Surgical affirmation | Transgender, non-binary and gender diverse children

coloured background and title of post on Surgical affirmation
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photo of Felicity St John

This blog post is a part of the resource – Supporting Transgender, Non-binary and Gender diverse Children & Young People, created by Felicity St John and Felicity’s collaborator and fellow Master of Sexology student Lindsay SmithFelicity, during a placement with Sex Ed Rescue in 2024.

Felicity St John has a Master of Sexology (Professional) with Distinction and a Bachelor of Human Services – Child and Family Studies. She currently works for an NGO as a supervisor of four practitioners, coaching and case managing families facing complex challenges. Felicity also offers professional development and consultancy. Her professional interest areas are sex education, puberty, LGBTQI+ people, child development, transgender/non-binary/gender-diverse people, relationship coaching, family coaching, and parenting psychoeducation. Felicity has a passion for supporting people to step into their capacity. When she’s not working Felicity loves to laugh, play, be with loves ones, rock climb, SUP board, explore nature, read, write, hike, cycle, swim, and laze about like a cat. You can contact Felicity via email.

We asked some transgender and non-binary people and parents of transgender/non-binary children what information they thought parents needed to know the most regarding gender affirming health care.

Here are some of their responses, relating to surgical affirmation.

‘So much gender-affirming care is completed on cisgender people, and nobody blinks an eye. Yet when somebody does something that is stepping away from cisnormativity there is an issue. Figure out why you can let your best mate Sally have a boob job, and Henry got a hair transplant in Turkey, but you want to stop a transgender person from accessing things that significantly impact their mental well-being.’  
– Bodhi (28yo trans man, he/him)

‘Medical transition is not the end game for all. The specialists have the knowledge so be curious and ask questions. Trust your child. Seek doctors who specialise in gender identity. If the doctor is not meeting your child’s needs and causing further harm, do your own research and find one who is suitable.’  
– Liam (35yo trans man)

‘The health care in Australia can be great, but it can be hard to find the right support’.
– Rich (father of a 24yo non-binary child, they/them)

‘It can be a long expensive process, but your child’s happiness is worth more than that’ 
– Nina (trans woman, she/hers)

‘Take the time to understand the ” expected ” steps and the steps your child might want to take may be different. Never force anything upon your children, but don’t discourage them from doing what they want because they know what is right for them. Instead, educate yourself and them to ensure they make informed choices’. 
– Bodhi (28yo trans man, he/him)

‘The range of pro & cons and impacts. Information is power. This should include the risks individuals face when they are not supported.’ 
– Daniel (father of an 18yo trans man, he/him)

‘Age restrictions for seeking medical health care. Some wait lists are long, and the age of the child will change when on the waitlist, and therefore health care options will change.’
– Stephanie (mother of an 18yo trans man. He/him)

Surgical affirmation is when a person affirms their gender by undergoing surgery that changes their body to look and function in a way that is aligned with their gender. Other terms used for this include gender-affirming surgery and medical transition. 

Surgical affirmation is not specific to transgender and non-binary people. Some cisgender people also access surgical affirmation. Most gender-affirming surgeries are done on cisgender people. For example, breast implants, labiaplasty, penis lengthening and thickening, hair transplants, testicular implants, and publicly funded male chest reductions. 

Not every transgender or non-binary person will have surgery. Different people may want no surgery, one surgery, or some surgeries. 

Many surgical affirmation procedures comprise multiple procedures rather than just one surgery. People also experience different constraints on whether they can access surgical affirmation. Some surgeries may be a prerequisite to accessing legal affirmation, such as changing gender markers on government documentation. This will depend on where a person lives. Most surgeries occur in the private health system despite the life-saving potential of gender-affirming surgeries.

Surgical affirmation is associated with the following: 

  • Improved quality of life (chest surgery, phalloplasty, breast augmentation, vaginoplasty)
  • Improved wellbeing
  • Reduction in gender dysphoria 
  • Increase in gender euphoria
  • Extremely low regret rates (only 0.2%-3% of consumers experienced regret)
  • ‘Improvement in romantic and sexual satisfaction for adolescents receiving puberty suppression, hormone treatment and surgery’ (Coleman et al., 2022).

