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Preparing for Gender Affirmation Surgery: Ask the Experts

Preparing for your gender affirmation surgery can be daunting. To help provide some guidance for those considering gender affirmation procedures, our team from the   Johns Hopkins Center for Transgender and Gender Expansive Health (JHCTGEH) answered some questions about what to expect before and after your surgery.

What kind of care should I expect as a transgender individual?

What kind of care should I expect as a transgender individual? Before beginning the process, we recommend reading the World Professional Association for Transgender Health Standards Of Care (SOC). The standards were created by international agreement among health care clinicians and in collaboration with the transgender community. These SOC integrate the latest scientific research on transgender health, as well as the lived experience of the transgender community members. This collaboration is crucial so that doctors can best meet the unique health care needs of transgender and gender-diverse people. It is usually a favorable sign if the hospital you choose for your gender affirmation surgery follows or references these standards in their transgender care practices.

Can I still have children after gender affirmation surgery?

Many transgender individuals choose to undergo fertility preservation before their gender affirmation surgery if having biological children is part of their long-term goals. Discuss all your options, such as sperm banking and egg freezing, with your doctor so that you can create the best plan for future family building. JHCTGEH has fertility specialists on staff to meet with you and develop a plan that meets your goals.

Are there other ways I need to prepare?

It is very important to prepare mentally for your surgery. If you haven’t already done so, talk to people who have undergone gender affirmation surgeries or read first-hand accounts. These conversations and articles may be helpful; however, keep in mind that not everything you read will apply to your situation. If you have questions about whether something applies to your individual care, it is always best to talk to your doctor.

You will also want to think about your recovery plan post-surgery. Do you have friends or family who can help care for you in the days after your surgery? Having a support system is vital to your continued health both right after surgery and long term. Most centers have specific discharge instructions that you will receive after surgery. Ask if you can receive a copy of these instructions in advance so you can familiarize yourself with the information.

An initial intake interview via phone with a clinical specialist.

This is your first point of contact with the clinical team, where you will review your medical history, discuss which procedures you’d like to learn more about, clarify what is required by your insurance company for surgery, and develop a plan for next steps. It will make your phone call more productive if you have these documents ready to discuss with the clinician:

• Medications. Information about which prescriptions and over-the-counter medications you are currently taking.
• Insurance. Call your insurance company and find out if your surgery is a “covered benefit" and what their requirements are for you to have surgery.
• Medical Documents. Have at hand the name, address, and contact information for any clinician you see on a regular basis. This includes your primary care clinician, therapists or psychiatrists, and other health specialist you interact with such as a cardiologist or neurologist.

After the intake interview you will need to submit the following documents:

• Pharmacy records and medical records documenting your hormone therapy, if applicable
• Medical records from your primary physician.
• Surgical readiness referral letters from mental health providers documenting their assessment and evaluation

An appointment with your surgeon. 

After your intake, and once you have all of your required documentation submitted you will be scheduled for a surgical consultation. These are in-person visits where you will get to meet the surgeon.  typically include: The specialty nurse and social worker will meet with you first to conduct an assessment of your medical health status and readiness for major surgical procedures. Discussion of your long-term gender affirmation goals and assessment of which procedures may be most appropriate to help you in your journey. Specific details about the procedures you and your surgeon identify, including the risks, benefits and what to expect after surgery.

A preoperative anesthesia and medical evaluation. 

Two to four weeks before your surgery, you may be asked to complete these evaluations at the hospital, which ensure that you are healthy enough for surgery.

What can I expect after gender affirming surgery?

When you’ve finished the surgical aspects of your gender affirmation, we encourage you to follow up with your primary care physician to make sure that they have the latest information about your health. Your doctor can create a custom plan for long-term care that best fits your needs. Depending on your specific surgery and which organs you continue to have, you may need to follow up with a urologist or gynecologist for routine cancer screening. JHCTGEH has primary care clinicians as well as an OB/GYN and urologists on staff.

Among other changes, you may consider updating your name and identification. This list of  resources for transgender and gender diverse individuals can help you in this process.

The Center for Transgender and Gender Expansive Health Team at Johns Hopkins

Embracing diversity and inclusion, the Center for Transgender and Gender Expansive Health provides affirming, objective, person-centered care to improve health and enhance wellness; educates interdisciplinary health care professionals to provide culturally competent, evidence-based care; informs the public on transgender health issues; and advances medical knowledge by conducting biomedical research.

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

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• Gender-Affirming Surgery: A Comprehensive Guide

A Comprehensive Guide to Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on April 15, 2024.

Gender-affirming surgery is an umbrella term for a series of surgical procedures that help transgender, non-binary and gender non-confirming individuals alleviate their gender dysphoria and promote a sense of congruence between their physical body and gender identity. Below we outline the different types of gender-affirming surgeries that are documented in the World Professional Association for Transgender Health’s (WPATH) Standards of Care 8 (SOC8) alongside important cost, insurance, and recovery information often solicited by patients.

At the Gender Confirmation Center (GCC), we believe that medically necessary gender-affirming surgical care should be made available to patients of diverse gender identities and body types with differing BMIs . If you are interested in making an individualized surgical plan to meet your unique needs, you can schedule a virtual or in-person consultation with one of our board-certified surgeons today.

Types of Gender-Affirming Surgeries

There are several types of gender-affirming surgeries available, each designed to help patients feel more congruence between their body and their gender identity. We highly recommend that patients seek out board-certified surgeons with hospital privileges and extensive experience in gender-affirming surgical care.

Top surgery refers to procedures that modify the chest area. In our practice, top surgery usually refers to chest reconstructions or breast reductions , both involving the removal of breast tissue. Patients can also modify the nipples through a free nipple graft to adjust the size, shape and placement of their nipples or remove the nipple completely . In addition, nerve preservation techniques can also be performed to prevent the loss of heightened, erotic sensation in the nipples.

Another type of top surgery procedure is a breast augmentation . In general, implants yield better results than fat transfers when a large increase in volume is desired and existing skin is relatively tight. Patients can choose between silicone and saline breast implants, their size and placement , as well as the location of their breast implant scars .

Bottom surgeries are gender-affirming procedures performed to reconstruct external genitalia or remove internal reproductive organs. Bottom surgery can involve the construction of structures that do not currently exist on the patient’s body (like a vaginal canal, vulva or penis).

Fertility planning considerations and/or preoperative hair removal may be required for some procedures.

• Zero-depth vaginoplasty or vulvoplasty: This involves the creation of a vulva and clitoris without the creation of a vaginal canal for penetrative sex.
• Penile-preserving vaginoplasty: This involves the creation of a vulva, clitoris, and vaginal canal by reconstructing penile and scrotal tissues.
• Labiaplasty and revisions: Dr. Ley is well-renowned for her expertise in bottom surgery revisions. These procedures allow for corrections to the size, shape and/or symmetry of their labia minora, labia majora and/or clitoral hood.
• Orchiectomy : This procedure involves the removal of the testicles. Patients interested in a vaginoplasty or vulvoplasty should have their scrotal tissue preserved for the construction of the labia. An orchiectomy can take place up to 8 weeks before their vaginoplasty or vulvoplasty procedure.
• Metoidioplasty : A metoidioplasty involves releasing erectile tissue (clitoris), from restraining structures, allowing it to move into a more forward and elevated position. This is typically less complex to perform and maintains more sensation compared to a phalloplasty procedure, but results in a smaller penis. Patients can opt for a urethral lengthening procedure the ability to urinate standing up is a priority.
• Phalloplasty : This surgery involves the creation of a penis using a tissue flap from the patient’s groin, outer thigh, or forearm. This allows the possibility of creating a larger penis that enables penetrative sex and the ability to urinate while standing. The risk of not having full, erotic sensation in the new penis may differ based on the type of phalloplasty performed.
• Hysterectomy, vaginectomy, scrotoplasty and more : Prior to, simultaneously or independent from other bottom surgery procedures, patients can have their vaginal canal, uterus and/or one or both of their ovaries removed. Dr. Ley only requires a vaginectomy or removal of the vaginal canal in the case of a urethral lengthening (to allow patients to urinate standing up) to prevent urinary complications. Additionally, Dr. Ley offers the possibility of constructing a scrotum, inserting testicular implants, and other procedures to help patients feel more aligned with their genitals.

Facial Feminization Surgery and Facial Masculinization Surgery

Gender-affirming facial surgery encompasses a broad set of procedures that seek to alter different features of the face to help patients feel more congruence between their appearance and their gender. Facial feminization surgery (FFS) involves procedures that soften facial features to give the face a more conventionally feminine appearance. Facial masculinization surgery (FMS) typically creates a more angular, and conventionally masculine appearance. Patients can choose between any of the following procedures: hairline advancement, brow bone reduction, brow bone augmentation, eyebrow lift, rhinoplasty (nose reconstruction), cheek augmentation, lip augmentation, Adam’s apple reduction/augmentation, or jaw and chin contouring or augmentation.

Body Contouring Surgery

Gender-affirming body contouring can include a variety of liposuction, fat grafting, or silicone implant procedures to alter the shape and appearance of the body. It may be helpful to learn about the common effects of androgenic and estrogenic puberties on body shapes to determine their surgical goals for Body Masculinization Surgery (BMS) or Body Feminization Surgery (BFS) . Procedures can include masculinizing liposuction , feminizing liposuction , fat transfer procedures such as a Brazilian Butt Lift (BBL) , or silicone pectoral implants .

Voice Feminization Surgery

Voice modification surgery, also known as voice feminization surgery or voice masculinization surgery, alters the vocal cords and other structures in the throat to help individuals achieve a voice that aligns with their gender identity. Procedures like a Wendler glottoplasty can help raise the pitch of the voice to create a more feminine tone by removing layers of vocal cord tissue. Vocal therapy is needed before and after surgery, not just for rehabilitation purposes, but also to help adjust resonance and tone. You can learn more about gender-affirming vocal therapy and surgical treatments from trusted providers like San Francisco Voice and Swallow .

Considerations for Gender-Affirming Surgery

Undergoing gender-affirming surgery is a deeply personal decision that requires careful consideration and preparation. It’s important to consult with qualified healthcare professionals, such as mental health providers and surgeons with expertise in gender-affirming care, to ensure that the procedures align with your goals and expectations.

