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To celebrate Pride, we’re elevating stories of strength, truth, and transformation from LGBTQIA+ influencers, activists, and community members, plus highlighting leaders in the field of gender confirmation surgery and hormone replacement therapy.
Across the country, there’s greater visibility of the transgender community than ever before—but that comes alongside alarmingly high rates of violence perpetrated against trans men and women, especially those of color. Society has a long way to go in terms of creating a safe, accepting environment, but there are rays of hope: growing destigmatization of gender dysphoria is leading more young people than ever to report transgender identity, and thanks to more comprehensive insurance, Medicaid, and Medicare coverage, gender confirmation surgeries are on the rise.
Whether you’re looking into procedures or educating yourself in order to become a better ally, here are seven important things to know about gender confirmation surgery—according to three leading surgeons in the field.
Gender confirmation surgery is not a “sex change” operation.
Sex change is an offensive, outdated, and inaccurate term to use when discussing any of the surgical procedures performed in the transition process, since one’s sex isn’t changing but, rather, aligning physically and anatomically with the gender they know themselves to be. Today, the preferred term is either gender confirmation surgery or sex reassignment surgery—and it encompasses much more than vaginoplasty or phalloplasty.
“People have historically thought of gender transition as predominantly being genital surgery; they don’t realize the amount of work that goes into restoring hairlines, altering facial features to appear either less masculine or more masculine or, conversely, more feminine or less feminine, dealing with hormone regulation and endocrinologists, et cetera,” says Dr. Jordan Deschamps-Braly, a board-certified plastic surgeon in San Francisco, who adds that this is “only in the context of people who want to affect a visual change.” Many transgender people choose not to, or cannot afford to, undergo gender confirmation surgeries.
Facial gender confirmation surgery is more common than genital surgery.
The doctors interviewed all agree: for the vast majority of people undergoing gender confirmation, facial surgery has the biggest impact on their quality of life. “A lot of people are living and dressing according to the gender they’ve always identified with long before they go down the road of looking at some of these body surgeries that they may or may not, ultimately, go through with,” says Dr. Deschamps-Braly. “If you’ve got a face that’s not really conforming to your gender or your dress, it can be very cognitively jarring to somebody who sees it, say, on the street or at the coffee shop.” When a stranger has a noticeable reaction to a trans person and stumbles over whether to call them “miss” or “sir,” it makes it hard for them to comfortably go about their day-to-day lives.
“Your face is how you interact with the world. It lets other people see your emotions and figure out quickly if you’re young, old, attractive, healthy. So you want your face to correctly convey who you are and your inner sense of self and external self to be consistent,” says Dr. Jeffrey Spiegel, a board-certified plastic surgeon in Newton, Massachusetts. For that reason, he says, facial surgery is usually always the first surgical step—and, in many cases, the last. “Once they have consistency between what they look like and how they identify, most of the stress goes away.”
Dr. Deschamps-Braly adds, “A lot of people, at least in my experience, don’t even get the bottom surgery and don’t have a lot of dysphoria around their genitals.”
Testosterone hormone therapy is much more powerful than estrogen therapy.
“Hormones do a very good job at making you look masculine,” says Dr. Spiegel. “With testosterone, you get facial hair, your skin gets rougher, your cheeks get flatter… so facial masculinization surgery is not as necessary.”
Not only are masculinization procedures requested far less often than feminization ones, but they’re also more difficult to perform. “Facial masculinization is all about adding volume—to the jaw, the chin, the forehead—whereas feminization procedures tend to be more subtractive,” says Dr. Praful Ramineni, a board-certified plastic surgeon in Washington, D.C., who estimates he does 300 total transitory surgeries per year. “You make the chin smaller, the nose smaller, the brow bone smaller… It’s always easier to take away than to add. You’re not as concerned about implants and prosthetics.”
A common misconception about facial feminization, says Dr. Deschamps-Braly, is that patients must wait around for a year or two before getting surgery in order to let the estrogen do its work. “Estrogen literally does nothing for the bones.”
