Skip to main content

Gender-Affirming Surgery — Overview

Gender-affirming surgery (GAS) encompasses procedures that align an individual's physical anatomy with their gender identity, broadly grouped into breast or chest surgery, genital reconstruction, and facial or body procedures.123 WPATH SOC8 lists chest, genital, facial, and body procedures among medically necessary gender-affirming interventions.4 The 2017 Endocrine Society guideline recommends genital surgery when the mental health and endocrine clinicians agree it is medically necessary and would benefit health or well-being.5 The AMA recognizes medical and surgical treatment for gender dysphoria or incongruence selected through shared decision making under accepted standards as medically necessary.16 ACOG specifically identifies desired hysterectomy for gender dysphoria as medically necessary.2

Detailed pages: Feminizing procedures, Masculinizing procedures, Revision & Salvage GAS, and Non-Binary & Nullification. For the cisgender congenital counterpart to feminizing reconstruction, see Müllerian Anomalies & Vaginal Agenesis.

Categories of Procedures​

Masculinizing (Transmasculine)23​

  • Top surgery. Subcutaneous mastectomy with chest reconstruction; a commonly requested transmasculine procedure; individual goals vary.
  • Genital surgery. Metoidioplasty (release of the hormonally enlarged clitoris to create a microphallus) or phalloplasty (creation of a neophallus using a tissue flap, often radial forearm); hysterectomy or oophorectomy; vaginectomy; scrotoplasty.
  • Other. Voice surgery, liposuction, pectoral implants.

Feminizing (Transfeminine)23​

  • Breast augmentation. Typically subglandular or subpectoral implants.
  • Genital surgery. Vaginoplasty (penile skin inverted to line the canal, with glans tissue forming the clitoris and genital skin forming the labia), orchiectomy, vulvoplasty.
  • Facial feminization surgery (FFS). Brow lift, rhinoplasty, mandible contouring, tracheal shave; often prioritized because it shapes public-facing appearance and personal safety.
  • Other. Voice surgery, body contouring, hair reconstruction.

Eligibility Criteria​

For adults, WPATH SOC8 emphasizes sustained gender incongruence, capacity for procedure-specific informed consent, assessment of relevant medical and mental health conditions, and discussion of fertility implications and preservation options. SOC8 recommends a single opinion from a professional competent in assessing transgender and gender diverse people (statement 5.5); if a letter is required, it does not routinely require two independent letters.4

Hormone timing is individualized. For gonadectomy, SOC8 suggests considering at least six months of hormone therapy when appropriate to the person's goals (statements 5.6 and 13.5). For genital reconstruction, it suggests evidence of stability on the current regimen, which may include six months or longer when needed for the intended result (statement 13.6); hormones are not obligatory when unwanted or contraindicated. For patients not taking hormones before gonadectomy, SOC8 notes that a hormone-replacement plan can be developed with the prescriber before surgery.4 These adult criteria differ from older guidance: the 2017 Endocrine Society guideline advised one year of hormones before genital surgery, also with exceptions. Clinical criteria, insurer documentation, and local legal requirements are separate considerations.54

Preoperative planning should document which organs and sexual functions the patient wants to retain, fertility goals, hair removal from skin intended for a neourethra or neovaginal lining, and practical access to postoperative care.4 A 2026 urologist Delphi panel considered prior pelvic surgery or radiotherapy relative contraindications to vaginoplasty and reached no consensus on perioperative hormone interruption or restart timing.7 A separate 2026 Delphi study invited 27 urologists to assess masculinizing genital surgery; its respondents considered a Charlson Comorbidity Index of 3 or higher a relative contraindication for phalloplasty but not metoidioplasty and reached no consensus on perioperative testosterone suspension.8

Outcomes and Safety​

Reported satisfaction and complications vary by procedure and follow-up; the 30-day registry studies below do not capture late neovaginal or urethral morbidity.191011

