Gender-affirming surgery
Gender-affirming surgery, often referred to as gender confirmation or sex reassignment surgery, encompasses various medical procedures that individuals may pursue as they transition to their self-identified gender. These procedures include facial surgery, top surgery (chest surgery), and bottom surgery (genital surgery). Research indicates that approximately one in four transgender or nonbinary individuals elect to undergo these surgeries, with many reporting significant improvements in mental health and overall well-being post-surgery.
Despite these potential benefits, a considerable number of individuals either choose not to pursue gender-affirming surgery or face barriers such as high costs, as many health insurance plans do not cover these procedures. Mental health challenges are more prevalent among transgender and gender-diverse (TGD) individuals, but those who have undergone gender-affirming surgery generally experience lower levels of distress and suicidal thoughts compared to those who have not.
The history of gender-affirming surgery dates back to the early 20th century, with significant milestones in the U.S. and Europe contributing to evolving understandings and practices surrounding these surgeries. While some people express opposition to gender-affirming surgery, often based on misconceptions, studies show that a vast majority of patients report satisfaction with their surgical decisions, especially when they have engaged in mental health counseling prior to the procedure. Overall, gender-affirming surgery is a critical component of the transition process for many TGD individuals, reflecting both personal identity and broader social recognition.
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Gender-affirming surgery
Gender-affirming surgery, also called gender affirmation or confirmation or sex reassignment surgery, refers to procedures that people may seek as they transition to their self-identified gender. Procedures may include facial surgery, chest or top surgery, or bottom (genital) surgery. About one in four transgender or nonbinary people have gender affirmation surgery. Many individuals who choose this route report improved mental health. Many individuals do not opt for gender-affirming surgery, while others are prevented from seeking these procedures by cost because many health insurance plans deny coverage for them. Research has shown that transgender and gender diverse (TGD) people have a higher incidence of mental health problems than the general population, but TGD individuals who have undergone gender-affirming surgery are less likely to experience distress, suicidal ideation, and other negative situations compared to TGD persons who do not have a history of gender-affirming surgery.
Background
A person who is transgender is one whose sex assigned at birth, which is usually based on visible genitalia, is not aligned with their sense of their gender, or gender identity. Some transgender persons experience distress because their gender identity and sex assigned at birth do not match. This psychological distress, which often begins in childhood, is known as gender dysphoria.
Until the later twentieth century, transgender or gender-nonconforming individuals were typically regarded as mentally ill. Gradually, ideas and approaches changed. The first recorded gender-affirming surgery, which at the time was termed “sex reassignment surgery,” occurred in 1931 at the Institute for Sexual Science in Berlin, Germany. Such procedures were performed to completely reassign an individual’s sex in keeping with beliefs of the time that gender was binary. Other options such as hormone therapy were not considered. Surgical procedures were available only in Europe for several decades.
The first international knowledge about gender-affirming surgery emerged in 1952 after an American veteran of World War II sought gender-affirming surgery in Denmark. This person, Christine Jorgensen, was identified publicly and a crowd of reporters and photographers greeted her return to the United States. Denmark became a leading destination for individuals from around the world seeking gender-affirming surgery.
The first academic institution in the United States to offer gender affirmation procedures was the Johns Hopkins University’s Gender Identity Clinic. It operated from 1966 to 1979. The Harry Benjamin International Gender Dysphoria Association (later the World Professional Association for Transgender Health, or WPATH) published the first edition of the standards of care (SOC) in 1979 in part because of the closure of the Gender Identity Clinic. The SOC provided guidelines for when surgery should be offered to patients. Options included intestinal vaginoplasty, which was developed in 1974, and radial forearm free flap phalloplasty, which was invented in 1982. By the middle of the 1980s, all of the major modern surgical techniques of genital reconstruction had been developed. Multiple studies supported gender-affirming surgery’s benefits.
Efforts to overcome earlier classification of TGD persons as mentally ill were also successful. In 2013 the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of the American Psychiatric Association eliminated gender identity disorder and replaced it with gender dysphoria. In 2018, the World Health Organization removed gender identity disorder, which was then known as transsexualism, from the mental health disorders section of the International Classification of Diseases.
