Gender or sex reassignment surgeries (SRS) are generally the next step in transition for some transgender people, though not all. It is not necessary to have SRS to live one’s life publicly as the opposite sex. After several years on HRT, some individuals can pass as the opposite sex, and never choose to have SRS. SRS is not just a single procedure; it can include numerous different options and multiple stages of surgery.
SRS is a surgery performed to create the appearance of the sex organs of the opposite sex, but it does not create fully functioning sex organs. The theory is that changing the appearance of the patient’s genitals (or breasts, in the case of top surgery) will alleviate their emotional distress over their biological sex. Some surgeons strive to create correct aesthetics and as much function as possible for their patients. However, outcomes and results can vary widely depending upon surgical techniques, patient health, and overall recovery.
There is no standard way to perform SRS, and every surgeon has a slightly different technique. In the United States, SRS is usually performed by plastic surgeons, and is considered elective surgery. As a result, the training and credentials required for a physician to perform SRS are less than what is required to perform many other procedures.
In the United States, physicians who perform surgeries such as hip replacement, for example, must receive specialized training and be certified by a board. This can be a state board, or a medical board. In many states, the only requirement a plastic surgeon must meet in order to practice is to be a licensed physician. (https://www.uclahealth.org/plasticsurgery/cosmetic-services) No other credentials or training are required by law. This has left not only a lack of oversight by both state and medical boards, but an atmosphere of confusion where some plastic surgeons are board certified and some are not. It is largely left to the patient seeking surgery to figure out if their surgeon is qualified to do the procedures they are asking for. (https://www.usatoday.com/story/money/2012/12/10/cosmetic-surgery-laws-effect-debated/1759839/)
As such, SRS can often be left in the hands of a surgeon who is not well-versed in the procedures being performed. Patients undergoing SRS from plastic surgeons run a higher risk of not receiving the proper care or attention they need when undergoing serious and complex surgeries.
In countries with universal health care, SRS is performed by doctors within the established medical community. These doctors are more likely to have received specific training and education on the procedures they are performing. However, wait times for SRS surgery can be several years, and some people opt to pay out of pocket for their procedures. This leads to some of the same issues present in the U.S. healthcare system, as patients seek surgeons willing to perform SRS with cash payment.
For FtM individuals, the most common SRS done is the removal of the breasts (double mastectomy), referred to as “top surgery”. Top surgery is best understood as a modified version of a double mastectomy in that the goal is to create a masculine-looking chest. This means that the muscles underneath the breasts are not usually disturbed, and the nipples are removed and grafted in a new position to appear like a male chest. Top surgery techniques can vary widely, and so can results.
Oophorectomy and Hysterectomy
Oophorectomy is the removal of the ovaries. This is usually done along with a hysterectomy (removal of the uterus). Removal of the female reproductive system is required before any SRS genital surgeries will be performed. However, many FtMs have their reproductive organs removed without the desire to have genital SRS. Once the ovaries have been removed, the body can no longer make its own sex hormones, and synthetic hormones will be required for the remainder of the person’s life to maintain proper health and bone density.
Metoidioplasty, Phalloplasty, and Vaginectomy
Metoidioplasty, commonly called “meta”, is an SRS genital surgery in which the ligaments of the enlarged clitoris are cut, allowing the clitoris to stand out further away from the body and resemble a micro-phallus. Some surgeons will take tissue from other areas of the body to create a thicker, more defined small phallus around the released clitoris. Some surgeons, but not all, require a vaginectomy (removal or closing of the vagina) along with this surgery. Patients can also have a scrotum constructed out of the labia majora and synthetic implants put in to resemble testicles. Urethral lengthening can also be performed with this surgery. Urethral lengthening is the creation of a urethra using tissue from other parts of the body, often the mouth, which will be attached to the existing urethra. The lengthened urethra is run through the newly created micro-phallus to allow the patent to be able to stand when urinating. Meta can be a multi-step procedure, with one surgery being completed and the patient allowed to heal before the next stage or stages. As with all SRS surgeries, the technique involved can vary widely, and patients can opt for one or more of the previously described surgeries.
Metoidioplasty is often assumed to be a less invasive SRS, with lower likelihood of complications compared to phalloplasty. It is hard to confirm or deny this assumption due to a lack of available research.
Phalloplasty (or “phallo”) is considered the most invasive of any of the SRS surgeries, with multiple stages of surgery completed over a one to two- year period. Complication rates for the constructed phallus is around 25% and up to 64% for urethroplasty, commonly known as urethra lengthening. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3901910/#:~:text=Although%20most%20patients%20report%20physical,%5B28%5D%20urethroplasty%20related%20complicationsPhalloplasty)
Phalloplasty is the creation of a phallus (artificial penis) from tissue and skin harvested from the abdomen, upper leg, or forearm. Phallo is a multistep process that requires skin grafts, tissue harvesting, and microsurgery. Phallo can also include urethral lengthening, vaginectomy, testicular implants, and the implantation of an erection rod or inflatable penile implant to achieve erection of the created phallus.
In the United States, these procedures are not researched or studied with the same thoroughness that is applied to other medical procedures, and are not held to standard medical practices. SRS is considered an elective surgery, and the physicians performing SRS are usually plastic surgeons who have not been board certified for SRS.
Breast augmentation is the implantation of silicone implants to achieve larger breast size then what might be obtained on HRT alone. This is the same procedure and performed in similar fashion as breast implants for natal women.
Orchiectomy is the removal of the testicles. Orchiectomy is an outpatient procedure with relatively low complication risk, often performed on men with testicular, breast or prostate cancer. In the case of a trans-identified male person (trans woman), the removal of the testicles is usually performed before or during srs. ( https://www.healthline.com/health/mens-health/orchiectomy)
With the removal of the testicles, the body no longer has the ability to produce normal levels of healthy hormones. This can affect bone density, especially if the person is unable or unwilling to continue their prescription for synthetic hormones at any point in their lifetime.
Vaginoplasty (or “lower surgery”) is the process of creating what is called a neovagina by inverting the penis to create an opening in the body between the urethra and rectum, similar to a vaginal canal. A depth of at least five inches is attempted to allow for penetrative sex. If there is not adequate skin from the penis to achieve this, skin grafts are taken from donor sites on other parts of the body. It is during this procedure that orchiectomy (removal of testicles) is also done. Labia majora are created using scrotal skin, and the clitoris is created from a portion of the glans penis.
The created vagina does not have the ability to self-clean or produce its own lubrication. To maintain the opening that was created during surgery, and to prevent it from healing over, dilation of the opening is required for up to one year after surgery. Dilation is often needed for the remainder of the patient’s life if they would like to maintain the neovagina.
Some common complications from vaginoplasty are neovaginal stenosis (narrowing of the created vaginal opening), urinary meatal stenosis (narrowing of the urethral opening), and rectovaginal wall perforations (also called a fistula, an abnormal connection or opening between lower bowel and neovagina, leading to fecal matter entering the neovagina). When complications from vaginoplasty arise, it is sometimes necessary to have a second or third revision surgery to repair stenosis (narrowing of opening) and fistulas. Long term dilation of the neovagina is sometimes needed to keep the opening from healing over or closing up. In cases where it has closed up or narrowed, a surgery is required to reopen the neovagina. (https://pubmed.ncbi.nlm.nih.gov/30269882/#:~:text=Abstract,stenosis%20and%20secondary%20revision%20surgery)