gender reassignment vs gender affirmation

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..

What is gender-affirming care?

Gender-affirming care, as defined by the World Health Organization, encompasses a range of social, psychological, behavioral, and medical interventions “designed to support and affirm an individual’s gender identity” when it conflicts with the gender they were assigned at birth. The interventions help transgender people align various aspects of their lives — emotional, interpersonal, and biological — with their gender identity. As noted by the American Psychiatric Association (APA), that identity can run anywhere along a continuum that includes man, woman, a combination of those, neither of those, and fluid.

The interventions fall along a continuum as well, from counseling to changes in social expression to medications (such as hormone therapy). For children in particular, the timing of the interventions is based on several factors, including cognitive and physical development as well as parental consent. Surgery, including to reduce a person’s Adam’s Apple, or to align their chest or genitalia with their gender identity, is rarely provided to people under 18.

“The goal is not treatment, but to listen to the child and build understanding — to create an environment of safety in which emotions, questions, and concerns can be explored,” says Rafferty, lead author of a policy statement from the American Academy of Pediatrics (AAP) on gender-affirming care.

Why do youths seek gender-affirming care?

Some children sense a difference between their assigned gender and their gender identity at an early age, says Deanna Adkins, MD, director of the Duke Child and Adolescent Gender Care Clinic in Durham, North Carolina. By the time an adolescent or teenager comes to the clinic to talk about gender-affirming therapy, “they’ve typically been thinking about it for a long time,” says Adkins, whose clinic is part of Duke University Hospital.

Those who seek gender-affirming care are often experiencing gender dysphoria, which the APA cites as “psychological distress” stemming from the incongruence between gender assignment and identity. Although many transgender people feel this distress without being diagnosed by a doctor, gender dysphoria is a defined clinical condition in the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The symptoms include “strong” desires to have the primary or secondary sex characteristics of another gender and to be treated as another gender, as well as “significant distress or impairment in social, occupational, or other important areas of functioning.”

Numerous studies have found that transgender youths, especially those experiencing gender dysphoria, are significantly more likely than other youths to suffer emotional distress and depression, to experience bullying and other forms of violence, and to harm themselves or attempt suicide. For example, a study led by the University of Minnesota of nearly 82,000 students in that state found that 61% of transgender youths reported suicidal ideation, more than three times the rate among cisgender youths.

In school, gender dysphoric youths often struggle to succeed socially and academically “due to pressure to dress in a way that’s associated with their sex assigned at birth or out of fear of being harassed or teased,” the Minnesota-based Mayo Clinic reports . When it comes to getting help, Mayo notes, “Accessing health services and mental health services can be difficult due to fear of stigma and a lack of experienced care providers.”

What types of emotional, social, and psychological care are available?

The fundamental thing that transgender people seek from health providers “is someone who’s culturally and medically competent to care for them in an environment where they feel safe,” says Imborek, whose LGBTQ Clinic is part of University of Iowa Hospitals and Clinics. “The primary care I provide is a gender-affirming environment.”

That environment allows for frank discussions about the patient’s gender identity and related stress, sexual activity, and potential transition toward a different gender identity. A young person’s stages of physical and psychological development are major factors in determining which interventions (if any) are most appropriate and when.

Most of the care — especially the more intensive care — is provided to youths during or after puberty. The World Professional Association for Transgender Health (WPATH) Standards of Care observes that “gender dysphoria during childhood does not inevitably continue into adulthood,” and “the persistence of gender dysphoria into adulthood appears to be much higher for adolescents.”

The transition supports might start with cosmetic changes and move toward more intensive interventions, drawing on an array of physicians, mental health counselors, and non-medical caregivers. That care includes:

• Counseling about coming out as transgender to family, peers, and others (such as teachers).
• Resources to assist with changing outward appearances and gender presentation. For example, IU Health Care's LGBTQ Clinic refers interested patients to the hair salon at the university hospital for hair and makeup lessons, Imborek says.
• Speech therapy to help match vocal characteristics (such as pitch and phrasing patterns) with gender identity.
• Hair removal through electrolysis, laser treatment, or waxing.
• Breast binding or padding, genital tucking, and padding of the hips or buttocks.

Specialists who provide this care stress that these interventions are reversible. Young people sometimes stop a process to reassess their identity or because they’ve transitioned to a point that feels right.

What hormone-related therapies are available?

Puberty blockers : Transgender youths who have not started or completed puberty can receive “puberty blocker” medication, which suppresses the release of sex hormones, including testosterone and estrogen. The Mayo Clinic explains that for those identified as male at birth, “the blockers decrease the growth of facial and body hair, prevent voice deepening, and limit the growth of genitalia.” For those identified as female at birth, “the treatment limits or stops breast development and stops menstruation.”

One purpose of puberty blockers is to allow a young person time to fully determine their gender identity and how far they wish to transition before the onset of permanent sex characteristics.

“They’re usually used in early puberty to slow things down,” Rafferty says. “They [the youths] haven’t had much of an option to explore who they are. They’re coming in and saying, ‘Something doesn’t feel right’” about their assigned gender.

If puberty blockers are stopped during puberty, hormone development resumes until the end of that child’s puberty, Rafferty says. Blockers are typically not initiated after a child finishes puberty, he explains, because they are not necessary and some of the blocked hormones are necessary for healthy adult development (such as estrogen for bone strength).

Hormone therapy : Older youths (usually in mid-adolescence) and adults can receive hormone therapy to increase their levels of estrogen or testosterone so that they develop sex characteristics more closely aligned with their gender identity. These include more hair growth and increased muscle mass for those transitioning to a more masculine presentation, and breast development and testicular atrophy for those transitioning to a more feminine presentation.

The changes occur slowly, and Rafferty notes that it’s not unusual for patients to stop hormone therapy before the secondary sex characteristics fully develop, deciding that they have biologically transitioned as far as they wish. He adds that depending on when the treatments stop, some of the effects partially or completely reverse, such as broadening of the shoulders for those taking male hormones and early breast development for those taking female hormones.

How is it determined that someone needs and is eligible for these procedures?

Criteria for gender-affirming care and therapy are provided in guidelines from several organizations, including the WPATH , the AAP , and the Endocrine Society . The WPATH Standards of Care caution that “before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken.”

