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Preparing for Gender Affirmation Surgery: Ask the Experts

Featured Expert:

Romy Smith, LMSW

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

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

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

Can I still have children after gender affirmation surgery?

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

Are there other ways I need to prepare?

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

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

An initial intake interview via phone with a clinical specialist.

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

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

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

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

An appointment with your surgeon. 

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

A preoperative anesthesia and medical evaluation. 

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

What can I expect after gender affirming surgery?

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

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

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

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

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What Is Gender Affirmation Surgery?

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

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

Why Is Gender Affirmation Surgery Performed?

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

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

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

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

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

Transgender vs Nonbinary

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

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

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

Hormone Therapy

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

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

Types of hormone therapy include:

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

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

Masculinizing Surgeries

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

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

Top Surgery

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

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

Metoidioplasty

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

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

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

Phalloplasty

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

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

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

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

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

Hysterectomy and Oophorectomy

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

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

Feminizing Surgeries

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

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

Breast Augmentation

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

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

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

Facial Feminization and Adam's Apple Removal

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

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

Vulvoplasty and Vaginoplasty

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

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

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

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

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

Orchiectomy and Scrotectomy

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

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

Other Surgical Options

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

Gender nullification procedures
Penile preservation vaginoplasty
Vaginal preservation phalloplasty

Gender Nullification

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

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

Breast tissue removal
Nipple and areola augmentation or removal

Penile Preservation Vaginoplasty

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

Vaginal Preservation Phalloplasty

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

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

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

Risks and Complications

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

Anesthesia risks
Hematoma, which is bad bruising
Poor incision healing

Complications from these procedures may be:

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

What To Consider

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

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

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

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

A Quick Review

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

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

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Waterschoot M, Hoebeke P, Verla W, et al. Urethral complications after metoidioplasty for genital gender affirming surgery . J Sex Med . 2021;18(7):1271–9. doi:10.1016/j.jsxm.2020.06.023

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Gender-Affirming Surgery: Embracing Gender Congruence

A Comprehensive Guide to Gender-Affirming Surgery

Medically reviewed by Paul Gonzales on April 15, 2024.

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

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

Types of Gender-Affirming Surgeries

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

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

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

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

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

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

Facial Feminization Surgery and Facial Masculinization Surgery

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

Body Contouring Surgery

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

Voice Feminization Surgery

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

Considerations for Gender-Affirming Surgery

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

Eligibility and Readiness

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

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

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

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

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

Additional Eligibility Requirements: Age, Gender and BMI

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

Costs and Insurance Coverage

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

Preparation for Surgical Gender Affirmation

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

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

Recovery from Gender-Affirming Surgery

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

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

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

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

Q: Is gender affirming surgery covered by insurance?

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

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

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

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

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

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

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

Q: Can gender affirming surgeries be reversed?

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

The ultimate guide for 2024: facial surgery costs and insurance coverage, understanding the types, costs, benefits and risks of transgender surgery procedures, demystifying and navigating your options: gender reassignment surgery, sign up for instructions to get a virtual consultation.

The virtual consultation will be billed to your insurance company. We will accept the insurance reimbursement as payment in full.

Dr. Scott Mosser Suite 1010, 450 Sutter St San Francisco, CA 94108 Phone: (415) 780-1515 Fax: ( 628) 867-6510

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Transgender Surgery FAQs

Is gender reassignment surgery safe.

Like all types of surgery, gender-confirmation procedures carry risk. That’s why we thoroughly evaluate your health before planning surgery. Our experienced team follows best practices when it comes to your safety.

How common is gender reassignment surgery?

Gender reassignment (confirmation) surgery is more common in transgender men (42 to 54%) than transgender women (28%). Top (chest gender confirmation) surgery is performed approximately twice as often as bottom (genital) surgery. In studies that assessed transgender men and women as an aggregate, top surgery accounts for 8 to 25% and bottom surgery accounts for 4 to 13%. Review study details .

How long does it take to transition to another gender?

The length of your journey depends on your individual needs and choices. Along with surgical procedures, you might also have hormone therapy, voice therapy, and counseling. It’s up to you where to start and when you feel you’ve met your goals.

Can breasts grow back after top surgery?

Removed breast tissue doesn’t grow back. We do leave some fat behind to create natural-looking chest contours. While this fat can enlarge like fat anywhere on the body, it likely will not take on a feminine appearance.

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 ].

Lots More Information

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.

How Gender Identity Disorder Works
Is gender just a matter of choice?
What is transgender voice therapy?
How fluid is gender?
Why do girls wear pink and boys wear blue?

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition. Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female: Tracheal Shave Breast Augmentation Facial Feminization Male-to-Female genital sex reassignment

Female-to-Male: Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.) Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy. Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals. For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals. Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation. The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method.

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination. Construction of a scrotum with testicular implants is done as a second stage. The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

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Trans kids’ treatment can start younger, new guidelines say

This photo provided by Laura Short shows Eli Bundy on April 15, 2022 at Deception Pass in Washington. In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy hopes to get breast removal surgery next year before college. Bundy, 18, who identifies as nonbinary, supports updated guidance from an international transgender health group that recommends lower ages for some treatments. (Laura Short via AP)

FILE - Dr. David Klein, right, an Air Force Major and chief of adolescent medicine at Fort Belvoir Community Hospital, listens as Amanda Brewer, left, speaks with her daughter, Jenn Brewer, 13, as the teenager has blood drawn during a monthly appointment for monitoring her treatment at the hospital in Fort Belvoir, Va., on Sept. 7, 2016. Brewer is transitioning from male to female. (AP Photo/Jacquelyn Martin, File)

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A leading transgender health association has lowered its recommended minimum age for starting gender transition treatment, including sex hormones and surgeries.

The World Professional Association for Transgender Health said hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance. The group acknowledged potential risks but said it is unethical and harmful to withhold early treatment.

The association provided The Associated Press with an advance copy of its update ahead of publication in a medical journal, expected later this year. The international group promotes evidence-based standards of care and includes more than 3,000 doctors, social scientists and others involved in transgender health issues.

The update is based on expert opinion and a review of scientific evidence on the benefits and harms of transgender medical treatment in teens whose gender identity doesn’t match the sex they were assigned at birth, the group said. Such evidence is limited but has grown in the last decade, the group said, with studies suggesting the treatments can improve psychological well-being and reduce suicidal behavior.

