What is gender-affirming surgery?
Surgery that supports a person’s gender identity is called gender-affirming surgery. This term covers a wide range of procedures for people of all genders. Often, it means surgery for a transgender, nonbinary or gender-diverse person to relieve lasting gender dysphoria.
People who choose gender-affirming surgery may have only 1 type of procedure, or they may have many, sometimes over several years. Their choices depend on their gender-related health goals. Each person is unique, and so is their treatment plan.
We work closely with patients and families to make decisions about surgery age and timing. For gender-affirming genital procedures, patients must be 18 or older by the time of surgery. For other surgeries, timing depends on many factors, like the patient’s stage of puberty and how surgery fits with the rest of their gender-related healthcare. A typical age is mid-teens or older. We treat some patients through age 26 for gender-affirming surgery.
What’s special about the experience at Seattle Children’s?
Seattle Children’s is the only pediatric academic medical center with fellowship-trained plastic surgeons who provide gender-affirming surgery in our region — Washington, Wyoming, Alaska, Montana and Idaho. We treat teens and young adults who are patients of Seattle Children’s Gender Clinic. We also accept patients who are receiving gender-affirming care through providers outside of Seattle Children’s.
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- Our plastic surgeons have special training and experience in gender-affirming surgery for young people, as well as adults. Knowledge and expertise are important to plan and perform these procedures well so patients achieve the results they expect.
- A urologist, dermatologist and gynecologist are part of our team to provide expert advice and treatment in support of patients’ health goals. They work closely with our plastic surgeons.
- Our gender surgery registered nurse also works closely with the doctors. They help with care each step of the way. They know in detail what these surgeries involve, how surgery can affect patients and how to best support a good recovery.
- Everyone on the team specializes in pediatric gender-affirming care. At Seattle Children’s, patients will receive care in a respectful environment from pediatric providers committed to their well-being.
- We follow guidelines of the World Professional Association for Transgender Health (WPATH) and current best practices for young people who want transition-related treatment.
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- Our team fully accepts each individual we treat. We meet each patient and family where they are, knowing that surgery is a step in a larger process. Before making a treatment plan, we talk with you in detail about your gender-related health goals, like how your body will look and work after surgery. Knowing these goals allows us to provide the most personalized care.
- We offer complete and accurate information about the range of surgery options, such as different techniques and what to expect during recovery. Our team knows how to explain treatments in ways that match a patient’s age and understanding.
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- Our specialized gender-affirmation surgery care coordinator is here to help you throughout the process, starting from the first time you call us. They offer one-on-one help with topics like seeking approval from your insurance company and getting the medical and mental health letters of support that are required.
- Seattle Children’s has many resources to make the experience as smooth as possible, from financial assistance to LGBTQ-friendly spiritual care.
- For patients and their families who travel to Seattle Children’s for gender-affirming surgery,we can help coordinate travel and housing.
What services does the Surgical Gender Affirmation Program offer?
The Surgical Gender Affirmation Program for teens and young adults provides:
- An opportunity to talk with our care coordinator before your first appointment. They will answer questions, help you prepare for an appointment and connect you with our schedulers.
- One or more consultations with surgeons and a gender surgery nurse to talk about your goals and surgery options and to plan the surgery. We will offer to connect you with Seattle Children’s Fertility Preservation Program before surgery if you are interested.
- Help after preoperative consultations to get ready for surgery, including working with your insurance company to have surgery approved.
- Complex procedures, including face and neck surgery, top surgery (breast/chest), bottom surgery (genitals) and body contouring.
- Follow-up care after surgery to check and support healing and to smoothly transition back to your usual gender care team.
- Support from a social worker to help arrange transportation and places to stay when you come to Seattle Children’s for care.
Telehealth (virtual) visits may be an option for some of your appointments.
What age patients does the program treat?
