Gender Reassignment Surgery: Types, Procedure, and Costs

05 November,2024

Gender reassignment surgery, aka gender confirmation surgery or sex reassignment surgery, is a crucial medical procedure for many transgender individuals seeking to align their physical appearance with their gender identity. This process, while complex, represents a significant step in affirming an individual's true identity. In this blog, we will delve into various aspects of gender reassignment surgery, from its history to the types of surgery available and the journey of recovery.

History of Gender Reassignment Surgery

The history of gender reassignment surgery dates back to the early 20th century, although the concept of gender transition can be traced back even further in various cultures. In the early 1900s, surgeries related to gender transformation were rare and often conducted in confidentiality due to the lack of social acceptance and the limitations of medical science at the time.

One of the earliest recorded gender reassignment surgeries took place in 1930 when Danish artist Lili Elbe, originally born as Einar Wegener, underwent several experimental surgeries in Germany. Elbe's story, later popularized in the book and film The Danish Girl, marked a watershed moment in transgender history. She was the first to undergo a uterus transplant. However, due to the primitive nature of the surgeries and the lack of post-operative care, she developed organ rejection and died on 13 September 1931.

As medical science progressed through the 20th century, surgeries became safer and more sophisticated. By the 1950s and 1960s, advancements in endocrinology (the study of hormones) and surgical techniques allowed for safer and more effective procedures. 

• Dr. Elmer Belt is known to have been one of the first American surgeons to perform gender affirmation surgery in about 1950.
• Dr. Harold Gillies was the first known plastic surgeon to develop phalloplasty (the first technique for female-to-male gender-affirming surgery). He performed the surgery on Laurence Michael Dillon in 1946.
• Dr. Harry Benjamin, a key figure in transgender health, was instrumental in providing hormonal and surgical care to transgender patients and advocating for their rights.
• Dr. Roberto Farina performed Brazil's first male-to-female surgery in 1971.
• In 1973, Singapore became the first Asian country to legalize gender-affirming surgeries.

Today, gender reassignment surgery has become much more advanced and widely available, with increasing acceptance of transgender individuals across many societies. While there are still challenges, the strides made in medical and social realms have allowed many to undergo these life-changing procedures with much better outcomes.

Statistics on Gender Reassignment Surgery

The number of individuals undergoing gender reassignment surgery has increased over the years, reflecting the growing acceptance and understanding of transgender identities. A study from the American Society of Plastic Surgeons reported a 20% increase in gender confirmation surgeries in the United States between 2017 and 2020. This increase aligns with the broader social movement advocating for transgender rights and visibility.

Globally, thousands of individuals undergo gender reassignment surgery every year. In the USA alone, approximately 9,000 gender affirmation surgeries are performed annually. It is estimated that between 2016 and 2019, more than 48,000 individuals sought at least one of the gender-affirming surgeries. These statistics, however, only scratch the surface, as not all transgender individuals opt for surgery, and many face barriers such as cost, access to healthcare, and legal constraints.

What is Gender Reassignment Surgery?

Before diving deep into what gender affirmation surgeries are and why they are done, let's understand some basic terminologies.

• Assigned male at birth (AMAB): AMAB are people whose sex is assigned as male at the time of birth based on their genital organs.
• Assigned female at birth (AFAB): AFAB is the terminology used for people who are identified as females at birth based on their external genitalia.
• Transman: Transgender men are males who were assigned female at birth but later recognized themselves as men. 
• Transwoman: Transgender women are females who were assigned male at birth. 
• Non-binary: People who do not identify themselves as either male or female come under the category of non-binary.

Gender reassignment surgery involves surgical procedures that help an individual's physical body align with their gender identity. It includes various surgeries, depending on whether the person is transitioning from female to male (FTM) or male to female (MTF). The surgery is part of a broader process known as gender transition, which may also include hormone therapy, psychological support, and social transition.

The goal of the surgery is not only to modify sexual characteristics but also to provide relief from gender dysphoria. In this condition, an individual feels a deep discomfort with their biological sex. Gender reassignment surgery helps many transgender people achieve a greater sense of unity between their body and identity, allowing them to live a more authentic life.