Starting treatment earlier allows transgender teens to experience physical puberty changes around the same time as other teens, said Dr. Eli Coleman, chair of the group’s standards of care and director of the University of Minnesota Medical School’s human sexuality program.

But he stressed that age is just one factor to be weighed. Emotional maturity, parents’ consent, longstanding gender discomfort and a careful psychological evaluation are among the others.

“Certainly there are adolescents that do not have the emotional or cognitive maturity to make an informed decision,” he said. “That is why we recommend a careful multidisciplinary assessment.”

The updated guidelines include recommendations for treatment in adults, but the teen guidance is bound to get more attention. It comes amid a surge in kids referred to clinics offering transgender medical treatment , along with new efforts to prevent or restrict the treatment.

Many experts say more kids are seeking such treatment because gender-questioning children are more aware of their medical options and facing less stigma.

Critics, including some from within the transgender treatment community, say some clinics are too quick to offer irreversible treatment to kids who would otherwise outgrow their gender-questioning.

Psychologist Erica Anderson resigned her post as a board member of the World Professional Association for Transgender Health last year after voicing concerns about “sloppy” treatment given to kids without adequate counseling.

She is still a group member and supports the updated guidelines, which emphasize comprehensive assessments before treatment. But she says dozens of families have told her that doesn’t always happen.

“They tell me horror stories. They tell me, ‘Our child had 20 minutes with the doctor’” before being offered hormones, she said. “The parents leave with their hair on fire.’’

Estimates on the number of transgender youth and adults worldwide vary, partly because of different definitions. The association’s new guidelines say data from mostly Western countries suggest a range of between a fraction of a percent in adults to up to 8% in kids.

Anderson said she’s heard recent estimates suggesting the rate in kids is as high as 1 in 5 — which she strongly disputes. That number likely reflects gender-questioning kids who aren’t good candidates for lifelong medical treatment or permanent physical changes, she said.

Still, Anderson said she condemns politicians who want to punish parents for allowing their kids to receive transgender treatment and those who say treatment should be banned for those under age 18.

“That’s just absolutely cruel,’’ she said.

Dr. Marci Bowers, the transgender health group’s president-elect, also has raised concerns about hasty treatment, but she acknowledged the frustration of people who have been “forced to jump through arbitrary hoops and barriers to treatment by gatekeepers ... and subjected to scrutiny that is not applied to another medical diagnosis.’’

Gabe Poulos, 22, had breast removal surgery at age 16 and has been on sex hormones for seven years. The Asheville, North Carolina, resident struggled miserably with gender discomfort before his treatment.

Poulos said he’s glad he was able to get treatment at a young age.

“Transitioning under the roof with your parents so they can go through it with you, that’s really beneficial,’’ he said. “I’m so much happier now.’’

In South Carolina, where a proposed law would ban transgender treatments for kids under age 18, Eli Bundy has been waiting to get breast removal surgery since age 15. Now 18, Bundy just graduated from high school and is planning to have surgery before college.

Bundy, who identifies as nonbinary, supports easing limits on transgender medical care for kids.

“Those decisions are best made by patients and patient families and medical professionals,’’ they said. “It definitely makes sense for there to be fewer restrictions, because then kids and physicians can figure it out together.’’

Dr. Julia Mason, an Oregon pediatrician who has raised concerns about the increasing numbers of youngsters who are getting transgender treatment, said too many in the field are jumping the gun. She argues there isn’t strong evidence in favor of transgender medical treatment for kids.

“In medicine ... the treatment has to be proven safe and effective before we can start recommending it,’’ Mason said.

Experts say the most rigorous research — studies comparing treated kids with outcomes in untreated kids — would be unethical and psychologically harmful to the untreated group.

The new guidelines include starting medication called puberty blockers in the early stages of puberty, which for girls is around ages 8 to 13 and typically two years later for boys. That’s no change from the group’s previous guidance. The drugs delay puberty and give kids time to decide about additional treatment; their effects end when the medication is stopped.

The blockers can weaken bones, and starting them too young in children assigned males at birth might impair sexual function in adulthood, although long-term evidence is lacking.

The update also recommends:

—Sex hormones — estrogen or testosterone — starting at age 14. This is often lifelong treatment. Long-term risks may include infertility and weight gain, along with strokes in trans women and high blood pressure in trans men, the guidelines say.

—Breast removal for trans boys at age 15. Previous guidance suggested this could be done at least a year after hormones, around age 17, although a specific minimum ag wasn’t listed.

—Most genital surgeries starting at age 17, including womb and testicle removal, a year earlier than previous guidance.

The Endocrine Society, another group that offers guidance on transgender treatment, generally recommends starting a year or two later, although it recently moved to start updating its own guidelines. The American Academy of Pediatrics and the American Medical Association support allowing kids to seek transgender medical treatment, but they don’t offer age-specific guidance.

Dr. Joel Frader, a Northwestern University a pediatrician and medical ethicist who advises a gender treatment program at Chicago’s Lurie Children’s Hospital, said guidelines should rely on psychological readiness, not age.

Frader said brain science shows that kids are able to make logical decisions by around age 14, but they’re prone to risk-taking and they take into account long-term consequences of their actions only when they’re much older.

Coleen Williams, a psychologist at Boston Children’s Hospital’s Gender Multispecialty Service, said treatment decisions there are collaborative and individualized.

“Medical intervention in any realm is not a one-size-fits-all option,” Williams said.

Follow AP Medical Writer Lindsey Tanner at @LindseyTanner.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.

Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

clinical psychologist
child psychotherapist
child and adolescent psychiatrist
family therapist
social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

family therapy
individual child psychotherapy
parental support or counselling
group work for young people and their parents
regular reviews to monitor gender identity development
referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

breast development (caused by taking oestrogen)
breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

psychological support, such as counselling
cross-sex hormone therapy
speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

blood clots
weight gain
dyslipidaemia (abnormal levels of fat in the blood)
elevated liver enzymes
polycythaemia (high concentration of red blood cells)
hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

lose weight if you are overweight (BMI of 25 or over)
have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

removal of both breasts (bilateral mastectomy) and associated chest reconstruction
nipple repositioning
dermal implant and tattoo

Gender surgery for trans men includes:

construction of a penis (phalloplasty or metoidioplasty)
construction of a scrotum (scrotoplasty) and testicular implants
a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

removal of the testes (orchidectomy)
removal of the penis (penectomy)
construction of a vagina (vaginoplasty)
construction of a vulva (vulvoplasty)
construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

you'll need lifelong monitoring of your hormone levels by your GP
you'll still need contraception if you are sexually active and have not yet had any gender surgery
you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

Non-surgical interventions for adults
Surgical interventions for adults
Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

Patient Care & Health Information
Tests & Procedures
Feminizing hormone therapy

Feminizing hormone therapy typically is used by transgender women and nonbinary people to produce physical changes in the body that are caused by female hormones during puberty. Those changes are called secondary sex characteristics. This hormone therapy helps better align the body with a person's gender identity. Feminizing hormone therapy also is called gender-affirming hormone therapy.