The Surgical Gender Affirmation Program treats teens and young adults. We work closely with patients and families to make decisions about surgery age and timing. Patients must be 18 or older by the time of surgery for gender-affirming genital procedures. For other surgeries, timing depends on many factors, like the patient’s stage of puberty and how surgery fits with the rest of their gender-related healthcare. A typical age is mid-teens or older. We treat some patients through age 26 for gender-affirming surgery.
Genital surgeries for other reasons — such as tumors, differences in sex development (DSDs) or fertility preservation — are offered through other Seattle Children’s programs, like ourDSD Program,Urology,GynecologyorReconstructive Pelvic Medicine.
Face and Neck Surgery
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Many different procedures can change the shape of the face to look more feminine or masculine. These are sometimes called facial feminization surgery or facial masculinization surgery. They include forehead reduction, forehead contouring or augmentation, brow lift, frontal sinus setback, facial fat grafting, cheek augmentation, nasal surgery (rhinoplasty), chin surgery (genioplasty), lower jaw surgery (mandible contouring) and others.
We use virtual surgical planning (computer modeling) and customized surgical models to guide facial surgeries and to show patients what results to expect.
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This is surgery that can make the Adam’s apple (thyroid cartilage) less visible (laryngochondroplasty) or more visible (thyroid cartilage enhancement).
Top Surgery (Breast/Chest)
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To increase breast size, surgeons can use implants filled with sterile salt water (saline) or a plastic gel (silicone), or they can use fat taken from another part of the body.
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In this procedure, surgeons remove breast tissue to create a natural chest contour that aligns with a patient’s gender identity. One option is to remove the nipple completely and then reattach it in a new position that will look natural (free nipple grafting).
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Some people assigned female at birth may feel most affirmed by keeping their breasts but making them smaller.
Bottom Surgery (Genitals)
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Surgeons have several options to make a vagina for people who have a penis. In this option, the surgeon removes the penis and testicles. They make a tunnel in front of the rectum and use skin from the penis to line the tunnel. They might use skin from the scrotum or another part of the body, like the thigh. The surgeon also makes inner and outer labia and a new opening for urine. They can use tissue from the penis to make a clitoris. People who may want to have biological children in the future can choose to have their sperm frozen and stored before surgery to remove the testicles.
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This is a method to reconstruct a person’s vagina or to make a vagina in a person assigned male at birth. The surgeon makes a vaginal canal using tissue from the lining of the abdomen (peritoneum). Based on the patient’s needs and wishes, the surgeon may also make inner and outer labia and a new opening for urine. For patients with a penis, the surgeon can use tissue from the penis to make a clitoris.
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Another way to reconstruct or make a vagina is to use a section of the bowel. Usually, this is not the first choice for gender-affirming surgery, but it may be an important option for someone who wants revision of an earlier surgery (like a penile inversion or peritoneal vaginoplasty). Based on the patient’s needs and wishes, the surgeon may also make inner and outer labia and a new opening for urine. For patients with a penis, they can use tissue from the penis to make a clitoris.
(Video) Gender Affirmation Surgery - EMPIRE Urology Lecture Series -
Some people decide to have surgery to make a vagina with a canal that is shorter than typical. This is 1 of many ways that surgery choices depend on the patient’s goals for how their body will look and work after they heal. In minimal-depth vaginoplasty, the surgeon makes a clitoris, inner and outer labia, an opening for urine and an opening of the vagina with a short vaginal canal.
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This is surgery to remove 1 or both testicles. Before the surgery, patients may choose to have their sperm frozen and stored so they will have the option to parent biological children later if they want to.
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A series of surgeries, done in stages over several months, can make a penis for someone assigned female at birth. The surgeon may make the penis using tissue from the vulva, forearm, thigh or side. Based on the patient’s needs and wishes, the surgeon may also do procedures to make the urethra longer, make a tip for the penis, make the scrotum and add testicle implants, put in an implant to make erections possible and close the opening of the vagina.
