Sex Reassignment Surgery Questions and Answers

Preparation and Procedures Involved in Gender Reassignment Surgery

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Answers to questions about sex reassignment surgery. Fuse / Getty Images

If you or a loved one are considering sex reassignment surgery, you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Sex Reassignment Surgery (SRS)

Sex reassignment surgery (SRS), also known as gender reassignment surgery (GRS), is a means of transitioning to a different gender through surgical alteration of the body.

This transition is also known as transsexualism.

Men who are transitioning to female are known as male-to-female (MTF) transsexual, transsexual female, and trans female or woman.

Women who are transitioning to male are known as female-to-male (FTM) transsexual, transsexual male, and trans male or man.

The Difference Between "Transgender" and "Transsexual"

“Transgender” refers to individuals who identify with a gender identity that differs from that usually associated with their sex at birth. The gender assigned is usually based on the appearance of the external genitalia. Transgender people may or may not have undergone sex reassignment surgery. Transgenderism has been recorded since ancient times.

“Transsexual” refers to individuals who have undergone surgery to change the appearance of their birth genitalia to that opposite of their biological sex.

Reasons Why a Person Undergoes Sex Reassignment Surgery

Many transgender people express discomfort with their biological sex and its associated gender role.

The American Psychiatric Association (APA) has identified this as gender identity disorder (GID). GID may cause people to experience major upset and impairment on social and personal levels.

For these individuals, gender role changing, hormone therapy, and sex reassignment surgery permit their outside appearance to match what they feel internally.

Understanding Gender Identity Disorder (GID)

There are two essential criteria for gender identity disorder (GID):

  • A desire to escape the biological/assigned gender: This is demonstrated as a consistent aversion to a person's biological sex and its associated gender role.
  • A desire to be a member of the other sex: This is demonstrated as a consistent identification with the other gender.

Transitioning to Another Gender

“Transitioning" to another gender may involve:

  • Dressing and living as a different gender in order to adopt an identity associated with the opposite biological sex, without surgery.
  • Taking sex hormones and/or surgically removing or modifying genitals and reproductive organs in order to adopt an identity associated with the opposite biological sex.

Steps Required Before Sex Reassignment Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in a sex change operation, there are other steps which must be accomplished before surgery is performed. Necessary steps include:

  • A mental health evaluation: A mental health evaluation is required to look at reasons for the sex change and to rule out other concerns and psychological variables.
  • A diagnosis of gender identity disorder (GID): A health professional must make the diagnosis of gender identity disorder.
  • A "real life" test: The individual must take on the role of the desired sex in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Purpose of the Mental Health Evaluation

Anyone who is considering a sex change operation must undergo a mental health evaluation. Some people become upset with this necessity, but keep in mind that it is in place to make sure the surgery is not done for reasons other than gender identity disorder.

For example, some people who have suffered sexual abuse have wished to have a sex change operation, but other treatments (such as trauma therapy) would be safer and more effective. This example may seem fairly obvious, but there are other factors which may suggest that a sex change operation, at least at the current time, is not the best option.

There are three main objectives of a mental health evaluation:

  • To assess the individual’s mental state with regard to gender identity and make a diagnosis of GID.
  • To rule out psychiatric abnormalities that could influence an individual’s mental state, such as psychosis, intersex state, endocrine disorders, perversions, or addiction.
  • To evaluate the individual’s readiness for hormone therapy and sex reassignment surgery. Sex reassignment surgery can be grueling, not to speak of the mood imbalance related to hormone changes, so it's important to assess readiness to undergo these sometimes dramatic, though usually temporary, discomforts.

The Role of Hormone Therapy in Transitioning

For transgender individuals desiring sex reassignment surgery, hormone therapy (HT), also called hormone replacement therapy (HRT), involves taking estrogen for a male to female transition or testosterone for a female to male transition. Hormone therapy may be used before, during, and after the surgical transition to another gender.

The purpose of hormone therapy is to change the physical appearance into that of the desired gender.

The Effects of Testosterone on Females

When a biological female begins taking testosterone, changes include both a reduction in female sexual characteristics and an increase in male sexual characteristics.

Bodily changes include:

  • Beard and mustache growth.
  • Deepening of the voice.
  • Enlargement of the clitoris.
  • Increased growth of body hair.
  • Increased muscle mass and strength.
  • Increase in number of red blood cells.
  • Redistribution of fat from the breasts, hips, and thighs to the abdominal area.
  • Development of acne, similar to male puberty.
  • Baldness or localized hair loss, especially at the temples and crown of the head.
  • Atrophy of the uterus and ovaries, resulting in an inability to have children.

