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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

What is gender-affirming care? Your questions answered

As states move to restrict certain treatments for transgender youth, experts explain the many types of care, the need for them, and their impact..

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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Related Articles

• Patient Care & Health Information
• Tests & Procedures
• Feminizing surgery

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

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

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

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Why it's done

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

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

Feminizing surgery may include:

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

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

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

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

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

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

How you prepare

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

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

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

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

Evaluation for surgery

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

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

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

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

Other considerations

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

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

What you can expect

Facial feminization surgery.

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

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

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

Tracheal shave

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

Top surgery

• Breast augmentation incisions

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

• Placement of breast implants or tissue expanders

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

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

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

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

Genital surgery

• Anatomy before and after penile inversion

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

• Anatomy before and after bowel flap procedure

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

Orchiectomy

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

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

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

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

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

Dilation after gender-affirming surgery

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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• Review Article
• Published: 12 April 2011

Gender reassignment surgery: an overview

• Gennaro Selvaggi 1 &
• James Bellringer 1  

Nature Reviews Urology volume  8 ,  pages 274–282 ( 2011 ) Cite this article

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This article has been updated

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

The management of gender dysphoria consists of a combination of psychotherapy, hormonal therapy, and surgery

Psychiatric evaluation is essential before gender reassignment surgical procedures are undertaken

Gender reassignment surgery refers to the whole genital, facial and body procedures required to create a feminine or a masculine appearance

Sex reassignment surgery refers to genital procedures, namely vaginoplasty, clitoroplasty, labioplasty, and penile–scrotal reconstruction

In male-to-female gender dysphoria, skin tubes formed from penile or scrotal skin are the standard technique for vaginal construction

In female-to-male gender dysphoria, no technique is recognized as the standard for penile reconstruction; different techniques fulfill patients' requests at different levels, with a variable number of surgical technique-related drawbacks

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26 april 2011.

In the version of this article initially published online, the statement regarding the frequency of male-to-female transsexuals was incorrect. The error has been corrected for the print, HTML and PDF versions of the article.

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Selvaggi, G., Bellringer, J. Gender reassignment surgery: an overview. Nat Rev Urol 8 , 274–282 (2011). https://doi.org/10.1038/nrurol.2011.46

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What is gender affirming surgery?

Gender affirming surgery refers to a variety of procedures that some trans or gender diverse people may use to affirm their gender.

Surgery is just one option for gender affirming care. All trans and gender diverse people are unique and will choose to affirm their gender in a way that feels right for them.

Gender affirming care might include:

• Social affirmation, such as changing names, pronouns, hair or clothing.
• Legal affirmation, such as changing legal name or gender.
• Medical affirmation, with hormones or surgery.

Read more about gender incongruence, gender dysphoria , and gender affirming care here.

This article talks more about gender affirming surgery.

What happens during gender affirming surgery?

There are many different gender affirming surgeries and procedures. They may include making changes to your face, chest, genitals, or other body parts.

For people assumed male at birth, feminising surgeries may include:

• Breast augmentation with insertion of breast implants.
• Facial feminisation — changing the shape of any or all facial features.
• Vocal surgery — shortening the vocal cords for a higher, more feminine voice.
• Tracheal shave — reducing the size of the ‘Adam’s apple’.
• Fillers or liposuction, to achieve a more typically feminine shape.
• Orchiectomy, or removal of testicles.
• Bottom surgery or ‘genital reconfiguration surgery’, involving changes to the genitals.

Bottom surgery is called ‘genital reconfiguration surgery’. This was previously known as ‘sex reassignment surgery’ or ‘gender confirmation surgery’. The name change shows that your genitals don’t define your sex or gender.

Feminising bottom surgery may involve a combination of the following procedures:

• Removing the testicles (orchiectomy).
• Removing and reshaping tissue from the penis to make a vulva. This includes external labia or lips, and a clitoris. This is known as vulvoplasty.
• Shortening the urethra (tube that you urinate — wee — from).
• Creation of a vaginal canal (vaginoplasty). This is a complicated step which some people choose to skip. After surgery, vaginal dilators will need to be used to maintain the shape of the vaginal canal.

For people assumed female at birth, masculinising surgeries may include:

• Top surgery, with reduction or removal of breast tissue (mastectomy). This creates a flatter or more neutral chest. There are many different techniques used to achieve this.
• Liposuction to achieve a more typically masculine shape.
• Hysterectomy , or removal of the uterus (womb) and ovaries.
• Bottom surgery or genital reconfiguration surgery. This involves changes to the genitals.

Masculinising bottom surgery may involve a combination of the following procedures:

• Hysterectomy, if not already performed.
• Vaginectomy, or removal of the vagina.
• Creation of a penis, which may include metoidioplasty or phalloplasty.
• Metoidioplasty involves making a penis shape wrapping tissue around the clitoris after it is enlarged by testosterone hormone therapy.
• Phalloplasty involves making a larger penis with tissue from the arm, thigh, back, or abdomen. This involves lengthening the urethra to be able to urinate from the tip of the new penis. An inflatable penile implant may be inserted inside the penis to allow an erection.

Is gender affirming surgery right for me?

Choosing to undergo any surgery is a big decision. Everyone affirms their gender in different ways, and that may or may not include surgery.

Surgery is permanent so you need to make sure it’s the right choice for you. Surgery doesn’t make you more or less trans.

Before being able to access gender affirming surgery, you need to meet the criteria below:

• A history of gender incongruence (for 6 months or more).
• The ability to make a fully informed decision.
• Be over the age of 16 for top surgery, or 18 for bottom surgery. Some surgeons will provide surgery to younger people in very specific situations.
• Ensure that any physical or mental health conditions are well managed.

