GENDER TRANSITION
GENDER-AFFIRMING SURGERY
Gender-affirming surgeries (GAS) include all or a combination of several types of surgeries, specifically facial reconstructive surgery, chest surgery and genital surgery. It is estimated that approximately 35% of transgender people undergo some form of GAS, with chest surgery being the most prevalent and facial reconstructive surgery being the least prevalent. Gender-affirming surgeries can be a great step towards fostering gender congruity (between sex assigned at birth and gender identity) and helping transgender people reduce strain experienced from diverging social attitudes and expectations. Because some of these surgeries are considered irreversible, it is also important to be aware of their scope and consequences, as well as of the present medical possibilities and limitations. Many health insurance plans now cover gender-affirming surgeries, though some require specific conditions for coverage, most commonly health records showing consistent gender dysphoria (over a period of at least a year) and a mental healthcare provider evaluation confirming gender dysphoria.
Facial Reconstructive Surgery
Facial reconstructive surgery describes the reshaping of certain facial features to obtain a more typically male or female appearance. In transwomen, this often includes cheekbone injections or implants, or a shaving down of the jawline to make for more feminine facial features. In transmen, this may include chin and jaw fillers (a gel-like substance containing hyaluronic acid to add volume and enhance collagen production) to achieve a more dominant, stronger, and masculine jawline. Such injections (fillers) usually last for about 6-12 months. Cheek or chin implants (for cheek or chin augmentation) are made of silicone and are inserted into the cheek or chin in a small surgical procedure. Scarring after these procedures is not common, as the operative area is accessed either from inside the mouth or the lower eyelid. The risks and complications for such procedures are minimal, though some swelling, scarring and possible implant infection may occur. There is also Adam's apple reduction surgery (chondrolaryngoplasty) in which the laryngeal prominence - made up of thyroid cartilage - is accessed via a small incision in the throat to shave off cartilage and reduce its size. Conversely, in Adam's apple augmentation surgery, cartilage is taken from other parts of the body (such as the rib cage) and implanted into the throat via a small incision.
Chest Surgery
Chest surgery can mean either a breast augmentation (in male-to-female transition) or mastectomy surgery (in female-to-male transition). These surgeries are performed by accessing the breast through an incision around the nipples (areolae), in the armpits or underneath the breast (inframammary fold) and either removing fatty breast tissue or inserting a silicone implant into the breast (between the fatty layer and the chest muscle). While breast augmentation is a fairly straightforward and low risk procedure which usually does not take more than two (2) hours, mastectomy surgery can be more difficult, because there is often a lot of excess skin tissue to remove, leading to more numerous and larger scars and sometimes making it difficult to preserve nipple aesthetics.
Genital Surgery
Genital surgery, both in masculinizing and feminizing cases, usually requires a set of different surgeries, which may be performed together in one procedure or in a series of several procedures.
In male-to-female transitions, a penectomy and orchiectomy (removal of penis and testicles) is followed by a female genitoplasty, i.e. vaginoplasty, labiaplasty and clitoroplasty (construction of clitoris, usually from penile head tissue, labia and invagination, i.e. a vaginal canal built from skin previously part of the penis or donor skin from another part of the body). In some cases, (laser) hair removal may need to precede surgery to avoid later complications, such as infections.
In female-to-male transitions, a (radical) hysterectomy (removal of uterus, Fallopian tubes and ovaries) is often followed by a phalloplasty and scrotoplasty (construction of penis and testicles). Instead of a phalloplasty, a metoidioplasty (surgical lengthening of the clitoris, which can achieve a penis of up to 8 cm length) may be an alternative. In phalloplasty (surgical grafting of a penis), donor tissue (skin and muscle) from other areas of the body, such as the arm, leg or abdomen, is shaped into the form of a penis and anchored into the genital region above the clitoris. The urethra is also lengthened with graft tissue (urethroplasty). A phalloplasty can be accompanied by nerve grafting to improve sensation, and medical tattoos to improve the aesthetic of the penile head (crown). During a scrotoplasty, the labia are repurposed as testicles via the insertion of testicular silicone implants.
After the procedure (both FTM and MTF) a catheter is placed to collect urine while the plasty heals. This usually takes several weeks. Any genital surgery comes with risks which should be carefully evaluated. These include infection, necrosis (tissue death, especially in the grafts), nerve damage (numbness), permanent scarring, fistulas (unintended openings to the urethra or rectum) and (urinary) incontinence. Moreover, infertility is generally a consequence of gender-affirming genital surgeries (with some exceptions, such as metoidioplasty without hysterectomy). This is why sperm and egg storage might be considered prior to any of these procedures.
