gender reassignment surgery wikipedia

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Gender-affirmation care

Development, advances in gender-affirming care.

• When did science begin?
• Where was science invented?

gender-affirming surgery

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• Table Of Contents

gender-affirming surgery , medical procedure in which the physical sex characteristics of an individual are modified. Gender-affirming surgery typically is undertaken when an individual chooses to align their physical appearance with their gender identity , enabling the individual to achieve a greater sense of self and helping to reduce psychological distress that may be associated with gender dysphoria .

An individual’s physical sex may not match their gender identity when the person is intersex , having been born outside the binary of male and female and thus having ambiguous genitalia, or when the person identifies as transgender . Parents of an intersex child may elect to have surgical procedures carried out in order to have the child’s anatomy conform to binary notions of gender . A person’s ascribed legal sex may not match their gender identity as they mature. However, this situation raises serious concerns regarding the appropriateness of performing unnecessary medical procedures on the bodies of minors. Intersexuality is a normal biological variation and is not considered a medical condition. Therefore, medical interventions such as surgery and hormone therapy are typically unnecessary for intersex children.

Transgender individuals may seek gender-affirming surgery to align their physical body with their perception of their gender identity. Gender identity refers to an individual’s perception of their own gender, which may or may not correspond to their designated gender at birth. Gender identity encompasses the identification as male, female, both, neither, or somewhere else on the spectrum of gender. It is distinct from biological sex, which is determined by the sex chromosomes and anatomy of an individual. While the gender identity of most individuals corresponds to their ascribed biological sex, the gender identity of some individuals differs from their ascribed sex at birth, which can result in gender dysphoria and thereby lead the individual to seek gender-affirming surgery.

Individuals assigned male at birth may undergo one or more procedures to feminize their anatomy, including facial feminization surgery, penectomy (removal of the penis ), orchidectomy (removal of the testicles ), vaginoplasty (construction of a vagina ), and a tracheal shave (reduction of the Adam’s apple). Individuals who are assigned female at birth and who desire surgical intervention to masculinize their anatomy may seek breast reduction surgery, hysterectomy (removal of the uterus ), oophorectomy (removal of the ovaries ), and phalloplasty (construction of a penis).

Gender-affirming surgeries were performed during the 1920s and ’30s, primarily in Europe. These procedures were experimental and not extensively accepted by the medical community . At the time, it was widely believed that gender identity was immutable and that surgery could not alter it. However, Magnus Hirschfeld , a German sexologist and vocal advocate for sexual and gender diversity , assisted with the care of several transgender individuals.

Dora Richter was the first transgender individual to undergo complete male-to-female genital surgery under Hirschfeld’s supervision. Richter was one of several transgender individuals under Hirschfeld’s care at the Berlin Institute for Sexual Research. In 1922 Richter underwent an orchidectomy and, in 1931, a penectomy and vaginoplasty.

In 1930 and 1931 Lili Elbe also underwent several gender-affirming surgeries. These procedures included an orchidectomy, an ovarian transplant, and a penectomy. Elbe underwent a fourth surgery in June 1931, which consisted of an experimental uterine transplant and vaginoplasty. Elbe’s body rejected the transplanted uterus, and she died of postoperative complications in 1931.

During the 1950s and ’60s, significant advancements were made in the field of gender-affirming surgery, including the establishment of several major medical centres and the refinement of surgical techniques. Christian Hamburger, a Danish endocrinologist, performed a gender-affirming surgery in 1952 on Christine Jorgensen , a transgender individual, who underwent hormone replacement therapy and surgery to remove her testicles and create a vagina. Jorgensen became a public figure advocating for transgender rights and promoting awareness about gender-affirming surgery after their case received significant media attention.

Other medical centres in Europe and the United States began conducting gender-affirming surgeries around the same time, including the Johns Hopkins Gender Identity Clinic, founded in 1966. The founder of the clinic, psychiatrist John Money, believed that gender was a social construct and that gender-affirming surgery could be an effective treatment for individuals with gender dysphoria. Money’s theories had a significant impact on the field of gender-affirming surgery and helped to change the attitudes of the medical community regarding the procedure.

During the 1960s, new surgical techniques were developed, including advances in vaginoplasty and phalloplasty. In the 1950s Belgian surgeon Georges Burou devised a technique involving the use of skin grafts from the patient’s thigh to create a vaginal canal lining. For penises, he attached the phallus to a blood supply using tissue . This technique improved tissue perfusion and decreased the risk of complications such as tissue necrosis . These procedures marked a turning point in the development of gender-affirming care because they demonstrated the potential for successful genital reconstruction in transgender patients.

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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review . Transgend Health . 2018;3(1):159-169. doi:10.1089/trgh.2018.0014

Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature . Plast Reconstr Surg. 2016;137(6):1759-70. doi:10.1097/PRS.0000000000002171

Hadj-moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery . Sex Med Rev . 2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004

Dowshen NL, Christensen J, Gruschow SM. Health Insurance Coverage of Recommended Gender-Affirming Health Care Services for Transgender Youth: Shopping Online for Coverage Information . Transgend Health . 2019;4(1):131-135. doi:10.1089/trgh.2018.0055

American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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Stages of Gender Reassignment

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The idea of getting stuck in the wrong body sounds like the premise for a movie in "Freaky Friday," a mother and a daughter swap bodies, and in "Big" and "13 Going on 30," teenagers experience life in an adult's body. These movies derive their humor from the ways in which the person's attitude and thoughts don't match their appearance. A teenager trapped in her mother's body, for example, revels in breaking curfew and playing air guitar, while a teenager trapped in an adult's body is astounded by the trappings of wealth that come with a full-time job. We laugh because the dialogue and actions are so contrary to what we'd expect from someone who is a mother, or from someone who is an employed adult.

But for some people, living as an incongruous gender is anything but a joke. A transgender person is someone who has a different gender identity than their birth sex would indicate. We interchange the words sex, sexuality and gender all the time, but they don't actually refer to the same thing. Sex refers to the parts we were born with; boys, we assume, have a penis, while girls come equipped with a vagina. Sexuality generally refers to sexual orientation , or who we're attracted to in a sexual and/or romantic sense. Gender expression refers to the behavior used to communicate gender in a given culture. Little girls in the U.S., for example, would be expected express their feminine gender by playing with dolls and wearing dresses, and little boys would be assumed to express their masculinity with penchants for roughhousing and monster trucks. Another term is g ender identity, the private sense or feeling of being either a man or woman, some combination of both or neither [source: American Psychological Association ].