Some barriers to accessing the surgical affirmation someone may want/need include:

  • Finances (surgery, medical readiness referrals, private consultations, allied health appointments, specialist appointments, tests, fertility preservation). This can be a considerable barrier as in the context of transphobia and minority stress, there are higher rates of unemployment for transgender people when compared to the general population. 
  • Whether private or public health insurance schemes can partially/fully reimburse the procedure
  • Laws limiting/barring access to gender-affirming surgery
  • Unsupportive workplaces
  • Limited number of surgeons completing surgical affirmation in some locations
  • Not having enough leave to take time off
  • Being able to sustain yourself during the surgery and recovery period financially
  • Health professionals not understanding the need for surgical affirmation
  • Gatekeeping processes
  • Discrimination
  • Finding healthcare professionals
  • Some surgeries are harder to access in different geographical locations and may require travelling to another state or country
  • Medical conditions
  • Obtaining medical readiness referrals from mental health professionals

When understanding surgery names, it can be helpful know what the suffixes -ectomy and -plasty mean. Ectomy means to remove. Plasty means to mould or form to replace/restore/repair. Augmentation means to make larger.

Feminising surgeries include:

  • Top surgery
    • Feminising mammoplasty/ breast augmentation
  • Neck and facial surgery
    • Chondrolaryngoplasty/ Tracheal shave (shaving Adam’s apple) 
    • Vocal feminisation
    • Chin/jaw modification
    • Lip shaping
    • Rhinoplasty/ nose shaping
    • Cheek filling
    • Brow lift
    • Forehead reduction
    • Hairline advancement
  • Bottom surgery
    • Bilateral orchiectomy
    • Penectomy
    • Scrotectomy
    • Vaginoplasty or colovaginoplasty (making a new vagina)
    • Vulvoplasty
  • Body contouring

Masculinising surgeries include:

  • Top surgery
    • Bilateral mastectomy – ‘top surgery’ (removing chest/breast tissue)
    • Chest reconstruction
  • Neck and facial surgery
    • Tracheal augmentation
    • Chin/Jaw augmentation
    • Rhinoplasty/ nose shaping
    • Buccal fat removal (cheek fat)
    • Brow bone augmentation
  • Bottom surgery
    • Hysterectomy ‘hysto’
      • +/-bilateral salpingo-oophorectomy
    • Mons resection
    • Vaginectomy
    • Metoidioplasty
      • +/- urethral lengthening
    • Phalloplasty
      • +/- urethra
      • Flap from forearm, thigh, abdomen, or back
      • Penile prosthesis
    • Scrotoplasty
    • Testicular prosthesis implant

In the United States, the two most common surgeries completed on transgender people are chest (bilateral mastectomy, chest reconstruction) and breast surgery (mammoplasty). In the United States, older transgender people were more likely than younger transgender people to access bottom surgeries.

Each surgery has its risks, which are discussed as part of a consent process.

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Top surgery

Breast augmentation

This is also known as top surgery. In breast augmentation, the breasts are made larger through the implantation of breast prostheses. Typically, the person will have been on oestrogen for around a year to ensure breast tissue growth has occurred first.

Bilateral mastectomy and chest reconstruction

This is also known as top surgery. A bilateral mastectomy is a surgery that removes chest/breast tissue. A chest reconstruction is typically done at the same time. This procedure reconstructs the chest area to look like the chest of someone assigned male at birth (AMAB). The pre-existing nipple is typically reshaped to a smaller nipple to be more masculine and is attached to the chest. Trans men and non-binary people may undertake top surgery for different reasons. This surgery is also referred to as chest surgery and chest masculinisation surgery. Research indicates that most transgender and non-binary youth who bind would like to proceed with chest/top surgery. 

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Genital reconfiguration surgery/Bottom surgery

Orchiectomy

An orchiectomy is a feminising surgery in which the testes are removed. Benefits of orchiectomy include the testosterone is no longer being made in the testes as they are gone, there is no more ability to make sperm, tucking may be simpler, and the person no longer needs to take anti-androgen medication. The scrotum may be left in this procedure if the person later wants the option of vaginoplasty, which uses tissue from the scrotum. The procedure takes about an hour.

