Gender-affirming surgery: what actually exists

It is discussed often, and usually poorly. Gender-affirming surgery is wielded in public debate as an emotional argument, almost always without data. The reality is different from how it is portrayed: these are established medical procedures, backed by decades of scientific literature, with satisfaction rates among the highest in surgery and a regulated access framework. This article presents the facts. It is not medical advice, but a starting point for understanding what exists, how it works, and what the evidence says. For the hormonal aspects of medical transition, we refer to the article on hormone therapy.

Not everyone chooses surgery

First fundamental fact: gender-affirming surgery is a possibility, not a requirement. Many trans people do not desire any surgical intervention. Others choose some procedures and not others. There is no one-size-fits-all standard pathway, and the validity of a person’s identity does not depend on which medical procedures they have or have not undergone.

The reasons for not having surgery are multiple and all legitimate: some people do not experience dysphoria about certain body parts, others prefer to avoid surgical risks, and others cannot afford it or face long waiting lists. None of these choices makes a person “less trans.”

That said, for those who desire it, surgery can be transformative. The scientific evidence shows a significant impact on reducing dysphoria, improving psychological well-being, and enhancing quality of life [5].

Top surgery

The term “top surgery” refers to chest surgical procedures.

Mastectomy (transmasculine individuals)

Gender-affirming mastectomy, often called “chest masculinization,” involves the removal of breast tissue and reshaping of the chest to achieve a masculine appearance. The two main techniques are:

• Periareolar mastectomy: indicated for people with small breasts (A-B cup). It involves an incision around the areola with minimal scarring. Post-operative satisfaction is 93% [7].
• Free nipple graft mastectomy: used for larger breasts. It involves complete tissue removal and repositioning of the nipple. Satisfaction is 90% [7].

Overall, post-operative satisfaction for transmasculine top surgery is 92%, with significant improvements in quality of life, self-confidence, and mental health related to dysphoria in 86% of cases [7]. It is often the first surgical procedure that transmasculine individuals choose, and in many cases the only one.

Recovery involves 1-2 weeks of rest, 4-6 weeks before resuming intense physical activities, and 3-6 months for complete healing.

Breast augmentation (transfeminine individuals)

Breast augmentation for trans women follows the same surgical techniques used for cisgender women, with some specific considerations. Estrogen therapy induces natural breast development, but often to a limited extent (generally 1-2 cup sizes less than the patient desires). For this reason, many trans women choose augmentation with implants.

WPATH guidelines recommend at least 12 months of hormone therapy before surgery, to allow maximum natural breast development [1]. Satisfaction is high, with 75% of patients reporting high scores [11]. Complications are comparable to those of breast augmentation in cisgender women: the capsular contracture rate is approximately 3%, and re-operations for complications are around 5% [11].

Bottom surgery

Bottom surgery includes genital procedures. These are the most complex procedures and the ones about which the most misinformation circulates.

Vaginoplasty (transfeminine individuals)

Vaginoplasty creates a functional vagina, with labia majora and minora, clitoris, and vaginal canal. The most common technique is penile-scrotal flap inversion vaginoplasty: the tissue from the penis and scrotum is repurposed to construct the vaginal canal and vulva. The glans, with its innervation, is reshaped to create the neoclitoris, preserving sensitivity.

There is also colovaginoplasty (or sigmoidovaginoplasty), which uses a segment of the colon to create the vaginal canal. It is chosen in specific cases, for example when available genital tissue is insufficient.

The data on vaginoplasty are robust [6]:

• Overall satisfaction: 91-93%
• Aesthetic satisfaction: 90%
• Functional satisfaction: 87%
• Ability to reach orgasm: 70-80%
• Regret rate: approximately 2%

Trans women after vaginoplasty report scores on the Female Genital Self-Image Scale comparable to those of cisgender women [6].

Recovery requires 6-8 weeks of rest and a regular vaginal dilation program, essential in the first months to maintain depth and width of the canal. Dilation becomes less frequent over time but remains part of the long-term routine.

Possible complications include stenosis (narrowing of the canal), granulation, need for surgical revisions, and in a variable percentage, dyspareunia (pain during intercourse). These are managed in post-operative follow-up [6].

Phalloplasty (transmasculine individuals)

Phalloplasty constructs a neophallus using tissue harvested from another part of the body. The most common donor sites are:

• Forearm (radial flap): produces the best aesthetic results, with good tactile sensitivity. It leaves a visible scar on the forearm.
• Thigh (anterolateral flap): less visible as a scar, generous flap dimensions.
• Abdomen: an alternative option in specific cases.

Phalloplasty is a multi-stage procedure that takes place over 12-24 months and includes: creation of the phallus and nerve connection, urethral lengthening (to allow standing urination), scrotoplasty with insertion of testicular prostheses, glanuloplasty, and potentially insertion of an erectile prosthesis for penetrative intercourse [10].

Functional results [10]:

• Standing urination: 75% of cases
• Erogenous sensitivity: 69%
• Penetration capability (with erectile prosthesis): 43%
• Aesthetic satisfaction: 70%

Urological complications are the main challenge: urethral fistulas in 36% and urethral strictures in 32% of cases often require corrective procedures [10]. This is an important piece of information to know in advance. Phalloplasty is among the most complex procedures in reconstructive surgery, and transparency about current limitations is essential for informed decisions.

