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What Is Gender Affirmation Surgery?

gender reassignment surgery types

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary, to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

  • Decreased antidepressant use
  • Decreased anxiety, depression, and suicidal ideation
  • Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

  • Both a man and a woman
  • Neither a man nor a woman
  • An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

  • Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
  • Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
  • Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

  • Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
  • Hysterectomy (uterus removal)
  • Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
  • Oophorectomy (ovary removal)
  • Phalloplasty (surgery to create a penis)
  • Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

  • Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
  • Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

  • Constructing a glans (head) to look more like a penis
  • Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
  • Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

  • Breast augmentation
  • Facial feminization surgery
  • Penis removal (penectomy)
  • Scrotum removal (scrotectomy)
  • Testicle removal (orchiectomy)
  • Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
  • Vaginoplasty
  • Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries. Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

  • Gender nullification procedures
  • Penile preservation vaginoplasty
  • Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

  • Breast tissue removal
  • Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

  • Anesthesia risks
  • Hematoma, which is bad bruising
  • Poor incision healing

Complications from these procedures may be:

  • Acute kidney injury
  • Blood transfusion
  • Deep vein thrombosis, which is blood clot formation
  • Pulmonary embolism, blood vessel blockage for vessels going to the lung
  • Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
  • Surgical site infection
  • Urethral stricture or stenosis, which is when the urethra narrows
  • Urinary tract infection (UTI)
  • Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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  • Patient Care & Health Information
  • Tests & Procedures
  • Masculinizing surgery

Masculinizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Masculinizing surgery includes several options, such as top surgery to create a more male-contoured chest and bottom surgery that changes the genitals.

Not everybody chooses masculinizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek masculinizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having masculinizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Options for masculinizing surgery include:

  • Surgical removal of breast tissue. This also is referred to as top surgery or masculinizing chest surgery.
  • Surgical placement of pectoral implants to create a male-contoured chest.
  • Genital surgery to remove the uterus and cervix — a total hysterectomy — or to remove the fallopian tubes and ovaries — a procedure called salpingo-oophorectomy.
  • Surgery to remove all or part of the vagina, called a vaginectomy, create a scrotum, called scrotoplasty, place testicular prostheses, increase the length of the clitoris, called metoidioplasty, or create a penis, called phalloplasty.
  • Other procedures such liposuction, a technique to remove fat from specific areas of the body, and fat grafting.

Your health care provider might advise against these surgeries if you have:

  • Significant medical conditions that haven't been addressed.
  • Behavioral health conditions that haven't been addressed.
  • Any condition that limits your ability to give your informed consent.

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Like any major surgery, many types of masculinizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

  • Delayed wound healing.
  • Fluid buildup beneath the skin, called seroma
  • Bruising, also called hematoma
  • Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
  • Damaged or dead body tissue — a condition known as tissue necrosis — such as in the nipple or in the surgically created penis
  • A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, a condition called pulmonary embolism
  • Development of an irregular connection between two body parts, called a fistula, such as in the urinary tract
  • Urinary problems, such as incontinence
  • Pelvic floor problems
  • Permanent scarring
  • Loss of sexual pleasure or function
  • Worsening of a behavioral health concern

Certain types of masculinizing surgery may limit or end fertility. If you want to have biological children, and you're having surgery that involves your reproductive organs, talk to your health care provider about your options. You may choose to freeze eggs with a procedure called mature oocyte cryopreservation, or freeze embryos using embryo cryopreservation. Another option involves having ovarian tissue surgically removed, frozen, and later thawed and reimplanted. That procedure is called ovarian tissue cryopreservation.

Egg freezing involves multiple steps, including ovulation induction, egg retrieval and freezing. If you want to freeze embryos, an additional step of having the eggs fertilized before they are frozen also is required.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because masculinizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

  • Risks and benefits
  • Alternatives to surgery
  • Expectations and goals
  • Social and legal implications
  • Potential complications
  • Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

  • A review of your personal and family medical history
  • A physical exam
  • A review of your vaccinations
  • Screening tests for some conditions and diseases
  • Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
  • Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

  • Gender identity
  • Gender dysphoria
  • Mental health concerns
  • Sexual health concerns
  • The impact of gender identity at work, at school, at home and in social settings
  • The role of social transitioning and hormone therapy before surgery
  • Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
  • Support from family, friends and caregivers
  • Your goals and expectations of treatment
  • Care planning and follow-up after surgery

Other considerations

Health insurance coverage for masculinizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had masculinizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Chest surgery.

Top surgery, also called masculinizing chest surgery, involves the removal of breast tissue — a procedure known as subcutaneous mastectomy. There are several approaches for this surgery, including:

  • Double incision mastectomy. This procedure may be recommended for people with larger breasts. During surgery, the surgeon makes cuts under and on top of each breast. Breast tissue and some chest skin is removed. The shape and location of the nipples may need to be changed. To do this, the surgeon removes the nipples and makes them smaller and more oval shaped. Then they are reattached to the chest wall. After this surgery, there is no feeling in the nipples and areolas.
  • Subcutaneous mastectomy with nipple preservation. If your breasts are smaller, this approach may be an option. The surgeon makes cuts under the breasts and removes breast tissue. Usually no skin is removed. The nipples may be reshaped, but the nipples and areolas stay attached. This helps preserve feeling in the nipples.
  • Periareolar mastectomy. This surgery may be used if your breasts are not large. A small cut is made around the areola of each breast and the breast tissue is removed. Usually, no skin is removed. The nipples and areolas stay attached. This helps preserve feeling in the nipples.

After surgery, you may need to stay in the hospital overnight. You might not be able to bear weight on your upper body for six weeks. Talk to your health care provider about the specific activity restrictions you need to follow.

Some breast tissue remains after surgery regardless of the surgery you have. Because of that, ask your health care provider about breast cancer screening you may need after surgery.

Genital surgery

Metoidioplasty.

Metoidioplasty is a procedure to increase the length of the clitoris without adding other tissue. During surgery, the clitoris is freed from its attachment against the body. The surgeon also can extend the urethra through the released clitoris using a graft typically taken from the lining of the mouth. This is called a urethral hookup. It makes standing urination possible.

This procedure usually results in a penis with an unstimulated length between 1 and 3 inches (3 and 8 centimeters). Typically after this surgery, you still have full sensation and the ability to have an orgasm.

