Patient information from BMJ

Gender-affirming care in adults: surgery

Last published:Aug 07, 2024

For some people, their internal sense of gender identity may not match their birth sex. This is known as gender incongruence. When this causes a person distress, it's known as gender dysphoria.

People experiencing gender incongruence and gender dysphoria may take steps to live and be accepted as a person of their experienced gender. This is known as gender transition. For more background information on this, see our patient information titled: Gender incongruence and Gender dysphoria in adults. 

Gender transition might involve medical or surgical treatment, but this varies and not every person will choose to have treatment.

The main treatments available are hormone treatment and surgery. Other treatments include: hair removal, speech and language therapy and supportive counselling.

This patient information will focus on surgery in adults.

Is gender-affirming surgery for me?

Having gender-affirming surgery is a major, personal decision. This is because surgery can involve permanent physical changes to your body that are extremely difficult to reverse.

Choosing to have surgery depends on the individual person. It’s important to remember that you can choose to have all, some, or none of the treatments available to you. There is no ‘one size fits all’ approach.

Regrets after surgery are rare, but they can happen; this is more likely if you’re struggling with changing your gender role.

Changing your gender role often involves:

• living as a person of your experienced gender

• changing your name and sex on legal documents (if possible, depending on where you live)

• asking your friends, family, and colleagues to treat you as a person of your gender identity.

Most doctors agree that you need to experience changing your gender role for at least 6 months to 1 year before having genital surgery. This is so you can be sure that you are happy and certain about living as a person of your gender identity before having major surgery.

Like with any treatment, there are criteria that doctors use to help understand whether surgery is right for you. These look at whether:

• you clearly have gender incongruence and have had it for a long time

• you are in the right state of mind to agree to surgery

• you understand that surgery may affect your ability to have children and you’ve looked into your options

• other possible causes of gender incongruence have been ruled out

• you have any mental health or physical conditions that could affect your surgery

• you have been stable on hormone treatment prior to surgery, if this is an option (in some cases, for at least 6 months).

If you choose to have this treatment, you will have psychological support from a team of gender identity specialists.

Your treatment team will help you understand what options there are for surgery, what surgery involves, and what you can expect from it.

Many people think this treatment only includes genital surgery (sometimes known as bottom surgery), or surgery to either remove or create breasts (sometimes known as top surgery). But there are several other types of surgery that can also change the appearance of your face and body.

Gender-affirming surgery for transgender women (feminising surgery)

There are several types of gender-affirming surgery that transgender women can consider.

Breast surgery (top surgery)

You might hear this type of surgery also being called breast augmentation. It involves using implants or other methods to increase breast size.

Genital surgery (bottom surgery)

This usually involves forming new female genitals (clitoris, labia, and vagina) from some of the male genital tissue, and removing the rest of the male genitals, including the penis and testicles.

Surgery to create a new vagina is called a vaginoplasty. Surgery to remove a penis is called a penectomy and the removal of testicles is called an orchidectomy.

Thyroid cartilage (‘Adam’s apple’) surgery

Some people have surgery to make their Adam’s apple look smaller and less masculine. They may also have another type of surgery in the same area called cricothyroid approximation. This is a voice surgery that increases the pitch of your voice so that it sounds more feminine. The change in voice pitch happens by increasing the tension of the vocal cords.

Doctors only recommend this operation if other methods of changing your voice, such as speech therapy, haven’t worked. If you have this operation you will usually still need to have speech therapy afterwards.

Surgery on the face and skull

The medical name for this is craniofacial surgery. The aim of this procedure is to change the shape of the face and skull. It is complicated and difficult, and doctors only recommend it after a long period of hormone treatment and when other cosmetic procedures haven’t worked well enough.

Hair removal

Although this is not technically surgery, it tends to come under this heading. Hair removal can be done with electrolysis or with laser treatment.

Electrolysis involves destroying individual hairs with heat treatment using a tiny probe. Some people find it slightly painful.

Laser treatment works by using light from a laser to damage hair follicles and stop them growing. It only works with dark-coloured hair and light-coloured skin.

Gender-affirming surgery for transgender men (masculinising surgery)

There are several types of gender-affirming surgery that transgender men can consider.

Breast surgery (top surgery)

This is surgery to remove the breasts and is also known as a bilateral mastectomy.

Genital surgery (bottom surgery)

This may involve surgery to remove all or part of the vagina (known as a vaginectomy) and surgery to create a penis (known as a phalloplasty).

A phalloplasty is complex and usually requires several operations. Only a small number of people choose to have this surgery.

Removal of uterus and ovaries

Some people choose to have an operation called a hysterectomy, which removes all or part of the womb (uterus), and an operation called an oophorectomy, which removes the ovaries.

Surgery on the face and skull

The medical name for this is craniofacial surgery. The aim of this procedure is to change the shape of the face and skull. It is complicated and difficult, and doctors only recommend it after a long period of hormone treatment and when other cosmetic procedures haven’t worked well enough.

Aesthetic procedures

Other treatment options are available that can make your body feel more masculine. These include liposuction and/or lipofilling (removing fat from one area of the body and/or moving it to another area), as well as pectoral implants which make the chest look more muscular.

Fertility

Some types of gender-affirming surgery can affect your fertility. Before receiving treatment, you should be given the chance to preserve your fertility, for example, through storing your eggs or sperm, or preserving your embryos. This gives you the option of having fertility treatment in the future if you choose to.

What will happen?

Choosing to have gender-affirming surgery is a major decision so it’s important you have all the information you need before making any choices. Counselling is a big part of this process. Your treatment team will explain all your options in detail and what to expect with surgery. They will also be able to answer any questions you have.

If you do decide to have surgery that removes your ovaries or testes, you will need to have lifelong hormone treatment. For more information on hormone treatment, see our patient information titled: Gender-affirming care in adults: hormone treatment.

Transgender people may experience stigma and discrimination. This can affect mental health and make some personal and professional relationships difficult to deal with. If you would like to talk to other people about their experiences, there is a lot of support. For example, in the UK, transunite.co.uk - a directory of more than 100 local support groups - is available.

Your treatment team might be able to put you in touch with a support group in your area, or you could search online.