Eligibility and Readiness

Most healthcare providers follow the WPATH Standards of Care , which outline criteria for eligibility and readiness for gender affirming surgeries. These criteria typically include:

• Persistent and well-documented gender dysphoria
• Capacity to make a fully informed decision and consent to treatment
• Clearance from a mental health professional experienced in treating gender dysphoria

At the GCC, we use an informed-consent model that ensures adults capable of making informed decisions are eligible for surgery. That said, patients who plan on using health insurance to cover their surgery need a letter of support from their therapist which is required for the insurance approval process. You can read more about the requirements for this process here .

Please note that per the WPATH’s SOC 8 Guidelines , patients must present a support letter from a lisenced mental health professional to be eligible for bottom surgery, regardless of whether or not you are seeking insurance coverage. However, Dr. Ley does not require that patients present a support letter to undergo a bottom surgery revision procedure. Whether or not you underwent your initial bottom surgery procedure with her, the support letter eligibility requirement will be waived.

Once you have solicited a free, virtual or in-person consultation , our patient care team can assist you in acquiring any and all of the necessary documentation.

Additional Eligibility Requirements: Age, Gender and BMI

Aside from support letters from a mental health provider, several other gatekeeping or discriminatory protocols can get in the way of a patient accessing medically necessary gender-affirming care. Historically, there have been extra barriers to access for patients who are non-binary, those with higher BMIs, and those who pursue transitional care at a later age. The GCC is one of the only practices that operate on patients with BMIs above 30 , and also has specialized protocols for patients with disabilities, adolescents and seniors. For more specific information about these eligibility requirements, click here .

Costs and Insurance Coverage

The costs of gender-affirming procedures can vary depending on the unique, surgical plan you and your surgeon come up with. Many insurance companies recognize these kinds of surgeries as medically necessary, and therefore provide full or partial coverage for them. For more information on costs and insurance coverage, click here .

Preparation for Surgical Gender Affirmation

Beyond eligibility requirements, there are various other preparations patients need to address before undergoing gender-affirming surgery. These may include:

• Undergoing laser hair removal prior to certain bottom surgery procedures
• Looking into your fertility preservation options prior to certain bottom surgery procedures
• Stopping any laser hair removal on your face at least 6 weeks prior to FFS
• Requesting time off work for surgery and recovery
• Booking travel and lodging if you are coming in from out-of-town
• Completing necessary lab work and getting your medications from the pharmacy
• Refraining from smoking any substance at least 3 weeks before and after surgery
• Refraining from drinking alcohol at least 1 week before and after surgery
• Getting a care team together of friends, loved ones and/or professionals to take care of you post-op

Recovery from Gender-Affirming Surgery

Just like preparing for surgery, recovery involves both physical and emotional processes. Emotionally, it is very common for patients to experience temporary feelings of depression and even regret in the postoperative period due to pain, inflammation and changes in mobility during recovery. As healing progresses and the results of surgery become more apparent, patients who undergo gender-affirming surgeries report significantly high levels of satisfaction . For this reason, we highly encourage patients to include supportive loved ones and/or a mental health professional as a part of their surgical recovery plan.

In terms of physical recovery, most patients will be advised to follow a low-sodium diet two weeks after surgery to reduce the formation of excessive swelling. Likewise, if surgery leaves any visible incisions, patients should follow incision and scar care protocols such as moisturizing incisions, scar massages , and minimizing sun exposure for at least a year after surgery.

You can find more specific recovery guidelines in the following articles:

• Recovering from top surgery (chest reconstruction or breast reduction)
• Recovering from breast augmentation
• Recovering from facial surgery
• Recovering from liposuction
• Recovering from fat grafting (BBL)
• Recovering from vaginoplasty, vulvoplasty and/or labiaplasty
• Recovery from metoidioplasty
• Recovery from phalloplasty

Q: Is gender affirming surgery covered by insurance?

Many insurance plans cover gender affirming surgeries. However, coverage and requirements vary by plan and state. It’s essential to check with your insurance provider for specific details on coverage, pre-authorization requirements, and any exclusions or limitations. For more information, click here .

Q: What is the recovery process like for gender affirming surgeries?

The recovery process differs depending on the specific procedure(s) performed. Generally, it involves some downtime, pain management, and follow-up appointments. Your surgeon will provide detailed recovery instructions and timelines. It’s important to follow these instructions carefully to ensure proper healing and minimize the risk of complications.

Q: Are there any risks associated with gender affirming surgeries?

As with any surgical procedure, there are potential risks and complications associated with gender affirming surgeries. These can include bleeding, infection, scarring, and adverse reactions to anesthesia. Your surgeon can discuss specific risks or complications, as well as steps to minimize these and ensure the best possible outcome. For more information on how you can minimize surgical risks, click here .

Q: How long does it take to recover from a vaginoplasty?

The recovery process for a vaginoplasty can take at least 3 months, which is when patients can begin to have penetrative sex. Initial healing typically takes 4-6 weeks, during which time you may experience discomfort, swelling, bruising, and the need for dilation to maintain the vaginal depth and width. Dilation is a life-long commitment to maintain the vaginal canal opening after surgery. However, it can take 6 months to a year for swelling to resolve so that final results are visible. For more in-depth information on vaginoplasty recovery, click here .

Q: Can gender affirming surgeries be reversed?

Depending on the surgery, some procedures can be reversed. For example, implants can be removed after a breast augmentation. However, attempting to reverse the outcomes of any surgery can be complex and may not restore function pre-operatively (i.e. inability to chest feed after mastectomy). Additionally, procedures that alter reproductive organs like an orchiectomy (removal of the testicles), hysterectomy (removal of the uterus) or oophorectomy (removal of one or more ovaries) are irreversible. For this reason, we recommend that our patients look into their fertility preservation options prior to undergoing said procedures.

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What Is Gender Affirmation Surgery?

A gender affirmation surgery allows individuals, such as those who identify as transgender or nonbinary , to change one or more of their sex characteristics. This type of procedure offers a person the opportunity to have features that align with their gender identity.

For example, this type of surgery may be a transgender surgery like a male-to-female or female-to-male surgery. Read on to learn more about what masculinizing, feminizing, and gender-nullification surgeries may involve, including potential risks and complications.

Why Is Gender Affirmation Surgery Performed?

A person may have gender affirmation surgery for different reasons. They may choose to have the surgery so their physical features and functional ability align more closely with their gender identity.

For example, one study found that 48,019 people underwent gender affirmation surgeries between 2016 and 2020. Most procedures were breast- and chest-related, while the remaining procedures concerned genital reconstruction or facial and cosmetic procedures.

In some cases, surgery may be medically necessary to treat dysphoria. Dysphoria refers to the distress that transgender people may experience when their gender identity doesn't match their sex assigned at birth. One study found that people with gender dysphoria who had gender affirmation surgeries experienced:

• Decreased antidepressant use
• Decreased anxiety, depression, and suicidal ideation
• Decreased alcohol and drug abuse

However, these surgeries are only performed if appropriate for a person's case. The appropriateness comes about as a result of consultations with mental health professionals and healthcare providers.

Transgender vs Nonbinary

Transgender and nonbinary people can get gender affirmation surgeries. However, there are some key ways that these gender identities differ.

Transgender is a term that refers to people who have gender identities that aren't the same as their assigned sex at birth. Identifying as nonbinary means that a person doesn't identify only as a man or a woman. A nonbinary individual may consider themselves to be:

• Both a man and a woman
• Neither a man nor a woman
• An identity between or beyond a man or a woman

Hormone Therapy

Gender-affirming hormone therapy uses sex hormones and hormone blockers to help align the person's physical appearance with their gender identity. For example, some people may take masculinizing hormones.

"They start growing hair, their voice deepens, they get more muscle mass," Heidi Wittenberg, MD , medical director of the Gender Institute at Saint Francis Memorial Hospital in San Francisco and director of MoZaic Care Inc., which specializes in gender-related genital, urinary, and pelvic surgeries, told Health .

Types of hormone therapy include:

• Masculinizing hormone therapy uses testosterone. This helps to suppress the menstrual cycle, grow facial and body hair, increase muscle mass, and promote other male secondary sex characteristics.
• Feminizing hormone therapy includes estrogens and testosterone blockers. These medications promote breast growth, slow the growth of body and facial hair, increase body fat, shrink the testicles, and decrease erectile function.
• Non-binary hormone therapy is typically tailored to the individual and may include female or male sex hormones and/or hormone blockers.

It can include oral or topical medications, injections, a patch you wear on your skin, or a drug implant. The therapy is also typically recommended before gender affirmation surgery unless hormone therapy is medically contraindicated or not desired by the individual.

Masculinizing Surgeries

Masculinizing surgeries can include top surgery, bottom surgery, or both. Common trans male surgeries include:

• Chest masculinization (breast tissue removal and areola and nipple repositioning/reshaping)
• Hysterectomy (uterus removal)
• Metoidioplasty (lengthening the clitoris and possibly extending the urethra)
• Oophorectomy (ovary removal)
• Phalloplasty (surgery to create a penis )
• Scrotoplasty (surgery to create a scrotum)

Top Surgery

Chest masculinization surgery, or top surgery, often involves removing breast tissue and reshaping the areola and nipple. There are two main types of chest masculinization surgeries:

• Double-incision approach : Used to remove moderate to large amounts of breast tissue, this surgery involves two horizontal incisions below the breast to remove breast tissue and accentuate the contours of pectoral muscles. The nipples and areolas are removed and, in many cases, resized, reshaped, and replaced.
• Short scar top surgery : For people with smaller breasts and firm skin, the procedure involves a small incision along the lower half of the areola to remove breast tissue. The nipple and areola may be resized before closing the incision.

Metoidioplasty

Some trans men elect to do metoidioplasty, also called a meta, which involves lengthening the clitoris to create a small penis. Both a penis and a clitoris are made of the same type of tissue and experience similar sensations.

