Trans Summer School: The Wide World of Surgical Transition
Whether you’re transgender or otherwise gender nonconforming, you may be thinking about the options when it comes to surgical transition, either now or in the future — and if you're under 18, “future” may be the operative (so to speak) word. While you may not be thinking about surgery for quite a while, it helps to be informed so that you can start thinking about your options and the decisions ahead.
Before we plunge into the OR, it’s important to know this: not every transgender or otherwise gender nonconforming person opts for surgical transition. Deciding against surgery for now, or for all time, doesn’t mean you’re “not trans enough” and it doesn’t invalidate your gender. Every transgender or otherwise gender nonconforming person has a different relationship with their body, and the physical appearance of your body doesn’t dictate who you are.
If you want surgery and can’t access it for various reasons — you’re too young, you can’t get clearance, your insurance won’t cover it, you can’t afford it — we know that can be tremendously stressful. (Which is perhaps an understatement.) Know that while you may be struggling with your body, your gender is still your own.
Your surgical status — whether you’ve had or plan to get surgery, which procedures you have or haven’t had, whether you’re “post-op” or “pre-op” — is your business and no one else’s. It is rude to ask questions about someone’s body, and in the context of work or school, such questions could be considered sexual harassment, and you should absolutely report them. In a medical context, it’s not always necessarily relevant, and you should feel free to tell doctors that. If you’re going to the gynecologist, it matters. If you’re getting a broken arm set, or being treated for a cough, the contents of your pants are not at all relevant.
Now, onwards and upwards.
There are a huge range of surgical transition options available to transgender or otherwise gender nonconforming people, including: Breast augmentation, subtotal mastectomy (“top surgery”), hysterectomy, orchiectomy, phalloplasty/metoidioplasty, vaginoplasty, and facial feminization surgery (we’re not big fans of this term, but it’s what the medical establishment calls it). You may hear people use terms like gender confirmation surgery, sexual reassignment surgery, top surgery, bottom surgery, or reconstructive surgery used to describe these procedures — “sex change,” while popular in some corners of the media, isn’t considered appropriate.
Some of these procedures are highly specialized, and tend to be performed by surgeons who focus on transgender care. Others are needed by cis people, too, and you may interact with a surgeon who handles a mix of trans and cis patients, or works primarily with cis people, especially for things like hysterectomy, oophorectomy, breast augmentation, and subtotal mastectomy (my own top surgery was performed by a breast cancer specialist, because no one knows how to take off boobs like a cancer surgeon!).
Depending on how insurance, health care, and policy work in your country, you will likely need “clearance” for gender confirmation surgery. Typically that involves consultations with a therapist who specializes in transgender issues, in which you’ll discuss the risks and benefits of surgery and talk about your relationship with gender. Some insurance companies or national health plans require a diagnosis of “gender dysphoria” or “gender identity disorder” before they will cover your surgery.
This is a controversial subject, as you might imagine. Being transgender or otherwise gender nonconforming is not a pathology, and there’s nothing wrong with you if you want to seek medical or surgical transition options. Many care providers dislike this arbitrary access barrier too, and the “diagnosis” is performed purely for the purpose of helping you get the health care you need.
What to expect when you're expecting surgery
Once you’re cleared for surgery, your care provider may refer you to a surgeon (as for example if you belong to an HMO and you need to work with an in-network provider), or you may be given a letter or form that you can bring to a surgeon you want to work with. It’s a good idea to research surgeons to pick the best fit for you — lots of trans communities online discuss surgeons, and some people post photos of their outcomes to give you an idea of what to expect. Surgeons are also rated by various organizations and you can look up their records with the medical organizations they belong to as well. Consumer Reports has an excellent guide to researching surgeons if you want a starting point.
Before surgery, you’ll have a “consult,” during which the surgeon’s office will collect some basic information (height, weight, bloodwork, medical history) to assess your fitness for surgery and identify any risk factors. Always be honest during this phase — a risk factor doesn’t necessarily mean you will be disqualified for surgery, but the surgical team needs to know about it because it will affect how they care for you. For example, if you have sleep apnea or another breathing disorder, that’s important for an anesthesiologist to know.
