancer, such as prostate cancer.
Have problems with blood clots, such as when a blood clot forms in a deep vein, a condition called deep vein thrombosis, or a there's a blockage in one of the pulmonary arteries of the lungs, called a pulmonary embolism.
Have significant medical conditions that haven't been addressed.
Have behavioral health conditions that haven't been addressed.
Have a condition that limits your ability to give your informed consent.

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Research has found that feminizing hormone therapy can be safe and effective when delivered by a health care provider with expertise in transgender care. Talk to your health care provider about questions or concerns you have regarding the changes that will happen in your body as a result of feminizing hormone therapy.

Complications can include:

Blood clots in a deep vein or in the lungs
Heart problems
High levels of triglycerides, a type of fat, in the blood
High levels of potassium in the blood
High levels of the hormone prolactin in the blood
Nipple discharge
Weight gain
Infertility
High blood pressure
Type 2 diabetes

Evidence suggests that people who take feminizing hormone therapy may have an increased risk of breast cancer when compared to cisgender men — men whose gender identity aligns with societal norms related to their sex assigned at birth. But the risk is not greater than that of cisgender women.

To minimize risk, the goal for people taking feminizing hormone therapy is to keep hormone levels in the range that's typical for cisgender women.

Feminizing hormone therapy might limit your fertility. If possible, it's best to make decisions about fertility before starting treatment. The risk of permanent infertility increases with long-term use of hormones. That is particularly true for those who start hormone therapy before puberty begins. Even after stopping hormone therapy, your testicles might not recover enough to ensure conception without infertility treatment.

If you want to have biological children, talk to your health care provider about freezing your sperm before you start feminizing hormone therapy. That procedure is called sperm cryopreservation.

How you prepare

Before you start feminizing hormone therapy, your health care provider assesses your health. This helps address any medical conditions that might affect your treatment. The evaluation may include:

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

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

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

People younger than age 18, along with a parent or guardian, should see a medical care provider and a behavioral health provider with expertise in pediatric transgender health to discuss the risks and benefits of hormone therapy and gender transitioning in that age group.

What you can expect

You should start feminizing hormone therapy only after you've had a discussion of the risks and benefits as well as treatment alternatives with a health care provider who has expertise in transgender care. Make sure you understand what will happen and get answers to any questions you may have before you begin hormone therapy.

Feminizing hormone therapy typically begins by taking the medicine spironolactone (Aldactone). It blocks male sex hormone receptors — also called androgen receptors. This lowers the amount of testosterone the body makes.

About 4 to 8 weeks after you start taking spironolactone, you begin taking estrogen. This also lowers the amount of testosterone the body makes. And it triggers physical changes in the body that are caused by female hormones during puberty.

Estrogen can be taken several ways. They include a pill and a shot. There also are several forms of estrogen that are applied to the skin, including a cream, gel, spray and patch.

It is best not to take estrogen as a pill if you have a personal or family history of blood clots in a deep vein or in the lungs, a condition called venous thrombosis.

Another choice for feminizing hormone therapy is to take gonadotropin-releasing hormone (Gn-RH) analogs. They lower the amount of testosterone your body makes and might allow you to take lower doses of estrogen without the use of spironolactone. The disadvantage is that Gn-RH analogs usually are more expensive.

After you begin feminizing hormone therapy, you'll notice the following changes in your body over time:

Fewer erections and a decrease in ejaculation. This will begin 1 to 3 months after treatment starts. The full effect will happen within 3 to 6 months.
Less interest in sex. This also is called decreased libido. It will begin 1 to 3 months after you start treatment. You'll see the full effect within 1 to 2 years.
Slower scalp hair loss. This will begin 1 to 3 months after treatment begins. The full effect will happen within 1 to 2 years.
Breast development. This begins 3 to 6 months after treatment starts. The full effect happens within 2 to 3 years.
Softer, less oily skin. This will begin 3 to 6 months after treatment starts. That's also when the full effect will happen.
Smaller testicles. This also is called testicular atrophy. It begins 3 to 6 months after the start of treatment. You'll see the full effect within 2 to 3 years.
Less muscle mass. This will begin 3 to 6 months after treatment starts. You'll see the full effect within 1 to 2 years.
More body fat. This will begin 3 to 6 months after treatment starts. The full effect will happen within 2 to 5 years.
Less facial and body hair growth. This will begin 6 to 12 months after treatment starts. The full effect happens within three years.

Some of the physical changes caused by feminizing hormone therapy can be reversed if you stop taking it. Others, such as breast development, cannot be reversed.

While on feminizing hormone therapy, you meet regularly with your health care provider to:

Keep track of your physical changes.
Monitor your hormone levels. Over time, your hormone dose may need to change to ensure you are taking the lowest dose necessary to get the physical effects that you want.
Have blood tests to check for changes in your cholesterol, blood sugar, blood count, liver enzymes and electrolytes that could be caused by hormone therapy.
Monitor your behavioral health.

You also need routine preventive care. Depending on your situation, this may include:

Breast cancer screening. This should be done according to breast cancer screening recommendations for cisgender women your age.
Prostate cancer screening. This should be done according to prostate cancer screening recommendations for cisgender men your age.
Monitoring bone health. You should have bone density assessment according to the recommendations for cisgender women your age. You may need to take calcium and vitamin D supplements for bone health.

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Feminizing hormone therapy care at Mayo Clinic

Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Oct. 10, 2022.
Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Oct. 10, 2022.
Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
AskMayoExpert. Gender-affirming hormone therapy (adult). Mayo Clinic; 2022.
Nippoldt TB (expert opinion). Mayo Clinic. Sept. 29, 2022.
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What to Know About Metoidioplasty (Bottom Surgery)

Who Qualifies?
Surgical Techniques
Neophallus Function
Surgery Follow-Up
Where to Have Surgery

Metoidioplasty , or "bottom surgery," is a gender-affirming surgical procedure that involves creating a neophallus (new penis) from a hormonally enlarged clitoris . Transgender men and transmasculine people assigned female at birth (AFAB) may elect for a metoidioplasty if they want their genital appearance to align with their gender identity.

In contrast to the more complex phalloplasty that involves several surgeries, metoidioplasty offers a more straightforward phallic reconstruction in one procedure.

During a metoidioplasty, a surgeon cuts the ligaments that connect the clitoris to the pubic bone to release the clitoris and create a penis with erogenous (sexual) sensations. It may also include additional steps, such as urethral lengthening and scrotoplasty (forming a scrotum), to enhance the appearance and functionality of the neophallus.

This article explores metoidioplasty surgical techniques, the recovery process, and what to expect post-surgery.

CarlosDavid.org / Getty Images

Who Qualifies for Metoidioplasty Surgery?

Metoidioplasty is a gender-affirming (sex-reassignment) surgery for transgender men assigned female at birth. According to the 2015 U.S. Transgender Survey, about 4% of trans men have undergone the procedure, while another 53% expressed a desire to undergo metoidioplasty in the future.

The World Professional Association for Transgender Health (WPATH) developed the criteria for gender reaffirmation surgeries to ensure optimal physical and psychological outcomes for those pursuing bottom (genital) surgeries. The eligibility criteria for metoidioplasty include the following:

Ongoing and well-documented gender dysphoria
The ability to make informed decisions and provide consent for treatment
Being 18 years of age or older
Medical or mental health concerns are well-managed (if applicable)
At least 12 consecutive months of gender-affirming testosterone therapy
Living as a male or masculine-presenting person for at least one year in all settings (e.g., work, school, with family members and community)

Though it is not required, regular visits with a mental health or other medical professional are highly recommended before undergoing a metoidioplasty.

Metoidioplasty Surgical Techniques

People can choose a few different metoidioplasty surgical techniques depending on their preferences. Other procedures can occur simultaneously (e.g., hysterectomy) if desired.

Simple Release Metoidioplasty

In the simple release procedure, ligaments attached to the pubic bone are cut and released, and the clitoris is separated from surrounding tissue to enhance the position and visibility of the clitoris. The labia minora are wrapped around the clitoris to create the glans (head) of the newly formed penis.

Ring Metoidioplasty

Similar to the simple release, this technique involves releasing the clitoral ligaments to lengthen the clitoris. This procedure also involves lengthening the urethra using a flap of tissue from the vaginal wall and labia minora. This procedure gives trans men a micropenis with more girth and the ability to stand while urinating.