Sometimes, a young boy may want to wear dresses and have tea parties, yet it's nothing more than a phase that eventually subsides. Other times, however, there is a longing to identify with another gender or no gender at all that becomes so intense that the person experiencing it can't function anymore. Transgender is an umbrella term for people who identify outside of the gender they were assigned at birth and for some gender reassignment surgeries are crucial to leading a healthy, happy life.

Gender Dysphoria: Diagnosis and Psychotherapy

Real-life experience, hormone replacement therapy, surgical options: transgender women, surgical options: transgender men, gender reassignment: regrets.

Transgender people may begin identifying with a different gender, rather than the one assigned at birth, in early childhood, which means they can't remember a time they didn't feel shame or distress about their bodies. For other people, that dissatisfaction with their biological sex begins later, perhaps around puberty or early adulthood, though it can occur later in life as well.

It's estimated that about 0.3 percent of the U.S. population self-identify as transgender, but not all who are transgender will choose to undergo a gender transition [source: Gates ]. Some may choose to affirm their new gender through physically transforming their bodies from the top down, while others may prefer to make only certain cosmetic changes, such as surgeries to soften facial features or hair removal procedures, for example.

Not all who identify with a gender different than their birth sex suffer from gender dysphoria or go on to seek surgery. Transgender people who do want gender reassignment surgery, however, must follow the standards of care for gender affirmation as defined by the World Professional Association for Transgender Health (WPATH).

In 1980, when gender identity disorder (GID) was first recognized, it was considered a psychiatric disorder. In 2013, though, GID was, in part, reconsidered as biological in nature, and renamed gender dysphoria . It was reclassified as a medical condition in the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-V), a common language and standards protocol manual for the classification of mental disorders. With this classification, transgender people must be diagnosed prior to any treatment [source: International Foundation for Gender Education ].

Gender dysphoria is diagnosed when a person has a persistent desire to become a different gender. The desire may manifest itself as disgust for one's reproductive organs, hatred for the clothing and other outward signs of one's given gender, and/or a desire to act and be recognized as another gender. This desire must be continuously present for six months in order to be recognized as a disorder [source: WPATH].

In addition to receiving the diagnosis from a mental health professional, a person seeking reassignment must also take part in psychotherapy. The point of therapy isn't to ignite a change, begin a conversion or otherwise convince a transgender person that it's wrong to want to be of a different gender (or of no specific gender at all) . Rather, counseling is required to ensure that the person is realistic about the process of gender affirmation and understands the ramifications of not only going through with social and legal changes but with permanent options such as surgery. And because feeling incongruous with your body can be traumatizing and frustrating, the mental health professional will also work to identify any underlying issues such as anxiety, depression, substance abuse or borderline personality disorder.

The mental health professional can also help to guide the person seeking gender reassignment through the next step of the process: real-life experience.

WPATH requires transgender people desiring gender reassignment surgery to live full-time as the gender that they wish to be before pursuing any permanent options as part of their gender transition. This period is a known as real-life experience (RLE) .

It's during the RLE that the transgender person often chooses a new name appropriate for the desired gender, and begins the legal name-change process. That new name often comes with a set of newly appropriate pronouns, too; for example, when Chastity Bono, biologically born as Sonny and Cher's daughter in 1969, began her transition in 2008 she renamed herself as Chaz and instructed people to use "he" rather than "she" [source: Donaldson James ].

In addition to a new name and pronouns, during this time gender-affirming men and women are expected to also adopt the clothing of their desired gender while maintaining their employment, attending school or volunteering in the community. Trans women might begin undergoing cosmetic procedures to rid themselves of body hair; trans men might take voice coaching in attempt to speak in a lower pitch. The goal of real-life experience is to expose social issues that might arise if the individual were to continue gender reassignment. How, for example, will a boss react if a male employee comes to work as a female? What about family? Or your significant other? Sometimes, during RLE people realize that living as the other gender doesn't bring the happiness they thought it would, and they may not continue to transition. Other times, a social transition is enough, and gender reassignment surgery isn't pursued. And sometimes, this test run is the confirmation people need to pursue physical changes in order to fully become another gender.

In addition to the year-long real-life experience requirement before surgical options may be pursued, WPATH recommends hormonal therapy as a critical component to transitioning before surgery. Candidates for hormone therapy may choose to complete a year-long RLE and counseling or complete six months of a RLE or three-months of a RLE/three months of psychotherapy before moving ahead with hormone therapy.

Upon successfully completing a RLE by demonstrating stable mental health and a healthy lifestyle, the transitioning individual becomes eligible for genital reconstructive surgery — but it can't begin until a mental health professional submits a letter (or letters) of recommendation indicating that the individual is ready to move forward [source: WPATH].

Hormone replacement therapy (HRT) , also called cross-sex hormones, is a way for transgender individuals to feel and look more like the gender they identify with, and so it's a major step in gender reassignment. In order to be eligible for hormone therapy, participants must be at least 18 years old (though sometimes, younger adolescents are allowed to take hormone blockers to prohibit their naturally occurring puberty) and demonstrate to a mental health professional that they have realistic expectations of what the hormones will and won't do to their bodies. A letter from that mental health professional is required, per the standards of care established by WPATH.

Hormone therapy is used to balance a person's gender identity with their body's endocrine system. Male-to-female candidates begin by taking testosterone-blocking agents (or anti-androgens ) along with female hormones such as estrogen and progesterone . This combination of hormones is designed to lead to breast growth, softer skin, less body hair and fewer erections. These hormones also change the body by redistributing body fat to areas where women tend to carry extra weight (such as around the hips) and by decreasing upper body strength. Female-to-male candidates begin taking testosterone , which will deepen the voice and may cause some hair loss or baldness. Testosterone will also cause the clitoris to enlarge and the person's sex drive to increase. Breasts may slightly shrink, while upper body strength will increase [source: WPATH].