Feminizing hormone therapy involves taking medicine to block the action of the hormone testosterone. It also includes taking the hormone estrogen. Estrogen lowers the amount of testosterone the body makes. It also triggers the development of feminine secondary sex characteristics. Feminizing hormone therapy can be done alone or along with feminizing surgery.

Not everybody chooses to have feminizing hormone therapy. It can affect fertility and sexual function, and it might lead to health problems. Talk with your health care provider about the risks and benefits for you.

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Why it's done

Feminizing hormone therapy is used to change the body's hormone levels. Those hormone changes trigger physical changes that help better align the body with a person's gender identity.

In some cases, people seeking feminizing hormone therapy experience discomfort or distress because their gender identity differs from their sex assigned at birth or from their sex-related physical characteristics. This condition is called gender dysphoria.

Feminizing hormone therapy can:

Improve psychological and social well-being.
Ease psychological and emotional distress related to gender.
Improve satisfaction with sex.
Improve quality of life.

Your health care provider might advise against feminizing hormone therapy if you:

Have a hormone-sensitive cancer, such as prostate cancer.
Have problems with blood clots, such as when a blood clot forms in a deep vein, a condition called deep vein thrombosis, or a there's a blockage in one of the pulmonary arteries of the lungs, called a pulmonary embolism.
Have significant medical conditions that haven't been addressed.
Have behavioral health conditions that haven't been addressed.
Have a condition that limits your ability to give your informed consent.

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Research has found that feminizing hormone therapy can be safe and effective when delivered by a health care provider with expertise in transgender care. Talk to your health care provider about questions or concerns you have regarding the changes that will happen in your body as a result of feminizing hormone therapy.

Complications can include:

Blood clots in a deep vein or in the lungs
Heart problems
High levels of triglycerides, a type of fat, in the blood
High levels of potassium in the blood
High levels of the hormone prolactin in the blood
Nipple discharge
Weight gain
Infertility
High blood pressure
Type 2 diabetes

Evidence suggests that people who take feminizing hormone therapy may have an increased risk of breast cancer when compared to cisgender men — men whose gender identity aligns with societal norms related to their sex assigned at birth. But the risk is not greater than that of cisgender women.

To minimize risk, the goal for people taking feminizing hormone therapy is to keep hormone levels in the range that's typical for cisgender women.

Feminizing hormone therapy might limit your fertility. If possible, it's best to make decisions about fertility before starting treatment. The risk of permanent infertility increases with long-term use of hormones. That is particularly true for those who start hormone therapy before puberty begins. Even after stopping hormone therapy, your testicles might not recover enough to ensure conception without infertility treatment.

If you want to have biological children, talk to your health care provider about freezing your sperm before you start feminizing hormone therapy. That procedure is called sperm cryopreservation.

How you prepare

Before you start feminizing hormone therapy, your health care provider assesses your health. This helps address any medical conditions that might affect your treatment. The evaluation may include:

A review of your personal and family medical history.
A physical exam.
A review of your vaccinations.
Screening tests for some conditions and diseases.
Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections.
Discussion about sperm freezing and fertility.

You also might have a behavioral health evaluation by a provider with expertise in transgender health. The evaluation may assess:

Gender identity.
Gender dysphoria.
Mental health concerns.
Sexual health concerns.
The impact of gender identity at work, at school, at home and in social settings.
Risky behaviors, such as substance use or use of unapproved silicone injections, hormone therapy or supplements.
Support from family, friends and caregivers.
Your goals and expectations of treatment.
Care planning and follow-up care.

People younger than age 18, along with a parent or guardian, should see a medical care provider and a behavioral health provider with expertise in pediatric transgender health to discuss the risks and benefits of hormone therapy and gender transitioning in that age group.

What you can expect

You should start feminizing hormone therapy only after you've had a discussion of the risks and benefits as well as treatment alternatives with a health care provider who has expertise in transgender care. Make sure you understand what will happen and get answers to any questions you may have before you begin hormone therapy.

Feminizing hormone therapy typically begins by taking the medicine spironolactone (Aldactone). It blocks male sex hormone receptors — also called androgen receptors. This lowers the amount of testosterone the body makes.

About 4 to 8 weeks after you start taking spironolactone, you begin taking estrogen. This also lowers the amount of testosterone the body makes. And it triggers physical changes in the body that are caused by female hormones during puberty.

Estrogen can be taken several ways. They include a pill and a shot. There also are several forms of estrogen that are applied to the skin, including a cream, gel, spray and patch.

It is best not to take estrogen as a pill if you have a personal or family history of blood clots in a deep vein or in the lungs, a condition called venous thrombosis.

Another choice for feminizing hormone therapy is to take gonadotropin-releasing hormone (Gn-RH) analogs. They lower the amount of testosterone your body makes and might allow you to take lower doses of estrogen without the use of spironolactone. The disadvantage is that Gn-RH analogs usually are more expensive.

After you begin feminizing hormone therapy, you'll notice the following changes in your body over time:

Fewer erections and a decrease in ejaculation. This will begin 1 to 3 months after treatment starts. The full effect will happen within 3 to 6 months.
Less interest in sex. This also is called decreased libido. It will begin 1 to 3 months after you start treatment. You'll see the full effect within 1 to 2 years.
Slower scalp hair loss. This will begin 1 to 3 months after treatment begins. The full effect will happen within 1 to 2 years.
Breast development. This begins 3 to 6 months after treatment starts. The full effect happens within 2 to 3 years.
Softer, less oily skin. This will begin 3 to 6 months after treatment starts. That's also when the full effect will happen.
Smaller testicles. This also is called testicular atrophy. It begins 3 to 6 months after the start of treatment. You'll see the full effect within 2 to 3 years.
Less muscle mass. This will begin 3 to 6 months after treatment starts. You'll see the full effect within 1 to 2 years.
More body fat. This will begin 3 to 6 months after treatment starts. The full effect will happen within 2 to 5 years.
Less facial and body hair growth. This will begin 6 to 12 months after treatment starts. The full effect happens within three years.