You will need letters of support from a mental health professional before having gender affirming surgery.

For top surgery, one letter is required. For bottom surgery two letters are required. For bottom surgery, you are also required to have ‘lived as your current gender’ for 12 months, meaning you have socially transitioned. The letter needs to state that surgery is appropriate for you and is likely to help affirm your gender and reduce any gender dysphoria that may be present.

If you are taking gender affirming hormones, or want to take hormones in the future, you should do this for 12 months before having surgery. This is to allow any significant body changes to occur before surgery.

Most people who have surgery are happy with their results and feel more comfortable in their bodies. But some people are disappointed with the results, or find that any gender dysphoria that was present is not fully resolved. Make sure you discuss any difficult feelings with your doctor or psychologist.

What questions should I ask before surgery?

It’s important to talk about the pros and cons of surgery in detail with your doctor. It’s a good idea to ask to see pictures of how other people look after surgery.

Questions to ask your surgeon include:

• What different surgical techniques are there?
• What are the pros and cons of each technique for me?
• What results can I expect?
• What are the possible risks and complications?

For help in having the discussion, visit healthdirect’s Question Builder .

What should I expect after surgery?

Surgical recovery can be long and uncomfortable. Your surgeon will be able to give you more information on what can be expected before, during, and after surgery. This might include spending time in hospital afterwards, any special dressings, surgical garments, or follow up care.

Make sure you do everything your doctor tells you and go to all follow-up appointments. This will help you get the best results from your surgery.

Having surgery is a big deal. Even if you’ve been looking forward to it and are happy with the result, it can still be quite confronting. It might take some time to get used to your new body.

Talk to your doctor if you are feeling any distress following surgery.

How much will gender affirming surgery cost me?

Gender affirming surgery can be very expensive. It can cost between $20,000 to more than $100,000, depending on which procedures you need.

Your surgeon will be able to tell you how much surgery will cost. The cost may include specialist visits before and after surgery, surgeon and anaesthetist fees, hospital and theatre costs, and any other products or services necessary.

Some costs may be covered by Medicare, such as specialist consults if you have a referral from your doctor. Unfortunately, most gender affirming surgery in Australia is done privately, meaning there will be large out-of-pocket costs.

You should ask your surgeon what Medicare item numbers they use. You can check the Medicare rebate at MBS Online .

Some private health insurance will also help with gender affirming surgery. If you have health insurance, it’s important to check with your health fund first about your level of cover. There is a range of health insurance comparison sites available online, such as privatehealth.gov.au .

Legal matters

Changing your gender on your passport, licence, Medicare card or birth certificate all require separate processes. These vary between states and territories. In some states and territories, you must have undergone specific types of gender affirmation surgery to change the gender marker on your birth certificate.

You can find out more about the specific processes at TransHub .

You are legally protected by the Sex Discrimination Act from discrimination on the grounds of sexual orientation, gender identity or intersex status. Visit the Australian Government Attorney-General’s Department for more details.

Where can I get more information on gender affirming surgery?

• TransHub has information about gender affirming surgery.
• The Gender Centre (NSW) provides resources and support.
• Transgender Victoria has resources and links to other services.
• The Australian Professional Association for Trans Health (AusPATH) lists some providers.

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Last reviewed: June 2022

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How Gender Reassignment Surgery Works (Infographic)

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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Gender reassignment surgery: an overview

Affiliation.

• 1 Gender Surgery Unit, Charing Cross Hospital, Imperial College NHS Trust, 179-183 Fulham Palace Road, London W6 8QZ, UK.
• PMID: 21487386
• DOI: 10.1038/nrurol.2011.46

Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.

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Should Gender Reassignment Surgery be Publicly Funded?

Johann j. go.

Worcester College, University of Oxford, Walton Street, Oxford, Oxfordshire, OX1 2HB UK

Transgender people have among the highest rates of suicide attempts of any group in society, driven strongly by the perception that they do not belong in the sex of their physical body. Gender reassignment surgery (GRS) is a procedure that can change the transgender person’s physical body to accord with their gender identity. The procedure raises important ethical and distributive justice concerns, given the controversy of whether it is a cosmetic or medical procedure and the economic costs associated with performing the procedure. This paper argues that there is a strong case for funding GRS as a matter of clinical necessity and justice. This paper will be divided in four key sections: First, the state of transgender health will be outlined, including the role of GRS and common objections to it. Second, a number of common objections to GRS will be analysed at the outset and shown to be unconvincing. Third, a constructive argument will be advanced, arguing that publicly funded GRS is clinically necessary, cost-effective, and demanded by principles of justice. Fourth, the paper will briefly discuss moralistic biases and why we demand a higher burden of justification for funding GRS compared with other analogous procedures.

Introduction

Healthcare rationing is inevitable. There are finite health resources for an almost infinite number of health needs. Given this reality, this paper analyses whether gender reassignment surgery (GRS) should be funded using our finite health budget and, if so, on what grounds. The issue of publicly funding gender reassignment surgery is fraught with immense difficulty, with complex ethical issues arising from clinical, policy, and economic considerations. The purpose of this paper is to argue that healthcare systems should publicly fund GRS and, where it is already funded, should make it more accessible to patients. The paper serves as additional affirmation for those jurisdictions who already fund GRS, showing that their policies are in line with their ethical and clinical obligations. Transgender persons are those whose physical or assigned sex does not accord with their gender identity (American Psychiatric Association [APA] 2013 ). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM), transgender persons generally suffer from gender dysphoria (GD), which is the clinical distress associated with not fitting in their physical sex (APA 2013 ). I will hereinafter use the terms GD and transgender interchangeably. Across virtually all measures of physical and mental health, transgender persons have poorer outcomes than their non-transgender counterparts (Reisner et al. 2016 ). Compared to non-transgender people, transgender persons have higher rates of drug and alcohol abuse, HIV seroprevalence, diabetes, suicide ideation, and suicide attempts (Reisner et al. 2016 ). There is evidence to suggest that as many as 50 per cent of transgender youth experience suicide ideation and as many as 32 per cent have attempted suicide (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D‘Augelli 2011 ). The primary contributor to these poor health outcomes is the transgender person’s strong psychological dissatisfaction with the fact that their physical sex does not correspond to their gender identity (Grossman and D‘Augelli 2011 ).

