Transition and Gender Affirming Surgery

The woman symbol against a purple background and the man symbol against a blue background.

Transition is the process for trans individuals to express their internal gender identity outwardly through emotional, social, or medical means. Gender dysphoria is defined as strong negative feelings such as distress an individual experiences when their sex assigned at birth does not match their social and psychological identity.1 Keep in mind that there is a clear difference between transgender and gender dysphoria. Experiencing a misalignment between one’s sex assigned at birth and gender identity is being transgender. Transgender men are individuals who were assigned female at birth but psychologically and socially identify as men. Transgender women are people who were assigned male at birth but feel as if their psychological and socially identify as women. To reiterate, the mismatch between one’s sex assigned at birth and internal identity is not a mental disorder. However, if the severe distress caused by this misalignment becomes disruptive to one’s everyday life and extends for over six months, it is classified as a psychiatric condition called gender dysphoria.

Oftentimes, these feelings become so severe that gender-dysphoric individuals choose to seek various kinds of medical and psychological treatments. Some transgender people elect to see a therapist in order to gain coping skills to alleviate the stress, depression, and anxiety they feel about their gender dysphoria. Others visit their physician in order to discuss hormonal treatments and surgical procedures. These medical interventions are in place to help a transgender person best resemble their identified gender.1

The mismatch between an individual’s physical body and their internal gender identity is not a medical or psychiatric condition; however, if the feelings of stress, depression, and anxiety about this mismatch are so debilitating that they begin to interfere with one’s quality of life, these feelings must be addressed, diagnosed, and treated by a health professional. This distress, otherwise known as gender dysphoria, can cause a lot of impairment and difficulty in an individual’s life. However, it is important to note that gender dysphoria is separate from gender nonconformity and a lesbian or gay sexual orientation. Gender nonconformity refers to behavior that does not match gender norms or stereotypes. For example, the female gender norm may include dressing and acting in a feminine manner, whether that is wearing feminine clothes or behaving in a gentle, reserved manner. A young girl may violate this female gender norm by wearing more manly clothes and behaving in a rambunctious, loud way. This is an example of behavior that deviates from social standards. Being gender nonconforming is not considered a mental disorder, it is simply behaving in a way that is different from social expectations.1

Gender Dysphoria

Gender dysphoria is defined as the discomfort someone feels due to the conflict between their biological and identified gender. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) released by the American Psychiatric Association (APA), in order for someone to be officially diagnosed with gender dysphoria, there must be (1) a difference between the way the individual expresses their gender and the gender that other people would assign to them, (2) a persistence of these feelings for at least six months, and (3) significant impairment to one’s ability to function in a social, occupational, or academic setting.1

A significant reason as to why gender dysphoria is included in DSM-5 is to provide transgender people access to treatment and health insurance. Being sensitive about word choice is also important in many medical settings in relation to those with gender dysphoria. Oftentimes, many transgender people feel as if there is something wrong with them; therefore, the APA decided that dysphoria was a more suitable term than disorder. Overall, the distress because of a mismatch between a person’s biological and identified gender is a feeling that almost 1 million Americans experience. There are many medical, psychological, social, and legal actions one can take in order to alleviate their gender dysphoria.2

Psychological and Counseling Services

Many gender-dysphoric people opt for psychotherapy in order to treat the distress they feel because of the conflict between their biological and identified gender. The purpose of these psychological and counseling services is not to convince a person that they should identify as their biological gender, but rather to provide some relief to the stress, depression, and anxiety the transgender person may experience.3

The first step of psychotherapy is for a mental health professional to diagnose a gender dysphoric individual. This is a very important component of seeking psychological and counseling services due to the fact that it gives a transgender person an official diagnosis from a health professional. This diagnosis not only helps the clinical psychologist identify the kinds of treatment plans they would like to take but also provides the gender dysphoric person with access to care and health insurance options.3

Depending on the types of feelings the transgender person has because of the mismatch between their biological and identified gender, a therapist can provide counseling in many different ways. If stress and anxiety are some of these emotions, a therapist may try to introduce coping mechanisms such as breathing exercises, guided imagery, and meditation. If depression is included in these feelings, a psychologist may try positive thinking activities, reframing, as well as self-efficacy measures.3

Another alternative or supplement to cognitive behavioral psychotherapy is medication. Feelings of stress and anxiety can be alleviated with selective serotonin reuptake inhibitors (SSRIs), anxiolytics, sedatives, and nerve-pain medications. Depressive symptoms can be treated with antidepressants and antipsychotic medications.3 Overall, there are many benefits for gender dysphoric people in seeking psychological and counseling services.

Social Transitions

A whiteboard that has multicolored writing that says "hello my pronouns are __/__.