Belgrade (Full) Metoidioplasty

The Belgrade technique, or full metoidioplasty, involves the removal of the vagina (vaginectomy) and releasing the clitoris to lengthen and straighten the clitoris. The urethra is lengthened using vaginal tissue and buccal mucosa (inner cheek) skin grafts. The penis is reconstructed with the remaining clitoral and labial skin to give it more girth.

Then, the labia minor flaps are joined to create a scrotum (scrotoplasty), and testicular implants may be inserted into the newly created scrotum. A penile pump or vacuum is recommended three weeks post-surgery to lengthen the neophallus and prevent retraction.

Simultaneous Procedures

In addition to metoidioplasty, some trans men may opt for additional procedures performed at the same time to achieve their desired outcomes. These procedures may include:

Hysterectomy : Removal of the uterus
Bilateral salpingo-oophorectomy : Removal of the ovaries and fallopian tubes
Vaginectomy : Removal of the vagina and surrounding tissues
Scrotoplasty : Forms a new scrotum; testicular implants may be placed to give the appearance of natural testicles
Erectile implant : A device is placed inside the neophallus to help achieve erections

Metoidioplasty vs. Phalloplasty

Metoidioplasty and phalloplasty are surgical options for transgender men seeking gender-affirming genital reconstruction. Metoidioplasty involves using existing genital tissue, such as the hormonally enlarged clitoris, to create a neophallus. It usually results in a smaller but functional neophallus.

Phalloplasty involves constructing a neophallus using various techniques, including grafting tissue from other body parts. This procedure can provide a larger and more visually realistic phallus but is more complex and may require multiple stages. The choice between metoidioplasty and phalloplasty depends on individual preferences, desired outcomes, and considerations such as surgical risk, recovery time, and aesthetic goals.

Risks to Understand Before Metoidioplasty

While metoidioplasty is generally considered safe, like any surgical intervention, it carries certain risks. Before undergoing metoidioplasty, discuss the risks with a healthcare provider to gain a comprehensive understanding and make an informed decision.

Potential risks include:

Urethral stricture or stenosis : Narrowing of the urethral passage, leading to difficulty with urination and potential obstruction of urine flow. Sometimes, urine flow may be blocked entirely, requiring surgery to correct the problem.
Urethral fistula : An abnormal connection or passageway between the urethra and the skin or surrounding tissues. This can result in urine leakage or an abnormal opening along the neophallus.
Sensation changes : The newly formed penis may have decreased or loss of sensation or feel hypersensitive and tender.

Function of Neophallus Post-Bottom Surgery

Trans men who have undergone metoidioplasty report high levels of satisfaction with the procedure's results, both in appearance and function.

While a neophallus created through metoidioplasty is usually considered a micropenis (1–4 inches), erections and orgasms are achieved by nearly all who have undergone the procedure. Penetrative sex may or may not be possible. Urinating while standing is possible for most men after metoidioplasty.

Metoidioplasty Recovery Period

The recovery period following metoidioplasty depends on the specific surgical technique and can vary from person to person. Most people can expect one week of bed rest immediately following the procedure and gradually resume their activities within about six weeks.

Initially, there will be discomfort, swelling, and bleeding in the genital region, which will gradually subside over time. You may also experience:

Bruising in the genital area that spreads from the belly down to the legs
Itching and short, sharp, shooting sensations as the area heals
Numbness at or near the incision sites, which can persist for months
Scarring on the genitals that will first appear red or pink and fade over time

Metoidioplasty Follow-Up (and Asking for Help)

You will need assistance and support during the follow-up period after metoidioplasty, as the recovery process can involve discomfort, limited mobility, and restricted activity. You will need a caretaker for at least a week or two after the procedure—someone who can help with daily tasks such as meal preparation, household chores, and running errands.

Your surgeon may restrict certain activities, such as driving, sex, and heavy lifting. You may need help with transportation to follow-up appointments for about six weeks. Most people can resume their normal activities within six weeks post-surgery. Still, getting the OK from a healthcare provider is important to ensure you are properly healed and to lower the risk of complications.

Where to Have Metoidioplasty Surgery

Specialized surgeons with experience in transgender healthcare often perform metoidioplasty surgery. The procedure is usually carried out in a hospital or surgical center with the necessary tools and equipment for the surgery. It is essential to choose a reputable medical facility that is experienced in transgender surgeries and maintains a supportive and inclusive environment.

When considering where to have metoidioplasty surgery, start by asking a mental health professional or another healthcare provider for referrals and recommendations of surgeons who specialize in the procedure. They can provide information and guidance on the options available to you.

Researching and gathering information about the surgeon's qualifications, experience, and success rates, as well as reading reviews or testimonials from other people who have undergone metoidioplasty at the facility, can also help you select the most suitable location for the surgery. Open communication with healthcare providers can ensure that all your questions and concerns are addressed before deciding where to have metoidioplasty surgery.

Metoidioplasty is a gender-affirming surgery for trans-male people assigned female at birth (AFAB). The procedure involves releasing the clitoral ligaments and utilizing the hormonally enlarged clitoris to create a neophallus (new penis).

There are a few different metoidioplasty techniques. Sometimes, people undergo simultaneous procedures, such as hysterectomy and vaginectomy. Metoidioplasty is considered a safe, effective procedure that results in a 1–4 inch functional penis that gives trans men the opportunity to align their physical characteristics with their gender identity.

Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: Techniques and outcomes . Transl Androl Urol . 2019;8(3):248-253. doi:10.21037/tau.2019.06.12

Kjölhede A, Cornelius F, Huss F, Kratz G. Metoidioplasty and groin flap phalloplasty as two surgical methods for the creation of a neophallus in female-to-male gender-confirming surgery: A retrospective study comprising 123 operated patients . JPRAS Open . 2019;22:1-8. doi:10.1016/j.jpra.2019.07.003

Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in gender affirmation: A review . Indian J Plast Surg . 2022;55(2):156-161. doi:10.1055/s-0041-1740081

National Center for Transgender Equality. Injustice at every turn: a report of the national transgender discrimination survey .

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

Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Phalloplasty: techniques and outcomes . Transl Androl Urol . 2019;8(3):254-265. doi:10.21037/tau.2019.05.05

Alberta Medical Association. Metoidioplasty .

Bordas N, Stojanovic B, Bizic M, et al. Metoidioplasty: Surgical options and outcomes in 813 cases . Front Endocrinol (Lausanne) . 2021;12:760284. doi:10.3389/fendo.2021.760284

TransCare BC. Provincial Health Services Authority. Metoidioplasty .

Michigan Medicine: University of Michigan. What to expect: Metoidioplasty at Michigan Medicine .

TransHealthCare. Metoidioplasty - list of surgeons in the USA .

November 16, 2016

A History of Transgender Health Care

As the stigma of being transgender begins to ease, medicine is starting to catch up

By Farah Naz Khan

This article was published in Scientific American’s former blog network and reflects the views of the author, not necessarily those of Scientific American

An estimated 1.4 million Americans, close to 0.6 percent of the population of the United States, identify as transgender. And, today, the topic of transgender health care is more widely discussed than ever before. Despite this, lost in the shuffle between conversations about equal access to bathrooms and popular culture icons is the history of a piece of modern medicine that should no longer remain so elusive. To be willing to embrace the future of this pivotal area of healthcare, it is imperative to understand the piecemeal roots and evolution of transgender medicine.

Magnus Hirschfeld, a German physician who could easily be considered the father of transgender health care, coined the term “ transvestite ” in 1918 at his Institute for Sexual Science in Berlin. Defining transvestism as the desire to express one’s gender in opposition to their defined sex, Hirschfeld and his colleagues used this now antiquated label as a gateway to the provision of sex changing therapies and as a means to protect his patients. Going against the grain, Hirschfeld was one of the first to offer his patients the means to achieve sex change, either through hormone therapy, sex change operations, or both.

In a time when his contemporaries aimed to “cure” transgender patients of their alleged mental affliction, Hirschfeld’s Adaptation Theory supported those who wanted to live according to the gender they felt most aligned with, as opposed to the gender that their sex obligated them to abide by. Much of the history of the institute’s early works were destroyed in the wake of the Nazi book burnings in 1933, but as far as history can prove, Hirschfeld’s institute was the first to offer gender reassignment surgery.