Gender reassignment surgery is promoted by the world’s leading medical authority on the issue, the World Professional Association for Transgender Health (WPATH), as an effective potential treatment for those whose GD meet specific clinical criteria (WPATH 2011 ). The clinical rationale for GRS is to alleviate the severe psychological angst the transgender person experiences as a result of their gender identity not aligning with their physical sex. Gender reassignment surgery can reduce or eliminate the psychological distress and is strongly associated with the prevention of suicide which might otherwise be attempted (Clements-Nolle et al. 2006 ; Grossman and D’Augelli 2011 ). It is currently offered in the United Kingdom in a limited capacity, with 457 operations performed in the last financial year (NHS, e-mail message to author, May 22, 2018). 1 In New Zealand, a very small number of operations are offered each year subject to very strict conditions, though the waiting list is significant due to a lack of willing surgeons to perform the procedure (Ministry of Health 2012 , 2017 ).

The Problem of GRS Funding

The philosophical literature on GRS is extremely limited, with scant publications focusing on the ethics of publicly funding the procedure. While a range of ethical issues surround the funding of GRS, space constraints necessitate the setting of some parameters for this discussion. First, this paper is concerned only with the funding of gender reassignment surgery in jurisdictions with a state-funded universal healthcare system. It is not concerned with the issue of individual patients having the right to access privately funded GRS. Second, I will assume that those seeking GRS are of legal adult age, competent, and seeking the treatment voluntarily. Third, I will not undertake an analysis of whether or not GD should even be classified as a health issue or not. Arguments in other fields such as sociology have sought to remove GD as a clinical pathology and to instead treat it as a variation of the norm (Ault and Bryzuzy 2009 ). This issue is beyond the scope of this paper, but it should be noted that if GD is removed as a diagnosable clinical condition, it may have implications for transgender persons’ health-based claim to GRS and may therefore affect their ability to draw on the arguments I intend to present. I will instead take the approach of the DSM-5, which classifies GD as a diagnosable mental health condition.

The proposal for publicly funding GRS is, not surprisingly, often met with controversy and strident objections. There are three primary objections to publicly funding GRS: First, GRS may be opposed on the grounds that it is supposedly a cosmetic or enhancement procedure rather than a medical one (NHS 2018 ). Second, those who oppose GRS may advance the claim that it is not cost-effective and that the conditions of scarcity and opportunity costs do not support its funding. Third, a slippery slope argument may be advanced to oppose the public funding of GRS. This argument suggests that if we fund GRS, we will inexorably have to fund other procedures such as elective cosmetic surgery or race-alteration surgery. I demonstrate that these arguments are faulty and unconvincing.

The first objection is what we may call the cosmetic objection. This objection argues that GRS is a cosmetic procedure rather than a clinically necessary one and that we should therefore not fund it. Consider the basic argument structure below:

• P1GRS is a cosmetic procedure.
• P2The state should not publicly fund cosmetic procedures.
• CTherefore, the state should not publicly fund GRS.

The problem with this argument is that it is not clear that Premise 1 or Premise 2 are as defensible as they may initially appear. First, Premise 1 is not altogether convincing, given that GRS is a clinically indicated procedure supported by medical evidence and experts to treat a recognized medical condition (APA 2013 ; WPATH 2011 ). It may involve cosmetic procedures on one level, but it is clearly not solely a cosmetic procedure. The objection therefore sets up a false dichotomy between clinical and cosmetic procedures. Second, even if Premise 1 is granted, it is not clear that Premise 2 can be defended. Some cosmetic procedures may be medically warranted for the attainment of an adequate state of mental and physical health, thus falling under the purview of the healthcare system, and thereby refuting Premise 2. Many public health systems, for example, fully fund breast reconstruction surgery for women who have undergone a mastectomy. This is a cosmetic procedure performed on the grounds that it will improve the patient’s mental well-being. Gender reassignment surgery, even if it involves cosmetic procedures, is done for this same reason. Cosmetic and clinical procedures, therefore, often intersect. Gender reassignment surgery is one such circumstance, given its rationale for promoting the mental and physical health of those with diagnosed GD.

The second objection is based on health resource scarcity and the opportunity costs of funding GRS. Information I obtained from the United Kingdom National Health Service (NHS) via a Freedom of Information Request identifies the average cost of one male-to-female GRS at £10,369 (NHS, e-mail message to author, May 22, 2018). 2 A GRS procedure for a female-to-male, which is far more complex, is an average of £31,780 (NHS, e-mail message to author, May 22, 2018). The majority of GRS performed are for male-to-female assignment, with a total cost to the NHS of £3,525,460 in the financial year of 2016/2017 (NHS, e-mail message to author, May 22, 2018). Using these funds for GRS, it is argued, means unjustifiably depriving other patients of other essential healthcare.

The resource scarcity argument is not convincing. First, GRS can itself be life-saving, and therefore analogous in this way to other essential healthcare services such as intensive care and emergency surgeries that cost more than a single GRS procedure. Without GRS, statistics suggest up to 32 per cent of transgender persons will attempt to commit suicide (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; Reisner et al. 2016 ). In purely economic terms, the cost of one death from suicide is identified by some sources at £1.7 million (NHS, 2017a ). It may well transpire, therefore, that a cost–benefit or cost–utility analysis would support funding GRS based on the benefits of saving lives, reducing the economic burden on mental health services, and losing fewer years of productive life to suicide.

