Gender expression is one of the most impactful and personal components of how you truly live as yourself. For some, an expression of gender means wearing a binder, hormone replacement therapy (HRT), or simple hairstyle and makeup choices that help them feel at home in their body. For others, gender dysphoria concerning certain body parts can be too severe to allow them to feel comfortable with their gender presentation with style choices alone. This may lead them to consider gender-affirming surgery.

What Is Gender-Affirming Surgery?

Gender-affirming or gender reassignment surgery is a surgical procedure used to help individuals feel more comfort, control, and agency over their bodies. These procedures are used to change a person’s physical appearance to match their gender identity, either by transforming or removing physical parts of their body to better express their gender or adding physical attributes that help them feel more content with their physical gender expression.

The term used to describe these feelings of discomfort with physical presentation is gender dysphoria, which denotes a disconnect between the physical and mental expression of gender. Here, we’ll use the term trans people to refer to people experiencing this disconnect. However, it should be noted that many trans people simply refer to themselves as men, women, agender, non-binary, or something else, depending on their gender identity.

Dysphoria can be increasingly distressing for trans people, leading to adverse mental health effects like anxiety and depression. Because of how distressing dysphoric feelings can be, studies have shown that trans people, especially trans youth, show a heightened sense of suicidal ideation because of their gender dysphoria. Taking steps to mitigate those feelings can be the difference between life and death for some individuals. Gender-affirming surgery can be a lifesaving component of a therapy plan for those experiencing intense gender dysphoria, but it is one of many aspects of gender-affirming care.

Common Forms of Gender-Affirming Surgery

Not all procedures for gender-affirming surgery are alike, and the extent of the procedures an individual will undergo varies from person to person. Because of how broad the gender spectrum is, a person does not need to go from one binary gender to another to be considered transgender. Those who are gender non-conforming, agender, gender fluid, or non-binary may choose gender-affirming surgery that only changes certain parts of their physical appearance. Others choose to transition from one binary gender to another and may undergo multiple surgeries.

While there are many forms of gender-affirming surgery, Dr. Nisha Garg and the qualified medical staff at Arizona Gynecology Consultants perform bottom surgery for individuals who were assigned female anatomy at birth. These surgeries include the following:

Hysterectomy

For people assigned female at birth, a hysterectomy can be a necessary surgical procedure for many reasons, including fibroids, endometriosis, prolapse, and gender dysphoria. As a result, hysterectomies are extremely common procedures and can be done non-invasively. This can occur via a transvaginal method, which involves only a single incision inside the vagina and no abdominal incisions. The laparoscopic method involves three tiny incisions and nearly eliminates visible scarring. Both procedures improve healing time, decrease infection risk, and reduce pain compared to traditional hysterectomy. Hysterectomy may or may not be accompanied by salpingectomy and/or oophorectomy (a procedure known as a total hysterectomy or a hysterectomy and salpingo-oophorectomy) and takes about two hours.

As a form of gender-affirming surgery, hysterectomy involves the total removal of the uterus and cervix, and can alleviate dysphoric feelings surrounding the potential for childbearing and childbirth. Gender-affirming hysterectomies can also promote masculinization, help individuals provide a legal basis for name changes and other legal documents, and enable people to avoid future women’s health concerns.

Salpingectomy

Salpingectomy, the removal of the fallopian tubes, may also take place during a gender-affirming hysterectomy procedure. Bilateral salpingectomy refers to the removal of both left and right fallopian tubes, and is often recommended even if the individual chooses not to remove the ovaries, since the fallopian tubes primarily exist to transport eggs and can be a cancer risk. Salpingectomy can be performed alongside hysterectomy or as a stand-alone procedure even if the individual chooses to forego hysterectomy, and can be performed transvaginally or laparoscopically. This procedure takes about an hour if performed on its own.

Oophorectomy

Oophorectomy refers to the removal of the ovaries, the physical structure that houses the eggs produced by individuals assigned female at birth. Since ovaries produce the female hormones estrogen and progesterone, their removal can lead to further masculinization and even a reduction in the dose of testosterone needed to maintain ideal hormone levels. Removing the ovaries also eliminates the risk of ovarian cysts, and can reduce the risk of certain cancers. Some patients choose to remove only one ovary, along with the fallopian tubes and uterus, to retain the necessary estrogen needed to prevent osteoporosis.