Why is Gender Reassignment Surgery Done?

Gender reassignment surgery is done for individuals experiencing gender dysphoria, a psychological condition that often leads to significant emotional distress, anxiety, and depression. For many, undergoing gender reassignment surgery is a vital part of alleviating this dysphoria and achieving mental well-being.

If you are transgender, nonbinary, or gender diverse, gender affirmation surgery may be part of your transition. This surgery can enhance or reduce physical attributes associated with being assigned female at birth (AFAB) or being assigned male at birth (AMAB), and it can also change the appearance of your genitals. The surgery allows transgender individuals to feel more comfortable in their skin and aligns their physical attributes with their gender identity.

Gender reassignment surgery is often one of the final stages of a comprehensive transition process that may include hormone therapy and social changes such as changing their name, using different pronouns (she/her, he/him, they/them), their style (hairstyle, clothing, makeup, etc.) and legal gender marker.

What are the Psychological Aspects of Gender Reassignment Surgery?

A gender reassignment surgery helps individuals battle various psychological conditions. Some of them are: 

• Gender Dysphoria: This is the primary psychological condition that leads individuals to seek gender reassignment surgery. It involves a significant disconnect between one's assigned sex and their gender identity.
• Anxiety and Depression: Gender dysphoria is often accompanied by depression and anxiety. It has a substantial impact on an individual's quality of life.
• Body Dysmorphia: This condition, characterized by a preoccupation with perceived flaws in one's appearance, can be exacerbated by gender dysphoria.
• Social Isolation: The stigma and discrimination associated with being transgender can lead to social isolation and difficulty forming meaningful relationships.
• Emotional Distress: The constant stress of living in a gender that doesn't align with one's identity can lead to significant emotional distress.

What are the Social Aspects of Gender Reassignment Surgery?

A person undergoing gender affirmation surgery experiences various social challenges. These include:

• Discrimination and Social Stigma: Transgender people often face discrimination and stigma in various life aspects, including employment, housing, and healthcare.
• Social Transition: This involves changing one's name, pronouns, and appearance. It can be very challenging, especially when faced with negative reactions from family, friends, and colleagues.
• Legal Recognition: Many countries have complex legal processes for transgender individuals to change their gender on official documents. This can be a lengthy and bureaucratic process.
• Workplace Discrimination: Transgender individuals may face discrimination in the workplace, including harassment, bullying, and unfair treatment.
• Healthcare Access: Access to quality healthcare, including gender-affirming surgery, can be limited, especially in countries with restrictive healthcare policies.

What are the Non-Surgical Methods for Gender Affirmation?

Not all transgender individuals opt for or require surgery. Many choose non-surgical methods as part of their transition. These methods include:

• Feminizing Hormone Therapy: For transgender women, estrogen and anti-androgen therapy encourage breast growth, skin softening, and fat redistribution to create a more feminine figure.
• Masculinizing Hormone Therapy: For transgender men, testosterone therapy promotes the development of masculine features, such as facial hair growth, voice deepening, and muscle mass increase.
• Voice Therapy: Many transgender individuals undergo voice training to modify their voice pitch and speech patterns to align with their gender identity.
• Electrolysis or Laser Hair Removal: These treatments are popular among transgender women to remove unwanted facial and body hair.

What are the Types of Gender Reassignment Surgery?

Gender reassignment surgery is broadly categorized into two types based on the direction of transition:

1. Male-to-Female (MTF) Surgery: This surgery helps individuals assigned male at birth transition to a female body.
2. Female-to-Male (FTM) Surgery: This surgery helps individuals assigned female at birth transition to a male body.

Multiple procedures may be performed within these categories, depending on a person's needs and desires. Some opt for only top surgery (chest surgery), while others may choose both top and bottom surgeries (genital reconstruction).