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For a person with a clitoris and labia, surgeons may be able to use these tissues to make a penis. This is done after the person has been on testosterone therapy, which will make the clitoris larger. Based on the patient’s needs and wishes, the surgeon may also make the urethra longer, make the scrotum and add testicle implants and close the opening of the vagina.
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This is surgery to make a tip for the penis or to correct a problem with the tip of the penis. In people who have had surgery to make a penis (phalloplasty), this may make the penis look more like that of a circumcised cisgender male.
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This is surgery to make a new scrotum or to correct a problem with the scrotum. In a person without testicles, the surgeon can also add testicle implants.
Other Gender-Affirming Procedures
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Procedures like fat grafting and liposuction can be done to shape a person’s body to better match their gender identity.
(Video) Gender Affirming Surgery - Marci Bowers, MD -
If the results of gender-affirming surgery do not meet the patient’s needs or goals, our experienced surgeons may be able to offer options to improve the results. We have done surgeries like this for people who had their earlier gender-affirming surgery at other hospitals.
Scheduling an Appointment About Gender-Affirming Surgery
- If you would like a referral to the Surgical Gender Affirmation Program, talk to your gender care provider (the provider who handles your gender-related medical care, such as hormones or menstrual suppression). Patients who are not on hormones or menstrual suppression can be referred by their primary care provider or a medical doctor who knows about their gender care needs.
- If you have a referral, call 206-987-2759, option 6, to talk about making an appointment. Our care coordinator will call you back to gather information and answer questions before we schedule.
- To schedule an appointment, you will also need to submit at least 1 of these letters:
- Medical template (DOCX)
- Mental health template – minor (DOCX)
- Mental health template – adult (DOCX)
- After we receive your referral and at least 1 of the required letters, our schedulers will call you to schedule an appointment.
- If you already have an appointment,learn more about how to prepare.
Resources for Patients and Families
- Templates for gender-affirming surgery letters:
- Medical template (DOCX)
- Mental health template – minor (DOCX)
- Mental health template – adult (DOCX)
- Help finding out if your insurance company must cover gender-affirming surgery under state law: Washington State Office of the Insurance Commissioner
- Masculinizing Top Surgery (PDF) (Spanish)
- Top Surgery Checklist and Resources (PDF) (Spanish)
- Fertility Preservation Program
- Gender-diverse care resources
- Plastic surgery resources
Contact Us
Contact Plastic Surgery at 206-987-2759, option 6, to talk with the care coordinator for gender-affirming surgery about an appointment, a second opinion or more information.
Providers, see how to refer a patient.
Related Links
- Anesthesiology
- Gender Clinic
- Plastic Surgery
Telemedicine at Seattle Children’s
You may be offered a telehealth (virtual) appointment. Learn more.
Paying for Care
Learn aboutpaying for care at Seattle Children’s, including insurance coverage, billing and financial assistance.
FAQs
Can kids get hormone blockers without parental consent? ›
Particularly when a child hasn't reached the age of medical consent, parents or other caretakers or guardians must consent to the treatment and support the adolescent through the treatment process.
How old do you have to be to start HRT in Washington state? ›Gender Affirming Hormone Therapy Services are available for patients 18 years and older at all of our eleven health centers in Eastern Washington.
What qualifies as gender affirming care? ›Gender-affirming care is a model of care which includes a spectrum of “social, psychological, behavioral or medical (including hormonal treatment or surgery) interventions designed to support and affirm an individual's gender identity.”
How old do you have to be to take testosterone in Washington? ›Gender-affirming medical care (such as puberty blockers, estradiol, and testosterone) for patients under age 18 requires consent from any parent or guardian that has medical decision-making rights for that patient.
What age is best for puberty blockers? ›The longer blockers are used past the typical start of puberty — generally age 14, at the latest — the greater the possible risk. When blockers are initiated in the early stages of puberty, Dr. Rosenthal typically suggests that his patients stop using them by age 14.