“Some people come in in a questioning phase, and we just take our time and they work with the therapist,” says Imborek at the Iowa clinic. “They lean into trying to figure out where their gender dysphoria lies and whether or not hormones would make that better.”

Among the criteria that are typical for providing hormone-related therapies for youths are:

• A finding that the youth has experienced several symptoms of gender dysphoria listed in the DSM for at least six consecutive months.
• A letter of support from the youth’s licensed therapist and written concurrence from a mental health professional for the provider.
• Parental consent for those under 18.
• Ongoing psychotherapy.

For youths in particular, providers must ensure that the patients understand the permanent nature of some of the changes and potential harmful side effects that might affect their lives years into adulthood (such as infertility). In supporting Gov. Abbot’s order in Texas, Attorney General Ken Paxton issued an opinion citing the potential risks — including infertility, cardiovascular disease, and elevated blood pressure — as reasons that the therapies violate child abuse laws.

What is the impact of the therapies?

Studies have linked gender-affirming care at various levels to a decrease in depression and harmful behaviors. For example, a study from the Stanford University School of Medicine in California, published in January, concluded that those who began hormone therapy in adolescence experienced less suicidal ideation, fewer mental health disorders, and less substance abuse than those who began such therapy later.

The WPATH says there is insufficient evidence about the long-term outcomes among younger children who receive those therapies.

The Texas attorney general’s opinion contends all the evidence is insufficient, stating, “There is no evidence that long-term mental health outcomes are improved or that rates of suicide are reduced by hormonal or surgical intervention.”

Providers attest to seeing positive changes in their patients from gender-affirming care. “Most of them are happier, less depressed, and less anxious,” says Adkins at the Duke Child and Adolescent Gender Care Clinic. “Their schoolwork often improves, their safety often improves.”

“Saving their lives is a big deal.”

Regardless of state government efforts against some treatments, Rafferty urges doctors to focus on all types of gender affirmation as essential health care:

“It’s important for providers to know that what they do, even if it’s just affirming someone’s [asserted] name, can have a positive influence on the health and development of that child. This support has to take place within a clinic. It’s not something that can be legislated.”

Facial feminization surgery is a combination of procedures designed to soften the facial features and feminize the face. There are many procedures that are available to feminize the face.

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Facial feminization surgery is always tailored to the individual, but as ASPS member Justine Lee, MD, PhD, explains there are general characteristics such as hairline, brow bones, cheeks and jawline that many patients note and plastic surgeons plan for.

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What Is Gender Affirmation Surgery?

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

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

Why Is Gender Affirmation Surgery Performed?

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

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

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

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

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

Transgender vs Nonbinary

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

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

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

Hormone Therapy

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

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

Types of hormone therapy include:

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

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

Masculinizing Surgeries

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

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

Top Surgery

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

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

Metoidioplasty

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

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

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

Phalloplasty

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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

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

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

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

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What Is Gender Affirmation Surgery?

Surgery to change the appearance of your body is a common choice for all kinds of people. There are many reasons that people might want to alter their appearance. For transgender or gender nonconforming people, making changes to their bodies is a way of affirming their identity.

A trans person can choose from multiple procedures to make their appearance match their self-identified gender identity. Doctors refer to this as gender "affirmation" surgery.

Trans people might decide to have surgery on their chest, genitals, or face. These surgeries are personal decisions, and each person makes their own choices about what is right for them.

Learn more about gender affirmation surgery and how it helps trans people.

What Does It Mean to Be Transgender or Nonbinary?

Transgender is a word to describe people whose gender identity or gender expression doesn't match the sex they were assigned at birth. Typically, parents and doctors assume a baby's gender based on the appearance of their genitals. But some people grow up and realize that their sense of who they are isn't aligned with how their bodies look. These people are considered transgender.

Trans people may identify as a different gender than what they were assigned at birth. For example, a child assigned male at birth may identify as female. Nonbinary people don't identify as either male or female. They may refer to themselves as "nonbinary" or "genderqueer."

There are many options for trans and nonbinary people to change their appearance so that how they look reflects who they are inside. Many trans people use clothing, hairstyles, or makeup to present a particular look. Some use hormone therapy to refine their secondary sex characteristics. Some people choose surgery that can change their bodies and faces permanently.

Facial Surgery

Facial plastic surgery is popular and accessible for all kinds of people in the U.S. It is not uncommon to have a nose job or a facelift . Cosmetic surgery is great for improving self-esteem and making people feel more like themselves. Trans people can use plastic surgery to adjust the shape of their faces to better reflect their gender identity.

Facial feminization. A person with a masculine face can have surgeries to make their face and neck look more feminine. These can be done in one procedure or through multiple operations. They might ask for:

• Forehead contouring
• Jaw reduction
• Chin surgery
• Hairline advancement
• Cheek augmentation
• Rhinoplasty
• Lip augmentation
• Adam's apple reduction

Facial masculinization. Someone with a feminine face can have surgery to make their face look more masculine. The doctor may do all the procedures at one time or plan multiple surgeries. Doctors usually offer:

• Forehead lengthening
• Jaw reshaping
• Chin contouring
• Adam's apple enhancement

Top Surgery

Breast surgeries are very common in America. The shorthand for breast surgeries is "top surgery." All kinds of people have operations on their breasts , and there are a lot of doctors who can do them. The surgeries that trans people have to change their chests are very similar to typical breast enhancement or breast removal operations.

Transfeminine. When a trans person wants a more feminine bustline, that's called transfeminine top surgery. It involves placing breast implants in a person's chest. It's the same operation that a doctor might do to enlarge someone's breasts or for breast reconstruction .

Transmasculine. Transmasculine top surgery is when a person wants a more masculine chest shape. It is similar to a mastectomy . The doctor removes the breast tissue to flatten the whole chest. The doctor can also contour the skin and reposition the nipples to look more like a typical man's chest.

Bottom Surgery

For people who want to change their genitals, some operations can do that. That is sometimes called bottom surgery. Those are complicated procedures that require doctors with a lot of experience with trans surgeries.

