Gender Dysphoria And Surgery

Medically reviewed by Jennifer Richman on November 20, 2024.

What is Gender Dysphoria and Euphoria?

Gender dysphoria surgery is synonymous to gender affirming surgery or gender reassignment surgery. All of these terms refer to a group of surgeries that help align an individual’s body with their gender identity and sense of self. Gender affirming surgery can be completely lifechanging for individuals that experience feelings of gender dysphoria. 

Gender Dysphoria and Euphoria: Definitions and Overview

Gender dysphoria is a term that is commonly used when talking about how people can feel about their bodies. The DSM IV describes dysphoria as psychological distress that arises from the incongruence between one’s gender identity and sex assigned at birth. Dysphoria is not just a feeling that people may have towards their bodies, and can traverse into someone’s social and emotional lives. Note that not all transgender and nonbinary people experience gender dysphoria, and not everyone who undergoes gender affirming surgery does so to relieve dysphoria. Another term used to describe how one feels about their gendered body is gender euphoria. Gender dysphoria can often misleadingly imply that gender exploration requires negative feelings about one’s body. Gender euphoria alternatively describes the joy that someone experiences from embodying their desired gender presentation. When someone affirms their gender, either through medical or social transition, they may feel a sense of satisfaction and comfort. Medical transition is a deeply personal process, and it can be helpful to reflect on your feelings of dysphoria or euphoria.

Types of Surgeries Available:

There are many ways our patients alleviate gender dysphoria. For many, surgery is an option that helps many address the parts of their body that cause them heavy dysphoria. Top surgery cna help alleviate dysphoria surrounding one’s chest. They may feel physical and mental distress with having a chest that does not align with their desired gender identity and expression. Bottom surgeries similarly address feelings of dysphoria that patients feel with their genitalia. Facial surgeries alter jawline and facial structure to appear as it would after a testosterone or estrogen dominant puberty. For others, surgery is not needed to alleviate dysphoria. Some transgender and nonbinary people may feel that HRT or other forms of gender affirming care address their dysphoria, and do not wish to undergo surgery. Forms of medical transition are as diverse and reflect the large spectrum of gender expression and identity. 

Gender Dysphoria Diagnosis and Surgery

There have been and continues to be many barriers to gender affirming care. Many medical professionals practice forms of gatekeeping that prevents transgender people from accessing life saving care. At GCC, we do not believe in gatekeeping gender affirming care and follow the informed consent model when it comes to a patient’s eligibility for surgery. We trust that our patients understand what they need to feel euphoria in their bodies and can determine if they are ready to have surgery. However, insurance companies often have different requirements for providing coverage, and other surgical practices may require a gender dysphoria surgery

Insurance Requirements

Many insurance companies cover gender affirming care. While at the GCC, we do not require HRT for our gender affirming care, some insurance companies require a diagnosis of “gender dysphoria”. You do not need to experience gender dysphoria to enjoy the life changing effects of gender affirming surgery. If you opt for surgery at GCC, our insurance advocacy team will work with you to get insurance approval. A common requirement for many forms of gender affirming surgery is a letter from a mental health professional. If we are an out of network provider under your insurance, you may also need a referral letter. 

Preoperative Considerations

A common consideration made by individuals experiencing dysphoria is how they will feel in their new body post-operation. For the vast majority of transgender and nonbinary patients, the gender euphoria they experience after gender affirming surgery is life-changing. Besides considering feelings of gender dysphoria and euphoria, you can prepare for surgery by taking time off from work, setting up your recovery and making plans for travel.

Psychological Evaluation

Gender-Competent Mental Healthcare

Therapy can provide valuable support through transition such as letters of support for surgery. These letters are sometimes required by surgical practices and insurance companies. Per WPATH Soc 8 guidelines, we ask that first time bottom surgery patients provide a letter of support. We recognize that there can be many barriers to finding a gender-competent therapist. There are several resources that can help with this process, such as the list of World Professional Association for Transgender Health or search engines such as Psychology Today. 