It usually takes two continuous years of treatment to see the full results of hormone therapy. If a person were to stop taking the hormones, then some of these changes would reverse themselves. Hormone therapy is not without side effects — both men and women may experience an increased risk for cardiovascular disease, and they are also at risk for fertility problems. Some transgender people may choose to bank sperm or eggs if they wish to have children in the future.

Sometimes hormonal therapy is enough to make a person feel he or she belongs to the desired gender, so treatment stops here. Others may pursue surgical means as part of gender reassignment.

Surgical options are usually considered after at least two years of hormonal therapy, and require two letters of approval by therapists or physicians. These surgeries may or may not be covered by health insurance in the U.S. — often only those that are considered medically necessary to treat gender dysphoria are covered, and they can be expensive. Gender reassignment costs vary based on each person's needs and desires; expenses often range between $7,000 and $50,000 (in 2014), although costs may be much greater depending upon the type (gender reconstructive surgeries versus cosmetic procedures) and number of surgeries as well as where in the world they are performed [source: AP ].

Gender affirmation is done with an interdisciplinary team, which includes mental health professionals, endocrinologists, gynecologists, urologists and reconstructive cosmetic surgeons.

One of the first surgeries male-to-female candidates pursue is breast augmentation, if HRT doesn't enlarge their breasts to their satisfaction. Though breast augmentations are a common procedure for cisgender women (those who identify with the gender they were assigned at birth), care must be taken when operating on a biologically male body, as there are structural differences, like body size, that may affect the outcome.

The surgical options to change male genitalia include orchiectomy (removal of the testicles), penile inversion vaginoplasty (creation of a vagina from the penis), clitoroplasty (creation of a clitoris from the glans of the penis) and labiaplasty (creation of labia from the skin of the scrotum) [source: Nguyen ]. The new vagina, clitoris and labia are typically constructed from the existing penile tissue. Essentially, after the testicles and the inner tissue of the penis is removed and the urethra is shortened, the skin of the penis is turned inside out and fashioned into the external labia and the internal vagina. A clitoris is created from excess erectile tissue, while the glans ends up at the opposite end of the vagina; these two sensitive areas usually mean that orgasm is possible once gender reassignment is complete. Male-to-female gender reconstructive surgery typically takes about four or five hours [source: University of Michigan ]. The major complication from this surgery is collapse of the new vaginal cavity, so after surgery, patients may have to use dilating devices.

Trans women may also choose to undergo cosmetic surgeries to further enhance their femininity. Procedures commonly included with feminization are: blepharoplasty (eyelid surgery); cheek augmentation; chin augmentation; facelift; forehead and brow lift with brow bone reduction and hair line advance; liposuction; rhinoplasty; chondrolargynoplasty or tracheal shave (to reduce the appearance of the Adam's apple); and upper lip shortening [source: The Philadelphia Center for Transgender Surgery]. Trans women may pursue these surgeries with any cosmetic plastic surgeon, but as with breast augmentation, a doctor experienced with this unique situation is preferred. One last surgical option is voice modification surgery , which changes the pitch of the voice (alternatively, there is speech therapy and voice training, as well as training DVDs and audio recordings that promise the same thing).

Female-to-male surgeries are pursued less often than male-to-female surgeries, mostly because when compared to male-to-female surgeries, trans men have limited options; and, historically, successful surgical outcomes haven't been considered on par with those of trans women. Still, more than 80 percent of surgically trans men report having sexual intercourse with orgasm [source: Harrison ].

As with male-to-female transition, female-to-male candidates may begin with breast surgery, although for trans men this comes in the form of a mastectomy. This may be the only surgery that trans men undergo in their reassignment, if only because the genital surgeries available are still far from perfect. Forty percent of trans men who undergo genital reconstructive surgeries experience complications including problems with urinary function, infection and fistulas [sources: Harrison , WPATH].

Female-to-male genital reconstructive surgeries include hysterectomy (removal of the uterus) and salpingo-oophorectomy (removal of the fallopian tubes and ovaries). Patients may then elect to have a metoidioplasty , which is a surgical enlargement of the clitoris so that it can serve as a sort of penis, or, more commonly, a phalloplasty . A phalloplasty includes the creation of a neo-phallus, clitoral transposition, glansplasty and scrotoplasty with prosthetic testicles inserted to complete the appearance.

There are three types of penile implants, also called penile prostheses: The most popular is a three-piece inflatable implant, used in about 75 percent of patients. There are also two-piece inflatable penile implants, used only 15 percent of the time; and non-inflatable (including semi-rigid) implants, which are used in fewer than 10 percent of surgeries. Inflatable implants are expected to last about five to 10 years, while semi-rigid options typically have a lifespan of about 20 years (and fewer complications than inflatable types) [source: Crane ].

As with trans women, trans men may elect for cosmetic surgery that will make them appear more masculine, though the options are slightly more limited; liposuction to reduce fat in areas in which cisgender women i tend to carry it is one of the most commonly performed cosmetic procedures.

As surgical techniques improve, complication rates have fallen too. For instance, long-term complication risks for male-to-female reconstructive surgeries have fallen below 1 percent. Despite any complications, though, the overwhelming majority of people who've undergone surgical reconstruction report they're satisfied with the results [source: Jarolím ]. Other researchers have noted that people who complete their transition process show a marked improvement in mental health and a substantial decrease in substance abuse and depression. Compare these results to 2010 survey findings that revealed that 41 percent of transgender people in the U.S. attempted suicide, and you'll see that finally feeling comfortable in one's own skin can be an immensely positive experience [source: Moskowitz ].

It's difficult, though, to paint a complete picture of what life is like after people transition to a new gender, as many people move to a new place for a fresh start after their transition is complete. For that reason, many researchers, doctors and therapists have lost track of former patients. For some people, that fresh start is essential to living their new lives to the fullest, while others have found that staying in the same job, the same marriage or the same city is just as rewarding and fulfilling and vital to their sense of acceptance.

In many ways, the process of gender affirmation is ongoing. Even after the surgeries and therapies are complete, people will still have to deal with these discrimination issues. Transgender people are often at high risk for hate crimes. Regular follow-ups will be necessary to maintain both physical and mental health, and many people continue to struggle with self-acceptance and self-esteem after struggling with themselves for so long. Still, as more people learn about gender reassignment, it seems possible that that these issues of stigma and discrimination won't be so prevalent.