Transmasculine bottom surgery. Some transmasculine people want to remove their uterus and ovaries. They can choose to have a hysterectomy to do that. This reduces the level of female hormones in their bodies and stops their menstrual cycles.

If a person wants to change their external genitals, they can ask for surgery to alter the vaginal opening. A surgeon can also construct a penis for them. There are several techniques for doing this.

Metoidioplasty uses the clitoris and surrounding skin to create a phallus that can become erect and pass urine. A phalloplasty requires grafting skin from another part of the body into the genital region to create a phallus. People can also have surgery to make a scrotum with implants that mimic testicles. ‌

Transfeminine bottom surgery. People who want to reduce the level of male hormones in their bodies may choose to have their testicles removed. This is called an orchiectomy and can be done as an outpatient operation.

Vaginoplasty is an operation to construct a vagina . Doctors use the tissue from the penis and invert it into a person's pelvic area. The follow-up after a vaginoplasty involves using dilators to prevent the new vaginal opening from closing back up.

How Much Does Gender Affirmation Surgery Cost?

Some medical insurance companies will cover some or most parts of your gender-affirming surgery. But many might have certain "exclusions" listed in the plan. They might use language like "services related to sex change" or "sex reassignment surgery." These limitations may vary by state. It's best to reach out to your insurance company by phone or email to confirm the coverage or exclusions.

If your company does cover some costs, they may need a few documents before they approve it.

This can include:

• A gender dysphoria diagnosis in your health records. It's a term used to describe the feeling you have when the sex you're assigned at birth does not match with your gender identity. A doctor can provide a note if it's necessary.
• A letter of support from a mental health professional such as a social worker, psychiatrist , or a therapist.

Gender affirmation surgery can be very expensive. It's best to check with your insurance company to see what type of coverage you have.

If you're planning to pay out-of-pocket, prices may vary depending on the various specialists involved in your case. This can include surgeons, primary care doctors, anesthesiologists, psychiatrists, social workers, and counselors. The procedure costs also vary, and the total bill will include a number of charges, including hospital stay, anesthesia, counseling sessions, medications, and the procedures you elect to have.

Whether you choose facial, top, or bottom or a combination of these procedures, the total bill after your hospital stay can cost anywhere from $5,400 for chin surgery to well over $100,000 for multiple procedures.

Recovery and Mental Health After Gender Affirmation Surgery

Your recovery time may vary. It will depend on the type of surgery you have. But swelling can last anywhere from 2 weeks for facial surgery to up to 4 months or more if you opted for bottom surgery.

Talk to your doctor about when you can get back to your normal day-to-day routine. But in the meantime, make sure to go to your regular follow-up appointments with your doctor. This will help them make sure you're healing well post-surgery.

Most trans and nonbinary people who get gender affirmation surgery report that it improves their overall quality of life. In fact, over 94% of people who opt for surgery say they are satisfied with the results.

Folks who have mental health support before surgery tend to do better, too. One study found that after gender affirmation surgery, a person's need for mental health treatment went down by 8%.

Not all trans and nonbinary people choose to have gender affirmation surgery, or they may only have some of the procedures available. If you are considering surgery, speak with your primary care doctor to discuss what operations might be best for you.

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

Gender-Affirming Surgery (Top Surgery)

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

What You Should Know About Gender-Affirming Surgery

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

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

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

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

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

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

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

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

Initial Consultation and Tests

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

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

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

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

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

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

Top Surgeries

Chest reconstruction - mastectomy, breast reduction.

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

Breast Augmentation

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

The Procedure Length

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

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

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

Why Choose Duke

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

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

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• Gender-Affirming Hormone Therapy

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• v.9(3); 2021 Mar

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

Valeria p. bustos.

From the * Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Samyd S. Bustos

† Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

Andres Mascaro

‡ Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla.

Gabriel Del Corral

§ Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

Antonio J. Forte

¶ Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

Pedro Ciudad

∥ Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

Esther A. Kim

** Division of Plastic and Reconstructive Surgery, University of California, San Francisco, Calif.

Howard N. Langstein

†† Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

Oscar J. Manrique

Associated data.

Supplemental Digital Content is available in the text.

Background:

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%–2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%–<1%) and 1% (CI <1%–2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin’s regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

Conclusions:

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Introduction

Discordance or misalignment between gender identity and sex assigned at birth can translate into disproportionate discomfort, configuring the definition of gender dysphoria. 1 – 3 This population has increased risk of psychiatric conditions, including depression, substance abuse disorders, self-injury, and suicide, compared with cis-gender individuals. 4 , 5 Approximately 0.6% of adults in the United States identify themselves as transgenders. 6 Despite advocacy to promote and increase awareness of the human rights of transgender and gender non-binary (TGNB) individuals, discrimination continue to afflict the daily life of these individuals. 4 , 7

Gender-affirmation care plays an important role in tackling gender dysphoria. 5 , 8 – 10 Gender-affirmation surgeries (GAS) aim to align the patients’ appearance with their gender identity and help achieve personal comfort with one-self, which will help decrease psychological distress. 5 , 10 These interventions should be addressed by a multidisciplinary team, including psychiatrists, psychologists, endocrinologists, physical therapists, and surgeons. 1 , 9 The number of GAS has consistently increased during the last years. In the United States, from 2017 to 2018, the number of GAS increased to 15.3%. 8 , 11 , 12

Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. 5 , 13 – 19 However, despite this, there is a minor population that experiences regret, occasionally leading to de-transition surgeries. 20 Both regret and de-transition may add an important burden of physical, social, and mental distress, which raises concerns about the appropriateness and effectiveness of these procedures in selected patients. Special attention should be paid in identifying and recognizing the prevalence and factors associated with regret. In the present study, we hypothesized that the prevalence of regret is less than the last estimation by Pfafflin in 1993, due to improvements in standard of care, patient selection, surgical techniques, and gender confirmation care. Therefore, the aim of this study was to evaluate the prevalence of regret and assess associated factors in TGNB patients 13-years-old or older who underwent GAS. 20

Search Methodology

Following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a comprehensive research of several databases from each database’s inception to May 11, 2020, for studies in both English and Spanish languages, was conducted. 21 The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by an experienced librarian, with input from the study’s principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies of de-transition and regret in adult patients who underwent gender confirmation surgery. The actual strategy listing all search terms used and how they are combined is available in Supplemental Digital Content 1. ( See Supplemental Digital Content 1, which displays the search strategy. http://links.lww.com/PRSGO/B598 .)

