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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

  • Transfeminine Tr

Transmasculine Transition

  • Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

  • Penectomy is the surgical removal of external male genitalia.
  • Orchiectomy is the surgical removal of the testes.
  • Vaginoplasty is the surgical creation of a vagina.
  • Feminizing genitoplasty creates internal female genitalia.
  • Breast implants create breasts.
  • Gluteoplasty increases buttock volume.
  • Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

  • Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
  • Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
  • Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
  • Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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when was the first gender reassignment surgery male to female

Hopkins Hospital: a history of sex reassignment

By RACHEL WITKIN | May 1, 2014

Editor’s note: this article makes several misleading claims. It does not properly contextualize psychologist John Money ’ s forced sexual reassignment surgery of David Reimer. It also implies that sexual reassignment surgery was introduced in the 1960s, though procedures took place earlier in the 1900s.

The News-Letter regrets these errors.

In 1965, the Hopkins Hospital became the first academic institution in the United States to perform sex reassignment surgeries. Now also known by names like genital reconstruction surgery and sex realignment surgery, the procedures were perceived as radical and attracted attention from The New York Times and tabloids alike. But they were conducted for experimental, not political, reasons. Regardless, as the first place in the country where doctors and researchers could go to learn about sex reassignment surgery, Hopkins became the model for other institutions. But in 1979, Hopkins stopped performing the surgeries and never resumed.

In the 1960s, the idea to attempt the procedures came primarily from psychologist John Money and surgeon Claude Migeon, who were already treating intersex children, who, often due to chromosome variations, possess genitalia that is neither typically male nor typically female. Money and Migeon were searching for a way to assign a gender to these children, and concluded that it would be easiest if they could do reconstructive surgery on the patients to make them appear female from the outside. At the time, the children usually didn’t undergo genetic testing, and the doctors wanted to see if they could be brought up female.

“[Money] raised the legitimate question: ‘Can gender identity be created essentially socially?’ ... Nurture trumping nature,” said Chester Schmidt, who performed psychiatric exams on the surgery candidates in the 60s and 70s.

This theory ended up backfiring on Money, most famously in the case of David Reimer, who was raised as a girl under the supervision of Money after a botched circumcision and later committed suicide after years of depression.

However, at the time, this research led Money to develop an interest in how gender identities were formed. He thought that performing surgery to match one’s sex to one’s gender identity could produce better results than just providing these patients with therapy.

“Money, in understanding that gender was — at least partially — socially constructed, was open to the fact that [transgender] women’s minds had been molded to become female, and if the mind could be manipulated, then so could the rest of the body,” Dana Beyer, Executive Director of Gender Rights Maryland, who came to Hopkins to consider the surgery in the 70s, wrote in an email to The News-Letter .

Surgeon Milton Edgerton, who was the head of the University’s plastic surgery unit, also took an interest in sex reassignment surgery after he encountered patients requesting genital surgery. In 2007, he told Baltimore Style : “I was puzzled by the problem and yet touched by the sincerity of the request.”

Edgerton’s curiosity and his plastic surgery experience, along with Money’s interest in psychology and Migeon’s knowledge of plastic surgery, allowed the three to form a surgery unit that incorporated other Hopkins surgeons at different times. With the University’s approval, they started performing sex reassignment surgeries and created the Gender Identity Clinic to investigate whether the surgeries were beneficial.

“This program, including the surgery, is investigational," plastic surgeon John Hoopes, who was the head of the Gender Identity Clinic, told The New York Times in 1966. “The most important result of our efforts will be to determine precisely what constitutes a transsexual and what makes him remain that way.”

To determine if a person was an acceptable candidate for surgery, patients underwent a psychiatric evaluation, took gender hormones and lived and dressed as their preferred gender. The surgery and hospital care cost around $1500 at the time, according to The New York Times .

Beyer found the screening process to be invasive when she came to Hopkins to consider the surgery. She first heard that Hopkins was performing sex reassignment surgeries when she was 14 and read about them in Time and Newsweek .

“That was the time that I finally was able to put a name on who I was and realized that something could be done,” she said. “That was a very important milestone in my consciousness, in understanding who I was.”

When Beyer arrived at Hopkins, the entrance forms she had to fill out were focused on sexuality instead of sexual identity. She says she felt as if they only wanted to consider hyper-feminine candidates for the surgery, so she decided not to stay. She had her surgery decades later in 2003 in Trinidad, Colo.

“It was so highly sexualized, which was not at all my experience, certainly not the reason I was going to Hopkins to consider transition, that I just got up and left, I didn’t want anything to do with it,” she said. “No one said this explicitly, but they certainly implied it, that the whole purpose of this was to get a vagina so you could be penetrated by a penis.”

Beyer thinks that it was very important that the transgender community had access to this program at the time. However, she thinks that the experimental nature of the program was detrimental to its longevity.

“It had negative consequences because when it was done it was clearly experimental,” she said. “Our opponents were able to use the experimental nature of the surgery in the 60s and the 70s against us.”

By the mid-70s, fewer patients were being operated on, and many changes were made to the surgery and psychiatry departments, according to Schmidt, who was also a founder of the Sexual Behaviors Consultation Unit (SBCU) at the time. The new department members were not as supportive of the surgeries.

In 1979, SBCU Chair Jon Meyer conducted a study comparing 29 patients who had the surgery and 21 who didn’t, and concluded that those who had the surgery were not more adjusted to society than those who did not have the surgery. Meyer told The New York Times in 1979: “My personal feeling is that surgery is not proper treatment for a psychiatric disorder, and it’s clear to me that these patients have severe psychological problems that don’t go away following surgery.”

After Meyer’s study was published, Paul McHugh, the Psychiatrist-in-Chief at Hopkins Hospital who never supported the University offering the surgeries according to Schmidt, shut the program down.

Meyer’s study came after a study conducted by Money, which concluded that all but one out of 24 patients were sure that they had made the right decision, 12 had improved their occupational status and 10 had married for the first time. Beyer believes that officials at Hopkins just wanted an excuse to end the program, so they cited Meyer’s study.

“The people at Hopkins who are naturally very conservative anyway … decided that they were embarrassed by this program and wanted to shut it down,” she said.

A 1979 New York Times article also states that not everyone was convinced by Meyer’s study and that other doctors claimed that it was “seriously flawed in its methods and statistics and draws unwarranted conclusions.”

However, McHugh says that it shouldn’t be surprising that Hopkins discontinued the surgeries, and that he still supports this decision today. He points to Meyer’s study as well as a 2011 Swedish study that states that the risk of suicide was higher for people who had the surgery versus the general population.

McHugh says that more research has to be conducted before a surgery with such a high risk should be performed, especially because he does not think the surgery is necessary.

“It’s remarkable when a biological male or female requests the ablation of their sexual reproductive organs when they are normal,” he said. “These are perfectly normal tissue. This is not pathology.”

Beyer, however, cites a study from 1992 that shows that 98.5 percent of patients who underwent male-to-female surgery and 99 percent of patients who underwent female-to-male surgery had no regrets.

“It was clear to me at the time that [McHugh] was conflating sexual orientation and the actual physical act with gender identity,” Beyer said.

However, she thinks that shutting down the surgeries at Hopkins actually helped more people gain access to them, because now the surgeries are privatized.

“Paul McHugh did the trans community a very big favor … Privatization [helps] far more people than the alternative of keeping it locked down in an academic institution which forced trans women to jump through many hoops.”

Twenty major medical institutions offered sex reassignment surgery at the time that Hopkins shut its program down, according to a 1979 AP article.

Though the surgeries at Hopkins ended in 1979, the University continued to study sexual and gender behavior. Today, the SBCU provides consultations for members of the transgender community interested in sex reassignment surgery, provides patients with hormones and refers patients to specialists for surgery.

The Hopkins Student Health and Wellness Center is also working toward providing transgender students necessary services as a plan benefit under the University’s insurance plan once the student health insurance plan switches carriers on Aug. 15.

“We are hopefully working towards getting hormones and other surgical options covered by the student health insurance,” Demere Woolway, director of LGBTQ Life at Hopkins, said. “We’ve done a number of trainings for the folks over in the Health Center both on the counseling side and on the medical side. So we’ve done some great work with them and I think they are in a good place to be welcoming and supportive of folks.”

Schmidt does ongoing work to provide the Hopkins population with transgender services, and says he would like for Hopkins to start performing sex reassignment surgeries again. But Chris Kraft, the current co-director of the SBCU, says that this is not feasible today, as no academic institution provides these surgeries since not enough people request them.

“It is unfortunate that no medical schools in the country have faculty who are trained or able to provide surgeries,” he wrote in an email to The News-Letter . “All the best surgeons work free-standing, away from medical schools. If we had surgeons who could provide the same quality services as the other surgeons in the country, then it would make sense to provide these services. Sadly, few physicians are willing to make gender surgery a priority in their careers because gender patients who go on to surgery are a very small population.”