It isn't necessary for the vagina to be closed or removed before metoidioplasty. But penetration and Pap tests might not be possible after it. As a result, your surgeon might suggest removing your uterus, cervix and ovaries during metoidioplasty.

After metoidioplasty, you have a tube temporarily placed in your urethra to collect urine. Recovery might take up to two weeks.

Phalloplasty

Phalloplasty, the surgical creation of a penis, involves several procedures. During phalloplasty, large amounts of skin are taken from other areas of the body. These may include the forearm, calf or lower abdomen. This can cause significant scarring. The skin is rolled into the shape of a penis and anchored into position above the clitoris. Phalloplasty also may include:

  • Urethral lengthening to allow for urination through the penis
  • Grafting of nerves and blood vessels to provide sensation
  • Sculpting the head of the penis — a procedure called glansplasty
  • Medical tattooing to create a distinct difference between the head and shaft

After phalloplasty, a tube is temporarily placed in the urethra to collect urine. You'll likely need to stay in the hospital for a few days. Phalloplasty carries a high rate of complications. It could require many follow-up surgeries. Depending on the procedure, recovery might take up to 12 weeks. The new penis will not become erect with sexual stimulation. A penile implant is needed to allow penetrative sex.

Scrotoplasty

Scrotoplasty is the surgical creation of a scrotum. During scrotoplasty, testicular implants are inserted into the labia. To prepare for the procedure, expanders are placed under the skin. The expanders are gradually filled with saline over several months. When the skin has been expanded enough, the implants are inserted. Some people find the implants uncomfortable. It is possible for the implants to wear through surrounding tissue or become infected.

Other masculinizing surgeries also are available, including surgery to place pectoral implants in the chest, as well as procedures to remove fat and fat grafting. Ask your health care provider about these options and the risks and benefits they involve.

Research has found that that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Masculinizing surgery care at Mayo Clinic

  • Tangpricha V, et al. Transgender men: Evaluation and management. https://www.uptodate.com/contents/search. Accessed July 22, 2022.
  • Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed July 25, 2022.
  • Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
  • AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
  • Sonmezer M, et al. Overview of fertility and reproductive hormone preservation prior to gonadotoxic therapy or surgery. https://www.uptodate.com/contents/search. Accessed July 25, 2022.
  • Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed July 25, 2022.
  • Health Education & Content Services (Patient Education). Chest masculinization surgery. Mayo Clinic; 2022.
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Gender-Affirming Surgery (Top Surgery)

Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as “top surgery" and "bottom surgery.” Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their appearance to align with their internal identity. If, after a consultation with our doctors, you decide to pursue top surgery, we work toward a positive outcome that improves your physical, emotional, and psychological well-being.

What You Should Know About Gender-Affirming Surgery

Choosing to pursue gender-affirming surgery is an individual, personal decision. You’ll want to consider how it will change your quality of life and how it will help you achieve your goals.

Gender Dysphoria One important step is understanding how much you are affected by gender dysphoria, a diagnosis that the American Psychiatric Association defines as a conflict between your physical or assigned gender and the gender with which you identify. 

Candidates for Top Surgery To be a candidate for top surgery, you must:

  • Be 18 or older
  • Be in good health without illness or a condition that can increase your risk of surgical complications
  • Have a BMI under 35
  • Provide a clearance letter from your mental health or primary care provider stating you have gender dysphoria and you have been living in your assigned gender for at least 12 months

Top Surgery Costs Some private insurance plans will cover transgender surgery when it is used to address a diagnosis of gender dysphoria. Check with your insurance plan to determine your coverage.

Understanding Which Top Surgery Is Right for You There are several approaches to transgender surgery. We will review these with you during your initial consultation and make a recommendation based on your physical exam and medical history.

You May Have Scars Your surgeon will use the natural contours of your breasts to minimize scarring as much as possible. In some cases, depending on your breast size and weight, a small bunching of tissue may result in scars known as “dog ears” following mastectomy. These can be corrected later with revision surgery.

Understand the Risks Top surgery carries the same risks as other standard surgeries. These include the risk of bleeding and infection and risks associated with general anesthesia. Your doctor will discuss these risks with you if surgery is recommended.

Initial Consultation and Tests

Consultation and Exam Your first step will be an in-person consultation. Our providers spend time meeting with you, evaluating your anatomy, answering your questions, and determining if this surgery will help you achieve your goals.

Your surgeon will review your family history, general health status, lifestyle habits such as smoking, previous operations, any medications you may be taking, and conditions that can put you at risk for surgery.

Measurements, Photographs, Tests Your breasts will be measured and assessed for size and shape, and photographs may be taken for your medical record. Before treatment is recommended, you will also undergo one or more of the following tests.

  • Blood tests may be necessary to evaluate your hormone levels. Pre-surgical testing also requires several blood tests to assess your liver and kidney function and to determine if you have a previously undetected infection, blood disorder, or anemia.
  • A mammogram may be performed to look for any underlying breast abnormalities. Additional imaging, including ultrasound and MRI, may also be requested.

Recommending Treatment Based on these findings, your surgeon will recommend an approach to surgery. She will discuss the expected outcome, potential risks and complications, and your post-operation recovery. Alternatively, your surgeon may recommend that you lose weight, quit smoking, or discontinue medication before surgery to ensure you experience the best possible outcome.

If You Take Hormone Therapy Some gender-affirming hormone therapy , such as testosterone, can be continued if you pursue transgender surgery. Others, such as anti-estrogen therapy, may be stopped. Your surgeon will explain what you need to do to prepare for surgery.

Top Surgeries

Chest reconstruction - mastectomy, breast reduction.

We use different approaches to remove breast tissue and contour breasts to appear more masculine. The right approach depends on your anatomy and the size of your breasts. Techniques for medium to large breasts include nipple-sparing, double incision, buttonhole, and inverted-T incision. Keyhole and peri-areolar techniques may be used for smaller breasts or for those with good skin elasticity. Your surgeon will discuss your options with you after your physical exam and consultation.

Breast Augmentation

There are also many different approaches to breast augmentation, including the use of implants and fat grafting. We can also combine breast augmentation with body contouring, liposuction, and neurotoxin injections such as Botox injections and dermal fillers.