Hormone Replacement Therapy

Hormone replacement therapy (HRT) is a tool used by transgender and nonbinary people, as well as cisgender people, to affirm their gender. HRT can involve using testosterone to achieve traditionally masculinizing effects, such as increased body hair or a lower voice. Other people use estrogen and progesterone to achieve feminizing effects, such as changes in fat distribution. 

HRT and Surgery

While we do not require HRT for surgery, some insurance plans may require a certain period of HRT for procedures such as bottom surgery. We advise you to be aware of how hormone therapy can have different effects on your procedure. Talking to your primary care provider or an endocrinologist can help you better understand these effects. For example, you may want to maximize your breast growth before having a breast augmentation. Regardless, our surgeons have performed gender-affirming surgery on several patients who did not undergo HRT. We encourage you to plan your goals with HRT separately from surgery. HRT is not necessarily a step to receive surgery, but can be a compliment to your medical transition.

HRT Timeline

Your timeline on hormone therapy will depend on your individual physiology and genetics, dosage, and duration. In general, there are no required timelines. However, if you are looking to maximize breast growth before an augmentation, a minimum of twelve months of feminizing hormones can facilitate this. Note that it is still very possible to undergo a breast augmentation without HRT. We also recommend not starting HRT immediately before surgery, as these changes may affect your mood before and after surgery. 

Types of Gender Affirming Surgeries

Top Surgery

What is Top Surgery?:

Top surgery refers to gender-affirming surgeries that give a patient a greater sense of congruence between the appearance of their chest and their gender identity. Some forms of top surgery will take away some or all volume to create a flatter chest, sometimes to “masculinize” the chest. This can be sought out to relieve feelings of chest movement dysphoria or euphoria with a flat chest presentation. Alternatively, many patients seek out techniques to add more volume to the chest. This may be done through a breast augmentation.

Breast Augmentation

There are many techniques for breast augmentation, and they mainly differ in material used in the implants. The most popular material is silicone or saline, which are occasionally accompanied by fat grafting. Breast size is measured in implant size, and we encourage using the rice bag test to get an understanding of how your breasts may look with your anatomy. Breast augmentation can relieve feelings of dysphoria many transfeminine and nonbinary patients may feel with a flatter chest. It can be euphoric to have a fuller chest that reflects your desired gender expression.

Chest Reconstruction

Chest reconstruction, or masculinizing top surgery techniques are frequently sought out by transgender and nonbinary people to relieve feelings of chest dysphoria. Techniques that remove volume and create a flat chest include double incision, periareolar and keyhole. Techniques that remove partial tissue, similar to a breast reduction such as buttonhole and inverted T anchor are also requested by patients. Some of these techniques, such as keyhole or buttonhole preserve nipple sensation, while those who receive nipple grafts may lose sensation. We encourage you to consider your goals around sensation and aesthetics when considering what technique is best for you.

Bottom Surgery

What is Bottom Surgery?:

Bottom surgery refers to procedures that reconstruct natal genital tissue to relieve bottom dysphoria. These procedures are often divided into “feminizing” and “masculinizing” techniques. We acknowledge that anatomy does not correspond to one’s gender identity or expression. For many, bottom surgery results elicit euphoria with how their body functions and looks.

Types of Procedures

Vaginoplasty and Vulvoplasty are procedures that many transfeminine and nonbinary patients who experience bottom dysphoria are interested in. A labia minora can also be created through a labiaplasty. Having a vagina and vulva and traditionally feminine anatomy can bring feelings of euphoria for transgender women. A vaginoplasty will create a vaginal canal whereas a vulvoplasty will not result in a vaginal canal. Individuals will sometimes choose to undergo this procedure if they are not interested in penetrative sex or vaginal dilation. Patients report still being able to experience orgasm through their clitoris.

Phalloplasty and Metoidioplasty are procedures that many transmasculine and nonbinary patients who experience bottom dysphoria opt for. There are two main techniques that create a phallus. Phalloplasty involves taking skin grafts from the forearm, groin or thigh, and using this skin to construct a phallus. This option is ideal for those who want to have more control over size. A metoidioplasty releases the natal erectile tissue, also known as a clitoris, from surrounding ligaments to appear more prominent as a penis. Generally, a metoidioplasty will have a shorter and less complicated recovery compared to phalloplasty.