Before metoidioplasty, testosterone therapy may be used to enlarge the clitoris. The procedure can be completed in one surgery, which may also include:

• Constructing a glans (head) to look more like a penis
• Extending the urethra (the tube urine passes through), which allows the person to urinate while standing
• Creating a scrotum (scrotoplasty) from labia majora tissue

Phalloplasty

Other trans men opt for phalloplasty to give them a phallic structure (penis) with sensation. Phalloplasty typically requires several procedures but results in a larger penis than metoidioplasty.

The first and most challenging step is to harvest tissue from another part of the body, often the forearm or back, along with an artery and vein or two, to create the phallus, Nicholas Kim, MD, assistant professor in the division of plastic and reconstructive surgery in the department of surgery at the University of Minnesota Medical School in Minneapolis, told Health .

Those structures are reconnected under an operative microscope using very fine sutures—"thinner than our hair," said Dr. Kim. That surgery alone can take six to eight hours, he added.

In a separate operation, called urethral reconstruction, the surgeons connect the urinary system to the new structure so that urine can pass through it, said Dr. Kim. Urethral reconstruction, however, has a high rate of complications, which include fistulas or strictures.

According to Dr. Kim, some trans men prefer to skip that step, especially if standing to urinate is not a priority. People who want to have penetrative sex will also need prosthesis implant surgery.

Hysterectomy and Oophorectomy

Masculinizing surgery often includes the removal of the uterus (hysterectomy) and ovaries (oophorectomy). People may want a hysterectomy to address their dysphoria, said Dr. Wittenberg, and it may be necessary if their gender-affirming surgery involves removing the vagina.

Many also opt for an oophorectomy to remove the ovaries, almond-shaped organs on either side of the uterus that contain eggs and produce female sex hormones. In this case, oocytes (eggs) can be extracted and stored for a future surrogate pregnancy, if desired. However, this is a highly personal decision, and some trans men choose to keep their uterus to preserve fertility.

Feminizing Surgeries

Surgeries are often used to feminize facial features, enhance breast size and shape, reduce the size of an Adam’s apple , and reconstruct genitals.  Feminizing surgeries can include: 

• Breast augmentation
• Facial feminization surgery
• Penis removal (penectomy)
• Scrotum removal (scrotectomy)
• Testicle removal (orchiectomy)
• Tracheal shave (chondrolaryngoplasty) to reduce an Adam's apple
• Vaginoplasty
• Voice feminization

Breast Augmentation

Top surgery, also known as breast augmentation or breast mammoplasty, is often used to increase breast size for a more feminine appearance. The procedure can involve placing breast implants, tissue expanders, or fat from other parts of the body under the chest tissue.

Breast augmentation can significantly improve gender dysphoria. Studies show most people who undergo top surgery are happier, more satisfied with their chest, and would undergo the surgery again.

Most surgeons recommend 12 months of feminizing hormone therapy before breast augmentation. Since hormone therapy itself can lead to breast tissue development, transgender women may or may not decide to have surgical breast augmentation.

Facial Feminization and Adam's Apple Removal

Facial feminization surgery (FFS) is a series of plastic surgery procedures that reshape the forehead, hairline, eyebrows, nose, cheeks, and jawline. Nonsurgical treatments like cosmetic fillers, botox, fat grafting, and liposuction may also be used to create a more feminine appearance.  

Some trans women opt for chondrolaryngoplasty, also known as a tracheal shave. The procedure reduces the size of the Adam's apple, an area of cartilage around the larynx (voice box) that tends to be larger in people assigned male at birth.

Vulvoplasty and Vaginoplasty

As for bottom surgery, there are various feminizing procedures from which to choose. Vulvoplasty (to create external genitalia without a vagina) or vaginoplasty (to create a vulva and vaginal canal) are two of the most common procedures.

Dr. Wittenberg noted that people might undergo six to 12 months of electrolysis or laser hair removal before surgery to remove pubic hair from the skin that will be used for the vaginal lining.

Surgeons have different techniques for creating a vaginal canal. A common one is a penile inversion, where the masculine structures are emptied and inverted into a created cavity, explained Dr. Kim. Vaginoplasty may be done in one or two stages, said Dr. Wittenberg, and the initial recovery is three months—but it will be a full year until people see results.

Surgical removal of the penis or penectomy is sometimes used in feminization treatment. This can be performed along with an orchiectomy and scrotectomy.

However, a total penectomy is not commonly used in feminizing surgeries . Instead, many people opt for penile-inversion surgery, a technique that hollows out the penis and repurposes the tissue to create a vagina during vaginoplasty.

Orchiectomy and Scrotectomy

An orchiectomy is a surgery to remove the testicles —male reproductive organs that produce sperm. Scrotectomy is surgery to remove the scrotum, that sac just below the penis that holds the testicles.

However, some people opt to retain the scrotum. Scrotum skin can be used in vulvoplasty or vaginoplasty, surgeries to construct a vulva or vagina.

Other Surgical Options

Some gender non-conforming people opt for other types of surgeries. This can include:

• Gender nullification procedures
• Penile preservation vaginoplasty
• Vaginal preservation phalloplasty

Gender Nullification

People who are agender or asexual may opt for gender nullification, sometimes called nullo. This involves the removal of all sex organs. The external genitalia is removed, leaving an opening for urine to pass and creating a smooth transition from the abdomen to the groin.

Depending on the person's sex assigned at birth, nullification surgeries can include:

• Breast tissue removal
• Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

Some gender non-conforming people assigned male at birth want a vagina but also want to preserve their penis, said Dr. Wittenberg. Often, that involves taking skin from the lining of the abdomen to create a vagina with full depth.

Vaginal Preservation Phalloplasty

Alternatively, a patient assigned female at birth can undergo phalloplasty (surgery to create a penis) and retain the vaginal opening. Known as vaginal preservation phalloplasty, it is often used as a way to resolve gender dysphoria while retaining fertility.

The recovery time for a gender affirmation surgery will depend on the type of surgery performed. For example, healing for facial surgeries may last for weeks, while transmasculine bottom surgery healing may take months.

Your recovery process may also include additional treatments or therapies. Mental health support and pelvic floor physiotherapy are a few options that may be needed or desired during recovery.

Risks and Complications

The risk and complications of gender affirmation surgeries will vary depending on which surgeries you have. Common risks across procedures could include:

• Anesthesia risks
• Hematoma, which is bad bruising
• Poor incision healing

Complications from these procedures may be:

• Acute kidney injury
• Blood transfusion
• Deep vein thrombosis, which is blood clot formation
• Pulmonary embolism, blood vessel blockage for vessels going to the lung
• Rectovaginal fistula, which is a connection between two body parts—in this case, the rectum and vagina
• Surgical site infection
• Urethral stricture or stenosis, which is when the urethra narrows
• Urinary tract infection (UTI)
• Wound disruption

What To Consider

It's important to note that an individual does not need surgery to transition. If the person has surgery, it is usually only one part of the transition process.

There's also psychotherapy . People may find it helpful to work through the negative mental health effects of dysphoria. Typically, people seeking gender affirmation surgery must be evaluated by a qualified mental health professional to obtain a referral.

Some people may find that living in their preferred gender is all that's needed to ease their dysphoria. Doing so for one full year prior is a prerequisite for many surgeries.

All in all, the entire transition process—living as your identified gender, obtaining mental health referrals, getting insurance approvals, taking hormones, going through hair removal, and having various surgeries—can take years, healthcare providers explained.

A Quick Review

Whether you're in the process of transitioning or supporting someone who is, it's important to be informed about gender affirmation surgeries. Gender affirmation procedures often involve multiple surgeries, which can be masculinizing, feminizing, or gender-nullifying in nature.

It is a highly personalized process that looks different for each person and can often take several months or years. The procedures also vary regarding risks and complications, so consultations with healthcare providers and mental health professionals are essential before having these procedures.

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Related Articles

What to Expect After Bottom Surgery: One Transgender Woman's Experience With Vaginoplasty

_In part one of our three-part series on vaginoplasty (one form of "bottom" or gender-affirming surgery), we heard about aftercare from a trans-knowledgeable visiting nurse who has supported transgender women through this experience. Now, we'll turn to Nyala Moon, an outreach specialist with Housing Works and screenwriter/actress of the feature film NOVA about a young trans woman of color trying to make it in New York City. Both spoke at Community Healthcare Network's 7th Annual Conference on Transgender Health in October 2017. Moon captivated the audience by sharing her experience and noting what others could consider and prepare for when it comes to the days and weeks after surgery. Here's her story:

Nyala Moon: A lot of trans people work really hard to get their surgeries covered. And you go through those hard journeys of finding a surgeon who will do it, of getting health insurance that will cover it. And you get to your surgery. And you're like: "I'm getting my surgery. It's tomorrow. I'm drinking the bowel prep. It's gross. I'm going to get through it." And you get your surgery.

And you're like: "I hate it. I have gotten this surgery that I have wanted to get all of my life. This is the tipping point. I've fallen off into this reality that I've been working hard to strive for." And you think that the journey is over, right? I did, at least. And it's not. It's not over.

After you finish with surgery, the journey begins of actually relearning yourself. Because once you get the surgery, and you're done, and you're healing, and you're in your room, and your family's there, your friends are there, supporting you, you think that you've made it. There's nothing else you need to worry about. Wrong.

Related: Gender-Affirming Aftercare for Trans Women: Healing From Vaginoplasty

Besides dilation. They tell you to dilate, and you're prepared for that, so you're like: "I'm going to dilate three times a day. Gonna make that work." But there are other factors that you should consider.

For one, you are relearning your body. The doctor has created this body part that is on you. But at first, it doesn't necessarily seem like it's yours. And a lot of trans people, myself included, felt that maybe it was wrong to have these feelings, to question whether you made the right decision. Those feelings are totally valid, of course. But a lot of trans people go through that, and they may experience a lot of postoperative depression -- which is real.

In New York City, we have had a surgery renaissance in the last few years. A lot of trans people have been able to get gender-confirming surgeries. And they have been able to make it past the finish line that they have been racing towards ever since they were born. And they think, "If I have any fears, if I have any doubts after surgery about how it looks, if I talk to my doctor about it, if I need more pain meds, then I'm complaining, and this is not for me."

This journey is a very hard journey.

For example, the first time I got home afterward, with my catheter, I was eating, watching TV, on Facebook, talking with all with my friends. And then I remembered; I was like, "Oh, crap, I haven't peed yet." And then I go back to what the doctor told me. The doctor was like, "Nyala, if you do not pee in six hours, you need to go back to the emergency room and you need to get another catheter."