Vaginoplasty

Vaginoplasty is a surgery done to the genitals to make a functional new vagina (internal genitalia) and labia (external genitalia). Vaginoplasty is a type of bottom surgery. This is most done by penile inversion, in which the vagina and vulva are constructed out of penile and scrotum tissue. The penile tissue becomes the lining of the vagina. The testes are removed during the procedure (orchiectomy), and the urethra is shifted and shortened. This procedure takes around 6 hours. Where there isn’t enough penile tissue, a colovaginoplasty may be completed. In this procedure, colon tissue is used. This takes around 3 hours.

Vulvoplasty

Vulvoplasty is a feminising surgery done to the genitals to make a vulva (external genitalia). This is done to help affirm the person’s gender. Vulvoplasty is a type of bottom surgery.

Penectomy

A penectomy is when the penis is removed. Another surgery may be done simultaneously, which involves the removal of the testes (orchiectomy). If the person chooses to, the penectomy can leave penile tissue (and the scrotum skin if an orchiectomy is done). This means the skin can be used in future gender-affirming surgeries.

Scrotectomy

A scrotectomy is when the entire scrotum is removed.  

Hysterectomy +/-bilateral salpingo-oophorectomy

Sometimes also referred to as ‘hysto’. There are several different types of hysterectomies. A total hysterectomy removes the cervix and uterus. Hysterectomies can also be partial. Hysterectomies can be done simultaneously with other surgeries that remove other reproductive organs. A salpingo-oophorectomy is when the ovaries (oophorectomy) and the fallopian tubes are removed. Benefits of hysterectomy include no longer being able to become pregnant and not menstruating. In some locations, a hysterectomy is required to access legal affirmation. A hysterectomy may involve elements that may make some people experience gender dysphoria. For example, bleeding from the genital area, shopping for and use of pads, wards with women on them, gendered language in the documentation and post-operative care instructions and being misgendered. 

Vaginectomy

In a vaginectomy, part or all of the vagina is removed.

Mons Resection

The Mons is the mound of flesh over the pubic bone, which is found above the labia/penis. A mons resection is a surgery where some of the fat and skin from the mons are removed. This can give the mons a flatter appearance and make a penis look bigger than if the mons resection was not done.

Metoidioplasty +/- urethral lengthening

Also known as ‘meta’. Metoidioplasty is a masculinising surgery where a new penis is made from the clitoris and other tissue (labia). The person has typically already been taking testosterone which enlarges the size of the clitoris and assists to create a more favourable outcome. In this simple metoidioplasty, the penis will look similar to a penis a person assigned male at birth (AMAB) would have before they started puberty. This penis can have erections. In simple metoidioplasty, the person would not be able to urinate out of this penis. There are different types of metoidioplasties; simple, full, ring, and centurion. Metoidioplasty can also be done with urethroplasty, which is when a urethra is created from labia or other tissue (e.g. cheek) to go through the new penis. This enables the person to urinate out of their penis. In full metoidioplasty, the new penis is created, the new urethra is created through the penis (urethroplasty and the vagina is removed and closed (Vaginectomy). 

Phalloplasty +/- urethra

Phalloplasty is a process of multiple surgeries to create a penis, which is bigger in size than the penis made in metoidioplasty. To create the penis, flap surgery will occur to harvest tissue from the forearm, thigh, abdomen, or back. Urethroplasty, where a urethra is constructed within the penis. This enables the person to urinate out of their penis. During this process, additional surgeries can be completed, including scrotoplasty (making a scrotum), implanting testicular prosthesis, hysterectomy, vaginectomy, and oophorectomy. Embedding a pump to enable erections may also be a part of surgery.

Scrotoplasty

Scrotoplasty is a surgery in which a scrotum is created. 