  • Short-term complications. In an NSQIP analysis of 4,114 patients, approximately 6% had a complication within 30 days: 3.5% after top surgery, 8% after bottom surgery and 2.1% after head and neck procedures.9
  • Vaginoplasty. In a retrospective NSQIP cohort of 488 cases, 5.5% had Clavien-Dindo grade 3–4 complications and none died within 30 days. Wound dehiscence or surgical site infection occurred in 46 cases (about 9%); higher BMI and higher ASA class were each associated with both grade 3–4 events and readmission.10
  • Phalloplasty is a complex reconstruction with substantial urethral and donor-site morbidity, which is discussed alongside individual functional goals.3
  • Satisfaction and long-term outcomes. In a 2025 report using 2019–2021 survey data from 2,176 patients, 776 of 946 surgical recipients (82%) reported high satisfaction.1 A 40-year follow-up study reported favorable outcomes, but only 15 of 97 identified patients participated; the attrition limits generalization of its mental-health and regret findings.112
  • Mortality. The 488-case vaginoplasty cohort reported no deaths within 30 days. Acute-care assessment should use the actual operative anatomy and hormone history.1013

In the same 2,176-person survey, 94.4% reported at least one barrier to accessing GAS, most often cost. This describes that recruited cohort and is not a population-wide access estimate.1

Outcome Data Sources and Registries​

Published outcome data for genital GAS come mostly from single-surgeon retrospective case series built on surgeon-reported complications, with inconsistent definitions and limited long-term follow-up of clinical and patient-reported outcomes (PROs).14 The datasets below differ in design, follow-up and in who reports the outcome, and those differences set how far each can support counseling.

TRANS Registry​

The Transgender and Non-Binary Surgery (TRANS) Registry is a prospective, longitudinal, observational registry of people seeking vaginoplasty or vulvoplasty, with clinical data and PROs captured through the electronic health record (EHR). Its 2024 design paper comes from a group including Geolani Dy, Gaines Blasdel, Daniel Dugi, Rachel Bluebond-Langner and Lee Zhao, with authors at Oregon Health & Science University, NYU Grossman School of Medicine, the University of Utah and the University of California San Francisco.14

  • Development. Work began in May 2019. Clinical outcomes were identified at a 3-hour session of 50 stakeholders (urologists, plastic surgeons, other team members and transgender and non-binary community leaders) at the 2019 AUA–Society of Genitourinary Reconstructive Surgeons research session. PRO selection was reviewed in two virtual community engagement studios in February 2021, each with 4–5 patients who had undergone vaginoplasty or vulvoplasty. Community input moved most baseline PROs to after surgical candidacy is agreed, because patients reported that answers given while the surgeon still controls access to surgery risk being inaccurate.14
  • Definitions. Clinicians at the registry sites agreed definitions for outcomes without established grading (for example, major versus minor wound separation) and recorded them in a manual of operations. The templates separate pelvic organ prolapse from neovaginal skin protrusion, two entities often reported under the single term vaginal prolapse.14
  • Data capture. Clinical data are entered in Epic SmartForms and PROs are collected through the EHR, transferred to identical REDCap databases at each site, and sent quarterly to a central deidentified registry. Clinical follow-up is recorded at 1, 3, 6 and 12 months and yearly; PROs are collected before surgery and at 6 or 12 months and yearly, depending on the measure.14
  • PRO instruments. A 12-item subset of PROMIS-29; PROMIS Sexual Function and Satisfaction 2.0, including its interfering-factors items; the Female Genital Self-Image Scale (renamed Genital Self-Image Scale after community input); the Transgender Congruence Scale; PHQ-2; PROMIS instrumental and emotional support; IPSS; and UDI-6. PHQ-2 replaced PHQ-9 because the EHR could not alert clinicians to a response indicating suicide risk. GENDER-Q was not available when measures were selected, and the authors anticipate updating the set as validated instruments appear.14
  • Scope and status. The initial phase is limited to three pilot academic centers; penile reconstruction is a planned extension that would need its own stakeholder process. Data requests are limited to investigators at registry sites, under a governance committee that includes patients. The design paper reports no enrollment figures and no clinical or PRO outcomes.14

TRANS-ARC​

The Transgender and Non-Binary Surgery Allied Research Collective (TRANS-ARC) is a research-prioritization project for genital GAS comparative-effectiveness research, separate from the registry although it shares investigators. Its steering committee, 80% of whom identified as transgender or non-binary, ran a modified Delphi process: an open survey (918 unique eligible responses) organized into 26 topics, a ranking survey (n = 325), a 2-day virtual summit of 78 attendees that drafted research questions, and a final ranking survey (n = 563).15 The ten highest-priority topics included outcomes and complications related to sexual health, genital sensation, urinary function, appearance satisfaction and mental health; transphobia within health care; surgeon quality; care coordination and follow-up; goal setting for surgery; and out-of-pocket costs. The project produced a research agenda and reports no patient-level outcomes.15