Some of the physical changes caused by feminizing hormone therapy can be reversed if you stop taking it. Others, such as breast development, cannot be reversed.

While on feminizing hormone therapy, you meet regularly with your health care provider to:

Keep track of your physical changes.
Monitor your hormone levels. Over time, your hormone dose may need to change to ensure you are taking the lowest dose necessary to get the physical effects that you want.
Have blood tests to check for changes in your cholesterol, blood sugar, blood count, liver enzymes and electrolytes that could be caused by hormone therapy.
Monitor your behavioral health.

You also need routine preventive care. Depending on your situation, this may include:

Breast cancer screening. This should be done according to breast cancer screening recommendations for cisgender women your age.
Prostate cancer screening. This should be done according to prostate cancer screening recommendations for cisgender men your age.
Monitoring bone health. You should have bone density assessment according to the recommendations for cisgender women your age. You may need to take calcium and vitamin D supplements for bone health.

Clinical trials

Explore Mayo Clinic studies of tests and procedures to help prevent, detect, treat or manage conditions.

Feminizing hormone therapy care at Mayo Clinic

Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Oct. 10, 2022.
Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Oct. 10, 2022.
Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
AskMayoExpert. Gender-affirming hormone therapy (adult). Mayo Clinic; 2022.
Nippoldt TB (expert opinion). Mayo Clinic. Sept. 29, 2022.
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Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

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Is Counseling Needed Before Gender Transition?

Psychological: Male
Psychological: Female

For people with gender dysphoria, transitioning from one’s birth gender to their desired gender can be a big step. It can involve hormonal treatment as well as surgery. Some professionals recommend a mental health screening and psychotherapy beforehand as part of the process. But is that really necessary?

The AMA Journal of Ethics discussed the debate in a recent commentary.

On one hand, counseling can help patients better understand the complex procedures and the adjustments that will be needed, even if one has been living as their desired gender for a while. Also, many view gender reassignment surgery as permanent, and patients need to be prepared.

On the other hand, many patients are confident about their decision and see no reason for a mental health professional to intervene or approve the transition. Others feel that the transition can be modified if they change their mind, even if a complete reversal is not possible.

According to the commentary, the World Professional Association for Transgender Health (WPATH) advises mental health screenings and recommends psychotherapy before any body modifications are made. However, such decisions could be made on a case-by-case basis.

It is still important for patients to provide informed consent before any hormonal or surgical procedure is conducted, acknowledging that they understand the procedures, the risks and benefits, consequences, and alternatives, the commentary noted.

AMA Journal of Ethics

Murphy, Timothy F., PhD

“Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?”

(November 2016)

http://journalofethics.ama-assn.org/2016/11/ecas2-1611.html

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Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

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Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

one of the assessments must be from a doctor or nurse practitioner
you have a diagnosis of persistent gender dysphoria
have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

have a diagnosis of persistent gender dysphoria
have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

find out about their ongoing project, Trans Health Connection
consult their service directory
find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

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5 Long-Term Problems After Meniscus Surgery

What is the meniscus.

Long-Term Problems
Long-Term Treatment

Alternatives to Surgery

Although arthroscopic surgery of the meniscus is minimally invasive, you may still experience knee pain after surgery. For some people, other problems can occur after surgery, such as arthritis, re-injury, incomplete rehabilitation, and more.

This article explores the potential long-term problems after meniscus surgery.

A review of 27 studies concluded that repairing the meniscus has a failure rate of 19.5% five or more years after surgery.

The meniscus is a c-shaped rubbery cartilage that works as a shock absorber between the tibia (shin bone) and the femur (thigh bone). It provides stability to the knee and protects the lower leg from the load created by your body weight.

How long does it take to recover from meniscus surgery?

Recovery time will depend on several factors, including the extent of the injury, type of repair done, and your daily activity level. Usual recovery time is 4-6 weeks, and up to 6 months for more complicated repair surgery.

Long-Term Problems After Meniscus Surgery

There are several potential long-term problems that can develop years after meniscus surgery.

People sometimes develop knee pain well after recovering from meniscus surgery. Some of the causes of long-term knee pain include:

Persistent swelling or inflammation
Infection (though this is rare)
Difficulties with postsurgical rehabilitation
Re-injuring the cartilage
Developing arthritis

Click Play to Learn More About Knee Pain After Meniscus Surgery

This video has been medically reviewed by Oluseun Olufade, MD .

Arthritis in the Joint

The type of meniscus surgery may make a difference in how likely it is that someone develops arthritis years later.

A partial meniscectomy involves removing only the torn portion of the meniscus, whereas a full meniscectomy involves removing the entire meniscus to help reduce pain. Full removal of the meniscus has a higher risk of developing osteoarthritis (OA) .

Arthroscopy is rarely recommended for people with osteoarthritis (OA) in the knee because arthroscopy has not been shown to relieve the pain associated with cartilage damage caused by OA.

Damaged Meniscus

Having had surgery to repair a torn meniscus may make people more likely to have meniscus tears or other meniscus injuries in the future.

Each knee has a lateral meniscus (on the outer side of the knee) and a medial meniscus (on the inner side of the knee). Depending on which meniscus is repaired, there may be a greater risk of re-injury. A 2020 study reported that 36% of medial meniscus surgeries required a repeat meniscus repair or partial removal of the meniscus after five or more years.

Other factors that can increase the risk of a re-tear include being older and playing contact sports.

Difficulty Walking

With knee pain before or after surgery, you may unknowingly limp or develop an abnormal gait (the manner in which you walk) in order to protect the joint and reduce pain.

Physical therapy , or rehabilitation, may be necessary after meniscus surgery to correct a limp, gait issues, or other problems with knee function once the surgery is done. Rehabilitation programs usually last four to six weeks and are designed to help improve joint strength, stability, and mobility.

Correcting these issues is important to prevent further injury.

Physical therapists warn that insufficient rehabilitation can be a cause of persistent knee pain after an injury. Examples of insufficient rehabilitation include:

Missing physical therapy appointments
Not doing necessary exercises as recommended
Returning to certain physical activities too soon

Spontaneous Osteonecrosis

Spontaneous osteonecrosis of the knee, or SONK, is a condition that causes a lack of blood supply to the bone. Osteo means "bone" and "necrosis" means "tissue death."

