A guide to gender-affirming surgery for transmasculine people

“Gender is multilayered,” says Jess Ting, MD, a plastic and reconstructive surgeon at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. The expression of gender is complex and diverse. “It’s how we wear our hair, it’s our chosen pronouns, how we dress. There are so many ways of expressing gender that have nothing to do with the physicality of your body.”

Similarly, 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).

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.

It’s important to recognize that not everyone seeks surgery as part of their process of gender affirmation. Some may take gender-affirming hormone therapy (GAHT, also known as hormone replacement therapy, or HRT) alone, while others may choose not to pursue medical approaches.

If you determine that gender-affirming surgery is right for you, 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 masculinizing surgeries are available?

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

Top surgery (or chest surgery)

During masculinizing chest surgery, a surgeon will remove breast tissue to create a more conventionally masculine-looking chest. Sometimes, but not always, the surgery will include nipple reconstruction to create smaller nipples. Pectoral implants are also available but are rarely used or asked for, says Dr. Ting.

Bottom surgery (which often includes genital surgery)

A hysterectomy involves removing the uterus, while an oophorectomy (also known as ovariectomy) removes the ovaries. Often, these two surgeries are performed together.

Transmasculine people may opt for hysterectomy and ovariectomy to enhance the effect of masculinizing GAHT (testosterone). Without ovaries to create estrogen, the testosterone may have more substantial effects on transmasculine people’s bodies.

A patient pursuing other genital surgeries may also have their uterus and ovaries removed, notes Laura Douglass, MD, an assistant professor of urology at Temple University Lewis Katz School of Medicine in Philadelphia specializing in transgender health and gender-affirming surgery. When making this decision, you’ll want to consider carefully and discuss with your HCP factors including future fertility plans and whether you may seek to take GAHT.

Vaginectomy is a surgery to remove vaginal tissue and close the entrance to the vagina. Usually, vaginectomy is done as part of a process that creates a penis, though it can be performed on its own.

Scrotoplasty creates a scrotum, the pouch of skin that holds testicles. This surgery is often done as part of the process of creating a penis. In addition to creating a scrotum, surgeons can use synthetic material, or prostheses, to create the appearance of testicles.

Metoidioplasty is the first of two primary options to create masculine-looking genitals. A surgeon will use existing tissue, including the labia, to create a penis. The surgeon will then use the clitoris, which usually gets larger on masculinizing hormone therapy, to create the head of the penis and will lengthen the urethra so a patient can pee standing up, says Dr. Douglass. Typically, a metoidioplasty will not give patients the ability to have penetrative sex.

Phalloplasty uses tissue from elsewhere on the body to create a penis. A prosthesis can then be added to provide for erections and penetrative sex. The penis created through phalloplasty will usually be larger than one created through metoidioplasty. Patients who want a phalloplasty may get most of the other genital surgeries in preparation. These are done in stages, often over the course of many months, explains Ting.

Facial surgeries

Facial surgeries are less common for transmasculine people compared to transfeminine people, says John Pang, MD, a plastic and reconstructive surgeon at Mount Sinai’s Center for Transgender Medicine and Surgery. Transmasculine people often find that hormone therapy sufficiently masculinizes their faces, which occurs in large part due to male pattern hair growth and skin changes.

If a patient wishes to pursue facial surgeries, surgeons can create an Adam’s apple and insert implants to create a more prominent brow bone or a bigger and sharper jawline.

Voice surgery

Voice surgery is also a less common request for transmasculine patients than it is for transfeminine patients. This is because testosterone treatments alone will often alter the sound of the voice to make it sound deeper. Voice surgeries are available, however, to create thicker vocal cords and a deeper voice, if desired. Vocal coaching with a speech-language pathologist is typically required before having this surgery done.

Fat redistribution

Body contouring surgeries have become more common for transmasculine patients at Mount Sinai, says Dr. Pang. To create a more conventionally masculine appearance, surgeons will typically move fat from the hips up to the waistline.

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). This 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 masculinizing 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 Bella Avanessian, MD, a plastic and reconstructive surgeon at Mount Sinai’s Center for Transgender Medicine and Surgery.

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.

Dr. Avanessian says that the only 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
• 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)
• If they are unsure about having the surgery

Even in those cases, the answer is not a hard no, but a “not yet,” she explains. “It depends on the individual and their readiness for surgery and their readiness for what comes after surgery.”

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.

Having good social support is essential, too, especially for genital surgeries when patients may not be able to do simple chores during the recovery process. If someone doesn’t have a partner, family member, or friend who’s willing to stay with them and take care of tasks like cooking, cleaning, and tending to surgical wounds, their surgeon might refer them to a skilled nursing facility where they can live for a month or two during recovery, Ting says. At-home nurses are also an option for someone who has little social support.

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 depending on the type of surgery. Chest surgeries are less invasive than genital surgeries, but still require at least a week of recovery at home and several weeks of avoiding strenuous activities that require lifting more than five pounds. You’ll also have to avoid taking showers as long as you have dressings on your surgical wounds.

Genital surgeries can require months of postoperative care, Ting says. A metoidioplasty typically requires a three-day hospital stay and six to eight weeks of recovery at home, as well as at least two follow-up appointments in the two weeks after surgery. Phalloplasty is done in stages, some of which require hospital stays and some of which don’t. 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.