Comparator Datasets​

  • ACS-NSQIP. A general surgical-quality registry analyzed retrospectively for GAS. It records perioperative events within 30 days (complications, readmission, reoperation) and no neovaginal, urethral or patient-reported endpoints. The 4,114-patient and 488-case analyses are summarized under Outcomes and Safety.910 One of the largest national vaginoplasty cohorts (978 procedures, 2011–2023, published 2026) reported any 30-day adverse event in 16.0%, recorded complications in 13.0%, unplanned readmission in 3.6% and unplanned reoperation in 4.9%; plastic surgeons performed 82.6% of procedures and urologists 16.2%. Black race (RR 1.59), obesity (RR 1.56) and urology as primary specialty (RR 1.52) were associated with higher recorded adverse-event risk; the authors note that the specialty association may reflect case complexity or practice patterns rather than surgeon specialty itself.16
  • Amsterdam Cohort of Gender Dysphoria. A retrospective review of the records of all 6,793 people seen at the Amsterdam gender identity clinic from 1972 to 2015; the clinic treats more than 95% of the transgender population of the Netherlands.17 Regret, identified from the medical files, was recorded in 0.6% of transgender women and 0.3% of transgender men who underwent gonadectomy.17 The same center's surgical series include 475 penile inversion vaginoplasties (2000–2014; median follow-up 7.8 years), with rectal injury in 2.3%, rectoneovaginal fistula in 0.6% and revision vaginoplasty in 2.9%,18 and a 1990–2015 review of 1,082 transgender women (1,037 primary and 80 revision vaginoplasties) in which 25 (2.3%) were treated for neovaginal fistula; rectoneovaginal fistula followed 0.8% of primary and 6.3% of revision procedures (OR 8.6).19 Technique detail is on Penile Inversion Vaginoplasty and Rectoneovaginal Fistula Repair.
  • ENIGI. The European Network for the Investigation of Gender Incongruence is a prospective multicenter cohort started in 2010. Its endocrine protocol (Ghent, Oslo, Florence and Amsterdam) had enrolled 333 transgender women and 343 transgender men by 2016 and measures hormonal, metabolic, bone, anthropometric and psychological outcomes, with no surgical complication measures. Follow-up has been extended to 10 years to address long-term safety.2021
  • GENDER-Q. A patient-reported outcome measure for gender-affirming care, not a registry. Interviews with 84 people in Canada, Denmark, the Netherlands and the US produced a 13-domain framework and a 55-scale field-test version, piloted in 601 participants.22 The international field test (2022–2024; 21 clinical sites in Canada, the US, the Netherlands and Spain, plus community recruitment) enrolled 5,497 adults. Rasch analysis produced 54 scales and 2 checklists, including urination, genital feminization and genital masculinization domains; for the scales evaluated for test-retest reliability, the average-measures intraclass correlation exceeded 0.70 except for the phalloplasty donor-flap scale (0.65).23
  • GenderCOS. International Delphi consensus with lived-experience and professional panels defined core outcome sets for genital GAS. The feminizing set has 11 outcomes, 6 of them patient-reported and 4 specific to procedures that create a vaginal canal.24 The masculinizing set comprises neophallic sensibility, additional surgery, ability to achieve orgasm, sexual well-being and satisfaction with neogenital aesthetics, plus fistula, stricture and voiding while standing after urethral lengthening and flap necrosis and donor-site morbidity after phalloplasty.25 A 2026 consensus recommended measurement instruments for 19 of the 20 unique core outcomes: GENDER-Q scales for most of the 12 PROs, PROMIS Global Health for quality of life in the feminizing set, and existing clinical guidelines for clinical outcomes and adverse events. Satisfaction with neogenital sexual function has no validated measure across all feminizing procedures; the GENDER-Q Vagina scale applies only after creation of a canal.26
SourceDesignScopeFollow-upWhat it providesRefs
TRANS RegistryProspective, EHR-enabled; 3 pilot US academic centersVaginoplasty and vulvoplasty1, 3, 6, 12 months, then yearlyDesign and instruments only; no outcomes published14
TRANS-ARCModified Delphi prioritizationGenital GAS research questionsNot applicablePrioritized research agenda; no patient outcomes15
ACS-NSQIPRetrospective analysis of a national surgical-quality registryGAS cases coded in NSQIP30 daysComplications, readmission, reoperation; no PROs91016
Amsterdam cohortRetrospective, single centerAll clinic attendees, 1972–2015; vaginoplasty seriesMedian 7.8 years in the 475-case seriesRegret after gonadectomy; vaginoplasty complications, fistula and revision171819
ENIGIProspective, multicenter European cohortHormone therapyExtended to 10 yearsEndocrine, metabolic and psychological outcomes; no surgical complications2021
GENDER-QPROM development and international field testAll gender-affirming careCross-sectional with test-retest54 validated scales and 2 checklists2223
GenderCOSDelphi consensusFeminizing and masculinizing genital GASNot applicableCore outcome sets and recommended instruments242526