Second, as far as medical procedures cost the NHS, this is fairly high, though it is comparable to other procedures which are routinely funded, highlighting the issue of consistency. For example, a lung transplant operation costs the NHS £40,076.32 per patient in the financial year 2016/2017 (NHS 2017b ). A case of complex tuberculosis costs the NHS £21,598.34 (NHS 2017b ). Treatment in an intensive care bed costs £1,932 per night, with a significant portion of patients requiring multiple days of care (NHS 2013 , 2017c ). Gender reassignment surgery fits within these parameters, given its life-saving and economic benefit, and so consistency demands that we either include it as part of the schedule of publicly funded procedures or identify a morally relevant difference. No such morally relevant difference stands up to critical scrutiny, as I shall later demonstrate.

The third objection to GRS is a slippery slope argument, claiming that if we fund GRS it will lead inexorably to the funding of numerous other procedures. For example, we may have to fund surgery for people who demand rhinoplasty. This objection can be responded to, again, through the principles of consistency. I am willing to accept the implications of this objection if, and only if, the rhinoplasty-seeking person experiences the same adverse health effects as the GD-sufferer. If rhinoplasty will prevent a severely anxious and insecure person from committing suicide, then it seems prima facie justified to publicly fund the procedure. However, the standards required to even be a candidate for GRS are very stringent, and similar standards should apply to the hypothetical life-saving rhinoplasty procedure. The patient must have a genuine and identifiable risk of self-harm and have made an autonomous request, there must be no other viable alternative treatments, and rhinoplasty should have been subjected to the two-level funding evaluation process I shall outline.

A related strand is around race appearance alteration surgery, for example, whether funding GRS means the state would also need to fund a dark-skinned person wanting to make her skin fairer on the basis of the mental distress she feels by being dark-skinned. Unlike GRS, race-based surgery may have morally important third-party effects, such as implicitly making others with dark-skin feel devalued or increasing racial stigma. Changing social attitudes is also the preferred approach since the insecurity stems almost purely from racism in society. While transgender people may be stigmatized in society, the primary effect of GD is the internal turmoil experienced independently of society’s discriminatory attitudes. Even if we removed transgender discrimination in society altogether, the GRS-seeking person would still suffer from the internal psychological distress of not belonging in their physical sex (APA 2013 ; WPATH 2011 ). The same does not seem to apply for racism. If we removed racist attitudes from society altogether, it is not clear that the dark-skinned person would continue to experience any distress from their skin colour. 3

The Constructive Argument for GRS

Having shown that the common objections against publicly funding GRS do not succeed, I now turn to a constructive argument in favour of such a policy. My constructive argument is to develop a two-level account with which to justify the public funding of GRS. This approach can also serve as a general framework for evaluating other issues of distributive justice in healthcare and is, in fact, likely already used in various jurisdictions around the world in some form or another. The first level of evaluating whether to fund GRS is to first ascertain whether the condition it intends to treat (i.e. GD) fits the criteria of a health issue and, if so, would the treatment (i.e. GRS) enable the person to improve their health. The second level of evaluation is to consider other morally relevant factors, such as opportunity costs of funding the treatment, third party effects, availability of qualified personnel, existence of alternatives, relative utility, and its impact on justice and health equity. The first-level requirement, namely that GD fits the definition of a health issue and that GRS improves health, is therefore a necessary but not sufficient condition for funding. The second level determines ultimately whether or not to fund GRS, given that the first level evaluation has been satisfied, based upon a series of further ethical considerations.

The First Level of Evaluation

The first stage of the constructive argument is to determine whether or not GRS is a clinically-indicated procedure for a medical condition, based on some definition of health. The definition of health we adopt has profound implications for the two-level approach, since it is the definition that primarily determines whether or not GRS should even be advanced to the second-level for consideration of public funding. At the same time, the definition of health we adopt has implications not only for GRS but for other health conditions more widely. Whatever definition we espouse, we must therefore be prepared to accept its implications and the demands of consistency.

Consider, for example, the World Health Organization’s (WHO) definition of health: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948 , 1–2). If a health system is given the duty of promoting health, as indeed is generally the case, then it follows that its responsibilities under a WHO definition will be very broad indeed. On the other hand, Daniel Callahan rejects the WHO concept of health in favour of a purely physical account, where health is merely a state of physical well-being (Callahan 1973 ). One implication of Callahan’s account is that mental health conditions would not fall within the purview of health, and so a health system would have no obligations to provide any mental health services.

Both the WHO and Callahan accounts have implications that few of us would likely be willing to accept. With the WHO account, it may transpire that the health system ought to fund or provide a great number of services on the basis that it would promote a person’s complete physical, mental, and social well-being. For example, it may have to provide lonely rural farmers with sex workers to satisfy their social well-being and buy car fanatics Ferraris to promote complete mental well-being. With Callahan’s account of health, the state has no duty to provide care for those suffering from severe clinical depression, hallucinations, post-traumatic stress disorder, or any other mental illness regardless of its impact. I suspect few of us would be willing to accept the implications of either of these accounts.