Study Selection

Search results were exported from the database into XML format and then uploaded to Covidence. 22 The study selection was performed in a 2-stage screening process. The first step was conducted by 2 screeners (V.P.B. and S.S.B.), who reviewed titles and abstracts and selected those of relevance to the research question. Then, the same 2 screeners reviewed full text of the remaining articles and selected those eligible according to the inclusion and exclusion criteria (Fig. ​ (Fig.1). 1 ). If disagreements were encountered, a third reviewer (O.J.M.) moderated a discussion, and a joint decision between the 3 reviewers was made for a final determination. Inclusion criteria were all the articles that included patients aged 13 years or more who underwent GAS and report regret or de-transition rates, and observational or interventional studies in English or Spanish language. Exclusion criteria were letter to the editors, case series with <10 patients, case reports correspondences, and animal studies.

PRISMA flow diagram for systematic reviews.

Data Extraction/Synthesis

After selecting the articles, we assessed study characteristics. We identified year of publication, country in which the study was conducted, population size, and number of transmasculine and transfemenine patients with their respective mean age (expressed with SD, range, or interquartile range if included in the study). In addition, we extracted information of the method of data collection (interviews versus questionnaires), number of regrets following GAS, as well as the type of surgery, time of follow-up, and de-transition procedures. We classified the type of regret based on the patient’s reasons for regret if they were mentioned in the studies. We used the Pfäfflin and Kuiper and Cohen-Kettenis classifications of regret (Table ​ (Table1 1 ). 20 , 23

Pfäfflin and Kuiper and Cohen-Kettenis Categories of Regret

Quality Assessment

To assess the risk of bias within each study, the National Institute of Health (NIH) quality assessment tool was used. 24 This tool ranks each article as “good,” “fair,” or “poor,” and with this, we categorized each article into “low risk,” “moderate risk,” or “high risk” of bias, respectively.

Our primary outcome of interest was the prevalence of regret of transgender patients who underwent any type of GAS. Secondary outcomes of interest were discriminating the prevalence of regrets by type gender transition (transfemenine and transmasculine), and type of surgery.

Data Analysis and Synthesis

The binominal data were analyzed, and the pooled prevalence of regret was estimated using proportion meta-analysis with Stata Software/IC (version 16.1). 25 Given the heterogeneity between studies, we conducted a logistic-normal-random-effect model. The study-specific proportions with 95% exact CIs and overall pooled estimates with 95% Wald CIs with Freeman-Turkey double arcsine transformation were used. The effect size and percentage of weight were presented for each individual study. 25 , 26

To evaluate heterogeneity, I 2 statistics was used. If P < 0.05 or I 2 > 50%, significant heterogeneity was considered. A univariate meta-regression analysis was performed to assess the significance in country of origin, tools of measurement, and quality of the studies.

To assess publication bias, we used funnel plot graphic and the Egger test. If this test showed us no statistical significance ( P > 0.05), we assumed that the publication bias had a low impact on the results of our metanalysis. To assess the impact of the publication bias on our missing studies, we used the trim-and-fill method.

A sensitivity analysis was conducted to assess the influence of certain characteristics in the magnitude and precision of the overall prevalence of regret. The following characteristics were excluded: <10 participants included, and the presence of a high risk of bias.

A total of 74 articles were identified in the search, and 2 additional records were identified through other sources. After the first-step screening process, 39 articles were relevant based on the information provided in their titles and abstracts. After the second-step process, a total of 27 articles were included in the systematic review and metanalysis (Fig. ​ (Fig.1 1 ).

Based on the NIH quality assessment tool, the majority of article ranged between “poor” and “fair” categories. 24 ( See Supplemental Digital Content 2, which displays the score of each reviewed study. http://links.lww.com/PRSGO/B599 .)

Study Characteristics

In total, the included studies pooled 7928 cases of transgender individuals who underwent any type of GAS. A total of 2578 (33%) underwent transmasculine procedures, 5136 (67%) underwent transfemenine surgeries, and 1 non-binary patient underwent surgery. In Table ​ Table2 2 characteristics of studies are listed. Without discriminating type of surgical technique, from all transfemenine surgeries included, 772 (39.3%) were vaginoplasty, 260 (13.3%) were clitoroplasty, 107 (5.5%) were breast augmentation, 72 (3.7%) were labioplasty and vulvoplasty, and a small minority were facial feminization surgery, vocal cord surgery, thyroid cartilage reduction, and oophorectomy surgery. The rest did not specify type of surgery. In regard to transmasculine surgeries, 297 (12.4%) were mastectomies, 61 (2.6%) were phalloplasties, and 51 (2.1%) hysterectomies (Table ​ (Table3 3 and ​ and4). 4 ). Overall, follow-up time from surgery to the time of regret assessment ranged from 0.8 to 9 years (Table ​ (Table2 2 ).

*Reflects the mean of both transmasculine and transfemenine.

†Includes both scheduled and completed surgery.

‡Includes both surgery and no surgery patients.

H, High; He, Heterosexual; Ho, Homosexual; I, Interview; IQR, Interquartile Range; L, Low; M, Moderate; Me, Median; NA, Not applicable; NS: Not specified, Q: Questionnaire; RAP: Radial Arterial Forearm-Flap Phalloplasty without or with cutaneous nerve to clitoral nerve anastomosis; SP: Suprapubic Pedicle-Flap Phalloplasty.

Studies Differentiating Type of Surgery among Transfemenine Patients

Studies Differentiating the Type of Surgery among Transmasculine Patients

Regrets and De-transition

Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic. 15 , 19 – 33 Most of the questions evaluating regret used options such as, “ yes,” “sometimes,” “no” or “ all the time,” “sometimes,” “never,” or “most certainly, ” “very likely,” “maybe,” “rather not,” or “definitely not.” 14 , 18 , 19 , 23 , 27 – 38 Other studies used semi-structured interviews. 34 , 37 , 39 – 43 However, in both circumstances, some studies provided further specific information on reasons for regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 – 46 Of the 7928 patients, 77 expressed regret (12 transmen, 57 transwomen, 8 not specified), understood by those who had “sometimes” or “always” felt it.