The Procedure Length

On average, top surgery takes about two to three hours and is performed under general anesthesia in an outpatient ambulatory surgery center. In some case, an overnight stay may be required. Sometimes a second procedure is needed to further tighten skin and achieve optimal cosmetic results.

Your chest will be wrapped in bandages, and a compression chest vest or surgical bra will be worn after the procedure. Drains will be required after mastectomy but not after breast augmentation. Initial recovery takes about one week. It may take three to six months for all swelling to subside and scars to fade.

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

Why Choose Duke

You'll Work With a Plastic Surgeon Experienced in Gender Affirmation Surgery Our plastic surgeon has worked with many individuals seeking gender confirmation surgery. She is fellowship trained in body contouring, which means she has completed additional training in procedures that improve the body shape. Our surgeon is also a member of the World Professional Association for Transgender Health (WPATH), a nonprofit organization working to standardize and improve transgender care.

Duke Health Is Committed to the LGBTQ+ Community Duke Health values diversity and has taken many steps to show its commitment to eliminating discrimination, promoting equality, and standing beside our lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community. Duke University Hospital, Duke Regional Hospital, and Duke Raleigh Hospital are recognized as LGBTQ+ Healthcare Equality Leaders by the Human Rights Campaign Foundation for perfect scores across areas of patient-centered care, support services, and inclusive health insurance policies for LGBTQ+ patients.

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Fellowship-trained gender surgeon in New York City who is passionate about Robotic Vaginoplasty and providing stellar care.

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Dr. Sherie is a board-certified surgeon who has extensive training in MTF surgery procedures, including Orchiectomy. Based in Charlotte.

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Gender Affirmation Surgery

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If you’re transgender, you may pursue hormone therapy or gender reassignment surgery to help align your body with your gender identity. Some transgender individuals also choose to pursue surgery to help reduce or enhance secondary sexual characteristics. For transgender men, this may include surgery to reduce breast size or remove the ovaries. Transgender women may elect for breast augmentation or facial feminization surgery to meet their needs. At MedStar Health, we offer the following procedures to help you be comfortable in your own skin. Types of gender reassignment surgery:

Feminizing vaginoplasty : Reconstructive surgery procedure that alters the structure of the genitals to create a vagina using penile or colon tissue. Dr. Del Corral uses a one-stage procedure, revisions can be necessary to enhance the final surgical result

Revision vaginoplasty (after loss of depth) : A secondary procedure allowing for revisions to the urethra, neovaginal canal, labia minora, and majora addressing asymmetries within the vagina, and scar revisions to help functionality. MedStar Center for Gender Affirmation specializes in revisional procedures after complications from primary vaginoplasty

Colon vaginoplasty : A different approach to an original vaginoplasty. The colon or small bowel can be used to line the vaginal wall to create depth, dilation, and providing a natural source of lubrication. At the MedStar Center for Gender Affirmation, we use a robotic-assisted approach to minimize incisions in the abdomen, and faster recovery while providing better access for the revision

Masculinizing phalloplasty/scrotoplasty : Reconstructive surgery that creates a penis using a free flap or pedicled flap of skin. These sections of the skin can be taken from the arm (radial forearm free-flap, RFF) or thigh (anterior lateral thigh pedicled flap phalloplasty, ALT).  These procedures are performed in a combined team that include a reconstructive urologist and plastic surgeons

Metoidioplasty : The use of local tissue to create an enlargement to the penile area (clitoral release/enlargement, may include urethral lengthening)

Masculinizing chest surgery (“top” surgery) : Breast tissue is removed and the nipples and areolae are altered to help masculinize the chest

Facial feminization : Reconstructive surgery procedures that alters the shape and size of facial features to make them closer to typical female facial features — this may include a brow lift, forehead re-contouring, hairline correction, and rhinoplasty (nose reshaping)

Facial masculinization : Reconstructive surgery that alters the shape and size of facial features to make them more masculine — this may include forehead lengthening and augmentation, cheek augmentation, chin re-contouring, jaw contouring, thyroid cartilage enhancement (Adam’s apple surgery), and rhinoplasty (nose reshaping)

Reduction thyrochondroplasty (thyroid cartilage shave) : Reconstructive surgery that reduces the size of the thyroid cartilage, also known as the “Adam’s apple.” It is shaved down to create a more feminine appearance

Breast augmentation mammoplasty : Surgery to reshape, enlarge, and modify the breasts and achieve a more desired shape and look to the chest

Hysterectomy with bilateral salpingo-oophorectomy : Surgical removal of the uterus, cervix, ovaries, fallopian tubes, and surrounding structures

Orchiectomy : Reconstructive surgery to remove the testicles

Vaginectomy : Reconstructive surgery to remove all parts of the vagina

Gender surgery planning and recovery

What to expect.

You may need to meet a few requirements before qualifying for certain gender affirming procedure(s) at MedStar Health. The exact requirements will depend on your insurance coverage and may include one or more letters of referral from qualified mental health professionals, well-documented gender dysphoria, and/or one year of continuous hormone therapy. Procedures that are considered strictly cosmetic by your insurance plan will have fewer requirements.

After properly qualifying for surgery, you’ll meet with one of our surgeons. They will examine you and ask questions to determine if you physically qualify for surgery. If you qualify, you’ll discuss any risks and potential complications and walk through the steps involved. You’ll be given specific instructions to follow prior to your surgery.

On the day of surgery, your surgeon may use a variety of leading-edge techniques to achieve the best results, such as minimally invasive surgery to significantly reduce scarring.

Recovery from surgery

It’s important to follow your surgeon’s instructions for proper care of your body after surgery. You may have specific directions about taking medications and how to clean and care for the surgical site. Healing may take several weeks as swelling decreases.

Why choose us?

MedStar Health is the largest health care system in Maryland and the Washington, D.C., region. When you choose us for care, you’ll have access to our network of 10 hospitals and a team of more than 3,000 physicians and specialists.

If you choose MedStar Health for a breast augmentation or reduction procedure, you’ll be choosing to work with a nationally recognized leader in breast surgeries. Our breast surgeons have years of experience working exclusively in breast procedures and have developed their own techniques to help patients recover faster and have better results.

Our providers

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Gabriel Alfonso Del Corral, MD

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Laura Tom, MD

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MedStar Health: Plastic Surgery at MedStar Washington Hospital Center

106 Irving St. NW POB North Ste. 3400 Washington, D.C., 20010

MedStar Franklin Square Medical Center

9000 Franklin Square Dr. Baltimore, MD 21237

Frequently asked questions

Do I need a referral?