Male-to-female (MTF) Sex Reassignment Surgery

Male-to-female surgery typically involves several procedures aimed at creating a feminine appearance. These may include:

• Breast Augmentation: Hormone therapy may naturally result in breast growth, but for many transgender women, additional breast augmentation surgery is desired to achieve a more feminine chest.
• Facial Feminization Surgery (FFS): This includes procedures that soften the features of the face, such as rhinoplasty (nose reshaping), brow lifts, and jaw contouring. FFS can significantly affect a person's appearance and is often considered essential to the transition process.
• Orchiectomy: It is the procedure done to remove the testicles. Not having testicles reduces testosterone production in the body. The surgeon may combine it with scrotectomy (removal of the scrotum).
• Penectomy: It is the removal of the penis. 
• Vaginoplasty: This is the main genital surgery for transgender women in which the surgeon uses penile tissue and other genitalia to form a vaginal canal. It may also involve constructing a clitoris (clitoroplasty) and a labia (labiaplasty). The surgery allows for both cosmetic and functional outcomes, including the ability to experience sexual pleasure.
• Tracheal Shave (Adam's Apple Reduction): This surgery reduces the prominence of the Adam's apple, often seen as a masculine feature.

MTF surgery focuses on achieving a feminine physical appearance, including external genitalia, facial features, and body contouring.

Female-to-male (FTM) Sex Reassignment Surgery

Female-to-male surgery involves procedures aimed at creating a masculine appearance. These procedures may include:

• Chest Reconstruction (Top Surgery): One of the most common procedures for transgender men, chest reconstruction involves removing breast tissue and reshaping the chest. It helps create a more masculine contour and is often the first surgical step in FTM transitions.
• Hysterectomy, Vaginectomy, and Oophorectomy: These surgeries remove the uterus, vagina, and ovaries, respectively. Some transgender men choose to undergo these procedures to stop menstruation and reduce the production of female hormones.
• Phalloplasty or Metoidioplasty: These are the two main types of bottom surgery for transgender men. Phalloplasty involves constructing a penis using tissue grafts from other parts of the body, while metoidioplasty uses existing genital tissue to create a smaller penis. Both surgeries may also involve the creation of a scrotum (scrotoplasty) and the insertion of testicular implants.
• Urethral Lengthening: This surgery allows for urination through the newly constructed penis, making it possible for the individual to stand while urinating.
• Facial Masculinization Surgery (FMS): Like facial feminization, facial masculinization includes procedures that enhance masculine features, such as jawline augmentation and brow bone enhancement.

FTM surgery focuses on achieving a masculine appearance, including chest reconstruction and genital modification.

The Team of Doctors Involved

Gender reassignment surgery is a multidisciplinary effort involving a team of doctors and other healthcare professionals working together to provide the best possible outcomes for the patient. Some key members of the team include:

• Endocrinologists: These specialists manage hormone therapy, which is often a precursor to surgery. They monitor hormone levels and adjust treatments to help the body develop characteristics that align with the patient's gender identity.
• Plastic and Reconstructive Surgeons: These are the primary surgeons who perform the actual gender reassignment surgeries, which involve reshaping sexual organs and other body parts.
• Psychiatrists and Psychologists: Mental health professionals play a critical role in the process. They provide counseling and evaluate whether the patient is psychologically ready for the surgery. They also help individuals navigate the emotional aspects of transitioning.
• Urologists: Urologists may be involved, especially in surgeries that deal with the urinary tract or genital reconstruction.
• Gynecologists: For female-to-male (FTM) transitions, gynecologists may be part of the surgical team, particularly if oophorectomy (ovaries removal) or hysterectomy (uterus removal) is involved.
• Anesthesiologists: As with any major surgery, an anesthesiologist ensures the patient is safely sedated during the procedure.

This team approach ensures that the individual receives comprehensive care before, during, and after the surgery.

How is Gender Reassignment Surgery Performed?