Reasons for Regret

The most prevalent reason for regret was the difficulty/dissatisfaction/acceptance in life with the new gender role. 23 , 29 , 32 , 36 , 44 Other less prevalent reasons were “failure” of surgery to achieve their surgical goals in an aesthetic level and psychological level. 29 , 32 , 36 , 47 Based on the reasons presented, we classified the types of regrets according to Pfäfflin’s types of regret and Kuiper and Cohen-Kettenis classification. According to Pfäfflin’s types, 28 patients had minor regret, and 34 patients had major regret. 14 , 20 , 23 , 29 , 32 , 36 , 41 , 44 , 45 Based on the Kuiper and Cohen-Kettenis regret classification, 35 patients had clear regret, 26 uncertain regret, 1 regret, and none presented with regret assumed by others. 23 In Table ​ Table5 5 and ​ and6, 6 , the reasons and classifications are shown.

Type of Regret

*8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation.

N, no; NS, not specified; Y, Yes.

Causes of Regret

NS, not specified.

Prevalence of Regret

The pooled prevalence of regret among the TGNB population after GAS was 1% (95% Confidence interval [CI] <1%–2%; I 2 = 75.1%) (Fig. ​ (Fig.2). 2 ). The prevalence for transmasculine surgeries was <1% (CI <1%–<1%, I 2 = 28.8%), and for transfemenine surgeries, it was 1% (CI <1%–2%, I 2 = 75.5%) (Fig. ​ (Fig.3). 3 ). The prevalence of regret after vaginoplasty was of 2% (CI <1%–4%, I 2 = 41.5%) and that after mastectomy was <1% (CI <1–<1%, I 2 = 21.8%) (Fig. ​ (Fig.4 4 ).

Pooled prevalence of regret among TGNB individuals after gender confirmation surgery. Heterogeneity χ 2 = 104.31 (d.f. = 26), P = 0.00, I 2 [variation in effect size (ES) attributable to heterogeneity] = 75.08%, Estimate of between-study variance Ʈ 2 = 0.02, Test of ES = 0, z = 4.22, P = 0.00.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on gender. ES, effect size.

Subgroup analysis of the prevalence of regret among TGNB individuals after gender confirmation surgery based on the type of surgery. ES, effect size.

Meta-regression and Publication Bias

No covariates analyzed affected the pooled endpoint in this metanalysis. The Funnel Plot shows asymmetry between studies (Fig. ​ (Fig.5). 5 ). The Egger test resulted in a P value of 0.0271, which suggests statistical significance for publication bias. The Trim & Fill method imputed 14 approximated studies, with limited impact of the adjusted results. The change in effect size was from 0.010 to 0.005 with no statistical significance (Fig. ​ (Fig.6 6 ).

Funnel plot.

Funnel plot of the Trim & Fill method.

Sensitivity Analysis

When excluding studies with sample sizes less than 10 and high-risk biased studies, the pooled prevalence was similar 1% (CI <1%–3%) compared with the pooled prevalence when those studies were included 1% (CI <1%–2%).

The prevalence of regret in the TGNB population after GAS was of 1% (CI <1%–2%). The prevalence of regret for transfemenine surgeries was 1% (CI <1%–2%), and the prevalence for transmasculine surgeries was <1% (CI <1%–<1%). Traditionally, the landmark reference of regret prevalence after GAS has been based on the study by Pfäfflin in 1993, who reported a regret rate of 1%–1.5%. In this study, the author estimated the regret prevalence by analyzing two sources: studies from the previous 30 years in the medical literature and the author’s own clinical practice. 20 In the former, the author compiled a total of approximately 1000–1600 transfemenine, and 400–550 transmasculine. In the latter, the author included a total of 196 transfemenine, and 99 transmasculine patients. 20 In 1998, Kuiper et al followed 1100 transgender subjects that underwent GAS using social media and snowball sampling. 23 Ten experienced regret (9 transmasculine and 1 transfemenine). The overall prevalence of regret after GAS in this study was of 0.9%, and 3% for transmasculine and <0.12% for transfemenine. 23 Because these studies were conducted several years ago and were limited to specific countries, these estimations may not be generalizable to the entire TGNB population. However, a clear trend towards low prevalences of regret can be appreciated.

The causes and types of regrets reported in the studies are specified and shown in Table ​ Table5 5 and ​ and6. 6 . Overall, the most common reason for regret was psychosocial circumstances, particularly due to difficulties generated by return to society with the new gender in both social and family enviroments. 23 , 29 , 32 , 33 , 36 , 44 In fact, some patients opted to reverse their gender role to achieve social acceptance, receive better salaries, and preserve relatives and friends relationships. These findings are in line with other studies. Laden et al performed a logistic regression analysis to assess potential risk factors for regret in this population. 46 They found that the two most important risk factors predicting regret were “poor support from the family” and “belonging to the non-core group of transsexuals.” 46 In addition, a study in Italy hypothesized that the high percentage of regret was attributed to social experience when they return after the surgery. 33

Another factor associated with regret (although less prevalent) was poor surgical outcomes. 20 , 23 , 36 Loss of clitoral sensation and postoperative chronic abdominal pain were the most common reported factors associated with surgical outcomes. 14 , 36 In addition, aesthetic outcomes played an important role in regret. Two studies mentioned concerns with aesthetic outcomes. 14 , 47 Only one of them quoted a patient inconformity: “body doesn’t meet the feminine ideal.” 14 Interestingly, Lawrence et al demonstrated in their study that physical results of surgery are by far the most influential in determining satisfaction or regret after GAS than any preoperative factor. 36 Concordantly, previous studies have shown absence of regret if sensation in clitoris and vaginal is achieved and if satisfaction with vaginal width is present. 36