Beyer, however, does not think that the transgender community needs Hopkins to reinstate its program, and that there are currently enough options available.

“We’re way, way past that,” she said. “It’s no longer the kind of procedure that needs an academic institution to perform research and development.”

Though she finds the way that Hopkins treated its sex reassignment patients in the 60s and 70s questionable, she thinks that the SBCU has been a great resource for the transgender community.

“Today those folks are wonderful people,” Beyer said. “They’re very helpful. They’re the go-to place up in Baltimore. They’ve done a lot of good for a lot of people. They’ve contributed politically as well to passage of gender identity legislation in Maryland and elsewhere.”

The Maryland Coalition for Trans Equality’s Donna Cartwright said that the transgender community does not have enough resources available to them. She said offering surgery at a nearby academic institution could provide more support to the community.

“Generally, the medical community needs to be better educated on trans health care and there should be greater availability [of sex reassignment surgery],” she said. “I think it would be good if there was an institution in the area that did provide health care, including surgery.”

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This page sketches the historical development and surgical details of vaginoplasty surgery (also often called 'sex reassignment surgery' (SRS) or 'gender reassignment surgery' (GRS )).  Before reading this page, please read the introduction to the concepts of gender identity, transgenderism and transexualism elsewhere in this website, so that you'll understand why transsexual women undergo these operations. This page clarifies that post-operative MtF transsexual women really do have female genitalia, and will also help readers visualize some of the ordeals trans women endure to achieve their new physical gender status.

  Historical Background

when was the first gender reassignment surgery male to female


Sex-Change nickname makes Colo. town cringe: 'Nobody cares'

Transformation via surgery has become common in community

By Pauline Arrillaga The Associated Press

* Stanley Biber, M.D.

Dr. Biber was one of the pioneering surgeons of the 20th century.  Over a 35 year period beginning in 1969, he performed over 5000 sex reassignment surgeries, almost single-handedly establishing SRS as an acknowledged and accepted treatment for transsexualism in the U.S.  Much beloved by the trans community, Dr. Biber passed away on Monday January, 16, 2006 at the age of 82.

Consider also these words from the webpage Zen and the Art of Post-Operative Maintenance :  " Another factor in sexual function is your endocrine system...After surgery, some women find that their adrenal glands (the other source of testosterone) do not produce enough to provide adequate libido or orgasm. You may require a small amount of supplemental testosterone to regain functioning. The amount required is typically far below the amount that will cause any other unwanted side effects, such as hair growth. Not everyone requires this, but keep in mind that some do. "  

Many natal women who are having difficulty in feeling turned-on and in achieving orgasms (especially post-menopausal women) are now taking Estratest tablets, which contain a combination of estrogen and small amounts of testosterone. Although Estratest is a somewhat controversial treatment, many natal women began taking it after it was featured in a story on Oprah Winfrey's hugely popular television show in the U.S . As a result of this news, and of advice like that on the Zen page, some post-op women who were experiencing difficulty in arousals and orgasms began using Estratest too, and some report that the therapy helps them. These tablets contain either 1.25 mg or 0.625 mg of estrogens (as in Premarin tablets), but also include a small amount of testosterone in each pill (for more information, see this link ). There may be some kind of threshold effect involved here, whereby some women need a small amount of testosterone to maintain orgasmic capability. On the other hand, many other postop (and post-menopausal) women enjoy strong orgasms even in the complete absence of testosterone.

In any event, once a postop woman begins experiencing arousals, the nerves in the clitoris and vulvar surfaces become highly sensitized, and sensual and sexy feeling permeate her body. Then, just as during pubertal sexual awakening, she will automatically feel urges to play with her body and to masturbate. The arousals will gradually intensify as her genital area fully heals from the SRS. Masturbation and sexual activity can likely play a role in helping neural regeneration and sensitivity during this period.

There are many ways to masturbate, but one favorite way for girls to do it is to "rub on a pillow". The girl does this by lying face down on her bed, with a firm pillow between her legs. This way she can rub her vulva and clitoris on the pillow while squeezing it, putting pressure on her clit and also being able to thrust and thrash around. At the same time she can play with her breasts and body with her hands. Alternatively, she can rub her clitoris with the fingers of one hand while squeezing her legs and thrashing around to stimulate her body. And there are many other ways to stimulate arousals and produce orgasms, including using vibrators and other women's sex toys . Girls discover these ways just as automatically as boys discover "jerking off", even though girls have been more secretive about it our society in the past.

While masturbating, the pubertal girl will suddenly begin to experience her first orgasms, and she is then on her way to developing her full sexuality as a woman. In just the same way, the postop woman needs to explore her new sexual anatomy and masturbate, and learn her new sexual responses and experience her first orgasms as a woman - learning what most girls do in their teens during puberty.

This ongoing pubertal aspect of immediate postop life can be very thrilling and exciting, but also very confusing and scary for the woman, much in the same way that the onset of sexual maturity is for any teenager.

For some insights into this process, I highly recommend that you read the very candid webpage by entitled " M -> F Transexual Post-Op Orgasms - A Personal Perspective", by Monica Stewart . Monica's site stresses the need to gain experience with your new sexual responses prior to having intercourse. It is also important to try to get over hang-ups about what's "OK" and what's "naughty". Then too, many woman enjoy experiencing playful anal stimulation, including using sex toys to overcome inhibitions and enhance arousals. Most women also learn to use fantasies to trigger and enhance arousals and orgasms. Those fantasies can be used during masturbation, and then later used to help heighten one's experiences during intercourse with a lover.

Thus we see that transition and SRS are just the very beginning: They enable the girl enter her new puberty. What she will make of herself as a woman is yet to be determined!

For more information, see:

Lynn's homepage:



TS information pages:


TS Successes page:



Andrea James TS Roadmap (the internet "bible of MtF transition"):


Andrea James SRS (vaginoplasty) page, which includes an international list of surgeons:


The WPATH international Standards of Care for transsexualism:



http://wpath.org/Documents2/socv6.pdf ( ES )


May 10, 2021

The Forgotten History of the World's First Trans Clinic

The Institute for Sexual Research in Berlin would be a century old if it hadn’t fallen victim to Nazi ideology

By Brandy Schillace

Magnus Hirschfeld (in glasses) holds hands with his partner, Karl Giese (center).

Costume party at the Institute for Sexual Research in Berlin, date and photographer unknown. Magnus Hirschfeld ( in glasses ) holds hands with his partner, Karl Giese ( center ).

Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Late one night on the cusp of the 20th century, Magnus Hirschfeld, a young doctor, found a soldier on the doorstep of his practice in Germany. Distraught and agitated, the man had come to confess himself an Urning —a word used to refer to homosexual men. It explained the cover of darkness; to speak of such things was dangerous business. The infamous “Paragraph 175” in the German criminal code made homosexuality illegal; a man so accused could be stripped of his ranks and titles and thrown in jail.

Hirschfeld understood the soldier’s plight—he was himself both homosexual and Jewish—and did his best to comfort his patient. But the soldier had already made up his mind. It was the eve of his wedding, an event he could not face . Shortly after, he shot himself.

The soldier bequeathed his private papers to Hirschfeld, along with a letter: “The thought that you could contribute to [a future] when the German fatherland will think of us in more just terms,” he wrote, “sweetens the hour of death.” Hirschfeld would be forever haunted by this needless loss; the soldier had called himself a “curse,” fit only to die, because the expectations of heterosexual norms, reinforced by marriage and law, made no room for his kind. These heartbreaking stories, Hirschfeld wrote in The Sexual History of the World War , “bring before us the whole tragedy [in Germany]; what fatherland did they have, and for what freedom were they fighting?” In the aftermath of this lonely death, Hirschfeld left his medical practice and began a crusade for justice that would alter the course of queer history.

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Hirschfeld sought to specialize in sexual health, an area of growing interest. Many of his predecessors and colleagues believed that homosexuality was pathological, using new theories from psychology to suggest it was a sign of mental ill health. Hirschfeld, in contrast, argued that a person may be born with characteristics that did not fit into heterosexual or binary categories and supported the idea that a “third sex” (or Geschlecht ) existed naturally. Hirschfeld proposed the term “sexual intermediaries” for nonconforming individuals. Included under this umbrella were what he considered “situational” and “constitutional” homosexuals—a recognition that there is often a spectrum of bisexual practice—as well as what he termed “transvestites.” This group included those who wished to wear the clothes of the opposite sex and those who “from the point of view of their character” should be considered as the opposite sex. One soldier with whom Hirschfeld had worked described wearing women’s clothing as the chance “to be a human being at least for a moment.” He likewise recognized that these people could be either homosexual or heterosexual, something that is frequently misunderstood about transgender people today.