If you’re exploring options for insurance coverage, you may need to request a referral from your primary care doctor, depending on your health insurance plan. Check with your carrier to see if medical coverage is an option for you and, if so, whether a referral is required.

How should I prepare?

Before surgery, you may be asked to get blood tests and take or adjust medications — this may include temporarily stopping hormone therapy. If you smoke, quitting will help you heal faster and avoid possible complications. You’ll also need to arrange for transportation to and from the hospital and for someone to stay with you the night after the surgery.

For more information visit Patient Resources  or Preparing for Surgery

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Types of gender confirmation surgeries (formerly sex reassignment), gender confirmation surgery.

Types of Gender Confirmation Surgeries (Formerly Sex Reassignment)

Board certified plastic surgeon Dr. Suzanne Quardt (Dr. Q) provides gender confirmation surgeries to patients in Palm Springs, Palm Desert, Rancho Mirage, Beverly Hills, CA, and surrounding communities.

Bottom Surgery for Folks Assigned Female at Birth (AFAB)

  • Metoidioplasty

A new phallus is created by releasing the enlarged clitoris from its clitoral hood. Urethra may need to be rerouted in this surgery with a graft from the inside of the vaginal wall or cheek to allow easy urination through the phallus.

  • Phalloplasty

The thigh, forearm or back is used as the source of graft for creating a new penis. The urethra in this procedure may be linked to allow normal urination through the penis. Implant may also be installed for the penis to get erect.

  • Vaginectomy , hysterectomy, and oophorectomy

AFAB transpeople have several options in terms of reconstructing their reproductive organs. This includes removal of the vagina (vaginectomy), uterus (hysterectomy), and one or both ovaries (oophorectomy).

Top Surgery for People Assigned Male at Birth (AMAB)

Absence of breast tissue can cause dysphoria and discomfort in non-binary or transfeminine people who were assigned male at birth (AMAB). Hormone therapy may increase the chest size marginally. However, some people who want a feminine looking appearance usually turn to top surgery for breast augmentation.

In breast augmentation, an incision is made around the areola and under the armpit. This is to insert a customized saline or silicone implant. Saline implants are usually less expensive, but silicone implants offer more natural and softer results. Breast augmentation cosmetic surgery is recommended for anyone desiring a larger chest.

Bottom Surgery for People Assigned Male at Birth (AMAB)

Most AMAB people have testicles and a penis. This can be uncomfortable for transfeminine and nonbinary AMAB folks. There are several types of bottom surgeries that can help with this.

Vaginoplasty

Existing tissue is used for constructing a functioning vagina. Penile inversion is the most common method used for achieving a vagina. Your penis will be inverted to create a vagina. The scrotal skin of the penis will become the labia and the tip of the penis will act like a functioning clitoris. This surgery is a poignant option for people desiring a functioning vagina.

Orchiectomy and scrotectomy

The entire scrotum, one or both testicles may be removed with these procedures. Orchiectomy is less expensive as compared to scrotectomy. In orchiectomy your testes will be removed to ensure that less endogenous testosterone is released. This is helpful for people on hormone replacement therapy.

Scrotectomy offers the same kind of results but is not recommended for individuals considering a vaginoplasty. This is because scrotal skin is necessary during a vaginoplasty. Cosmetic surgeon Dr. Suzanne Quardt (Dr. Q) receives patients from Palm Springs, Palm Desert, Rancho Mirage, Beverly Hills, CA, and nearby areas for gender reconfirmation surgery.

Schedule a Consultation with California Board Certified Plastic Surgeon, Dr. Q 

To learn more about the plastic surgery treatments and procedures performed by Board Certified Plastic Surgeon,  Dr. Suzanne Quardt (Dr. Q) please contact us at 760-324-2660. To learn more about Dr. Q’s Medical Spa please visit drqmedicalspa.com

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Dr. Q receives patients from Palm Springs, Palm Desert, Rancho Mirage, Beverly Hills CA, and other Southern California areas.

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What Is Gender-Affirming Hormone Therapy?

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Gender-affirming hormone therapy helps transgender and other gender-nonconforming people align their bodies with their gender identity . Not all transgender (trans) people are interested in hormone therapy. However, many transgender people, particularly binary transgender people, turn to hormones to affirm their gender.

Gender-affirming hormone therapy is comprised of masculizing hormone therapy used in trans men and feminizing hormone therapy used in trans women.

This article describes the goals of gender-affirming hormone therapy, how the treatment is administered, and the different types of hormones used. It also explains what to expect when undergoing gender-affirming hormone therapy and the possible risks.

Verywell / Brianna Gilmartin

Definitions

The term "gender affirmation" is preferred over "gender confirmation" because a transgender person does not need to confirm their gender to anyone. The word "confirm" suggests proof, while "affirm" means to assert strongly.

Who Is Gender-Affirming Hormone Therapy For?

Gender-affirming hormone therapy is the primary medical treatment sought by transgender people. It allows their secondary sex characteristics to be more aligned with their individual gender identity.

Gender-affirming hormone therapy comes in two types:

  • Masculinizing hormone therapy used to develop typically male sex characteristics
  • Feminizing hormone therapy used to develop typically female sex characteristics

Hormone therapy can be used on its own for people who have no interest in pursuing gender-affirming surgery . It can also be used in advance of surgery (usually for six months to one year) to improve the outcomes of surgery, such as breast augmentation.

According to the National Transgender Discrimination Survey, 95% of transgender people and 49% of non-binary people were interested in hormone therapy.

Hormone Therapy vs. Puberty Blockers

Puberty blockers are used to delay the onset of puberty in young, gender-diverse people prior to the start of hormone therapy. They are considered to be a distinct but complementary component of gender-affirmation therapy.

How to Get Started 

Gender affirmation is a process in which hormones only play a part. It typically starts with social gender affirmation in which you alter your appearance, wardrobe, and manner of grooming while updating your name, pronouns, and legal documentation.

Medical gender affirmation is typically the next step in which you work with a healthcare provider to identify your personal goals and which type of types of treatments are needed to achieve those goals.

Hormone therapy is typically overseen by a specialist in the endocrine (hormonal) system called an endocrinologist . Other healthcare providers trained in gender-affirming medical care may be equally qualified to administer treatment.