As many as 91 percent Americans are familiar with the term "transgender" and 76 percent can correctly define it; 89 percent agree that transgender people deserve the same rights, privileges and protections as those who are cisgender [source: Public Religion Research Institute ]. But that's not to say that everything becomes completely easy once a person transitions to his or her desired gender.

Depending upon where you live, non-discrimination laws may or may not cover transgender individuals, so it's completely possible to be fired from one's job or lose one's home due to gender expression. Some people have lost custody of their children after divorces and have been unable to get courts to recognize their parental rights. Historically, some marriages were challenged — consider, for example, what happens when a man who is married to a woman decides to become a woman; after the surgery, if the two people decide to remain married, it now appears to be a same-sex marriage, which is now legalized in the U.S. Some organizations and governments refuse to recognize a person's new gender unless genital reconstructive surgery has been performed, despite the fact that some people only pursue hormone therapy or breast surgery [sources: U.S. Office of Personnel Management , Glicksman ].

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Author's note: stages of gender reassignment.

It's interesting how our terminology changes throughout the years, isn't it? (And in some cases for the better.) What we used to call a sex change operation is now gender realignment surgery. Transsexual is now largely replaced with transgender. And with good reason, I think. Knowing that sex, sexuality and gender aren't interchangeable terms, updating "sex change" to "gender reassignment" or "gender affirmation" and "transsexual" to "transgender" moves the focus away from what sounds like something to do with sexual orientation to one that is a more accurate designation.

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• Why do girls wear pink and boys wear blue?

More Great Links

• DSM-5: Gender Dysphoria
• National Center for Transgender Equality
• The Williams Institute
• American Medical Student Association (AMSA). "Transgender Health Resources." 2014. (April 20, 2015) http://www.amsa.org/AMSA/Homepage/About/Committees/GenderandSexuality/TransgenderHealthCare.aspx
• American Psychological Association (APA). "Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation." 2011. (July 1, 2015) http://www.apa.org/pi/lgbt/resources/sexuality-definitions.pdf
• AP. "Medicare ban on sex reassignment surgery lifted." May 30, 2014. (April 20, 2015) http://www.usatoday.com/story/news/nation/2014/05/30/medicare-sex-reassignment/9789675/
• Belkin, Lisa. "Smoother Transitions." The New York Times. Sept. 4, 2008. (Aug. 1, 2011) http://www.nytimes.com/2008/09/04/fashion/04WORK.html
• Crane, Curtis. "The Total Guide to Penile Implants For Transsexual Men." Transhealth. May 2, 2014. (April 20, 2015) http://www.trans-health.com/2013/penile-implants-guide/
• Donaldson James, Susan. "Trans Chaz Bono Eyes Risky Surgery to Construct Penis." ABC News. Jan. 6, 2012. (April 20, 2015) http://abcnews.go.com/Health/transgender-chaz-bono-seeks-penis-genital-surgery-risky/story?id=15299871Gates, Gary J. "How many people are lesbian, gay, bisexual, and transgender?" April 2011. (July 29, 2015) http://williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
• Glicksman, Eve. "Transgender today." Monitor on Psychology. Vol. 44, no. 4. Page 36. April 2013. (April 20, 2015) http://www.apa.org/monitor/2013/04/transgender.aspx
• Harrison, Laird. "Sex-Change Operations Mostly Successful." Medscape Medical News. May 20, 2013. (April 20, 2015) http://www.medscape.com/viewarticle/804432
• HealthResearchFunding.org (HRF). "14 Unique Gender Identity Disorder Statistics." July 28, 2014. (April 20, 2015) http://healthresearchfunding.org/gender-identity-disorder-statistics/
• International Foundation for Gender Education. "APA DSM-5 Sexual and Gender Identity Disorders: 302.85 Gender Identity Disorder in Adolescents or Adults." (April 20, 2015) http://www.ifge.org/302.85_Gender_Identity_Disorder_in_Adolescents_or_Adults
• Moskowitz, Clara. "High Suicide Risk, Prejudice Plague Transgender People." LiveScience. Nov. 18, 2010. (April 20, 2015) http://www.livescience.com/11208-high-suicide-risk-prejudice-plague-transgender-people.html
• Nguyen, Tuan A. "Male-To-Female Procedures." Lake Oswego Plastic Surgery. 2013. (April 20, 2015) http://www.lakeoswegoplasticsurgery.com/grs/grs_procedures_mtf.html
• Public Religion Research Institute. "Survey: Strong Majorities of Americans Favor Rights and Legal Protections for Transgender People." Nov. 3, 2011. (April 20, 2015) http://publicreligion.org/research/2011/11/american-attitudes-towards-transgender-people/#.VSmlgfnF9bw
• Steinmetz, Katy. "Board Rules That Medicare Can Cover Gender Reassignment Surgery." Time. (April 20, 2015) http://time.com/2800307/medicare-gender-reassignment/
• The Philadelphia Center for Transgender Surgery. "Phalloplasty: Frequently Asked Questions." (April 20, 2015) http://www.thetransgendercenter.com/index.php/surgical-procedures/phalloplasty-faqs.html
• U.S. Office of Personnel Management. "Guidance Regarding the Employment of Transgender Individuals in the Federal Workplace." 2015. (April 20, 2015) http://www.opm.gov/diversity/Transgender/Guidance.asp
• University of California, San Francisco - Department of Family and Community Medicine, Center of Excellence for Transgender Health. "Primary Care Protocol for Transgender Patient Care." April 2011. (April 20, 2015) http://transhealth.ucsf.edu/trans?page=protocol-hormones
• University of Miami - Miller School of Medicine, Department of Surgery, Plastic, Aesthetic and Reconstructive Surgery. "Transgender Reassignment." 2015. (April 20, 2015) http://surgery.med.miami.edu/plastic-and-reconstructive/transgender-reassignment-surgery
• University of Michigan Health System. "Gender Affirming Surgery." (April 20, 2015) http://www.uofmhealth.org/medical-services/gender-affirming-surgery
• World Professional Association for Transgender Health (WPATH). "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." Version 7. 2012. (April 20, 2015) http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care,%20V7%20Full%20Book.pdf
• World Professional Association for Transgender Health (WPATH). "WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide." 2015. (April 20, 2015) http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947

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Vaginoplasty for Gender Affirmation

Featured Experts:

Fan Liang, M.D.