Accordingly, I will present a basic definition of health that is pragmatic, likely to be widely accepted, has plausible implications, and is already in use by most healthcare systems. Space constraints will not allow me to defend or develop this account in any detail, but it will be sufficient to support my present argument. I propose that health is a state of physical and mental well-being. To be healthy is to be in an adequate but not necessarily complete nor perfect state of physical and mental health. My basic definition is distinct from Callahan’s account, though not drastically so. The definition does not expand the concept of health to include social and spiritual well-being and can therefore accommodate Callahan’s concerns about the “tyranny of health” where nearly every negative experience ends up being subsumed within the domain of health. The definition also does not give health a utopic or unrealistic goal of complete well-being, unlike the WHO’s definition, which Callahan is rightly critical of. However, my account can capture the problem of mental illness as a domain of health, which accords with most clinicians’ and laypeople’s considered judgements about health. It is also how most health systems and funders today view the nature of health and the role of clinicians.

The basic definition of health I propose is sufficientarian rather than “perfectionist” in nature; it strives to reach a certain threshold rather than some absolute standard. The state has no obligation to promote complete health in all its citizens. A further clarification should also be made. A condition that fits my basic definition of health does not necessarily mean that the state ought therefore to publicly fund the associated treatments. The role of the definition of health is to clarify and delineate which conditions fit within the purview of the healthcare system. There may be other morally relevant considerations, such as opportunity costs, third party effects, availability of qualified personnel, and existence of reliable clinical evidence. However, these considerations should be addressed in the second-level evaluation after understanding the health condition itself. In general, a condition that falls within the purview of the definition of health should at least be given consideration for public funding.

A consistency or derivative argument for the funding of GRS can then be advanced on the basis of this definition of health. First, given the profound effects of GD on mental and physical health, in accordance with our definition, it is a health issue that falls under the purview of the health system. Second, given that we fund a raft of other analogous health conditions on the basis of clinical necessity, for example, depression, anxiety, and other conditions which affect a person’s mental health, consistency demands that we also fund GRS unless we can highlight the presence of morally relevant differences. This argument can, of course, be rebutted by using consistency to argue that we should not fund any of the above treatments for depression or anxiety. However, this would diverge with most reasonable persons’ considered judgement that diagnosable mental health conditions should generally fall within the purview of health. The argument could also be rebutted on the basis of faulty analogy, either on the grounds that GD is not analogous to other mental health conditions or that the treatment for those conditions is not analogous to GRS. This argument, however, is not convincing. The conditions are analogous in that they fit our basic definition of health and are diagnosable conditions with a set of accepted guidelines (APA 2013 ). The treatments are analogous in that they are clinically necessary and are based on an attempt to enable a person to improve towards or reach an adequate state of physical and mental health (WPATH 2011 ).

The claim I am advancing, then, is that what matters for our first level of evaluation is not the specific condition nor the treatment itself, but rather the effect of the condition on the person’s state of physical or mental health and the ability for the treatment to help the person attain an adequate state of physical or mental health. This approach means the first-level evaluation is condition-blind . It does not matter what specific condition it is as long as it fits our definition of health. Gender dysphoria passes the criteria required in the first-level analysis. Gender dysphoria is a recognized and diagnosable condition, which affects a person’s health per our definition. Gender reassignment surgery, as a course of treatment, is supported by the clinical evidence and is effective for restoring a person to the threshold of physical and mental health or at least greatly improving the transgender person’s health (Wierck, Caenege, and Elaut 2011 ; WPATH 2011 ).

The Second Level of Evaluation

Once the first-level evaluation is completed, namely that the condition (GD) be one that fits our definition of health, we turn to the second-level evaluation to analyse other relevant factors regarding public funding. A number of relevant considerations should be taken into account. One important consideration for publicly funding GRS is the wider distributive justice impact as a result of using scarce health resources. These may include considerations of efficiency, relative utility, and opportunity costs. As already pointed out in my rejoinder to the cost-effectiveness objection to funding GRS, the claims of the critics do not stack up empirically. On the face of it, the economic impact of publicly funding GRS seems favourable (NHS 2017a , 2017b ).

Opportunity costs are important considerations in any issue involving health resource allocation, given our finite health budget (Bognar and Hirose 2014 ; Daniels 2008 ). The £10,369 to fund one male-to-female GRS could be used for an alternative need, such as funding a certain number of immunizations or a health promotion programme. There must therefore be strong grounds for funding GRS over another procedure. The case for publicly funding GRS is strong, given its potential to be a life-saving procedure and provide immense benefit to the GD patient (APA 2013 ; WPATH 2011 ).

Identifying and ethically reasoning about opportunity costs is complex, however, as we cannot be certain that cutting funding from one area will mean it going into another area of essential health need. The £10,369 could, for example, be used to install a new car park for the hospital manager or fund a hospital corporate function instead. Opportunity cost is an important consideration to acknowledge as a general principle of distributive justice in healthcare, but it cannot be the sole justification for declining funding unless the treatment is exceedingly expensive such that it would very clearly deprive other patients’ access to an even more important health service. It is not clear that GRS fits this criterion, and so we may not rely solely upon its opportunity costs to deny public funding.

Considerations of justice and health equity are morally relevant in deciding to fund GRS. If a particular procedure has especially high benefits for a marginalized or disadvantaged group, we may have extra grounds for supporting it. This could be defended on a number of different grounds including prioritarian distributive justice, whereby we ought to morally give priority to the worst-off; on utilitarian grounds, whereby the principle of diminishing marginal utility posits that the gain in utility is greater for those who are worse off; or on Rawlsian maximin reasoning (Parfit 1997 ; Rawls 1999 ). Transgender persons remain one of the most discriminated-against people in society, as well as experiencing poorer physical and mental health than their non-transgender counterparts (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; Reisner et al. 2016 ). Gender reassignment surgery improves the mental and physical health of a disadvantaged group, and we may therefore have an increased obligation to publicly fund the treatment on prioritarian, Rawlsian, or utilitarian grounds.

