Gender Confirmation Surgery: Insights and Facts
RealSelf is proud to support and stand with the LGBTQIA+ community throughout the year. Our platform serves as an impartial resource for all, regardless of age, ethnicity, sexual orientation, or gender identity.
To celebrate Pride, we're highlighting stories of strength, truth, and transformation from LGBTQIA+ influencers, activists, and community members. We're also spotlighting leaders in the fields of gender confirmation surgery and hormone replacement therapy.
Across the nation, the transgender community is more visible than ever before. However, this comes with alarmingly high rates of violence against trans men and women, especially those of color. Society still has a long way to go in creating a safe and accepting environment. But there are signs of hope: The increasing acceptance of gender dysphoria is leading more young people to identify as transgender, and due to more comprehensive insurance, Medicaid, and Medicare coverage, gender confirmation surgeries are becoming more common.
Whether you're exploring the procedures or educating yourself to be a better ally, here are seven key points to know about gender confirmation surgery, as shared by three leading surgeons in the field.
Gender Confirmation Surgery Is Not a "Sex Change" Operation
Sex change is an offensive, outdated, and inaccurate term when discussing the surgical procedures involved in the transition process. One's sex isn't changing; rather, it's aligning physically and anatomically with the gender they perceive themselves to be. Currently, the preferred terms are gender confirmation surgery or sex reassignment surgery, and it encompasses far more than just vaginoplasty or phalloplasty.
"People have historically regarded gender transition mainly as genital surgery; they fail to understand the extensive effort involved in restoring hairlines, modifying facial features to appear either less or more masculine or feminine, dealing with hormone regulation and endocrinologists, and so on," says Dr. Jordan Deschamps-Braly, a board-certified plastic surgeon in San Francisco. He adds that this is "only for those who wish to create a visual change." Many transgender individuals choose not to, or are unable to, undergo gender confirmation surgeries.
Facial Gender Confirmation Surgery Is More Prevalent Than Genital Surgery
The doctors interviewed unanimously agree: For the vast majority of those undergoing gender confirmation, facial surgery has the most significant impact on their quality of life. "A lot of people have been living and dressing according to the gender they've always identified with long before considering some of these body surgeries, which they may or may not ultimately undergo," says Dr. Deschamps-Braly. "If your face doesn't match your gender or your style of dress, it can be very disconcerting for someone who sees you, say, on the street or in a coffee shop." When a stranger has a notable reaction to a trans person and hesitates over what title to use, it makes it difficult for them to lead a normal daily life.
"Your face is how you interact with the world. It allows others to see your emotions and quickly determine if you're young, old, attractive, or healthy. Therefore, you want your face to accurately convey who you are and ensure your inner and external selves are consistent," says Dr. Jeffrey Spiegel, a board-certified plastic surgeon in Newton, Massachusetts. For this reason, he states, facial surgery is typically the first surgical step and, in many cases, the last. "Once there is consistency between their appearance and how they identify, most of the stress disappears."
Dr. Deschamps-Braly further adds, "A significant number of people, at least in my experience, don't even undergo bottom surgery and don't have much dysphoria regarding their genitals."
Testosterone Hormone Therapy Is More Potent Than Estrogen Therapy
"Hormones are highly effective in creating a masculine appearance," says Dr. Spiegel. "With testosterone, you develop facial hair, your skin becomes rougher, and your cheeks flatten... so facial masculinization surgery is not as necessary."
Not only are masculinization procedures requested less frequently than feminization ones, but they are also more challenging to perform. "Facial masculinization involves adding volume to the jaw, chin, and forehead, whereas feminization procedures tend to be subtractive," says Dr. Praful Ramineni, a board-certified plastic surgeon in Washington, D.C., who estimates he conducts 300 total transitory surgeries per year. "You make the chin smaller, the nose smaller, the brow bone smaller... It's always easier to remove than to add. You're not as concerned about implants and prosthetics."