The specific gender affirmation surgical procedures vary depending on the type of transition. However, gender reassignment surgeries generally follow these steps:

1. Consultation and Preparation: Patients must undergo extensive psychological and medical evaluations. They typically work with their healthcare providers to ensure they meet the eligibility criteria for surgery, including living as their gender identity for a specific period (often referred to as the "real-life experience").
2. Pre-Surgery Hormone Therapy: Most individuals undergo hormone therapy before surgery to help their body develop some of the characteristics of their desired gender.
3. Surgical Procedure: The surgeries vary but are usually performed under general anesthesia. Depending on the intricacy of the procedure, the surgery may take several hours. For instance, a vaginoplasty might take up to 6 hours, while chest reconstruction may take 2-4 hours.
4. Post-Surgical Care: After the surgery, the patient is monitored in the hospital for a few days before discharge. Follow-up visits and proper aftercare are critical to ensure healing and optimal outcomes.

What is Aftercare Required Following a Gender Reassignment Surgery?

Post-operative care is essential for recovery. Patients undergoing gender affirmation surgery will typically need to:

• Follow a Specific Diet: Especially after genital surgeries, patients may be required to follow a soft or liquid diet to promote healing.
• Engage in Wound Care: To avoid infections, it is crucial to keep the surgical and incision sites clean and follow wound care instructions.
• Medications: Pain management and antibiotics are often prescribed to prevent infections and manage post-surgical discomfort.
• Dilate (for MTF patients): For transgender women who have undergone vaginoplasty, regular dilation of the neovagina is required to maintain its depth and elasticity.
• Avoid Heavy Lifting or Strenuous Activities: Patients must avoid vigorous physical activities, especially during the early stages of recovery.

What is the Recovery Timeline For Gender Reassignment Surgery?

The recovery process for gender reassignment surgery varies based on the type and complexity of the surgery. Here's a general overview:

• First Few Days: Most patients spend 3-5 days in the hospital following surgery. During this time, they are monitored for complications and receive initial wound care.
• First Two Weeks: During this period, the patient may experience swelling, bruising, and discomfort. Pain medication and rest are critical.
• First Three Months: Many patients can resume light activities within six to eight weeks, but it can take up to three months for swelling to subside entirely and for the patient to feel more comfortable.
• Six to Twelve Months: Complete recovery, especially after genital surgeries, can take up to a year. During this time, sensitivity in the new genital area improves, and any scars continue to heal.

The recovery timeline according to the type of gender reassignment surgery performed is as follows.

• Top Surgery: People undergoing top surgeries such as chest reduction or breast augmentation may take one to two weeks before returning to work. Swelling and soreness peak during the initial 48 to 72 hours of the surgery and then reduce over the coming weeks. Chin, nose, jaw, and cheek surgery swelling takes four to eight weeks to disappear. Patients must wait at least six weeks before engaging in vigorous activities.
• Bottom Surgery: Patients receiving bottom surgeries such as phalloplasty or vaginoplasty stay at the hospital for a few days. They should not lift objects heavier than 4 kg for the first two weeks. Walking is to be limited to 3,000 steps per day for several weeks. Patients should avoid wide leg movements, especially when getting in or out of bed.

What are the Risks and Benefits of Gender Reassignment Procedures?

As with any major surgery, there are risks associated with gender reassignment procedures. Some risks include:

• Infection: There is always a risk of infection after surgery, especially for complex genital reconstruction.
• Scarring: Surgical scars are inevitable, although they typically fade over time.
• Loss of Sensation: There is a risk of nerve damage, which can lead to partial or complete loss of sensation in the genital area or other operated sites.
• Blood Clots: There is a risk of developing blood clots, such as deep vein thrombosis (DVT), particularly with longer surgeries. 

Despite these risks, the benefits of gender reassignment surgery are significant for many transgender individuals. According to several researches, 94 to 100% of people undergoing gender reassignment surgeries are satisfied with the results and experience reduced gender incongruence. A few benefits associated with these surgeries are:

• Improved Mental Health: Many transgender people experience reduced symptoms of gender dysphoria, anxiety, and depression after surgery.
• Enhanced Quality of Life: Many individuals report a higher quality of life after surgery, feeling more comfortable in their bodies and socially integrated.
• Appearance and Gender Expression: Changes in face, chest, and genitals help people cope with gender dysphoria. How you perform your routine things (urinating in a standing position or sitting) also helps express gender more confidently.
• Sexual Benefits: Most people engage in sexual and pleasure activities more comfortably once their gender aligns with their identity.

