View source for Gender-affirming surgery

{{Short description|Surgical procedures to affirm gender identity}}
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{{Infobox medical intervention
| name          = Gender-affirming surgery
| synonyms      = gender confirmation surgery, sex reassignment surgery
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| specialty     = [[Gynecology]], [[Urology]], [[Maxillofacial surgery]], [[Otorhinolaryngology]], [[sexual health]]
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| MeshID        = D057830
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{{Transgender sidebar|medicine}}

'''Gender-affirming surgery''' ('''GAS''') is a [[surgical]] procedure, or series of procedures, that alters a person's physical appearance and [[sexual characteristics]] to resemble those associated with their [[gender identity]]. The phrase is most often associated with [[transgender health care]], though many such treatments are also pursued by [[cisgender]] individuals. It is also known as '''sex reassignment surgery''' ('''SRS'''), '''gender confirmation surgery''' ('''GCS'''), and several [[#Terminology|other names]].

Professional medical organizations have established [[Standards of Care for the Health of Transgender and Gender Diverse People|Standards of Care]], which apply before someone can apply for and receive reassignment surgery, including psychological evaluation, and a period of real-life experience living in the desired gender.

[[Gender-affirming surgery (male-to-female)|Feminization surgeries]] are surgeries that result in female-looking anatomy, such as [[vaginoplasty]], [[vulvoplasty]] and [[breast augmentation]]. [[Gender-affirming surgery (female-to-male)|Masculinization surgeries]] are those that result in male-looking anatomy, such as [[phalloplasty]] and [[breast reduction]].

In addition to gender-affirming surgery, patients may need to follow a lifelong course of [[Masculinizing hormone therapy|masculinizing]] or [[Feminizing hormone therapy|feminizing]] hormone replacement therapy to support the endocrine system.

[[Sweden]] became the first country in the world to allow transgender people to change their [[legal gender]] after "reassignment surgery" and provide free hormone treatment, in 1972.<ref>{{Cite web |date=1 May 2009 |title=Sweden has been named the most LGBTQ+ friendly country for travellers |url=https://www.trafalgar.com/real-word/sweden-lgbtq-friendly-country/ |url-status=live |archive-url=https://web.archive.org/web/20220122025323/https://www.trafalgar.com/real-word/sweden-lgbtq-friendly-country/ |archive-date=22 January 2022 |access-date=12 February 2022 |publisher=Trafalgar.com}}</ref> [[Singapore]] followed soon after in 1973, being the first in Asia.<ref name="1973SG">{{Cite web |vauthors=Chan MC |date=4 August 2011 |title=First sex reassignment surgery |url=https://eresources.nlb.gov.sg/infopedia/articles/SIP_1828_2011-08-04.html |access-date=17 September 2022 |work=National Library Board (NLB) eResources |publisher=Government of Singapore |archive-date=1 June 2019 |archive-url=https://web.archive.org/web/20190601195553/http://eresources.nlb.gov.sg/infopedia/articles/SIP_1828_2011-08-04.html |url-status=live }}</ref>

== Terminology ==
Gender-affirming surgery is known by many other names, including ''gender-affirmation surgery'', ''sex reassignment surgery'', ''gender reassignment surgery'', and ''gender confirmation surgery''.<ref name="ASPS-2017">{{Cite web |title=Gender Confirmation Surgeries |url=https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries |url-status=live |archive-url=https://web.archive.org/web/20200612071848/https://www.plasticsurgery.org/reconstructive-procedures/gender-confirmation-surgeries |archive-date=12 June 2020 |access-date=7 August 2017 | work = American Society of Plastic Surgeons}}</ref> It is also sometimes called a ''sex change'',<ref name="Harrington-2016">{{Cite book | vauthors = Harrington L |url=https://books.google.com/books?id=PBMHDAAAQBAJ&pg=PT287 |title=Traversing Gender: Understanding Transgender Realities |date=1 May 2016 |publisher=Mystic Productions Press |isbn=978-1-942733-83-6 |page=287 |oclc=947837700 |access-date=15 October 2018 |archive-url=https://web.archive.org/web/20200316143005/https://books.google.com/books?id=PBMHDAAAQBAJ&pg=PT287 |archive-date=16 March 2020 |url-status=live}}</ref> though this term is usually considered offensive.<ref>{{Cite web |title=Definition of ''sex change'' |url=https://www.merriam-webster.com/dictionary/sex+change |access-date=25 September 2022 | work = Merriam-Webster, Incorporated |language=en}}</ref> ''Top surgery'' and ''bottom surgery'' refer to surgeries on the chest and genitals respectively.<ref>{{Cite web |title=Glossary of Transgender Terms |url=https://www.hopkinsmedicine.org/news/articles/glossary-of-terms-1 |access-date=17 May 2022 | work = Johns Hopkins Medicine |language=en}}</ref>

Some transgender people who want medical assistance to [[transitioning (transgender)|transition]] from one sex to another identify as "[[transsexual]]".<ref name="Bevan">{{Cite book | vauthors = Bevan TE |title=The Psychobiology of Transsexualism and Transgenderism |year=2014 |publisher=Bloomsbury Publishing USA |isbn=978-1-4408-3127-0}}, page 42: "The term transsexual was introduced by Cauldwell (1949) and popularized by Harry Benjamin (1966) [...]. The term transgender was coined by John Oliven (1965) and popularized by various transgender people who pioneered the concept and practice of transgenderism. It is sometimes said that Virginia Prince (1976) popularized the term, but history shows that many transgender people advocated the use of this term much more than Prince."</ref><ref name="Polly">{{cite journal | vauthors = Polly R, Nicole J | title = Understanding the transsexual patient: culturally sensitive care in emergency nursing practice | journal = Advanced Emergency Nursing Journal | volume = 33 | issue = 1 | pages = 55–64 | date = January 2011 | pmid = 21317698 | doi = 10.1097/TME.0b013e3182080ef4 | s2cid = 2481961 }}</ref>

[[Trans women]] and others [[assigned male at birth]] may undergo one or more feminizing procedures: genital surgeries such as [[penectomy]] (removal of the penis), [[orchiectomy]] (removal of the testes), [[vaginoplasty]] (construction of a vagina), [[vulvoplasty]] (construction of a vulva); as well as [[breast augmentation]], [[tracheal shave]] (reduction of the [[Adam's apple]]), [[facial feminization surgery]], and [[voice feminization surgery]] among others.

[[Trans men]] and others [[assigned female at birth]] may undergo one or more masculinizing procedures; such as [[chest reconstruction]], [[breast reduction]], [[hysterectomy]] (removal of the uterus), [[oophorectomy]] (removal of the ovaries). A penis can be constructed through [[metoidioplasty]] or [[phalloplasty]], and a [[scrotum]] through [[scrotoplasty]].<ref>{{Cite web |title=Gender-Affirming Surgery: Masculinizing Options |url=https://www.ohsu.edu/transgender-health/gender-affirming-surgery-masculinizing-options |url-status=live |archive-url=https://web.archive.org/web/20220425222921/https://www.ohsu.edu/transgender-health/gender-affirming-surgery-masculinizing-options |archive-date=25 April 2022 |access-date=8 June 2021 | work = Oregon Health & Science University (OHSU) }}</ref>