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In 1922, Hirschfeld performed castration on Dora Richter , one of the institute’s employees who later went on to complete her sex reassignment in 1931 with further surgeries at the institute. The institute's most famous patient was arguably Danish painter Lili Elbe (born Einar Wegener) whose life story has been fictionalized in the popular film The Danish Girl . Starting in 1930, Elbe had five surgeries performed as part of her male-to-female transition. Unfortunately, Elbe died from infection-related complications of her final surgery in 1931.

World War II and Nazi Germany forced Hirschfeld into exile and this along with the destruction of his Berlin institute, minimal further advancements were made by his group at that time. Pioneering influences in America began emerging in the 1940s, including Dr. Alfred Kinsey , the biologist who founded the Institute for Sex Research at Indiana University in 1947 (now known as the Kinsey Institute). Kinsey was one of the first to use the term transsexual in his gender studies, and he helped introduce America to a concept that for some reason still seems foreign to many today despite its obvious place in history for years.

The first American to undergo a sex change operation was Christine Jorgensen, who brought significant attention to the transgender revolution in America when her story hit New York Times headlines in 1952. Jorgensen’s willingness to publicly tell her story helped bring a face to the growing transgender revolution in the states, but at the time the lack of quality transgender healthcare in the U.S. meant that Jorgensen had to travel to Denmark to get the treatment she needed.

Following Jorgensen's successful treatment in Denmark by Dr. Christian Hamburger , many other transgender Americans wrote to Hamburger for similar treatment. Hamburger referred these individuals to endocrinologist Henry Benjamin, who had offices in both New York City and San Francisco. Benjamin had been studying transgender issues since at least the 1950s , but it was his 1966 book The Transsexual Phenomenon that left the most indelible impact on American transgender healthcare.

Having spent time with Hirschfeld and his Berlin institute, Benjamin supported the same principles, that those who feel their sex to be discordant from their gender deserve treatment in the form of hormonal therapy and reassignment surgeries and not psychotherapy for a “cure.” In covering such a highly stigmatized health care issue at the time of its publication, The Transsexual Phenomenon laid the foundation for modern transgender healthcare.

Over a decade later, a 1979 study out of Johns Hopkins called sex reassignment surgeries into question by suggesting that psychosocial outcomes in transgender patients who underwent reassignment surgery were not better than those who went without surgery. Despite criticism and a nod to flaws in its methodology, the study led to the closure of the Johns Hopkins Gender Identity Clinic and an end to the sex reassignment surgeries offered there.

In an attempt to standardize care in response to this study’s accusations, the Henry Benjamin International Gender Dysphoria Association, now better known as the World Professional Association for Transgender Health (WPATH), created the first version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Now in its seventh iteration, the WPATH Standards of Care provide guidance on everything from hormone therapy to surgical interventions and everything in between.

Despite all of the apparent advancements in transgender health care noted above, the 1980 addition of “ gender identity disorder ” to the American Psychiatric Association’s (APA) third Diagnostic and Statistical Manual (DSM-3) seemed like a giant leap backwards, but this controversial move actually helped transgender individuals gain access to an often impenetrable healthcare system. Slowly, but surely, strides were made towards removing the notion of “ disorder ” in the context of gender identity, and with the release of the DSM-5 in 2013, gender identity disorder was replaced with the diagnosis “gender dysphoria.”

Destigmatization of this diagnosis was a major milestone for transgender individuals in America, and further strides were achieved when a government appeals board in 2014 ruled that Medicare must cover surgery for gender transitions, overturning a policy that had been in place since the 1980s. Given that the surgeries are no longer experimental in nature and that the updated WPATH standards of care reference many studies which have proven the beneficial effects of sex reassignment therapy for transgender individuals, this ruling was a long time coming.

Gone are the days of rudimentary surgeries and experimental therapies, because we now know what works. And in an effort to make treatment of transgender patients even easier and more accessible for providers everywhere, in 2009, the Endocrine Society put together brief clinical practice guidelines . These guidelines cover diagnosis, treatment, and preventive care needs for transgender patients, while also drawing attention to the potential risks associated with gender transition therapies.

Modern transgender healthcare encompasses all of the above, along with a shift in focus on patient care. Our transgender patients are like all of our other patients, and their gender identity is just one facet of their overall identity. Multidisciplinary clinics that focus on key issues for transgender patients are important, because they can provide access to subspecialists who can focus on hormone therapy, fertility questions, mental health, etc—but equally important is the understanding that transgender patients need to be able to see a primary care physician for their common cold without fear of stigma due to their gender identity. We can only hope that these widespread stigmas and hesitancies will dissipate with time, because as history has clearly proven, where there is a will, there most certainly is a way.

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Transgender Surgical Program

617-726-3525

Contact Information

Phone: 617-726-3525 Fax: 617-724-7126

Email: [email protected]

Explore This Treatment

About gender-affirming surgery at mass general.

Specialists in the Transgender Health Program and Transgender Surgical Program at Massachusetts General Hospital are dedicated to ensuring a welcoming and affirming environment for all patients. We offer patients a wide spectrum of gender-affirming services to support them throughout their entire care journey, including comprehensive primary care, surgical treatment, hormone management, case management and behavioral health support.

The Transgender Surgical Program is a collaboration with specialists from the Mass General Division of Plastic and Reconstructive Surgery , the Department of Urology and the Department of Obstetrics and Gynecology . Our multidisciplinary surgical team works closely with providers from the Transgender Health Program and every patient to develop a safe and all-inclusive surgical plan that aligns with the patient’s personal goals.

Gender-Affirming Surgical Procedures

Our expert team performs a variety of highly specialized gender-affirming surgical procedures tailored to meet the needs of transgender and gender-nonconforming patients.

Vaginoplasty , sometimes referred to as bottom surgery, is a surgery that is used to create a vulva, labia, and vaginal canal
Orchiectomy , also known as testicle removal surgery and/or bottom surgery, is a procedure in which the testicles are surgically removed
Hysterectomy and/or oophorectomy is a surgery that involves the removal of the uterus and, in some case, the ovaries
Phalloplasty , sometimes referred to as bottom surgery, is surgery to create a penis. It can include a variety of different procedures, depending on individual goals
Mastectomy , sometimes referred to as top surgery, is a surgery to remove breast tissue from the chest
Breast augmentation is surgery that uses implants made of silicone or saline to enhance the size of a person’s natural breasts
Facial feminization or masculinization is surgery to alter facial features—the chin, nose, cheeks, forehead, etc.—to create a more feminine or masculine facial structure
Voice feminization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more feminine sound though surgery that involves lengthening the vocal cords or adjusting the tension of the vocal cords. Before undergoing surgical intervention, patients will work with a speech therapist specializing in voice feminization
Voice masculinization surgery is a procedure that alters the pitch and quality of an individual's voice to align it with a more masculine sound though surgery to decrease the tension of the vocal cords. In addition to surgery, some individuals may benefit from speech therapy to further refine their vocal skills and communication. This procedure is not common, as only 75% of people can masculinize their voice with hormone therapy

Frequently Asked Questions About Gender-Affirming Surgery

For genital or “bottom” surgery, the first step is to schedule an initial visit with the Transgender Health Program. To schedule this appointment, call 617-726-3525 or email us . For breast or “top” surgery, you are not required to schedule an intake visit with the Transgender Health Program, unless you need a referral for support services. Instead, please contact the Transgender Surgery Program team at 617-726-3525 to learn how to proceed with a surgical consult. Providers should fax referrals to 617-724-7126.

Following confirmation from the Transgender Health Program that you are ready to move forward with bottom surgery, the Transgender Surgery Program team will contact you to set up a surgical consult.

Fertility preservation offers the opportunity to freeze eggs or sperm to be used for building a family in the future. This can be done prior to initiation of gender affirming hormone therapy or surgery. For some, it can also be used after hormonal therapy has already been started. Resources and care are also available for coordinating use of eggs or sperm from another person (donor) or for another individual to carry a pregnancy (gestational carrier).