The surgeon will also conduct a physical exam, and may take pictures for internal records — these are used in surgical planning as a reference and are kept confidential in your medical record. (If your surgeon wants to use before/after photos of you in marketing materials or consults with other patients, you must give explicit permission.) You’ll talk about any presurgical preparation, which can vary depending on the surgeon and the procedure, and set a date for the big event. The night before, you’re typically asked not to eat or drink. You may need to stop taking some medications, like blood thinners, and sometimes you’ll need to take an industrial-strength laxative (yeah, it’s about as fun as it sounds — keep a copy of War and Peace by the toilet!).
On surgery day, admitting staff will go over some questions with you one more time, and confirm that you’re ready for surgery — if you’ve been sick, for example, it may not be safe to operate that day. You’ll also meet with the anesthesiologist or nurse anesthetist if you haven’t already. Once you change into a nifty hospital gown, a nurse will start an intravenous line to start delivering fluids and medications. (Protip: if the fluids feel cold going in, ask for a warm blanket or towel to drape over the line if the hospital doesn’t have a fluid warmer available.)
Perioperative nurses are the unsung heroes of the surgical world. They’re very invested in your health and want to keep you safe, so speak up if you have any questions or concerns. Whether you’re worried about a possible medication conflict or you want to know why your urine changed color (it shoudn’t!), let someone know. Most hospitals will allow a friend to hang out with you in preop for a while, and you can ask your friend to hang on to your stuff for you while you’re incommunicado.
Depending on hospital policy and which drugs they hooked you up with, you may be wheeled into the OR in style, or you may walk. You’ll probably notice that the OR feels cold and looks really bright, and there will be all sorts of commotion as they get you situated on the OR table. Then your anesthesiologist will give you a sedative injection and/or gas anesthesia, and…
...mysterious things will happen...
...and then you’ll wake up. You may feel nauseous, cold, and shivery after waking up from surgery, depending on the length of the procedure, which medications they used, and how your body reacted. A nurse will be keeping a close eye on you, and can hook you up with one of those nifty puke pans, medications to help you stop shaking, and blankets to warm up. Don’t be afraid to be an annoying patient: The nurse wants to know if you feel “weird,” beyond the obvious. Communicate about your pain levels, and say something if you just don’t feel right, even if you can’t quite explain how.
Nurses are also used to some of the more unfortunate aftereffects of surgery. Don’t be ashamed or worried about being a bother if you have to vomit, experience incontinence, or develop breakthrough bleeding.
Once you’re awake and responsive, you’ll probably relax in recovery for a while, and a nurse may work on getting you moving around. This can be uncomfortable and annoying, but it’s critical for surgical recovery, even if you can only shuffle around for a few steps. Depending on your procedure, you may be bundled up with drugs and sent home, or you might hang out in the hospital for a few days. The discharge nurse will discuss side effects, how to use your medications, and any potential concerns, and you’ll be given a number to call if there are any problems.
Everyone reacts to surgery differently, but you can expect to feel tired and sluggish for a few days (I know, you just slept through how many hours on the OR table and you want to go back to bed?). You may also have trouble eating — foods can taste, feel, or smell different. It helps to have soft, boring foods around, but if your body wants something different, go for it! As in the hospital, it’s important to move around — recruit a friend or family member to take a couple of walks around the block with you a day. You should also make an effort to take a few minutes of very deep breaths every hour to prevent pneumonia and other breathing complications.
Take your pain medication on schedule. The most effective pain management involves medicating before the onset of pain, because if you wait until you’re hurting, then you have to wait while your medication takes effect. Pain can also be an underlying issue — you might feel irritable or angry and not realize that you’re in pain. While many doctors prescribe opioids for post-operative recovery, don’t let that scare you: when you use them as directed for pain management, your risks of developing addictive habits are very, very low.
