“She’s transitioning? Has she had ‘the surgery’ yet?”
This is one of the most common questions transgender people get. Many nontrans people assume that genital surgery is the ultimate goal of transitioning. Yet within transgender communities there is significant diversity as to people’s desire for surgery and, if they want it, what kind. When people outside transgender communities talk about surgery, they often mean genital surgery. However, there are all kinds of gender-affirming surgeries, including breast augmentation, “top” surgery (to create a male-contoured chest), and facial feminization surgeries. Contrary to popular belief, many trans people never have “bottom” or genital surgery. Transgender men, for example, are much more likely to have chest reconstruction than genital surgery.
Trans people’s desires for surgery are a reflection of the diversity of gender identities in trans communities. Some people, particularly those who identify as genderqueer, feel most comfortable appearing androgynous, and they may take low-dose hormones or have top surgery with the goal of looking somewhere between male and female. The decision to have (or not have) a particular surgery is often related to people’s identity and what they feel will make them most comfortable.
There are numerous reasons trans people may or may not choose a particular surgery. Some surgeries cost tens of thousands of dollars, and, historically, most employer-sponsored health plans and state Medicaid plans have specifically excluded transition-related health care, forcing people to pay for hormones and surgeries out of pocket. This is close to impossible for low-income people and difficult for many in the middle class. Even for those whose employer-sponsored or state Medicaid programs do purport to pay for gender-affirming surgeries, the amount that the insurance company or state pays may be lower than some surgeons are willing to accept, either because surgeons are trying to make a significant profit or, in some instances, because surgeons are not even sure they can break even after paying the operating room and staff expenses.
Some people forgo or delay surgery to maintain relationships with partners or family members who oppose it. Sexual functioning can also play a role in some people’s decisions. Though, in recent years, improved surgical techniques have enabled people to enjoy satisfying sexual functioning, many people still choose to retain their original parts and continue to use them.
An overlooked consideration of surgery is its effect on personal safety. Some trans women, for example, prioritize facial feminization surgery because it can improve their ability to move through the world as female, with less fear of being subject to ridicule and violence.
There are also many systemic barriers that can make it difficult for trans people to access surgeries. For certain procedures, there are few well-trained surgeons here in the United States and abroad. Trans women interested in vaginoplasty, or trans men seeking phalloplasty, often end up flying to see the handful of surgeons with good reputations; some people travel outside the United States, commonly to Thailand or Mexico, where there are also expertly trained surgeons. Unfortunately, many surgeons, here and abroad, practice techniques that are out of date or dangerous, and it can be hard to tell the difference between good and bad doctors without doing extensive research.
Traveling far from home for surgery, whether within the United States or overseas, can have other disadvantages. Though some people are able to afford to stay on site for a week or two after a procedure, it can significantly add to the cost to stay in a hotel and possibly to bring a loved one for assistance, making this luxury unattainable for many who must return home, often to areas with little access to quality follow-up care if there are complications. Even when staying in the United States for surgery, many people travel far from home and, because of the expense, may return before they have fully healed.
There is also a backlog for many procedures in the United States, which stems from a dearth of surgeons trained in trans health care. Surgeons working in this area of medicine come from a variety of specialties, including plastic surgery, gynecology, and urology, and there are no clearly defined guidelines or board certifications that make someone eligible to perform transition-related surgeries. In addition, almost no surgical residency programs provide any exposure to transgender care. Surgeons interested in learning how to perform gender-affirming surgeries have traditionally completed short apprenticeships with someone who is already performing these surgeries, but this training involves seeking out mentorship and taking time off from paid work. Because there are few such trained surgeons, and no clear way of vetting those who do exist, it is possible to start a practice doing gender-related surgeries for the sole purpose of making money, without much regard for good technique or outcomes. The quality of surgeons varies greatly. In recent years, some academic medical centers have begun discussing how to start fellowships—additional training after residency—for those who desire to go into transgender surgery. In addition, some organizations, such as the World Professional Association for Transgender Health (WPATH), have taken steps toward creating certification programs for those who provide transgender care.
Surgical options for trans women include facial feminization, tracheal shave, breast augmentation, and genital surgeries (orchiectomy, vaginoplasty). With facial feminization, a plastic surgeon makes changes to areas of the face (forehead, nose, cheeks, lips, jaw, chin) that result in a more feminine-appearing profile. These surgeries are very expensive and, because they are considered “cosmetic,” typically not covered by insurance. Yet they may be important-even vital—to a person’s day-to-day life as they provide the ability to pass, and therefore greater opportunity to find employment and increased physical safety when moving through the world. A tracheal shave reduces the size of the thyroid cartilage (the Adam’s apple), also resulting in a more feminine appearance. Breast augmentation for transgender women is a similar but not identical procedure to breast augmentation in cisgender women. Silicone or saline implants are inserted into the chest, but the placement of the prosthetics may vary slightly due to differing underlying physiology. The World Professional Association for Transgender Health’s Standards of Care recommend at least twelve months of hormone treatment before breast augmentation to assess how much breast growth develops prior to surgery.