Magnus Hirschfeld, director of the Institute for Sexual Research, in an undated portrait. Credit: Magnus-Hirschfeld-Gesellschaft e.V., Berlin

Perhaps even more surprising was Hirschfeld’s inclusion of those with no fixed gender, akin to today’s concept of gender-fluid or nonbinary identity (he counted French novelist George Sand among them). Most important for Hirschfeld, these people were acting “in accordance with their nature,” not against it.

If this seems like extremely forward thinking for the time, it was. It was possibly even more forward than our own thinking, 100 years later. Current anti-trans sentiments center on the idea that being transgender is both new and unnatural. In the wake of a U.K. court decision in 2020 limiting trans rights, an editorial in the Economist argued that other countries should follow suit , and an editorial in the Observer praised the court for resisting a “disturbing trend” of children receiving gender-affirming health care as part of a transition.

Related: The Disturbing History of Research into Transgender Identity

But history bears witness to the plurality of gender and sexuality. Hirschfeld considered Socrates, Michelangelo and Shakespeare to be sexual intermediaries; he considered himself and his partner Karl Giese to be the same. Hirschfeld’s own predecessor in sexology, Richard von Krafft-Ebing, had claimed in the 19th century that homosexuality was natural sexual variation and congenital.

Hirschfeld’s study of sexual intermediaries was no trend or fad; instead it was a recognition that people may be born with a nature contrary to their assigned gender. And in cases where the desire to live as the opposite sex was strong, he thought science ought to provide a means of transition. He purchased a Berlin villa in early 1919 and opened the Institut für Sexualwissenschaft (the Institute for Sexual Research) on July 6. By 1930 it would perform the first modern gender-affirmation surgeries in the world.

A Place of Safety

A corner building with wings to either side, the institute was an architectural gem that blurred the line between professional and intimate living spaces. A journalist reported it could not be a scientific institute, because it was furnished, plush and “full of life everywhere.” Its stated purpose was to be a place of “research, teaching, healing, and refuge” that could “free the individual from physical ailments, psychological afflictions, and social deprivation.” Hirschfeld’s institute would also be a place of education. While in medical school, he had experienced the trauma of watching as a gay man was paraded naked before the class, to be verbally abused as a degenerate.

Hirschfeld would instead provide sex education and health clinics, advice on contraception, and research on gender and sexuality, both anthropological and psychological. He worked tirelessly to try to overturn Paragraph 175. Unable to do so, he got legally accepted “transvestite” identity cards for his patients, intended to prevent them from being arrested for openly dressing and living as the opposite sex. The grounds also included room for offices given over to feminist activists, as well as a printing house for sex reform journals meant to dispel myths about sexuality. “Love,” Hirschfeld said, “is as varied as people are.”

The institute would ultimately house an immense library on sexuality, gathered over many years and including rare books and diagrams and protocols for male-to-female (MTF) surgical transition. In addition to psychiatrists for therapy, he had hired Ludwig Levy-Lenz, a gynecologist. Together, with surgeon Erwin Gohrbandt, they performed male-to-female surgery called Genitalumwandlung —literally, “transformation of genitals.” This occurred in stages: castration, penectomy and vaginoplasty. (The institute treated only trans women at this time; female-to-male phalloplasty would not be practiced until the late 1940s.) Patients would also be prescribed hormone therapy, allowing them to grow natural breasts and softer features.

Their groundbreaking studies, meticulously documented, drew international attention. Legal rights and recognition did not immediately follow, however. After surgery, some trans women had difficulty getting work to support themselves, and as a result, five were employed at the institute itself. In this way, Hirschfeld sought to provide a safe space for those whose altered bodies differed from the gender they were assigned at birth—including, at times, protection from the law.


1926 portrait of Lili Elbe, one of Hirschfeld's patients. Elbe's story inspired the 2015 film The Danish Girl . Credit: https://wellcomeimages.org/indexplus/image/L0031864.html (CC BY 4.0)

Lives Worth Living

That such an institute existed as early as 1919, recognizing the plurality of gender identity and offering support, comes as a surprise to many. It should have been the bedrock on which to build a bolder future. But as the institute celebrated its first decade, the Nazi party was already on the rise. By 1932 it was the largest political party in Germany, growing its numbers through a nationalism that targeted the immigrant, the disabled and the “genetically unfit.” Weakened by economic crisis and without a majority, the Weimar Republic collapsed.

Adolf Hitler was named chancellor on January 30, 1933, and enacted policies to rid Germany of Lebensunwertes Leben , or “lives unworthy of living.” What began as a sterilization program ultimately led to the extermination of millions of Jews, Roma, Soviet and Polish citizens—and homosexuals and transgender people.

When the Nazis came for the institute on May 6, 1933, Hirschfeld was out of the country. Giese fled with what little he could. Troops swarmed the building, carrying off a bronze bust of Hirschfeld and all his precious books, which they piled in the street. Soon a towerlike bonfire engulfed more than 20,000 books, some of them rare copies that had helped provide a historiography for nonconforming people.

The carnage flickered over German newsreels. It was among the first and largest of the Nazi book burnings. Nazi youth, students and soldiers participated in the destruction, while voiceovers of the footage declared that the German state had committed “the intellectual garbage of the past” to the flames. The collection was irreplaceable.

Levy-Lenz, who like Hirschfeld was Jewish, fled Germany. But in a dark twist, his collaborator Gohrbandt, with whom he had performed supportive operations, joined the Luftwaffe as chief medical adviser and later contributed to grim experiments in the Dachau concentration camp. Hirschfeld’s likeness would be reproduced on Nazi propaganda as the worst kind of offender (both Jewish and homosexual) to the perfect heteronormative Aryan race.

In the immediate aftermath of the Nazi raid, Giese joined Hirschfeld and his protégé Li Shiu Tong, a medical student, in Paris. The three would continue living together as partners and colleagues with hopes of rebuilding the institute, until the growing threat of Nazi occupation in Paris required them to flee to Nice. Hirschfeld died of a sudden stroke in 1935 while still on the run. Giese died by suicide in 1938. Tong abandoned his hopes of opening an institute in Hong Kong for a life of obscurity abroad.

Over time their stories have resurfaced in popular culture. In 2015, for instance, the institute was a major plot point in the second season of the television show Transparent , and one of Hirschfeld’s patients, Lili Elbe, was the protagonist of the film The Danish Girl . Notably, the doctor’s name never appears in the novel that inspired the movie, and despite these few exceptions the history of Hirschfeld’s clinic has been effectively erased. So effectively, in fact, that although the Nazi newsreels still exist, and the pictures of the burning library are often reproduced, few know they feature the world’s first trans clinic. Even that iconic image has been decontextualized, a nameless tragedy.

The Nazi ideal had been based on white, cishet (that is, cisgender and heterosexual) masculinity masquerading as genetic superiority. Any who strayed were considered as depraved, immoral, and worthy of total eradication. What began as a project of “protecting” German youth and raising healthy families had become, under Hitler, a mechanism for genocide.


One of the first and largest Nazi book burnings destroyed the library at the Institute for Sexual Research. Credit: Ullstein Bild and Getty Images

A Note for the Future

The future doesn’t always guarantee progress, even as time moves forward, and the story of the Institute for Sexual Research sounds a warning for our present moment. Current legislation and indeed calls even to separate trans children from supportive parents bear a striking resemblance to those terrible campaigns against so-labeled aberrant lives.

Studies have shown that supportive hormone therapy, accessed at an early age, lowers rates of suicide among trans youth. But there are those who reject the evidence that trans identity is something you can be “born with.” Evolutionary biologist Richard Dawkins was recently stripped of his “humanist of the year” award for comments comparing trans people to Rachel Dolezal , a civil rights activist who posed as a Black woman, as though gender transition were a kind of duplicity. His comments come on the heels of legislation in Florida aiming to ban trans athletes from participating in sports and an Arkansas bill denying trans children and teens supportive care.

Looking back on the story of Hirschfeld’s institute—his protocols not only for surgery but for a trans-supportive community of care, for mental and physical healing, and for social change—it’s hard not to imagine a history that might have been. What future might have been built from a platform where “sexual intermediaries” were indeed thought of in “more just terms”? Still, these pioneers and their heroic sacrifices help to deepen a sense of pride—and of legacy—for LGBTQ+ communities worldwide. As we confront oppressive legislation today, may we find hope in the history of the institute and a cautionary tale in the Nazis who were bent on erasing it.

Brandy Schillace is editor in chief of BMJ's Medical Humanities journal and author of the recently released book Mr. Humble and Doctor Butcher , a biography of Robert White, who aimed to transplant the human soul.

Scientific American Magazine Vol 325 Issue 2

How Gender Reassignment Surgery Works (Infographic)

Infographics: How surgery can change the sex of an individual.