Andrew Jason Cohen, M.D.

Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

1 of 4 in series. Enlarged image .

2 of 4 in series. Enlarged image .

3 of 4 in series. Enlarged image .

4 of 4 in series. Enlarged image .

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

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Phalloplasty for Gender Affirmation

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Transgender Surgery

Gary J. Alter, M.D. and his entire team are committed to ensuring compassionate, individualized care for all our patients seeking gender-reassignment surgery, where ensuring your comfort and achieving the very best outcome is our top priority.

World Renown Gender-Affirming Surgeon

Dr. Alter is one of the rare doctors (only a handful in the United States), who is certified by both the American Board of Plastic Surgery and the American Board of Urology. He specializes in genital reconstruction as well as facial and body surgery for transgender patients. He has extensive experience in genital surgery, including male-to-female and female-to-male reassignment 

Our State-of-the-Art Facilities

Dr. Alter’s office is located at 416 North Bedford Drive, in the heart of Beverly Hills. We’re approximately 30 minutes from Los Angeles International Airport and in close proximity to a wide range of hotels, shopping, and sightseeing.

Supporting Staff

Zena DelVecchio, our patient coordinator, will help you every step of the way, including answering general questions, scheduling appointments and surgery, and assisting in travel and lodging arrangements. She has been working in plastic surgery for 20 years and understands the myriad of operations and options available to you. She has worked with transgender patients for years and thoroughly understands your particular needs during this exciting but stressful time.

Olympia Medical Center

Olympia Medical Center is a fully accredited 200-bed hospital located a mile from our office in Beverly Hills. Most patients undergoing gender-affirming surgery will have a private room in this modern, comfortable hospital. Midway staff have supported many patients through gender-affirming surgeries, so you can be at ease while in their care every step of the way. They are also very familiar with caring for a wide range of patients, including celebrities, politicians, and royalty, so your privacy is assured.

The Summit Surgical Center

The Summit Surgical Center is a fully accredited facility adjacent to Dr. Alter’s office. It is used for secondary genital surgery and most cosmetic outpatient procedures. The highly professional and friendly staff is also very experienced caring for transgender patients, while anesthesia is performed by highly skilled, board certified anesthesiologists. 

Post-gender-affirming surgery, patients can return home, to short-term accommodations with a friend, family member, or trained attendant, or plastic surgery recovery hotel.

Pre-Surgical Requirements

Dr. Alter follows the guidelines of the World Professional Association of Transgender Health. These guidelines are in place to help prepare patients prior to undergoing gender-reaffirming surgery.

Prior to surgery, we require letters from two therapists recommending you for the surgery. These therapists must be experienced with gender dysphoria patients and must have worked with you for at least a year. They also need to be a psychiatrist, psychologist, or social worker with a master’s degree.

If any questions arise as you’re fulfilling these requirements, we request you be evaluated locally by:

Christine Milrod, MA, MFT ag  http://www.transgendercounseling.com or The Gender Wellness of Los Angeles –   http://www.genwell.org  . or The staff of Los Angeles Gender Center – http://www.lagendercenter.com

• – Male-to-Female Confirmation Surgery
• – Female-to-Male Confirmation Surgery
• – Transgender Breast Surgery
• – Transgender Facial & Cosmetic Surgery

Patient-First Policy

Dr. Alter and the entire team are dedicated to providing every patient with exceptional individualized care—from consultation to recovery. We take the time to learn about your concerns, goals, and desires, so we can build a plan that addresses your concerns and gets you the results you deserve.

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gender reassignment surgery

Definition of gender reassignment surgery

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender through surgery, rather than using surgery to align their outward appearance with their gender identity. Gender confirmation surgery and gender-affirming surgery are the preferred terms in the medical and LGBTQ+ communities, and surgery is seen as one of many possible ways to affirm one's gender identity, rather than as an essential part of transitioning (see transition entry 2 sense 2 )

Examples of gender reassignment surgery in a Sentence

These examples are programmatically compiled from various online sources to illustrate current usage of the word 'gender reassignment surgery.' Any opinions expressed in the examples do not represent those of Merriam-Webster or its editors. Send us feedback about these examples.

Word History

1969, in the meaning defined above

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Merriam-Webster's Short List of Gender...

Merriam-Webster's Short List of Gender and Identity Terms

In case you (or someone you know) has questions about what they mean

Dictionary Entries Near gender reassignment surgery

gender reassignment

gender-specific

Cite this Entry

“Gender reassignment surgery.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/gender%20reassignment%20surgery. Accessed 26 Jul. 2024.

Medical Definition

Medical definition of gender reassignment surgery.

Note: This term is sometimes considered to be offensive in its implication that a transgender or nonbinary person takes on a different gender through surgery, rather than using surgery to align their outward appearance with their gender identity. Gender confirmation surgery and gender-affirming surgery are the preferred terms in the medical and LGBTQ+ communities, and surgery is seen as one of many possible ways to affirm one's gender identity, rather than as an essential part of transitioning (see transition entry 2 ).

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Gender Confirmation Surgery

Gender confirmation surgery (sometimes called sexual reassignment surgery) refers to any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity . Surgical procedures are usually preceded by hormone replacement therapy .

Some forms of gender confirmation surgery include:

• Bottom surgery , or surgery to alter the genitalia.
• Top surgery , or surgery to alter the chest and breast tissue.
• Facial reconstruction surgery , to alter the appearance of the face.

Those who plan to have surgery but not yet done so are often referred to as pre-op , while those who have already had surgery are referred to as post-op . Those who do not wish to include surgery in their transition are referred to as non-op .

Musk says estranged child's gender-affirming care sparked fight against 'woke mind virus'

Tesla CEO Elon Musk said his estranged transgender daughter was "killed" by the "woke mind virus" after he was tricked into agreeing to gender-affirming care procedures .