I was like: "Oh, my God. I don't want to get another catheter while I'm awake. No. They need to put me out to do that." So, I remember, time goes by, and it's midnight. I'm sitting on the toilet, and I'm, like, crying. My boyfriend is there. And I'm pouring water on myself and I'm like: "Pee. Pee. Please pee."

And then I call the emergency room, and they're just like, "Ma'am, you need to go and get a catheter again."

I'm like: "No. I can do this. I can do this." And, literally, in the eleventh hour, I peed. I cried. I didn't imagine that peeing again would be a different and a complex process of getting gender reassignment surgery.

So, I peed, and I prayed to God that I could pee again the next time. I drank a lot of water and, luckily, I peed again.

Dilation is also a complicated process. It is a full-time job to dilate. In the first three months, you have to be religious about it. I dilated a lot to TV shows. They tell you to dilate for 20 minutes a day. But you're so scared that it's going to close up that you probably dilate -- well, I dilated till like an hour. I would watch the Atlanta Housewives , and I would get in my bathtub. Because at first it was the only place that I could dilate. There was so much blood.

The blood is a lot. But you'll be OK.

So, I would get my pillow. I would sit in my tub. I would have my iPad, and I would watch The Real Housewives of Atlanta while I was dilating. I'd watch the whole episode. Then I was done. I knew I was finished dilating, and I could go back to lying in bed. Because your body is also healing, too. So you're learning. Your day is pretty much taken up with dilating, resting, cleaning up the blood, and healing.

A lot of fear that trans people also have is the need for revision. So I dilated religiously -- some may think to the level of being OCD. But I didn't want it to close up. So, I dilated, dilated, got better, and got better.

But still, I needed a revision.

And I was so scared to tell my doctor that I needed a revision, because I thought, "Nyala, you worked hard to get this surgery covered." I said: "If you go in there, they're going to think that you didn't dilate as you should have (even though I did). And then you just asked them for more pain medication. And they're just going to blame you in your failure because this didn't work. And maybe health insurance won't cover it again."

So, I had a huge fear of going back in and seeking another revision. Now that I look back on it, I tell myself, and I tell other trans people: "You are a customer. And the medical professionals are there to service you and your needs."

You need to be your own advocate while going through the first six months. Because you're going to mess up. There are going to be complications. And you may need a revision. But you have to be your own advocate -- or at least have someone else be your advocate: a friend, or someone who is there for you, who's close to you and can help you advocate your needs.

You're in a very fragile point in your life. You have just done something that is life changing, and it's hard to do. So, I had finally gotten the guts to go to my surgeon and tell him that I messed up and I needed a revision.

Once he told me, "You have a complication, and we're going to have do a revision surgery," I thought to myself: "Nyala, you just got done. You've gone through all the pain, in the process of getting the surgery. You can't do this again. You know? You need to work. You have to move on in your life."

And I waited. I waited a while before I went back in and got the revision. And revisions are very tough on trans people, because getting the surgery is a spiritual journey, too. And so I didn't know if I had enough spirit to go through this process again.

But I did, luckily.

Sex: Sex is a very joyous experience after getting the surgery. It's a very tricky experience, as well. What motivated me to have sex and to explore myself -- cliché enough -- was The Vagina Monologues . I read them. And it worked, too. Because you get this new body -- or this new body part -- and it's different than what you had. A lot of trans women fit into two camps. Preoperatively, they liked to use their penis or they didn't. Right?

For the ones who did like to before, they think, "Oh, it's the same way." It's not. And for the trans women who didn't, they're like, "This is what I wanted, so I'm going to be able to work it, right?"

No. You're not.

It took a lot of exploration, a lot of mirror time, a lot of listening to other trans women, to actually figure it out. A lot of people don't really talk about it. They don't really talk about it, especially women, empowering women's bodies to masturbate and to enjoy it, to figure themselves out. So, that was a tough time.

And also actually having penetrative sex. I broke up with my boyfriend and I was like: "Nyala, you're going to have casual, random sex. ... It's going to work. Everything's going to go well." I'm like: "You got your vajine. You're dilating again like a champ. Everything is working."

So, I met a guy. I invited him out. I'm like: "We're going to have sex; we are going to do it." Right? And so, we do all the romantic stuff. We get there, and I'm like lying on my back. And I'm like, "Let's do this."

He's like, "Wait. What's wrong? It won't go in."

I'm like, "Oh, my God. Why is it not going in?"

And then he's like, "You have to relax."

I'm like, "I am relaxed."

He's like, "No, you're not. You have to open your legs more."

And then I'm like, "Hey." I'm thinking, "This is how it goes in when I dilate," right? And, no. This is totally different, completely different. I remember leaving that experience. We did not end up having sex at that time because I was just like: "I gotta go. This is not working."

I remember leaving that experience with a lot of shame, too. Because I was like: "Why is this not working? Why is this not happening for me?" And after talking with a lot of other trans people, I realized it's not easy the first time. It does not go in the first time. You have to finesse it until you learn how to work your own body to -- to make it happen.

So, I tell you guys all of these anecdotal stories to say that the first year after, of being post-op, is a lot of self-discovery -- a lot of figuring your own self out and your own body out.

And growing yourself spiritually, too. I am not a spiritual person, but getting the surgery made me a spiritual person. It grew me as a person, too, to actually love my body more. Because a lot of trans people, until we get the surgery (if that's what we choose to get), we carry a lot of shame about ourselves. It's a lot of unpacking that we have to do, even after we do the surgery.

It's a lot of work, going beyond it, and moving on beyond it, and even reestablishing your life.

I missed a Beyoncé concert.

My doctor was like: "No, Nyala. You cannot travel."

And I was like, "But it's Beyoncé."

And he was like, "You cannot go see Beyoncé."

And I'm like, "But she's 'On the Run.'"

And he was like: "I do not care, Nyala. You have to stay, and you can't travel."

Gender reassignment surgery is a lot of work. It takes a lot of growth. It takes a lot of spiritual growth, and it takes a lot of figuring it out.

To speak on the relationship stuff, when you're getting the surgery done you have to be very selfish. You are not at the giving-love moment, because you're focusing on healing. And you're sleeping, and you're watching TV, and you're doing all these things to get better.

What I like to tell a lot of trans people who are getting the surgery is that you maybe should talk to your partner about this. And if your partner is not completely supportive, maybe you should break up, because you don't have the time to devote to them.

What got me through my first three months was a good group of friends who I went to college with and who I knew when I was a teenager because, for me, in my surgery journey, they were more my rock than my partner turned out to be. My best friend since I was 17, in the first week after I got out of surgery, she stayed in my waiting room with me. And my friends visited me. Other friends, they visited me daily. They were more of a support system for me than my at-that-time boyfriend.

Honestly, you are at the precipice when you get the surgery done. So, a lot of stuff that doesn't necessarily work out or is not working out will fall to the wayside. When you get the surgery done, you will learn who truly supports you. Because it is work to be supportive of someone who is getting the surgery done.

This transcript has been condensed and edited for clarity.

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The Transgender and Intersex Specialty Care Clinic (TISCC) at Mayo Clinic delivers integrated gender-affirming care that includes medical therapy, psychosocial care and surgery to transgender, gender diverse and intersex people. TISCC staff are committed to fostering an inclusive and safe environment that inspires hope and promotes health and well-being.

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• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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QUINN JACKSON, MD, MPH, NICOLE T. YEDLINSKY, MD, AND MEREDITH GRAY, MD

Am Fam Physician. 2024;109(6):560-565

Published online May 14, 2024.

Author disclosure: No relevant financial relationships.

Gender-affirming surgery includes a range of procedures that help align a transgender or gender diverse person's body with their gender identity. As rates of gender-affirming surgery increase, family physicians will need to have the knowledge and skills to provide lifelong health care to this population. Physicians should conduct an anatomic survey or organ inventory with patients to determine what health screenings are applicable. Health care maintenance should follow accepted guidelines for the body parts that are present. Patients do not require routine breast cancer screening after mastectomy; however, because there is residual breast tissue, symptoms of breast cancer warrant workup. After masculinizing genital surgery, patients should have lifelong follow-up with a urologist familiar with gender-affirming surgery. If a prostate examination is indicated after vaginoplasty, it should be performed vaginally. If a pelvic examination is indicated after vaginoplasty, it should be performed with a Pederson speculum or anoscope. After gonadectomy, patients require hormone therapy to prevent long-term morbidity associated with hypogonadism, including osteoporosis. The risk of sexually transmitted infections may change after genital surgery depending on the tissue used for the procedure. Patients should be offered the same testing and treatment for sexually transmitted infections as cisgender populations, with site-specific testing based on sexual history. If bowel tissue is used in vaginoplasty, vaginal bleeding may be caused by adenocarcinoma or inflammatory bowel disease. ( Am Fam Physician . 2024;109(6):560-565. Copyright © 2024 American Academy of Family Physicians.)

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Nolan IT, Dy GW, Levitt N. Considerations in gender-affirming surgery: demographic trends. Urol Clin North Am. 2019;46(4):459-465.

Meerwijk EL, Sevelius JM. Transgender population size in the United States: a meta-regression of population-based probability samples. Am J Public Health. 2017;107(2):e1-e8.

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Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(suppl 1):S1-S259.

James SE, Herman JL. Rankin S, et al. The report of the 2015 U.S. transgender survey. National Center for Transgender Equality; 2016. Accessed August 3, 2023. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):168-171.

van Heesewijk J, Kent A, van de Grift TC, et al. Transgender health content in medical education: a theory-guided systematic review of current training practices and implementation barriers & facilitators. Adv Health Sci Educ Theory Pract. 2022;27(3):817-846.

Thawanyarat K, Johnstone T, Rowley M, et al. Travel distance and national access to gender-affirming care. J Am Coll Surg. 2022;235(5):S212.

Grasso C, Goldhammer H, Thompson J, et al. Optimizing gender-affirming medical care through anatomical inventories, clinical decision support, and population health management in electronic health record systems. J Am Med Inform Assoc. 2021;28(11):2531-2535.

Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people, 2nd ed. University of California–San Francisco, June 17, 2016. Accessed August 3, 2023. https://transcare.ucsf.edu/guidelines

Schrager S, Lyon SM, Poore SO. Breast implants: common questions and answers. Am Fam Physician. 2021;104(5):500-508.

Klein DA, Paradise SL, Goodwin ET. Caring for transgender and gender-diverse persons: what clinicians should know. Am Fam Physician. 2018;98(11):645-653.

Dakkak M, Kriegel DL, Tauches K. Caring for transgender and gender-diverse people: guidelines from WPATH. Am Fam Physician. 2023;108(6):626-629.

Oles N, Darrach H, Landford W, et al. Gender affirming surgery: a comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (part 1: breast/chest, face, and voice). Ann Surg. 2022;275(1):e52-e66.

Frederick MJ, Berhanu AE, Bartlett R. Chest surgery in female to male transgender individuals. Ann Plast Surg. 2017;78(3):249-253.

Wolter A, Scholz T, Pluto N, et al. Subcutaneous mastectomy in female-to-male transsexuals: optimizing perioperative and operative management in 8 years clinical experience. J Plast Reconstr Aesthet Surg. 2018;71(3):344-352.

Gooren LJ, van Trotsenburg MAA, Giltay EJ, et al. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med. 2013;10(12):3129-3134.

Burcombe RJ, Makris A, Pittam M, et al. Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast. 2003;12(4):290-293.

Nikolic DV, Djordjevic ML, Granic M, et al. Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy. World J Surg Oncol. 2012;10:280.

Katayama Y, Motoki T, Watanabe S, et al. A very rare case of breast cancer in a female-to-male transsexual. Breast Cancer. 2016;23(6):939-944.

Brown A, Lourenco AP, Niell BL, et al.; Expert Panel on Breast Imaging. ACR Appropriateness Criteria® transgender breast cancer screening. J Am Coll Radiol. 2021;18(11S):S502-S515.

Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. Ann Oncol. 2013;24(6):1434-1443.

Patel DP, Goodwin IA, Acar O, et al. Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know. Fertil Steril. 2021;116(4):924-930.

Jolly D, Wu CA, Boskey ER, et al. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294.

Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: a systematic review. Ann Transl Med. 2021;9(7):607.

Heston AL, Esmonde NO, Dugi DD, et al. Phalloplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):254-265.

Rooker SA, Vyas KS, DiFilippo EC, et al. The rise of the neophallus: a systematic review of penile prosthetic outcomes and complications in gender-affirming surgery. J Sex Med. 2019;16(5):661-672.

Schardein JN, Zhao LC, Nikolavsky D. Management of vaginoplasty and phalloplasty complications. Urol Clin North Am. 2019;46(4):605-618.

Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7(9):e2442.

Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021;70(4):1-187.

Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors [published correction appears in J Low Genit Tract Dis . 2020; 24(4): 427]. J Low Genit Tract Dis. 2020;24(2):102-131.

Reisner SL, Deutsch MB, Peitzmeier SM, et al. Test performance and acceptability of self-versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients. PLoS One. 2018;13(3):e0190172.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline [published corrections appear in J Clin Endocrinol Metab . 2018; 103(2): 699, and J Clin Endocrinol Metab . 2018; 103(7): 2758–2759]. J Clin Endocrinol Metab. 2017;102(11):3869-3903.

van der Sluis WB, Steensma TD, Bouman MB. Orchiectomy in transgender individuals: a motivation analysis and report of surgical outcomes. Int J Transgend Health. 2020;21(2):176-181.

Hontscharuk R, Alba B, Hamidian Jahromi A, et al. Penile inversion vaginoplasty outcomes: complications and satisfaction. Andrology. 2021;9(6):1732-1743.

Krempasky C, Grimstad FW, Harris M, et al. Feminizing gender-affirming surgery. J Gynecol Surg. 2021;37(4):283-290.

Grimstad F, McLaren H, Gray M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am J Obstet Gynecol. 2021;224(3):266-273.

Ferrando CA. Vaginoplasty complications. Clin Plast Surg. 2018;45(3):361-368.

van der Sluis WB, de Haseth KB, Elfering L, et al. Neovaginal discharge in transgender women after vaginoplasty: a diagnostic and treatment algorithm. Int J Transgend Health. 2020;21(4):367-372.

Radix AE, Harris AB, Belkind U, et al. Chlamydia trachomatis infection of the neovagina in transgender women. Open Forum Infect Dis. 2019;6(11):ofz470.

Bodsworth NJ, Price R, Davies SC. Gonococcal infection of the neovagina in a male-to-female transsexual. Sex Transm Dis. 1994;21(4):211-212.

Elfering L, van der Sluis WB, Mermans JF, et al. Herpes neolabialis: herpes simplex virus type 1 infection of the neolabia in a transgender woman. Int J STD AIDS. 2017;28(8):841-843.

Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47(3):398-402.

Kronawitter D, Gooren LJ, Zollver H, et al. Effects of transdermal testosterone or oral dydrogesterone on hypoactive sexual desire disorder in transsexual women: results of a pilot study. Eur J Endocrinol. 2009;161(2):363-368.

Cocchetti C, Ristori J, Mazzoli F, et al. Management of hypoactive sexual desire disorder in transgender women: a guide for clinicians. Int J Impot Res. 2020;33(7):703-709.

Jiang DD, Gallagher S, Burchill L, et al. Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty. Obstet Gynecol. 2019;133(5):1003-1011.

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Yamada K, Shida D, Kato T, et al. Adenocarcinoma arising in sigmoid colon neovagina 53 years after construction. World J Surg Oncol. 2018;16(1):88.

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Gender Affirmation Surgery

At UChicago Medicine, we are committed to providing comprehensive, affirming care  to transgender and gender-diverse people. We are here to support you by offering a full range of gender affirmation surgeries in a welcoming, inclusive environment.

Our highly skilled surgical team includes plastic surgeons, urologists, gynecologists and otolaryngologists who have extensive experience working with LGBTQ+ patients.

Our aim is simple: to respect you and improve your quality of life through a reconstructive process in which we support you before, during and after your operation.

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Our surgeons can perform a wide array of masculinizing and feminizing procedures  to affirm your identity and enhance your appearance. We also recognize that voice is an important part of your gender expression and offer surgery to feminize the voice .

When you come to UChicago Medicine, we take time to listen to your concerns and develop a customized treatment plan based on your specific needs. We also make sure that you have the answers you need so you know what to expect at every stage of your journey.

A Multidisciplinary Team Committed to You

At UChicago Medicine, we have assembled one of the most comprehensive teams in transgender health. If you choose us for your gender affirmation surgery, you will have access to a wide range of specialists and subspecialists that you can only find at an academic medical center. From gender-affirming hormone therapy to primary and preventive care specifically for transgender and gender-diverse patients, our team can connect you with any medical or surgical care you need.

We deliver treatments based on research and expert consensus and adhere to the standards of care set forth by the World Professional Association for Transgender Health (WPATH). By doing so, we aim to optimize your well-being and your overall health.

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UChicago Medicine has been named a LGBTQ+ Healthcare Equality Leader by the Human Rights Campaign’s Healthcare Equality Index (HEI) because of our inclusive policies and practices related to LGBTQ+ patients, visitors and employees. We are especially dedicated to improving access to gender affirmation surgery for underserved transgender and gender-diverse people on Chicago’s South Side. We also collaborate with public and private institutions to improve care for transgender and gender-diverse people at the local, national and global levels.

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Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery

John j straub.

1 Department of Emergency Medicine, University of Texas Medical Branch at Galveston, Galveston, USA

Krishna K Paul

Lauren g bothwell, sterling j deshazo, georgiy golovko.

2 Department of Pharmacology, University of Texas Medical Branch at Galveston, Galveston, USA

Michael S Miller

3 Department of Psychiatry and Behavioral Services, University of Texas Medical Branch at Galveston, Galveston, USA

Dietrich V Jehle

Introduction.

With the growing acceptance of transgender individuals, the number of gender affirmation surgeries has increased. Transgender individuals face elevated depression rates, leading to an increase in suicide ideation and attempts. This study evaluates the risk of suicide or self-harm associated with gender affirmation procedures.

This retrospective study utilized de-identified patient data from the TriNetX (TriNetX, LLC, Cambridge, MA) database, involving 56 United States healthcare organizations and over 90 million patients. The study involved four cohorts: cohort A, adults aged 18-60 who had gender-affirming surgery and an emergency visit (N = 1,501); cohort B, control group of adults with emergency visits but no gender-affirming surgery (N = 15,608,363); and cohort C, control group of adults with emergency visits, tubal ligation or vasectomy, but no gender-affirming surgery (N = 142,093). Propensity matching was applied to cohorts A and C. Data from February 4, 2003, to February 4, 2023, were analyzed to examine suicide attempts, death, self-harm, and post-traumatic stress disorder (PTSD) within five years of the index event. A secondary analysis involving a control group with pharyngitis, referred to as cohort D, was conducted to validate the results from cohort C.

Individuals who underwent gender-affirming surgery had a 12.12-fold higher suicide attempt risk than those who did not (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001). Compared to the tubal ligation/vasectomy controls, the risk was 5.03-fold higher before propensity matching and remained significant at 4.71-fold after matching (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001) for the gender affirmation patients with similar results with the pharyngitis controls.

Patients who have undergone gender-affirming surgery are associated with a significantly elevated risk of suicide, highlighting the necessity for comprehensive post-procedure psychiatric support.

The prevalence of transgender individuals in the United States is approximately 0.3% to 0.6% of the adult population based on self-reporting studies [ 1 ]. Investigations that only include individuals with transgender diagnostic codes, hormone therapy, or gender-affirming surgery report a much lower rate of approximately 0.008% of the population [ 2 ]. People who identify as transgender are shown to have a higher risk of suicide in the United States and across many other countries [ 3 - 6 ].