Other factors associated to regret were identified. Blanchard et al in 1989 noted a strong positive correlation between heterosexual preference and postoperative regret. 32 All patients in this study who experienced regret were heterosexual transmen. 32 On the contrary, Lawrence et al in 2003 did not find such correlation and attributed their findings to the increase in social tolerance in North American and Western European societies. 36 Bodlund et al found that clinically evident personality disorder was a negative prognostic factor for regret in patients undergoing GAS. 48 On the other hand, Blanchard et al did not find a correlation among patient’s education, age at surgery, and gender assigned at birth. 32

In the present review, nearly half of the patients experienced major regret (based on Pfäfflin classification), meaning that they underwent or desire de-transition surgery, that will never pass through the same process again, and/or experience increase of gender dysphoria from the new gender. One study found that 10 of 14 patients with regret underwent de-transition surgeries (8 mastectomies, 2 vaginectomies, 2 phalloplasties, 2 testicular implants removal, and 1 breast augmentation) for reasons of social regret, true regret or feeling non-binary. 23 On the other hand, based on the Kuiper and Cohen Kettenis’ classification, half of the patients in this review had clear regret and uncertain regret . This means that they freely expressed their regret toward the procedure, but some had role reversal to the former gender and others did not. Interestingly, Pfäfflin concluded that from a clinical standpoint, trangender patients suffered from many forms of minor regrets after GAS, all of which have a temporary course. 20 This is an important consideration meaning that the actual true regret rate will always remain uncertain, as temporarity and types of regret can bring a huge challenge for assessment.

Regret after GAS may result from the ongoing discrimination that afflicts the TGNB population, affecting their freely expression of gender identity and, consequently feeling regretful from having had surgery. 15 Poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors associated with regret. 15 Hence, assessing all these potential factors preoperatively and controlling them if possible could reduce regret rates even more and increase postoperative patient satisfaction.

Regarding transfemenine surgery, vaginoplasty was the most prevalent. 14 , 19 , 23 , 30 – 33 , 35 , 36 , 44 , 45 Interesintgly, regret rates were higher in vaginoplasties. 14 , 36 , 44 In this study, we estimated that the overall prevalence of regret after vaginoplasty was 2% (from 11 studies reviewed). This result is slightly higher than a metanalysis of 9 studies from 2017 that reported a prevalence of 1%. 13 Moreover, vaginoplasty has shown to increase the quality of life in these patients. 13 Mastectomy was the most prevalent transmasculine surgery. Also, it showed a very low prevalence of regret after mastectomy (<1%). Olson-Kennedy et al demonstrated that chest surgery decreases chest dysphoria in both minors and young adults, which might be the major reason behind our findings. 38

In the current study, we identified a total of 7928 cases from 14 different countries. To the best of our knowledge, this is the largest attempt to compile the information on regret rates in this population. However, limitations such as significant heterogeneity among studies and among instruments used to assess regret rates, and moderate-to-high risk of bias in some studies represent a big barrier for generalization of the results of this study. The lack of validated questionnaires to evaluate regret in this population is a significant limiting factor. In addition, bias can occur because patients might restrain from expressing regrets due to fear of being judged by the interviewer. Moreover, the temporarity of the feeling of regret in some patients and the variable definition of regret may underestimate the real prevalence of “true” regret.

Based on this meta-analysis, the prevalence of regret is 1%. We believe this reflects and corroborates the increased in accuracy of patient selection criteria for GAS. Efforts should be directed toward the individualization of the patient based on their goals and identification of risk factors for regrets. Surgeons should continue to rigorously follow the current Standard of Care guidelines of the World Professional Association for Transgender Health (WATH). 49

CONCLUSIONS

Our study has shown a very low percentage of regret in TGNB population after GAS. We consider that this is a reflection on the improvements in the selection criteria for surgery. However, further studies should be conducted to assess types of regret as well as association with different types of surgical procedure.

Acknowledgments

All the authors have completed the ICMJE uniform disclosure form. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supplementary Material

Published online 19 March 2021

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com .

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Gender Affirmation Surgery

The following pages will discuss body parts in medical terms. We recognize that medical language about bodies is based on binary sex categories and can be pathologizing. Inform your provider of the language you would like used to refer to your body.

Urgent or After Hours Issues

5pm-8am or Weekends

Call 801-581-2121

Ask for the plastic surgery resident on call

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Mon-Fri, 8 am-5 pm

Any bottom surgery: call plastic surgery at 801-581-7719

Urinary catheter issues: call urology at 801-213-2700 (option 2)

Following Professional Care Standards

We are a team of surgeons dedicated to developing a center of excellence for gender affirming surgery in the Mountain West. We are passionate about serving the transgender community in our area, and across the country.

Our surgical providers at University of Utah Health work together with other specialties in the Transgender Health Program to provide a coordinated, safe approach to medical and surgical care. All of our providers follow the World Professional Association for Transgender Health (WPATH) Standards of Care .

Start The Process

Because every gender journey is unique, we don’t assume what types of surgeries someone may choose. However there are a few steps you can take before any surgical appointment.

Attend a Free Patient Education Seminar

Every month we host patient education seminars for patients and families to meet providers in our Program and learn about the different services and requirements.

Call Your Insurance Company to Ask if Gender Affirming Surgery is a Covered Benefit

See all insurance information .

Complete New Patient Questionnaire

You will be asked to complete an intake questionnaire before your consultation. Our team will help you  set up a MyChart account  where you will have the ability to fill this out online.

These questionnaires help us provide gender affirming services unique to you and your needs. Although some of the information asked is used to understand if you will meet WPATH criteria, none of your answers will disqualify you from accessing care with our program. Our goal is to help you get the services and resources you need to feel fully aligned with your identity.

Letters of Support

All surgical services require between one to two letters of support. These should be provided by a master’s level mental health provider indicating your readiness for surgery and documentation of gender dysphoria. You do NOT need these letters of support until after your consultation, but we will need them prior to scheduling your surgery and submitting the prior authorization for your insurance.

You can download this  template letter of support  for your mental health provider that includes the criteria we need to submit your prior authorization.

Looking for a mental health provider? View  mental health  resources.

Transmasculine

Transfeminine, pre/post op photos & delayed surgery, surgery pre and post-op photos.

To protect our patients’ privacy, we do not post pre and post-operative photos on our website. However, when you schedule a consultation for any surgery you can request to see these photos at your consultation.

