Transgender surgery goes by a constellation of names. People call it gender reassignment, realignment, or confirmation surgery; masculinization or feminization surgery; male-to-female or female-to-male surgery; or even sex reassignment surgery. Increasingly, as medicine breaks out of a gender-binary box, more inclusive and culturally appropriate descriptors, such as “gender-affirmation surgery” and “gender-affirming care,” are catching on.
Having surgery to change one or more sex characteristics—breasts/chest, genitalia, or facial features, for example—is a highly personal decision. But to say it’s a “choice” misses the mark, explains Steph DeNormand (they/them), Trans Health Program Manager at Fenway Health in Boston. It’s a matter of survival; it’s “can I be the person that I know I am?” they tell Health.
Whether you are supporting someone who’s transitioning, or you're on your own journey to align your body with your sense of self, it’s important to know what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications. We spoke with surgeons and trans health professionals from to find out more about this expanding category of care.
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Before transgender surgery: what to consider
“What I always tell patients is if you don’t have dysphoria about a body part, [then] don’t have surgery,” Christopher McClung, MD, a urologist with OhioHealth in Columbus, Ohio, tells Health. Dysphoria refers to the distress that trans people may experience when their gender identity doesn’t match their sex assigned at birth. In some cases, surgery may be medically necessary to treat the dysphoria, according to the World Professional Association for Transgender Health (WPATH), which publishes evidence-based standards for the care of transsexual, transgender, and gender non-conforming people.
Hormone therapy is another option for treating gender dysphoria, and it can be helpful either as a stand-alone therapy or in combination with other treatments. Hormone therapy is also recommended before most surgeries; they induce many of the physical changes that masculinize or feminize the body.
There’s also psychotherapy. People may find it helpful to work through the negative mental health effects of their dysphoria, per WPATH. Typically, people seeking gender-conforming surgery must be evaluated by a qualified mental health professional to obtain a referral.
Some may find that living in their preferred gender is all that’s needed to ease their dysphoria, WPATH points out. Doing so for one full year prior is a prerequisite for many surgeries.
While these are guidelines, every person’s treatment is individualized, so “there’s not one linear path,” Julie Thompson, a physician assistant and medical director of trans health at Boston’s Fenway Health, tells Health.
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What are masculinizing surgeries, and how do they work?
The process of masculinizing often includes “top surgery” to remove breast tissue. ”I think a lot of trans men in general will just get top surgery and stop there,” depending on the level of dysphoria, says Dr. McClung. Others opt for “bottom surgery” to reconstruct the pelvic area.
Hormone therapy, which is required before most surgeries, produces obvious changes in appearance. “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, tells Health.
Some trans men elect to do metoidioplasty—also called a meta—which involves lengthening the clitoris, extending the urethra (the tube through which urine passes), and making a scrotum. Some patients may request a variation called a simple release (or simple meta) “to stretch the clitoris out and doing nothing else,” observes Dr. McClung.
Other trans men opt for phalloplasty to give them a phallic structure with sensation. 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, tells Health. Those structures are then reconnected under an operative microscope using very fine sutures—“thinner than our hair,” he says. That surgery alone can take 6 to 8 hours, he adds.
In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, says Dr. Kim. Due to possible urinary complications after phalloplasty, such as urinary fistulas or strictures, some people prefer to skip that step, especially if urinating through the penis while standing is not a priority, he explains. Patients who want to have penetrative sex must have prosthesis implant surgery, too.
As for removal of the uterus and ovaries, it depends. Patients may want a hysterectomy to address their dysphoria, says Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.
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What do feminizing surgeries involve?
Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.
As for bottom surgery, there are a variety of feminizing procedures from which to choose. “You could do an orchiectomy alone, which is just removal of the testicles,” says Dr. McClung. “You could do an orchiectomy and scrotectomy [removal of the scrotum],” he says, Other options include vulvoplasty (to create external genitalia without a vagina) or a full vaginoplasty (creating a vulva and vaginal canal).
Dr. Wittenberg notes that patients may undergo six to 12 months of electrolysis or laser hair removal prior to surgery to remove pubic hair from 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 out and inverted into a created cavity, explains Dr. Kim. Vaginoplasty may be done in one or two stages, says Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until patients see results.
Wound healing difficulties are a common complication. Vaginoplasty patients must use a dilator to maintain the vaginal cavity’s depth and width, which places stress on the surgical site, says Dr. Kim. “So you have two competing goals,” he says, one of trying to heal wounds and the other trying to keep the vaginal cavity “as deep and wide as possible,” he adds. If wounds become infected, antibiotics may be necessary or even another operation to clean out the infection.