In 2021, the Centers for Disease Control reported that 48,183 people died by suicide in the United States. Depression, substance abuse, other mental illness, legal/financial problems, harmful relationships, community risk factors, and easy access to lethal means are contributing factors to successful suicide. Transgender individuals have a higher prevalence of depression across several age groups, often due to life experiences that include discrimination, harassment, violence, misgendering, and enacted stigma that may generate poor mental health outcomes and harmful behaviors [ 4 , 7 , 8 ]. It is widely accepted that depression puts an individual at higher risk for suicidal ideation and suicide attempts [ 9 ]. Individuals at higher risk for suicide and post-traumatic stress disorder (PTSD) should have comprehensive psychiatric interventions and care throughout their lifetime. A better understanding of the relationship between suicide and gender affirmation remains particularly important.

There is ongoing controversy surrounding the benefits of gender-affirmation surgery on mental health [ 10 - 20 ]. This controversy reflects diverse perspectives within the medical and research communities, emphasizing the need for a more comprehensive understanding of the psychological outcomes of gender-affirming procedures. Despite the increasing acceptance of transgender individuals, questions persist about the psychological outcomes of gender-affirming procedures. Responses to the discussion surrounding the benefits of gender-affirmation surgery have been diverse, as evidenced by studies conducted by Branstrom and colleagues [ 11 ], Almazan et al. [ 13 ], and others [ 10 , 14 - 20 ].

The purpose of this study is to assess the risk of adverse outcomes, specifically suicide, death, self-harm, and PTSD in the five years following gender-affirmation surgery. Suicide risk over time among patients who received gender-affirmation surgery is compared to individuals in several control groups. The TriNetX (TriNetX, LLC, Cambridge, MA) database will be utilized to better understand the relationship between sex change and these outcomes.

This article was previously presented virtually as a meeting abstract at the 2023 Texas College of Emergency Physicians (TCEP) Research Forum on April 07, 2023.

Materials and methods

TriNetX is a global health research network providing access to de-identified retrospective electronic medical records. The database consists of over 90 million patients from 56 healthcare organizations (HCOs) within the United States. This study utilized TriNetX to identify patients who had a “personal history of sex reassignment” and evaluate their relative risk for suicide attempt, death, suicide/self-harm, and PTSD. The term “sex reassignment” was based on the International Classification of Diseases, 10th Revision (ICD-10) code in the database but will be referred to as the current term “gender-affirmation surgery” for the remaining article. All outcomes were evaluated during the five years after gender-affirmation surgery.

Patients who have undergone gender-affirmation surgery of all sexes, races, and ethnicities were identified by using the ICD-10 code, ICD10CM:Z87.890. Sex, race, and ethnicity were derived from the electronic medical record. Patients who have undergone gender-affirmation surgery are identified by their affirmed gender. A total of four cohorts were identified for this study. Cohort A consisted of patients ages 18 to 60 who had both gender-affirmation surgery and an emergency visit. Cohort B was the study control group that consisted of patients ages 18 to 60 who had no history of gender-affirmation surgery but had an emergency visit. In this database, propensity matching is not possible for very large cohorts, more than 8.3 million patients with 12 covariates.

Additional control groups were chosen to perform propensity matching, which controls for confounders. Cohort C was the study's second control group and consisted of adult patients (18-60 years) who had no history of gender-affirmation surgery, had an emergency visit, and had a tubal ligation or vasectomy. Patients who had undergone tubal ligation were identified through the ICD-10 code, ICD10CM:Z98.51, while the vasectomy procedure was identified by Current Procedural Terminology (CPT), CPT:55250. A secondary sub-group analysis, cohort D, was performed utilizing acute pharyngitis (ICD10CM:J02) as a control group for patients aged 18-60 that was run on June 2, 2023. This was performed to ensure that the vasectomy or bilateral tubal ligation (BTL) group acted as an appropriate control. The relative risk for suicide attempt, death, suicide/self-harm, and PTSD was evaluated during the five years following gender-affirmation surgery in comparison to those without gender-affirmation surgery with the diagnosis of pharyngitis. Cohort A was used again and compared with cohort D, which included patients presenting to the emergency room after diagnosis of acute pharyngitis.

The outcome analysis between the three cohorts was performed for four events: suicide attempt (ICD10CM:T14.91), death (vital status: deceased), suicide/self-harm (ICD10CM:T14.91 or ICD10CM:X71-X83), and PTSD (ICD10CM:F43.1). An analysis was performed utilizing the measures contained in the TriNetX platform, which compared the individual outcomes between cohorts A and B and also cohorts A and C within the designated time frame. Patients who had the outcome before the time window were excluded from the analysis. The final TriNetX data reported RR, 95% CI, ORs, and a risk comparison expressed as a p-value. To control potentially confounding risk factors for the measured outcomes, the propensity matching tool in TriNetX was utilized. Factors involved in the data propensity matching are based on age at index, race, ethnicity, and sex. Propensity matching was only performed between the comparison of cohorts A and C, but not cohort B, due to the large sample size limitation.

Propensity score matching (PSM) is often used in observational studies to reduce confounding biases. It has been investigated and well-documented regarding its properties for statistical inference. PSM is a quasi-experimental method in which the researcher uses statistical techniques to construct an artificial control group by matching the affected group with a non-affected group of similar characteristics. Using these matches, the researcher can estimate the difference between both groups without the confounding variables’ influence [ 21 ]. To justify our use of propensity matching for age, race, sex, and ethnicity, we considered established risk factors for suicide such as older age, male gender identity, and racial or ethnic minority status [ 3 , 4 ].

The cohort was analyzed descriptively using univariate and bivariate frequencies with chi-square and t-testing to assess differences. All eligible persons in the cohort were analyzed using both binary event estimation with RRs, 95% CIs, and probability values. Using the TriNetX database, a 1:1 propensity match using linear and logistic regression for age, sex, race, and ethnicity was employed for maximum generalization of the United States population. Greedy nearest-neighbor matching was used with a tolerance of 0.1 and a difference between propensity scores less than or equal to 0.1. Comparisons were made between cohorts before and after propensity matching. Statistical significance was set at a two-sided alpha <0.05. TriNetX provides data that have been de-identified, and as a result, an Institutional Review Board (IRB) review is not required for this study [ 22 ]. Three comparison reports were generated on February 4, 2023. Data gathered from HCOs was from February 4, 2003, to February 4, 2023.

We identified 15,609,864 adult patients from TriNetX who were adults and had a visit to an emergency department within the United States Collaborative Network. Cohort A consisted of 1,501 adult patients who had a visit to the emergency department and a history of gender-affirmation surgery. Cohort B consisted of 15,608,363 patients who had an emergency visit but no history of gender-affirmation surgery. Cohort C consisted of 142,093 adult patients who had a visit to the emergency department and no history of gender-affirmation surgery but had a vasectomy or BTL.

Without propensity matching between cohorts A and B, patients with a history of gender-affirmation surgery exhibited a significantly higher risk for each possible outcome compared to patients without a history of gender-affirmation surgery (Table ​ (Table1). 1 ). Patients who had a history of gender-affirmation surgery had a 12.12 times greater risk of suicide attempts (3.47% vs. 0.29%, RR 95% CI 9.20-15.96, p < 0.0001) vs. patients who had no history of gender-affirmation surgery. In patients with a history of gender-affirmation surgery, there was a 3.35 times greater risk of being deceased (4.9% vs. 1.5%, RR 95% CI 2.673-4.194, p < 0.0001). Patients with a history of gender-affirmation surgery had a 9.88 times higher risk of self-harm or suicide (4.5% vs. 0.5%, RR 95% CI 7.746-12.603, p < 0.0001). Lastly, patients who had a history of gender-affirmation surgery had a 7.76 times higher risk of PTSD (9.2% vs. 1.2%, RR 95% CI 6.514-9.244, p < 0.0001).

PTSD, post-traumatic stress disorder

Before the propensity matching of cohorts A and C, there was a significantly higher risk for each outcome when considering patients with a history of gender-affirmation surgery compared to those without a history of gender-affirmation surgery but with a prior vasectomy or BTL (Table ​ (Table2). 2 ). Patients with a history of gender-affirmation surgery had a 5.03 times higher risk of suicide attempts (3.5% vs. 0.7%, RR 95% CI 3.795-6.676, p < 0.0001), a 2.37 times higher risk of being deceased (4.9% vs. 2.1%, RR 95% CI 1.889-2.982, p < 0.0001), a 5.44 times higher risk of suicide or self-harm (4.5% vs. 0.8%, RR 95% CI 4.233-6.981, p < 0.0001), and a 3.74 times higher risk of PTSD (9.2% vs. 2.5%, RR 95% CI 3.125-4.463, p < 0.0001) compared to patients without a history of gender-affirmation surgery but with a prior vasectomy or BTL.

After propensity matching of cohorts A and C, each cohort had 1,489 patients of similar age at index, race, and ethnicity (Tables ​ (Tables3 3 - ​ -4). 4 ). Patients who had a history of gender-affirmation surgery compared to patients without a gender-affirmation surgery history but had a vasectomy or BTL showed significantly higher risks for each outcome (Table ​ (Table3). 3 ). The adjusted suicide attempt risk for patients with gender-affirmation surgery compared to no history of gender-affirmation surgery but with a prior BTL or vasectomy was adjusted to a 4.71 times greater risk (3.50% vs. 0.74%, RR 95% CI 2.46-9.024, p < 0.0001). The risk of being deceased was 4.26 times greater in patients with a history of gender-affirmation surgery vs. patients with no history of gender-affirmation surgery but vasectomy or BTL (4.9% vs. 1.1%, RR 95% CI 2.520-7.191, p < 0.0001). Patients with a history of gender-affirmation surgery showed a 5.10 times higher risk of suicide or self-harm compared to patients with no history of gender-affirmation surgery but vasectomy or BTL (4.5% vs. 0.9%, RR 95% CI 2.816-9.227, p < 0.0001). Lastly, patients with a history of gender-affirmation surgery showed a 3.23 times higher risk for PTSD compared to patients with no history of gender-affirmation surgery but vasectomy or BTL (9.2% vs. 2.8%, RR 95% CI 2.278-4.580, p < 0.0001).

Cohort A: Adult patients who had a visit to the emergency department and a history of sexual reassignment.

Cohort C: Adult patients who had a visit to the emergency department and no history of sexual reassignment but had a vasectomy or bilateral tubal ligation.