Costs of Gender Reassignment Surgery in Various Nations

The cost of gender reassignment surgery varies widely across the world. Costs can depend on the healthcare system in place, the type of surgery, and whether or not insurance covers the procedures. Below is an overview of the expenses in various countries:

Turkey

Turkey is known for offering the best cosmetic and plastic surgery results. The cost of gender reassignment surgery is generally low in Turkey. The average costs are as follows.

• MTF Surgery: The cost of vaginoplasty in Turkey starts at USD 4,000 and can go up to USD 8,000. Similarly, breast augmentation costs range from USD 3,500 to USD 6,000.
• FTM Surgery: A combination of chest reconstruction and genital surgeries, including phalloplasty, usually costs USD 10,000 to USD 15,000 in Turkey.

Thailand

Thailand is a popular medical tourism destination, particularly for gender reassignment surgery, due to its lower costs and experienced surgeons. It is considered to be the world leader in the number of gender affirmation surgeries performed after Iran.

• MTF Surgery: Vaginoplasty costs in Thailand range from USD 3,000 to USD 6,000, depending on the surgeon and clinic. Due to the significantly lower costs, many patients from Western countries travel here.
• FTM Surgery: Chest reconstruction in Thailand costs between USD 5,000 and USD 7,000, while phalloplasty ranges from USD 12,000 to USD 16,000, considerably lower than in the US or Europe.

India

In India, gender reassignment surgeries are performed regularly. It is one of the most sought-after destinations for various plastic surgeries. The costs of gender reassignment surgeries in India are much lower than in other developed nations, including Thailand and Turkey.

• MTF Surgery: Vaginoplasty in India costs between USD 1,000 to USD 2,500, while breast augmentation may cost an additional USD 1,500 to USD 2,500.
• FTM Surgery: Chest reconstruction in India costs around USD 1,500 to USD 4,000, and phalloplasty can range from USD 3,500 to USD 8,000.

Germany

Germany's healthcare system generally covers most gender reassignment surgeries if deemed medically necessary.

• MTF Surgery: Vaginoplasty and other procedures are typically covered by health insurance. Out-of-pocket costs for private surgeries range from USD 15,000 to USD 25,000.
• FTM Surgery: Phalloplasty and chest reconstruction are also covered by insurance, though private costs for phalloplasty can range from USD 20,000 to USD 50,000.

United States

In the US, gender reassignment surgery can be expensive, especially when the insurance does not cover it:

• MTF Surgery: Vaginoplasty costs between USD 6,000 and USD 14,000. Breast augmentation may range from USD 7,500 to USD 12,000, and facial feminization surgery can cost up to USD 50,000, depending on the number of procedures.
• FTM Surgery: Chest reconstruction typically costs USD 8,000 to USD 10,000, while phalloplasty can cost between USD 30,000 and USD 50,000, depending on the complexity.

While some insurance policies in the US cover gender reassignment surgery, not all do. People looking for gender reassignment surgery need to check with their insurance provider and verify coverage options.

United Kingdom

In the UK, gender affirmation surgery is available through the National Health Service (NHS). However, long waiting times may lead some to seek private healthcare options.

• MTF Surgery: On the NHS, vaginoplasty and breast augmentation may be covered. Privately, the cost of vaginoplasty ranges from USD 8,000 to USD 15,000.
• FTM Surgery: Chest reconstruction and phalloplasty are also available through the NHS. Depending on the procedures chosen, the cost of FTM surgery at a private clinic can range from USD 30,000 to USD 70,000.

Conclusion

Gender reassignment surgery is a vital step for many transgender individuals seeking to align their physical appearance with their gender identity. With a rich history and continued advancements in medical science, the surgery offers life-changing benefits for those experiencing gender dysphoria. While it is a complex procedure that requires careful consideration and skilled medical teams, the result is often a newfound sense of authenticity, comfort, and happiness.