Gender Affirming Care: Surgical

What is gender-affirming care?

Gender-affirming care (GAC) is an umbrella term for health care that aims to help a transgender or gender diverse person’s body better align with their gender identity. You might seek out GAC if you experience gender incongruence—when the gender you identify with conflicts with the sex you were assigned at birth. There are many different forms of GAC, including both lifestyle changes and medical interventions. The World Professional Association for Transgender Health (WPATH)—the organization often recognized as the gold standard for GAC—outline guiding recommendations for GAC. Additionally, it’s helpful to keep in mind that medical transition isn’t necessary to identify as transgender or gender diverse. Reflecting on your goals and speaking with a trans-competent health care professional (more on this later) might be the best way to figure out what GAC (if any) may be appropriate for you.  

What are surgical GAC options?

You might seek gender affirming surgery (GAS) if you feel that non-surgical GAC doesn’t completely address your gender incongruence. There are many different types of GAS: 

• Facial surgeries: 
  • Creation of features sometimes associated with a more feminine look like a lower hairline, fuller cheeks, rounded jaw, and a smaller Adam’s apple or 
  • Creation of features sometimes associated with a more masculine look like a wider forehead, angular cheeks, pronounced jawline, and Adam’s apple 
  • Voice training surgery: shaving of the vocal cords to result in a higher pitched voice 
• Top or chest surgeries: 
  • Breast enhancement: introduction of breast implants 
  • Top surgery: partial removal of breast tissue to flatten chest 
  • Mastectomy: total removal of breast tissue 
• Bottom or genital surgeries: 
  • Removal of reproductive organs such as... 
    • Penis 
    • Testicles 
    • Scrotum 
    • Uterus 
    • Ovaries 
    • Vagina 
  • Construction or alteration of genitourinary anatomy (can be constructed with existing reproductive organs, implants, or skin grafts) to: 
    • mimic the appearance of labia, clitoris, and vulva 
    • mimic the appearance of penis, testicles, and scrotum 
    • create a vaginal canal 
    • lengthen or revise the existing urethra 

Your recovery time depends heavily on the type of surgery. Swelling from facial surgeries may last around two weeks to four months, chest surgeries require at least one month recovery, and bottom surgery usually takes at least six weeks. As with any surgery, GAS risks include bleeding, infection, or negative reactions to anesthesia. You will likely meet with your surgeon or other provider for follow-up visits. However, if you have prolonged bleeding days after surgery, have pain that doesn’t go away for several weeks, or if your wounds change color or show signs of infection, feel free to reach out to your provider between visits. 

Are you eligible for surgery? 

Currently, WPATH criteria requires individuals who want to have GAS to meet a few different requirements. WPATH requires that you must: 

• Demonstrate gender incongruence: You must demonstrate gender incongruence—sometimes with diagnosis 
• Provide consent: You must provide consent for surgery necessary to support a transition 
• Understand the mental and physical impacts of surgery: It’s recommended that your mental and physical health be evaluated and that you’re informed how your mental and physical health, including your reproductive capabilities, would be altered from surgery 

If you want to be on GAHT, it’s recommended that you undergo GAHT for more than six months before surgery. Hormones can affect underlying tissues and muscles, so surgeries often have better outcomes if the body is on a stable hormone regimen. However, GAHT is not a requirement for surgery, so if you aren’t interested in GAHT, you can still undergo surgery, provided you meet the other requirements. Additionally, you will likely be required to provide one letter from a mental health professional or other provider who’s trained in assessing transgender or gender diverse patients recommending GAS for you. 

Will your insurance cover surgery? 

If you’re hoping to use insurance to pay for GAS, it can be helpful to research what, and how much is covered. Some insurance plans may not cover any GAS. Others may limit how many surgeries—including revisions—they will cover. Or they’ll cover surgeries, like mastectomies, but not additional “cosmetic” alterations, like nipple shaping. If you want to know whether your insurance will cover GAS, consider searching for your plan on your insurance company’s website. There may be information included under headings like "Evidence of Coverage," or "Certificate of Coverage." You can also call the insurance company directly for more information. If you’re still unsure about whether your insurance will cover GAS, consider checking other online resources about which major insurance companies cover care. If your insurance doesn’t cover surgery costs or if you don’t have insurance, you might consider looking into financial assistance programs for GAS.

It’s also possible that your surgeon won't take insurance. In this case, you would have to file for out-of-network benefits through your insurance. This probably means you will be paying more money than you would if your surgeon was in-network. If there are no in-network surgeons, or if the in-network surgeons are unsuitable given their training, however, you might be able to submit an appeal to your insurer directly or through a third party. 

How can you find a surgeon? 

With all of this in mind, if you decide to proceed with GAS, you might start your process by doing research to find a competent and knowledgeable surgeon, who follows WPATH protocol. When you’re looking into different providers, there are a lot of factors to consider: 

• What would make you feel most comfortable as a patient—are there certain personal characteristics of your surgeon, such as age, race, ethnicity, or gender identity, that would matter to you? 
• How much will finances play a role in the surgeon you choose? What kind of care are you able to afford? 
• Is the surgeon in network with your insurance? 
• Are there certain surgeons whose services are in a more convenient or safe location for you? 
• What’s your time frame—are there certain surgeons who have more availability for appointments? 
• Do you want your surgeon to be board-certified in their area of medicine? 
• Can you find photos of their work? Do they have testimonials online? 
• What technique(s) do they specialize in? 
• How many surgeries have they performed using the specific procedure you're interested in? How recently have they performed this procedure? 
• What is the surgeon's revision rate? (A low revision rate might indicate a surgeon isn't appropriately following their patients' post-surgical outcomes.) 

After narrowing down your preferences, you’ll have a clearer idea of which surgeon is a good fit for you. 

Finding the right surgeon is no easy feat, especially if you’re looking on your own. If you have a trusted medical or mental health professional you’ve already met with, you might consider asking for a recommendation. They may know a trans-competent surgeon you can get things started with. As an additional resource, TransHealthCare has a searchable list of qualified surgeons who provide GAC across the globe.