This complication of knee arthroscopy is thought to be the result of microscopic fractures of the bone around the knee joint. These fractures cause inflammation within the bone and significant, persistent pain, typically along the inner (medial) side of the knee. The pain is typically worsened by activity and relieved by rest.

SONK is most often found in middle-aged women.

Treatment of SONK can be very frustrating. Many patients find the pain is worse than the pain they had before arthroscopy. While the pain eventually settles down, often the only way to find relief is to use crutches for weeks or months after knee arthroscopy.

Braces and medications can also help with the symptoms. In some patients, the symptoms can be so severe that they end up having either a partial knee replacement or a full knee replacement .

How Is a Long-Term Meniscus Injury Treated?

The treatment will depend on a number of factors, including:

Your symptoms
Your activity level
Type, size, and location of the injury

If someone underwent a surgical meniscus repair and still experiences pain and swelling, or if a re-tear occurs in the cartilage, a revision meniscus repair may be necessary if non-surgical options don't provide relief. If it's determined that surgery is needed, treatment may involve:

Partial meniscectomy: The damaged meniscus tissue is trimmed off. This procedure usually allows for immediate weight bearing, and full range of motion soon after surgery.

Meniscus repair: This procedure involves stitching the torn cartilage pieces together to repair it. Whether this procedure can be done depends on the type of tear and the overall condition of the injured meniscus. Because the meniscus must heal back together, recovery time for a repair is longer than for a partial meniscectomy.

Physical therapy: Once the initial healing is complete, your healthcare provider will provide rehabilitation exercises or refer you to a physical therapist. You will start with exercises to improve your range of motion and then strengthening exercises will gradually be added. Rehabilitation time for a meniscectomy is about three to six weeks, while a meniscus repair is about three to six months.

Many times surgery is not always needed to heal a meniscus injury. Non-surgical therapies may include:

R.I.C.E. protocol is an initial treatment :

Rest with modified activity.
Apply ice or a cold pack to your knee for 15- to 20-minute sessions, several times a day.
Compress your knee with a brace or knee sleeve to prevent additional swelling.
Elevate your leg above your heart while icing it or whenever resting/relaxing.

Nonsteroidal anti-inflammatory drugs (NSAID) can further reduce pain and swelling.

A steroid (cortisone) injection into the knee joint is sometimes given to reduce inflammation and pain.

Physical therapy after the R.I.C.E. protocol and other treatments can provide specific exercises to help restore optimal function in your knee.

Meniscus tears and injuries may require non-surgical treatments or arthroscopic surgery depending on the type and location of the injury and the overall condition of the cartilage. While this surgery is less invasive than other surgeries and often involves a quick recovery period, it doesn't always improve knee pain.

Knee pain, osteoarthritis, re-injury, inadequate rehabilitation, and spontaneous osteonecrosis are potential long-term problems after meniscus surgery. Talk with your healthcare provider about treatments to help you find relief if you're experiencing pain or other post-surgery problems.

Friberger Pajalic K, Turkiewicz A, Englund M. Update on the risks of complications after knee arthroscopy . BMC Musculoskelet Disord . 2018;19(1):179. doi:10.1186/s12891-018-2102-y

Nepple JJ, Block AM, Eisenberg MT, Palumbo NE, Wright RW. Meniscal Repair Outcomes at Greater Than 5 Years: A Systematic Review and Meta-Analysis . J Bone Joint Surg Am . 2022;104(14):1311-1320. doi:10.2106/JBJS.21.01303

American Academy of Orthopaedic Surgeons. Meniscus tears .

Schweizer C, Hanreich C, Tscholl PM, et al. Nineteen percent of meniscus repairs are being revised and failures frequently occur after the second postoperative year: a systematic review and meta-analysis with a minimum follow-up of 5 years . Knee Surg Sports Traumatol Arthrosc. 2022;30(7):2267-2276.doi:10.1007/s00167-021-06770-x

Arthritis Foundation. Arthroscopy not recommended for arthritis .

American Academy of Orthopaedic Surgeons. Knee conditioning program .

American Academy of Orthopaedic Surgeons. Osteonecrosis of the knee .

Son IJ, Kim MK, Kim JY, Kim JG. Osteonecrosis of the knee after arthroscopic partial meniscectomy . Knee Surg Relat Res . 2013;25(3):150-154. doi:10.5792/ksrr.2013.25.3.150

Yang W-M, Zhao C-Q, Lu Z-Y, Yang W-Y, Lin D-K, Cao X-W. Clinical characteristics and treatment of spontaneous osteonecrosis of medial tibial plateau: a retrospective case study . Chinese Medical Journal . 2018;131(21):2544-2550. doi:10.4103/0366-6999.244113

Di Caprio F, Meringolo R, Navarra M, Mosca M, Ponziani L. Postarthroscopy osteonecrosis of the knee: current concepts . Joints . 2017;05(04):229-236. doi:10.1055/s-0037-1608666

Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA. Osteonecrosis of the knee: review . Ann Transl Med. 2015;3(1):6. doi:10.3978/j.issn.2305-5839.2014.11.13

US National Library of Medicine. Meniscus tears - aftercare .

Wilderman I, Berkovich R, Meaney C, Kleiner O, Perelman V. Meniscus-Targeted Injections for Chronic Knee Pain Due to Meniscal Tears or Degenerative Fraying: A Retrospective Study . J Ultrasound Med . 2019 Nov;38(11):2853-2859. doi:10.1002/jum.14987

By Jonathan Cluett, MD Dr. Cluett is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the U.S. national soccer teams.

What to Expect After Knee Replacement Surgery

Get to know your options for knee replacement surgery and what to expect in terms of recovery.

This article is based on reporting that features expert sources.

What to Know After a Knee Replacement

Over time, knee cartilage can deteriorate due to years of wear and tear. Since the knees take an enormous amount of pressure and stress as we move about, cartilage loss can lead to disabling knee pain , stiffness and inflammation.

The first line of defense is strengthening muscles that support the knee , losing weight and getting injections of anti-inflammatory medications (corticosteroids).

Knee replacement surgery is a last resort. The invasive procedure to install an artificial joint comes only after all efforts to cope with worn out knee cartilage ( osteoarthritis ) have failed to relieve disabling pain.

If your doctor determines you’re a good candidate for knee replacement surgery , here’s what to know about the procedure and the recovery process.