As knowledge of [[non-binary gender]]s expands in the medical community, more surgeons are willing to tailor operations to individual needs. Bigenital operations allow individuals to construct a penis or vagina and retain their original organs. Gender nullification is the removal of all external genitalia except the urethral opening, typically pursued by people assigned male at birth.<ref name="Baum_2022">{{Cite web | vauthors = Baum SE |date=2022-11-14 |title=Trans People Are Seeking Nonbinary Bottom Surgeries |url=https://www.vice.com/en/article/trans-people-are-seeking-nonbinary-bottom-surgeries/ |access-date=2023-09-29 | work = Vice |language=en}}</ref><ref>Ascha, M., Rigsby, S., Shoham, M., Akhavan, A. A., Swanson, M., Streed Jr, C. G., Gurjala, A., Morrison, S. D., Pang, J. H., & Satterwhite, T. (2024). Individually customized gender affirming genital procedures: Techniques and considerations. ''The Journal of Sexual Medicine, 21''(9), 827-834. https://doi.org/10.1093/jsxmed/qdae075</ref>

''Gender-affirming surgery'' can also refer to operations pursued by [[cisgender]] people, such as [[mammaplasty]], [[penile implant]], or testicular implants following [[orchiectomy]].<ref name="Schall_2023">{{cite journal | vauthors = Schall TE, Moses JD | title = Gender-Affirming Care for Cisgender People | journal = The Hastings Center Report | volume = 53 | issue = 3 | pages = 15–24 | date = May 2023 | pmid = 37285414 | doi = 10.1002/hast.1486 | s2cid = 259110063 | doi-access = free }}</ref>

Gender-affirming surgery is often sensationalized and misrepresented by [[Anti-gender movement|anti-trans]] activists through terms such as ''genital-mutilation surgery''.<ref>{{cite journal| vauthors = McClain LC |title="Do Not Ever Refer to My Lord Jesus Christ with Pronouns": Considering Controversies over Religiously Motivated Discrimination on the Basis of Gender Identity|url=https://www.cambridge.org/core/journals/journal-of-law-and-religion/article/do-not-ever-refer-to-my-lord-jesus-christ-with-pronouns-considering-controversies-over-religiously-motivated-discrimination-on-the-basis-of-gender-identity/01807DD25D8E081017C6ED5D8EF0D681|journal=Journal of Law and Religion|date=27 January 2023|issn=0748-0814|pages=1–9|volume=38|issue=1|doi=10.1017/jlr.2023.1}}</ref><ref>{{cite journal | vauthors = Burton JS, Pfeifauf K, Skolnick GB, Sacks JM, Snyder-Warwick AK | title = Determinants of Public Opinion Toward Gender-Affirming Surgery in the United States | journal = Transgender Health | volume = 9 | issue = 3 | pages = 241–253 | date = June 2024 | pmid = 39109263 | pmc = 11299100 | doi = 10.1089/trgh.2022.0119 }}</ref><ref>{{cite web| vauthors = Birenbaum G |access-date=2024-08-15|title=Rand Paul tried to derail Rachel Levine's historic confirmation hearing with transphobic misinformation|url=https://www.vox.com/2021/2/25/22301138/rand-paul-transphobic-confirmation-hearing-dr-rachel-levine|date=25 February 2021| work = Vox }}</ref>

== Surgical procedures ==
{{main|Feminizing gender-affirming surgery|Masculinizing gender-affirming surgery}}The best-known gender-affirming procedures are those that reshape the genitals, which are also known as ''genital reassignment surgery'', ''genital reconstruction surgery'', ''sex reassignment surgery,'' and ''bottom surgery'' (the latter is named in contrast to ''top surgery'', which is surgery to the breasts). However, the meaning of "sex reassignment surgery" has been clarified by the medical organization, the [[World Professional Association for Transgender Health]] (WPATH), to include any of a larger number of surgical procedures performed as part of a medical treatment for [[gender dysphoria]].{{update inline|date=December 2022}}<!--Previous text relies on SOC7, not SOC8.-->

WPATH says medically necessary gender-affirming surgeries include "complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation ... including breast prostheses if necessary, genital reconstruction (by various techniques which must be appropriate to each patient ...)... and certain facial plastic reconstruction."<ref name="WPATH Clarification">{{Citation |title=Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S. |url=http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf |access-date=7 October 2011 |archive-url=https://web.archive.org/web/20110930040306/http://www.wpath.org/documents/Med%20Nec%20on%202008%20Letterhead.pdf |archive-date=30 September 2011 |publisher=WPATH}}</ref> Other non-surgical procedures are also considered medically necessary treatments by WPATH, including facial hair [[electrology|electrolysis]].<ref name="WPATH Clarification" />

=== Genital surgery ===
==== Feminizing====
{{further|Feminizing gender-affirming surgery#Vaginoplasty}}
For [[trans women]] and [[Transgender#Other terms|transfeminine people]], genital reconstruction usually involves [[vaginoplasty|surgical construction of a vagina]]. The most common techniques are [[penile inversion]], [[Gender-affirming surgery (male-to-female)#bowel vaginoplasty|rectosigmoid vaginoplasty]] and [[Gender-affirming surgery (male-to-female)#Peritoneal vaginoplasty|peritoneal pullthrough vaginoplasty]] (PPT).<ref>{{Cite web |title=Overview of Sigmoid Colon Vaginoplasty for MtF (Sigmoid Colon SRS) |url=https://www.transgendersurgerythailand.com/blog/an-overview-of-sigmoid-colon-vaginoplasty-for-mtf-sigmoid-colon-srs.html |access-date=September 30, 2024 |website=Estetica Thailandia}}</ref> Another technique, the non-penile inversion technique, uses perforated scrotal tissue to construct the vaginal canal.<ref>{{Cite web |title=Dr. Chettawut's Skin Graft Technique for SRS {{!}} Chettawut Plastic Surgery |url=https://www.chet-plasticsurgery.com/skin-graft-technique-for-srs/ |access-date=2024-09-30 |website=Dr.Chettawut- Sex reassignment and Facial feminization surgery center |language=en-US}}</ref> A less invasive procedure with reduced postoperative care requirements is [[vulvoplasty]], which creates external female genitalia without a vaginal canal. The downside of this procedure is that it does not allow for penetrative sex.

====Masculinizing====
{{further|Masculinizing gender-affirming surgery#Genital reassignment}}
For [[trans men]] and [[Transgender#Other terms|transmasculine people]], genital reconstruction may involve the construction of a penis through either [[phalloplasty]] or [[metoidioplasty]], which is less invasive but results in a smaller penis.

====Non-binary people====
[[Non-binary gender|Non-binary]] people may elect to get any of the surgeries listed above, depending on their [[sex assignment]]. They may also opt for bigenital or gender nullification surgeries. Bigenital operations include androgynoplasty, a vaginoplasty procedure that retains the penis,<ref name="Vincent_2019">{{cite journal | vauthors = Vincent B | title = Breaking down barriers and binaries in trans healthcare: the validation of non-binary people | journal = The International Journal of Transgenderism | volume = 20 | issue = 2–3 | pages = 132–137 | date = 2019-07-03 | pmid = 32999601 | pmc = 6831034 | doi = 10.1080/15532739.2018.1534075 }}</ref> or vagina-preserving phalloplasty.<ref name="Baum_2022" /> These procedures tend to be rarely performed.<ref name="Baum_2022" /> In 2017, one of the leading UK trans surgeons, [[James Bellringer]], commented that he had never received a request for it.<ref>{{Cite book | vauthors = Bellringer J |chapter=Surgery for Bodies Commonly Gendered as Male | veditors = Richards C, Bouman WP, Barker MJ | language=en| year=2017| title=Genderqueer and Non-Binary Genders |publisher=Springer |pages=247–263 |doi=10.1057/978-1-137-51053-2_12|isbn=978-1-137-51052-5 }}</ref>