Cisgender people undergo gender confirmation surgeries too.
“Gender confirmation surgeries are not exclusively for transgender people,” says Dr. Spiegel. Anytime someone doesn’t feel their gender is being accurately represented by their face or body and gets surgery to help correct the issue, that can be considered gender confirmation. “We do facial masculinization surgery for cisgender men who feel they look too feminine and say, ‘I really want a strong, angular look.’”
Dr. Deschamps-Braly doesn’t limit the definition to only include trans patients either and estimates he operates on a dozen to two dozen cisgender women per year. “You can be genetically female and have a very masculine forehead or masculine jawline, so gender confirmation surgery can be very important to people for lots of different reasons.”
You can get gender confirmation surgery at any age.
The doctors see patients who range in age from late teens to mid-70s—the “right” time is dependent on when the person has the financial and emotional stability required to begin the surgical journey. But of course, the younger a patient is, the more resilient their bones, muscle, and even hair follicles are. Dr. Deschamps-Braly says that a decade ago, his patients were exclusively 50+, but he thinks the average age is slowly getting younger, thanks to “public understanding that these operations are available and parents’ willingness to help support their children going through the process.”
There’s an extremely high satisfaction rate associated with gender confirmation procedures, and Dr. Ramineni attributes this to the fact that patients are typically more mature and “have been wanting this their whole life.” He says he’s “never had a patient say that they wish they didn’t do surgery or they want it undone.”
Related: 6 Nonbinary, Trans, and Gender Nonconforming Tastemakers Share Their Skin-Care Routines That Work
Insurance coverage policies for gender confirmation procedures vary greatly.
As Dr. Spiegel explains it, your employer decides which procedures they would like the insurance policy to cover. Some employers tend to be very generous with facial feminization/masculinization, whereas others will cover only vaginoplasty or phalloplasty. Then, if insurance does cover a procedure, it’s not a guarantee that you can see the doctor you want or even one who specializes in gender confirmation. “There is really no set answer,” he says.
No matter how generous the policy, Dr. Ramineni adds, breast augmentation and chest masculinization are rarely covered. “It’s a pretty big commitment, financially, to go through all three [facial, chest, and genital surgeries],” he says, which is why many people end up having to pick which is most important to them.
The average plastic surgeon doesn’t have the specialized skill set to perform gender confirmation procedures.
Just because a plastic surgeon regularly performs some of the same procedures done for gender confirmation on cis patients does not mean they know how to successfully apply those skills to trans patients.
“The techniques of facial feminization surgery are the most advanced types of facial surgery, which is why a facial feminization surgeon can fix anybody but a typical plastic surgeon couldn’t do facial feminization unless they were very familiar with these very different techniques,” says Dr. Spiegel.
The same goes for the body: “A lot of plastic surgeons think they can do the procedures exactly the same on transgender patients as they do on cis patients, but there are definitely differences with breast augmentation and, certainly, with vaginoplasties or genital surgery,” says Dr. Ramineni, noting that some doctors will prey on transgender patients who have “a lot of inherent societal discrimination against them already.”
Dr. Spiegel regularly sees patients who went to a local plastic surgeon for rhinoplasty, ended up with a nose that doesn’t fit their face, and now need a revision, which is always more difficult. But that’s hardly the worst outcome. Adam’s apple reduction, for example, is relatively quick and easy for a surgeon who specializes in it; in the wrong hands, “there is a very, very high risk of damaging the vocal cords—and once that happens, it’s incredibly hard to get the voice back to a semblance of what it used to be,” says Dr. Deschamps-Braly. It’s crucial to ask potential surgeons how many gender confirmations they perform each year and to make sure they have plenty of before-and-afters to look through.
Learn more about gender confirmation surgery procedures:
• Facial feminization surgery
• FTM chest masculinization surgery
• FTM phalloplasty
• MTF breast augmentation
• MTF vaginoplasty