Patients who desire fertility preservation or family building through Mass General must:

Complete a consultation with the Mass General Fertility Center
Be of reproductive age (requirements vary by family building plan)
Follow center-specific guidance and protocols for selected treatment

During your surgical consultation, your physician will ask you about your fertility preservation goals and will assist you with setting up a consultation with a fertility specialist. We are committed to supporting you and guiding you through this process.

Required documents prior to gender-affirming surgery vary depending on the type of procedure. Our surgical program coordinator will assist you with questions and provide you with more information during your surgical consult.

Once we’ve scheduled a date for your surgery, we will submit a prior authorization for surgery to your insurance company for approval. Some out-of-network insurances may require you to obtain prior authorization for surgical consultations. Please reach out to your insurance company to determine what is required. Our dedicated surgical coordinator is happy to assist you with this process.

There are medical rates at many of the surrounding local hospitals. Depending on the procedure, you may need to remain local for a few weeks. If you are interested in medical rates, our dedicated surgical coordinator will be happy to provide you with more information.

Patient Stories

Patients who underwent gender-affirming surgery at Mass General share their experiences.

Finally, Herself: Elise’s Journey to Gender-Affirming Surgery

When Elise first heard of gender-affirming surgery, it seemed next to impossible in her situation. After a few years filled with research and conversations about her gender identity, what seemed impossible became achievable. She sought care with the Mass General Transgender Health Program team.

Tanner Chose Mass General for Gender-Affirming Care

"I wouldn’t have been able to do it if I didn’t have my team by my side every step of the way. I went from worrying, to feeling grateful," Tanner Bonanza, gender-affirming surgical patient.

Photo of patient Tanner Bonanza with a camera

Meet Our Team

The Mass General Transgender Surgical Program and the Transgender Health Program form a multidisciplinary and collaborative team of providers and staff who work together to provide gender-affirming care for all patients.

Jay Austen, MD

Chief, Plastic and Reconstructive Surgery
Chief, Division of Burn Surgery
Interim Chief of the Department of Oral & Maxillofacial Surgery

Branko Bojovic, MD

Plastic and Reconstructive Surgery
Department of Surgery

Katherine Carruthers, MD, MS

Attending Surgeon, Massachusetts General Hospital

Beth Drzewiecki, MD

Pediatric Urology, MassGeneral Hospital for Children

Rich Ehrlichman, MD

Assistant Professor of Surgery, Harvard Medical School
Assistant Surgeon, Massachusetts General Hospital

Ariel Frey-Vogel, MD, MAT

Primary Care
Department of Medicine
Department of Pediatrics

Youngwu Kim, MD

Urogynecologist
Urogynecology and Reconstructive Pelvic Surgeon

Jenny Siegel, MD

Eleanor Tomczyk, MD

Milena Weinstein, MD

Chief of Urogynecology and Reconstructive Pelvic Surgery (URPS)
Co-chair, Center for Pelvic Floor Disorders
Director of Research, Urogynecology and Reconstructive Pelvic Surgery Fellowship

Jonathan Winograd, MD

Associate Visiting Surgeon, Massachusetts General Hospital
Associate Professor, Harvard Medical School

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If you would like to request an appointment with or refer a patient to the Division of Plastic and Reconstructive Surgery, please use the following contact information.

Introduction
Conclusions
Article Information

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

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.

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

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

Data Sharing Statement

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

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

Findings 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.

Meaning 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.

Importance 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.

Objective 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.

Results 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.

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 - 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 - 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.

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.

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.

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.

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%]).

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 ).

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.

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.

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.

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.

Accepted for Publication: July 15, 2023.

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

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

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 .

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

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

Media Information

Release Date: September 16, 2022

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Kristin Samuelson

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

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

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

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

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

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

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

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

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

Transgender individuals’ right to bodily autonomy

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

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

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v.5(3); 2016 Jun

Laser hair removal for genital gender affirming surgery

William r. zhang, giorgia l. garrett, sarah t. arron, maurice m. garcia.

Genital gender affirming surgery (GAS) involves reconstruction of the genitals to match a patient’s identified sex. The use of hair-bearing flaps in this procedure may result in postoperative intra-vaginal and intra-urethral hair growth and associated complications, including lower satisfaction with genital GAS. Despite the significant increase in genital GAS within the past 50 years, there is limited data regarding hair removal practices in preparation for genital GAS and notable variation in hair removal techniques among dermatologists and other practitioners. We present a literature review, recommendations from our experience, and a practical laser hair removal (LHR) approach to hair removal prior to genital GAS.

Introduction

Genital gender affirming surgery (GAS) involves reconstruction of the genitals to match a patient’s identified sex. The use of hair-bearing flaps in this procedure may result in postoperative intra-vaginal and intra-urethral hair growth ( 1 ). This undesirable side effect is associated with irritation, infections, hairball and calculi formation, and ultimately a lower patient satisfaction with genital GAS ( 2 - 4 ). Because genital GAS aims to treat gender dysphoria—a condition diagnosed and deemed treated by self-reports ( 5 - 7 ) —addressing patient satisfaction is critical.

To prevent the unwanted hair growth and associated complications, genital GAS has become a recognized indication for hair removal ( 3 , 8 ). However, even with the significant increase in incidence of genital GAS within the past 50 years ( 9 , 10 ), there is limited data regarding hair removal practices in preparation for genital GAS and notable variation in hair removal techniques among practitioners. Consolidation of the limited literature can help guide the implementation of standardized care. To this end, we present a practical approach to hair removal prior to genital GAS. Modern hair removal techniques and a review of the literature provide context for our recommendations.

Hair removal techniques

Hair removal has advanced from physical methods of shaving, plucking, and waxing to the more technologically sophisticated techniques of electrolysis and laser hair removal (LHR) ( 11 , 12 ). While no technique achieves 100% permanent removal of all unwanted hair, electrolysis and LHR are the preferred treatments for permanent removal because of their higher efficacy. Surgeons performing genital GAS require preoperative permanent hair removal from any skin area that will either be brought into contact with urine (e.g., used to construct a neourethra) or be moved to reside within a partially closed cavity within the body (e.g., used to line the neovagina) ( 13 - 15 ). Hair within a neourethra will obstruct urine outflow, promote urine retention within the urethra, and often become encrusted with stone and sebaceous debris—all of which increase the risk of urinary infections and post-void dribbling of urine. Hair within the neovagina serves as a nidus for infection and encrustation of debris. Hair bearing skin that remains outside of the body after GAS does not need to be removed ( Table 1 ).

*, The patient’s GAS surgeon should always be consulted to confirm which exact areas should be rendered hair-free, as surgical techniques and surgical planning vary.

Prior to the advent of LHR, electrolysis was the predominant method used for removal of unwanted hair. Electrolysis is the process of electric epilation, in use since 1875 and approved by the FDA for permanent hair removal ( 16 , 17 ). It involves the insertion of a fine needle or probe into each hair follicle for delivery of an electric current in attempt to destroy the follicular unit responsible for hair regeneration ( 17 ). Hair reductions up to 90% have been reported; however, the treatment efficacy is highly variable and operator- and modality-dependent, with regrowth ranging from 15–50% ( 16 , 18 ). Because each hair follicle must be treated individually, multiple hours of treatment on a weekly or biweekly basis for up to a year are generally required for best results ( 17 , 19 ).

LHR is an FDA-approved form of permanent hair reduction rather than permanent hair removal. The distinction between hair removal and reduction is mechanistic: LHR does not reduce the number of hair follicles, as electrolysis does, but rather reduces the number of hairs by damaging the follicular bulb while leaving the follicle intact. The mechanism of action of LHR is based on selective photothermolysis: laser light selectively targets melanin in the hair shaft, leading to destruction of the follicular epithelium ( 20 ). LHR can be performed with ruby, alexandrite, diode, and neodymium:yttrium aluminum garnet (Nd:YAG) lasers and intense pulsed light (IPL) sources, which operate at different wavelengths suitable for varying skin types and indications ( 21 ). Since the first FDA approval of LHR in 1995, LHR has become the fastest growing procedure in cosmetic dermatology, spread to several home-based devices, and demonstrated the longest hair-free period for removal of unwanted hair ( 12 , 21 , 22 ).