You may also experience postoperative depression, which is a weird and not very well understood phenomenon. Depression symptoms might not emerge right away, and can last for months. If you have a history of depression, definitely talk about your surgery with your doctor. If you don’t but you notice your mood is unusually low, that’s the surgery talking — and help is available.
Recovery times can vary depending on your procedure, and it can take two years or more for your body to “settle,” so don’t panic if the results aren’t quite what you expected right out the gate. Care for your surgery site as directed, communicate with your doctor about anything abnormal, and keep your eyes on the prize!
Enough generalities: You want to know what happens while you’re asleep. Want to jump to your main area of concern? Prefer to read in smaller chunks? We've got you covered!
- Breast augmentation
- Subtotal mastectomy ("top surgery")
- Phalloplasty/metoidioplasty ("bottom surgery")
- Vaginoplasty (also "bottom surgery")
- Facial feminization surgery
....or scroll on to read the whole thing.
After about two years of estrogen, your body will be pretty maxed out in the boob department. What you see is what you get...but if you’re not happy with the look and feel of your breasts, you can explore breast augmentation. There are a huge range of procedures available, broken down by type of incision and implant, and your best option depends on the preferences of your surgeon, your body, and your desired outcome.
Augmentation is typically available as an outpatient (same day) procedure. During your consult, you can discuss your ideal cup size and the best approach with your surgeon, who will have an array of implants available for you to feel, as well as some photos of surgical outcomes to give you an idea of what to expect. During the surgery, the doctor will make a small incision to insert the implant, and after the initial swelling has gone down, you’ll be looking at a whole new you.
You will likely need at least one followup appointment to remove sutures, and the surgeon will have instructions for you on physical activity, including sex, after surgery. It can be frustrating, but it’s important to follow them to help your breasts heal. If that means some Netflix and chill sans chill, well, at least there’s a good back catalogue of dorky shows to enjoy while you recover.
Some things to know about augmentation: breast implants can and do migrate, rupture, and develop other issues. If you’re young, you will likely need to undergo another reconstructive surgery in the future. If you want larger implants, you may need to undergo a two-step procedure with tissue expanders, which help stretch your skin to ensure there will be enough to cover your implants.
Subtotal mastectomy (“top surgery”)
Fun fact: while top surgery is often described as a “mastectomy,” that’s actually usually inaccurate. Many surgeons perform a “subtotal mastectomy,” which involves removing most, but not all, of the breast tissue. This prevents a sunken or fallen appearance after surgery, and makes it look like you have a sweet set of pecs (if you aren’t already sporting them). It does mean, however, that enough breast tissue remains for you to think about breast cancer risks. You should make sure your health care provider knows that you had a subtotal mastectomy so you can determine which, if any, preventative and screening measures (like mammograms) you should undertake. If you have a family history of breast cancer and/or have genetic testing suggesting you’re at greater risk, that may affect your surgical planning, so be sure to discuss it with your surgeon.
Many top surgery procedures are performed on an outpatient basis. There are a number of options for approaching the surgery, primarily dictated by the size of your breasts. Those with larger breasts will likely need a double incision, while others may be able to have a t-anchor or periareolar surgery, which involves a much smaller incision. That means less scarring and less healing time. Surgical outcomes can also be better for patients who don’t carry a lot of fat in their upper bodies, though your surgeon may perform a little liposuction to tidy things up.
For those eagerly looking forward to taking off their binders, sorry: For about a month after surgery, you’ll need to wear a compression garment to help shape your healing chest. You may also be directed to wear surgical drains, tubes that allow fluid to drain from your chest and collect in a little bulb. They’re about as gross as they sound, but you’ll need to empty them regularly and report any problems to your surgeon.
Once your compression garment comes off, you may need to take special care of your nipples if they were removed and grafted, to ensure that they heal well. Your chest will likely be swollen, bruised, and uncomfortable, and it will take around two years for it to completely settle. If you’re not happy with your outcome, you can meet with your surgeon to discuss a revision.