Key Takeaways

There are two types of knee replacement surgery: total knee replacement and partial knee replacement.
Because total knee replacement surgery is more invasive than partial knee replacement, recovery generally takes longer.
The most important aspect of recovery is physical therapy, which you do at an outpatient center a few times a week.
You can typically get 15 to 20 years of use from a partial knee replacement, and up to 30 years for a full knee replacement.

Types of Knee Replacement Surgery

There are two main types of knee replacement surgery:

Total knee replacement

Partial knee replacement.

A total knee replacement sounds like it involves getting an entirely new joint, but it’s a bit of a misnomer.

“It’s more of a knee resurfacing, like getting a crown for your tooth. Dentists shave down the tooth and put a cap on it,” says Dr. Adam Sassoon, a hip and knee surgeon at UCLA Health . “That’s similar to what we do with the femur (thighbone), tibia (shin bone) and patella (kneecap). We remove about 9 millimeters of the surface of each bone to fit a cap (implant) on there and give the bone a new, smooth surface.”

Artificial knee parts are made of metal and plastic. Installing them requires an orthopedic surgeon to make an incision about 6 to 10 inches long, cut out one or more major ligaments, separate the femur and tibia from the knee, and sometimes cut into the quadriceps muscles.

“When you cut off the top of the tibia, you have to sacrifice the anterior cruciate ligament in the center of the knee,” says Dr. Seth Jerabek, a hip and knee surgeon at the Hospital for Special Surgery in Manhattan. “The implant then makes up for the ACL to stabilize the joint, but really, there’s no way to make it perform like an ACL, so it can be harder after knee replacement to pivot and twist in activities like soccer or basketball.”

Whether you’re a good candidate for a total knee replacement depends on the severity and location of the cartilage loss. The more damage you have, the more likely it is that you’ll need a total knee replacement.

When the cartilage loss is limited to one part of the knee, you might be a candidate for a partial knee replacement. The most common scenario is arthritis isolated to the medial compartment, or inner side of the knee between the femur and tibia, closer to your other leg.

“Those patients do well with partial knee replacements,” Jerabek says.

Like a total knee replacement, a partial knee replacement involves an incision approximately 4 or 5 inches long, as well as the removal of damaged cartilage and bone, and the installation of replacement parts.

“The parts are smaller, thus less bone is removed and the implants are not inserted as deep into the bone,” Jerabek notes.

Because the parts are smaller and limited to one location, doctors don’t have to remove knee ligaments either.

“That’s better for people who are more active,” Sassoon says.

However, even if you’re a great candidate for a partial replacement, it doesn’t mean you’ll avoid further knee problems .

“The potential problem with a partial knee replacement is that you can still get arthritis in the other knee compartments that weren’t replaced, so some patients elect to have a total replacement rather than a partial knee replacement,” Jerabek says.

The recovery process for surgery after a total knee replacement procedure is generally longer than a partial replacement.

Whether you’re having a partial or total knee replacement surgery, here’s what you can expect for the weeks following the procedure:

Day of surgery

Surgery typically lasts 1 to 2 hours under regional or general anesthesia.
After the procedure, you’ll be taken to the recovery room and monitored as you wake up from anesthesia.
Pain management begins post-surgery with nerve blocks or other modalities.
Your surgery team will likely get you up and walking as soon as a few hours after surgery.

Knee replacement surgeries are typically done on an outpatient basis at either an ambulatory surgery center or hospital-based outpatient department, with most patients going home the same day. People with underlying medical conditions, such as an irregular heart rhythm or kidney problems , will likely have to be monitored overnight in a hospital for a full knee replacement.

Days 1 to 6

If you’re not discharged on the first day, you may stay in the hospital overnight for one to three days.
You’ll begin physical therapy and start walking with assistance of a walker or crutches.
Pain management medication options are available.
Elevating your leg and icing your knee may help reduce pain and swelling.
If your surgeon uses waterproof dressing, you may be able to shower immediately; otherwise, post-op instructions may guide you to avoid showering for five to seven days.
You may receive instructions on changing or removing your surgical bandages.

Once at home, you’ll have to be on the lookout for infection, blood clots and partial knee stiffness, which are all risks of knee replacements. The most important aspect of recovery is physical therapy, which you do at an outpatient physical therapy center a few times per week.

“For a total knee replacement, most people are in formal physical therapy for three months,” Jerabek says. “For partial knees, you bounce back faster – probably around twice as fast as a total knee replacement – because we’ve removed less bone and kept all of the ligaments, and we didn’t have to dislocate the tibia from underneath the femur.”

Weeks 2 to 4

Depending on individual factors, by weeks 2 to 3, many patients are able to walk without the support of a walker or cane.
Continue regular physical therapy.
Though you can begin showering now, avoid taking baths or soaking the incision site, as this could lead to infection.
By week 4, many patients are cleared to drive after surgery, especially if your left leg was operated on.

Weeks 6 to 12

Continuing physical therapy for up to three months following a total knee replacement may be beneficial, according to the American Association of Hip and Knee Surgeons. However, this will depend on your condition before surgery, recovery progress and overall health.
You’ll begin to incorporate more normal activities to your routine, like walking. Strenuous or physically demanding activities that impact the knee should still be avoided.
You’ll notice decreased pain and swelling as time goes on.

Months 3 to 6

After three months, you’re likely able to return to most activities.
If full range of motion hasn’t returned, your surgeon may recommend continuing physical therapy.

Months 6 to 12

Most patients take from six months up to a full year to make a complete recovery.

How to Prepare for Knee Replacement Recovery

Advanced planning and surgery prep will go a long way to help ease the challenges in the weeks following your surgery.

Prepare your home

Before you go in for your procedure, prepare your home for recovery and gather some necessary items to have on hand:

Get supportive equipment. Purchase or install supportive equipment, such as a walker, safety bar in the shower or raised toilet seat.
Consider cold therapy. Have plenty of ice packs on hand in the freezer. If you’re able to, get a cold therapy machine, an optional recovery device that circulates water through an ice reservoir and makes it simpler to ice your knee after surgery. This helps reduce swelling and inflammation to help speed up recovery.
Prepare meals. Prepare and freeze meals in advance to avoid spending too much time on your feet or moving about the kitchen. If you're looking for inspiration, the Mediterranean diet , DASH diet and flexitarian diet are the top eating approaches for bone and joint health, according to U.S. News's Best Diets for Bone and Joint Health .
Arrange home for easier, safer access. Set up a bed and living space on the first floor of your home, as stairs may be challenging or restricted in the first few days of recovery.
Remove rugs. Remove loose rugs or other items that could cause disruptions or tripping hazards when trying to move around.