A common misunderstanding about facial feminization, according to Dr. Deschamps-Braly, is that patients must wait for a year or two before having surgery to allow the estrogen to take effect. "Estrogen literally has no impact on the bones."
Cisgender People Undergo Gender Confirmation Surgeries Too
"Gender confirmation surgeries are not solely for transgender individuals," says Dr. Spiegel. Whenever someone feels their gender is not accurately represented by their face or body and opts for surgery to rectify the issue, it can be considered gender confirmation. "We perform facial masculinization surgery for cisgender men who feel they look too feminine and say, 'I really desire a strong, angular look.'"
Dr. Deschamps-Braly does not restrict the definition to only include trans patients and estimates he operates on a dozen to two dozen cisgender women each year. "You can be genetically female and have a very masculine forehead or jawline, so gender confirmation surgery can be highly significant to people for various reasons."
You Can Undergo Gender Confirmation Surgery at Any Age
The doctors see patients ranging from late teenagers to those in their mid-70s. The "right" time depends on when the individual has the financial and emotional stability to embark on the surgical journey. Of course, the younger a patient is, the more resilient their bones, muscles, and even hair follicles are. Dr. Deschamps-Braly mentions that a decade ago, his patients were exclusively 50 and above, but he believes the average age is gradually getting younger, thanks to "public awareness that these operations are available and parents' willingness to support their children through the process."
There is an extremely high satisfaction rate associated with gender confirmation procedures, and Dr. Ramineni attributes this to the fact that patients are typically more mature and "have desired this throughout their lives." He says he's "never had a patient express regret about the surgery or wish to reverse it."
Related: 6 Nonbinary, Trans, and Gender Nonconforming Tastemakers Share Their Skin-Care Routines That Work
Insurance Coverage Policies for Gender Confirmation Procedures Vary Widely
As Dr. Spiegel explains, your employer determines which procedures the insurance policy will cover. Some employers are very generous with facial feminization/masculinization, while others will only cover vaginoplasty or phalloplasty. Even if insurance covers a procedure, it doesn't guarantee that you can see the doctor you prefer or one who specializes in gender confirmation. "There is truly no fixed answer," he says.
No matter how generous the policy, Dr. Ramineni adds, breast augmentation and chest masculinization are rarely covered. "It's a significant financial commitment to undergo all three [facial, chest, and genital surgeries]," he says, which is why many people have to decide which is most crucial to them.
The Average Plastic Surgeon Lacks the Specialized Skills for Gender Confirmation Procedures
Just because a plastic surgeon routinely performs some of the same procedures for gender confirmation on cis patients doesn't mean they know how to apply those skills successfully to trans patients.
"The techniques of facial feminization surgery are among the most advanced in facial surgery. This is why a facial feminization surgeon can handle any case, but a typical plastic surgeon couldn't perform facial feminization unless they were very familiar with these distinct techniques," says Dr. Spiegel.
The same holds true for the body: "Many plastic surgeons think they can perform the procedures identically on transgender patients as they do on cis patients, but there are definite differences, especially with breast augmentation and, of course, vaginoplasties or genital surgery," says Dr. Ramineni, noting that some doctors take advantage of transgender patients who already face a lot of inherent societal discrimination.
Dr. Spiegel frequently sees patients who went to a local plastic surgeon for rhinoplasty, ended up with a nose that doesn't suit their face, and now require a revision, which is always more challenging. But that's not the worst outcome. For example, Adam's apple reduction is relatively quick and straightforward for a specialized surgeon; in the wrong hands, "there is an extremely high risk of damaging the vocal cords – and once that occurs, it's incredibly difficult to restore the voice to its original state," says Dr. Deschamps-Braly. It's essential to ask potential surgeons how many gender confirmations they perform each year and ensure they have plenty of before-and-after examples to review.
Learn more about gender confirmation surgery procedures:• Facial feminization surgery• FTM chest masculinization surgery• FTM phalloplasty• MTF breast augmentation• MTF vaginoplasty