LHR has significant benefits over electrolysis, though studies with long-term follow-up are limited ( 23 ). Alexandrite-LHR provides higher clearance rates than electrolysis (74% vs . 35%, respectively) 6 months following treatment, is 60 times faster and less painful, and requires fewer treatment sessions ( 24 ). Electrolysis may be cheaper per session, but many hours may be required to treat each area of hair; in contrast, LHR will treat the entire area for hair removal during each session with faster procedure times, low occurrence of side effects, and fewer needed sessions ( 25 ). In addition, a Cochrane systematic review of 30 controlled trials concluded that efficacy of LHR is superior to that of electrolysis ( 23 , 26 ).

Hair removal prior to genital GAS

Although the literature on hair removal prior to genital GAS is limited, electrolysis has been commonly used for this indication, as it had been the sole solution for long-term hair removal before the advent of LHR ( 2 , 3 , 13 , 27 , 28 ). Reliance on this practice has persisted in public and professional transgender health care forums, despite the absence of evidence-based clinical guidelines or peer reviewed data to support favoring electrolysis over LHR.

However, more recent studies specific to genital GAS support the use of LHR over electrolysis in this setting. A follow-up study of 232 patients who had undergone electrolysis before genital GAS found that those who underwent preoperative genital electrolysis did not report a reduction in postoperative vaginal hair complications compared to those who were not treated ( 3 ). On the other hand, a recent case report of long-pulsed alexandrite LHR on scrotal skin prior to genital GAS demonstrated no intra-vaginal hair growth at 15 months following vaginoplasty ( 27 ). Several case reports have also described the use of LHR for removal of urethral hair following hypospadias and stricture repair with minimal side effects and satisfactory outcomes up to 1 year following LHR ( 29 - 33 ).

A proposed approach for preoperative genital LHR

The shift towards LHR as a superior method of hair removal suggests that it should also be the treatment of choice prior to genital GAS. Based on the literature as well as from our own experience, we present the following recommendations specifically for hair removal prior to genital GAS.

Preoperative evaluation: treatment planning and management of expectations

The majority of transgender patients, unfortunately, report that they have experienced discrimination when seeking health services. During preoperative evaluation, practitioners of LHR should be attentive to using correct pronouns for each patient. We recommend that practitioners simply ask what pronouns a patient prefers. Some patients may not have had their name legally changed at the time of evaluation so asking patients their preferred name is also recommended.

LHR practitioners should confirm with patients that they have reviewed with their GAS surgeon which (if any) areas of their genitalia and flap donor sites should be rendered hair-free before surgery. Given the delay to surgery and costs that hair removal can create for patients, unnecessary hair removal should be avoided. Ideally, there can be direct communication between the GAS surgeon and treating dermatologist. In our experience, it is useful for the GAS surgeon to use a permanent ink-marking pen to outline the area to be made hair-free before the patient presents for hair removal. A photograph of this outlined area can also be useful during each treatment to ensure the correct area is being targeted.

Realistic patient expectations should be established, detailing potential adverse outcomes. The mean socio-economic status of transgender patients is lower than that of non-transgender patients, and thus, affordability may be a substantial issue for many patients. The anticipated out-of-pocket costs to the patient and the likely number of treatments needed should be established before treatment (while LHR is not often covered by insurance, some companies cover LHR prior to genital GAS). Patients should be informed that each treatment will target existing hair bulbs, but that resting (telogen) follicles will grow hairs in between treatments until all the follicles have been treated. Patients should be aware that, in some cases, hair may regrow years later—though late onset hair regrowth is generally more sparse, thinner, and paler ( 21 ). LHR achieves best results for dark hair on light skin, as it targets the melanin in the hair bulb. Patients with darker skin should be treated with longer wavelength lasers to protect the epidermis ( 34 ). For these same reasons, LHR is not suitable for blond or white hair, and patients with these features should be directed to undergo electrolysis instead. Although home laser units are now available, patients should be advised that the process is significantly more time consuming and may not yield the same results.

Preparation before LHR

Hair should be shaved prior to LHR to ensure that the melanin of the dermal hair bulb absorbs the laser energy without interference from melanin of hair above the epidermal surface. Shaving hair prior to LHR has been demonstrated to improve the efficacy of laser transmission and the mechanism of selective thermolysis ( 35 ). Any plucking, waxing, electrolysis, or other methods that remove the hair bulb should be avoided for at least 4 weeks before LHR because an intact bulb is the chromophore necessary to achieve selective photothermolysis ( 21 , 36 ). Patients should adhere to strict sun avoidance for a minimum of 6 weeks before and after each treatment because any tanning limits treatment efficacy and increases the risk of side effects, such as dyspigmentation ( 21 ). Further, patients taking minoxidil (or with partners using the topical agent) should be advised that the stimulating effects of the drug may disrupt hair removal ( 37 ).

Topical anesthetic pretreatment includes 30-minute to 1-hour incubation with creams, such as lidocaine, prilocaine, or tetracaine ( 21 ). Tetracaine has been documented in use for LHR of scrotal skin ( 27 ). The use of a cooling fan or device may provide comfort during the procedure, and ice can be applied immediately afterwards. Topical steroids can be used following treatment to reduce redness and swelling.

Area of hair removal

Areas of hair removal for genital GAS can include the forearm, anterior thigh, and scrotum. The surgeon should always confirm with the patient and, whenever possible, the treating dermatologist exactly which area should be rendered hair-free before surgery.

Male-to-female (MtF) genital GAS

Creation of a vulva (vaginoplasty) can include or not include creation of a vaginal cavity. Vaginoplasty without creation of a neovaginal cavity generally does not require any hair removal preoperatively, as any hair-bearing skin will be visible and easily accessible after surgery. Vaginoplasty with creation of a neovaginal cavity requires that the penile shaft skin be made hair-free because with the most common vaginoplasty technique (penile inversion vaginoplasty), the penile shaft skin is used to line the vaginal cavity and will be out of reach for hair removal procedures after surgery ( 38 ). Some transgender women undergoing vaginoplasty with vaginal cavity formation may require harvest of scrotal skin for use to line the vaginal cavity. If the surgeon plans to use a pedicled scrotal skin flap, the anterior midline face of the scrotum is dissected but left in continuity with the perineum at midline proximally. The distal end (closest to the base of the penile shaft) is sutured to the end of the penile shaft skin (detubularized along the dorsal midline). The lateral edges of both flaps are sutured together to form a tube, lined on the inside by penile and scrotal skin epithelium. For this, a 10 cm-wide midline vertical strip of scrotal skin extending from the scrotal-perineal junction (proximally) to the base of the penis (distally) should be permanently cleared of hair growth ( Figure 1A ).

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Scrotum hair removal. Patients who will undergo MtF vaginoplasty with creation of a neovaginal cavity using scrotal skin require permanent hair removal from scrotal skin. (A) If the surgeon plans to use scrotal skin as (free) grafts to augment the depth of the epithelium-lined neovaginal cavity, the entire scrotum should be treated to ensure that the skin used has been rendered hair-free; (B) when a pedicle-flap of scrotal skin (hatched outline) will be used, only the flap area needs to be rendered hair-free. Typically, the flap is made from a midline segment of scrotal skin that is 10-cm wide (stretched), and extends cephalad, from a 1-cm wide base of skin at the junction of the perineum and scrotal skin.

Some surgeons choose to use a portion of excess scrotal skin (normally discarded during the surgery) as a full-thickness free skin graft to augment the length of intact (i.e., still tubularized) penile shaft skin. In such cases, it is difficult to pre-determine exactly which areas of scrotal skin will be used, and it is safest to treat the entire scrotum for permanent hair removal ( Figure 1B ). Perineal skin never needs to be treated for hair removal preoperatively.

Female-to-male (FtM) genital GAS

Only transgender men undergoing phalloplasty with urethral lengthening (construction of a neourethra) require preoperative permanent hair removal. The skin-flap area that will be used to construct the neourethra must be rendered free of hair-growth to avoid hair-related complications. Residual hair on the skin that will be used to make the phallus shaft need not be treated, as it is easily accessible for treatment post-op. Skin for phalloplasty with urethral lengthening is commonly harvested from the forearm radial artery (forearm flap) phalloplasty (RAP) ( 39 ) or the anterolateral thigh [(ALT) flap phalloplasty] ( 40 - 42 ). With RAP, the skin used for construction of the neourethra is ~5 cm wide and harvested from the medial aspect of the ventral face of the forearm ( Figure 2 ). For RAP, we recommend hair removal of the medial aspect of the entire ventral forearm.