What age do puberty blockers start? ›The protocol always starts with puberty
Puberty blockers are only given to children who have started puberty. For a child who is assigned female at birth, Dr. Cartaya says puberty typically starts between the ages of 8 and 13. For a child who was assigned male at birth, the range is between 9 and 14.
You may need to wait until you are 16 to begin hormone treatment, but you may be able to take puberty blockers in the meantime. Does hormone treatment also work as birth control? No, hormone treatment is not a replacement for birth control.
Are puberty blockers covered by insurance? ›Between the 2 practices, 89% of patients who presented for puberty blockers obtained therapy, and insurance covered the cost in 72% of cases.
What age is HRT prescribed? ›You can usually begin HRT as soon as you start experiencing menopausal symptoms and will not usually need to have any tests first. However, a blood test to measure your hormone levels may be carried out if you're aged 40 to 45.
How successful is gender affirmation surgery? ›Most people who choose these surgeries experience an improvement in their quality of life. Depending on the procedure, 94% to 100% of people report being satisfied with their surgery results.
Is gender-affirming surgery medically necessary? ›
Can gender-affirming surgery and/or hormone therapy be considered “medically necessary” by doctors for people with gender dysphoria? Yes, doctors have found such treatments to be medically necessary for many people.
How old do you have to be to go on estrogen? ›If you are on hormone therapy, you can utilize the health center for ongoing care and monitoring. In order to receive gender affirming hormone therapy services you need to be over 18 (or 16-17 with parental consent) and capable of providing consent for services. There are special consents for these services.
At what age can a child transition? ›The Endocrine Society's guidelines suggest starting puberty blockers for transgender children when they hit a stage of development known as Tanner stage 2 — usually around 10 or 11 years old for a girl and 11 or 12 years old for a boy.
Can you start testosterone at 12? ›Hormonal induction of puberty in boys with permanent hypogonadism should be started at an appropriate age for a physiological onset of puberty [105]. In practice, testosterone therapy is often started around the chronological age of 12 in these boys [7].
Do you need parental consent to transition? ›In most cases, youth under the age of 18 must obtain the permission of their parents or guardian to access any medical treatment, including treatment for gender transition.
Do puberty blockers delay mental development? ›Puberty blockers delay the start of puberty, including development of secondary sex characteristics. Surprisingly, even though puberty blockers are widely used to help transgender adolescents go through gender transition, their impact on brain function during this critical stage of brain development is largely unknown.
What are the cons of puberty blockers? ›- Lower bone density. ...
- Delayed growth plate closure, leading to slightly taller adult height.
- Less development of genital tissue, which may limit options for gender affirming surgery (bottom surgery) later in life.
- Other possible long-term side effects that are not yet known.
WASHINGTON (TND) — Earlier this month, the U.S. Food and Drug Administration added a warning to gonadotropin-releasing hormone (GnRH) agonists, commonly known as “puberty blockers,” indicating there were serious risks for youth who take them.
Can puberty cause gender dysphoria? ›Additionally, while some transgender adolescents have shown gender non-conformity since early childhood, other adolescents might experience gender dysphoria during or after the onset of pubertal physical changes. Some adolescents may have kept their gender incongruence to themselves for a long time.
Should kids take puberty blockers? ›Critics have cautioned against children receiving gender-transitioning treatments, such as puberty blockers. The American College of Pediatricians (ACPeds) has said there is no evidence that these type of treatments are safe for children, and that youth transition is experimental.
Do puberty blockers make you taller? ›
According to medical research, doctors prescribe the puberty blocking drug to short kids to essentially give them more time to get taller, since puberty culminates with the body's long bone growth ending. Medical researchers have repeatedly warned against such off-label usage.
Who is the youngest person to change gender? ›Meet the world's youngest transgender model, Noella McMaher: the 10 year old is about to walk at New York Fashion Week, knew her gender identity before age 3 and is already an LGBT activist.
Can parents change their child's gender? ›If you and the other parent agree, you can ask the court together. You file a petition, go to a court hearing if needed, and get a decree recognizing your child's gender and changing their name. The process generally takes up to 3 months.