The secondary sub-group analysis utilizing pharyngitis (N = 1,390,880) as a control revealed that patients presenting to the emergency department with a history of gender-affirmation surgery had a 7.95 times greater risk of suicide attempt than patients with pharyngitis (1.5% vs. 0.2%, RR CI 5.379-11.755, p < 0.0001), a 3.65 times greater risk of death (4.6% vs. 1.3%, RR CI 2.921-4.563, p < 0.0001), a 7.33 times greater risk of suicide or self-harm (2.7% vs. 0.4%, RR CI 5.448-9.850, p < 0.0001), and a 4.61 times greater risk of PTSD (9.2% vs. 2.0%, RR CI 3.901-5.438, p < 0.0001) compared to patients who were sent to the emergency department following acute pharyngitis. After propensity matching, mortality was 3.59 times greater in patients with a history of gender-affirmation surgery (4.6% vs. 1.3%, RR CI 2.224-5.806, p < 0.0001), and PTSD was 5.49 times greater (9.2% vs. 1.7%, RR CI 3.648-8.267, p < 0.0001) compared to patients with acute pharyngitis. There were too few suicides or self-harm outcomes to report results from the propensity-matched pharyngitis group. These results were similar to the results with cohort C.

The purpose of this study was to explore the relationship between gender-affirmation surgery and the risk of suicide outcomes compared to two control groups with data from 2003 to 2023. The significance of this investigation lies not only in its scale but also in its methodology, as it relies on real-world data rather than meta-analyses and self-reported surveys.

The first controlled group was a large number of patients who had emergency department visits but had not had gender-affirmation surgery. Propensity matching is not possible in the TriNetX database for large groups with millions of patients like the first control group. The second control group consisted of individuals who had not had gender-affirmation surgery but had either a vasectomy or BTL. This control group was selected to allow for propensity matching. Propensity matching was done for this comparison to control for the confounding influence of age, sex, and race/ethnicity. This is particularly important since the rate of successful suicide is much higher in men. At the start of this study, the hypothesis that was proposed predicted individuals who had undergone gender-affirmation surgery would have a greater risk of suicide, death, and self-harm compared to the two controls. This was confirmed by comparing the two control groups. In the second analysis, it was determined that patients who had undergone gender affirmation had a statistically significant increase in suicide attempts, death, self-harm, and PTSD after completion of gender affirmation in comparison with those who had undergone BTL or vasectomy and had not undergone gender-affirmation before propensity matching. After propensity matching our cohorts for age at index, race, and ethnicity, we also found a statistically significant increased risk of suicide attempts, death, self-harm/suicide, and PTSD. These outcomes confirmed the hypothesis. The secondary sub-group analysis utilizing pharyngitis as a control showed results that were comparable to the BTL/vasectomy control group, validating cohort C as an appropriate control group for propensity matching.

These data are supported by previous studies from multiple geographic regions of the globe, including Lebanon [ 3 ], Turkey [ 3 ], Pakistan [ 4 ], China [ 5 ], and Canada [ 6 ], as well as data from within the United States [ 3 - 4 , 6 ]. The large size of our study is an asset to our findings, which will help further our understanding of the relationship between sex change and suicide. To our knowledge, a study of this size has not been described in the literature. Using two control groups, a) those who had not experienced gender-affirmation surgery and had presented to the emergency department and b) a group that had not experienced gender-affirmation surgery, had visited the emergency department, and had a vasectomy or BTL, also helped effectively control for confounding variables utilizing propensity matching. Over the last 20 years, this study demonstrated a 12.12 times greater risk of suicide utilizing the first control group and a 4.71 to 5.03 times increased risk with the other control groups.

Transgender individuals, encompassing both those seeking gender-affirming surgery and those who have undergone it, demonstrate a significantly elevated risk of developing PTSD compared to the general population [ 10 , 23 ]. Among those who seek access to gender-affirming surgery, the commonality of discrimination, interpersonal assault, and a lack of social support have been identified as influential factors in the development of PTSD within this group [ 23 ]. Financial stress and insufficient insurance coverage prove to be significant obstacles for those trying to access gender-affirming surgery. Additionally, the limited availability of medical professionals with expertise in gender-affirming procedures, particularly in areas of lower socioeconomic status, further exacerbates the challenges faced by individuals seeking such care [ 10 ]. However, it is important to consider PTSD development in those who have undergone gender-affirming procedures. The emergence of PTSD following surgery often stems from the pre-operative challenges (such as harassment, limited social support, etc.) in conjunction with suboptimal surgical outcomes and insufficient psychiatric assistance.

This study has revealed a significantly elevated prevalence of PTSD in post-operative transgender individuals, with a 7.76-fold increase in comparison to cohort B and a 3.74-fold increased risk compared to cohort C after propensity matching. These findings were consistent with other studies investigated previously. A study conducted by Livingston et al. in 2022 used probabilistic and rule-based modeling on Veterans Health Administration (VHA) records from 1999 to 2021 to assess the differences in PTSD prevalence among 9,995 transgender and 29,985 cisgender veterans (1:3 ratio). They concluded that transgender veterans experienced PTSD at 1.5-1.8 times the rate of veterans identifying as cisgender, especially higher in recent users of VHA services [ 24 ]. There have proven to be many obstacles when comparing our findings to other studies assessing general population PTSD risk in those who have undergone gender-affirmation surgery. A 2018 systematic review conducted by Valentine et al. showed that many studies used assessment tools not particularly appropriate for evaluating mental health in transgender or gender non-conforming individuals [ 25 ]. The poor psychometric framework has led to many studies not acknowledging confounding and contextual variables, such as exposure to discrimination or minority identity when assessing PTSD in this demographic [ 10 , 25 ]. To avoid the repeated shortcomings of prior research, future studies should employ rigorous and reliable assessment tools such as cross-sectional studies or the collection of prospective data [ 25 ]. Improving transgender representation in emerging PTSD treatment trials is another step in improving the understanding and management of PTSD in transgender individuals [ 10 ].

In light of the examination of the relationship between gender-affirmation surgery and mental health outcomes discussed in this study, it is imperative to acknowledge the broader landscape of research on this topic. Our investigation contributes broad insight, examining real-world data over two decades and encompassing a diverse cohort. However, to further expand upon the contextual significance, it is essential to compare findings from other studies that explore multifaceted aspects of mental health post-gender-affirmation surgery. A study published in the American Journal of Psychiatry by Branstrom et al. in October 2019 drew strong conclusions regarding the positive impact of gender-affirmation surgery on mental health [ 11 ]. However, the study faced criticism of its methodology, leading to a correction/retraction by the journal's editors that stated, "the results demonstrated no advantage of surgery about subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts” [ 12 ]. In a subsequent study conducted in 2021, Almazan et al. compared the mental health outcomes of a group of patients who were not approved for gender-affirmation surgery with a group that had undergone the surgery [ 13 ].

Their findings suggested better mental health outcomes for those who underwent surgery, but notable limitations warrant careful interpretation. First, the study conducted a comparison between two groups: one that had not been approved for surgery, a process requiring two mental health screenings as per the World Professional Association for Transgender Health's standard of care recommendations, and another group that had already undergone surgery. Therefore, it is plausible that the surgery group could inherently have been healthier, irrespective of the surgery. Second, when the analysis was broadened to include lifetime outcomes, the positive association with the surgery became insignificant [ 14 ].

Although our study has revealed a statistically significant increase in suicide risk among those who have undergone gender-affirming surgery, it remains vital to recognize and support the positive impacts that these surgical interventions can have on the lives of transgender individuals. The results of a study by Park et al., published in October 2022 in the Annals of Plastic Surgery, provide a different perspective on the enduring effectiveness and consequences of gender-affirmation surgery [ 20 ]. While our research specifically examined the risk of suicide, death, self-harm, and PTSD in the five years following surgery, Park et al. surveyed the outcomes of 15 gender-affirming surgeries over a more extended period. Their results reveal an improvement in patient well-being, with high satisfaction levels, reduced dysphoria, and persistent mental health benefits even decades after surgery. Notably, the study highlights the durability of these positive outcomes and significantly reduced suicidal ideation following gender-affirmation surgery.

The number of non-gender-conforming individuals continues to increase globally. It is likely, therefore, that a growing number of medical professionals will care for an individual who has undergone gender-affirmation at some point in their career. Apart from additional assistance in surgical recovery, the most common aftercare needs for patients following gender-affirmation surgery is consultation with a mental health professional [ 26 ]. To properly address the mental health needs of transgender individuals, Lapinski et al. emphasize the significance of cultural competency, a patient-focused approach, and collaborative efforts involving psychiatric professionals [ 27 - 30 ]. Transgender individuals tend to see mental health care providers and face discrimination in clinical settings at a far higher rate than the cis-gendered population [ 27 , 28 , 30 ]. Competent medical care following gender-affirming surgery is vital in effectively managing PTSD and its respective mental health challenges for this population [ 27 ].

It is important to note that this study has several limitations. The retrospective cohort design can only demonstrate associations but not causality. However, the larger size of this study, in conjunction with propensity matching, gives this investigation a greater power to identify differences between groups. Additionally, with the extensive timeline of data collection, the findings are relevant and contemporary to modern situations. A limitation of the study design could include the fact that only adult data was analyzed, so the research cannot be generalized to those under the age of 18. The data were also only extracted from a population of residents from the United States. Patients who have undergone gender-affirmation surgery and our control groups may have refrained from disclosing their suicidal ideations or other psychiatric symptoms to their medical providers, potentially influenced by societal pressures or other factors such as perceived attitudes toward those with psychiatric complaints. It may be worth examining if groups considering gender-affirmation surgery who have not yet received the surgery share the same increased risk levels for suicidal actions and ideations. However, given the standard practice of undergoing psychiatric testing before being approved for gender-affirmation surgery, individuals contemplating the procedure may potentially pose a greater suicide risk compared to those who have been approved for surgery.

Conclusions

The results of this study indicate that patients who have undergone gender affirmation surgery are associated with significantly higher risks of suicide, self-harm, and PTSD compared to general population control groups in this real-world database. With suicide being one of the most common causes of death for adolescent and middle-aged individuals, it is clear that we must work to prevent these unfortunate outcomes. This further reinforces the need for comprehensive psychiatric care in the years that follow gender-affirmation surgery.