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Facial and neck surgeries

Chondrolaryngoplasty/ Tracheal shave 

Also known as a ‘trach shave’ although the trachea isn’t shaved. A trach shave is a feminising surgery to remove some of a person’s Adam’s apple (laryngeal prominence) to make it less noticeable. The Adam’s apple is made of thyroid cartilage. The procedure takes an hour or less.

Tracheal augmentation

In this surgery, rib cartilage is used to make the Adam’s apple (made of thyroid cartilage) stand out more to give it a more masculine appearance.

Vocal feminisation

Vocal feminisation is a surgery in which the vocals are altered to make them sound more feminine/ ‘brighter’. It’s not a very common procedure.

Chin/Jaw modification

To feminise the face, part of the jaw can be removed and the jaw re-shaped. Chin implants may also be used.

Jaw and chin augmentation

Jaw augmentation is where implants may give the jaw and chin a more masculine appearance. The jaw and chin may also be contoured.

Lip lift and reshaping

Different surgical procedures can be done on the lips to give them a more feminine or masculine appearance. These include shortening the top lip, lip-filling, reducing the fullness of the top lip, and surgery to the lip corners.

Cheek augmentation

The surgery enhances the cheeks using implants or fat grafts to make them look higher and more feminine.

Buccal fat removal

This procedure involves the removal of fat from the cheeks to give a more masculine look to the face.

Rhinoplasty/Nose shaping

Rhinoplasty can be a feminising or masculinising surgery. Rhinoplasty is a facial surgery in which the nose is shaped to look more masculine or feminine.

Browplasty/Brow lift

Browplasty is a feminising surgery to put the brows in a higher position on the face.

Brow bone augmentation

This procedure is where implants may be used to give a more masculine appearance to the brow. Hair repositioning may also be done at this time.

Forehead reduction

A surgery to remove some forehead bone to give a more feminine appearance to the face. 

Hairline advancement

This is a feminising surgery that moves the hairline forward and may shape the hairline to be more round. 

Recommendations for people having surgery (from trans people who have been through surgery)

  • Know the procedure and the aftercare.
  • Be aware of gender dysphoric aspects of the procedure/post operative care; what gender are people on the ward, do you need gendered products such as pads (hysterectomy), will you bleed (hysterectomy), will you be misgendered, will paperwork have gendered language.
  • Use a packing list.
  • Keep active pets outside of your bedroom during the first parts of recovery.
  • Prepare food ahead of time.
  • Ask for help and make it specific. Consider how you want to be cared for.
  • Use shoes that are easy to slide on/off.
  • Think about how the surgery will limit your mobility. What does this mean for being in your home, going to the toilet, caring for pets, picking things up off the floor.
  • Have the phone number nearby for the clinic/hospital ward if you have post-op questions.
  • Make lifestyle changes that will optimise your recovery. For example, reduce/cease smoking, reduce weight if overweight.
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What about surgery for children and adolescents?

It’s common for parents to wonder whether their child’s gender identity will stay the same. Parents may worry about this, especially when the young person wants surgery. 

Surgery is not recommended for pre-pubescent children. Social transition is available at that stage of development as a gender-affirming support.

Current recommendations include only proceeding with surgery for adolescents if the gender dysphoria/incongruence has been persistent over time (Coleman et al., 2022). Where it has been persistent for adolescents over several years, there appears to be low regret rates, though more research is needed. A small subset of adolescents may go through a healthcare assessment process and decide not to have surgery at that time.

Parents/guardians are typically involved in the health care assessment and treatment process, and they do have input. When healthcare is in line with the international standards of care, it is a deliberate and unrushed process. Though the adolescent needs to have the capacity to give informed consent to surgery, typically, the parent/guardian is the one to give consent if their child is a minor. In some places, the consent of both parents is required. If, for some reason, the adolescent is providing legal consent to their procedure, it is recommended the consent process be longer, more considered, and involve other health care professionals.

The evidence-based international Standards of Care for the Health of Transgender and Gender Diverse People have specific recommendations for adolescents who may be requesting surgery.