Bradley Manning, the U.S. Army private who was sentenced Aug. 21 to 35 years in a military prison for releasing highly sensitive U.S. military secrets, is seeking gender reassignment. Here’s how gender reassignment works:

Converting male anatomy to female anatomy requires removing the penis, reshaping genital tissue to appear more female and constructing a vagina.

An incision is made into the scrotum, and the flap of skin is pulled back. The testes are removed.

A shorter urethra is cut. The penis is removed, and the excess skin is used to create the labia and vagina.

People who have male-to-female gender-reassignment surgery retain a prostate. Following surgery, estrogen (a female hormone) will stimulate breast development, widen the hips, inhibit the growth of facial hair and slightly increase voice pitch.

Female-to-male surgery has achieved lesser success due to the difficulty of creating a functioning penis from the much smaller clitoral tissue available in the female genitals.

The uterus and the ovaries are removed. Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by hormones, or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty).

Breasts need to be surgically altered if they are to look less feminine. This process involves removing breast tissue and excess skin, and reducing and properly positioning the nipples and areolae. Androgens (male hormones) will stimulate the development of facial and chest hair, and cause the voice to deepen.

Reliable statistics are extremely difficult to obtain. Many sexual-reassignment procedures are conducted in private facilities that are not subject to reporting requirements.

The cost for female-to-male reassignment can be more than $50,000. The cost for male-to-female reassignment can be $7,000 to $24,000.

Between 100 to 500 gender-reassignment procedures are conducted in the United States each year.

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This topic will review surgeries that are commonly performed as part of feminizing transition. Other topics related to the care of transgender persons include:

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

when was the first gender reassignment surgery male to female

  • 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
  • 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
  • 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.


Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).


Figure 1 . The initial circumferential subcoronal incision.


Figure 2 . The de-gloved penis being passed through the scrotal opening.


Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.


Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.


Figure 5 . The inverted penile skin flap.


Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.


Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.


Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .


Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).


Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.


The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

20. Hess J, Rossi NR, Panic L, Rubben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DtschArztebl Int. (2014) 111:795–801. doi: 10.3238/arztebl.2014.0795

21. Silva DC, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals. J Sex Med. (2016) 13:988–93. doi: 10.1016/j.jsxm.2016.03.370

22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

Sex Reassignment Surgery at 74: Medicare Win Opens Door for Transgender Seniors

CHICAGO — Denee Mallon marveled at the view of Lake Michigan from her hospital bed in the Windy City, where she had just made history: the then 74-year-old transgender woman underwent a milestone sex reassignment surgery she’d sought for decades. “Here I am, finally, after all these years,” she said. “It happened.”

Her operation will be one of the first paid for by Medicare after she won a challenge in May to end the government insurance program’s ban on covering such procedures for transgender individuals. Mallon’s victory opened the door for other seniors to access this care and may influence whether more insurers – private and public - will cover them. LGBT advocates also hailed her case as another step forward to securing equal rights for transgender people.

View Gallery: Transgender Army Veteran Undergoes Sex Reassignment Surgery

“I feel congruent, like I’m finally one complete human being where my body matches my innermost feelings, my psyche,” said Mallon, of Albuquerque, New Mexico, two days after undergoing sex reassignment surgery in mid-October. “I feel complete.”

The Medicare ban was imposed in 1989, stemming from earlier information years before that found there was a “lack of well controlled, long-term studies of the safety and effectiveness of the surgical procedures and attendant therapies.” It deemed such treatment “experimental” and noted a “high rate of serious complications.”

But since then, research has found that sex reassignment surgery is a proven therapy for some individuals suffering from gender dysphoria, with decades-long studies and clinical case reports showing positive results, experts say. There is “agreement among professionals in the field that this is effective treatment,” said Jamison Green, president of the World Professional Association for Transgender Health.

The American Medical Association , the American Psychiatric Association and the American Psychological Association are among the professional medical groups that have in the last decade endorsed sex reassignment surgery, which can include a number of procedures such as a complete hysterectomy, bilateral mastectomy and genital reconstruction.

Yet no one challenged the Medicare prohibition until Mallon did.

Image: Denee Mallon pumps gas into her Ford Mustang in Albuquerque, New Mexico.

Long road home

Mallon said she first became aware of her gender identity when she was a child in the 1940s. “People would ask, ‘How is your little girl today,’ and that was me,” she said. “Well, it's taken me all these years and detours, potholes and whatnot to finally be where I am right now.”

For Mallon, life – work, five kids and three marriages - had gotten in the way of having sex reassignment surgery. When she could afford it in the late 1970s and early 1980s, she couldn’t get her doctors to approve it. They balked, she said, because she was having sex with women – which they felt was inconsistent with her needing the operation. By the time she got the okay in the late 1980s, she could no longer afford it.

“I've tried to be the kind of man that society wanted and my feminine self just kept creeping up.”

“I lived what transsexuals call the stealth life, didn’t disclose the fact that I was originally male,” said Mallon, who prior to surgery had taken hormones as part of her transition. “And in 2012, I came out of stealth mode and started being more of an activist.”

Her decision to take on Medicare came after she was denied sex reassignment surgery by her secondary private insurer and then the government insurance program. Male-to-female transitions can run about $25,000; for female-to-male transitions it’s around $100,000. Such costs are prohibitively expensive for many on Medicare. Mallon, for example, lives on $650 a month in Social Security income and shares a trailer with another transgender woman.

Mallon’s challenge of what is known as Medicare’s national coverage determination took about 18 months. Medicare never defended its policy before a U.S. health and human services (HHS) board tasked with hearing the challenge, nor did it question the new evidence, which included medical studies, provided by several experts in this field as part of the review.

The HHS board, in its decision, said it was comfortable with that evidence and thus didn’t feel it was necessary to independently consult with scientific or clinical experts on it.

“The new evidence indicates that transsexual surgery is an effective treatment option in appropriate cases,” the board said .

Medicare didn’t respond to NBC’s questions about why it didn’t defend the former policy. Data for reimbursement requests for sex reassignment surgery since the change wasn’t yet available, Medicare said, but a spokesman noted that the decision on whether to cover the procedures was now up to the program’s contractors. (The HHS board said its determination doesn’t bar Medicare or its contractors from denying individual claims for payment for others reasons allowed by the law.)

'There's no escaping it'

Transgender people and the issues they face are being discussed and embraced more openly than at any other time in history, with television shows featuring transgender characters — like “Transparent” and “Orange is the New Black” — helping to bring more awareness.

But seniors, like Mallon, grew up during a time when transgender issues were invisible at best. Mallon had grappled for decades with her gender identity: She had tried, as she said, to “man up” by joining the high school football team, the Army and then a police force. She lost marriages and family ties as she haltingly made her transition. She struggled and lacked confidence in jobs where she presented herself as a man.

“I have a difficult time relating to somebody what it feels like to be me. One of the obvious things people will say is, ‘It’s a lifestyle choice. You've made this choice.’ Well, it's far deeper than that. It's so a part of my basic psyche, there's no escaping it,” she said. “I've tried to be the kind of man that society wanted and my feminine self just kept creeping up.”

Mallon, now 75, began living full time as a woman when she turned 40, taking fashion merchandising courses with 20-somethings at a vocational school in Albuquerque to learn how to walk and talk like the woman she knew herself to be. She’d known since she was about 12 that she needed to have sex reassignment surgery after news broke in 1952 that Christine Jorgensen , a transgender New Yorker, had done it in Europe.

“I was delivering the morning paper at the time and eagerly anticipated each article. That's when I knew that I could actually have the surgery and become a woman,” Mallon said. “She'd get on TV shows and people would just eagerly watch the show to catch a glimpse of her because that was so novel back then. He was this Army veteran, now a woman, and looking quite good.”

Image: Transgender surgery

Of Mallon’s five children, she said, her eldest fully accepts her gender identity and is proud of her for leading the Medicare fight.

“I'm so sad it took so long,” Kelly Mallon-Salter said of Denee’s surgery, getting emotional. “But I'm so happy that she's helping others to have it.”

Coverage expands in private sector

The Medicare decision comes as the number of private insurance companies offering transition-related coverage has surged in recent years. Human Rights Campaign, which advocates for LGBT equality, said about 34 percent of the Fortune 500 companies today — up from 10 percent in 2009 — offer transgender-inclusive health care benefits, including surgical. Many employers have started to address coverage for transgender individuals, and most have experienced little to no premium increases as a result, HRC said in its annual Corporate Equality Index .

Five states’ Medicaid programs — California, Massachusetts, Vermont, the District of Columbia and Oregon — cover transgender health services, including sex reassignment surgery, in their plans for lower-income and disabled people. Ten states have banned health insurance discrimination against transgender people (the five listed above plus Colorado, Connecticut, Illinois, Washington, and most recently, New York).

The hope, transgender advocates say, is that the Medicare decision will encourage more Medicaid programs and private insurers to offer coverage.

