A guide to gender-affirming surgery for transfeminine people

There are a variety of ways that transgender, gender nonconforming, and nonbinary people may pursue gender affirmation, depending on their goals, resources, and access to healthcare providers (HCPs). Some people may take gender-affirming hormone therapy (GAHT, also known as hormone replacement therapy, or HRT). Others may seek surgery. And others still may choose not to pursue medical approaches.

“The choice for surgery is a very personal one,” says Jess Ting, MD, a plastic and reconstructive surgeon at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. If you determine that gender-affirming surgery is right for you, the benefits can be profound.

Many gender-diverse people experience gender dysphoria or social dysphoria based on their physical features, such as facial bone structure, genitalia, breast tissue, and patterns of body fat. (Gender dysphoria refers to the discomfort someone might experience when they feel their gender identity doesn’t align with their physical or physiological characteristics. Social dysphoria is the distress a person may feel when others do not recognize them as the correct gender.)

Gender-affirming surgeries may help alleviate gender and social dysphoria. In fact, gender-affirming care, including masculinizing and feminizing surgeries, is considered medically necessary by the World Professional Association of Transgender Health (WPATH). For many people, it may even be lifesaving.

If you are pursuing feminizing gender-affirming surgery, here’s what you need to know about the options available, plus how to find providers and what to consider before and after your procedure.

What types of feminizing surgeries are available?

The most common procedures for transfeminine people pursuing surgical affirmation include the following:

Top surgery (or chest surgery)

Breast tissue will typically grow with feminizing GAHT, so some transfeminine people might feel affirmed without surgery. For those who aren’t, breast augmentation can provide a fuller, more feminine-looking chest.

It can be difficult, however, to create the appearance of cleavage, Dr. Ting notes, because people assigned male at birth tend to have nipples that are much farther apart than people assigned female at birth and breast implants need to be centered under the nipples for optimal appearance. “If the nipples are far apart,” he says, “the implants tend to be far apart.”

Bottom surgery (which often includes genital surgery)

Penectomy is a surgery to disassemble the penis. It’s almost always one of the first steps toward creating a vagina.

Orchiectomy is the removal of the testicles and scrotum. It’s required prior to the surgical creation of a vagina, though some transfeminine people might get an orchiectomy without a penectomy or vaginoplasty in order to make feminizing hormone therapy more effective. (Without testicles creating testosterone, the estrogen that is central to feminizing GAHT is better able to affect transfeminine people’s bodies.)

Clitoroplasty is the creation of a clitoris. Often, it’s one part of a larger surgery to create a vagina. Surgeons will use existing tissue from the head of the penis to form the clitoris.

Vulvoplasty is the creation of a vulva. Like clitoroplasty, vulvoplasty is often one part in a multistep process toward creating a vagina. A surgeon will use existing tissues to create not only a mons pubis, but also labia majora and labia minora, the various structures surrounding, supporting, and underpinning the vulva.

Vaginoplasty is the creation of a vagina using existing genital tissue. Penile-inversion vaginoplasty, one frequently used method, is the most common genital surgery for transfeminine people, according to Bella Avanessian, MD, a plastic and reconstructive surgeon at Mount Sinai’s Center for Transgender Medicine and Surgery.

Vaginoplasty is the culmination of many surgeries, starting with penectomy and orchiectomy and ending with clitoroplasty, vulvoplasty, and (sometimes, but not always) the creation of a vaginal canal. Patients who don’t want or need a vaginal canal can opt for a “zero-depth” vaginoplasty, which requires less overall post-operative care.

Note: Zero-depth vaginoplasty doesn’t allow for penetrative sex. It also involves discarding excess skin and tissues that could be used to line the vaginal canal. If there is a chance that penetrative sex or the presence of a vaginal canal may become important to a patient later, Dr. Avanessian recommends proceeding with a standard (or full depth) vaginoplasty to avoid losing these reconstructive tissues.

Facial feminization surgery

To create a more conventionally feminine-looking face, surgeons can use several approaches, including:

• Shaving the brow bone
• Lowering the hairline
• Changing the position of the eyebrows
• Creating a smaller, narrower nose
• Changing the fullness of the lips
• Shaping the cheekbones and jaw
• Removing the Adam’s apple

Patients won’t usually take all of these steps, says John Pang, MD, a plastic and reconstructive surgeon at Mount Sinai’s Center for Transgender Medicine and Surgery. They’ll typically choose whatever combination will make them feel most themselves. The surgeries they choose will usually be done all at once.

Social dysphoria was the impetus for Amy Stephens, a transgender woman in upstate New York, to schedule facial feminization surgery. Too often, people would stare at Amy when she was trying to do everyday things like buy groceries. After her surgery, the stares stopped.

“It’s had a very positive, dramatic impact on my life,” Amy says. “I can go to the store and people leave me alone.”

Voice surgeries

Voice surgeries are more common for transfeminine people than for transmasculine people. That’s because many transmasculine people feel affirmed with the voice changes brought on by masculinizing hormone therapy (testosterone). The estrogen that is the basis of feminizing hormone therapy, on the other hand, does not typically alter the voice.