A significant component of a transgender person’s distress is the misalignment between the way they identify their own gender identity and the way others identify their gender identity. For example, an individual who is biologically male but identifies as female is continuously referred to as “she” or “her” when they prefer to be called “he” or “him.” This social conflict may exacerbate their distress with their gender identity.4

There are many ways in which an individual interacts with their social environment, whether that is through their name, pronouns, clothing, hairstyle, makeup, hobbies, activities, interests, and even the ways they decorate their living spaces.4

Transgender men may manage the distress they feel about their gender identity by binding their chests, cutting their hair, wearing more masculine-style clothes, changing their names, participating in more masculine activities, and asking the people around them to refer to them as “he” or “him.”

On the other side of the spectrum, transgender women may alleviate their distress with their gender identity by padding their chests, putting on wigs, wearing more feminine-style clothes, changing their names, participating in more feminine activities, and asking the people around them to refer to them as “she” or “her.” Ultimately, there are numerous ways an individual may change their social environment in order to alleviate the distress they feel from their gender dysphoria.

Legal Documentations

Many gender dysphoric people choose to alleviate their distress by legally changing their names. This process varies based on the state. Usually, however, the process of filing a Petition to Change of Name may take several months. After filing this petition, one must get a court date and then follow the necessary steps so that the court can approve their request. Afterward, one will receive a court order or a decree for changing their name. The length and specific steps of this process may depend on which state one lives in.5

All states in the United States allow the gender marker on a driver’s license to be changed, however, there are different requirements for this process depending on the state. Changing the gender marker on a driver’s license is usually easier to do than changing the gender marker on a birth certificate. Additionally, some states require gender affirming surgery to be conducted before an individual is allowed to change the gender marker on their birth certificate.

Hormone Therapy

Aside from psychological, social, and legal actions, a transgender person may also seek hormone therapy as a part of their transitioning process. Testosterone is administered to transgender men in order to suppress feminine characteristics and induce masculine traits. On the other side of the spectrum, estrogen is administered to transgender women in order to suppress masculine characteristics and induce feminine traits. But there are many medical precautions a physician must take before they choose to perform hormone therapy on any given patient. For example, the patient must have solid cardiovascular and bone health before they proceed with any hormone therapy, due to the fact that this medical intervention may have many negative side effects. Doctors also take the time to monitor their patients throughout the process of undergoing cross-sex hormone therapy.6

Many transgender men have differing ideas for what their desired outcomes are. For example, some transgender men only want to suppress their feminine characteristics, while other transgender men want to both suppress their feminine characteristics and induce masculine traits. A physician may tailor the length and type of hormone therapy they administer based on their patient’s needs, wants, and health history.6

After several months of testosterone therapy, many transgender men report experiencing increased facial and body hair, increased amounts of acne, increased dryness in the skin, increased muscle mass, increased libido, deepening in the voice, increased clitoral size, in addition to other changes in the vaginal area.6

Similar to transgender men, transgender women have differing ideas for what their desired outcomes are and either want to only suppress their masculine traits or want to both suppress their masculine characteristics and induce feminine traits. A tailor-made combination of drugs can be unique to each patient.7 Following several months of estrogen therapy, many transgender women report experiencing increased breast growth, increased body fat, decreased facial and body hair, decreased penis size, and decreased erectile function. Some transgender women who choose to undergo estrogen therapy may also elect to pair it with anti-androgen therapy.

According to many longitudinal studies, hormone therapy appears to have a positive effect on individuals with gender dysphoria. Some physiological evidence has demonstrated that cortisol and stress levels have been significantly lower after a transgender person starts on hormone therapy.7

Surgical Procedures

On top of psychological, social, legal, and hormonal actions, a transgender person can also choose to undergo surgical procedures in order to better resemble their identified gender. These surgical procedures involve removing breast tissue (mastectomy), removing the penis (penectomy), removing the testicles (orchiectomy), constructing a vagina (vaginoplasty), enlarging the clitoris (metoidioplasty), and constructing a penis (phalloplasty).


A topless person sitting on the edge of a bathtub. The person has gauzes covering their chest.

A mastectomy is performed for a variety of reasons, some medical and others cosmetic. Medical reasons for a mastectomy include breast cancer. Sometimes, the breast tissue in a female’s body becomes cancerous, so physicians obtain patient consent in order to remove the tissue and preserve the patient’s health. Other times, however, there are elective, cosmetic reasons for a mastectomy. Transgender men, for example, may decide that they want to remove unwanted breast tissue in order to create a more masculine appearance in their chest area. A more informal title for a mastectomy is “top surgery.”8

Surgeons utilize many different types of techniques in order to perform a mastectomy. The most common technique is a bilateral mastectomy with free nipple grafts, which enables a surgeon to remove all breast tissue, including milk ducts and excess skin to implement appropriate placement and reduction of the nipples.8

Another technique is called the keyhole technique, which involves removing the breast tissue through a small incision around the nipple; however, this technique is only suitable for patients that have slimmer, smaller frames.8

The mastectomy is a common procedure transgender men choose in order to best resemble their identified gender. It is also one of the first procedures some transgender men elect to have.8


People have penectomies, or amputations of the penis, for a variety of reasons. For example, some may choose to remove all or a section of their penis for medical reasons, such as penile cancer. Furthermore, complications with circumcision may require a partial penectomy.