“That's going to have a ripple effect, we believe, across other third-party payers,” said Dr. Loren Schechter, a plastic surgeon who performed Mallon’s surgery at Weiss Memorial Hospital in Chicago. “And the important recognition is that this surgery is not cosmetic, it's not an individual's lifestyle choice.”

“It was extreme anxiety that there was something totally wrong and I wasn’t able to fix it. And if I'm doomed to live this horrible life with these feelings, then it's not worth living.”

Having sex-reassignment surgery for some individuals suffering from gender dysphoria is medically necessary, said Green of WPATH. Being unable to access such care can create stress, depression, anxiety, heart conditions, disorders or worse. Data is limited on suicide among transgender individuals, though 41 percent of respondents to the National Transgender Discrimination Survey in 2011 said they’d attempted to take their life. “There is nothing more meaningful than to be able to be at home in your body,” Green said.

Veronica Shema, a 65-year-old transgender woman living in Tucson, Arizona, said she has attempted suicide and has been on suicide watch four times. She began to transition 10 years ago.

“I could not take it anymore,” she said. “It was extreme anxiety that there was something totally wrong and I wasn’t able to fix it. And if I'm doomed to live this horrible life with these feelings, then it's not worth living.”

Shema met with Schechter in November to plan her sex reassignment surgery. She said she’d been turned down by private insurance and was waiting on Medicare, calling it her “last hope.”

“I’m hitting an end-of-life crisis,” she said. “I can't continue living like this another 10, 15 years. Once I get the gender marker (changed) on my birth certificate, I will feel like I would have accomplished my task. And I'm not there. It's hard to live with.”

Obstacles remain

Despite the Medicare win, there are still many obstacles ahead: the surgery’s expense combined with typically low Medicare reimbursement rates (for any procedure) may discourage the few surgeons working in this area to accept patients with government insurance.

Dr. Marci Bowers, a pelvic and gynecologic surgeon who has performed more than 3,000 sex reassignment-related surgeries, said she has been getting “scores” of inquiries every week from Medicare patients since the decision. Although she has operated on some of them, she doesn’t think she’ll be able to accept more patients through the government insurer. The costs of this specialty are high, she said, and doctors must accept whatever the insurer reimburses as payment in full. They can’t seek additional payment from patients.

“It's actually having an unintended harmful effect on patients’ access to care,” she said. “There are an overwhelming number of patients out there. And potentially, if they were all to come in, they would overwhelm our ability to care for them,” she added. “If the reimbursement is paltry, as we are fearful it will be, it’s going to be very difficult to continue to take any kind of Medicare payments. The surgery is just too difficult, too risky, too complicated.”

But the Medicare change could encourage university medical programs to add this surgical expertise to their curriculum, which may increase the number of qualified surgeons, in turn leading to more competition and better access to care, said Bowers. There is currently no approved training program for sex reassignment surgeons in the U.S. Universities also can afford to sometimes take lower payments on treatments — such as from Medicare — with the tradeoff being that surgeries happen at teaching hospitals, she added.

Despite the ongoing challenges, Mallon said now that the door has opened, other transgender seniors who need sex reassignment surgery shouldn’t hesitate. As she savored her new beginning, Mallon mused about all the fun things she looked forward to: swimming comfortably in a pool and going on some dates.

“I’m just a normal everyday woman who is bound to get into trouble,” she said. “I’m so flirtatious, it’s ridiculous.”

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Hours of operation, gender affirming surgery (sex reassignment surgery).

Thank you for your interest in gender affirming surgery at Denver Health. There is no one-size-fits-all approach for the gender affirmation process and we are here to support you in your journey. We are proud to offer surgeries with a truly talented multi-disciplinary team of surgeons. Our services are growing as the unique needs of each individual evolve. Currently we offer the following gender affirming surgeries: MTF Top Surgery , FTM Top Surgery , Orchiectomy ,  FTM Hysterectomy , and  Vaginoplasty  surgeries.

What is Gender Affirming Surgery?

Gender affirming surgery, also known as sex reassignment surgery (SRS) or confirmation surgery, is the surgical procedure(s) by which a transgender or non-binary person’s physical appearance and functional abilities are changed to align with the gender they know themselves to be.

Complete Our Surgical Interest Form

If you are interested in a gender affirmation surgery at Denver Health, please complete one of the following forms.

Top Surgery and Hysterectomy

For vaginoplasty, breast augmentation and orchiectomy, our approach to surgical assessment.

Denver Health adheres to the guidelines for surgical assessment as described in the World Professional Association for Transgender Health Standards of Care, 8th Version . The standards were created by international agreement using the latest scientific research on transgender health so that doctors can best meet the unique health care needs of transgender and gender-nonconforming people. Most insurance companies also adhere to these guidelines.

Patients may provide referral letters from their own outside mental health providers, or the assessment process via our Behavioral Health team. Patients seeking to undergo the assessment at Denver Health should make an appointment with our Behavioral Health Team .

Read more about common frequently asked general surgery questions:

How long will my hospital stay be.

Hospital stays will vary based on specific patient response. 

MTF top surgery, FTM chest surgery, FTM Hysterectomy, and orchiectomy surgery patients are usually released from the hospital the same day of surgery. Vaginoplasty patients typically spend 3 days in the hospital during recovery. 

What medications will I be prescribed after surgery?

You will likely receive painkillers and antibiotics to reduce the chance of infection.

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Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

when was the first gender reassignment surgery male to female

The 14th Amendment to the Constitution is truly a magical amendment. It was used to justify attempts to kick Donald Trump off the 2024 ballot. Through the decades, judges who want to play at social engineering have used it frequently to justify questionable law. 

It's even been invoked to bypass Congress to raise the debt limit.

Now, the Fourth Circuit Court of Appeals has decided that the amendment's "equal protection" clause means that state Medicaid programs have to cover gender reassignment surgeries.

The appeals court ruled that West Virginia's Medicaid rules on mastectomies are unconstitutional because they violate the "equal protection standard" by not covering mastectomies for gender dysphoria.

Yes, really.

The ruling also includes a North Carolina Medicaid case that the state government won't cover "sex changes." The Fourth Circuit nullified the state ban on gender change surgeries, citing the 14th Amendment’s guarantee of “equal protection of the laws.”

This was a court looking for an excuse to make law.

Judge Roger Gregory who wrote the majority opinion in Kadel v. Folwell (8-6) asked, “Is removing a patient’s breasts to treat cancer the same procedure as removing a patient’s breasts to treat gender dysphoria?” He continued, “There is no case law to ground this discussion nor obvious first principles.”

Wall Street Journal:

He is undeterred, and he concludes that gender dysphoria and transgender status are intertwined, so that such insurance exclusions are nothing more than a proxy for discriminating against gender identity. Then he goes further, finding that West Virginia’s and North Carolina’s policies also unconstitutionally discriminate based on sex. How so? Imagine, Judge Gregory says, an unidentified patient seeking a vaginoplasty. Is this a biological female with a rare birth defect? Is it a transgender patient? “By virtue of the fact that they are seeking a vaginoplasty, we know that they were born without a vagina,” he writes. “But we do not know what sex they were assigned at birth. Without that information, we cannot say whether the Plan or Program will cover the surgery.” Ergo, sex discrimination.

Gregory gets even nuttier.

The differences in coverage "is rooted in a gender stereotype: the assumption that people who have been assigned female at birth are supposed to have breasts, and that people assigned male at birth are not."

It's not a "gender stereotype." It's a biological fact. 

"No doubt, the majority of those assigned female at birth have breasts, and the majority of those assigned male at birth do not. But we cannot mistake what is for what must be.”

Not just a "majority." It's a universal biological fact with a tiny number of exceptions.

Treating different things differently doesn’t violate the 14th Amendment’s Equal Protection Clause, and jurists aren’t supposed to ignore the obvious. Writing in dissent at the Fourth Circuit, Judge Julius Richardson struggles to contain his exasperation. “The states,” he says, “have chosen to cover alterations of a person’s breasts or genitalia only if the person experiences physical injury, disease, or (in West Virginia) congenital absence of genitalia.” That determination does not turn on the patient’s sex or gender. “Christopher Fain—one of the plaintiffs below—received coverage for a hysterectomy based on a diagnosis unrelated to Fain’s transgender status,” the dissent says. Likewise, males with gynecomastia qualify for surgery coverage in West Virginia only “if they have physical symptoms, like breast pain,” meaning that isn’t a procedure done merely “to affirm a patient’s biological sex.”

The ruling that opened this can of worms was Bostock v. Clayton County, a case that "held that Title VII of the Civil Rights Act of 1964 protects employees against discrimination because of  sexuality or gender identity." Now, as a dissenting judge in Kadel v. Folwell,  Judge J. Harvie Wilkinson III is saying that this ruling could be a Roe v Wade  ruling for the transgender community.