Orchiectomy is a procedure in which the testicles are removed but the penis remains. There are several reasons someone might choose to have an orchiectomy rather than a vaginoplasty, which is the removal of the testicles and penis and creation of a vagina. Orchiectomies are far less expensive than vaginoplasties (approximately $5,000 versus $30,000), and an orchiectomy may be a first step, prior to vaginoplasty, for someone who cannot yet afford vaginoplasty but would like to stop the production of androgens (masculinizing hormones like testosterone). This can have risks for individuals who would later pursue vaginoplasty, as some argue the penile and scrotal tissue may atrophy, leaving less material for the creation of a vulva and vaginal canal. Others have no intention of proceeding to vaginoplasty and would like to retain their penises but decrease androgen production.
Vaginoplasty is the procedure many people are referring to when they use the phrase “the surgery.” It involves removing the testicles and much of the penis (though preserving parts of the penis as the new clitoris) and creating a vaginal canal (typically from penile tissue) and labia (typically from scrotal tissue). Many trans women are pleased with the results of vaginoplasty, which, for such a complex procedure, has low complication rates. The abilities to urinate and orgasm are generally well preserved. Vaginoplasty requires lifetime “maintenance” with dilators to maintain flexibility and depth.
Surgical options for trans men include chest reconstruction and genital surgeries (metoidioplasty, phalloplasty, scrotoplasty). Top surgery is the most common procedure trans men undergo. There is more than one method of top surgery, and the choice is generally based on the size of a person’s chest. Smaller-chested people are able to undergo a “keyhole” procedure that removes tissue through an incision in the nipple, resulting in minimal scarring, and larger-chested people undergo a double-incision procedure that removes tissue through incisions under each breast. After top surgery, many trans men enjoy the freedom to go shirtless, especially when swimming. Many people find creative ways to address scarring by allowing their chest hair to grow over scars or getting tattoos.
Genital surgeries for trans men are not as advanced as they are for trans women. One of the most common procedures in the United States is metoidioplasty, in which the length of the clitoris is extended to better represent a penis. This can be done with or without extending the urethra through the new penis so that the man can stand to pee. Metoidioplasty generally does not produce a penis comparable in size to those of cisgender men. Phalloplasty, which is performed infrequently in the United States but is common in countries with national health-care systems that finance it, does create a comparably sized penis, but it has drawbacks. The cost of phalloplasty is high (approximately $100,000), and it frequently involves multiple procedures. A “donor site,” often a forearm or thigh, is needed. Skin and tissue below the skin (nerves and blood vessels) are harvested from this site. Phalloplasties can result in numerous complications and often do not allow for erections, though for some people, the appearance of the penis is more important than the ability to produce an erection. Metoidioplasty and phalloplasty are sometimes accompanied by scrotoplasty, which is the creation of scrotum, usually by inserting egg-shaped silicone testicles into reshaped labia.
In spite of the many options for surgeries, the myth that surgery makes a trans person “fully” male or female still circulates. It’s not uncommon to hear that a person is “more trans” for desiring surgery, and that those who haven’t yet had or cannot afford these changes are “less” trans. Even within trans communities, there are hierarchies set up between those who are “pre-op” (pre-operative), “non-op,” and “post-op” (post-operative), often resulting in shame and low self-esteem in those who cannot afford or do not want the surgeries others consider important.
One of the goals that many outside trans communities imagine trans people would prioritize is being able to have sex “normally”—meaning, as a heterosexual person. The notion of becoming heterosexual after transition had been institutionalized in the earlier WPATH Standards of Care and became so inherent in the conversations others have about trans people that cisgender people frequently ask things like “If she wanted to be with women, why didn’t she just stay a man?” People wonder why those with a functioning penis would want to lose that organ if they were going to end up sleeping with women. And the reverse: Why would someone who identifies as a woman and is attracted to men not want to have a vaginoplasty so she can have “normal” sex with men? Thinking this way conflates gender identity and sexuality, and devalues sex that is not understood to be traditionally heterosexual.
Surgery is one of many ways in which trans people are judged about how trans they really are. Another is their gender histories. Trans people are generally expected to have understood that they were different early in life (preschool age) and to have discovered their trans identity as children. If they are transitioning as adults, they are presumed to have hidden their secret until they could not stand it anymore. In this scenario, they are assumed to have hated their pre-transition bodies and to enjoy everything about one gender while rejecting everything about the other. This narrative is true for some people, but not for many others. Those who don’t feel “different” until later in life, or who don’t hate their bodies, or who enjoy things considered both masculine and feminine, are often seen as imposters. For many years, trans people could not access hormones or surgery without providing a familiar narrative, and so some learned to hide their true selves—a fascinating paradox given that transitioning is thought of as the process of revealing your true self.
It is easy to see how the idea of being “complete” or “fully” trans after surgery may make sense to nontrans people; a surgeon makes physical changes to the body that result in a different appearance. But it is crucial to remember that there is so much more to being a man than having a penis, and so much more to being a woman than having a vagina, and that the countless other gender possibilities are no less worthy.