Delayed or Cancelled Surgery

Unfortunately, there are times when surgery will have to be delayed or cancelled. This is due to various reasons; however, our teams are here to ensure we can get you rescheduled for a new surgery date.  Find resources in the local Utah area and out of state .

Our Training

Before starting the gender affirming surgery program at University of Utah, our team travelled to sites across the country to compare different surgical techniques. 

We picked sites that are known for high volume and excellent outcomes:

• Chicago, Illinois;
• Portland, Oregon;  and
• New York University. 

We have also participated in dissection courses, focusing in-depth on the anatomy of the pelvis and the changes made during gender affirming surgery.

In hopes of creating the best experience possible for our patients, we have also worked within the hospital community at U of U Health to educate all members of the hospital staff (intake clerks, nursing, food services, physical therapy, occupational therapy) with whom our patients will interact. 

Bringing a Team Approach to Our Patients’ Care

We have seen that a team approach allows us to handle any complication that arises and gives our gender affirming surgery patients easy access to their surgeons. 

We also have four surgeons involved in our phalloplasty and vaginoplasty surgeries. Having four surgeons involved in these surgeries allows us to continually fine-tune our approach, which helps us improve our patient's satisfaction with their outcomes. 

Our surgical team is passionate about providing the following services to all our patients:

• high quality, compassionate health care to all our patients,
• close follow-up,
• transparent outcomes for patients, and
• research designed to improve our care for all our patient.

Find a Transgender Health Doctor

Hear from our patients.

Gender Affirmation Does More Than Affirm—It Heals

When River Jude August arrived for surgery, they faced yet another challenge in their long journey to align their body with who they know they are. River, who identifies as agender—or outside the female/male binary—had already changed their legal gender to X. They had transitioned socially, opted for several medical treatments, and now faced their biggest surgery yet. River was about to undergo phalloplasty, the construction of a phallus.

Authentic Life Begins Thanks to Transgender Health Program

Jace was standing in the bra section of a clothing store with his mom when suddenly he began to cry. Jace hadn’t been the kind of kid who struggled with his gender identity from a young age. But when puberty hit and his body became more feminine, it didn’t feel right.

Pioneering Patient Finally at home in Her Own Body

“I definitely feel complete. I feel whole. But that doesn’t describe it… that doesn’t even begin to describe it,” beams Josie Jesse as she sits, finally comfortable, in her new body that reflects who she has always been. Although she belongs to the larger community of transgender individuals, Josie is one of a kind: she is the first patient ever to undergo comprehensive gender confirmation surgery at University of Utah Health.

FACT CHECK: Is The Rate Of Regret After Gender-Affirming Surgery Only 1%?

A post shared on social media  claims only 1% of people regret their gender-affirmation surgery.

  View this post on Instagram   A post shared by matt bernstein (@mattxiv)

Verdict: Misleading

While the study cited does find a 1% regret rate, it and other subsequent studies share disclaimers and the limitations of research, suggesting the rate may actually be higher.

Fact Check:

The Instagram post claims that only 1% of patients regret their gender transition surgeries. The source used is “Regret after Gender-affirmation Surgery: A systematic Review and Meta-analysis of Prevalence” from the National Library of Medicine (NLM).

The caption is misleading, due to several factors and lack of research that were identified by the study itself and other subsequent papers. (RELATED: Did Canada Release A New Passport That Features Pride Flags?)

This study did not conduct original research, but rather compiled research done in many different places which resulted in a disclaimer warning of the danger of generalizing the results. “There is high subjectivity in the assessment of regret and lack of standardized questionnaires,” which varies from study to study, according to the NLM document.

The study quotes a 2017 study published in the Journal of Sex and Marital Therapy , which conducted a follow-up survey of regret among patients after their transition. The study notes a major limitation was that few patients followed up after surgery.

“This study’s main limitation was the sample representativeness. With a response rate of 37%, similar to the attrition rates of most follow-up studies,” according to the study. Out of the response rate, six percent reported dissatisfaction or regret with the surgery, the study claims.

Additional data found in a Cambridge University Press study showed subjects on average do not express regret in the transition until an average of 10 years after their surgery. The study also claimed twelve cases out of the 175 selected, or around seven percent, had expressed detransitioning.

“There is some evidence that people detransition on average 4 or 8 years after completion of transition, with regret expressed after 10 years,” the study suggests. It also states that the actual rate is unknown, with some ranging up to eight percent.

Another study published in 2007 from Sweden titled, “ Factors predictive of regret in sex reassignment ,” found that around four percent of patients who underwent sex reassignment surgery between 1972-1992 regretted the measures taken. The research was done over 10 years after the the procedures.

The National Library of Medicine study only includes individuals who underwent transition surgery and does not take into account regret rates among individuals who took hormone replacement. Research from The Journal of Clinical Endocrinology and Metabolism (JCEM) found that the hormone continuation rate was 70 percent, suggesting nearly 30 percent discontinued their hormone treatment for a variety of reasons.

“In the largest surgery study, approximately 1% of patients regretted having gender-confirmation surgery,” Christina Roberts, M.D, a professor of Pediatrics at the University of Missouri-Kansas City School of Medicine and a participant for the study for the JCEM, told Check Your Fact via email.

Roberts stated that while there were multiple major factors in regards to those regretting the surgery, including poor cosmetic outcome and lack of social support, she claimed discontinuation of hormone therapies and other treatment are “not the same thing as regret.”

“This is an apples to oranges comparison,” Roberts added. (RELATED: Is Disney World Replacing The American Flag With The LGBTQ+ Pride Flag In June 2023?)

Check Your Fact reached out to multiple doctors and researchers associated with the above and other studies and will update this piece if responses are provided.

Joseph Casieri

Fact check reporter.

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Gender-Affirming Surgery Rare Among Transgender Children in US

In 2019, no transgender and gender diverse (TGD) children aged 12 years and younger underwent gender-affirming procedures in the United States (US). These findings were published in JAMA Network Open .

Gender-affirming health care procedures are aimed at aligning one’s physical appearance with their gender identity for TGD individuals. However, these procedures can also include breast reduction for cisgender men and boys with gynecomastia.