All the following have to be in place first:

The adolescent 

  • Is requesting it
  • Meets diagnostic criteria in the ICD or similar (for more on this read the mental health section)
  • Has had marked gender diversity/incongruence over time (years)
  • Has the capacity to give informed consent
  • Mental health, which may impact consent and treatment, has been addressed
  • Impacts on fertility and fertility preservation have been talked about 
  • ‘Has reached Tanner stage for pubertal suppression to be’ started 
  • Has completed 12 months of gender-affirming hormones (unless unable or not wanted). This can help the adolescent adjust and, for some surgeries, lead to better outcomes.

(Coleman et al., 2022) 

So, what surgeries might a minor get? For trans-masculine youth, the international standards of care state that chest masculinisation surgery may be appropriate, depending on individual factors. There is less known about breast augmentation as this is less researched in youth and requested less by trans feminine youth. Despite this, it may be appropriate. Some minors in the United States are accessing vaginoplasty, and small studies indicate this has reduced gender dysphoria and improved well-being for trans-feminine youth.

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Resources

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References

  • A Comprehensive Guide to Facial Masculinization Surgery by Gender Confirmation Center 2024.
  • Bilateral Orchiectomy for Transgender Patients: An Efficient Surgical Technique That Anticipates 
  • Facial Feminisation Surgery by University of California San Fransisco 2024.
  • Facial Surgery by Trans Hub 2021.
  • Future Vaginoplasty and is Associated with Minimal Morbidity by Washington, et al., 2017.
  • Gender Affirming Surgery in Australia -An Evidence Brief by AusPATH 2021.
  • Genital Reconfiguration Surgery by Australian Society of Plastic Surgeons 2024.
  • Genital Reconfiguration Surgery by Trans Hub 2021.
  • Hysterectomy by Trans Hub 2021.
  • https://www.transhub.org.au/hysterectomy
  • Merriam-Webster Dictionary by Merriam Webster 2024.
  • Metoidioplasty by Gender Aid 2024.
  • Mons Resection by Dr. Marci L. Bowers 2024.
  • National Estimates of Gender-Affirming Surgery in the US by Wright et al., 2023.   
  • Orchiectomy by Trans Hub 2021.
  • Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience by Jedrzejewski et al., 2023. 
  • Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 by Coleman et al., 2022.
  • The Health and Well-Being of Transgender Australians: A National Community Survey by Bretherton et al., 2021.
  • Trans Surgery by Masada Private Hospital 2024. https://www.masadaprivate.com.au/Our-Services/Trans-Surgery
  • Urological Focus on Gender Affirmation Surgery by The Royal Australian College of General Practitioners (RACGP) 2024. 
  • What You Should Know About Orchiectomy for Transgender Women by Aditi Pai 2018.
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Informed consent model

One pathway of consent is referred to as the informed consent model. This model places the transgender/non-binary/gender-diverse (TGD) person at the centre as an expert in their gender and life and de-emphasises the reliance on external assessments by medical professionals on whether a person is truly transgender. The informed consent model sees the transgender person as the decision-maker whom the health care professional can go through the ins and outs of any medical care with. 

What does this look like? A local doctor can prescribe hormones after talking to the trans person about benefits, risks, and other treatments. This model is often considered more respectful of human rights. It can also reduce some of the barriers to accessing medical care.

References 

  • Australian Informed Consent Standards of Care for Gender Affirming Hormone Therapy by AusPATH 2022.
  • Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 by Coleman et al., 2022.
  • Urological Focus on Gender Affirmation Surgery by The Royal Australian College of General Practitioners (RACGP) 2024.  https://www1.racgp.org.au/ajgp/2024/may/urological-focus-on-gender-affirmation-surgery Aimed at Australian General Practitioners (GPs)/doctors. 

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Felicity St John holds a Master of Sexology (Professional) with Distinction and a Bachelor of Human Services – Child and Family Studies. She supervises a team in an NGO, coaching and supporting families with complex needs, and offers professional development and consultancy. Her interests include sex education, puberty, LGBTQI+ inclusion, child development, and family coaching. Outside work, Felicity enjoys time with loved ones, outdoor adventures, and creative pursuits.
You can find Felicity at LinkedIn - https://www.linkedin.com/in/felicity-st-john-726365256/