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Object name is tau-05-03-381-f2.jpg

Radial artery forearm flap hair removal. For patients who will undergo FtM radial artery forearm flap phalloplasty, the majority of skin from the forearm (non-dominant) is used for reconstruction. While flap dimensions may vary with patient anatomy and by surgeon preference, we typically create both a neourethra (U) and neophallus (P) using a single skin-flap with the dimensions shown (in cm). The urethral skin segment is typically located medially, where people naturally have less hair. Only patients who will undergo phalloplasty with urethral lengthening require preoperative permanent hair removal in the area of the urethral segment (U). Patients undergoing phalloplasty without urethral lengthening can undergo permanent hair removal of the neophallus (P) skin any time after surgery, as all phallus skin is exposed.

With ALT flap phalloplasty, the skin area used to construct the neourethra can be harvested from the medial or lateral aspect of the same flap template as is used with RAP. The flap is located on the anterolateral surface of the thigh, centered slightly distal or proximal to the halfway point between the anterior superior iliac crest (proximally) and the lateral aspect of the patella (distally) ( Figure 3 ). The exact location of the skin area to be used in ALT flap phalloplasty is less predictable, as the surgical margins vary with the vasculature to the flap area. Generally speaking, the entire flap area lies within the middle 2/3 of the ALT. We recommend that patients undergoing ALT flap phalloplasty ask their surgeon to specify exactly what area should be rendered hair-free before the patient commences hair removal treatments.

An external file that holds a picture, illustration, etc.
Object name is tau-05-03-381-f3.jpg

Anterolateral thigh (ALT) flap hair removal. An alternative source for well-vascularized skin for phalloplasty with or without urethral lengthening is the ALT. The anatomic landmarks for an ALT-flap are the anterior superior iliac spine (A, cephalad), and the lateral aspect of the patella (C, distal). An imaginary line is drawn between these two points (AC), and the exact halfway-point is marked (B). The flap is supported via muscle perforators from the descending branch of the lateral circumflex femoral artery that usually perforates the vastus lateralis muscle. The most cephalad perforator usually lies within a 3-cm area of point B. The flap dimensions can be exactly the same as for a radial artery forearm flap. The longer urethral segment (unmarked) can be medial or lateral to the wider segment used to construct the phallus.

Laser settings

The laser to be used should be a long-pulsed laser with a wavelength appropriate to target melanin, such as a diode, alexandrite, or long-pulsed Nd:YAG. Selection of laser wavelength should take the patient’s skin color into account, and the fluence, pulse duration, and cooling should be optimized to achieve immediate destruction of the bulb with perifollicular erythema, while protecting the epidermis from thermal injury. Selection of laser settings requires training in the use of these devices. The American Society for Dermatologic Surgery recommends that LHR be practiced only in an appropriate setting by, or under the direct supervision of, a physician.

Number of treatments

An evidence-based review reported that multiple LHR treatments result in increased efficacy of hair removal ( 22 , 26 , 43 ). The European Society for Laser Dermatology recommends three to eight LHR treatments ( 36 ), and the American Academy of Dermatology states that most patients need between two to six treatments. Treatments, which may each take up to 30 minutes, should be spaced at least 6 weeks apart to allow for hair cycling. Our experience with genital GAS is that it is best to wait 3 months after the last planned hair removal treatment before proceeding with surgery, in order to confirm that no further hair regrowth will occur.

Conclusions

Despite long experience with electrolysis for hair removal prior to GAS, evidence-based outcomes studies have shown LHR to be the superior modality. LHR has largely supplanted electrolysis for permanent hair removal in the medical setting. We present a practical approach to LHR for genital GAS, which will inform future studies needed to develop evidence-based guidelines for best practice in the field.

Acknowledgements

Conflicts of Interest: The authors have no conflicts of interest to declare.

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After two years, still no timeline for transgender surgeries at VA

Two years after Veterans Affairs leaders announced they would make “life saving” surgery options for transgender veterans available through department medical centers for the first time, no such operations have been performed, and VA officials admit there is no timeline for when they might begin.

The delay comes as a national debate has erupted over both the surgeries and transgender rights . Instead of alleviating some of the stress associated with that, Veterans Affairs officials are adding to the anxiety by failing to follow through with its promise, advocates say.

“The frustration level is extremely high,” said Cassandra Williamson, executive director of Transgender and Diverse Veterans of America. “This is impacting veterans’ mental health and well-being, and postponing some medically necessary procedures. We’re losing faith in VA in a big way.”

On June 19, 2021, Veterans Affairs Secretary Denis McDonough publicly vowed to start offering gender confirmation procedures through department facilities for the first time. Officials at the time drew praise from LGBTQ activists for the move, even as department officials warned that the rulemaking process could drag on for months.

VA to offer gender surgery to transgender vets for the first time

Officials do not know how long the rule making process will take or when surgeries will begin to be scheduled..

Now, those months have turned into years. In the meantime, at least 20 states have placed limits on gender confirmation surgeries, largely aimed at minors. Florida Governor and Republican presidential candidate Ron DeSantis recently compared the operations to “mutilation.”

In a statement, VA press secretary Terrence Hayes said department leaders are still committed to providing the surgery options to transgender veterans, and insisted that the larger political debate over transgender rights has not slowed down the rulemaking work.

But he also said there is no timeline for when the first surgeries may be scheduled. Officials are “moving ahead methodically because we want this important change in policy to be implemented in a manner that has been thoroughly considered” and “meets VA’s rigorous standards for quality health care.”

Past estimates from the National Center for Transgender Equality and other advocacy groups put the number of transgender veterans in America today between 130,000 and 150,000. VA officials have estimated that around 4,000 veterans nationwide may be interested in gender confirmation surgeries, also known as gender reassignment surgeries.

Conservative groups have disputed both the estimates of transgender veterans and the need for VA to provide the surgery options, especially in states where it may run afoul of local laws.

Although gender confirmation surgeries are not yet available through VA, the department does offer hormone therapies and other transgender-specific medical options.

But advocates say that isn’t enough, and question the reasons behind the delay.

Transgender vets call for more protections from Congress, VA

Advocates want va to move ahead with plans to provide gender-affirming surgery to transgender veterans, a policy change first promised in summer 2021..

In late March, 157 outside groups — including Minority Veterans of America, Student Veterans of America and Iraq and Afghanistan Veterans of America — sent a letter to McDonough calling the continued delay over transgender surgery availability “not just an equity issue, but also a safety issue.” They said that offering the operations could help cut down on depression and suicide rates among transgender veterans.

Lindsay Church, executive director and founder of Minority Veterans of America, called the lack of progress on the issue disheartening.

“When they announced this plan, they said it would save lives,” Church said. “So where is the action now that trans people’s lives are on the line?”

Church, who identifies as non-binary, was given breast implants years ago as part of reconstructive surgery from medical complications that arose during their time in the Navy. Earlier this year, during a medical appointment with VA, Church found out those implants had ruptured, causing a series of new health problems.

“I couldn’t take them out earlier, because that falls under the transgender surgery options,” Church said. “So the government can give you breast implants to affirm the gender they think you are, but they won’t help you with other options unless it’s a medical emergency.”

Williamson, a Navy and Marine Corps veteran, said she has heard similar stories from other transgender veterans. “We’re hearing that having these surgery options would have helped greatly, but for now, these veterans are still waiting.”

House Veterans’ Affairs Committee ranking member Mark Takano, D-Calif., said he is “concerned about the two-year delay” regarding the surgeries and hopes for resolution on the issue soon.

However, he said he still has faith that McDonough and his administration is committed to “providing much-needed healthcare to transgender veterans” in the near future.

Veterans Affairs health care websites promise that transgender veterans who reach out to the department will “receive affirming care and services to achieve optimal health and well-being.” But for now, the list of services still excludes gender confirming surgeries.

“I just keep telling our folks to keep fighting, to stay on this,” Williamson said. “We understand the regulatory process does take time. But we didn’t expect it to be this long.”