Gather a support system

Once at home after surgery, you’ll likely need someone who can help take care of you for a few days or more and assist with medications, bandage changes and food preparation.

If you do not have a friend or loved one nearby to help out, plan ahead to ensure you have the necessary assistance and resources during your recovery.

Ask your surgeon’s office for suggested available resources to you, and consider the following:

Home health services, like a nurse or home health aide to assist with daily activities
Transportation services to and from the hospital and follow-up appointments
Meal delivery services, including local community programs
In-home or virtual physical therapy options, if getting to outpatient therapy is a challenge
Telehealth options for follow-up visits with your surgeon

Long-Term Risks and Recovery

There will always be a small risk, around 1% per year, that the new parts fail for a variety of reasons, such as loosening, stiffness, instability or infection. Therefore, it’s important to do everything you can to maximize the replacement, such as keeping up with exercises to strengthen the muscles that support the knee joint and maintain motion and avoiding putting too much pressure on the knee.

“Focus on lower impact exercises like cycling, swimming or using an elliptical machine ,” Sassoon says. “You can do more with a partial knee replacement. I don’t think I’d go back to training for a marathon or sports that require a lot of jumping, but things like tennis are OK, as long as you stick to doubles with less court to cover or play on grass or clay.”

Ultimately, it’s important to enjoy being active – whatever that looks like for you.

“You can get back to doing things for the first time in a while without pain. I call it the ‘second first time.’ Maybe it’s skiing or surfing, or just walking through your house or a store,” Sassoon says. “You’ll value the feeling of function without pain.”

Once you’re back to your regular activities, you should be able to get 15 to 20 years of use from a partial knee replacement, and up to 30 years for a full knee replacement.

The U.S. News Health team delivers accurate information about health, nutrition and fitness, as well as in-depth medical condition guides. All of our stories rely on multiple, independent sources and experts in the field, such as medical doctors and licensed nutritionists. To learn more about how we keep our content accurate and trustworthy, read our editorial guidelines .

Jerabek is a hip and knee surgeon at Hospital for Special Surgery in Manhattan.

Sassoon is a hip and knee surgeon at UCLA Health.

Tags: health , patients , patient advice , surgery , knee replacement , bone joint health , osteoarthritis , arthritis

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How Much Does it Cost to Spay a Dog?

S pay surgery is the common name for the sterilization of a female dog. For pet parents, this is an important part of a dog’s overall wellness plan.

While spaying your dog helps control the pet population — which is hugely important — the procedure also comes with health benefits for your dog. For example, spayed dogs have a lower risk of developing cancer and uterus infections.

Read on to learn about veterinary clinic options for spaying your dog, including average costs, factors that might increase cost, what’s included in the surgery and how to find the best price for a spay surgery without compromising quality.

What’s the average cost to spay a dog, what’s included in the cost of spaying your dog, how to save on your dog’s spay surgery.

Benefits of spaying your dog

Disadvantages of spaying your dog

How much does it cost to spay a dog faqs.

The average cost to spay a dog varies depending on where you choose to have the procedure done. You may be able to get your dog spayed for free, or you may pay more than $500. You should consider these costs as you budget for a new dog , as well as any dogs you currently have that are not yet sterilized.

Average cost to spay a dog

What’s included in the cost of spaying your dog can vary depending on the facility that performs the spay surgery. Generally, the price includes anesthetic to reduce discomfort during the procedure. However, you should confirm this with the vet’s office beforehand.

Other services, some of which may be optional, may be free of charge — or they may add to the cost of your service. Be sure to ask your vet about the following:

Blood work – The veterinarian may require blood work to determine your dog’s overall health before the surgery.
Vaccines – If your dog is not vaccinated, the shelter may require a rabies and DA2PP vaccine. (DA2PP covers distemper virus, parvovirus, canine adenovirus types one and two and parainfluenza virus.) You may be charged extra for this service.
Pain medication – The cost of spay surgery may cover pain medication for up to three days.
E-collar – Many vets send newly operated dogs home with an appropriately sized Elizabethan collar, or e-collar. This cone-shaped device helps prevent the dog from licking, scratching or biting the surgical incision.
Sterilization tattoo – During surgery, it’s common for vets to tattoo a small green line near the incision site to indicate the dog has been sterilized. This practice, which helps avoid unnecessary second surgeries, is recommended by the Association of Shelter Veterinarians’ Veterinary Medical Care Guidelines for Spay-Neuter Programs.
Microchip – Spay-neuter assistance programs sometimes offer to microchip your dog during surgery.
Nail trim – Some veterinarians may trim your dog’s nails during the surgery.
Flea treatment – Flea treatment might be administered to your dog. This is more common at low-cost spay and neuter clinics, shelters and nonprofit organizations, but it could also be provided at any veterinary facility.

Factors that may affect the cost of spaying a dog

The cost of spay surgery can vary based on standard factors like pet health, breed and age.

Size and weight – Spaying costs for bigger dogs are typically higher because these dogs require more from the service, such as additional anesthesia, sutures and pain medications.
Age – Some clinics offer lower-cost spay and neuter services to young dogs. Other clinics may charge more for an older dog with health complications.
Breed – Dogs with short snouts, such as English bulldogs and pugs, may be considered high-risk. Certain dog breeds may require an additional charge for closer monitoring and extra medical care.
Your location – Veterinary service pricing varies across the U.S. due to operational expenses, as well as state and local taxes.

Why spaying costs more than neutering

Spaying is a more invasive surgery than neutering, and therefore costs slightly more. Spaying is the common name for an ovariohysterectomy, which in this case refers to the surgical procedure to remove the reproductive organs of a female dog. The surgery usually lasts between 20 and 90 minutes and requires that the dog be under general anesthesia and intubated with a breathing tube.

Neutering, or castration, is the removal of the male dog’s testes. Like spaying, it requires general anesthesia and intubation. However, the procedure is shorter, typically lasting between two and 20 minutes, making neutering costs slightly lower than spaying.

In a spay surgery, an incision is made below the dog’s belly button in order to remove the ovaries and uterus. (Some vets perform an ovariectomy instead, in which only the ovaries are removed.) During a neutering procedure, the testicles are removed through an incision at the base of the penis near the scrotum. Large breed dogs may also have their scrotum removed.