However, transgender women usually do not remove the entire penis. This is due to the fact that the glans of the penis must be preserved so that it can be formed into an artificial clitoris. The skin around the shaft of the penis is also kept in order to be shaped into a vagina.9


The orchiectomy is a surgical procedure that some transgender women choose to have in order to remove their testicles. There are different types of orchiectomies: simple, subcapsular, and inguinal.

Usually, transgender women have simple orchiectomy, which is an easy procedure that can usually be completed in approximately thirty minutes. This procedure involves the removal of the testicle and a short segment of the spermatic cord through an incision in the wall of the scrotum.

The subcapsular, or radical orchiectomy is primarily given to prostate cancer patients and is also a procedure that only takes thirty minutes. This procedure is composed of the removal of the section of the testicles that produces testosterone through an incision in the wall of the scrotum. Following this procedure, the scrotum will appear smaller than it previously was.

The inguinal orchiectomy is only given to testicular cancer patients when the physician does not want the cancer cells to spread to the rest of the body. The procedure involves removing one or both testicles and the entire spermatic cord through an incision in the lower lateral abdomen.10


A vaginoplasty is a surgical procedure that involves the construction of a vagina. It is considered a type of gender affirming surgery. The surgical techniques employed throughout this surgery include inverting the penile skin in order to increase depth, using sections of the large intestine and small intestine to form an artificial vagina, adding skin flaps from the scrotum, or even skin grafts from other parts of the body. These tissues are used in order to construct a vagina.11


Metoidioplasty is a type of surgical procedure that uses a transgender patient’s existing genital tissue in order to create a new penis or rather an enlarged clitoris. Anyone with significant clitoral growth from testosterone hormone therapy is suitable for this surgery.12


A phalloplasty is a procedure that involves the construction of a penis. It is different from a metoidioplasty due to the fact that it requires an implanted erectile prosthesis so that the transgender patient can acquire an erection. Some erectile prostheses include a malleable rod-shaped medical device that can allow the artificial penis to stand up or hang down, emulating a natural penis.13

Concluding Remarks

A person in a white coat with a stethoscope on their neck. The person is wearing gloves.

Some transgender people pair certain surgeries together. For example, a transgender man may undergo a mastectomy to remove their breasts and a metoidioplasty to enlarge their clitoris. A transgender woman may undergo a penectomy to remove their penis, an orchiectomy to remove their testicles, and a vaginoplasty to construct a vagina.

On the other hand, some other transgender people may refrain from undergoing surgery due to the fact that they do not have a desire to alter their bodies permanently. They may feel most comfortable simply by undergoing psychotherapy, adjusting their social environment, wearing the clothing of their identified gender, and legally changing their name and gender marker. All in all, every transgender person is different, and they may or may not choose to have surgery depending on their personal preferences. They may implement a variety of different techniques in their life, be it psychological, social, legal, hormonal, or surgical in order to experience the utmost health and happiness.


  1. Parekh, Ranna. “What Is Gender dysphoria?” What Is Gender dysphoria?, American Psychiatric Association, Feb. 2016. 27 Date Accessed: Apr. 2018.
  2. Meerwijk, Esther L., and Jae M. Sevelius. “Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples.” American Journal of Public Health, American Public Health Association, Feb. 2017 Date Accessed: 27 Apr. 2018.
  3. “Dysphoria.” Therapy Blog, 18 Apr. 2016 Date Accessed: 27 Apr. 2018.
  4. “Social Affirmation and Transition.” Transgender Health Information Program Date Accessed: 27 Apr. 2018.
  5. “File a Petition to Change Your Name.” California Courts – The Judicial Branch of California Date Accessed: 27 Apr. 2018.
  6. Deutsch, Maddie. “Information on Estrogen Hormone Therapy.” UCSF Transgender Care Date Accessed: 27 Apr. 2018.
  7. Unger, Cécile A. “Hormone Therapy for Transgender Patients.” Translational Andrology and Urology, AME Publishing Company, Dec. 2016 Date Accessed: 27 Apr. 2018.
  8. “Mastectomy.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 1 Feb. 2018 Date Accessed: 27 Apr. 2018.
  9. “Total Penectomy.” Orchid Cancer Date Accessed: 27 Apr. 2018.
  10. “Radical Orchiectomy.” Johns Hopkins Medicine Health Library Date Accessed: 27 Apr. 2018.
  11. Tannan, Shruti, et al. “Vaginoplasty | Vaginal Rejuvenation.” American Society of Plastic Surgeons Date Accessed: 27 Apr. 2018.
  12. “Metoidioplasty – List of Surgeons in the USA.” Trans Health Care Date Accessed: 27 Apr. 2018.
  13. “Phalloplasty – List of Surgeons in the USA.” Trans Health Care Date Accessed: 27 Apr. 2018.

Last Updated: 27 April 2018.