In an interview with psychologist and conservative commentator Dr. Jordan Peterson , the X owner called gender-reassignment surgery "child mutilation and sterilization." He then discussed his 20-year-old child Vivian Jenna Wilson , who he said underwent the procedures during the pandemic.

"I was essentially tricked into signing documents for one of my older boys," Musk told Peterson in a Daily Wire interview during which he referred to his child by their deadname. "This was really before I had any understanding of what was going on, and we had COVID going on, so there was a lot of confusion and I was told (Musk's child) might commit suicide."

The SpaceX founder claimed the process is done to children "who are far below the age of consent" and said he agreed with Peterson's belief that anyone who promotes the practice should go to prison.

"I was tricked into doing this," Musk said. "I lost my son, essentially. They call it 'deadnaming' for a reason. The reason they call it ‘deadnaming’ is because your son is dead."

Musk went on to say that the experience set him on a mission.

"I vowed to destroy the woke mind virus after that," Musk said. "And we’re making some progress."

Vivian Jenna Wilson cut ties with father in 2022

Wilson was legally granted her name and gender change at age 18 at the Santa Monica courthouse in California on June 22, 2022.

She said the name change was due to gender identity and an apparent dislike of Musk, according to a petition filed on April 18, 2022, in Los Angeles County Superior Court.

"I no longer live with or wish to be related to my biological father in any way, shape or form," Wilson wrote in the petition.

Wilson's mother is Justine Wilson, a Canadian author who divorced Musk in 2008; the couple shares six children.

Musk called 'woke mind virus' threat to modern civilization

Musk has previously criticized what he calls "woke mind virus"  in a December 2021 interview with conservative outlet The Babylon Bee, where said called it "a world without humor"  and "arguably one of the greatest threats to modern civilization."

Musk announced his intent to buy Twitter for $44 billion on April 25, 2022 , and closed the deal about six months later . He promised to restore "free speech" on the platform and has increased his conservative political commentary since the purchase.

Earlier this month, Musk said he fully endorsed former President Donald Trump after the attempted assassination at a Pennsylvania rally on July 13.

Gender-affirming care is a valid, science-backed method

Gender-affirming care  is a  valid, science-backed method  of medicine that saves lives for people who require care while navigating their gender identity. Gender-affirming care can range from talk or hormone therapy to  surgical intervention .

Some experts claim that that  gender-affirming care  should be viewed like other forms of medicine where methods of treatment can be debated and discussed rather than the validity of it's need.

"In any medical field, we're continuously improving the care, changing the care, developing new  guidelines , developing research," Dr. Ximena Lopez, a pediatric endocrinologist in California, previously told USA TODAY. "So it should not be a surprise that it's the same in gender care."

Transgender adults  make up less than 2% of the U.S. population with about 5% of young adults identifying as  transgender  or nonbinary.

"We need to take a step back from acknowledging yes, they might have side effects, but that's why they're not done so flippantly," Dr. Ramiz Kseri , assistant professor in the department of clinical sciences at Florida State University College of Medicine, previously told USA TODAY. "That's why there is conversation about it, there is discussion, in terms of which outcomes are desired, and which outcomes are not desired."

Contributing: Natalie Neysa Alund, Jessica Guynn and David Oliver, USA TODA Y

Morrisey takes sex-reassignment surgery ruling to Supreme Court

BRIDGEPORT, W.Va (WDTV) - West Virginia Attorney General Patrick Morrisey is backing the state’s decision not to cover sex-reassignment surgeries under its Medicaid plan and taking the case to the U.S. Supreme Court.

Morrisey made the announcement in a news conference in Bridgeport Thursday following an 8-6 decision from the U.S. Court of Appeals for the Fourth Circuit in April that said the exclusion of the surgery violated the Equal Protection Clause, the Medicaid Act, and the Affordable Care Act’s non-discrimination provision.

Morrisey said states have wide discretion to determine what procedures their programs can cover based on cost and other concerns under Medicaid and that West Virginia should have the ability to determine how to spend their resources to care for the “vital medical needs of their citizens.”

“Just one single sex-reassignment surgery can cost tens of thousands of dollars — taxpayers should not be required to pay for these surgeries under Medicaid,” Morrisey said.

Read a copy of the SCOTUS filing here .

Copyright 2024 WDTV. All rights reserved.

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Iran will pay for gender-transition surgery, but it comes at a cost — your dignity

Life under Iran's LGBTQ+ paradox

As a child growing up in Tehran, Shayan Varamini didn't know what it meant to be transgender.

Assigned female at birth, Varamini always felt drawn to dressing boyishly. He'd once had romantic feelings for a girl in his school, leading him to assume he might be a lesbian.

But in Iran , where same-sex relations can lead to imprisonment, corporal punishment, and even execution, he needed to be sure.

When he turned 18, just over a decade ago, Varamini sought guidance from a psychologist, who told him he was not a lesbian. Instead, he was diagnosed with "gender-identity disorder," an outdated term used to describe being transgender.

Because of its classification as an illness, Varamini's diagnosis came with a proposed treatment — what the Iranian government calls "sex-reassignment surgery."

After a lengthy bureaucratic procedure, the Iranian state not only recognized Varamini's transition but also helped finance it.

Varamini's surgeries were covered by his public health insurance, along with a modest grant the state paid him upon completion. Varamini paid 250,000 tomans, or about $60, out of pocket for the surgeries.

This generous coverage has led some to describe Iran, a deeply religious and socially repressive culture, as an unlikely "hub" for gender-affirming care.

While exact figures are hard to come by, a 2022 report by the UK's Home Office said that about 4,000 gender-affirming surgeries were performed each year in Iran. In 2007, The Guardian reported that Iran ranked second only to Thailand in the number of gender-affirming surgeries performed.

But transgender Iranians told Business Insider that this portrayal doesn't capture their reality — one marked by humiliation, rejection, and even violence.

On the surface, Iran's transgender policy might seem surprisingly liberal, an anomaly in the Muslim world. But a closer look reveals a darker picture.

Iran permits and funds gender-affirming care while discriminating against lesbian, gay, and bisexual people, along with others who identify as queer.

In a country that has executed people for being gay , what's behind this paradox?

Thanks in part to an edict issued by a Muslim ruler in the 1980s, being transgender in Iran is considered a medical disorder, while being gay is considered a sin.