Facial Feminization Surgery (FFS)

What is FFS?

Facial feminization surgery refers to a number of different procedures that alter facial structure. For many transfemmine and nonbinary patients, having “softer” features brings feelings of immense euphoria and relief from dysphoria. It can be a dysphoric experience to have experienced changes to the face from an incongruent puberty, and shifting these can be incredibly euphoric. 

Recovery and Aftercare

Post-Surgery Recovery Process

While everyone’s recovery looks different, you can expect to follow similar general recovery steps. You will need to take time off from work depending on how much bed rest is necessary. For example, we recommend taking one to two weeks off for procedures such as top surgery, but four to six weeks is best for bottom surgery recovery. Resting after surgery is vital to your recovery, and will facilitate your healing. Similarly, it helps to maintain a balanced and low sodium diet to give your body strength to heal and reduce inflammation. You will likely need to abstain from intensive exercise until about six weeks after surgery. After your incisions have healed, you may want to practice scar care with massage or silicone to change the coloration and texture of your scars. To get a better understanding of how your recovery could look, we recommend looking into recovery timelines associated with specific procedures. 

Support Systems

Surgery can have many complex emotions associated with it, ranging from euphoria to post-operative depression. It is completely normal to feel frustrated or stressed after surgery; you have undergone a massive change to your body. You may also feel restless and upset at not being able to return to your usual routine due to limitations on what you can do. Sometimes, patients can feel unsatisfied with the immediate result. It is vital to keep in mind that you may not be able to see the full results of surgery for a few months for many reasons including swelling and adjusting to a new body. It can be helpful to reach out to your support systems, such as a therapist or loved ones to discuss feelings around surgery and recovery. For the vast majority of patients, gender affirming surgery has a positive effect on their wellbeing and self image.

Risks and Complications

Staying mindful of potential risks and complications can help make your recovery more smooth, and can help you prepare mentally and physically. Some complications to be aware of around bottom surgery are urethral complications and issues with swelling and blood clotting. Patients undergoing top surgery should watch for seromas and hematomas, which occur from excessive fluid buildup. You will be sent home with drains which can help filter out fluid from the surgical site. Nipple complications can also occur with top surgery, and can range from nipple rejection to infections. With surgery, it is important to also monitor your incisions and grafts for signs of infection. 

There are many ways to help mitigate these risks and complications. Make sure you are seeking out care with an accredited and board certified surgeon with experience around gender affirming surgery. A surgical consultation is an important step that allows for you to discuss your medical history and how you can prepare for surgery. At GCC, our surgical consultations are free regardless of procedure. After your surgery, following your surgeons post-operative instructions closely will help in healing properly. You will likely also need to have a post-operative appointment, where your surgeon will look at your surgical site and monitor your healing and address complications. In general, abstaining from smoking and alcohol will lower your chance of experiencing complications, especially surrounding skin grafts. 

FAQ

Do I need a gender dysphoria diagnosis to have surgery?

At the GCC, we do not require a gender dysphoria diagnosis for surgery. For first time bottom surgery patients, we request letters of support from a mental health professional. For insurance purposes, you may need a referral letter or diagnosis from your primary care provider. This letter may contain a gender dysphoria diagnosis.

Do I need to undergo HRT prior to surgery?

We do not require HRT prior to surgery. For a breast augmentation, you may wish to maximize breast growth from estrogen, but this is not a requirement. We encourage patients to assess their wants and needs around surgery separately from whether they feel they will benefit from HRT. These forms of gender affirming care affect the body differently and may or may not align with your transition goals.

Do all transgender and nonbinary people have gender dysphoria?

Gender dysphoria does not make someone transgender. Some transgender people experience gender dysphoria, and can be a motivation to access gender-affirming care. Cisgender people and people who do not identify as transgender can also experience feelings of gender dysphoria. Some in the trans community feel that the term pathologizes gender expansive people. Gender euphoria may be preferable to some, as it highlights positive experiences of gender congruence. Dysphoria is simply a word that describes a feeling of discomfort in how their body is gendered.