====Other considerations====
Genital surgery may also involve other medically necessary procedures, such as [[orchiectomy]], [[penectomy]], or [[vaginectomy]]. Complications of penile inversion vaginoplasty are mostly minor; however, rectoneovaginal fistula (abnormal connection between the neovagina and the rectum) can occur in about 1–3% of patients. These require further surgery to correct.<ref name="Gaither_2018">{{cite journal | vauthors = Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, Breyer BN | title = Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-to-Female Transgender Patients | journal = The Journal of Urology | volume = 199 | issue = 3 | pages = 760–765 | date = March 2018 | pmid = 29032297 | doi = 10.1016/j.juro.2017.10.013 | url = https://escholarship.org/uc/item/3gp4s8p0 | url-status = live | access-date = 23 May 2021 | s2cid = 42635923 | archive-url = https://web.archive.org/web/20220311010924/https://escholarship.org/uc/item/3gp4s8p0 | archive-date = 11 March 2022 }}</ref>

=== Other surgeries ===
[[File:Double mastectomy.jpg|thumb|Transgender man with healed [[Chest reconstruction#Double incision|double incision chest reconstruction]], 2020]]

As underscored by WPATH, gender transition may entail a variety of non-genital surgeries that change primary or secondary sex characteristics, any of which are considered "gender-affirming surgery" when done to affirm a person's [[gender identity]].<ref name=":3">{{cite journal | vauthors = Coleman E, Radix AE, Bouman WP, Brown GR, de Vries AL, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HF, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TL, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BP, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J | title = Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 | journal = International Journal of Transgender Health | volume = 23 | issue = Suppl 1 | pages = S1–S259 | date = 19 August 2022 | pmid = 36238954 | pmc = 9553112 | doi = 10.1080/26895269.2022.2100644 }}</ref> For trans men, these may include [[mastectomy]] (removal of the breasts) and [[chest reconstruction]] (the shaping of a male-contoured chest), or [[hysterectomy]] and [[bilateral salpingo-oophorectomy]] (removal of ovaries and [[fallopian tube]]s). For some trans women, [[facial feminization surgery]], [[hair transplant]]s, and [[breast augmentation]] are also aesthetic components of their surgical treatment.<ref>{{Cite web |title=What Do I Need to Know About the Transitioning Process? |url=https://www.plannedparenthood.org/learn/sexual-orientation-gender/trans-and-gender-nonconforming-identities/what-do-i-need-know-about-transitioning |url-status=live |archive-url=https://web.archive.org/web/20190505022744/https://www.plannedparenthood.org/learn/sexual-orientation-gender/trans-and-gender-nonconforming-identities/what-do-i-need-know-about-transitioning |archive-date=5 May 2019 |access-date=5 May 2019 | work = Planned Parenthood Federation of America, Inc. (PPFA) }}</ref> Voice feminizing surgery is a procedure in which the overall pitch range of the patient's voice is reduced.<ref>{{Cite web |title=Voice feminizing therapy and surgery – Mayo Clinic |url=https://www.mayoclinic.org/tests-procedures/voice-feminizing-therapy-and-surgery/about/pac-20470545 |url-status=live |archive-url=https://web.archive.org/web/20210523024145/https://www.mayoclinic.org/tests-procedures/voice-feminizing-therapy-and-surgery/about/pac-20470545 |archive-date=23 May 2021 |access-date=23 May 2021 |work=Mayo Clinic |language=en}}</ref> Adam's apple reduction surgery ([[chondrolaryngoplasty]]) or tracheal shaving is a procedure in which the most prominent part of the thyroid cartilage is reduced.<ref>{{cite journal |vauthors=Cohen MB, Insalaco LF, Tonn CR, Spiegel JH |date=October 2018 |title=Patient Satisfaction after Aesthetic Chondrolaryngoplasty |journal=Plastic and Reconstructive Surgery. Global Open |volume=6 |issue=10 |article-number=e1877 |doi=10.1097/GOX.0000000000001877 |pmc=6250475 |pmid=30534483}}</ref>

There is also Adam's apple enhancement therapy, in which cartilage is used to bring out the Adam's apple in female-to-male patients.<ref>{{Cite web |title=Facial Masculinization Surgery (FMS) |url=https://constructivesurgery.org/ftm-facial-masculinization-surgery/ |url-status=live |archive-url=https://web.archive.org/web/20210523025647/https://constructivesurgery.org/ftm-facial-masculinization-surgery/ |archive-date=23 May 2021 |access-date=23 May 2021 |work=Constructive Surgery}}</ref>{{Better source needed|date=July 2023}}

== History ==
Reports of people seeking gender-confirming surgery (vaginoplasty) go back to the 2nd century, such as Roman Emperor [[Elagabalus]].<ref name="Smith-Han">{{Cite journal | vauthors = Smith S, Han J |date=1 April 2019 |title=The trans-formation of gender confirming surgery: a brief history |journal=The Journal of Urology |volume=201 |issue=4S |page=e244 |doi=10.1097/01.JU.0000555394.71572.8e |s2cid=149966616|doi-access=free }}</ref><ref>{{cite book | veditors = Goldberg AE, Beemyn G |date=2021 |chapter=Ancient and Medieval Times |title=The SAGE Encyclopedia of Trans Studies |publisher=SAGE Publishing |page=32 |doi=10.4135/9781544393858.n188 |isbn=978-1-5443-9381-0 |s2cid=242422061}}</ref>

=== 20th century ===
In the US in 1917, [[Alan L. Hart]], an American tuberculosis specialist, became one of the first trans men to undergo [[hysterectomy]] and [[gonadectomy]] as treatment of what is now called gender dysphoria.<ref name="Munro_20182">{{Cite web | vauthors = Munro D |title=Trans Media Watch |url=http://www.transmediawatch.org/timeline.html |archive-url=https://web.archive.org/web/20191218150249/http://transmediawatch.org/timeline.html |archive-date=18 December 2019 |access-date=1 November 2018}}</ref>

[[Dora Richter]] is the first known trans woman to undergo complete male-to-female genital surgery. She was one of several transgender people in the care of sexologist [[Magnus Hirschfeld]] at Berlin's [[Institut für Sexualwissenschaft|Institute for Sexual Research]]. In 1922, Richter underwent orchiectomy. In early 1931, a penectomy, followed in June by vaginoplasty.<ref name="Munro_20182" /><ref>{{Cite book | vauthors = Mancini E |url=https://books.google.com/books?id=mWXFAAAAQBAJ&q=Dora+Richter+1930+Hirschfeld&pg=PA70 |title=Magnus Hirschfeld and the Quest for Sexual Freedom: A History of the First International Sexual Freedom Movement |date=8 November 2010 |publisher=Palgrave Macmillan |isbn=978-0-230-11439-5 |edition=1st |location=New York |oclc=696313936}}</ref>