Leo covers Congress, Veterans Affairs and the White House for Military Times. He has covered Washington, D.C. since 2004, focusing on military personnel and veterans policies. His work has earned numerous honors, including a 2009 Polk award, a 2010 National Headliner Award, the IAVA Leadership in Journalism award and the VFW News Media award.

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Wyoming governor signs bill banning gender reassignment surgery, care

March 23 (UPI) -- Wyoming's Republican governor has signed a bill into law banning doctors in that state from performing gender transitioning and gender reassignment procedures for children.

Wyoming became the 24th state to enact similar legislation after Gov. Mark Gordon signed the bill Friday.

Legislators in both the state House and Senate passed the legislation earlier this month.

"I signed SF99 because I support the protections this bill includes for children, however it is my belief that the government is straying into the personal affairs of families," Gordon said in a statement.

"Our legislature needs to sort out its intentions with regard to parental rights. While it inserts governmental prerogative in some places, it affirms parental rights in others," he said.

In addition to doctors, the law also subjects pharmacists and other healthcare professionals to legal penalties for providing gender-affirming care to minors, including the revocation of licenses.

"There was an opportunity to find common cause on issues we agreed with: surgery for minors is inappropriate, other healthcare options ... should remain the purview of parents and their qualified physicians," Wyoming Equality Executive Director Sara Burlingame said in a statement to WyoFile .

She said she was "dismayed" at the new law, calling it a clear case of "government overreach."

Two states, Montana and Idaho have had similar bans blocked by federal judges.

Last month, officials in Idaho asked the Supreme Court to allow the state to enforce its felony ban on minors receiving gender-affirming healthcare, calling the scope of the lower court's decision too broad.

A timeline of allegations against Sean ‘Diddy’ Combs

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A string of recent sexual assault allegations against Sean “Diddy” Combs, the billionaire music mogul and entrepreneur, have damaged the legacy of the man once revered as hip-hop royalty.

Four women , including Combs’ longtime girlfriend Casandra “Cassie” Ventura, filed explosive lawsuits against Combs in November and December, accusing the artist of sexually and physically abusing them. In February, producer Rodney “Lil Rod” Jones filed a similar suit, alleging Combs’ sexually assaulted and harassed him and that several people in his circle engaged in illicit behavior.

On Monday evening, federal agents from Homeland Security raided Combs’ Los Angeles and Miami homes as part of a sweeping sex trafficking inquiry.

Photo illustration of Sean Diddy Combs with half his face falling into small square pieces

Behind the calamitous fall of hip-hop mogul Sean ‘Diddy’ Combs

In the wake of multiple lawsuits filed against him, former members of Combs’ inner circle told The Times that his alleged misconduct against women goes back decades.

Dec. 13, 2023

Combs has denied all the recent allegations and his lawyer, Aaron Dyer, slammed the execution of the Homeland Security investigation as an “excessive show of force” in a statement to The Times.

“Yesterday, there was a gross overuse of military-level force as search warrants were executed at Mr. Combs’ residences,” Dyer said. “There is no excuse for the excessive show of force and hostility exhibited by authorities or the way his children and employees were treated. Mr. Combs was never detained but spoke to and cooperated with authorities.”

“Despite media speculation, neither Mr. Combs nor any of his family members have been arrested nor has their ability to travel been restricted in any way,” Dyer’s statement added. “This unprecedented ambush — paired with an advanced, coordinated media presence — leads to a premature rush to judgment of Mr. Combs and is nothing more than a witch hunt based on meritless accusations made in civil lawsuits. There has been no finding of criminal or civil liability with any of these allegations. Mr. Combs is innocent and will continue to fight every single day to clear his name.”

Combs — a hip-hop artist, producer and record label executive who built fashion and liquor empires — is facing a dramatic downfall in light of allegations of violence and abuse. Here is a timeline of the allegations against Combs.

Authorities walk on a street near a property belonging to Sean "Diddy" Combs' on Monday, March 25, 2024, in Los Angeles, after federal law enforcement executed a raid as part of an ongoing sex trafficking investigation by federal authorities in New York. (AP Photo/Eric Thayer)

Sean ‘Diddy’ Combs faces sweeping sex-trafficking inquiry: What the feds have, need to prove

Legal experts say it could take time to build a criminal case against the hip-hop mogul but note that civil lawsuits against him could offer investigators a road map.

March 26, 2024

1990: In a November 2023 lawsuit, Liza Gardner alleged Combs and R&B singer Aaron Hall sexually assaulted her and her friend in 1990.

1991: In another November 2023 lawsuit, Joi Dickerson-Neal alleged that Combs drugged and sexually assaulted her when she was 19. Combs also allegedly recorded and shared a video of the assault.

1993: Combs founded Bad Boy Records and began discovering and developing hip-hop artists and producing work for musicians including the Notorious B.I.G.

April 1999: Combs was arrested on suspicion of assaulting Interscope Records executive Steve Stoute and pleaded guilty to harassment.

December 1999: Combs was charged with criminal possession of a weapon after police found a gun in his car following a shooting at a club in New York City. He and then-girlfriend Jennifer Lopez were both arrested.

2003: According to a December 2023 lawsuit, Combs, former Bad Boy president Harve Pierre and a third unidentified person allegedly drugged and gang-raped a then-17-year-old girl, only identified in the complaint as Jane Doe. The alleged assault took place at a New York City recording studio after Pierre and the unidentified man flew in with the victim from Detroit.

2005: Combs, then in his mid-30s, met 19-year-old Ventura and expressed interest in signing her to Bad Boy Records.

2006: Ventura signed a 10-album deal with Combs’ label, and alleged in a November 2023 lawsuit that he used this time to “set the groundwork for his manipulative and coercive romantic and sexual relationship” with Ventura.

A law enforcement agent carries a bag of evidence to a van as federal agents stand at the entrance to a property belonging to rapper Sean "Diddy" Combs, Monday, March 25, 2024, on Star Island in Miami Beach, Fla. Two properties belonging to Combs in Los Angeles and Miami were searched Monday by federal Homeland Security Investigations agents and other law enforcement as part of an ongoing sex trafficking investigation by federal authorities in New York, two law enforcement officials told The Associated Press. (AP Photo/Rebecca Blackwell)

Sean ‘Diddy’ Combs’ L.A., Miami homes raided in sex-trafficking inquiry, sources say

Agents search Sean Combs’ Holmby Hills and Miami mansions as part of a federal inquiry into sex trafficking allegations, law enforcement sources said.

October 2007: Combs signed a multiyear deal with Diageo, a British beverage company, to develop Ciroc vodka for a 50/50 share in profits.

2007: Combs and Ventura were romantically linked for the first time. In a November 2023 lawsuit, Ventura alleged that Combs took advantage of his position as the head of her record label and convinced her to take illegal drugs before having sex with her for the first time.

She also alleged that over their nearly decade-long relationship, Combs physically and sexually abused her, often with witnesses present. The complaint detailed one incident in which Combs allegedly beat Ventura and repeatedly kicked and stomped her face, only stopping when she vomited. Ventura said in the suit that Combs’ “tremendously loyal network” who witnessed her repeated assaults “were not willing to do anything meaningful” to stop the violence.

2012: At a point when Combs and Ventura were broken up, Ventura briefly dated musician Kid Cudi. According to the November 2023 lawsuit, Combs told Ventura that he was going to blow up Kid Cudi’s car and that “he wanted to ensure that Kid Cudi was home with his friends when it happened.” Around this time, the lawsuit says, the musician’s car exploded in his driveway. A representative for Kid Cudi confirmed the explosion to the New York Times .

2013: Combs launched media company Revolt as a co-founder.

2014: Combs expanded his deal with Diageo to acquire high-end tequila brand DeLeon .

June 2015: Combs was arrested on suspicion of assault with a deadly weapon at a UCLA athletic complex following an altercation with a coach during which police said Combs used a kettlebell. Combs’ son played football at UCLA at the time of the altercation.

August 2015: Ventura alleged in the November 2023 lawsuit that throughout her relationship with Combs, he forced her to perform sexual acts on male sex workers. He allegedly forced Ventura and the hired sex workers to take illegal drugs, as was the case in a 2015 meeting described in the complaint. Combs also allegedly recorded the encounters and threatened violence if Ventura refused to participate, the suit said.