Vaginectomy

Individuals who no longer want a vaginal opening and do not wish to resume penetrative sex may choose a vaginectomy. This procedure involves accessing the vagina internally and making incisions to separate the tube of the vagina from the surrounding tissue. The surgeon can finish by closing the vaginal opening. For people assigned female at birth who wish to remain female, a vaginal reconstruction is recommended at this point, but people wishing to present as male may choose a phalloplasty instead.

Phalloplasty

People assigned female at birth may consider a phalloplasty, which is when a new penis and scrotum are constructed using implants and skin grafting. Radial forearm flap surgery is the procedure used for the majority of phalloplasties. This treatment creates a phallus from existing forearm skin that appears and functions like traditional male genitalia, including the creation of a urethra that allows standing urination. These procedures can be completed at the same time as a hysterectomy or vaginectomy. The second stage includes the creation of a scrotum using testicular implants.

Other Procedures

Whether or not they are used in conjunction with total hysterectomy, phalloplasty and vaginectomy are informally referred to as “bottom surgeries” because they deal with altering the external genitalia on the lower half of the body. Other forms of gender-affirming surgery, like the removal of breast tissue in “top” surgery, facial masculinization surgery, and more, can also be performed to help give trans individuals a more gender-affirming and reinforcing appearance. Beyond surgical procedures, hormone replacement therapy (HRT) is often prescribed to help encourage physical changes like breast tissue growth, voice deepening, and hair growth. These procedures can be used alongside “bottom surgeries,” in combination with one another, alone, or not at all.

Here at Arizona Gynecology Consultants, we are pleased to offer bottom surgeries like total hysterectomy, hysterectomy, salpingectomy, oophorectomy, salpingo-oophorectomy, vaginectomy, and phalloplasty to people assigned female at birth. However, we do not perform top or facial surgeries.

Effects of Gender-Affirming Surgery

Depending on the procedure, the recovery times for gender-affirming surgery can vary. Both vaginectomy and phalloplasty require aftercare and specific practices to ensure the functionality of the new organs after the initial healing process concludes. According to Harvard’s T.H. Chan School of Public Health, in comparison to transgender and gender-diverse individuals who had not yet undergone a procedure but desired one, those experiencing gender-affirming surgeries had a 42% decrease in mental distress and a 44% decrease in suicidal ideation. The study also discovered a 35% decrease in smoking among those who underwent gender-affirming surgery.

For many trans individuals, the only way to combat dysphoric feelings about their bodies is by pursuing gender-affirming surgery. Because of the connection between the physical appearance of the body and gender dysphoria, the physical appearance of the body is inextricably linked to mental health for these individuals. By changing the aspects of the body that lead to dysphoria, mental health symptoms may be decreased.

How Old Do You Need to Be for Gender-Affirming Surgery?

Transgender rights and legislation have been at the forefront of the news for years now, and this media sensationalization has affected access to gender-affirming care. In 2022, the Arizona legislature signed a bill making it illegal to supply those under the age of eighteen with access to gender-affirming surgery.

Lawmakers have honed in on the procedure’s “irreversibility” as the reason for the legislation. Although the minimum age for surgery is now eighteen, other forms of gender-affirming care, like hormone therapy or puberty blocking, are still available to trans youth under the age of eighteen. As the discussion about the right to gender-affirming care continues, we expect more developments in the near future.

What Are the Requirements for Gender-Affirming Surgery?

The international organization promoting positive healthcare for transgender individuals is known as the World Professional Association for Transgender Health, or WPATH, has established a set of guidelines for individuals wishing to schedule gender-affirming surgery. We consider whether individuals seeking gender-affirming surgery demonstrate the following requirements before scheduling:

• Gender dysphoria on a consistent basis, thoroughly documented by the individual and healthcare providers
• Legal capacity to make an informed decision and provide consent for gender-affirming care
• Attaining the age of legal consent in Arizona (18)
• Thorough control of any co-occurring mental health conditions
• At least one year of continuous hormone replacement therapy, if appropriate to the desired gender/situation
• At least one year of living continuously as the desired gender

Gender-Affirming Surgery Checklist

Once your doctor has confirmed the date of your surgery, it’s important to determine what you need to do before the procedure. Depending on the situation, physical preparation for surgery will look different for each patient and may include things like changing medical routines or losing weight.