Greedy nearest-neighbor matching

The most common implementation of propensity matching is pair-matching, in which pairs of treated and control participants are formed. There are several common implementations of pair-matching. The most commonly used is greedy nearest-neighbor matching (NNM), which we used, in which a treated participant is selected at random and then matched to the control participant whose propensity score is closest to that of the treated participant. The process is described as greedy because, at each stage, the control is selected who is closest to the currently considered treated participant, even if that untreated participant would serve better as a control for a subsequently treated participant. This process is then repeated until a matched control participant has been selected for each treated participant. This process generally uses matching without replacement so that once a control participant is matched to a treated participant, that control participant is no longer available to match to a subsequently treated participant. A refinement to NNM is NNM with a caliper restriction. Using this approach, a control participant is an acceptable match for a treated participant only if the difference in their propensity scores is less than a maximum amount (the caliper width or distance). For technical reasons, one typically matches the logit of the propensity score and uses a caliper width that is defined as a proportion of the (0.1-0.2) SD of the logit of the propensity score. A crucial step in any study that uses PSM is to assess the degree to which matching the propensity score resulted in the formation of a matched sample in which the distribution of baseline characteristics is similar between treated and control participants. This assessment is critical as it allows both the researcher and readers to assess whether matching the estimated propensity score has removed systematic baseline differences between treatments. The use of the standardized difference, which is the difference in means in units of SD, is often used for assessing the similarity of matched treated and control participants. Some authors have suggested that a threshold of 0.10 (or 10%) be used to denote acceptable balance after matching. Once an acceptable balance has been achieved, analysts can unblind themselves to the outcome and compare outcomes between treated and control participants in the matched sample. The analyses conducted in the propensity score-matched sample can be similar to those that would be done in an RCT with a similar outcome.

Funding Statement

This study was conducted with the support of the Institute for Translational Sciences at the University of Texas Medical Branch, supported in part by a Clinical and Translational Science Award (UL1 TR001439) from the National Center for Advancing Translational Sciences, National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have declared that no competing interests exist.

Author Contributions

Acquisition, analysis, or interpretation of data:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Georgiy Golovko, Michael S. Miller, Dietrich V. Jehle

Drafting of the manuscript:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Dietrich V. Jehle

Critical review of the manuscript for important intellectual content:   Krishna K. Paul, John J. Straub, Lauren G. Bothwell, Sterling J. Deshazo, Georgiy Golovko, Michael S. Miller, Dietrich V. Jehle

Supervision:   Krishna K. Paul, Dietrich V. Jehle

Concept and design:   Georgiy Golovko, Dietrich V. Jehle

Human Ethics

Consent was obtained or waived by all participants in this study

Animal Ethics

Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

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Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study

Affiliations.

• 1 Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands; Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands.
• 2 University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium; Ghent University, Department of Experimental-Clinical and Health Psychology, Ghent, Belgium.
• 3 University Medical Center Hamburg-Eppendorf, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Hamburg, Germany.
• 4 University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium.
• 5 Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
• 6 Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands; Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands. Electronic address: [email protected].
• 7 Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands.
• PMID: 34548264
• DOI: 10.1016/j.jsxm.2021.08.005

Background: While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.

Aim: To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.

Methods: As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.

Outcomes: Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.

Results: Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.

Clinical implications: Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.

Strengths & limitations: We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.

Conclusion: These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.

Keywords: Aftercare; Gender-Affirming Surgery; Health Care Quality; Physiotherapy; Quality of Life; Transgender Persons.

Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

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Biden ‘Gender-Reassignment’ Surgery Mandate Blocked

The ruling expands an earlier court decision that blocked the mandate for hospitals in Texas and Montana to all hospitals.

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender-reassignment” surgeries or face a range of penalties, including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” said Paxton.

The Biden administration will likely appeal the ruling to the 5th Circuit Appellate Court.

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Trump repeats false claims that children are undergoing transgender surgery during the school day

Former President Donald Trump repeated his false claim that children are undergoing transition-related surgery during their school day, worsening fears among some conservatives that educators are pushing children to become transgender and aiding transitions without parental awareness.

“Can you imagine you’re a parent and your son leaves the house and you say, ‘Jimmy, I love you so much, go have a good day in school,’ and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?” Trump said Saturday at a campaign rally in Wisconsin, a vital swing state. 

Trump made similar remarks — saying children were returning home from school after having had surgical procedures — the previous weekend at an event hosted by Moms for Liberty, a parent activist group that has gained outsized influence in conservative politics in recent years.

Asked by one of the group’s co-founders how he would address the “explosion in the number of children who identify as transgender,” Trump said: “Your kid goes to school and comes home a few days later with an operation. The school decides what’s going to happen with your child.”

There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure elsewhere. 

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About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare . In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers . Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

A spokesperson for Trump’s campaign did not substantiate his claims and pointed NBC News to reports about parents’ being left in the dark about their children’s gender transitions at school. 

“President Trump will ensure all Americans are treated equally under the law regardless of race, gender or sexual orientation,” said the spokesperson, Karoline Leavitt.

Kate King, president of the National Association of School Nurses, said that even when it comes to administering over-the-counter medication such as Advil or Tylenol, school nurses need explicit permission from a physician and a parent.

“There is no way that anyone is doing surgery in a classroom in schools,” she said when she was asked about Trump’s remarks.

Trump’s claims stand out even amid years of allegations by conservative politicians and right-wing media pundits that teachers, Democratic lawmakers and LGBTQ adults are “grooming” or “indoctrinating” children to become gay or transgender. 

The practice of labeling LGBTQ people, particularly gay men and trans women, as “groomers” and “pedophiles” of children had been relegated to the margins for decades, but the tropes resurfaced during the heated debate over Florida’s so-called Don’t Say Gay law, which Gov. Ron DeSantis signed in March 2022. The law limits the instruction of sexual orientation and gender identity in school and has been replicated in states across the country.

At the Republican National Convention in July, at least a dozen speakers — including DeSantis and Rep. Marjorie Taylor Greene, R-Ga. — mentioned gender identity or sexuality negatively in their speeches, according to an NBC News analysis. DeSantis, for example, alleged that Democrats want to “impose gender ideology” on kindergartners.

Nearly 70% of public K-12 teachers who have been teaching for more than one year said topics related to sexual orientation and gender identity “rarely or never” come up in their classrooms, according to a recent poll from the Pew Research Center. Half of all teachers polled, including 62% of elementary school teachers, said elementary school students should not learn about gender identity in school.

Trump vowed last year that if he is re-elected he would abolish gender-affirming care for minors, which he equated to “child abuse” and “child sexual mutilation.” This year, Trump also said he would roll back Title IX protections for transgender students “on day one” of his potential second presidential administration.

His campaign website says he would, if he is re-elected, cut federal funding for schools that push “gender ideology on our children” and “keep men out of women’s sports.”

More broadly, Trump has promised to eliminate the Education Department, claiming that doing so would give states more authority over education.

During his first administration, Trump barred trans people from enlisting in the military — which he has vowed to do again if he is re-elected — and rolled back several antidiscrimination protections for LGBTQ people. 

For more from NBC Out, sign up for our weekly newsletter.

Matt Lavietes is a reporter for NBC Out.

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Breaking news, cnn’s erin burnett appears shocked that kamala harris backed taxpayer-funded gender surgery for migrants.

CNN host Erin Burnett appeared surprised that Vice President Kamala Harris had at one point indicated that she supported “taxpayer-funded gender transition surgeries for detained illegal migrants” — a far cry from the more centrist positions she has staked out during the current presidential campaign.

“She actually said she supported that?” Burnett asked CNN colleague Andrew Kaczynski during a segment on her nightly show Monday.

Kaczynski had reported on Monday that Harris supported avowedly liberal positions when she filled out a questionnaire distributed by the American Civil Liberties Union in 2019, when she was a US senator representing California.

According to CNN, Harris backed taxpayer-funded gender transition surgeries for undocumented migrants and federal prisoners as well as decriminalizing federal drug possession for personal use.

“It is important that transgender individuals who rely on the state for care receive the treatment they need, which includes access to treatment associated with gender transition,” Harris wrote in the questionnaire.

She touted her record as California attorney general, when she “pushed the California Department of Corrections and Rehabilitation to provide gender transition surgery to state inmates.”

“Transition treatment is a medical necessity, and I will direct all federal agencies responsible for providing essential medical care to deliver transition treatment,” she added.

Harris also wrote in the questionnaire that she favored drastic funding cuts for Immigration and Customs Enforcement (ICE), the federal agency that is tasked with rounding up and deporting undocumented migrants.

Take 3:33 of your time and watch CNN’s Erin Burnett struggle to grasp how someone could take the positions Kamala Harris has taken over her career. Taxpayer-funded gender transition surgery for detained migrants? Yup: Legalize ALL dangerous drugs? Yup. pic.twitter.com/vHeuKcWfWT — Tim Murtaugh (@TimMurtaugh) September 10, 2024

On the ACLU form, Harris also indicated she backed an “end” to immigrant detention centers.

“Our immigrant detention system is out of control, and I believe we must end the unfair incarceration of thousands of individuals, families and children,” Harris wrote in the questionnaire.

She pledged that “as president, I will focus enforcement on increasing public safety, not tearing apart immigrant families.”

“I was one of the first Senators after President Trump was elected to advocate for a decrease in funding to ICE.”

“This includes requiring ICE to obtain a warrant where probable cause exists as to end the use of detainers.”

The ACLU sent the questionnaire to all Democratic and Republican candidates who ran for the presidency in 2020.

Harris that year sought the Democratic nomination for president, but she bowed out of the race before voting began in primaries and caucuses.

Former Vice President Joe Biden eventually won the nomination and went on to defeat President Donald Trump in the 2020 election.

Harris has only granted one interview since it was announced that Biden would not seek a second term — effectively handing her the nomination.

She has been criticized for reversing her policy positions from years prior as well as declining to answer questions as to what her positions are at present.

The Harris campaign declined to say whether the vice president holds the same positions today as she did in 2019.

A Harris campaign adviser told CNN that “the vice president’s positions have been shaped by three years of effective governance as part of the Biden-Harris administration.”

The campaign declined to elaborate.

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