At the end of both surgeries, the incision is stitched up under the skin, often followed by additional stitches, skin staples or glue to close the skin. Vets typically provide pain medications after either sterilization surgery.

Additional factors that could increase the cost of spaying your dog

When booking an appointment to spay your dog, be sure to ask the veterinarian about all costs involved in the procedure. The following are some of the additional expenses you may incur:

Booking deposit – Some veterinary clinics require an upfront deposit. Be sure to find out if this charge is deducted from the overall surgery cost.
Biohazard disposal fee – This fee is often included in the surgery cost; however, if it isn’t, it typically averages around $2.50 per dog.
E-collar – A cone-like collar that helps prevent your dog from reaching the incision site may or may not be included in the surgery cost.
Vaccinations – Spay surgery typically requires a rabies vaccine. If your dog isn’t already vaccinated, the vet may administer the vaccine and include the cost in your bill.
Pre-existing medical conditions – Additional monitoring fees might be applied if your dog has a medical condition that could complicate the procedure, such as diabetes or asthma.
Estrus – Dogs in heat (also called estrus or estrous) can be spayed with little additional risk to the dog’s health. However, the procedure may take longer due to increased blood flow to the reproductive organs, which increases the overall cost.
Pregnancy – Pregnant dogs can be spayed, even if the dog is already carrying embryos. During the procedure, the reproductive organs and embryos will be removed, effectively terminating the pregnancy and sterilizing the dog. However, this process will cost more compared to a standard spay.
Obesity – Spaying or neutering an overweight pet presents certain risks, and the procedure may take longer. Clinics typically charge an extra fee for spaying overweight dogs.
Late pick-up – There might be an additional fee if you’re delayed in picking up your dog after surgery, especially if the clinic closes and has to board your dog overnight.

There are ways to save on your dog’s spay surgery that don’t compromise the quality of service. Consider the following options:

Check your local animal shelter – Find out if a local animal shelter offers free or low-cost options.
Search low-cost clinics – You can browse the internet for low-cost clinics in your area or search for a clinic using a referral network, such as Pet Help Finder or SpayUSA.
Look for a local Spay-A-Thon – Animal welfare organizations, including the American Society for the Prevention of Cruelty to Animals (ASPCA) and the Humane Society, organize free or low-cost mass spay and neuter events. Check your local organization’s website or social media channels for possible dates.
Apply for financial aid – Organizations like Best Friends, Pet Lifeline and Friends of Animals offer funding help.
Check veterinary colleges – Some veterinary colleges offer low-cost veterinary care. You can find listings by state via the American Veterinary Medical Association (AVMA).
Apply for a payment plan – Veterinary service payment plans, such as VetBilling, allow pet owners to pay for services over time, rather than upfront.
Start a crowdfunding campaign – You can use any crowdfunding platform to raise funds, or try a pet-specific platform such as Waggle, which directs all funds raised to your veterinarian.

Does pet insurance cover the cost of spaying?

Pet insurance typically does not cover the cost of spaying or neutering. However, the best pet insurance companies offer a preventative care rider, through which you can be reimbursed for the cost. Additionally, some wellness riders can reimburse you up to $150.

Benefits of spaying Your dog

The benefits of spaying your dog are plenty. Not only will you be helping control pet overpopulation, but also setting your dog up for a healthier, happier life.

Benefits of spaying your dog include:

Lower risk of cancer – Sterilized dogs, whether male or female, are at a lower risk for developing cancer, according to a Merck Veterinary Manual study. In female dogs, for example, the more heat cycles she experiences before being spayed, the higher her risk of mammary tumors in the future. Male dogs have a lower risk of testicular cancer if neutered.
No side effects of heat cycle – During heat, which occurs about every eight months, female dogs experience a bloody, sometimes odorous vaginal discharge. They also often exhibit nervous behavior, including howling and increased urination.
Avoid pyometra, a life-threatening condition – Older, unspayed dogs are most susceptible to uterine infections such as pyometra. Symptoms include poor appetite, vomiting, lethargy and increased thirst or urination. Studies show that one in four unspayed dogs that reach 10 years old will develop pyometra.
Reduce hormone-driven behavior – Some dogs become less aggressive and exhibit more consistently calm behavior after spaying due to the decrease in hormones, whether testosterone or estrogen.
A longer life – Spaying your dog may increase her lifespan. Studies show that, on average, sterilized dogs live almost two years longer than intact dogs.

Breeding organizations and affiliated websites occasionally highlight the disadvantages of spaying dogs. However, reputable studies demonstrate that the risks associated with spaying your dog are actually minimal.

Veterinarians widely agree that the only negative change in spayed dogs is a reduced metabolism. However, this can be managed by maintaining healthy eating habits, such as feeding them the best dog food with no more than a 12-hour interval between each meal and opting for nutritious treats like fruits and vegetables .

Can you spay a pregnant dog?

How long does it take to spay a dog, when can you spay a dog, how long do you have to wait to spay a dog after heat, what is the difference between spay and neuter a dog, summary of money’s how much does it cost to spay a dog.

The cost to spay a dog varies depending on your chosen veterinary facility. At a private veterinary practice, the cost ranges from $145 to $700. You may be able to spay your dog for free through a nonprofit organization or find a reduced price — somewhere between $55 and $475 — at a low-cost spay/neuter clinic. Cost may also be affected by your dog’s size, age, breed, pre-existing health issues and your geographical location.

Spaying your dog is an important part of pet ownership. It’s a way to help control the pet population, and it also carries a plethora of benefits for your dog, including lowering their risk of health problems and extending their lifespan.

This article originally appeared on Money.com and may contain affiliate links for which Money receives compensation. Opinions expressed in this article are the author's alone, not those of a third-party entity, and have not been reviewed, approved, or otherwise endorsed. Offers may be subject to change without notice. For more information, read Money’s full disclaimer .

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Preparing for Gender Affirmation Surgery: Ask the Experts

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

Can I still have children after gender affirmation surgery?

Are there other ways I need to prepare?

An initial intake interview via phone with a clinical specialist.

An appointment with your surgeon.

A preoperative anesthesia and medical evaluation.

What can I expect after gender affirming surgery?

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

Find a Doctor

Find a Treatment Center

Request an Appointment

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An appointment with your surgeon. 

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