Some Iranian leaders have made it a mission to erase homosexuality in the country — and activists believe that the government funds gender-affirming surgery in part to accomplish that.

But even once a person has transitioned, they are by no means safe.

Earlier this year, Tehran's city council started creating no-go zones for transgender people. Antidiscrimination laws for LGBTQ+ people don't exist in Iran, nor is there any recognition of genders beyond the binary male and female.

Becca Kia, who now lives in the US, postponed her transition until leaving Iran, recognizing that the country's rigid definitions of sexuality and gender left no room for her.

"Trans people are being suppressed," she told BI. "Like trans lesbian women or trans men who are gay, they cannot transition unless they submit to that rule that, OK, I'm a trans man, but I'm attracted to a woman."

Anti-gay laws

In Iran, same-sex relations are strictly prohibited by law , which doesn't differentiate between consensual and nonconsensual acts.

Punishments vary based on the roles people play in sexual encounters. Under the Islamic Penal Code, engaging in penetrative sex could result in a punishment of up to 100 lashes or, in some cases, the death penalty. Sexual intercourse between women carries a penalty of up to 100 lashes, while those who engage in lustful kissing or touching may face up to 74 lashes.

The Iranian government does not publicize its punishment of gay or lesbian people. However, a 2021 report by Eleos Justice and the Capital Punishment Justice Project estimated over 250 people were executed for same-sex conduct between 1979 and 2004, and at least 79 people have been executed since 2004.

Individuals who identify outside their assigned gender are at risk of these penalties — unless they undergo a physical transition.

"If I were caught in a compromising situation with a man, the sodomy punishments would apply," Raha Ajoudani, a trans woman who is sexually interested in men, said.

On a video call earlier this year, Ajoudani brushed her blond bob behind her ears, showing off her perfectly manicured nails. She'd recently had a tense interaction with the Iranian morality police , but she said she's experienced far worse.

Ajoudani dresses femininely and uses she/her pronouns , but because she has refused to undergo surgical procedures, legal documents mark her as male.

Despite pressure from the authorities, Ajoudani said she refuses to get surgery because she doesn't "have a problem with my body."

The surgical blade is a legal must for trans people Raha Ajoudani

When she was 15, Ajoudani said she was made to visit a state psychologist, only to be presented with an ultimatum.

Related stories

"They told me I had two options," she told BI. "Either go back to what society expected of me or undergo surgery."

She didn't do either, and in October 2022 she was detained by the morality police.

Ajoudani said she fell victim to a honey-trap scenario in which a man she was talking to online lured her to a public spot, where two dozen officers apprehended her.

In December 2022, she was detained again.

In that instance, Ajoudani said that Revolutionary Guard Corps officers raided her home, confiscated her phone, and searched her belongings. She was dressed in a miniskirt and wearing makeup when arrested and was dressed the same when placed in solitary confinement in a men's prison.

Ajoudani initially received a 30-month prison sentence and a temporary travel ban for insulting "Islamic sanctities," among other charges.

Ajoudani told BI that the court determined no prison facilities were equipped to house her — a transgender person deemed to have "mental and sexual issues" because she had not undergone gender-affirming surgeries.

"The surgical blade is a legal must for trans people," Ajoudani said. "Either you undergo it, or you are completely deprived of your civil rights, and that is exactly what they did to me."

A historic fatwa

In 1987, the leader of Iran's Islamic Republic, Ayatollah Ruhollah Khomeini, issued a fatwa — an Islamic legal decree — declaring that gender-affirming surgery did not violate Islamic law.

The key player behind Khomeini's decree was Maryam Khatoon Molkara, a trans woman whose story convinced him to declare the fatwa.

When Molkara was 2 years old, her mother found her mimicking putting on makeup by applying chalk to her face. As she grew older, Molkara knew she was transgender, but as a devout Muslim , she struggled to understand how she could reconcile her gender dysphoria with her faith.

She began corresponding with religious figures, including Khomeini, a respected Shiite jurist living in exile in Iraq at the time, seeking religious blessing to undergo a transition.

In 1979, a revolution shook Iran , leading to the establishment of the Islamic Republic. The new government enacted a legal code rooted in Sharia law, which ushered in a period of profound adversity for LGBTQ+ people.

Under the new laws, Molkara lost her job, had to dress like a man, was forcibly given male hormones, and was confined for a time to a psychiatric facility.

But she persisted in her attempts to communicate with Khomeini, who had risen to become the supreme leader of the newly formed republic.

"I knew I could get the operation easily enough in London, but I wanted the documentation so I could live," she told The Guardian in 2005.

Dressed in a man's suit and clutching a Quran, she confronted Khomeini at his compound in Tehran to plead her case. At first, she was beaten by security guards, but seeing the commotion, Khomeini's relatives intervened, granting her an audience with the ayatollah.

Khomeini provided her with a letter giving her religious authorization to proceed with the surgeries. This was the start of a new era in which transgender Iranians could physically transition.

Home visits and scrutiny

Nonetheless, getting permission to proceed with the surgeries in Iran is no easy feat.

People seeking government support for transitioning must consent to home visits and scrutiny of their private lives, according to a document published by the State Welfare Organization of Iran and seen by BI.

And that's just one facet of the invasive, arduous, and often degrading process.

A 2023 report by Australia's Department of Foreign Affairs and Trade said obtaining approval for the surgery in Iran may take "several years of public court hearings, virginity tests, and mandatory counseling."

Those seeking surgery may bounce back and forth between the Legal Medicine Organization — a medical institution within the judiciary — and the court system while undergoing various tests to determine whether they meet the criteria for Iran's version of a gender-dysphoria diagnosis.

Pooya Mohseni, an Iranian American actor and trans activist, recalled the humiliation of being "interrogated" in 1994 by a panel of psychologists.

"The questions were so graphic that my mom, at some point, left the room," she told BI.

A questionnaire handed to patients by a Tehran clinic, reviewed by BI, prompted psychologists to ask about a person's "wet, sexual dreams" and whether "cross-dressing" sexually excited them.

It also asked whether they had been sexually abused or grew up in a "female-headed" household, and it suggested that practitioners check for "other sexual deviations."