In 1930-1931, [[Lili Elbe]] underwent four sex reassignment surgeries, including orchiectomy, an [[ovarian transplant]], and penectomy. In June 1931, she underwent her fourth surgery, including an experimental [[uterine transplant]] and vaginoplasty, which she hoped would allow her to give birth. However, her body rejected the transplanted uterus, and she died of post-operative complications in September, at age 48.<ref name="Harrod, 2015">{{Cite news | vauthors = Harrod H |date=8 December 2015 |title=The tragic true story behind ''The Danish Girl'' |work=The Telegraph |url=https://www.telegraph.co.uk/film/the-danish-girl/true-story-lili-elbe-transgender/ |url-status=live |access-date=11 December 2015 |archive-url=https://web.archive.org/web/20160421213437/http://www.telegraph.co.uk/film/the-danish-girl/true-story-lili-elbe-transgender/ |archive-date=21 April 2016}}</ref><ref>{{Cite web |date=10 September 2015 |title=Lili Elbe |url=https://www.biography.com/artist/lili-elbe |access-date=25 September 2022 |website=Biography.com |archive-date=8 April 2019 |archive-url=https://web.archive.org/web/20190408080904/https://www.biography.com/people/lili-elbe-090815 |url-status=live }}</ref><ref>{{Cite book |url=https://archive.org/details/dli.ministry.16778 |title=Man into Woman: an authentic record of a change of sex | location = London | publisher = Jarrold Publisher's |year=1933 | veditors = Hoyer N |page=128}}</ref>

A previous sex reassignment surgery patient was Magnus Hirschfeld's [[Housekeeper (domestic worker)|housekeeper]],<ref>{{Cite book | vauthors = Hirschfeld M |title=Zeitschrift für Sexualwissenschaft |year=1908 |author-link=Magnus Hirschfeld}}</ref> but their name has not been discovered.{{Citation needed|date=October 2023}}

[[Elmer Belt]] may have been the first U.S. surgeon to perform gender affirmation surgery, in about 1950.<ref>{{Cite book | vauthors = Meyerowitz J |title=How Sex Changed: A History of Transsexuality in the United States |publisher=Harvard University Press |year=2002 |page=214}}</ref>

In 1951, [[Harold Gillies]], a plastic surgeon active in World War II, worked to develop the first technique for [[female-to-male gender-affirming surgery]], producing a technique that has become a modern standard, called [[phalloplasty]].<ref>{{Cite news | vauthors = Roach M |date=18 March 2007 |title=Girls Will Be Boys |work=The New York Times |url=https://www.nytimes.com/2007/03/18/books/review/Roach.t.html |url-status=live |access-date=5 May 2019 |archive-url=https://web.archive.org/web/20190505010658/https://www.nytimes.com/2007/03/18/books/review/Roach.t.html |archive-date=5 May 2019}}</ref> Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

In 1971, [[Roberto Farina Case|Roberto Farina]] performed Brazil's first male-to-female gender-affirming surgery.<ref>{{Cite news |title='Monstro, prostituta, bichinha': como a Justiça condenou a 1ª cirurgia de mudança de sexo do Brasil |language=pt-BR |work=BBC News Brasil |url=https://www.bbc.com/portuguese/geral-43561187 |access-date=2023-10-25 |archive-date=27 December 2023 |archive-url=https://web.archive.org/web/20231227165349/https://www.bbc.com/portuguese/geral-43561187 |url-status=live }}</ref>

In 1984, [[Jalma Jurado]] developed a new surgical technique, which he used in surgeries for more than 500 [[trans women]] in Brazil and from around the world.<ref>{{Cite web |date=2014-03-22 |title=<nowiki>}} Revista Tpm</nowiki> |url=http://revistatpm.uol.com.br/75/perfil_luciana/02.htm |access-date=2023-10-22 |archive-url=https://web.archive.org/web/20140322030230/http://revistatpm.uol.com.br/75/perfil_luciana/02.htm |archive-date=22 March 2014 }}</ref>

Following phalloplasty, in 1999, the procedure for [[metoidioplasty]] was developed for female-to-male surgical transition by the doctors Lebovic and Laub.<ref name="Djordjevic_2009">{{cite journal | vauthors = Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, Perovic SV | title = Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience | journal = The Journal of Sexual Medicine | volume = 6 | issue = 5 | pages = 1306–1313 | date = May 2009 | pmid = 19175859 | doi = 10.1111/j.1743-6109.2008.01065.x }}</ref> Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient's present clitoris. This allows the patient to have a sensation-perceiving penis head.<ref name="Djordjevic_2009" /> Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more "[[Cisgender|cis]]-appearing" penis in multiple stages.<ref name="Djordjevic_2009" />

=== 21st century ===
On 12 June 2003, the [[European Court of Human Rights]] ruled in favor of Carola van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as [[Feminizing hormone therapy|hormone replacement therapy]]. The legal arguments related to the [[Article 6 of the European Convention on Human Rights]] as well as the [[Article 8 of the European Convention on Human Rights|Article 8]]. This affair is called ''van Kück vs Germany''.<ref>{{Cite web |date=12 June 2003 |title=European Court of Human Rights – Third Section – Case of Van Kück v. Germany |url=https://www.menschenrechte.ac.at/orig/03_3/Kuck.pdf |url-status=live |archive-url=https://web.archive.org/web/20210309041447/https://www.menschenrechte.ac.at/orig/03_3/Kuck.pdf |archive-date=9 March 2021 |access-date=23 May 2021 | work = Österreichisches Institut für Menschenrechtet | trans-work = Austrian Institute for Human Rights }}</ref>

In 2011, [[Christiane Völling]] won the first successful case brought by an [[intersex]] person against a surgeon for non-consensual surgical intervention described by the [[International Commission of Jurists]] as "an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent".<ref name="icj2">{{Cite web |last=International Commission of Jurists |title=SOGI Casebook Introduction, Chapter six: Intersex |url=http://www.icj.org/sogi-casebook-introduction/chapter-six-intersex/ |url-status=live |archive-url=https://web.archive.org/web/20190507231116/https://www.icj.org/sogi-casebook-introduction/chapter-six-intersex/ |archive-date=7 May 2019 |access-date=27 December 2015}}</ref>

{{As of|2017|post=,}} some European countries require forced sterilization for the legal recognition of sex reassignment.<ref>{{Cite news |last=M.H. |date=1 September 2017 |title=Why transgender people are being sterilized in some European countries |newspaper=[[The Economist]] |url=https://www.economist.com/blogs/economist-explains/2017/09/economist-explains |url-status=live |access-date=2 September 2017 |archive-url=https://web.archive.org/web/20170901233033/https://www.economist.com/blogs/economist-explains/2017/09/economist-explains |archive-date=1 September 2017}}</ref> {{As of|2020|}}, Japan also requires an individual to undergo sterilization to change their legal sex.<ref name="Human_Rights Watch_2019">{{Cite news |date=19 March 2019 |title=A Really High Hurdle |language=en |work=Human Rights Watch |url=https://www.hrw.org/report/2019/03/19/really-high-hurdle/japans-abusive-transgender-legal-recognition-process |url-status=live |access-date=26 October 2020 |archive-url=https://web.archive.org/web/20201022154815/https://www.hrw.org/report/2019/03/19/really-high-hurdle/japans-abusive-transgender-legal-recognition-process |archive-date=22 October 2020}}</ref>

The early history of gender-affirming surgery in trans people has been reviewed by various authors.<ref name="pmid4902840">{{cite journal | vauthors = Edgerton MT, Knorr NJ, Callison JR | title = The surgical treatment of transsexual patients. Limitations and indications | journal = Plastic and Reconstructive Surgery | volume = 45 | issue = 1 | pages = 38–46 | date = January 1970 | pmid = 4902840 | doi = 10.1097/00006534-197001000-00006 | s2cid = 27318408 }}</ref><ref name="pmid5726922">{{cite journal | vauthors = Hoopes JE, Knorr NJ, Wolf SR | title = Transsexualism: considerations regarding sexual reassignment | journal = The Journal of Nervous and Mental Disease | volume = 147 | issue = 5 | pages = 510–516 | date = November 1968 | pmid = 5726922 | doi = 10.1097/00005053-196811000-00007 | s2cid = 22252676 }}</ref>

