Gender affirmation surgery


The purpose of gender-affirming surgery is to help alleviate distress associated with anatomical structures which (1) cannot be altered or eliminated by medical treatment, (2) have not changed enough with medical treatment, or (3) require the patient to take additional medication to maintain their body in congruence with their gender. Not all individuals who identify as transgender (or gender diverse) want or need surgery. However, surgery is a powerful potential tool to help an individual reach their gender goals.

Some surgical and related procedures can be minimally impactful on a person's athletic activities, in the case of injectable medications such as fillers, or these procedures can be significantly impactful on a person's daily functioning as well as athletic activities, as in the case of genital reconstructive procedures.

This chapter is provided to help act as a guide to help individuals and providers anticipate the potential course and impact of several common gender-affirming procedures. It is not fully comprehensive, nor should it serve to replace the role of effective communication between patients and their surgeons or between practitioners caring for a patient. Individual practices may vary, so be sure to maintain open communication with individual surgical providers.

Preparing for surgery

Every surgical protocol is different, but some guidelines for preparing for surgery are as follows.

Tobacco, marijuana, and their components

Many plastic surgeons require discontinuation of nicotine products prior to elective procedures [ ]. Tobacco smoking and nicotine in general is known to impair wound healing [ ]. Thus, it is recommended that all forms of nicotine be discontinued prior to surgery.

Cannabis use has also gained in popularity. There is some evidence that cannabis smoke can impair wound healing [ ]. The most well-studied cannabinoids are D9-tetrahydrocannabinol (D9-THC) and cannabidiol (CBD); their effects on wound healing are not well-appreciated. Studies of bone healing suggest CBD may have a positive effect on bone health and metabolism, whereas D9-THC may have a negative effect [ ]. D9-THC has been found to have a significant antiinflammatory effect, which may negatively affect wound healing [ ], as the inflammatory response is a normal part of initial wound healing. Regular cannabis use can also decrease the effect of opioid pain medications, raise anesthetic requirements, and withdrawal can result in hyperemesis [ ]. Taken together, there is some evidence to suggest avoidance of marijuana smoking before and after surgery, and, potentially, to avoid THC use before and after surgery. It appears that it may be safe to continue CBD products before and after surgery. However, there is great need for additional study of these substances.


Systemic corticosteroids and disease-modifying antirheumatic drugs (DMARDs), among other medications, are well known to interfere with wound healing [ ]. Systemic corticosteroids should be discontinued safely prior to surgery and timing for surgery should be coordinated with providers managing DMARD administration (typically timing surgery to be after at least one half-life of the medication) [ ]. Failure to discontinue these medications can lead to dysfunctional wound healing, including wound separation, delayed wound healing, poor scarring, and other problems. As always, specific cases should be navigated with the patient's specialists and surgeon.

Hormone therapy

Hormone therapy is frequently used to help alleviate gender dysphoria in gender diverse individuals. For individuals designated male at birth (DMaB) seeking “feminizing” therapies, this treatment consists of some formulation of estrogen as well as a medication specifically to suppress testosterone production by the body, often spironolactone. For individuals designated female at birth (DFaB) seeking “masculinizing” therapies, hormone treatment often consists of some formulation of testosterone, but can include other medications to provide contraception, to help the cessation of menses, and to reduce some potentially undesired effects of testosterone [ , ].

Hormone replacement therapy with estrogen is known to increase risk of development of a deep vein thrombosis (DVT) or pulmonary embolism (PE). The formulation of estrogen and the route of administration can play a role in its thrombogenicity [ ]. There is controversy over the need to discontinue estrogen therapy prior to major surgery.

Some surgeons require discontinuation of estrogen therapy 2 weeks prior to major surgery to decrease the risk of DVT/PE. This can lead to perimenopausal symptoms in some patients. The need to discontinue estrogen before therapy should be a discussion with the operating surgeon. Factors that might contribute to needing to discontinue estrogen include the patient's medical history, body mass index (BMI), duration of the planned procedure, travel time before and after surgery, mobility status, family history, and other considerations.

Generally, there is weaker evidence for the discontinuation of testosterone prior to major surgery, however some surgeons do recommend or require it.

Blood thinners

Medications that promote bleeding are typically discontinued before surgery unless the benefits significantly outweigh the risks. Patients on blood thinners will need to check with their doctor and surgeon to assess the safety of discontinuing the medications prior to any procedure.

Aspirin should not be used as a pain medication within 2 weeks of surgery, due to its irreversible effect on circulating platelets. If aspirin is being taken for any other reason, there will been to be a discussion of the risks versus benefits of discontinuation.

There is some controversy over the role of nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen and naproxen. While they may slightly increase risk of bleeding, their benefit as a nonnarcotic pain medication. There is growing evidence that NSAIDs do not meaningfully contribute to postoperative bleeding [ ].

Herbal supplements

Some herbal supplements, such as gingko and garlic, can promote bleeding if taken in significant amounts. Other herbal remedies, such as St. John's wort, can interfere with other medications. Patients should check with their surgeons if they feel they want to continue any herbal supplements.


Patients who have prolonged travel time for a surgical procedure may be at increased risk for venous thromboembolism (VTE) which can result in PE. PE can cause death, severe disability, or significant impact on exercise capacity. Patients traveling for several hours should plan for multiple breaks to walk around to decrease risk of VTE [ ].

Recovery between surgical procedures has significant variability. Patients should review with their surgeons how long they should remain in the area following their procedure.

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