Metoidioplasty (transmasculine individuals)

Metoidioplasty is an alternative to phalloplasty that uses the clitoris, enlarged by testosterone therapy (generally after at least 1-2 years of HRT), to create a micropenis of 5-9 cm [1]. It is a less invasive procedure with shorter recovery times.

Results [10]:

• Standing urination: 74-90% of cases
• Erogenous sensitivity: 100% (the tissue is native)
• Aesthetic satisfaction: 87%
• Urethral complications: approximately 25% (less than phalloplasty)

Metoidioplasty generally does not allow penetration during sexual intercourse, as the size of the neophallus is limited. The choice between metoidioplasty and phalloplasty depends on individual priorities: those who prioritize sensitivity and faster recovery tend to prefer metoidioplasty; those who desire a standard-sized phallus opt for phalloplasty.

Orchiectomy and hysterectomy

Orchiectomy (removal of the testicles) is a relatively straightforward procedure that trans women may choose to eliminate endogenous testosterone production, reducing or eliminating the need for anti-androgens. It can be performed as a standalone procedure or as part of vaginoplasty.

Hysterectomy with salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries) is an option for trans men. It may be motivated by dysphoria or medical reasons, and is sometimes performed in preparation for phalloplasty or metoidioplasty.

Both procedures are irreversible and result in loss of fertility.

Facial feminization surgery (FFS)

Facial Feminization Surgery (FFS) comprises a set of procedures that modify the bony and soft tissue characteristics of the face to attenuate traits perceived as masculine [8]. The most common procedures include:

• Forehead reshaping: reduction of the frontal bone prominence (bossing), the most requested procedure
• Rhinoplasty: nose reshaping
• Jaw and chin reshaping: reduction of the jaw angle and chin
• Upper lip lift: shortening the distance between nose and upper lip
• Scalp advancement: to correct hairline recession

A prospective multicenter study showed that the median facial feminization score rose from 47.2 before surgery to 80.6 after six or more months, with a satisfaction level rated as excellent [9]. The literature confirms that FFS plays a significant role in reducing dysphoria and improving quality of life, and is considered safe with a good complication profile [8].

FFS is particularly important for many trans women because the face is the primary gender marker in daily social interactions.

Other procedures

Chondrolaryngoplasty (tracheal shave)

Adam’s apple reduction is a relatively simple cosmetic procedure that reduces the prominence of the thyroid cartilage. It is performed under local or general anesthesia, with short recovery times (1-2 weeks). It does not affect the voice.

Voice feminization surgery

Different from the tracheal shave, vocal surgery directly modifies the vocal cords to raise the fundamental frequency of the voice. The most common technique is Wendler glottoplasty, which joins the anterior third of the vocal cords with sutures, reducing the vibrating length and raising pitch. An alternative is feminization laryngoplasty, which removes portions of the vocal cords and larynx.

Long-term results show high efficacy and satisfaction, with few complications. Recovery requires one week of vocal silence and approximately six months for complete tissue healing, with gradual reintroduction of vocal exercises.

Body contouring

Procedures such as liposuction or fat grafting can be used to harmonize the body silhouette. They are not specific to trans people, but are sometimes chosen as a complement to other procedures.

Satisfaction and regret rates

This is the point where the data are most clear and most distant from the public narrative.

A 2021 meta-analysis published in Plastic and Reconstructive Surgery analyzed the prevalence of regret after gender-affirming surgery: the overall rate is less than 1% [2]. A 2024 systematic review published in The American Journal of Surgery compared regret across different surgical specialties, finding that gender-affirming surgery has among the lowest regret rates overall [3]. Knee replacement surgery, for example, has dissatisfaction rates between 6% and 30%, up to 100 times higher [3].

The factors associated with the rare cases of regret are not so much about gender identity as about the physical results of the procedure, poor social support, pre-existing mental health issues, and post-operative complications [2]. In other words, regret is almost always related to how the operation went, not to who the person is.

A 2024 JAMA study confirmed that 99.7% of trans people who had access to surgery report satisfaction with the results [4].

Recovery and realistic expectations

Each procedure has its own recovery pathway, but there are common elements to be aware of.

Physical expectations: swelling, pain, and limited mobility in the first weeks are normal. Top surgery requires 4-6 weeks; vaginoplasty requires 6-8 weeks of rest with daily dilation; phalloplasty, being multi-stage, extends over 12-24 months.

Emotional expectations: the post-operative period can be emotionally complex. It is not unusual to experience a range of unexpected emotions, including moments of anxiety, sadness, or doubt, even when one is deeply convinced of one’s choice. Temporary post-operative depression is a common phenomenon after any major surgical procedure. In the long term, satisfaction is very high [5].

Aesthetic and functional expectations: surgical results improve over time. The final appearance of scars, tissues, and functionality stabilizes over 6-12 months. It is important to have realistic expectations and maintain open dialogue with the surgical team. “Before and after” photos found online are not representative of the real variability of results.

Practical support: planning recovery means organizing assistance during the first weeks, having work flexibility, and ideally emotional support from close people. Those going through this process alongside family members can find useful resources in our guide for families.

The overall picture

Gender-affirming surgery is neither a miracle nor a horror: it is a set of medical procedures with solid evidence, documented results, and known limitations. Science says it works, that those who choose it are almost always satisfied, and that regret is a rare exception, not the rule [2][3][4].

The decision to have surgery is personal. It belongs to the person who lives it, with the support of competent professionals. No article, no social media comment, and no public opinion can substitute for that individual process. What we can do is ensure that the available information is accurate, complete, and respectful of each person’s autonomy.