The questionnaire requested a chromosome test, pelvic and abdominal ultrasounds, and hormone testing.

A medical document from the same clinic, also reviewed by BI, showed the results of a karyotype test, which checks a person's chromosomes for any "abnormality."

Homosexuality as a sin

Javad Sadidi, a Mashhad surgeon who specializes in gender-affirming surgeries, told BI that the process takes a minimum of two years.

It's so demanding, he said, in part because it's used as a filter to distinguish between transgender people and those seeking the surgery for different reasons, such as gay and lesbian people hoping to gain legal rights.

Sadidi said that gay people "never" slipped through.

Past reports, however, have accused Iranian authorities of coercing gay people into transitioning as part of a mission to eradicate homosexuality in the country.

In 2007, Mahmoud Ahmadinejad, Iran's president at the time, said in a speech at Columbia University: "In Iran, we do not have homosexuals like in your country."

Elina, a 33-year-old masculine-presenting Iranian lesbian who asked that their last name not be published for safety reasons, told BI that they saw this attitude in action.

They recalled a psychologist trying to persuade them that they were transgender.

"I was not uncomfortable with my body," Elina said, adding that the therapist thought all gays and lesbians were trans.

Elina, who refused to undergo the procedures, eventually left the country.

Shadi Sadr, an Iranian human-rights lawyer and a cofounder of Justice for Iran, told BI that direct coercion of gay people into transitioning was less common than in the past but that societal pressures remain strong.

"Against the context where homosexuality is not only a sin but a crime, many people in the LGBTQ+ community see that, going through the process of sex reassignment, they would gain relative freedom and human rights," she said.

"That's the whole coercive situation," she said.

An independent expert tasked by the United Nations to examine human-rights issues in Iran painted a bleak picture of the quality of gender-affirming care for Iranians in a March 2015 report

It described a system that was "clearly substandard and not in line with professional norms." It said people were often left with complications like severe bleeding, infections, scarring, and abnormally shaped sexual organs.

Soheil, an Iranian whose last name BI is withholding for his safety, underwent a mastectomy , oophorectomy, and hysterectomy 13 years ago at an Iranian public hospital in Karaj.

He said he received about $3,000 toward the surgery from the state, but the operations left him with lasting scars and health complications.

Soheil, who's now living as a refugee in Canada, is hoping to have corrective surgeries to repair the botched work done by Iranian surgeons.

They do garbage, garbage surgery Soheil

Anecdotal evidence from BI's sources suggests that only a few surgeons are trained in gender-affirming surgeries.

Indeed, there aren't many surgeons at all — a Lancet Commission on Global Surgery reported that Iran has 1.7 surgeons per 100,000 people, compared to 36.1 in the US.

"They do garbage, garbage surgery," Soheil said.

He has a "big hole" in his chest where muscle tissue was removed, he said. "When I go somewhere and need to remove my shirt, I feel embarrassed."

Soheil's experience was not just physically traumatic. From the outset, he said, nurses subjected him to harassment and ridicule. One nurse messed with his catheter, taunting him repeatedly about his decision to transition, he said.

He also recounted the story of a friend who decided to get surgery at a private Iranian hospital after being put off by horror stories about the public system.

After the surgery, the friend was unable to afford a stay in the hospital, so he checked himself into a motel, Soheil said. "He called one of his friends, saying that he didn't feel OK," Soheil said. "When his friend went, he had passed away."

Not a trans haven

Being ridiculed and othered is common for Iran's LGBTQ+ populations , said Varamini, the transgender man who had his surgery paid for by the state.

That's why, after his own transition, he worked with the State Welfare Organization of Iran to offer support to fellow transgender Iranians.

Later, he established his own organization, the Mahtaa Institute, which provides clandestine support to LBGTQ+ communities and sex workers . (He said the government heavily monitors his organization.)

While Varamini is grateful for his transition, he's confronted daily by the harsh realities others face.

Iran does offer opportunities for some transgender individuals, he said, but for many others, life is nothing short of "hellish."

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Pamela Paul

Why Is the U.S. Still Pretending We Know Gender-Affirming Care Works?

By Pamela Paul

Opinion Columnist

Imagine a comprehensive review of research on a treatment for children found “remarkably weak evidence” that it was effective. Now imagine the medical establishment shrugged off the conclusions and continued providing the same unproven and life-altering treatment to its young patients.

This is where we are with gender medicine in the United States.

It’s been three months since the release of the Cass Review, an independent assessment of gender treatment for youths commissioned by England’s National Health Service . The four-year review of research, led by Dr. Hilary Cass, one of Britain’s top pediatricians, found no definitive proof that gender dysphoria in children or teenagers was resolved or alleviated by what advocates call gender-affirming care, in which a young person’s declared “gender identity” is affirmed and supported with social transition, puberty blockers and/or cross-sex hormones. Nor, she said, is there clear evidence that transitioning kids decreases the likelihood that gender dysphoric youths will turn to suicide, as adherents of gender-affirming care claim. These findings backed up what critics of this approach have been saying for years.

“The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress,” Cass concluded. Instead, she wrote, mental health providers and pediatricians should provide holistic psychological care and psychosocial support for young people without defaulting to gender reassignment treatments until further research is conducted.

After the release of Cass’s findings, the British government issued an emergency ban on puberty blockers for people under 18. Medical societies, government officials and legislative panels in Germany, France, Switzerland, Scotland , the Netherlands and Belgium have proposed moving away from a medical approach to gender issues , in some cases directly acknowledging the Cass Review. Scandinavian countries have been moving away from the gender-affirming model for the past few years. Reem Alsalem, the United Nations special rapporteur on violence against women and girls, called the review’s recommendations “seminal” and said that policies on gender treatments have “ breached fundamental principles ” of children’s human rights, with “devastating consequences.”

But in the United States, federal agencies and professional associations that have staunchly supported the gender-affirming care model greeted the Cass Review with silence or utter disregard.

There’s been no response from the Department of Health and Human Services , whose website says that “gender-affirming care improves the mental health and overall well-being of gender diverse children and adolescents” and which previously pushed to eliminate recommended age minimums for gender surgery . Nor has there been a response from the American Medical Association , which also backs gender-affirming care for pediatric patients .

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