== Prevalence ==
The prevalence of transgender-related surgeries is difficult to measure and likely underestimated. In 2015, the largest survey of transgender people in the United States reported that 25% of respondents reported had undergone such a surgery.<ref>{{cite journal | vauthors = Nolan IT, Kuhner CJ, Dy GW | title = Demographic and temporal trends in transgender identities and gender confirming surgery | journal = Translational Andrology and Urology | volume = 8 | issue = 3 | pages = 184–190 | date = June 2019 | pmid = 31380225 | pmc = 6626314 | doi = 10.21037/tau.2019.04.09 | doi-access = free }}</ref>

== Prior to surgery ==

=== Medical considerations ===
Some medical conditions, including [[diabetes]], [[asthma]], and HIV, can lead to complications with future therapy and pharmacological management.<ref>{{cite journal | vauthors = Bishop BM | title = Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review | journal = Pharmacotherapy | volume = 35 | issue = 12 | pages = 1130–1139 | date = December 2015 | pmid = 26684553 | doi = 10.1002/phar.1668 | s2cid = 37001563 }}</ref> Typical gender-affirming surgery procedures involve complex medication regimens, including [[sex-hormone therapy]], throughout and after surgery. Typically, a patient's treatment involves a healthcare team consisting of a variety of providers including [[Endocrinology|endocrinologists]], whom the surgeon may consult when determining if the patient is physically fit for surgery.<ref name="Hage_1995">{{cite journal | vauthors = Hage JJ | title = Medical requirements and consequences of sex reassignment surgery | journal = Medicine, Science, and the Law | volume = 35 | issue = 1 | pages = 17–24 | date = January 1995 | pmid = 7877467 | doi = 10.1177/002580249503500105 | s2cid = 22752221 }}</ref><ref>{{cite journal | vauthors = Bizic MR, Jeftovic M, Pusica S, Stojanovic B, Duisin D, Vujovic S, Rakic V, Djordjevic ML | title = Gender Dysphoria: Bioethical Aspects of Medical Treatment | journal = BioMed Research International | volume = 2018 | article-number = 9652305 | date = 13 June 2018 | pmid = 30009180 | pmc = 6020665 | doi = 10.1155/2018/9652305 | doi-access = free }}</ref> Health providers including pharmacists can play a role in maintaining safe and cost-effective regimens, providing patient education, and addressing other health issues including smoking cessation and weight loss.<ref>{{cite journal | vauthors = Redfern JS, Jann MW | title = The Evolving Role of Pharmacists in Transgender Health Care | journal = Transgender Health | volume = 4 | issue = 1 | pages = 118–130 | date = April 2019 | pmid = 31289749 | pmc = 6608700 | doi = 10.1089/trgh.2018.0038 }}</ref>

People with HIV or [[hepatitis C]] may have difficulty finding a surgeon able to perform successful surgery. Many surgeons operate in small private clinics that cannot treat potential complications in these populations. Some surgeons charge higher fees for HIV and hepatitis C-positive patients; other medical professionals assert that it is unethical to deny surgical or hormonal treatments to transgender people solely on the basis of their HIV or hepatitis status.<ref>{{Cite web |title=Standards of Care | work = WPATH World Professional Association for Transgender Health |url=https://www.wpath.org/publications/soc |url-status=live |archive-url=https://web.archive.org/web/20150814230505/http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%2C%20V7%20Full%20Book.pdf |archive-date=14 August 2015 |access-date=23 May 2021 }}</ref>

Fertility is also a factor considered in gender-affirming surgery, as patients are typically informed that if an orchiectomy or oöphoro-hysterectomy is performed, it will make them irreversibly infertile.<ref name="Hage_1995" />

=== Gender dysphoric children ===
Gender-affirming surgery is generally not performed on children under 18, though in rare cases may be performed on adolescents if health care providers agree there is an unusual benefit to doing so or risk to not performing it.<ref>{{cite journal | vauthors = Rafferty J | title = Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents | journal = Pediatrics | volume = 142 | issue = 4 | article-number = e20182162 | date = October 2018 | pmid = 30224363 | doi = 10.1542/peds.2018-2162 | s2cid = 52288840 | doi-access = free }}</ref> Preferred treatments for children include [[puberty blockers]]<ref>{{Cite web |date=3 October 2018 |title=Gender dysphoria treatment |url=https://www.nhs.uk/conditions/gender-dysphoria/treatment/ |url-status=live |archive-url=https://web.archive.org/web/20131102135038/http://www.nhs.uk/Conditions/Gender-dysphoria/Pages/Treatment.aspx |archive-date=2 November 2013 |access-date=27 August 2021 | location = U.K. | work = National Health Service}}</ref> and [[gender affirming hormone therapy]], which reduces the need for future surgery. Medical protocols typically require long-term mental health counseling to verify persistent and genuine [[gender dysphoria]] before any intervention, and consent of a parent or guardian or court order is legally required in most jurisdictions.<ref name=":3" />{{citation needed|date=February 2022}}

=== Intersex children and cases of trauma ===
{{main|Sex assignment#Assignment in cases of infants with intersex traits, or cases of trauma}}

Infants born with intersex conditions might undergo interventions at or close to birth.<ref name="Bradley_1998">{{cite journal | vauthors = Bradley SJ, Oliver GD, Chernick AB, Zucker KJ | title = Experiment of nurture: ablatio penis at 2 months, sex reassignment at 7 months, and a psychosexual follow-up in young adulthood | journal = Pediatrics | volume = 102 | issue = 1 | article-number = e9 | date = July 1998 | pmid = 9651461 | doi = 10.1542/peds.102.1.e9 | s2cid = 7364636 | doi-access =  }}</ref> This is controversial because of the [[Intersex human rights|human rights]] implications.<ref name="un-fact">{{Cite conference |last1=United Nations |last2=Office of the High Commissioner for Human Rights |date=2015 |title=Free & Equal Campaign Fact Sheet: Intersex |url=https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |archive-url=https://web.archive.org/web/20160304071043/https://unfe.org/system/unfe-65-Intersex_Factsheet_ENGLISH.pdf |archive-date=4 March 2016 |access-date=14 March 2016 |url-status=live}}</ref><ref name="coe">{{Citation |last1=Council of Europe |title=Human rights and intersex people, Issue Paper |date=April 2015 |url=https://rm.coe.int/16806da5d4 |archive-url=https://web.archive.org/web/20220121014309/https://rm.coe.int/16806da5d4 |access-date=23 May 2021 |archive-date=21 January 2022 |last2=Commissioner for Human Rights |author-link=Council of Europe |url-status=live}}</ref>