Depending on state law and other factors, healthcare providers may be able to dispense treatment on the same day. No letter from a mental health provider may be needed. Call Planned Parenthood or your local LGBTI organization to learn about the laws in your state.

To receive authorization for insurance coverage, many insurers require a diagnosis of gender dysphoria . To do so, a therapist or mental health professional must confirm that there is a mismatch between a person's expressed or experienced gender and the gender they were assigned at birth for a period of at least six months.

How to Choose the Right Provider

Not every endocrinologist is equally well-suited to administer gender-affirming hormone therapy. Those who have undergone a comprehensive, multidisciplinary gender-affirmation training program are generally preferred.

Do not hesitate to ask about a healthcare provider's experience and qualifications in administering gender-affirming care.

Masculinizing Hormone Therapy

Masculinizing hormone therapy uses various types of testosterone to promote masculinizing changes in both binary and non-binary individuals. Testosterone is most often given as an injection, but other formations are available, including pills and creams.

There has been growing interest in the use of subcutaneous pellets for testosterone treatment, as they only need to be inserted two to four times a year. However, they are not always available or covered by insurance.

Changes that can be induced by masculinizing hormone therapy include:

  • Facial and body hair growth
  • Increased muscle mass
  • Lowering of the pitch of the voice
  • Increased sex drive
  • Growth of the glans clitoris
  • Interruption of menstruation
  • Vaginal dryness
  • Facial and body fat redistribution
  • Sweat- and odor-pattern changes
  • Hairline recession; possibly male pattern baldness
  • Possible changes in emotions or interests

Masculinizing hormone therapy cannot reverse all of the changes associated with female puberty. If transmasculine individuals have experienced breast growth that makes them uncomfortable, they may need to address that with binding or top surgery .

Testosterone will also not significantly increase height unless it is started reasonably early. Finally, testosterone should not be considered an effective form of contraception, even if menses have stopped.

Feminizing Hormone Therapy

Feminizing hormone therapy uses a combination of estrogen and a testosterone blocker. The testosterone blocker is needed because testosterone has stronger effects on the body than estrogen.

The blocker most commonly used in the United States is spironolactone , a medication also used for heart disease. The medication used as a puberty blocker, called Supprelin LA (histerline), can also be used to block testosterone.

Various forms of estrogen can be used for feminizing hormone therapy. In general, injectable or topical forms are preferred as they tend to have fewer side effects than oral estrogens. However, some trans women prefer oral estrogens.

Changes that can be induced by feminizing hormone therapy include:

  • Breast growth
  • Softening of the skin
  • Fat redistribution
  • Reduction in face and body hair (but not elimination)
  • Reduced hair loss/balding
  • Muscle-mass reduction
  • Decrease in erectile function
  • Testicular size reduction

Estrogen cannot reverse all changes associated with having undergone testosterone-driven puberty. It cannot eliminate facial or body hair or reverse shoulder width, jaw size, vocal pitch, or facial structure. Many of these can be addressed with aesthetic or surgical treatments.

What to Expect During Treatment

Some hormones used for gender-affirming hormone therapy are self-administered or given by someone you know. Others need to be administered by a healthcare provider.

Thereafter, regular follow-ups are needed to evaluate the effects of treatment and possible side effects. Most healthcare providers recommend visiting every 3 months for the first year and every 6 to 12 months thereafter.

Effects of Therapy

It can take three to five years for your body to show the full effects of gender-affirming hormone therapy. Some changes can occur within the first six months, such as the development of larger breasts. Others, like changes in facial structure, can take years.

In addition to physical changes, hormone therapy can cause emotional changes. If you are sexually active, it may improve sexual satisfaction as well as your overall sense of well-being. Hormone therapy can also help to ease the stress associated with gender dysphoria.

If you discontinue therapy, some changes may be reversible. Others like changes in bone structure may be permanent.

Possible Risks

As beneficial as gender-affirming hormone therapy can be, it also carries certain risks depending on which hormone you are taking.

Possible risks of feminizing hormone therapy include:

  • High blood pressure
  • Blood clots
  • Heart disease
  • Type 2 diabetes
  • Weight gain
  • Infertility
  • Breast and prostate cancer

Risks of masculinizing hormone therapy:

  • Male pattern baldness
  • High cholesterol
  • Pelvic pain
  • Sleep apnea
  • Interfertility

Access to Gender-Affirming Hormone Therapy

Until relatively recently, access to gender-affirming hormone therapy was largely managed through gatekeeping models that required gender-diverse people to undergo a psychological assessment before they could access hormone treatment.

However, there has been a growing movement toward the use of an informed consent model to better reflect access to other types of medical care. This change has been reflected in the standards of care for transgender health produced by the World Professional Association of Transgender Health (WPATH).

Gender-affirming hormone therapy is considered to be a medically necessary treatment for gender dysphoria. It should be covered by most insurers in the United States after legal changes that occurred as part of the passage of the Affordable Care Act.

However, state laws vary substantially in terms of transgender protections, and some states do allow policies to exclude various aspects of transgender health care, including gender-affirming hormone therapy.

Access to hormone therapy can be prohibitively expensive for many people if they need to pay out of pocket, which may lead some people to try to get these medications from friends or other unlicensed sources.

In addition, individuals who are involved with carceral systems such as immigrant detention may be denied access to hormones. This can have significant negative physical and psychological effects.

Gender-affirming hormone therapy is the primary form of treatment for transgender people. Masculizing hormone therapy involving testosterone is used to develop secondary male sex characteristics like larger muscles. Feminizing hormone therapy involving estrogen and a testosterone blocker is used to develop secondary female sex characteristics like breasts.

Some masculinizing and feminizing effects can occur within months, while others may take years. If you stop treatment, many of the effects will reverse while some will be permanent. Regular follow-up care is needed to avoid potential side effects and long-term complications.

Gardner I, Safer JD. Progress on the road to better medical care for transgender patients . Curr Opin Endocrinol Diabetes Obesity . 2013 20(6):553-8. doi:10.1097/01.med.0000436188.95351.4d

James SE, Herman JL, Rankin S, Keisling M, Mottet M, Anafi M. The Report of the 2015 U.S. Transgender Survey . Washington, DC: National Center for Transgender Equality. 2016.