Limits of Current Data​

  • Patient-reported measures. A systematic review of 406 GAS cohort publications found that 68.7% of genital surgery papers addressed patient-centered outcomes but only 1.0% used metrics validated in transgender populations. Forty-three instruments were used, none in more than 15% of series, and 38 appeared in only one or two publications.27
  • Who reports the complication. A narrative review of systematic reviews by Blasdel, Dy, Dmitriy Nikolavsky, Cecile Ferrando, Bluebond-Langner and Zhao compared surgeon-reported cohorts with data not reported by the primary surgeon. After vaginoplasty or vulvoplasty, the latter showed more voiding dysfunction (47–66% versus 5.6–33%), incontinence (23–33% versus 4–19.3%) and misdirected stream (33–55% versus 9.5–33%).11 After phalloplasty or metoidioplasty, alternate cohorts reported fistula in 39.5–56.4% and stricture in 31.8–65.5%, against 14–25% fistula and 8–12.2% stricture or meatal stenosis in the systematic reviews.11 The authors conclude that the literature does not completely describe urologic complications of genital GAS.11 In a community-based online survey of 129 people after phalloplasty or metoidioplasty, recruited across 3 continents and many centers, respondents reported 281 complications requiring 142 revisions, including urethrocutaneous fistula in 40% and urethral stricture in 32%; the clinical data could not be verified, and recall and selection bias apply.28
  • Loss to follow-up. In a multicenter follow-up study 4 to 6 years after first clinical contact, 201 of 546 eligible people (37%) responded.29 A gender-affirming mastectomy survey (chest surgery, cited here for method) reached 59.1%, and nonresponders differed from responders in follow-up length and recorded depression and anxiety.30
  • Regret. Estimates depend on how regret is ascertained: chart review in the Amsterdam cohort (0.6% and 0.3% after gonadectomy);17 self-report in the multicenter follow-up study, where 8 of 136 surgical respondents (6%) reported dissatisfaction or regret, associated with preoperative psychological symptoms or self-reported surgical complications;29 and a 2024 systematic review pooling 24 studies and 3,662 patients, which found 1.94% overall (4.0% transfeminine, 0.8% transmasculine).31
  • Detransition. A Finnish national register study found that 7.9% of 1,359 people discontinued established hormone therapy over a mean 8.5 years, with a higher hazard among those first seen in 2013–2019 than in 1996–2005 (HR 2.7).32 A Canadian qualitative study of 28 people who stopped, shifted or reversed a transition described varied reasons, including an evolving understanding of gender identity, and a majority were pleased with the results of earlier treatment.33 One participant in the Canadian interview study described partial reversal of an unspecified genital operation after years of complications.33

Postoperative Considerations​

Patients with a constructed vaginal canal usually need a long-term dilation regimen, tailored by the operating team. Penile-inversion canals are principally skin-lined and require external lubricant; peritoneal and intestinal techniques have different lining and secretion characteristics. Vulvoplasty without a canal does not require canal dilation. Patients with persistent pain during dilation may benefit from pelvic floor physical therapy.2 SOC8 suggests surgeons encourage lifelong urological follow-up after metoidioplasty or phalloplasty; after vaginoplasty, it recommends that surgeons encourage follow-up with the primary surgeon, primary care physician, or gynecologist.4 Long-term follow-up includes surveillance of cardiovascular risk and mental health.34

Podcasts​

Gender-Affirming Care: A Primer
BackTable Urology, Ep. 33 (2022) · Jennifer Anger, Aditya Bagrodia
backtable.com