There can be negative outcomes (including [[PTSD]] and suicide) when the surgically assigned gender does not match the person's gender identity, which will be realized by the person only later in life.<ref>{{Cite book | vauthors = Boyle GJ |title=Transgenders and Intersexuals |publisher=Fast Lane (imprint of East Street Publications |year=2005 |isbn=978-0-9751145-4-4 | veditors = May L |location=Bowden, South Australia |pages=95–100 |chapter=The scandal of genital mutilation surgery on infants}}</ref><ref>{{Cite book | vauthors = Colapinto J |title=As Nature Made Him: The Boy Who Was Raised as a Girl |title-link=As Nature Made Him: The Boy Who Was Raised as a Girl |publisher=Harper Collins Publishers |year=2002 |isbn=978-0-7322-7433-7 |location=Sydney |author-link=John Colapinto}}</ref><ref name="si">{{Cite web | vauthors = Diamond M |date=6 November 2009 |title=Sexual Identity, Monozygotic Twins Reared in Discordant Sex Roles and a BBC Follow-Up |url=http://www.hawaii.edu/PCSS/biblio/articles/1961to1999/1982-sexual-identity.html |url-status=live |archive-url=https://web.archive.org/web/20190830075115/http://www.hawaii.edu/PCSS/biblio/articles/1961to1999/1982-sexual-identity.html |archive-date=30 August 2019 |access-date=1 August 2011 | work = University of Hawaiʻi }}</ref>{{Citation needed|date=November 2022}} [[Milton Diamond]] at the [[John A. Burns School of Medicine]], [[University of Hawaii]] recommended that physicians not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a [[Disorders of sex development|disorder]].<ref name="moi">{{cite journal | vauthors = Diamond M, Sigmundson HK | title = Management of intersexuality. Guidelines for dealing with persons with ambiguous genitalia | journal = Archives of Pediatrics & Adolescent Medicine | volume = 151 | issue = 10 | pages = 1046–1050 | date = October 1997 | pmid = 9343018 | doi = 10.1001/archpedi.1997.02170470080015 }}</ref><ref>{{cite journal | vauthors = Diamond M, Beh HG | title = Changes in the management of children with intersex conditions | journal = Nature Clinical Practice. Endocrinology & Metabolism | volume = 4 | issue = 1 | pages = 4–5 | date = January 2008 | pmid = 17984980 | doi = 10.1038/ncpendmet0694 | hdl-access = free | s2cid = 13382948 | hdl = 10125/66380 }}</ref>

=== Standards of care ===
{{See also|Transgender rights}}

Gender-affirming surgery can be hard to obtain due to financial barriers, insurance coverage, and lack of providers. A growing number of surgeons are now training to perform such surgeries. In many regions, a person's pursuit of gender-affirming surgery is often governed, or at least guided, by documents called [[Standards of Care for the Health of Transgender and Gender Diverse People]] (SOC). The most widespread SOC in this field is published and often revised by the [[World Professional Association for Transgender Health]] (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association or HBIGDA). Many jurisdictions and medical boards in the US and other countries recognize the WPATH Standards of Care for the treatment of transgender individuals. Some treatment may require a minimum duration of [[psychological evaluation]] and living as a member of the target gender full-time, sometimes called the real life experience (RLE) (sometimes mistakenly called the real life test [RLT]) before sex reassignment surgeries are covered by insurance.{{Citation needed|date=March 2019}}

Standards of Care usually give certain very specific "minimum" requirements as guidelines for progressing with treatment, causing them to be highly controversial and often maligned documents among transgender patients seeking surgery. Alternative local standards of care exist, such as in the Netherlands, Germany, and Italy. Much of the criticism surrounding the WPATH/HBIGDA-SOC applies to these as well, and some of these SOCs (mostly European SOC) are actually based on much older versions of the WPATH SOC. Other SOCs are entirely independent of the WPATH. The criteria of many of those SOCs are stricter than the latest revision of the WPATH-SOC. Many qualified surgeons in North America and many in Europe adhere almost unswervingly to the WPATH SOC or other SOCs. However, in the United States many experienced surgeons are able to apply the WPATH SOC in ways which respond to an individual's medical circumstances, as is consistent with the SOC.{{Citation needed|date=March 2019}}

Many surgeons require two letters of recommendation for gender-affirming surgery. At least one of these letters must be from a mental health professional experienced in diagnosing gender identity disorder (now recognized as [[gender dysphoria]]), who has known the patient for over a year. Letters must state that sex reassignment surgery is the correct course of treatment for the patient.<ref>{{Cite web | vauthors = Weber-Main AM |date=July 2012 | veditors = Fall H |title=Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (Version 7) |url=http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf |archive-url=https://web.archive.org/web/20120920085610/http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf |archive-date=20 September 2012 |access-date=31 October 2013 |website=wpath.org |publisher=[[World Professional Association for Transgender Health]]}}</ref><ref>{{Cite web |date=17 December 2003 |title=WPATH Standards of Care |url=http://www.tssurgeryguide.com/WPATH-standards-of-care.html |archive-url=https://web.archive.org/web/20140901020629/http://www.tssurgeryguide.com/WPATH-standards-of-care.html |archive-date=1 September 2014 |access-date=11 August 2014 |publisher=Tssurgeryguide.com}}</ref>{{update inline|date=December 2022}}<!--Previous text apparently relies on SOC7 not SOC8; the latter specifies that one 1 letter is needed if written documentation is needed at all.-->

Many medical professionals and many professional associations have stated that surgical interventions should not be required for transsexual individuals to change sex designation on identity documents.<ref name="WPATH Clarification" /><ref name="APA Policy Statement">{{Cite web |title=APA Policy Statement Transgender, Gender Identity, and Gender Expression Non-Discrimination |url=http://www.apa.org/pi/lgbc/policy/transgender.pdf |archive-url=https://web.archive.org/web/20090211231509/http://www.apa.org/pi/lgbc/policy/transgender.pdf |archive-date=11 February 2009}}</ref><ref name="NASW Policy Statment">{{Cite web |date=August 2008 |title=NASW Policy Statement on Transgender and Gender Identity Issues |url=https://www.socialworkers.org/assets/secured/documents/da/da2008/reffered/Transgender.pdf | work = National Association of Social Workers (NASW) |orig-date=2006 |access-date=2 September 2022 |archive-date=15 March 2023 |archive-url=https://web.archive.org/web/20230315223712/https://www.socialworkers.org/assets/secured/documents/da/da2008/reffered/Transgender.pdf }}</ref> However, depending on the legal requirements of many jurisdictions, transsexual and transgender people are often unable to change the listing of their sex in public records unless they can furnish a physician's letter attesting that sex reassignment surgery has been performed. In some jurisdictions legal gender change is prohibited in any circumstances, even after genital or other surgery or treatment.<ref>{{Cite web | vauthors = Wareham J |title=New Report Shows Where It's Illegal To Be Transgender In 2020 |url=https://www.forbes.com/sites/jamiewareham/2020/09/30/this-is-where-its-illegal-to-be-transgender-in-2020/ |url-status=live |archive-url=https://web.archive.org/web/20210430203254/https://www.forbes.com/sites/jamiewareham/2020/09/30/this-is-where-its-illegal-to-be-transgender-in-2020/ |archive-date=30 April 2021 |access-date=8 June 2021 | work = Forbes |language=en}}</ref>

=== Insurance ===
{{Globalize|section|United States|date=October 2019}}
A growing number of public and commercial health insurance plans in the US now contain defined benefits covering sex reassignment-related procedures, usually including genital reconstruction surgery (MTF and FTM), chest reconstruction (FTM), breast augmentation (MTF), and [[hysterectomy]] (FTM).<ref name="hrc.org">{{Cite web |date=26 February 2009 |title=Health Insurance Discrimination for Transgender People |url=http://www.hrc.org/issues/transgender/9568.htm |archive-url=https://web.archive.org/web/20090226224337/http://www.hrc.org/issues/transgender/9568.htm |archive-date=26 February 2009 | work = Human Rights Campaign }}</ref> For patients to qualify for insurance coverage, certain insurance plans may require proof of the following:
* a written initial assessment by a qualified licensed mental health professional
* persistent, well-documented gender dysphoria
* months of prior physician-supervised hormone therapy