Planned Parenthood. Gender-affirming hormone therapy: what to expect on your first visit and beyond .

Boskey ER, Taghinia AH, Ganor O. Association of surgical risk with exogenous hormone use in transgender patients: A systematic review . JAMA Surg . 2019;154(2):159-169. doi:10.1001/jamasurg.2018.4598

Almazan AN, Benson TA, Boskey ER, Ganor O. Associations between transgender exclusion prohibitions and insurance coverage of gender-affirming surgery. LGBT Health . 2020;7(5). doi:10.1089/lgbt.2019.0212

White Hughto JM, Reisner SL. A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals . Transgender Health . 2016;1(1),21–31. doi:10.1089/trgh.2015.0008

Cavanaugh T, Hopwood R, Lambert C. Informed consent in the medical care of transgender and gender-nonconforming patients . AMA Journal of Ethics . 2016;18(11),1147–1155. doi:10.1001/journalofethics.2016.18.11.sect1-161

World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th Version) . WPATH. 2011.

By Elizabeth Boskey, PhD Elizabeth Boskey, PhD, MPH, CHES, is a social worker, adjunct lecturer, and expert writer in the field of sexually transmitted diseases.

  • Introduction
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Error bars represent 95% CIs. GAS indicates gender-affirming surgery.

Percentages are based on the number of procedures divided by number of patients; thus, as some patients underwent multiple procedures the total may be greater than 100%. Error bars represent 95% CIs.

eTable.  ICD-10 and CPT Codes of Gender-Affirming Surgery

eFigure. Percentage of Patients With Codes for Gender Identity Disorder Who Underwent GAS

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Wright JD , Chen L , Suzuki Y , Matsuo K , Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348

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National Estimates of Gender-Affirming Surgery in the US

  • 1 Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
  • 2 Department of Obstetrics and Gynecology, University of Southern California, Los Angeles

Question   What are the temporal trends in gender-affirming surgery (GAS) in the US?

Findings   In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

Meaning   These findings suggest that there will be a greater need for clinicians knowledgeable in the care of transgender individuals with the requisite expertise to perform gender-affirming procedures.

Importance   While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective   To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants   This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures   Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results   A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance   Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Gender dysphoria is characterized as an incongruence between an individual’s experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient’s gender identity with their physical appearance. 2 - 4

While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2 , 4 Prior studies 2 - 7 have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria. Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8 Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2 , 4

Given the benefits of GAS, the performance of GAS in the US has increased over time. 9 The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10 , 11 While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9 This is important as many GAS procedures occur in ambulatory settings. We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS). NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospital-owned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospital-owned facilities. NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population. Both NIS and NASS contain weights that can be used to produce US population estimates. 12 , 13 Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board. This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline.

We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision ( ICD-10 ) diagnosis codes for gender identity disorder or transsexualism ( ICD-10 F64) or a personal history of sex reassignment ( ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1 ). We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort. GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2 , 4 Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction. Genital reconstructive procedures included any surgical intervention of the male or female genital tract. Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1 ). Patients might have undergone procedures from multiple different surgical groups. We measured the total number of procedures and the distribution of procedures within each procedural group.

Within the data sets, sex was based on patient self-report. The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent. The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record. Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics. Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, self-pay, and other). Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other. Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS. The income status captured national quartiles of median household income based of a patient’s zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high). The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14 Patients were classified as 0, 1, 2, or 3 or more. We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses. Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West). Hospital bed sizes were classified as small, medium, and large. The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15 The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively. The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated. The difference by age group was examined and tested using Rao-Scott χ 2 test. All hypothesis tests were 2-sided, and P  < .05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

A total of 48 019 patients who underwent GAS were identified ( Table 1 ). Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged 12 to 18 years. Private insurance coverage was most common in 29 064 patients (60.5%), while 12 127 (25.3%) were Medicaid recipients. Depression was reported in 7192 patients (15.0%). Most patients (42 467 [88.4%]) were treated at urban, teaching hospitals, and there was a disproportionate number of patients in the West (22 037 [45.9%]) and Northeast (12 396 [25.8%]). Within the cohort, 31 668 patients (65.9%) underwent 1 procedure while 13 415 (27.9%) underwent 2 procedures, and the remainder underwent multiple procedures concurrently ( Table 1 ).

The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020. Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 ( Figure 1 and eFigure in Supplement 1 ). Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures. For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.

Breast and chest procedures were most common and were performed for 27 187 patients (56.6%). Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( Table 2 ). The most common individual procedure was breast reconstruction in 21 244 (44.2%), while the most common genital reconstructive procedure was hysterectomy (4489 [9.3%]), followed by orchiectomy (3425 [7.1%]), and vaginoplasty (3381 [7.0%]). Among patients who underwent other facial and cosmetic procedures, liposuction (2945 [6.1%]) was most common, followed by rhinoplasty (2446 [5.1%]) and facial feminizing surgery and chin augmentation (1874 [3.9%]).

The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 ( Figure 1 ). Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020. The distribution of the individual procedures performed in each class were largely similar across the years of analysis ( Table 3 ).

When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 ( Figure 2 ). There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years. Among patients younger than 19 years, 3678 GAS procedures were performed. GAS was less common in those cohorts older than 50 years. Overall, the greatest number of breast and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.

When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients ( Figure 2 ). Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures. This decreased to 16 067 patients (64.0%) in those aged 19 to 30 years, 4918 (46.9%) in those aged 31 to 40 years, and 1650 (37.9%) in patients aged 41 to 50 years ( P  < .001). In contrast, 405 patients (11.0%) aged 12 to 18 years underwent genital surgery. The percentage of patients who underwent genital surgery rose sequentially to 4423 (42.2%) in those aged 31 to 40 years, 1546 (52.3%) in those aged 51 to 60 years, and 742 (58.4%) in those aged 61 to 70 years ( P  < .001). The percentage of patients who underwent facial and other cosmetic surgical procedures rose with age from 9.5% in those aged 12 to 18 years to 20.6% in those aged 51 to 60 years, then gradually declined ( P  < .001). Figure 2 displays the absolute number of procedure classes performed by year stratified by age. The greatest magnitude of the decline in 2020 was in younger patients and for breast and chest procedures.