Recent US legislative efforts have attempted to restrict gender-affirming health care to TGD individuals. Although supporters of these legislations often site concerns about TGD children, the number of TGD children undergoing gender-affirming procedures is expected to be low.

Investigators from the Harvard T.H. Chan School of Public Health conducted a cross-sectional study sourcing data from the Inovalon Insights database. Among a cohort of 47,437,919 adults and 22,827,194 children and adolescents, the rates of gender-affirming procedures in 2019 were assessed on the basis of gender and age. Surgery for other indications, such as cancer or injury, were excluded from the analysis.

Among children and adolescents, 16.8% were aged 15 to 17 years, 11.9% were aged 13 to 14 years, and 71.3% were aged 12 years and younger.

The rate of gender-affirming surgery among TGD individuals was 5.3 per 100,000 adults, 2.1 per 100,000 adolescents aged 15 to 17 years, 0.1 per 100,000 adolescents aged 13 to 14 years, and 0 among children aged 12 years and younger.

Most gender-affirming procedures were chest-related among adults (59.7%) and children and adolescents (96.4%). Of all gender-affirming breast reductions among adults and children/ adolescents , 80% were performed on cisgender men and 97% were performed on cisgender boys.

The major limitation of this study was the reliance on diagnostic coding, which may have resulted in misidentification of the clinical justification for TGD or cisgender identities, and the exclusion of patients without insurance and patients who self-paid for gender-affirming surgery.

The study authors concluded that “these findings suggest that concerns around high rates of gender-affirming surgery use, specifically among TGD minors, may be unwarranted. Low use by TGD people likely reflects adherence to stringent standards of gender-affirming care.”

This article originally appeared on Endocrinology Advisor

References:

Dai D, Charlton BM, Boskey ER, et al. Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Netw Open . Published online June 27, 2024. doi:10.1001/jamanetworkopen.2024.18814

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Fact Check: Walz Didn't Sign Bill Permitting 'Gender Reassignment Surgery for Children'

U.S. Democratic vice presidential nominee and Minnesota Gov. Tim Walz signed a bill allowing "gender reassignment surgery for children."

After presidential hopeful (and current U.S. vice president) Kamala Harris picked Minnesota Gov. Tim Walz to be her running mate on Aug. 6, 2024, rumors began to circulate that he had signed a bill allowing gender-reassignment surgery for children:

Tim Walz signed a bill that lets the State take away ur kids if you d/n/agree to sterilize them & chop off their body parts in the name of “gender affirming care.” So if your 14-yr-old is sad but thinks it’s gender confusion & u object to castrating him, the St takes custody — Megyn Kelly (@megynkelly) August 6, 2024

The above post ( archived ) by conservative television and podcast host Megyn Kelly had been viewed 2.4 million times as of this writing, and had received 70,000 likes. People responded to the claim with outrage, warning that Walz would "destroy" the country:

Tim Walz has destroyed MN and will do the same for this country if people don’t wake up! — Sarah Smith (@Defundmedianow) August 6, 2024

After examining the text of the law, and in light of current standards of gender-affirming care, however, we have rated the claim "False." Here is what's true:

First, on March 8, 2023, Walz signed an executive order protecting the right of gender-diverse adults and parents of gender-diverse children to seek and obtain gender-affirming medical care. The same order turned Minnesota into a sanctuary state for gender-diverse people from other states to seek and obtain gender-affirming medical care, shielding them from extradition or sanctions.

Second, in April 2023, Walz signed a bill into law that protected gender-diverse people, including children, who have obtained gender-affirming care in Minnesota from "out-of-state" interference, thereby enshrining Minnesota's status as a sanctuary state for gender-diverse people seeking care .

The same bill gave Minnesota courts " temporary emergency jurisdiction " if a child from another state seeking gender-affirming care had been unable to obtain it. Contrary to Kelly's claim, however, which the Republican Donald Trump/J.D. Vance presidential ticket also helped spread , in such a situation the state, under this legislation, did not give itself the right to claim custody of the child. Instead, it claimed jurisdiction to rule in custody disputes. The legislation allowed a path to conflict resolution for parents and a child who disagree on whether the child should obtain care, Kat Rohn, executive director of LGBTQ+ advocacy organization OutFront, told The Washington Post . 

Based on Snopes' reading, the legislation granted Minnesota courts jurisdiction over custody matters if the child was present in the state, including if the child had arrived in Minnesota for the purpose of seeking gender-affirming health care. The mechanism of "temporary emergency jurisdiction" already existed, but the new legislation amended it to include cases where the child had been unable to obtain gender-affirming care.

Neither the executive order nor the new law consecrated a right to "gender reassignment surgery for children," however. Both texts emphasized access to gender-affirming health care. Further, a word search revealed no mention of "surgery" in either document. This made sense, as gender-affirming health care includes a large array of interventions. 

It was also consistent with the current standard of such care , which in childhood allowed for psychological and medical support for a social transition, such as adopting other names, choosing other pronouns, and being able to present oneself as part of one's chosen gender. It may also allow for treatment that slows puberty, which is reversible. However, the same guidance recommends that irreversible procedures — notably, gen*t*l surgery — should be delayed until adulthood.

HF 146 1st Engrossment - 93rd Legislature (2023 - 2024). https://www.revisor.mn.gov/bills/text.php?number=HF146&version=1&session=ls93&session_year=2023&session_number=0 . Accessed 8 Aug. 2024.

Nirappil, Fenit. 'Walz Made Minnesota a "Trans Refuge", Championing Gender Affirming Care'. The Washington Post, 7 Aug. 2024, https://www.washingtonpost.com/politics/2024/08/07/tim-walz-minnesota-trans-refuge-bill/ . https://archive.is/PC3Xd.

Rascouët-Paz, Anna. 'No, Biden Didn't Say Kids Should Be Allowed to Get "Transgender Surgery"'. Snopes, 23 May 2024, https://www.snopes.com//fact-check/biden-gender-affrming-surgery/ .

Walz, Tim. EO 23-03, 8 Mar. 2023, https://mn.gov/governor/assets/EO%2023-03%20Signed%20and%20filed_tcm1055-568332.pdf .