How do gender-affirming surgeries work out?

Dear Reader,

You ask a complicated question, and in order to adequately answer, it's key to understand sex, gender, and gender identity. Sex and gender are often conflated — sex is what medical professionals assign at birth based on body parts, genes, and hormones. Gender, on the other hand, is a social construct based on what Western society has designated into the categories of men and women, though many people acknowledge that this binary doesn't recognize those who feel their gender identity doesn't align with those categories. Gender identity is the gender that people feel they are inside regardless of their sex assigned at birth. Many people feel that their sex assigned at birth matches their gender identity; cisgender is a term that indicates this experience. While society may view gender as binary, the idea of gender has evolved to be more expansive and is often described as a spectrum on which individuals may identify (inclusive of those who identify as trans, gender non-binary, genderqueer, or intersex among others), or they may identify outside of the gender binary entirely. Some people with these experiences may choose to make changes to their body to better reflect their identity; one way to do this is through surgery, often referred to as gender-affirming surgeries. Depending on the individual, they may seek to undergo top or bottom surgery, or both. Top surgery involves either removal or augmentation of breasts. Bottom surgery may involve the modification of genitalia or body parts associated with reproduction. Once an individual has recovered from these surgeries it’s possible for them to experience sexual behaviors, such as masturbation, but likely not possible to ejaculate. However, not all people will opt for these surgeries, and that doesn’t make their gender identity any less valid. Read on for more information about the types of surgery, the counseling and diagnostic requirements, and what can be expected following the various procedures.

People vary tremendously about how they feel their body aligns with their desire to express their gender, whether or not they choose to seek gender-affirming surgeries, and if so, which ones they elect to undergo. For those whose gender identity is different from the sex they were assigned at birth, they may want to make their body more like what society considers masculine or feminine. They also could be intersex, having been born with genitalia that may not fit neatly into the gender binary. Many intersex people were subject to surgery on their genitalia as infants, during which their genitalia was surgically altered to fit societal norms. Some intersex folks may seek out gender-affirming surgery in order to address problems or distress resulting from early surgeries or simply to feel more comfortable in their bodies. It's also the case that many people choose to affirm their gender through dress, name changes, pronoun changes, and other non-medical methods and some folks choose to take hormones (such as testosterone or estrogen) to express their gender in ways that feel more true to themselves.

For those opting for gender-affirming surgery, there are a number of steps they’re required to complete. In order to proceed, the person has to be diagnosed with gender dysphoria, which, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), refers to distress associated with feeling that they don't identify with the sex they were assigned at birth. As a side note, this is separate from gender nonconformity (which isn't a diagnosis), in which someone's gender expression, role, or identity doesn't align with the social expectations or norms of the sex they were assigned at birth; not every gender non-conforming person experiences gender dysphoria. Currently, surgeons in the United States generally follow the World Professional Association for Transgender Health (WPATH) Standards of Care. These standards and the requirements for those seeking surgery continue to shift over time and could vary based on the procedure being sought. That being said, some of the requirements may include referrals from a mental health professional, hormone therapy, and living according to their gender identity for at least a year.

Before getting into the logistics of the procedures and genital functioning as a result, it may be helpful to think about why you’re asking this question. If this is something you’re learning about because you’re considering these procedures for yourself, it can be helpful to think about all the ways in which these procedures would or wouldn’t change how you feel about your body and expressing your gender. If you’re asking out of curiosity, it may be helpful to remember that this is a private decision. Using tools such as Go Ask Alice! to educate yourself about these topics is a great way to learn more, especially if you're looking to support others in your life. However, when interacting with people in the real world, just as cisgender folks aren't often asked to describe the appearance and functioning of their genitals outside of a medical setting, asking trans, gender non-binary, or intersex folks about their genitals directly can be similarly invasive. Further, whether or not someone decides to have any of these procedures has no bearing on their gender identity. Many facets create a person's identity, and people live whole and fulfilling lives, regardless of what their genitals may look like. 

All of that being said, some of the procedures that are used to construct a vagina and clitoris include:

• Orchiectomy: This is the removal of the testes by cutting the spermatic cord. This reduces the levels of testosterone in the body, which can potentially lower the amount of estrogen treatment needed for their transition process. An orchiectomy takes approximately 20 minutes and can be performed under general or local anesthesia.
• Vulvoplasty: This involves the creation of the vulva, the external part of the vagina. The glans, or head, of the penis is used to form the clitoris and the inner and outer labia is created through skin from the penis and scrotum. A urethra and vaginal opening are also formed. This procedure excludes the creation of the vaginal canal, which means that after this surgery, the individual can't have vaginal sex but can have an external orgasm with the clitoris.
• Vaginoplasty: This includes the steps of a vulvoplasty, but adds the creation of the vaginal canal using the skin from the scrotum or the penile shaft. After the procedure, the surgeon places gauze into the vagina for about five days so that the skin graft can set properly. Then, the vagina will need to be stretched multiple times a day for six weeks, so that, eventually, the person may be able to have penetrative vaginal sex, with varying levels of sensation.

Some people who go through these procedures may also be interested in other procedures that make their appearance more feminine, such as fuller breasts and changes in their voice. To enlarge breasts, the individuals may choose to take hormones to stimulate breast growth or undergo breast augmentation — both of which maintain some amount of nipple sensitivity. Some people are even able to breastfeed with careful administration of hormones and regular screenings. To increase the pitch of the voice, voice therapy, hormones, and surgical procedures are all methods that may help. 

For those who are looking to construct the vulva, vagina, and clitoris into a penis, some of the options include:

• Phalloplasty: This involves constructing a penis using skin from other parts of the body, which may lead to scarring. It’s an extensive surgery done in three or four stages. In order to maintain some sensation, surgeons will graft nerves and blood vessels for the penis. They'll also lengthen the urethra so the person is able to urinate through the penis. At the end of it, a person may urinate standing up and can have an erection by way of a penile implant.
• Metoidioplasty: This procedure preserves sensation because the penis is created by lengthening the clitoris. During this procedure, they also lengthen the urethra so the individual can urinate while standing. The resulting penis is approximately one to three inches and maintains all the sensation and orgasmic ability. However, a penis created through metoidioplasty might be too small for penetration.

Those who wish to construct a vulva and vagina into a penis and testes tend to have more associated complications, such as more trouble with scarring, blood clots, and loss of sensation or sexual pleasure. They’re also less likely to maintain sensation or ability to have penetrative sex with the penis. For both types of surgery, health care providers may recommend also removing the uterus, cervix, and ovaries. It’s also worth noting that neither procedure will result in a penis will be able to ejaculate. Some people may also opt to get a mastectomy or bind their breasts to flatten their shape. Binders require caution, as wearing them too tightly can cause chest pain, breathing difficulties, or rib fractures. 

For those who desire surgery and aren't covered by health insurance, the out-of-pocket expense is, much like other surgeries, significant. For those who do have insurance, the cost will vary by person, depending on their plan and level of coverage. All of these surgeries require some time for healing before masturbation and sexual activity can safely (and enjoyably) be resumed. For more extensive information on transgender health, including information on gender presentation, hormones, identity documents, and much more check out the Center of Excellence for Transgender Health and the World Professional Association for Transgender Health.

If you’re feeling out of alignment with your gender identity and your body or considering gender-affirming surgery, it may be helpful to seek support from other lesbian, gay, bi, trans, queer (LGBTQ+) folks online, through student organizations (if you're a student), or at a local LGBTQ+ center. There are also health care centers that focus on providing care to those in LGBTQ+ communities, and for students, some campuses may have medical and mental health care that's specifically intended to meet the needs of trans students.

Take care,