Other considerations at the second-level include the availability of qualified medical and support personnel and the availability of viable alternative treatments. Most developed countries have qualified GRS surgeons, often qualified as plastic surgeons. In the event that no qualified medical personnel are available to perform the procedure, the primary obligation becomes recruiting a workforce that is able to perform GRS. It is not an appropriate response to refuse to publicly fund GRS solely on the basis of the state of the workforce, in the same way that if no qualified clinicians are available to treat schizophrenia, the answer is to recruit such personnel rather than using it as a reason to not treat schizophrenics. As for the existence of viable alternative treatments, WPATH does not actually recommend GRS as a first-line course of treatment for those with GD. In fact, there are strict sets of guidelines for clinicians to follow (WPATH 2011). Gender reassignment surgery is therefore the appropriate treatment for certain people, given that there are no viable alternative treatments available for their GD.

One consideration that may worry policymakers is around consumer behaviour and increased demand for GRS services if it becomes fully funded. A number of responses can be offered to address this concern. First, GD is a recognized condition with diagnostic criteria in the DSM and strict treatment protocols outlined in the WPATH document (APA 2013 ; WPATH 2011 ). This fact alone limits the number of those who can make a legitimate claim on the healthcare system to fund their GRS procedure. Second, if the number of people seeking GRS increases as a result of public funding, this will likely be due to more people being able to access a service they needed all along. In such cases, existing clinical need is the driving factor. It is unlikely that people will suddenly “decide” they want to change their gender identity simply because the state now subsidizes GRS. Even if people make decisions on a whim, the criteria in the DSM and WPATH guidelines can respond by declining GRS as an appropriate avenue of treatment. Considerations about inducing demand therefore do not withstand critical scrutiny, and the constructive argument in favour of publicly funding GRS is not affected.

GRS and Moralistic Bias

The constructive argument in favour of public funding GRS, then, can be summarized as follows: First, GD is a recognized clinical condition with diagnosable criteria. It passes the first stage of evaluation, namely that the condition we are treating be one that falls within the purview of the health per our sufficientarian definition (APA 2013 ; WPATH 2011 ). Second, GRS is an effective and evidence-based procedure with clear guidelines, and one that is clinically indicated for the treatment of GD (WPATH 2011 ). Third, considerations of other morally relevant factors do not damage the constructive case to publicly fund GRS. Gender reassignment surgery is cost-effective, and the opportunity costs are worth incurring given its strong potential to be a life-saving procedure (Clements-Nolle, Marx, and Katz 2006 ; Grossman and D’Augelli 2011 ; NHS 2017a ; WPATH 2011). There are strong justice-based considerations grounded in prioritarian, utilitarian, or Rawlsian theory to fund GRS, given that transgender people are one of the most disadvantaged groups in society (Reisner et al. 2016 ). Qualified medical personnel are available to carry out the procedure, and there are no other alternative treatments in the subset of GD patients for whom GRS is clinically indicated (APA 2013 ; WPATH, 2011 ).

The constructive argument I have presented in favour of publicly funding GRS may strike some as surprisingly straightforward. However, the fact that people place such a high burden on having to justify an evidence-based, potentially life-saving medical procedure for a medically recognized condition shows that other biases may be at play. These “moralistic biases” refer to existing views and intuitions people may have about GRS and transgender and gender identity issues in general. If there were a pill that could alleviate a person’s severe psychological distress and prevent them from committing suicide at a one-off cost of £10,369, I suspect the burden of justification to fund it would be significantly less than what is demanded for GRS. The fact that we do not place such a high burden of justification for even more expensive life-saving procedures such as transplants, intensive care, and emergency department treatment shows that there are other intuitions at play in the GRS funding debate.

One of these other intuitions could be an implicit bias against altering the human body in any way (NHS 2018 ). However, altering the human body is often an essential part of medical procedures—appendectomy for the treatment of appendicitis, amputation of a limb with gangrene, or even breast reduction surgery to alleviate weight for those with back problems. These critics would very likely not object to these procedures. The intuition, then, cannot merely be about objecting to altering the body. The biases people have against GRS is probably that they do not see it as a real, medical condition that warrants clinical intervention. Given the large body of medical and scientific evidence about GD and GRS, the burden of proof now rests with those who are attempting to oppose the clinical consensus (APA 2013 ; Ministry of Health 2012 ; NHS 2017a , 2018 ; WPATH, 2011 ). In the absence of a cogent rebuttal of the clinical consensus, we should treat GRS as merely another clinical procedure for a recognized condition.

Another subset of those who oppose the public funding of GRS could be those influenced by conservative or religious views about the rights of transgender people (NHS 2018 ; Schwartz and Lindley 2009 ). In a secular, liberal state, this would arguably be problematic (Raz 1986 ). Decisions about which medical procedures to fund should be informed by clinical evidence, economic analysis, and sound ethical reasoning. If we allow religious views to dictate which clinical procedures to provide, we may find a host of services being opposed, including contraception and sexual health services. Regardless, my constructive argument does not necessarily depend on subscribing to the transgender rights movement. The argument is driven primarily by the notions of clinical necessity, as well as reasoning in an ethically consistent manner given that we fund other analogous life-saving procedures.

Not all opponents of publicly funding GRS are influenced by so-called moralistic biases. The vast majority of people who oppose GRS, I suspect, are simply unaware of the facts surrounding GD and GRS. This is not necessarily through any fault of their own, as the issue is seldom discussed in social or political circles. The lack of awareness of the empirical evidence leads critics of GRS to resort to knee-jerk intuitions, often informed through biases, social attitudes, the media, and prevailing norms. However, once we acknowledge that GD is a recognized clinical condition and that GRS is a cost-effective evidence-based surgical procedure to treat it, it becomes very difficult to continue opposing public funding.