“This is imperial judging at its least defensible,” he says, “What plaintiffs propose is nothing less than to use the Constitution to establish a nationwide mandate that States pay for emerging gender dysphoria treatments.”

He's not wrong. But getting the ruling past this Supreme Court would be a stretch. 

Rick Moran

Rick Moran has been writing for PJ Media for 18 years. His work has appeared in dozens of media outlets including the Washington Times  and ABC News. He was an editor at American Thinker for 14 years. His own blog is Right Wing Nut House . For media inquiries, please contact [email protected] .


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Medindia » Articles » Procedure » Gender-Reassignment Surgery: Everything You Need to Know

Gender-Reassignment Surgery: Everything You Need to Know

  • Indications

Non-Surgical Procedures

  • Surgical Procedures

Risks in Non-Surgical and Surgical Procedures

  • Whom to consult?
  • Pre-Op Considerations
  • Post-Op Considerations

Impact on Mental Health

  • Cost of the Surgery

Gender reassignment surgery, also known as gender-affirming surgery, is a medical procedure or series of procedures aimed at altering an individual's physical appearance and sexual characteristics to align with their gender identity.

In Simple words, it can be defined as the alteration of a person's physical sex characteristics by surgery in order to match the person’s gender identity

This transformative process is often pursued by transgender individuals, as well as some cisgender and non-binary individuals. It involves various surgical interventions to modify primary and secondary sexual characteristics, thereby affirming an individual's gender identity( 1 ✔ ✔ Trusted Source Sex Reassignment Surgery in the Female-to-Male Transsexual Go to source ).

Alternative Names for Gender-Affirming Surgery

  • Gender reassignment surgery (GRS)
  • Gender-affirmation surgery
  • Gender confirmation surgery
  • Sex reassignment surgery

Who Can Get Gender Reassignment Surgery?

Transgender individuals.

Transgender individuals are those whose gender identity differs from the sex they were assigned at birth. Many transgender individuals experience gender dysphoria, a condition characterized by distress or discomfort caused by a misalignment between their gender identity and physical body. Gender reassignment surgery is often sought by transgender individuals as part of their transition journey to alleviate gender dysphoria and align their physical appearance with their gender identity.

Trans Women: Assigned male at birth but identify and live as women. Trans women may pursue feminizing surgeries such as vaginoplasty (creation of a vagina), breast augmentation, facial feminization surgery, and voice feminization surgery to affirm their gender identity.

Trans Men: Assigned female at birth but identify and live as men. Trans men may undergo masculinizing surgeries such as chest reconstruction (removal of breast tissue), hysterectomy (removal of the uterus), and phalloplasty or metoidioplasty (creation of a penis) to align their bodies with their gender identity.

Intersex Individuals

Intersex is a term used to describe individuals who are born with variations in their biological sex characteristics (chromosomes, gonads (testes/ovaries), reproductive organs (prostate/uterus) or external genitalia (penis/clitoris)) that do not fit typical definitions of male or female.

Intersex Individuals with Gender Dysphoria: While intersex individuals can be transgender if their gender identity does not match the sex they were raised or assigned as, some intersex individuals may experience distress or discomfort, known as gender dysphoria , due to a misalignment between their gender identity and assigned sex characteristics, and seek gender-affirming surgery to align their physical appearance with their gender identity( 2 ✔ ✔ Trusted Source Gender Affirmation Surgeries Go to source ).

Drag Performers

Drag performers are individuals who utilize clothing, makeup, and performance art to explore and celebrate gender expression. They are typically associated with a gender different from their own. These performers engage in drag for various reasons, including self-expression, artistic exploration, and entertainment purposes.

While some drag performers may identify as transgender or non-binary and use drag as a form of self-expression or exploration of their gender identity, others may identify as cisgender and engage in drag purely for entertainment or artistic expression.

Drag Queens and Drag Kings : Drag queens are typically male individuals who dress in feminine attire and adopt exaggerated female personas for performance. Drag kings, on the other hand, present as male or masculine while performing. While some drag performers may identify as transgender and may ultimately pursue gender-affirming surgeries, the act of performing drag does not inherently imply a desire for surgical intervention.

Individuals with Klinefelter Syndrome

Klinefelter syndrome is a chromosomal condition in which individuals are born with an extra X chromosome (XXY), resulting in differences in sexual development and often leading to infertility and other physical characteristics such as tall stature, reduced muscle mass, and gynecomastia (enlarged breast tissue in males)( 4 ✔ ✔ Trusted Source Klinefelter syndrome Go to source ).

While not directly related to transgender identity, some individuals with Klinefelter syndrome may experience gender dysphoria and seek gender-affirming treatments, including surgery. These individuals may undergo procedures to modify their physical characteristics to better align with their gender identity and alleviate distress associated with gender dysphoria.

Non-Binary Individuals

"Non-binary" is a term used to describe individuals whose gender identity does not exclusively align with the categories of male or female. This is a deeply personal and internal sense of one's own gender. Non-binary individuals may identify as both, neither, a combination of both, or as a gender entirely different from male or female.

Bigenital Operation: Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Some non-binary individuals may opt for these surgeries to achieve a physical presentation that aligns with their gender identity while maintaining aspects of their original anatomy. These surgeries cater to the diverse spectrum of gender identities and expressions and provide options for individuals who do not fit within the traditional binary understanding of gender.

"Cisgender" is a term used to describe individuals whose gender identity aligns with the sex they were assigned at birth. In other words, someone who is cisgender identifies as the gender typically associated with the biological sex they were born with. For example, a person who was assigned female at birth and identifies as a woman is considered cisgender. The term "cisgender" is often used in contrast to "transgender," which describes individuals whose gender identity differs from the sex they were assigned at birth

While gender dysphoria is often associated with transgender individuals, cisgender people can also experience it. In some cases, cisgender individuals with severe gender dysphoria may seek gender-affirming surgeries to alleviate their distress and bring their physical appearance into alignment with their gender identity. These surgeries are typically pursued after extensive evaluation and therapy, and they can significantly improve the mental health and well-being of individuals experiencing gender dysphoria.

Is Gender Dysphoria the only Reason for Gender Reassignment Surgery?

No, not only gender dysphoric individuals seek gender reassignment surgery. While gender dysphoria is a common reason why individuals pursue gender-affirming surgeries, it's not the only factor. Some people may choose to undergo these surgeries for reasons beyond alleviating distress associated with gender dysphoria.

For example, individuals with intersex variations may seek gender-affirming surgeries to align their physical appearance with their gender identity, even if they do not experience gender dysphoria. Similarly, some non-binary individuals may opt for surgeries to achieve a physical presentation that better aligns with their gender identity, regardless of whether they experience gender dysphoria.

Furthermore, some cisgender individuals may also undergo gender-affirming surgeries for reasons related to body dysmorphia or dissatisfaction with their physical appearance, rather than gender dysphoria.

Ultimately, the decision to pursue gender reassignment surgery is deeply personal and can be influenced by a variety of factors beyond gender dysphoria alone.

Hormonal injections is the only available non-surgical procedure.It isa form of hormone replacement therapy (HRT) commonly used in transgender healthcare to induce and maintain desired physical changes consistent with an individual's gender identity.

These injections typically involve the administration of testosterone for transmasculine individuals (female-to-male, or FtM) and estrogen for transfeminine individuals (male-to-female, or MtF).

Testosterone Injections (for Transmasculine Individuals)

Purpose : Testosterone injections are administered to induce masculine changes, such as increased facial and body hair growth, deepening of the voice, muscle development, and redistribution of body fat.

Types of Testosterone : There are different formulations of testosterone available for injection, including testosterone cypionate, testosterone enanthate, and testosterone undecanoate.

Administration : Testosterone injections are typically administered intramuscularly (into the muscle) in either the gluteal (buttocks) or deltoid (upper arm) muscle.

Dosage and Frequency : The dosage and frequency of testosterone injections can vary depending on individual factors such as age, weight, hormone levels, and desired changes. Typically, injections are administered every one to two weeks to maintain stable testosterone levels in the body.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant markers is essential to ensure the safety and effectiveness of testosterone therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Estrogen Injections (for Transfeminine Individuals)

Purpose : Estrogen injections are administered to induce feminine changes, such as breastdevelopment, redistribution of body fat, softening of the skin, and reduction of muscle mass.

Types of Estrogen : The most common form of estrogen used in injections is estradiol valerate.

Administration : Estrogen injections are typically administered intramuscularly, similar to testosterone injections, in the gluteal or deltoid muscle.

Dosage and Frequency : The dosage and frequency of estrogen injections vary depending on individual factors and treatment goals. Typically, injections are administered every one to two weeks.

Monitoring : Regular monitoring of hormone levels, liver function, and other relevant parameters is crucial for ensuring the safety and effectiveness of estrogen therapy. Blood tests may be conducted periodically to assess hormone levels and adjust the dosage as needed.