2018: Ventura repeatedly tried to sever ties with Combs and met him for dinner in September 2018, per the November 2023 lawsuit. Combs allegedly forced himself into Ventura’s home after the dinner and raped her “while she repeatedly said ‘no’ and tried to push him away.” Following this alleged assault, Ventura took further steps to “completely separate” herself from Combs.

July 2022: Combs accepted a lifetime achievement award at the BET Awards.

Sean Combs arrives at a pre-Grammy party

Diddy’s ‘Love’ producer Lil Rod accuses him and associates of sexual assault, illicit behavior

Rodney ‘Lil Rod’ Jones has filed a bombshell lawsuit against Sean ‘Diddy’ Combs accusing the media mogul of sexually harassing and threatening him.

Feb. 27, 2024

2022-2023: Music producer Jones alleged that Combs sexually assaulted him over a yearlong period when Jones was living on Combs’ properties and working on the production of “The Love Album: Off the Grid.” Jones also alleged in the February lawsuit that Combs tried to groom him into engaging in sex with producer Steven Aaron Jordan, also known as Stevie J.

Other allegations from the explosive federal complaint , which was originally filed in February but amended Monday, include Jones’ claim that Oscar-winning actor Cuba Gooding Jr. sexually harassed and assaulted him and that Combs forced Jones to take illegal drugs and solicit sex workers, some of whom were allegedly underage.

June 2023: Combs sued beverage company Diageo for allegedly treating the brands he co-owned, DeLeon tequila and Ciroc vodka, as inferior “Black brands” or “ethnic brands,” per the racial discrimination lawsuit his company filed. Diageo denied allegations of racism in previous statements to The Times.

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Mo’ money, mo’ problems? Diddy returns publishing rights to Bad Boy artists, including Mase

Hip-hop mogul Diddy has reassigned publishing rights once held by his Bad Boy Entertainment brand to the artists who helped build the legendary record label.

Sept. 6, 2023

September 2023: Combs returned publishing rights to some of the artists and songwriters signed to Bad Boy Entertainment. The surprise move restored the publishing rights back to artists including Mase, 112, the Lox, the Notorious B.I.G. and his widow Faith Evans.

November 2023: Ventura filed a sex trafficking and sexual assault lawsuit against Combs alleging a years-long period of physical and sexual abuse. The complaint says Ventura hoped to “confront her abuser, and to hold him and those who enabled his abuse accountable for their actions.” Through his lawyers, Combs denied the allegations and settled the suit 24 hours after Ventura filed.

Following the news of Ventura’s filing, Dickerson-Neal and Gardner also filed lawsuits alleging Combs sexually abused them.

November 2023: Combs stepped down from his position as chairman at Revolt TV.

December 2023: A fourth lawsuit accusing Combs and former Bad Boy label president Pierre of gang-rape and sex trafficking was filed on behalf of a victim who was 17 years old at the time of the alleged assault. Pierre said in a statement the allegations were “disgusting,” “false” and a “desperate attempt for financial gain.”

January 2024: Combs withdrew his racial discrimination lawsuit against Diageo. In a joint statement to The Times, Combs and Diegeo said the former partners had “no ongoing business relationship, either with respect to Ciroc vodka or DeLeon tequila, which Diageo now solely owns.”

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Sean ‘Diddy’ Combs sexual harassment suit includes notable music industry names

A new suit from music producer Rodney “Lil Rod” Jones makes new, explosive claims about Combs’ alleged assaults and misconduct in granular detail, naming several prominent artists and music executives as well.

Feb. 28, 2024

February 2024: Jones became the fifth person to file a lawsuit against Combs alleging that he sexually assaulted them. Jones’ suit names several notable entertainment industry figures , including Combs’ son Justin Dior Combs, Universal Music Group CEO Lucian Grainge, Stevie J, Yung Miami and others.

March 25, 2024: Homeland Security agents searched Combs’ L.A. and Miami mansions as part of a federal inquiry into sex trafficking allegations against him conducted by the prosecutors in the Southern District of New York. The investigation is ongoing.

March 26, 2024: TMZ reported that Combs recently sold off all of his shares in Revolt TV, the company he co-founded in 2013, for an undisclosed amount.

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Kaitlyn Huamani is a 2024 intern for the Entertainment and Arts section at the Los Angeles Times. Previously, she interned at People Magazine, covering celebrity and pop culture news, as a part of the American Society of Magazine Editors’ internship program. A New Jersey native, she studied journalism at the University of Southern California.

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Rates of Suicide Attempts Doubled After Gender-Reassignment Surgery: Study

Attempted suicide rates among people who identified as transgender more than doubled after receiving a vaginoplasty, according to a peer-reviewed study published in The Journal of Urology.

Researchers found the rates of psychiatric emergencies were high both before and after gender-altering surgery, with similar overall rates in both groups. However, suicide attempts were markedly higher in those who received vaginoplasties.

“In fact, our observed rate of suicide attempts in the phalloplasty group is actually similar to the general population, while the vaginoplasty group’s rate is more than double that of the general population,” the study authors wrote.

Among the 869 patients who underwent vaginoplasty, 38 patients attempted suicide—with nine attempts before surgery, 25 after surgery, and four attempts before and after surgery. Researchers found a 1.5 percent overall risk of suicide before vaginoplasty and a 3.3 percent risk of suicide after the procedure. Almost 3 percent of those who attempted suicide after undergoing vaginoplasty did not present with a risk of suicide prior to surgery.

Among the 357 biologically female patients who underwent phalloplasty, there were six suicide attempts with a 0.8 percent risk of suicide before and after surgery.

‘Affirmation at All Costs’: What Internal Files Reveal About Transgender Care

Overall, the proportion of those who experienced an emergency room and inpatient psychiatric encounter outside of suicide attempts was similar between the vaginoplasty and phalloplasty groups. Approximately 22.2 percent and 20.7 percent of patients, respectively, experienced at least one psychiatric encounter.

Suicide Rate 19-Fold Higher

“It’s hard to refute this paper because it’s a longitudinal study,” Dr. Oliva said. “In Sweden, everyone is in a database, and through diagnosis codes, they’re able to follow what happens to every citizen in terms of their medical history. They waited more than 10 years after people had surgery and found that death by suicide had an adjusted hazard ratio of 19.1.”

Surgical Procedures

A penial inversion is the most commonly performed procedure where the skin is removed from the penis and inverted to form a pouch that is inserted into the vaginal cavity created between the urethra and the rectum. Surgeons then partially remove, shorten, and reposition the urethra and create a labia majora, labia minora, and clitoris.

Another surgical method involves using a robotic system that enables surgeons to reach into the body through a small incision in the belly button to create a vaginal canal. The type of vaginoplasty performed varies among patients. For example, younger patients who have never experienced puberty may have insufficient penile skin to do a standard penile inversion.

Vaginoplasty Associated With Serious Risks

“For cosmetic surgery, if the complication rate was more than 2 percent to 3 percent, you wouldn’t have any patients,” Dr. Oliva told The Epoch Times. “These are very high percentage rates that we just accept.”

Dr. Oliva said complications with these surgical procedures are very high and he thinks this is why suicide rates are so high.

“People think this is going to solve the problem and it doesn’t,” he said.

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Gender Affirmation Surgeries: Common Questions and Answers
Overview. 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 ...
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Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.. Often used to refer to vaginoplasty, sex reassignment surgery can also more broadly refer to other gender-affirming ...
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Research consistently shows that people who choose gender affirmation surgery experience reduced gender incongruence and improved quality of life. Depending on the procedure, 94% to 100% of people report satisfaction with their surgery results. Gender-affirming surgery provides long-term mental health benefits, too.
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Featured Expert: Fan Liang, M.D. Phalloplasty is surgery for masculinizing gender affirmation. Phalloplasty is a multistaged process that may include a variety of procedures, including: Creating the penis. Lengthening the urethra so you are able to stand to urinate. Creating the tip (glans) of the penis. Creating the scrotum.
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Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.. Often used to refer to phalloplasty, metoidoplasty, or vaginectomy, sex reassignment surgery can also more broadly refer to many procedures an individual may have ...
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Patients and Methods

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Postoperative Care and Follow-Up

Statistical Analysis

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