This paper has argued that the state should publicly fund GRS. First, I have argued that initial objections to the state funding GRS do not withstand critical scrutiny. Second, I have gone on to propose a constructive argument, based on the principles of clinical necessity, cost-effectiveness, justice, and ethical consistency. Given that the procedure is analogous to numerous other cost-effective, evidence-based, life-saving procedures we fund routinely, there is a strong argument for publicly funding GRS. Third, I considered a number of further important factors and objections. None of the objections against publicly funding GRS hold, and several considerations lend further support to my constructive case. Once we overcome our initial biases and moralistic intuitions about GD and GRS, and instead treat it as we would any other condition and medical procedure, the positive case for publicly funding GRS becomes very hard to deny.

1 Data from Freedom of Information Request. Received from the NHS via email on May 22, 2018.

2 Information obtained through a Freedom of Information Request. Information received 22 May 2018

3 In our non-ideal real world, I will deliberately leave open the question of whether such race-alteration surgeries should be funded if the dark-skinned person is at very serious risk of suicide, as the lesser of two evils.

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• Cambridge Dictionary +Plus

Meaning of sex reassignment surgery in English

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• She has not yet decided whether to undergo sex reassignment surgery .
• Sex reassignment surgery is a major operation and the cultural shift from presenting as male to presenting as female is a major change of lifestyle .
• Sex reassignment surgery consists of processes transgender women and men take in order to match their anatomical sex to their gender identity .
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Translations of sex reassignment surgery

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something that you do, or a thing that you give someone, that expresses your feelings or intentions, although it might have little practical effect

Renowned and celebrated (Words meaning ‘famous’)

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gender reassignment

Definition of gender reassignment

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than making changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

Word History

1969, in the meaning defined at sense 2

Articles Related to gender reassignment

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Dictionary Entries Near gender reassignment

genderqueer

gender reassignment surgery

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“Gender reassignment.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment. Accessed 16 Mar. 2024.

Medical Definition

Medical definition of gender reassignment.

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender, rather than makes changes to align their outward appearance and presentation with their gender identity. Gender transition is the preferred term in the medical and LGBTQ+ communities.

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Is gender reassignment surgery defined as 'mutilation' in the NSW Crimes Act?

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"Mutilation" is not the “correct medico-legal term” for referring to gender reassignment surgery, experts have said in response to a claims by the Liberal Party's candidate for Warringah, Katherine Deves.

Katherine Deves, the Liberal candidate for the Sydney seat of Warringah, is embroiled in another controversy after claiming gender reassignment surgery for teenagers was referred to as 'mutilation' in the NSW Crimes Act.

'That is the correct terminology". Katherine Deves speaking to Sky News' Chris Kenny just now & appearing to walk back from her previous apologies for describing transgender children as 'surgically mutilated and sterilised'. #AusVotes #AusPol pic.twitter.com/zW4oyS3sgY — Tina Quinn (@TinaMQ) May 9, 2022

Her comments lit up Twitter. A video posted on Sky News Twitter attracted more than 132,000 views and 4,100 views on the Sky News YouTube channel.

The most recent intervention came in her roadside interview with Sky News presenter Chris Kenny, who asked Ms Deves: "So when you said that gender reassignment surgery for teenagers was mutilation, that was inappropriate?" 

Deves: "Look, that is the correct medico-legal term.." 

Kenny: "So you were wrong to use that language .."

Deves: "Look, it's very emotive, and it's very confronting, and it's very ugly, so of course, people are going to be offended, but when you look at medical negligence cases, that is the terminology that they use, and it is also contained in the Crimes Act of New South Wales."

Kenny: "So you are not really apologising or stepping back from that language?"

Deves: "Well, I'm apologising for how people might have perceived it and the fact that it is confronting and it is ugly, and I certainly don't want to hurt anyone's feelings, but that is the correct terminology.

RMIT FactLab asks: What does the NSW Crimes Act say about gender reassignment, and does the legislation refer to mutilation?

Furthermore, as Ms Deves says, is mutilation the "correct medico-legal term" for gender reassignment?

RMIT FactLab asked three experts for their views. This is what they said:  

Professor Cameron Stewart, a specialist in health, law and ethics at Sydney University, said: "Gender reassignment is not directly discussed in the NSW Crimes Act. That Act criminalises female genital mutilation, but appropriately authorised treatments involving gender reassignment are expressly excluded from that definition."

Professor Jenni Millbank from the University of Technology Sydney's law faculty said the NSW Crimes Act expressly and very clearly exempts corrective or affirmative surgery for gender identity. 

She said it was "completely false" to assert otherwise. 

A senior lecturer in criminology at the University of Sydney, Andrew Dyer, said: "The only references to 'mutilation' in the Crimes Act are to female genital mutilation." 

Referring to sections 45 and 45a of the Act, he said: "The section that criminalises female genital mutilation, section 45, explicitly states that that section does not prohibit sexual reassignment procedures performed by medical practitioners."

To clarify the distinction between the crime of genital mutilation and gender reassignment surgery, the Act also includes a definition of "sexual reassignment procedure" as; "a surgical procedure to alter the genital appearance of a person to the appearance (as nearly as practicable) of the opposite sex to the sex of the person.

All three experts consulted said mutilation was not the “correct medico-legal term” for referring to gender reassignment surgery. 

The Verdict: The claim that gender reassignment surgery is defined as mutilation in the NSW Crimes Act is incorrect.  

Deves split the NSW branch of the Liberal Party with her forthright opposition to transgender women competing in sports. The Minister for Women Marise Payne and NSW Treasurer Matt Keane refused to endorse her comments even though she has the backing of Prime Minister Scott Morrison. 