A growing number minimal-depth vaginoplasties are being performed in response to patients wanting feminine genitalia but not willing to risk complications or the hassle of dilating. “Recently, we’re finding out that from a patient’s perspective the external appearance of the vulva is just as important as the vaginal cavity,” says Dr. Kim.
Other surgeries that may be options
People who are agender or asexual may opt for nullification, meaning the removal of all sex organs. The external genitalia are removed, leaving an opening for urine to pass.
Some gender non-conforming patients assigned male at birth want a vagina but also want to preserve their penis, says Dr. Wittenberg. This is called a penile preservation vaginoplasty, or “phalgina,” as one of her patients coined it. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.
Alternatively, a patient assigned female at birth can undergo phalloplasty and retain the vaginal opening.
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What doctors wish their patients knew before surgery
All in all, the entire transition process—living as your preferred gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, doctors say. By the time they finally have a surgical consult, patients tend to be focused on doing the surgery as quickly as possible, says Dr. Wittenberg.
Yet it’s important to proceed with the utmost care. Dr. McClung wishes patients had a better idea of the potential risks. Complication rates related to vaginoplasties, phalloplasties, and other procedures can be as high as 25%, he says. “I always tell my patients, ‘Look, I want the same thing as you: I want a cosmetically and functionally perfect set of genitals that is going to make you happy,’” he says. But the procedures need to be done in the safest way possible to avoid complications.
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Imagine suddenly developing a painful or itchy rash, then heading to Dr. Google to find out if a trip to urgent care is warranted. If you're a person with darker skin, the rash photos that come up may not give you a clear picture of what's ailing you. Why not? Because those diagnostic images will likely show only white skin. And skin conditions present differently depending on skin color.
Malone Mukwende noticed this lack of skin diversity on health websites. The second-year medical school student at St. George’s University of London also realized that it's not necessarily helpful for doctors to ask a patient with darker skin to look for symptoms like bruising, redness, and paleness. “When I’d ask about how to identify these signs and symptoms, I never really got an answer,” Mukwende tells Health.
So Mukwende, along with two instructors, set about creating a guidebook called Mind the Gap. When the guidebook is published, it'll be one of the few resources for medical students and practitioners that show various skin conditions on a wide range of complexions, with language that describes symptoms in darker skin.
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Mukwende is not the only person of color in medicine who is working toward fixing the lack of skin diversity in photos. Lavanya Krishnan, MD, dermatologist and the founder of San Francisco-based Arya Derm, is also addressing this bias. “Dermatology is a very visual field,” she tells Health, confirming that the diagnostic images for doctors and research are overwhelmingly white.
It's not just a lack of diagnostic images of brown and black skin that is a problem—there may also be fewer brown and black patients who can teach dermatologists about the wide range of symptoms. People with dark skin are more likely to have health insurance that isn't always accepted by many practicing dermatologists. Not only is their access to care decreased, but it reduces the real-world experience that dermatologists can obtain by evaluating and diagnosing more patients with skin of color,” says Dr. Krishnan.
Not being seen by dermatologists as often as white patients ultimately decreases the chances of creating diverse visuals. And these visuals matter. A recent example: One symptom of COVID-19 is a skin condition dubbed "COVID Toes," yet all of the reported images show white or pink feet, Dr. Krishnan says.
Dr. Krishnan adds that almost every skin condition looks different on darker skin. “Conditions as common as acne and eczema can look differently, and this can extend to certain skin cancers and rashes associated with infectious diseases,” she says. (One example: On a page about melanoma on the Skin Cancer Foundation website, the images of what this type of skin cancer looks like only shows white skin.)
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So what's the fallout? Without diagnostic images showing diverse skin tones, patients of color may be misdiagnosed and treated incorrectly. “This can sometimes cause the original condition to get worse, or morph in a manner that makes it even more difficult to diagnose down the road,” says Dr. Krishnan.
Mukwende’s Mind the Gap manual doesn’t have an official release date yet, but it will be a comprehensive guide that he hopes will become part of the medical school curriculum. It will also provide language to help practitioners better describe the appearance of different skin conditions on darker skin. For more information on its release, visit this website to sign up for updates.
Where to find diverse skin images
Until then, social media is trying to fill in the gaps. Accounts like Brown Skin Matters on Twitter show side-by-side photos of different skin conditions on brown versus white skin. One example from the site is this photo of shingles; the man whose skin is shown here did not know he had shingles because his case did not look like the images that he found online.
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Dr. Krishnan believes that battling white skin bias will take constant learning: “It is important for all practitioners to gain experience in how conditions present differently in various skin types. This takes practice, experience, and keeping up-to-date with the most recent journal articles and literature."
"As a practicing dermatologist in San Francisco who also has brown skin," she continues, "I find that I have a higher percentage of patients with skin of color. This valuable experience has helped improve my diagnostic skills in this patient group.”
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