Time Frame of Use of Hormonal Injections

Initiation : Hormonal injections are often initiated after a thorough evaluation by healthcare providers, including discussions about treatment goals, potential risks and benefits, and informed consent. The timing of initiation may vary depending on individual factors such as age, readiness for treatment, and presence of any underlying health conditions.

Duration : Hormonal injections are typically used as part of long-term hormone replacement therapy to maintain desired physical changes and support overall well-being. The duration of hormone therapy may vary from individual to individual and often continues indefinitely, especially for those who desire ongoing maintenance of gender-affirming changes.

Discontinuation : In some cases, individuals may choose to discontinue hormonal injections for various reasons, such as personal preference, changes in health status, or the achievement of desired physical changes. It's essential for individuals to discuss any plans to discontinue hormone therapy with their healthcare provider to ensure proper management of any potential effects or complications.

Surgical Procedures: Gender Affirming Surgery

These surgical procedures play vital roles in gender affirmation for transgender individuals, aligning their physical appearance with their gender identity( 3 ✔ ✔ Trusted Source Gender Confirmation Surgery Go to source ).

Male-to-Female (MtF) Transitions:

  • Tracheal Shave: This procedure reduces the prominence of the Adam's apple, a typically male characteristic, to create a smoother, more feminine neck contour.
  • Breast Augmentation: Transfeminine individuals undergo breast augmentation to develop fuller, more feminine breast contours. Breast implants are placed behind breast tissue or chest muscle to achieve the desired size and shape.
  • Facial Feminization Surgery (FFS): FFS encompasses various surgical procedures aimed at feminizing facial features. Techniques may include forehead contouring, rhinoplasty , cheek augmentation, chin and jaw reshaping, tracheal shave, lip augmentation, and hairline lowering to achieve a more traditionally feminine appearance.
  • Male-to-Female Genital Sex Reassignment (Vaginoplasty): This surgical procedure constructs female genitalia for transfeminine individuals seeking alignment with their gender identity. Techniques involve using penile and scrotal tissue to create the vaginal canal, labia, and clitoral hood. The procedure may also include the creation of a neurovascular neoclitoris, providing both aesthetic and functional female genitalia in one operation.

Female-to-Male (FtM) Transitions:

  • Hysterectomy and Oophorectomy: This procedure involves the removal of the uterus and ovaries, reducing the production of female hormones (estrogen and progesterone).
  • Vaginectomy: Vaginectomy is the surgical removal of the vaginal canal, aligning the physical anatomy with a masculine appearance.
  • Chest Reconstruction (Top Surgery): FtM individuals undergo chest reconstruction surgery to remove breast tissue and reshape the chest to achieve a more masculine contour. Techniques include subcutaneous mastectomy or double mastectomy with or without nipple reconstruction.
  • Female-to-Male Genital Sex Reassignment (Phalloplasty): Phalloplasty is a surgical procedure to construct a phallus for FtM individuals seeking male genitalia. The radial forearm flap method is commonly used, involving tissue grafting from the forearm to create the phallus and urethra for standing urination. This procedure can be performed concurrently with a hysterectomy/vaginectomy to complete the transition process. A scrotum with testicular implants may be constructed in a second stage.

These surgical interventions are integral to gender affirmation for transgender individuals, helping align their physical appearance with their gender identity and alleviating gender dysphoria. Each procedure is tailored to the individual's unique needs and goals, reflecting the diversity of experiences within the transgender community.

Treatment of Gender-Reassignment Surgery

Risks in Hormone Therapies

  • Cardiovascular Risks : Hormone replacement therapy (HRT) may increase the risk of cardiovascular events such as heart attacks and strokes, especially in older individuals or those with pre-existing cardiovascular conditions.
  • Thromboembolic Events : Estrogen therapy, particularly in forms like oral contraceptives, may elevate the risk of blood clots, leading to thromboembolic events such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
  • Endocrine Disruption : Hormone therapies can disrupt the body's natural hormone balance, leading to potential complications such as metabolic disturbances, including insulin resistance and dyslipidemia.
  • Breast Cancer Risk : Some studies suggest that long-term use of hormone replacement therapy, especially estrogen-only formulations, may increase the risk of breast cancer in transgender women.
  • Liver Dysfunction : Hormone therapies, particularly oral estrogen formulations, may affect liver function and increase the risk of liver disease or dysfunction.

Risks in Gender Reassignment Surgeries

  • Surgical Complications : As with any surgical procedure, gender reassignment surgeries carry risks such as infection, bleeding , anesthesia complications, and adverse reactions to medications.
  • Scarring : Gender-affirming surgeries, especially those involving breast augmentation, chest reconstruction, or genital reconstruction, may result in visible scarring that could impact body image and self-esteem.
  • Loss of Sensation : Surgeries involving genital reconstruction, such as vaginoplasty or phalloplasty, may result in loss of sensation or altered sensation in the genital region, affecting sexual function and satisfaction.
  • Functional Complications : Some individuals may experience functional complications post-surgery, such as urinary incontinence , erectile dysfunction, or difficulties with sexual arousal or orgasm.
  • Psychological Impact : Gender reassignment surgeries can have profound psychological effects, including adjustment difficulties, post-operative depression, and challenges related to body image and identity.

Guidance on Surgical Procedures: Whom to Consult?

When contemplating gender reassignment surgery, it's essential for individuals to consult with a team of experienced healthcare providers specializing in transgender care. Here's whom to consider consulting:

1. Gender-Affirming Surgeons

Gender-affirming surgeons specialize in performing gender reassignment surgeries and have expertise in various surgical techniques, including chest surgery (for both masculinization and feminization procedures), genital reconstruction, and facial feminization surgery. These surgeons can provide comprehensive information about the surgical options available, discuss the potential risks and benefits, and guide individuals through the decision-making process.

2. Endocrinologists

Endocrinologists play a crucial role in managing hormone therapy for transgender individuals. They can provide guidance on hormone replacement therapy (HRT), including the use of testosterone for transmasculine individuals and estrogen for transfeminine individuals. Endocrinologists can assess hormone levels, monitor any potential side effects, and adjust hormone regimens as needed to support the transition process.

3. Mental Health Professionals

Mental health professionals, such as psychologists, psychiatrists, or licensed therapists, offer invaluable support throughout the gender transition journey. They can assist individuals in exploring their gender identity, coping with gender dysphoria, and addressing any psychological concerns or challenges that may arise before, during, or after surgery. Mental health professionals also play a role in assessing readiness for surgery and providing pre- and post-operative counseling and support.

4. Primary Care Physicians

Primary care physicians are essential members of the healthcare team and can provide general medical care, coordinate referrals to specialists, and monitor overall health and well-being. They can also assist with managing any pre-existing medical conditions and ensuring that individuals are physically fit for surgery.

5. Support Groups and Advocacy Organizations

Support groups and advocacy organizations within the transgender community can offer valuable peer support, resources, and information about gender-affirming surgeries. These groups provide opportunities for individuals to connect with others who have undergone similar experiences, share insights, and seek guidance from those who have navigated the transition process.

Consulting with a multidisciplinary team of healthcare providers ensures that individuals receive comprehensive care tailored to their unique needs and goals. This collaborative approach helps individuals make informed decisions about gender reassignment surgery and supports their overall health and well-being throughout the transition process.

Pre-operative Considerations

1. Medical Considerations

Transgender individuals may have preexisting health conditions like diabetes , asthma , or HIV, which can impact their eligibility for surgery and postoperative care. Surgeons often consult with endocrinologists to assess the patient's physical fitness for surgery, especially considering the complex medication regimens involved in hormone therapy before and after surgery.

2. Fertility Concerns

Patients considering sex reassignment surgery (SRS) are informed about potential infertility, particularly if procedures like orchiectomy or oophorectomy are performed as part of the transition process. Preservation of fertility options may be discussed before surgery.

3. Age and Consent

SRS is generally not performed on children under 18, with rare exceptions made for adolescents based on healthcare provider assessments and potential benefits or risks. Consent from parents or legal guardians is required, along with long-term mental health counseling to confirm persistent gender dysphoria.

4. Intersex and Trauma Cases

Infants born with intersex traits may undergo surgical interventions at or near birth, raising ethical concerns about human rights implications. Trauma cases also require careful consideration, as surgically assigned gender may not align with the individual's gender identity, leading to negative outcomes later in life.

5. Standards of Care

Many regions follow Standards of Care for the Health of Transgender and Gender Diverse People (SOC), such as those published by the World Professional Association for Transgender Health (WPATH). These guidelines outline minimum requirements for treatment, including psychological evaluation and living as the desired gender before surgery.

6. Insurance Coverage

Obtaining insurance coverage for SRS may require documented assessments by mental health professionals, evidence of persistent gender dysphoria, and completion of physician-supervised hormone therapy for a specified duration.