How old do you have to be to start testosterone FTM? ›In the U.S., most people can access T therapy at age 18 years, which is when they are capable of consent. At 17 years old, a person may have access, but they will require a parent or guardian to accompany them to appointments.
How do you get prescribed puberty blockers? ›How Does Someone Get a Prescription for Puberty Blockers? Young people who want to start blockers must work with an endocrinologist or primary care doctor and a mental health professional, and must have documented proof of gender dysphoria or gender non-conformity that started or worsened at the onset of puberty.
What happens if you take puberty blockers after puberty? ›If you were already done with puberty, the body will again be exposed to sex hormone and things like menstruation or other body changes will resume. When taking these medications, the body will not be making the hormones of puberty, testosterone or estrogen.
How do you get diagnosed with gender dysphoria? ›- Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. ...
- DSM-5.
Embarking on standardised HRT too early can result in unpleasant side effects for someone already producing plenty of natural oestrogen. Symptoms include sore and tender breasts, heavy bleeding and often severe PMT.
What are the disadvantages of HRT? ›Combined HRT can be associated with a small increase in the risk of breast cancer. The increased risk is related to how long you take HRT, and it falls after you stop taking it. Because of the risk of breast cancer, it's especially important to attend all your breast cancer screening appointments if you're taking HRT.
Will HRT stop my periods? ›Sequential HRT
Most women take this type of HRT for around four years, or until they reach 55 (whichever comes first). By 55, most women's periods have stopped. Sequential HRT contains oestrogen and progestogen.
Is gender affirming surgery safe? ›
Results: Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low.
Does medical cover gender affirming surgery? ›Most health insurances that are based in California cover gender affirming surgeries as part of their Transgender Health Benefits. Each insurance plan's coverage varies, so contact your health insurance directly to see what surgeries are covered as well as requirements for surgery.
What are the long term effects of gender reassignment surgery? ›Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.
Does insurance cover gender dysphoria? ›Gender Dysphoria / Gender Reassignment
Virtually all major insurance companies recognize that transgender-related medical care is medically necessary and have a written policy describing their criteria for when plans they administer will cover it.
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| Report Attribute | Details |
|---|---|
| Segments Covered | Gender transition |
| Country scope | U.S. |
The Americans with Disabilities Act, for example, does not count transsexualism in itself as a disability, but medical conditions that may result from a difference between someone's gender identity and sex assigned at birth, such as gender dysphoria, are not excluded.
How long does it take to grow breasts on estrogen? ›Breast development is a key feature of feminization and therefore important to transwomen. The Clinical Practice Guidelines of the Endocrine Society indicate that breast development starts 3 to 6 months after start of cross-sex hormone therapy (CHT).
Can you get hard on estrogen? ›Soon after beginning hormone treatment, you will notice a decrease in the number of erections you have; and when you do have one, you may lose the ability to penetrate, because it won't be as firm or last as long. You will, however, still have erotic sensations and be able to orgasm.
How long does it take to transition from female to male? ›Guidelines recommend people spend 12 months on hormone therapy before they get genital reassignment surgery (GRS). This operation involves recreating a person's genitals to that of the opposite sex. Removal of the gonads may be done as well.
What is the hardest child to transition? ›- The nap break is over. ...
- You have to learn to divide your attention. ...
- Dealing with unexpected regressions (Also see: tantrums) ...
- You reach next-level tired. ...
- The parenting guilt multiplies. ...
- Your second baby is a totally different human.
At what age is gender dysphoria most common? ›
Transgender Men
Gender dysphoria history: Of the 55 TM patients included in our study, 41 (75%) reported feeling GD for the first time by age 7, and 53 (96%) reported first experiencing GD by age 13 (Table 2). A total of 80% of patients reported that feelings of GD were among their earliest childhood memories.
Ask questions – asking questions about your teen's experience of gender dysphoria is a way to communicate openness, interest, and genuine caring. It can also help your child feel safe and may even encourage them to open up more to you.