These findings suggest that the number of GAS procedures performed in the US has increased dramatically, nearly tripling from 2016 to 2019. Breast and chest surgery is the most common class of procedure performed while patients are most likely to undergo surgery between the ages of 19 and 30 years. The number of genital surgical procedures performed increased with increasing age.

Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time. 9 , 16 A prior study examining national estimates of inpatient GAS procedures noted that the absolute number of procedures performed nearly doubled between 2000 to 2005 and from 2006 to 2011. In our analysis, the number of GAS procedures nearly tripled from 2016 to 2020. 9 , 17 Not unexpectedly, a large number of the procedures we captured were performed in the ambulatory setting, highlighting the need to capture both inpatient and outpatient procedures when analyzing data on trends. Like many prior studies, we noted a decrease in the number of procedures performed in 2020, likely reflective of the COVID-19 pandemic. 18 However, the decline in the number of procedures performed between 2019 and 2020 was relatively modest, particularly as these procedures are largely elective.

Analysis of procedure-specific trends by age revealed a number of important findings. First, GAS procedures were most common in patients aged 19 to 30 years. This is in line with prior work that demonstrated that most patients first experience gender dysphoria at a young age, with approximately three-quarters of patients reporting gender dysphoria by age 7 years. These patients subsequently lived for a mean of 23 years for transgender men and 27 years for transgender women before beginning gender transition treatments. 19 Our findings were also notable that GAS procedures were relatively uncommon in patients aged 18 years or younger. In our cohort, fewer than 1200 patients in this age group underwent GAS, even in the highest volume years. GAS in adolescents has been the focus of intense debate and led to legislative initiatives to limit access to these procedures in adolescents in several states. 20 , 21

Second, there was a marked difference in the distribution of procedures in the different age groups. Breast and chest procedures were more common in younger patients, while genital surgery was more frequent in older individuals. In our cohort of individuals aged 19 to 30 years, breast and chest procedures were twice as common as genital procedures. Genital surgery gradually increased with advancing age, and these procedures became the most common in patients older than 40 years. A prior study of patients with commercial insurance who underwent GAS noted that the mean age for mastectomy was 28 years, significantly lower than for hysterectomy at age 31 years, vaginoplasty at age 40 years, and orchiectomy at age 37 years. 16 These trends likely reflect the increased complexity of genital surgery compared with breast and chest surgery as well as the definitive nature of removal of the reproductive organs.

This study has limitations. First, there may be under-capture of both transgender individuals and GAS procedures. In both data sets analyzed, gender is based on self-report. NIS specifically makes notation of procedures that are considered inconsistent with a patient’s reported gender (eg, a male patient who underwent oophorectomy). Similar to prior work, we assumed that patients with a code for gender identity disorder or transsexualism along with a surgical procedure classified as inconsistent underwent GAS. 9 Second, we captured procedures commonly reported as GAS procedures; however, it is possible that some of these procedures were performed for other underlying indications or diseases rather than solely for gender affirmation. Third, our trends showed a significant increase in procedures through 2019, with a decline in 2020. The decline in services in 2020 is likely related to COVID-19 service alterations. Additionally, while we comprehensively captured inpatient and ambulatory surgical procedures in large, nationwide data sets, undoubtedly, a small number of procedures were performed in other settings; thus, our estimates may underrepresent the actual number of procedures performed each year in the US.

These data have important implications in providing an understanding of the use of services that can help inform care for transgender populations. The rapid rise in the performance of GAS suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures. However, numerous reports have described the political considerations and challenges in the delivery of transgender care. 22 Despite many medical societies recognizing the necessity of gender-affirming care, several states have enacted legislation or policies that restrict gender-affirming care and services, particularly in adolescence. 20 , 21 These regulations are barriers for patients who seek gender-affirming care and provide legal and ethical challenges for clinicians. As the use of GAS increases, delivering equitable gender-affirming care in this complex landscape will remain a public health challenge.

Accepted for Publication: July 15, 2023.

Published: August 23, 2023. doi:10.1001/jamanetworkopen.2023.30348

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Wright JD et al. JAMA Network Open .

Corresponding Author: Jason D. Wright, MD, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 161 Fort Washington Ave, 4th Floor, New York, NY 10032 ( [email protected] ).

Author Contributions: Dr Wright had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wright, Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wright.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Wright, Chen.

Administrative, technical, or material support: Wright, Suzuki.

Conflict of Interest Disclosures: Dr Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.

Data Sharing Statement: See Supplement 2 .

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Sex Reassignment Surgery, Marriage, and Reproductive Rights of Intersex and Transgender People in Sunni Islam

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  • Sayyed Mohamed Muhsin 1 ,
  • Firdaus Yahya 2 ,
  • Rasheed Parachottil 3 ,
  • Sirajuddin Shaikh 3 &
  • Alexis Heng Boon Chin   ORCID: orcid.org/0000-0002-3547-5271 4  

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The traditional gender binary constitutes an integral aspect of Islamic social ethics, which has a pivotal role in shaping religious obligations, legal proceedings, and interpersonal judgments within Muslim communities. Within the familial sphere, this gender binary underscores fundamental responsibilities encompassing parenthood, filial duties, and inheritance rights. Recent years have witnessed a growing challenge to the traditional concept of the gender binary within Islamic societies. This shift is driven by increasing social libertarianism that emphasizes gender fluidity and individual choice. Hence, this article aims to critically scrutinize evolving discussions and controversies about the rights of intersex and transgender individuals, particularly issues relating to sex reassignment or gender-affirming surgery, marriage, and reproduction, from the perspective of the Sunni tradition of Islam. To support the various interpretations and insights presented here, a comprehensive and rigorous analysis is carried out on various religious texts and scholarly sources to elucidate the theological and jurisprudential positions on gender issues. It is thus concluded that Shariah offers greater flexibility in the treatment of intersex individuals compared to those with gender dysphoria because the intersex condition is viewed as a physical impairment that is not the choice of the afflicted individual. By contrast, in the case of individuals with gender dysphoria, they are willfully attempting to change their recognized biological sex, that God had naturally given to them at birth. Therefore, it is recommended that such transgender individuals deserve respectful psychological and social rehabilitation with help and guidance from religious authorities, their families, and communities.

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Newsweek

California Paying for Illegal Migrants to Gender Transition Sparks Fury

C onservatives have reacted with fury after it was reported that illegal migrants in California can be eligible for gender-affirming care from Medi-Cal, the state's version of Medicare.