If you’ve got a uterus and you don’t want one, you’ll be spending some personal time with a gynecological surgeon. While this is obvious, it bears mentioning up front: if you have a hysterectomy, you will not be able to get pregnant — and this is an irreversible surgical procedure, so if you change your mind about getting pregnant and carrying a pregnancy to term in the future, you’re going to be out of luck. (Until uterus transplants are widely available, anyway.)
Depending on your circumstances and the surgeon’s approach, you may get a supracervical hysterectomy (your cervix remains in place) or a total hysterectomy (your uterus and cervix are removed). It may be possible to perform your surgery laparoscopically through small incisions in your abdomen and the miracles of science, or transvaginally, which is exactly what it sounds like, but you may be looking at an abdominal surgery — this isn’t just an issue because of the nifty scar, but because of the longer recovery time, since your surgeon will cut through the muscles in your abdominal wall. (Ouch!)
Sometimes your surgeon won’t be able to tell which approach is best until you’re already under anesthesia, so it’s possible you’ll go to sleep expecting a laparoscopic procedure and wake up with a nifty abdominal incision. The vaginal approach has the shortest recovery time, though, and it tends to be the procedure of choice, according to our friends at the American College of Obstetricians and Gynecologists.
When your uterus is removed, you may request the removal of your fallopian tubes and/or your ovaries, since you don’t need them anymore — and if you have concerns about ovarian cancer, you might as well take those little punks out. If both are being removed, you’ll be getting a salpingo-oophorectomy — if it’s just your tubes that are taking a long walk off a short pier, it’s called a salpingectomy, and if just your ovaries are heading out the door, it’s an oophorectomy.
Once you lose your ovaries, your body won’t be able to produce very much estrogen on its own, and would go into menopause without hormone replacement therapy. If you’re already on testosterone therapy, you’ll need to continue for life unless you want menopause symptoms (you don’t). If you aren’t on testosterone, you may consider starting after surgery. You can also discuss estrogen replacement therapy if that's of interest.
After your procedure, your uterus will get its revenge one last time: You’ll experience some bleeding for a couple of weeks, and you’ll need to wear pads for a little while. (Tampons and other insertables are a no-go during surgical recovery.) If you had a transvaginal or laparoscopic hysterectomy, you’ll probably stay in the hospital overnight, so queue up your favorite podcasts. If you have an abdominal incision, you’ll likely be looking at another day in the hospital.
Once you get sprung from the hoosegow, your doctor will have specific aftercare directions, but they typically include no sex for about a month (and specifically, no inserting anything into your vagina, whether solo, partnered, or otherwise), restrictions on how much you can lift, and a recommendation to get active and stay that way.
If you know you’re planning to get a phalloplasty, you might want to hold off on that hysterectomy. Getting the two procedures done at the same time can save money and recovery time. If you’re not sure, or if you want to get them done separately, surgeons who perform phalloplasties recommend a transvaginal approach to the hysterectomy so that you won’t have any scarring that might interfere with their work. Since different surgeons have different needs, you may want to identify the surgeon you want to perform your phalloplasty first, and discuss the best surgical approach.
In this procedure, the surgeon removes the testicles with or without the scrotum. This procedure stops the production of testosterone, which allows patients to adjust their doses of anti-androgens and estrogen. Getting an orchiectomy doesn’t mean that genital confirmation surgery is out of the question in the future — some patients take a “slow as you go” approach. Your surgeon may ask if you plan to stop with orchiectomy or if you’re considering other procedures in the future (it’s fine to change your mind!) because this could affect the optimal surgical approach.
Some surgeons have strict requirements when it comes to getting clearance for ochiectomy. Once you’ve had this procedure, you will not be able to produce sperm — so if you think you might want to contribute your genes to someone in the future, you should make arrangements to bank your sperm for future use.