Post-operative Considerations

1. Quality of Life and Physical Health

Studies assessing postoperative quality of life vary, with some reporting similar quality to control groups while others note lower quality in domains of health and limitations. Overall, many individuals report improvements in mental health, satisfaction with physical appearance, and overall well-being after surgery.

2. Psychological and Social Consequences

SRS has been shown to be effective in relieving gender dysphoria, though some studies highlight methodological limitations. Patients often report reduced anxiety, depression , and hostility levels post-surgery, with improvements in self-perceived physical and mental health.

3. Sexuality and Sexual Satisfaction

SRS can significantly impact individuals' sexual experiences and satisfaction. Most transsexual individuals report enjoying better sex lives and improved sexual satisfaction after surgery, with changes in orgasm frequency, intensity, and masturbation habits observed. However, satisfaction levels may vary between trans men and trans women, and expectations for sexual aspects of life may differ from cisgender individuals.

4. Continued Support

Comprehensive postoperative care involves ongoing psychological support, management of any complications, and assistance with adjustment to physical changes. Social support networks play a crucial role in helping individuals navigate their post-surgical experiences and integrate their gender identities into their daily lives.

The denial or limited access to gender-affirming surgeries can have severe consequences for the mental health and well-being of transgender individuals.

1. Persistent Gender Dysphoria

Without access to surgery, transgender individuals may continue to experience intense distress and discomfort due to the misalignment between their gender identity and physical characteristics. This persistent gender dysphoria can lead to heightened anxiety, depression, and a sense of hopelessness.

2. Heightened Anxiety

Living in a body that does not align with one's gender identity can contribute to persistent anxiety. The frustration of being unable to access necessary medical care and the ongoing struggle to navigate societal expectations can exacerbate feelings of stress and worry.

3. Increased Depression

Untreated gender dysphoria and the inability to undergo gender-affirming surgeries can lead to deepening feelings of depression and despair. Transgender individuals may struggle with low self-esteem, feelings of worthlessness, and a sense of isolation from not being able to live authentically.

4. Social Withdrawal

The distress caused by the incongruence between one's gender identity and physical appearance can result in social withdrawal and avoidance of social interactions. Transgender individuals may feel ashamed or uncomfortable in social settings, leading to further isolation and loneliness.

5. Suicidal Ideation

The lack of access to gender-affirming surgeries and the ongoing struggle with gender dysphoria can significantly increase the risk of suicidal thoughts and behaviors. Without the hope of being able to live authentically and alleviate their distress, transgender individuals may experience profound feelings of hopelessness and desperation.

Click here to know more about Mental health in transgender community

Affordable Surgery Options

Gender-affirming surgeries, including gender reassignment surgery (GRS), vary widely in cost globally. Affordable options exist in countries like Turkey, Brazil, Argentina, and Belgium. Turkey offers the most budget-friendly option, followed by Brazil, Argentina, and Belgium. While these countries provide competitive prices, individuals should consider factors beyond cost, such as healthcare quality and legal protections.

Click here for detailed information on the global cost of these surgeries and to find out which options are more affordable

In summary, gender reassignment surgery serves as a vital tool in validating the gender identities of transgender and intersex individuals, enabling them to harmonize their external appearance with their innate sense of self. Despite its transformative potential, many face obstacles in accessing this essential care, including financial constraints, inadequate insurance coverage, and legal hurdles.

As society progresses towards greater awareness and acceptance of transgender rights, it's imperative to prioritize equitable access to gender-affirming treatments and offer unwavering support to individuals throughout their transition journey. By dismantling these barriers and fostering inclusivity within healthcare systems, we can empower transgender individuals to live authentically and flourish in their gender identity.


  • Sex Reassignment Surgery in the Female-to-Male Transsexual - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312187/)
  • Gender Affirmation Surgeries - (https://www.hopkinsmedicine.org/health/wellness-and-prevention/gender-affirmation-surgeries)
  • Gender Confirmation Surgery - (https://www.uofmhealth.org/conditions-treatments/transgender-services/gender-confirmation-surgery)
  • Klinefelter syndrome - (https://www.nhs.uk/conditions/klinefelters-syndrome/)

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  • Court rules surgery not mandatory for legal gender change

Published : May 9, 2024 - 14:51

Link copied

(Getty Images)

A recent court ruling has declared it unlawful for the first time to require gender-affirmation surgery as a prerequisite for legally changing one's gender.

Judges at the Yeongdong branch of the Cheongju District Court recently granted permission to five people who have not undergone gender reassignment surgeries to change their legal gender from male to female on their family registers. The decision was confirmed by the court on Thursday.

The individuals, originally registered as male at birth, have adopted a female gender identity since childhood, according to local news reports. The reports indicate that they have all pursued hormone therapy for several years to affirm their gender expression.

In elucidating the reasoning behind their decision, the judges highlighted that the Supreme Court revised the administrative guidelines on gender registration for transgender individuals in 2020.

The judges underscored that the requirement of undergoing gender-affirmation surgery has shifted from being a mandatory "criteria for approval" for legal gender change to being a "reference point."

The judges noted that requiring people to receive surgery as a prerequisite to legally change genders could be a violation of the Constitution, which ensures human dignity and the right to pursue happiness.

The judges further explained that the requirements are “in conflict with the fundamental right of people to have protected their physical integrity and personal autonomy in connection with their human dignity.”

However, the judges simultaneously recognized that "some courts, at their discretion, have requested documents pertaining to gender-affirming surgery and have utilized the absence of such documentation as justification for denying the legal gender change."

Article 6, Paragraphs 3 and 4 of the “Guidelines for the Handling of Petition for Legal Sex Change Permit of Transgender People,” a rule set by the Supreme Court, stipulates that whether the person in question has undergone gender confirmation surgery or is sterile may be taken under consideration when deciding whether to accept or deny a request to change one's gender on official records.

“The Supreme Court should quickly eliminate the relevant guidelines’ articles so that lower courts can be consistent in their authorization standards,” said Song Ji-eun, a lawyer representing the five gender change applicants.

Overseas, a growing number of countries do not require gender reassignment surgery as a prerequisite for legal gender change. Japan’s highest court ruled in October 2023 that requiring gender reassignment surgery to obtain a legal gender transition was unconstitutional. The Czech Constitutional Court ruled the same on Tuesday.

Other countries such as Denmark, Belgium, and Argentina do not require surgery for legal gender changes.

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    Lili Elbe was the first well-known recipient of male-to-female sex reassignment surgery, in Germany in 1930, the first being Dora Richter. She was the subject of four surgeries: one for orchiectomy, one to transplant an ovary, one for penectomy, and one for vaginoplasty and a uterus transplant. However, she died three months after her last ...

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  6. Christine Jorgensen

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    Much beloved by the trans community, Dr. Biber passed away on Monday January, 16, 2006 at the age of 82. The Current Protocol for Referring Transsexuals for Vaginoplasty (SRS) Vaginoplasty (sex reassignment surgery) is a dramatic and irrevocable final step in male to female gender transition. This step is usually taken only after the deepest ...

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    All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. ... Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open ...

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    Male-to-female transitions can run about $25,000; for female-to-male transitions it's around $100,000. Such costs are prohibitively expensive for many on Medicare.

  21. Gender Affirming Surgery

    Gender affirming surgery, also known as sex reassignment surgery (SRS) or confirmation surgery, is the surgical procedure(s) by which a transgender or non-binary person&rsquo;s physical appearance and functional abilities are changed to align with the gender they know themselves to be.

  22. How does female-to-male surgery work?

    Female-to-male surgery is a type of gender-affirmation or gender-affirming surgery. There are multiple forms of gender-affirming surgery, including altering the genital region, known as "bottom ...

  23. Appeals Court Finds a Constitutional Right to Gender Reassignment Surgery

    The Fourth Circuit nullified the state ban on gender change surgeries, citing the 14th Amendment's guarantee of "equal protection of the laws." This was a court looking for an excuse to make ...

  24. Gender-affirming surgery (female-to-male)

    Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning. Often used to refer to phalloplasty, metoidoplasty, or vaginectomy, sex reassignment surgery can also more broadly ...

  25. Gender-Reassignment Surgery: Everything You Need to Know

    Male-to-Female Genital Sex Reassignment (Vaginoplasty): This surgical procedure constructs female genitalia for transfeminine individuals seeking alignment with their gender identity. Techniques ...

  26. Court rules surgery not mandatory for legal gender change

    A recent court ruling has declared it unlawful for the first time to require gender-affirmation surgery as a prerequisite for legally changing one's gender. Judges at the Yeongdong branch of the ...

  27. State health plans must cover gender-affirming surgery, US appeals

    April 29 (Reuters) - Health insurance plans run by U.S. states must cover gender-affirming surgeries for transgender people, a U.S. appeals court ruled on Monday. The 8-6 opinion , opens new tab ...