Footnotes​

  1. Pletta DR, Quint M, Radix AE, et al. "Gender-Affirming Surgical History, Satisfaction, and Unmet Needs Among Transgender Adults." JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  2. Cronin B, Stockdale CK. "Health Care for Transgender and Gender Diverse Individuals." American College of Obstetricians and Gynecologists, 2021. ↩ ↩2 ↩3 ↩4 ↩5

  3. Safer JD, Tangpricha V. "Care of Transgender Persons." N Engl J Med. 2019;381(25):2451–2460. doi:10.1056/NEJMcp1903650 ↩ ↩2 ↩3 ↩4

  4. Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." Int J Transgend Health. 2022;23(Suppl 1):S1–S259. doi:10.1080/26895269.2022.2100644 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  5. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. "Endocrine Treatment of Gender-Dysphoric / Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab. 2017;102(11):3869–3903. doi:10.1210/jc.2017-01658 ↩ ↩2

  6. American Medical Association. "Clarification of Evidence-Based Gender-Affirming Care" (Policy H-185.927). AMA PolicyFinder. Reaffirmed 2024. Policy ↩

  7. Pezzoli M, Lo Re M, Pizziconi V, et al. "International Delphi consensus on feminising genital surgery in assigned-male-at-birth individuals." BJU Int. 2026. doi:10.1111/bju.70196 ↩

  8. Lo Re M, Pezzoli M, Cocci A, et al. "Urological issues in masculinising genital surgery: a Delphi consensus study." BJU Int. 2026. doi:10.1111/bju.70428 ↩

  9. Scott KB, Thuman J, Jain A, Gregoski M, Herrera F. "Gender-Affirming Surgeries: A National Surgical Quality Improvement Project Database Analyzing Demographics, Trends, and Outcomes." Ann Plast Surg. 2022;88(5 Suppl 5):S501–S507. doi:10.1097/SAP.0000000000003157 ↩ ↩2 ↩3 ↩4

  10. Mishra K, Ferrando CA. "Postoperative Adverse Events Following Gender-Affirming Vaginoplasty: An American College of Surgeons National Surgical Quality Improvement Program Study." Am J Obstet Gynecol. 2023;228(5):564.e1–564.e8. doi:10.1016/j.ajog.2023.01.011 ↩ ↩2 ↩3 ↩4 ↩5

  11. Blasdel G, Dy GW, Nikolavsky D, Ferrando CA, Bluebond-Langner R, Zhao LC. "Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots." Plast Reconstr Surg. 2024;153(4):792e–803e. doi:10.1097/PRS.0000000000010813 ↩ ↩2 ↩3 ↩4

  12. Park RH, Liu YT, Samuel A, et al. "Long-Term Outcomes After Gender-Affirming Surgery: 40-Year Follow-Up Study." Ann Plast Surg. 2022;89(4):431–436. doi:10.1097/SAP.0000000000003233 ↩

  13. Rosendale N, Goldman S, Ortiz GM, Haber LA. "Acute Clinical Care for Transgender Patients: A Review." JAMA Intern Med. 2018;178(11):1535–1543. doi:10.1001/jamainternmed.2018.4179 ↩

  14. Dy GW, Blasdel G, Dugi D, et al. "Transgender and Non-Binary Surgery Registry: Building a Patient-Focused Registry for Genital Gender Affirming Surgery." Transgend Health. 2024;9(5):399–412. doi:10.1089/trgh.2022.0111 ↩ ↩2 ↩3 ↩4 ↩5 ↩6 ↩7 ↩8

  15. Dy GW, Blasdel G, Downing JM. "Centering Transgender and Nonbinary Voices in Genital Gender-Affirming Surgery Research Prioritization." JAMA Surg. 2022;157(7):628–629. doi:10.1001/jamasurg.2022.1049 ↩ ↩2 ↩3

  16. Yang LD, Amrami MB, Rohde C. "Determinants of Adverse Events After Gender-Affirming Vaginoplasty: A National NSQIP Analysis." J Sex Med. 2026;23(9):qdag268. doi:10.1093/jsxmed/qdag268 ↩ ↩2

  17. Wiepjes CM, Nota NM, de Blok CJM, et al. "The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets." J Sex Med. 2018;15(4):582–590. doi:10.1016/j.jsxm.2018.01.016 ↩ ↩2 ↩3 ↩4