Does testosterone affect height? ›Though testosterone is not a growth hormone, it does stimulate the production of HGH and IGF-1. This is why high testosterone levels can lead to an increase in height, especially during puberty.
How many genders are there in the world? ›There are many different gender identities, including male, female, transgender, gender neutral, non-binary, agender, pangender, genderqueer, two-spirit, third gender, and all, none or a combination of these.
Does testosterone make you infertile FTM? ›Patients and providers should be aware that testosterone treatment causes lowered sperm counts and hormone alterations. Men of reproductive age should avoid testosterone treatment if they want to have biological children or consider freezing sperm for use later.
What age are puberty blockers? ›The longer blockers are used past the typical start of puberty — generally age 14, at the latest — the greater the possible risk. When blockers are initiated in the early stages of puberty, Dr.
Do you need counseling before transitioning? ›According to the commentary, the World Professional Association for Transgender Health (WPATH) advises mental health screenings and recommends psychotherapy before any body modifications are made.
What is the parents role in transition planning? ›They help professionals learn about youths' strengths and needs and are active and knowledgeable participants in transition planning. Parents assist youth in exploring interests related to living and work questions, are part of discussions, and help develop postsecondary and employment goals.
Do parents have to give consent for puberty blockers? ›In situations such as this, the parent may consent on behalf of the child and if the doctor and the parent agree then they can go ahead and offer the child treatment. There may also be cases where the child wants one thing and the doctor agrees but the parent disagrees.
Can a 13 year old take hormone blockers? ›The Endocrine Society and the World Professional Association for Transgender Health support the use of puberty blockers for kids who want to delay or prevent unwanted physical changes. The U.S. Food and Drug Administration has approved puberty blockers for children who start puberty at a young age.
Are puberty blockers FDA approved for children? ›
None of the puberty blocker medications are approved by the Food and Drug Administration to take for gender dysphoria (dis-FOR-ee-uh), but they are still very commonly used to treat it.
Can you take puberty blockers at 16? ›After an assessment, a person may start taking puberty blockers. The GIDS recommend that young people take puberty blockers until reaching 16 years of age or having taken puberty blockers for 12 months before considering other medical procedures.
Does insurance pay for puberty blockers? ›Between the 2 practices, 89% of patients who presented for puberty blockers obtained therapy, and insurance covered the cost in 72% of cases.
Are there any downsides to puberty blockers? ›Puberty blockers are considered to be very safe overall. We are not sure if puberty blockers have negative side effects on bone development and height. Research so far shows that the effects are minimal.
Do puberty blockers affect mental development? ›Puberty blockers delay the start of puberty, including development of secondary sex characteristics. Surprisingly, even though puberty blockers are widely used to help transgender adolescents go through gender transition, their impact on brain function during this critical stage of brain development is largely unknown.
Do puberty blockers stop height growth? ›Puberty blockers stunted the height and impaired the bone mass density of children wishing to change gender, researchers have found.
How many kids are on hormone blockers? ›The number of children who started on puberty-blockers or hormones totaled 17,683 over the five-year period, rising from 2,394 in 2017 to 5,063 in 2021, according to the analysis.
Can hormones cause gender dysphoria? ›However, recent studies point toward a biological basis involving endocrine, neurobiological and genetic factors. For instance, an increased prevalence of gender dysphoria was observed among people who experienced atypical prenatal androgen exposure in utero, such as females with congenital adrenal hyperplasia (8–15).
Can a 15 year old get puberty blockers? ›Transgender children are not offered puberty blockers or hormone treatments until they reach puberty. Medical guidelines generally do not recommend genital gender-affirming surgeries before a child reaches age 18.
Do I have gender dysphoria? ›You may feel: certain that your gender identity conflicts with your biological sex. comfortable only when in the gender role of your preferred gender identity (may include non-binary) a strong desire to hide or be rid of physical signs of your biological sex, such as breasts or facial hair.