Devas has drawn national attention via social media for her stand on transgender issues, a stand also endorsed by former Liberal Prime Minister Tony Abbott and conservative groups.

Her comments were broadcast on Sky News YouTube channel and on Twitter. - At the time of writing, this video has been seen more than 132,000 times. In addition, the comments and video were included in an article published at 10:39pm on May 9 .

What does the NSW Crimes Act say about sexual reassignment exemption?

The NSW Crimes Act, division 6, section 45 - refers to 'female genitalmutilation' , as a crime committed by someone who excises, infibulates or otherwise mutilates the whole or any part of the labia majora or labia minora or clitoris of another person. 

It explicitly exempts cases where the procedure " is a sexual reassignment procedure performed by a medical practitioner."

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What to know about the 'confusion' over Kate Middleton's edited family photo

Bill Chappell

Fatima Al-Kassab

Kate, Princess of Wales, says she edited a photo that seemed to promise to ease concerns about her health — but only raised new questions. She's seen here greeting the public on Christmas Day, last December. Stephen Pond/Getty Images hide caption

Kate, Princess of Wales, says she edited a photo that seemed to promise to ease concerns about her health — but only raised new questions. She's seen here greeting the public on Christmas Day, last December.

The family photo might have helped ease concerns and questions about Kate, the Princess of Wales — but then viewers noted irregularities in the image, and a flurry of new questions emerged. And now the princess has acknowledged that the photo she released on Sunday was manipulated.

"Like many amateur photographers, I do occasionally experiment with editing," the princess said on social media Monday . "I wanted to express my apologies for any confusion the family photograph we shared yesterday caused."

Acknowledgment of the doctored photo came after several news agencies retracted the photo. The Associated Press, for instance, noted the odd "alignment of Princess Charlotte's left hand with the sleeve of her sweater" and stated, "At closer inspection it appears that the source has manipulated the image."

View this post on Instagram A post shared by The Prince and Princess of Wales (@princeandprincessofwales)

The photo was released on the U.K.'s Mother's Day, showing Kate (Princess Catherine) seated in a chair, sharing a hug with her children: Princess Charlotte, Prince Louis and Prince George. In the post, Kate credited her husband, Prince William, with taking the picture.

"Thank you for your kind wishes and continued support over the last two months," Kate wrote.

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What the royal family doesn't understand about pr in 2024.

On its face, the cheery image seemed to suggest the princess was healthy and happy after she virtually disappeared from public view in late December. Kensington Palace had shared scant details about Kate, 42, saying that after having "successful" abdominal surgery in January, she spent nearly two weeks in the hospital.

But then the questions arose, growing from rumor to full retraction. In its discussion of the photo, the AP noted that its standards prohibit substantial editing of an image, as well as the removal of "red eye" effects.

The doctored photo led to a social media frenzy and fueled conspiracy theories over Kate's health and wellbeing.

William And Kate: The Royal Wedding

Modern monarch: is the new royal couple the last.

Robert Hardman, a royal biographer and the author of The Making of a King, told NPR that although the royal family is a public-facing institution, Kate's absence is understandable given her recent health condition.

"Most of us, if we've had surgery or some medical issue, that takes a bit of time to recover," he said. "So I totally get why for her, this is a private matter."

Here's a brief timeline of the events leading up to Sunday's photo release:

Christmas Day, 2023

Kate joins the rest of the royal family to attend a Christmas morning church service in Sandringham, Norfolk. It's the last time she's seen in an official capacity until the controversial family portrait emerges on March 10.

Jan. 17, 2024

The royal family issues two major health updates . Kensington Palace announces that the Princess of Wales is recovering after undergoing "planned abdominal surgery." It calls the surgery a success, saying the princess will stay in hospital for up to 14 days and "is unlikely to return to public duties until after Easter," on March 31.

Hours later, Buckingham Palace announces King Charles III, 75, will have a "corrective procedure" for an enlarged prostate gland, a condition it describes as benign. Charles is discharged on Jan. 29.

King Charles has "a form of cancer," the royal family says , adding that it was diagnosed after his treatment for an enlarged prostate raised concerns about a separate issue.

Prince William attends high-profile events without Kate, including the black-tie British Academy Film Awards (BAFTA) ceremony, where he's seen walking the red carpet alone .

Prince William unexpectedly pulls out of a memorial service at Windsor Castle, citing a "personal matter." William had been due to deliver a reading at the service for one of his godfathers, the late King Constantine of Greece, but less than an hour before the memorial was scheduled to start, it was announced that the prince would not be present. Kensington Palace did not elaborate further on the reason why Prince William could not attend but reiterated that the Princess of Wales continued to be doing well.

Move over, Kate Middleton, for Spain's 'middle-class queen'

U.S. websites publish grainy paparazzi photos appearing to show Kate in a car with her mother — what would be the first pictures of the princess to be published since her surgery. The photos show a woman wearing sunglasses in the passenger seat of an SUV driven by Kate's mother, Carole Middleton, near Windsor Castle. The pictures were not published in the U.K. , according to the Daily Mail , after Kensington Palace asked for Kate to be able to recuperate in private.

The British Army removes from its website an announcement saying that the Princess of Wales would appear at a military parade in June. Tickets were being sold for the event, alongside a photo of Kate. The palace says it never confirmed her schedule.

Kensington Palace releases a photograph of Kate and her three children on social media channels. The message concludes, "Wishing everyone a Happy Mother's Day. C," with the "C" denoting Catherine herself. It credits the picture to "Prince of Wales, 2024." As observers question the fidelity of the image, some also question the date it was taken, noting the green foliage in the background.

Kate issues a message acknowledging the photo was edited and apologizing for any confusion it caused.

NPR's Juliana Kim contributed reporting.

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