Once you set a surgery date, the preparation for your procedure will include the following tasks:

• Notifying your employer about your surgery, including days you will need to take for recovery, travel, or additional time away from work.
• Arranging for transportation to and from your surgery center, especially for procedures that limit your mobility.
• Taking the time to connect with friends and family to limit anxiety before your procedure, so you can go into your surgery stress-free.
• Arranging for someone to act as a caregiver after surgery and providing them with a list of personal care tasks you will need assistance with during your recovery.
• Checking in with your caregivers about what chores and tasks need to be taken care of while you are in recovery, including cleaning, laundry, cooking, pet care, etc.
• Preparing your recovery space, often by laying out protective drop cloths or clothes and cleaning the surrounding area.
• Preparing for beginning medical care, including purchasing and organizing your supplies, as well as critical documents like insurance information and an advance directive.

Before the surgery begins, make sure you speak with your doctor about any issues or complications that may occur. For example, for some trans men taking testosterone, stopping hormone therapy before an operation may be necessary. Before taking these steps, speak with your doctor to get the right advice in anticipation of your procedure.

Risks Associated with Gender-Affirming Surgery

Risks are different for different operations and can vary drastically based on the individual. For instance, those who have had bottom surgery may experience changes in their sexual experience or difficulty emptying their bladder. Significant problems are generally uncommon when the procedure is carried out by a skilled surgeon.

Every operation carries a slight risk of side effects during recovery, including:

• Bleeding
• Infection
• Decreased mobility

Thus, the recovery period after your surgery is one of the most important parts of the process. Always listen to your surgeon’s instructions, as recovery times and procedures may differ from person to person. By the second week following surgery, most patients start to feel more at ease.

Throughout the first two weeks, you will need to get more sleep than usual. By weeks six to eight, you should be able to resume most of your regular activities, including work. During the recovery phase, certain activities, including driving, lifting heavy objects, exercising, intercourse, and soaking in a tub or hot tub, are typically prohibited. It may take up to a year to fully recover from surgery, but speaking to your physician about your recovery is the best way to get the most accurate recovery timeline.

It should be noted that infertility is the most significant side effect of gender-affirming surgery, simply due to the nature of the surgery. Although gender-affirming surgery does not allow trans individuals to have children in the way most people do, they can choose to freeze their eggs before the procedure for use later on. Just like cisgender individuals unable to have children due to infertility, surrogacy, and adoption are both available to trans people, allowing them to have children of their own whether they are biologically related or not.

How Do You Pay for Gender-Affirming Surgery?

Payment for gender-affirming surgery can be completed like any other form of surgery: either through private insurance or with an upfront payment. Because of the nature of the procedure, some insurance companies may not cover this type of surgery since it may be deemed a cosmetic procedure. However, when applying for these procedures, including the reasoning for your request can help your provider see the necessity of this surgery.

For example, if someone has a severely deviated septum that prevents them from breathing well and needs rhinoplasty – traditionally a cosmetic surgery – to address it, they can provide the diagnosis of a deviated septum to their insurance provider to help prove the surgery is medically necessary.

Although this example does not carry the same gravity of a situation involving gender-affirming surgery, it is necessary to present your claim in this way to ensure your need for surgery is formally recognized by your insurance provider. Providing proof of your dysphoria, along with any record of HRT or blockers, may be helpful for getting your claim accepted. It is important to note that many insurance providers request the following before approving coverage of bottom surgery:

• Alignment of the individual with the WPATH guidelines listed above
• Letters from at least two mental health professionals confirming a gender dysphoria diagnosis
• Top surgery (mastectomy) already in place, or scheduled concurrently

If an insurance agency does not accept your claim, you can pay the cost of the surgery yourself. Alternatively, many individuals choose crowdfunding efforts to accept donations to help pay for surgery. In addition to sourcing donors, mutual aid networks that cater to transgender individuals can help those in need of financial support to apply for a grant that can cover surgery costs.

Finding the Right Doctor for Your Procedure

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Resources

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6903884/
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082431/
3. https://www.hsph.harvard.edu/news/hsph-in-the-news/mental-health-benefits-associated-with-gender-affirming-surgery/