Behavioral changes include:

  • Aggression.
  • Increased sex drive.

The Effects of Estrogen on Males

When a biological male begins taking estrogen, changes include both a reduction in male sexual characteristics and an increase in female characteristics.

Changes to the body include:

  • Breast development.
  • Loss of erection.
  • Shrinkage of testicles.
  • Decreased acne.
  • Decreased facial and body hair.
  • Decreased muscle mass and strength.
  • Softer and smoother skin.
  • Slowing of balding.
  • Redistribution of fat from abdomen to the hips, thighs, and buttocks.

Behavioral changes include:

  • Decreased sex drive.
  • Mood swings.

When are the Effects of Hormone Therapy Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses although it may be several years before a person is satisfactorily transitioned. This is especially true of breast development.

How Long Does the Sex Reassignment Surgery Process Take?

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after the first mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Surgeries Involved in Transitioning From a Male to a Female

Most often, surgeries involved in sex reassignment surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures which may be considered are listed below.

Top surgery includes:

  • Breast augmentation.
  • Facial feminization.
  • Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
  • Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.
  • Jaw surgery: The jaw bone may be shaved down to become more feminine appearing.
  • Chin reduction: Female chin structure is often more delicate, so chin reduction may be performed.
  • Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.
  • Lips: A lift lip may be done.
  • Creation of female hairline.
  • Male pattern hair removal.
  • Reduction of Adam’s apple.
  • Voice change surgery.

Bottom surgery includes:

  • Removal of the penis (penectomy) and scrotum (orchiectomy).
  • Creation of a vagina and labia (feminizing genitoplasty).

What Surgeries are Involved in Transitioning from a Female to a Male?

As with male to female transitions, sex change surgery involves top surgery and bottom surgery.

Top surgery includes:

  • Subcutaneous mastectomy/breast reduction surgery.

Bottom surgery includes:

  • Removal of the uterus and ovaries.
  • Creation of a penis and scrotum (masculinizing genitoplasty).

Complications and Side Effects

SRS is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots (deep vein thrombosis and pulmonary emboli) for transgender women. There is also the potentially increased risk of breast cancer, and even without hormones we know that males can also develop breast cancer. Testosterone use in transgender men has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.

With surgery, there are surgical risks such as bleeding and infection, as well as the risk of anesthesia. Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.

How Much Does Sex Reassignment Surgery (SRS) Cost?

SRS can be prohibitively expensive for many transgendered individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. It is somewhat more expensive to transition from male to female than from female to male. Health insurance sometimes covers a portion of the expenses. Learn more about insurance coverage and the WPATH guidelines with regard to gender reassignment surgery.

Quality of Life After Sex Reassignment Surgery

Quality of life appears to improve after sex affirming surgery both for people who transition from female to male and those who transition from male to female. One 2017 study found that surgical satisfaction ranged from 94 percent to 100 percent. Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of SRS for those who feel it is their best choice.

Bottom Line on Sex Reassignment Surgery

Sex reassignment surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person clearly has a diagnosis of gender identity disorder. After this is complete, hormonal treatment is begun with testosterone for those transitioning from female to male and estrogen for those transitioning from male to female. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

SRS is costly, but a precise estimate is difficult due to many variables including possible complications and the number and extent of surgeries selected. Finding a surgeon who focuses on SRS alone and has performed many of these procedures is a plus.

For those who follow through with these preparation steps, hormone treatment, and surgeries, quality of life appears to be good, and many people state that they would undergo SRS again.


American Psychological Association. Transgender People, Gender Identity, and Gender Expression.

Colebunders, B., Brondel, S., D’Arpa, S., Hoebeke, P., and S. Monstrey. An Update on the Surgical Treatment for Transgender Patients. Sexual Medicine Reviews. 2017. 5(1):103-109.

Streed, C., Harfouch, O., Marvel, F., Blumenthal, R., Martin, S., and M. Mukherjee. Cardiovascular Disease Among Transgender Adults Receiving Hormone Therapy: A Narrative Review. Annals of Internal Medicine. 2017. 167(4):256-267.

van de Grift, T., Elaut, E., Cerwenka, S., Cohen-Kettenis, P., and B. Kreukels. Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study. Journal of Sex and Marital Therapy. 2017 May 4. (Epub ahead of print).