Beginning January 1, all undocumented immigrants in California who meet certain criteria, such as having been resident in the state since 2014 and having income below a certain threshold, automatically qualified for Medi-Cal.

The U.S. has recorded a substantial surge in illegal crossings at the southern border over the past few months, with law enforcement reporting more than 9,600 migrant encounters a day during the first three weeks of December, with 192,000 apprehensions reported for November. Control over the U.S.-Mexico border looks to be a major issue during the upcoming presidential election, with the Democratic mayors of New York, Chicago and Denver admitting they are struggling to deal with the influx .

Posting on X, formerly Twitter , Colorado House Republican Lauren Boebert hit out at the policy commenting : "California is now paying for illegal aliens to get sex changes. There's no punchline to this tweet. California is the punchline."

While state guidelines say that illegal migrants can qualify for gender-affirming care, it is unclear if any have taken up this option.

Responding to Boebert, conservative commentator Paul Szypula, who has more than 101,000 X followers, said: "California is horrible but so is the US border. Republicans in Congress had a year as majority to address it but refused to be tough when needed."

Another X user responded by attacking Boebert, posting: "Almost made it the whole day without some blathering bigotry. So close."

Medi-Cal had been available to those age 25 and under, or 50 and over, who met the income and residency thresholds for some time, but starting Monday it was extended to all unregistered migrants, with an estimated 700,000 more people becoming eligible.

A 2022 California state memo, viewed by online news outlet The Daily Caller, makes it clear that "gender affirming care is a covered Medi-Cal benefit when medically necessary." This matches advice from the Transgender Law Center, a transgender advocacy group, which in a recent publication on gender reassignment surgery said: "Despite what many Medi-Cal recipients have heard, Medi-Cal will cover some procedures."

On January 2, The Daily Caller published excerpts of the memo on receiving gender-affirming health care: "Gender affirming care is a covered Medi-Cal benefit when medically necessary. Requests for gender affirming care should be from specialists experienced in providing culturally competent care to transgender and gender diverse individuals and should use nationally recognized guidelines.

"Medical necessity is assessed and services shall be recommended by treating licensed mental health professionals and physicians and surgeons experienced in treating patients with incongruence between their gender identity and gender assigned at birth."

According to the Transgender Law Center, Medi-Cal "should cover hormone treatment, gender reassignment surgery, and other necessary procedures."

The organization explains: "Medi-Cal is required by law to evaluate requests on a case-by-case basis. They must approve those requests that they find to be medically necessary so long as the procedure is not considered to be 'experimental.' Medi-Cal's definition of experimental does not include gender reassignment surgery."

Newsweek has reached out to the office of California Governor Gavin Newsom by email for comment.

USA Boxing recently released a policy update allowing transgender women to compete as their chosen gender , sparking mixed response on social media.

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Migrants take part in a caravan heading towards the border with the United States in Tapachula, Chiapas State, Mexico, on December 24, 2023. Around 700,000 more migrants in California have been eligible for Medi-Cal, which can include gender affirming care, since Monday.

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    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. Insurance Coverage for Sex Reassignment Surgery.

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    It involves removing the penis, testicles and scrotum. Vaginoplasty involves rearranging tissue in the genital area to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. To create the vaginal canal, the surgeon uses a combination of the skin surrounding the existing penis along with the scrotal skin.

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    Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.. Often used to refer to vaginoplasty, sex reassignment surgery can also more broadly refer to other gender-affirming ...

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    Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender.The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals.

  11. Gender Affirmation Surgeries: Common Questions and Answers

    Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender. A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery. The term "transexual" was previously used by the medical community to describe people ...

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    Overview. Masculinizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Masculinizing surgery includes several options, such as top surgery to create a more male-contoured chest and bottom surgery that changes the genitals.

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    Gender-affirming surgery is a collection of surgical procedures for adults ages 18 and older diagnosed with gender dysphoria. The operations are often referred to as "top surgery" and "bottom surgery.". Duke Health offers several top surgery options to transgender, gender-diverse, nonbinary, and gender-nonconforming adults who want their ...

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    A 2018 study found that 94-100% of participants who had undergone gender-affirming surgery reported satisfaction with the surgical results, with the variance depending on the type of procedure.

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    Types of Top Surgery. Depending on the patient's goals, the surgeon may recommend several different approaches for top surgery: For chest feminization: Breast augmentation with implants. Breast augmentation with fat grafting. Breast augmentation with implants and fat grafting. For chest masculinization: Remove breast tissue and overlying skin.

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    Key Points. Question What are the temporal trends in gender-affirming surgery (GAS) in the US?. Findings In this cohort study of 48 019 patients, GAS increased significantly, nearly tripling from 2016 to 2019. Breast and chest surgery was the most common class of procedures performed overall; genital reconstructive procedures were more common among older individuals.

  24. Sex Reassignment Surgery, Marriage, and Reproductive Rights ...

    The case of sex reassignment surgeries is recognized and practiced within specific segments of Shia Islam, and Iran has become one of the centers for Sex-Reassignment Surgery for non-intersex individuals with gender dysphoria in the world (Kalbasi-Isfahani & Deleer, 2016; Mamoojee et al., 2017). However, it is crucial to exercise caution when ...

  25. Gov. Mike DeWine signs executive order to ban gender reassignment ...

    In the interim, DeWine has signed an executive order banning gender reassignment surgery for people under 18. The ban applies to hospitals and ambulatory surgical facilities, effective immediately.

  26. USA Boxing Now Requires Trans Boxers to Get Surgery in Order to ...

    USA Boxing will now require trans athletes to declare they have "completed gender reassignment surgery" and provide at least four years of quarterly hormone evaluations before stepping in the ...

  27. HB 5297 Text

    "Irreversible gender reassignment surgery" means a medical procedure performed for the purpose of assisting an individual with a gender transition, including any of the following: (1) Penectomy, orchiectomy, vaginoplasty, clitoroplasty, or vulvoplasty for biologically male patients or hysterectomy or ovariectomy for biologically female patients ...

  28. California Paying for Illegal Migrants to Gender Transition ...

    According to the Transgender Law Center, Medi-Cal "should cover hormone treatment, gender reassignment surgery, and other necessary procedures." The organization explains: "Medi-Cal is required by ...