In June 2008, the [[American Medical Association]] (AMA) House of Delegates stated that the denial to patients with gender dysphoria or otherwise covered benefits represents discrimination, and that the AMA supports "public and private health insurance coverage for treatment for gender dysphoria as recommended by the patient's physician."<ref name="ama-assn.org">{{Citation |title=AMA Resolution 122 "Removing Financial Barriers to Care for Transgender Patients" |url=http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf |archive-url=https://web.archive.org/web/20090327094235/http://www.ama-assn.org/ama1/pub/upload/mm/15/digest_of_actions.pdf |archive-date=27 March 2009}}</ref> Other organizations have issued similar statements, including WPATH,<ref name="WPATH Clarification" /> the [[American Psychological Association]],<ref name="APA Policy Statement" /> and the [[National Association of Social Workers]].<ref name="NASW Policy Statment" />

In 2017, the United States [[Defense Health Agency]] for the first time approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who is a trans woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on 14 November at a private hospital, since US military hospitals lack the requisite surgical expertise.<ref name="FirstMilitarySRS">{{Cite web | vauthors = Kube C |date=14 November 2017 |title=Pentagon to pay for surgery for transgender soldier |url=https://www.nbcnews.com/news/us-news/pentagon-oks-surgery-transgender-soldier-military-hospital-n820721 |url-status=live |archive-url=https://web.archive.org/web/20200730233535/https://www.nbcnews.com/news/us-news/pentagon-oks-surgery-transgender-soldier-military-hospital-n820721 |archive-date=30 July 2020 |access-date=15 November 2017 | work = NBC News}}</ref>

== Post-procedural effects ==

=== Mental health and quality of life ===
Clinical research on long-term quality-of-life outcomes following surgery is limited and confounded by various factors, including small sample sizes, and baseline rates of [[mental health]] issues and suicide among transgender people compared to the general population.<ref name="Shelemy_2024">{{Cite journal | vauthors = Shelemy L, Cotton S, Crane C, Knight M |date=2024-04-03 |title=Systematic review of prospective adult mental health outcomes following affirmative interventions for gender dysphoria |journal=International Journal of Transgender Health |volume=26 |issue=3 |language=en |pages=480–500 |doi=10.1080/26895269.2024.2333525 |pmid=40756726 |issn=2689-5269|doi-access=free |pmc=12312132 }}</ref>

A 2020 meta-analysis found "evidence of low quality" that gender-affirming surgery, particularly [[Male chest reconstruction|chest reconstruction]] for trans men, improves quality of life.<ref>{{Cite journal |last1=Passos |first1=Taciana Silveira |last2=Teixeira |first2=Marina Sá |last3=Almeida-Santos |first3=Marcos Antonio |date=2020-06-01 |title=Quality of Life After Gender Affirmation Surgery: a Systematic Review and Network Meta-analysis |journal=Sexuality Research and Social Policy |language=en |volume=17 |issue=2 |pages=252–262 |doi=10.1007/s13178-019-00394-0 |issn=1553-6610}}</ref> A 2022 systematic review found that gender-affirming surgical procedures led to "reduced rates of suicide attempts, anxiety, depression, and symptoms of gender dysphoria along with higher levels of life satisfaction, happiness and QoL after gender-affirming surgery."<ref name=":2">{{Cite journal |last1=Swan |first1=Jaime |last2=Phillips |first2=Tania M. |last3=Sanders |first3=Tait |last4=Mullens |first4=Amy B. |last5=Debattista |first5=Joseph |last6=Brömdal |first6=Annette |date=2023-01-02 |title=Mental health and quality of life outcomes of gender-affirming surgery: A systematic literature review |journal=Journal of Gay & Lesbian Mental Health |volume=27 |issue=1 |pages=2–45 |doi=10.1080/19359705.2021.2016537 |issn=1935-9705}}</ref> A 2024 systematic review found that genital surgeries significantly improved depression and dissociation in trans and gender-diverse individuals, with "mixed results" for other mental health outcomes. It concluded there was "less conclusive evidence" of mental health improvement after trans surgical procedures compared to hormonal therapy, though expressed tentative support for both.<ref name="Shelemy_2024" />

A secondary analysis of the [[U.S. Transgender Survey]] found that gender-affirming surgery was significantly associated with lower rates of psychological distress, smoking, and suicidal ideation, compared to rates among respondents who desired surgery but had not undergone it.<ref name=":1">{{Cite journal |last1=Almazan |first1=Anthony N. |last2=Keuroghlian |first2=Alex S. |date=2021-07-01 |title=Association Between Gender-Affirming Surgeries and Mental Health Outcomes |url=https://jamanetwork.com/journals/jamasurgery/fullarticle/2779429 |journal=JAMA Surgery |language=en |volume=156 |issue=7 |doi=10.1001/jama |doi-broken-date=15 October 2025 |issn=2168-6254 |archive-url=http://web.archive.org/web/20250916041809/https://jamanetwork.com/journals/jamasurgery/fullarticle/2779429 |archive-date=2025-09-16 |quote=Our study has several limitations. The nonprobability sampling of the USTS may limit generalizability. All measures are self-reported and may be subject to response bias. [...] In this article, we present the largest study to our knowledge to date on associations between gender-affirming surgeries and mental health outcomes. Our results demonstrate that undergoing gender-affirming surgery is associated with improved past-month severe psychological distress, past-year smoking, and past-year suicidal ideation.}}</ref> This was the largest controlled study on the subject to date (N=19,960), though the design of the survey and self-reported responses introduced some limitations and possible [[response bias]].<ref name=":1" />

Gender-affirming surgery can be seen as [[human enhancement]].<ref name="g077">{{cite journal | last1=Zohny | first1=Hazem | last2=Earp | first2=Brian D. | last3=Savulescu | first3=Julian | title=Enhancing Gender | journal=Journal of Bioethical Inquiry | volume=19 | issue=2 | date=2022 | issn=1176-7529 | pmid=35129785 | pmc=9233637 | doi=10.1007/s11673-021-10163-7 | doi-access=free | pages=225–237 | url=https://link.springer.com/content/pdf/10.1007/s11673-021-10163-7.pdf | access-date=19 January 2025}}</ref>

==== Social obstacles ====
Transgender people often fall victim to different social obstacles which may hinder their experiences with care, such as discrimination, prejudice, harassment, and other stigmatizing behaviours.<ref name=":2" /><ref>{{Cite journal |last1=Shires |first1=Deirdre A. |last2=Jaffee |first2=Kim |date=May 2015 |title=Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals |journal=Health & Social Work |volume=40 |issue=2 |pages=134–141 |doi=10.1093/hsw/hlv025 |issn=0360-7283 |pmid=26027422}}</ref> The rejection faced by trans people is much more severe than what is experienced by lesbians, gays, and bisexuals.<ref>{{Cite journal |last1=Norton |first1=Aaron T. |last2=Herek |first2=Gregory M. |date=2013-06-01 |title=Heterosexuals' Attitudes Toward Transgender People: Findings from a National Probability Sample of U.S. Adults |journal=Sex Roles |language=en |volume=68 |issue=11 |pages=738–753 |doi=10.1007/s11199-011-0110-6 |issn=1573-2762}}</ref> Due to these [[Minority stress|minority stressors]], gender-affirming surgery may result in only limited quality of life improvements,<ref name=":2" /> and transgender individuals receiving it may not be fully alleviated of mental health disparities after the procedure.<ref>{{Cite journal |last1=Dhejne |first1=Cecilia |last2=Lichtenstein |first2=Paul |last3=Boman |first3=Marcus |last4=Johansson |first4=Anna L. V. |last5=Långström |first5=Niklas |last6=Landén |first6=Mikael |date=2011-02-22 |title=Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden |journal=PLOS ONE |volume=6 |issue=2 |article-number=e16885 |doi=10.1371/journal.pone.0016885 |doi-access=free |issn=1932-6203 |pmc=3043071 |pmid=21364939 |bibcode=2011PLoSO...616885D }}</ref> 

