How Transgender Surgery and Hormones Affect the Body

Bruce Jenner joins a number of transgender celebs who have been outspoken about their experiences. From left to right: Chaz Bono, Ian Harvie, Laverne Cox, Andreja Pejic, Bruce Jenner, Jeffrey Tambor (who portrays a transgender woman on the Amazon show “Transparent”), Alexis Arquette, and Jazz Jennings. (Photo: Getty Images; Everett Collection; graphic by Jared Harrell for Yahoo Health)

Gender confirmation, the preferred term among the transgender community for what is also known as “gender reassignment” or a “sex change,” is the process of transitioning from one gender to another. Gender confirmation is typically a preferred treatment when someone has gender dysphoria, a condition where there is a conflict between a person’s physical gender and the gender with which he or she identifies.

But the formal gender confirmation process doesn’t happen overnight. According to guidelines set by the World Professional Association for Transgender Health (WPATH), patients undergo several months of psychological therapy and may also use hormone therapy to block the sex hormones naturally produced by their bodies and introduce new hormones of their preferred gender. Once they have undergone the required amount of therapy and their doctor has decided they meet the right requirements, they’re able to get a note that they can take to a surgeon to perform gender confirmation surgery. Patients may then go through a number of surgeries on their face, body, and genitalia to reflect outside how they feel inside.

Not everyone goes through the entire process, explains Thomas Satterwhite, a San Francisco-area plastic surgeon who specializes in gender confirmation surgery. While most who elect to do the surgery are taking hormones, some will just undergo hormone therapy and never have surgery.

Bruce Jenner addressed rumors about his transition from male to female. (Photo: Daniel Robertson/Startracksphoto)

According to experts, gender confirmation surgery, hormone therapy, and counseling have seen recent spikes in popularity after insurance companies started covering these under the Affordable Care Act. “We’ve been extremely busy,” says Satterwhite, whose practice has a six-month-long wait list. Psychiatrist Alex Keuroghlian, a clinical fellow in psychiatry at Massachusetts General Hospital who works with patients who are transgender, has noticed the same thing — he says his practice now sees 35 new patients a month, on average.

But between constant hormone therapy and multiple surgeries, what effects does gender confirmation have on overall health? Here’s a closer look at some of the top surgeries for transgender men and women:

Cross-sex hormone therapy

Research on the long-term health impact of cross-sex hormone therapy is ongoing, but studies conducted so far have had mixed results.

Research published in the Journal of Clinical Endocrinology and Metabolism concluded that the hormone therapy is “acceptably safe” over the short and medium term. But a recent study published in the European Journal of Endocrinology found that male-to-female transgender people had a 51 percent higher early death rate than the general population, mostly due to suicide, AIDS, cardiovascular disease, and drug abuse. Lung and hematological cancer mortality rates also increased. However, researchers found that female-to-male transgender people had no difference in mortality compared with the general population (they did not indicate why this was the case).

It’s also not yet known whether a man transitioning to a woman would take on the typical health risks of a woman, like an increased risk of developing Alzheimer’s disease, says Satterwhite. But he’s doubtful that would be the case for most patients. “Someone who started the process of taking hormone blockers early, that might be beneficial,” he says. “But I have some patients who come to me who are in their 50s, 60s, and 70s, whose bodies have been doused with testosterone their entire life. I don’t think that would have an impact.”

Related: Transgender Parents Speak Out About What Makes a Family

Facial surgeries

Transgender patients may choose to undergo a number of surgeries depending on the gender they want to be, says John Martin, a board-certified facial plastic surgeon in Miami who specializes in the facial feminization of transgender patients. He performs brow lifts, facelifts, and eyelid surgeries and also adds fillers to the cheeks.

Martin says his patients don’t need to space procedures out for health reasons since they’re typically done with local sedation, but many people do for financial reasons. Most procedures have up to two weeks of bruising, but it can take up to three months for all of the swelling to go down.

“There are not many health risks with these facial surgeries,” he says.

Vaginoplasty

This involves the use of one of several techniques to create a vaginal canal and vulvovaginal structure for patients transitioning from a man to a woman. Satterwhite typically performs the penile inversion vaginoplasty, which takes skin from the penile shaft and uses it to create a vaginal canal. The process can take five to six hours to complete. “It’s a complicated operation,” he says.

Risks include bleeding and the need for a blood transfusion, damage to nearby organs (the urethra, bladder, and rectum), and potential loss of sensation in the area. “My goal is to create a vagina that has erogenous sensation,” Satterwhite says. “There is a potential risk of losing that sensation, but I haven’t seen it happen on a permanent basis.”

The new vagina is at risk of collapsing on itself, so transgender women need to use dilators regularly — more often at first and then less frequently over time.

Patients also run the risk of developing a fistula, an unnatural connection between the vagina and other organs. When that happens, feces and urine can travel into the vagina and leak out of the vaginal opening. “It’s a rare thing, but I warn my patients,” says Satterwhite.

Breast augmentation

Breast augmentations are one of the top procedures Satterwhite performs on transgender women. People who undergo one are at risk for capsular contracture, where scarring develops around the implant, and, less frequently, a ruptured implant.

Related: Saying Goodbye to ‘Mr.’ and ‘Ms.’ and Hello to 'They’

Mastectomy

This surgical operation removes the breasts for women transitioning to men and involves removing the nipple and areola as skin grafts, making them smaller, and repositioning them higher on the chest. While Satterwhite has never seen it happen in his own practice, he says it’s possible that the skin graft can be rejected by the body, die, and then fall off. (Smokers are at a higher risk of developing this condition.)

Patients who undergo a mastectomy are also at risk for developing a hematoma (a collection of blood) or seroma (a fluid collection) in the breast area — which could lead to infection or the fluid being absorbed back into the body.

Metoidioplasty

Metoidioplasty is a procedure that creates a penis by extending the clitoris that has been enlarged by testosterone hormones. It’s an outpatient surgery and has a short recovery time, says Satterwhite.

However, the penis created by metoidioplasty is typically very short (on average 4 to 6 centimeters), and patients can sometimes have difficulty urinating hygienically.

Phalloplasty

Phalloplasty constructs a penis using skin from the inner forearm and vaginal tissue, which is then attached to the vaginal area. While it creates a more realistic-looking penis, Satterwhite notes that it’s a technically difficult operation with a long recovery time (patients are in the hospital for five days and off from work for up to a month).

Phalloplasty patients also have a higher risk of complications like hardening of the urinary tract and tissue death in the new penis. They may also have scars on their arms or leg where the skin was taken from, which can be a giveaway that someone has had the operation.

Physical vs. mental harms — and benefits

Of course, there are risks associated with any type of surgery and hormone therapy. But how does the overall risk stack up against the potential psychological damage of being trapped in the wrong body?

According to Keuroghlian, people with gender dysphoria can be “highly distressed” (before gender confirmation), and may suffer from depression and anxiety. They’re also at a high risk of developing a substance abuse disorder. But “these symptoms routinely improve once patients are fully able to express their gender identity to the world,” he says.

Satterwhite says his patients improve on many levels postconfirmation — psychologically, emotionally, physically, and spiritually. And overall, Keuroghlian says the benefits “strongly outweigh” any possible risks, adding that people are thrilled with the outcome: “I have not yet encountered a patient who has regretted transitioning if the process was pursued thoughtfully.”

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