Phalloplasty/metoidioplasty (“bottom surgery”)
If you’re equipped with a clit and some labia and you’d like a penis (with or without testicles), you’re looking at either a phalloplasty or metoidioplasty. The procedures have different advantages and disadvantages that you’ll want to consider before making a decision.
Phalloplasty involves the construction of a penis from grafted tissue taken from elsewhere on the body — one option is the lower abdomen. The surgeon can create a circumcised or uncircumcised johnson for you, complete with testicles if desired. To construct testicles, the surgeon recycles your labia (and can add implants as well). You’ll retain sensation in your clitoris, and you should be able to have penetrative intercourse (some surgeons add a prosthesis that will allow you to get hard, but prostheses can fail). If you want to be able to stand to urinate, it will require a lengthy extension of your urethra, which comes with a lot of risks including stenosis (becoming fully or partially blocked) or fistula (springing a leak). Because of these issues, some surgeons won’t do it.
This procedure comes with risks. You can experience infection and scarring at the donor site, and the tissue on your penis could develop necrosis (die) even if you’ve cared for it as directed. The ultimate shape and size could be different from expected, and there will be some scarring. Depending on the surgeon and the procedures used, you may need multiple surgeries, and it’s possible you will have to return for revisions to address complications. This procedure is also quite expensive, and not always covered by insurance providers.
Metoidioplasty, also known as clitoral release, involves “elevating” your clitoris and may include constructing a new urethra along with it. While your resulting penis can allow you to stand to pee and it will be highly sensitive, it will also be quite small – around two inches or so. Complications can include scarring, infection, loss of sensation or excessive sensation, narrowing of your vaginal opening (which may not be a concern for you, depending on whether you want to be able to have vaginal penetrative intercourse), or problems with your constructed urethra similar to those discussed above. As with phalloplasty, your doctor can hook you up with a set of testicles if desired.
Vaginoplasty (also “bottom surgery”)
In vaginoplasty, which may require multiple surgeries, depending on the surgeon’s preference and your case, your existing genital tissue is creatively recycled into a vagina, set of labia, and a clitoris. After vaginoplasty, you will be able to have vaginal intercourse, you should be able to have orgasms, and your body will produce some lubrication. (Your surgeon may recommend the use of additional lubrication to protect your vagina from microtearing and other issues.)
You will need to stay in the hospital for several days following surgery, and you will be pretty uncomfortable — there’s a lot of packing and bandaging down there. Once your vagina has its grand opening, you’ll be directed in the use of dilators (also called stents), which look and work rather a lot like dildos — you’ll be gently inserting them, with plenty of lube, to keep your shiny new vagina open for business.
Facial feminization surgery
They call it “feminization surgery,” but that’s a bit of a misnomer. More accurately described, it tends to make the features of the face finer and more delicate, and people of any gender can have delicate features. You can meet with a plastic surgeon to discuss the look and feel you want, and some example photos are a good idea.
This family of plastic surgery procedures change the look and shape of your face. You’ll consult with your surgeon to discuss the options, but they can include contouring of the facial bones, lip and eyelid surgery, chin sculpting, hairline relocation, a facelift, a nose job, and/or a reduction of your thyroid cartilage (also known as tracheal shaving — it will reduce the size of your Adam’s apple).
Risks and complications can vary, depending on the nature of the procedure(s) performed, but can include scarring, infection, uneven facial features, and nerve damage.
If the thought of all of this makes you want to give up and lie on the floor, that’s okay. Transgender and otherwise gender nonconforming people who opt to pursue surgery can do it at any time in their lives — yes, even in their 80s! — and there’s no rush to think about, let alone get, surgery. Every year, surgical techniques are improving and more surgeons are training to provide services to transgender and otherwise gender nonconforming people, so in a way, a wait can be good: You may benefit from state of the art approaches to surgery that people are only just starting to explore!
Previously on Trans Summer School: The Magic of Hormones
Coming up next time: Dating While Trans, Yes You Can!