More people are getting ‘sex change’ surgeries than ever before… but it’s not what you think

The American Society of Plastic Surgeons released its first-ever report tracking national statistics on transgender surgery, increasingly referred to as “gender confirmation surgeries,” that showed close to a 20 percent increase in 2016 over the previous year.

The ASPS, which represents 94 percent of all U.S. board-certified plastic surgeons, revealed that members of the organization performed 3,256 “transmasculine” and “transfeminine” surgeries last year.

“Gender confirmation surgery” covers a wide spectrum of surgery types.
 
Contrary to public perception, the number of genital operations transforming the male genitalia and reconstructing it into that of a female, or transforming the female genitalia and reconstructing it into that of a male, is miniscule. Only 15 of the more than 3,200 procedures in 2016, or about 0.5 percent, were genital operations, all of which were performed on men seeking to transition. No genital operations were performed on women seeking to transition.

“In the past few years, we’ve certainly seen an exponential increase in the number of individuals who are seeking surgical treatment for gender dysphoria, which is a disconnect between how an individual feels and what their anatomic characteristics are,” said Loren Schechter, MD, a board-certified plastic surgeon in Chicago.

Gender confirmation procedures can include everything from facial and body contouring to reassignment surgeries. Dr. Schechter says gender transitions usually include more than just surgery, and that plastic surgeons often partner with other experts to provide the most comprehensive care possible.

Among male-to-female patients, the vast majority of procedures (92 percent) were breast operations. Seven percent were facial.

Among female to male patients, there is a similar distribution of surgeries: 95 percent involved patient’s breasts or chests, and 5 percent were facial procedures.

A slightly higher number of men (54 percent) chose transition surgery.

These data appear to conflict with a previous survey of a much larger transgender population. As reported by NBC News, ultimately, “Most transgender people forgo gender reassignment surgery, with only 11 percent of transgender women having had their testicles removed and 12 percent undergoing vaginoplasty, according to a landmark U.S. survey of nearly 28,000 transgender adults released last year by the National Center for Transgender Equality.”

Regardless of the disparity, the number of genital reassignment surgeries remains a minor component of the burgeoning transgender surgery industry.

A crash course in transfeminine (male-to-female) procedures

According to ASPS literature, an implant is placed in the chest to create a defined, more feminine shape to the breast.
 
The testicles are removed, and the skin along the shaft of the penis is removed from the penile tissue and preserved to create the new vagina. A small portion of the glans of the penis, along with the corresponding nerves and blood vessels, are dissected off the penile tissue and preserved to create the clitoris.

The remainder of the penile tissues are removed from the body. A space is subsequently created between the bladder and rectum. The skin of the penis that was preserved is inverted and placed into this space. A conformer is placed inside the new vagina to maintain the position of the skin. The urethra and preserved glans of the penis are placed in the female position. The scrotal skin is rearranged and used to create the labia majora.

A crash course in transmasculine (female-to-male) procedures

The procedures that are commonly employed to masculinize the face include forehead lengthening, cheek augmentation, rhinoplasty, jaw reshaping, chin contouring, and Adam's apple enhancement.

A mastectomy is performed and after the breast tissue and any excess skin is removed, the remaining tissues are repositioned to create a masculine contour to the chest.

Sometimes the nipple and the areola need to be reduced and/or repositioned on the chest after the mastectomy is performed. The nipple and areola tend to be smaller and lie slightly more lateral and inferior on the male chest.

Often, the vagina, uterus, and ovaries have already been removed in a previous procedure. The blood vessels and nerves in the pelvis that will receive the attachments to the newly reconstructed penis are identified and preserved.

The tissue used to reconstruct the penis is harvested from another part of the body and shaped to look like a penis. This tissue is transferred to the pelvis where the blood vessels and nerves are attached to recipient vessels in the pelvis. The urethra is also lengthened.

A support garment is used to stabilize the position of the penis. The donor sites where the tissues were taken from are closed.

An uncertain industry future

As reported in USA Today, “The uptick in gender confirmation surgeries may be due to a number of things including more representation of transgender men and women in popular media and increased insurance coverage, according to Randi Kaufman, a clinical psychologist for the Gender and Family Project at the Ackerman Institute for the Family.”

Beginning in 2014, Medicare ended its policy of blanket denial of coverage of gender transition procedures.

However, the expansion of the plastic surgery branch of the burgeoning industry may be short-lived. There may be a reduced need for transgender-related surgeries in the future.
 
Schechter told USA Today in an email interview, "As people get access to care earlier (i.e., adolescence [sic] who undergo pubertal suppression to prevent development of secondary sexual characteristics), we may see less surgery because many of the stigmata of the male face will not necessarily develop."