  18. Buncamper ME, van der Sluis WB, van der Pas RSD, et al. "Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women." Plast Reconstr Surg. 2016;138(5):999–1007. doi:10.1097/PRS.0000000000002684 ↩ ↩2

  19. van der Sluis WB, Bouman MB, Buncamper ME, et al. "Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women." Obstet Gynecol. 2016;127(6):1118–1126. doi:10.1097/AOG.0000000000001421 ↩ ↩2

  20. Dekker MJ, Wierckx K, Van Caenegem E, et al. "A European Network for the Investigation of Gender Incongruence: Endocrine Part." J Sex Med. 2016;13(6):994–999. doi:10.1016/j.jsxm.2016.03.371 ↩ ↩2

  21. Cocchetti C, Romani A, Collet S, et al. "The ENIGI (European Network for the Investigation of Gender Incongruence) Study: Overview of Acquired Endocrine Knowledge and Future Perspectives." J Clin Med. 2022;11(7):1784. doi:10.3390/jcm11071784 ↩ ↩2

  22. Kaur MN, Morrison SD, Kennedy SL, et al. "International Study to Develop a Patient-Reported Outcome Measure to Evaluate Outcomes of Gender-Affirming Care: The GENDER-Q." J Patient Rep Outcomes. 2024;8(1):134. doi:10.1186/s41687-024-00785-x ↩ ↩2

  23. Kaur MN, Rae C, Morrison SD, et al. "Development and Assessment of a Patient-Reported Outcome Instrument for Gender-Affirming Care." JAMA Netw Open. 2025;8(4):e254708. doi:10.1001/jamanetworkopen.2025.4708 ↩ ↩2

  24. Vallinga MS, Roijer PJ, Pidgeon TE, et al. "The Core Outcome Set for Studies on Feminizing Genital Gender-Affirming Surgery: Findings from the GenderCOS Project." EClinicalMedicine. 2025;85:103323. doi:10.1016/j.eclinm.2025.103323 ↩ ↩2

  25. Roijer PJ, Vallinga MS, Pidgeon TE, et al. "A Core Outcome Set for Research on Masculinizing Genital Gender-Affirming Surgery: International Consensus Results from the GenderCOS Project." EClinicalMedicine. 2025;85:103325. doi:10.1016/j.eclinm.2025.103325 ↩ ↩2

  26. Angelini M, Roijer PJ, Vallinga MS, et al. "Outcome Measurement Instruments for the Core Outcome Sets on Genital Gender-Affirming Surgery: The GenderCOS Project." EClinicalMedicine. 2026;95:103907. doi:10.1016/j.eclinm.2026.103907 ↩ ↩2

  27. Oles N, Darrach H, Landford W, et al. "Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-Reviewed Literature and Methods of Assessing Patient-Centered Outcomes (Part 2: Genital Reconstruction)." Ann Surg. 2022;275(1):e67–e74. doi:10.1097/SLA.0000000000004717 ↩

  28. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. "Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients." J Sex Med. 2021;18(4):800–811. doi:10.1016/j.jsxm.2021.01.183 ↩

  29. van de Grift TC, Elaut E, Cerwenka SC, Cohen-Kettenis PT, Kreukels BPC. "Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study." J Sex Marital Ther. 2018;44(2):138–148. doi:10.1080/0092623X.2017.1326190 ↩ ↩2

  30. Bruce L, Khouri AN, Bolze A, et al. "Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy." JAMA Surg. 2023;158(10):1070–1077. doi:10.1001/jamasurg.2023.3352 ↩

  31. Ren T, Galenchik-Chan A, Erlichman Z, Krajewski A. "Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review." Ann Plast Surg. 2024;92(5):597–602. doi:10.1097/SAP.0000000000003895 ↩

  32. Kaltiala R, Helminen M, Holttinen T, Tuisku K. "Discontinuing Hormonal Gender Reassignment: A Nationwide Register Study." BMC Psychiatry. 2024;24(1):566. doi:10.1186/s12888-024-06005-6 ↩

  33. MacKinnon KR, Kia H, Salway T, et al. "Health Care Experiences of Patients Discontinuing or Reversing Prior Gender-Affirming Treatments." JAMA Netw Open. 2022;5(7):e2224717. doi:10.1001/jamanetworkopen.2022.24717 ↩ ↩2

  34. Wylie K, Knudson G, Khan SI, et al. "Serving Transgender People: Clinical Care Considerations and Service Delivery Models in Transgender Health." Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6 ↩