In the 2020s, depending on where an individual lives, TGD persons may choose various types of gender affirmation. These include social affirmation, or changing a person’s name and pronouns; legal affirmation, or changing gender information on documents; medical affirmation, or use of hormones; and surgical affirmation, which encompasses a range of procedures.
Overview
Medical experts may recommend patients for gender-affirming surgery (surgical affirmation) if the individuals experience gender dysphoria. This diagnosis might be made if an individual has two or more symptoms, such as a strong desire to be of a gender other than the assigned gender, a strong desire for primary and/or secondary sex characteristics of another gender, or a strong desire to be treated as another gender. The patient must also experience clinically significant distress or have difficulties in social life, work, or other areas that are related to the assigned gender. Treatment for gender dysphoria may also involve other forms of affirmation.
Common options of gender-affirming surgery include facial reconstructive surgery, top surgery, and bottom surgery. Individuals seek facial reconstructive surgery to achieve more masculine or feminine features. This may involve sculpting the chin or jaw, using fillers in cheekbones and other areas, or rhinoplasty. Top surgery either removes breast tissue (mastectomy) to achieve a more masculine appearance or uses implants to change breast size and shape for a more feminine appearance. Bottom surgery reconstructs genitalia. This may consist of feminizing genitoplasty, or construction of labia and vagina; removal of the penis and scrotum, known as penectomy and orchiectomy; removal of the ovaries and uterus, or oophorectomy and hysterectomy; or metoidioplasty, phalloplasty, and scrotoplasty, which are penis and scrotum construction. Swelling usually lasts a few weeks but may last up to four months. As with any surgery, complications may develop.
Some people oppose gender-affirming surgery. They may believe that it is performed on children, though this is not the case, or that patients often regret their decision. Research shows TDG individuals usually see lasting mental health benefits. Patients overall express satisfaction with their choices to undergo gender-affirming surgery; those who worked with a mental health provider before surgery are most likely to be satisfied with the results. According to the research of Valeria Bustos and colleagues, a study of 7,928 patients who had gender-affirming surgery found that just 1 percent regretted their decision.
Before gender-affirming surgery, patients should discuss the risks and benefits of such procedures. Health insurance companies may require patients to provide documentation such as a letter supporting the decision from a psychiatrist or social worker and health records indicating gender dysphoria.
Bibliography
Bustos, Valeria, et al. “Regret After Gender-Affirmation Surgery: A Systematic Review and Meta-Analysis of Prevalence.” Plastic and Reconstructive Surgery—Global Open, vol. 9, no. 3, 2021, DOI: 10.1097/GOX.0000000000003477. Accessed 30 Aug. 2023.
Deutsch, Madeline B. “Overview of Gender-Affirming Treatments and Procedures.” University of California, San Francisco, Transgender Care, 17 June 2016, transcare.ucsf.edu/guidelines/overview. Accessed 30 Aug. 2023.
“Gender Affirmation (Confirmation) or Sex Reassignment Surgery.” Cleveland Clinic, 3 May 2021, my.clevelandclinic.org/health/treatments/21526-gender-affirmation-confirmation-or-sex-reassignment-surgery. Accessed 30 Aug. 2023.
“Gender Dysphoria Diagnosis.” American Psychiatric Association, www.psychiatry.org/psychiatrists/diversity/education/transgender-and-gender-nonconforming-patients/gender-dysphoria-diagnosis. Accessed 30 Aug. 2023.
Mumford, Kelsey. “Ethically Navigating the Evolution of Gender Affirmation Surgery.” AMA Journal of Ethics, Vol. 25, No. 6, 2023. DOI: 10.1001/amajethics.2023.383. Accessed 30 Aug. 2023.
Sandroff, Ronni. “Does Insurance Cover Gender-Affirming Care?” Investopedia, 26 June 2023, www.investopedia.com/paying-for-transgender-surgeries-5184794. Accessed 30 Aug. 2023.
Turban, Jack. “What Is Gender Dysphoria?” American Psychiatric Association, Aug. 2022, www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria. Accessed 30 Aug. 2023.