Regret after gender-affirming surgery may also be an outcome of the discrimination transgender individuals face. According to a systematic review published in 2021, "poor social and group support, late-onset gender transition, poor sexual functioning, and mental health problems are factors associated with regret." Nevertheless, it found the prevalence of regret after gender-affirming surgery to be quite low, at around 1% of the 7.928 transgender patients studied.<ref name=":0">{{Cite journal |last1=Bustos |first1=Valeria P. |last2=Bustos |first2=Samyd S. |last3=Mascaro |first3=Andres |last4=Del Corral |first4=Gabriel |last5=Forte |first5=Antonio J. |last6=Ciudad |first6=Pedro |last7=Kim |first7=Esther A. |last8=Langstein |first8=Howard N. |last9=Manrique |first9=Oscar J. |date=March 2021 |title=Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence |journal=Plastic and Reconstructive Surgery. Global Open |volume=9 |issue=3 |article-number=e3477 |doi=10.1097/GOX.0000000000003477 |issn=2169-7574 |pmc=8099405 |pmid=33968550}}</ref>

=== Sexuality ===
Looking specifically at transsexual people's genital sensitivities, both trans men and trans women are capable of maintaining their genital sensitivities after gender-affirming surgery. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexuals to avoid unnecessary harm or injury to the genitals, allowing trans men to obtain erection by inserting a [[penile implant]] after [[phalloplasty]],<ref name="Selvaggi_2007">{{cite journal | vauthors = Selvaggi G, Monstrey S, Ceulemans P, T'Sjoen G, De Cuypere G, Hoebeke P | title = Genital sensitivity after sex reassignment surgery in transsexual patients | journal = Annals of Plastic Surgery | volume = 58 | issue = 4 | pages = 427–433 | date = April 2007 | pmid = 17413887 | doi = 10.1097/01.sap.0000238428.91834.be | s2cid = 46169398 }}</ref> the ability of trans people to experience erogenous and [[tactile sensitivity]] in their reconstructed genitals is one of the essential objectives surgeons want to achieve in gender-affirming surgery.<ref name="Selvaggi_2007" /><ref name="Hage_1993">{{cite journal | vauthors = Hage JJ, Bouman FG, de Graaf FH, Bloem JJ | title = Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience | journal = The Journal of Urology | volume = 149 | issue = 6 | pages = 1463–1468 | date = June 1993 | pmid = 8501789 | doi = 10.1016/S0022-5347(17)36416-9 }}</ref> Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasm after phalloplasty is to preserve both the clitoral hood and the clitoris underneath the reconstructed [[phallus]].<ref name="Selvaggi_2007" /><ref name="Hage_1993" />

Erogenous sensitivity is measured by the abilities to reach [[orgasm]] in genital sexual activities, like masturbation and intercourse.<ref name="Selvaggi_2007" /> Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,<ref name="Wierckx_2011">{{cite journal |vauthors=Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, Weyers S, Hoebeke P, Monstrey S, De Cuypere G, T'Sjoen G |date=December 2011 |title=Quality of life and sexual health after sex reassignment surgery in transsexual men |journal=The Journal of Sexual Medicine |volume=8 |issue=12 |pages=3379–3388 |doi=10.1111/j.1743-6109.2011.02348.x |pmid=21699661}}</ref><ref name="De_Cuypere_2005">{{cite journal | vauthors = De Cuypere G, T'Sjoen G, Beerten R, Selvaggi G, De Sutter P, Hoebeke P, Monstrey S, Vansteenwegen A, Rubens R | title = Sexual and physical health after sex reassignment surgery | journal = Archives of Sexual Behavior | volume = 34 | issue = 6 | pages = 679–690 | date = December 2005 | pmid = 16362252 | doi = 10.1007/s10508-005-7926-5 | s2cid = 42916543 }}</ref> implying the possibilities to maintain or even enhance genital sensitivity after gender-affirming surgery.

Most trans persons report enjoying better sex lives and improved sexual satisfaction after gender-affirming surgery.<ref name="De_Cuypere_2005" /> The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.<ref name="De_Cuypere_2005" /> Before gender-affirming surgery, trans patients had unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone gender-affirming surgery are more satisfied with their bodies and experienced less stress when participating in sexual activity.<ref name="De_Cuypere_2005" />

Most of the individuals report that they have experienced sexual excitement during sexual activity, including masturbation.<ref name="De_Cuypere_2005" /> The ability to obtain orgasm is positively associated with sexual satisfaction.<ref name="Wierckx_2011" /> Frequency and intensity of orgasm are substantially different for trans men and trans women. Almost all female-to-male individuals revealed an increase in sexual excitement and can achieve orgasm through sexual activity with a partner or via masturbation,<ref name="De_Cuypere_2005" /><ref name="Wierckx_2011" /> whereas only 85% of the male-to-female individuals are able to achieve orgasm after gender-affirming surgery.<ref>{{cite journal | vauthors = Lawrence AA | title = Sexuality before and after male-to-female sex reassignment surgery | journal = Archives of Sexual Behavior | volume = 34 | issue = 2 | pages = 147–166 | date = April 2005 | pmid = 15803249 | doi = 10.1007/s10508-005-1793-y | s2cid = 25671520 | citeseerx = 10.1.1.538.6381 }}</ref> A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male trans individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female persons have been encountering longer and more gentle feelings.<ref name="De_Cuypere_2005" />

Rates of masturbation have also changed after gender-affirming surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies in most transsexuals and 78% of them were able to reach orgasm by masturbation after gender-affirming surgery.<ref name="Wierckx_2011" /><ref name="De_Cuypere_2005" /><ref name="Gómez-Gil_2014">{{cite journal | vauthors = Gómez-Gil E, Zubiaurre-Elorza L, de Antonio IE, Guillamon A, Salamero M | title = Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery | journal = Quality of Life Research | volume = 23 | issue = 2 | pages = 669–676 | date = March 2014 | pmid = 23943260 | doi = 10.1007/s11136-013-0497-3 | s2cid = 23051224 }}</ref> A study showed that there were differences in masturbation frequency between trans men and trans women; female-to-male individuals masturbated more often than male-to-female.<ref name="De_Cuypere_2005" /> The possible reasons for the difference in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.<ref name="Wierckx_2011" />

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels).<ref name="Gómez-Gil_2014" /> When comparing trans with [[cisgender]] persons of the same gender, [[trans women]] had a similar sexual satisfaction to cis women, but [[trans men]] had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.<ref name="Wierckx_2011" />

== Legal status ==
{{main|Legal status of gender-affirming healthcare}}

== See also ==
{{Columnslist|colwidth=30em|
* [[Baptist Medical Center sex reassignment surgery controversy]]
* ''[[Femalia]]''
* [[Genitoplasty]]
* [[Healthcare and the LGBT community]]
* [[Morphological freedom]]
* ''[[O'Donnabhain v. Commissioner]]''
* [[Sexual and reproductive health]]
* [[Transgender health care]]
* [[Yogyakarta Principles]]
}}

== References ==
{{Reflist}}

== External links ==
*{{commons-inline}}

{{Transgender topics}}

{{DEFAULTSORT:Sex Reassignment Surgery}}
[[Category:Gender transition and medicine]]
[[Category:Surgical procedures and techniques]]