At Mount Sinai, surgeons who perform feminizing vocal surgeries typically shorten the length of the vocal cords to create a higher pitch. Vocal coaching with a speech-language pathologist is typically required before having this surgery done.

Fat redistribution

Although less common among transfeminine patients than transmasculine people, surgeries like liposuction and lipofilling can move fat from male-pattern areas (like the abdomen) to female-pattern areas (like the hips). The overall effect is to create a more conventionally feminine silhouette.

How to find a gender-affirming surgeon

Gender-affirming surgery has made great progress in terms of safety and outcomes in recent years, with more major hospitals and health systems opening transgender care centers. Still, finding knowledgeable and culturally competent surgeons can be challenging.

The first step is typically to consult with your primary care physician. They should be able to refer you to a transgender care center in your area. If you are seeking additional resources, TransHealthCare has a comprehensive database of gender-affirming surgeons you can search by state or procedure. The provider directories from OutCare, GLMA, or Included Health can also help.

It’s important to seek surgeries at reputable centers that have experience performing gender-affirming procedures. Remember that any procedure carries with it a certain degree of risk. Be sure to discuss those potential risks and benefits with your surgeon before moving forward.

What is required before scheduling surgery?

When setting up and performing surgeries, many medical providers and most health insurers adhere to the WPATH’s Standards of Care (SOC). The SOC is a set of guidelines for healthcare professionals who treat transgender, gender nonconforming, and nonbinary people.

Requirements for surgery differ from procedure to procedure, but for some genital surgeries, the WPATH SOC recommends that people have been on GAHT for a minimum of 6 months. (Requirements may look different for different people, and candidates for top surgery may not need to be on hormones.)

Common feminizing surgeries also require referral letters from HCPs. For example, the WPATH SOC requires that you obtain at least one letter to get genital, chest, facial, or other surgeries. (Previous versions of the SOC required two letters or more.) The SOC also advises that HCP recommend gender-affirming medical treatment only when a person’s experience of gender incongruence is “marked and sustained.”

Gender incongruence refers to feeling a lack of compatibility between one’s gender identity and the gender expected of them based on their sex assigned at birth. It is related to gender dysphoria. Not all transgender, gender nonconforming, or nonbinary people experience gender dysphoria, but a diagnosis of gender dysphoria has typically been a requirement for obtaining many gender-affirming treatments.

In addition to documenting a patient’s readiness for surgery, the letters should explain that any preexisting medical conditions, such as diabetes or autoimmune diseases, are well-controlled. The goal is to indicate that the patient is a good candidate for surgery and that they should be able to handle potential setbacks during recovery, explains Avanessian.

Surgeons may also ask that patients work to reduce risk factors that might affect surgical outcomes, such as by quitting smoking or losing weight. That said, patients are not necessarily refused surgery if they smoke or are considered overweight.

The most important factors in scheduling surgery are confidence and assuredness in their gender, Avanessian says. She looks for patients who can say, “This is what I want. This is how I want it. This is what I’ve wanted for a long time.”

Avanessian says that the only additional factors that would lead her to initially turn a patient away from surgery are if a patient habitually uses narcotics that could lead to poor decisions or behaviors during recovery or if they have poorly controlled mental health conditions without established coping mechanisms. (Such coping strategies might include regular consultation with a therapist or the use of medication or stress-reduction practices.)

Even in those cases, the answer is not a hard no, but a “not yet,” she explains.

If a patient doesn’t have a clear picture of what they might want to change about their body at their first meeting, Avanessian often asks patients to reflect on what features cause them distress, if any. From there, they can create a personalized approach to realistically and appropriately meet their affirmation needs.

Finally, because social support is such an important factor when planning gender-affirming surgeries, surgeons will want to know whether patients will have someone at home during the recovery period to help with tasks like cooking, cleaning, and caring for surgical wounds.

Not having a support system for recovery doesn’t mean you can’t get surgery, though. According to Ting, some transgender care centers will connect patients with at-home nurses or make referrals to skilled nursing facilities where they can live for a month or two during recovery if they have no one at home to take care of them.

It’s important to have a postsurgical care plan in place before your procedure. Many facilities have patient advocates who can help you develop and follow such a plan. Talk to your surgeon if you are unclear about any aspects of your recovery.

How long will it take to recuperate?

Recovery times vary from surgery to surgery. As Amy tells it, she was able to walk 13 miles five days after her facial feminization surgery, but she felt wiped out after her vaginoplasty.

Overall, recovery from vaginoplasty can take up to three months. Bed rest is usually recommended for the first 7 to 10 days with patients typically getting up only to use the bathroom. If someone opts for a vaginoplasty with a vaginal canal, they will have to use dilators to stretch their vaginal canal every day for at least the first year and may need to continue using a dilator for several years afterward.

Breast augmentation, facial feminization surgery, and testicle removal without a vaginoplasty require shorter recoveries, with most people expected to recuperate fully after a few weeks. Vocal surgery requires not speaking for one full week after surgery and then slowly beginning to speak more over the next month.

Your surgeon will be able to tell you how long you may need to take off work or restrict other activities as you recuperate.