Transgender healthcare is any and all healthcare that supports transgender people in their health and well-being. It can include primary care, as well as specialized medical care or gender-affirming care that supports their gender transition or gender affirmation goals. Transgender healthcare can include gender-affirming hormone therapy (GAHT, sometimes called HRT), gender-affirming surgery including feminine facialization surgery (FFS), top surgery, breast augmentation and other surgeries, emotional support, mental health services, peer support, reproductive medicine, and other types of care.
What are your options for bottom surgery? How do you plan to pay for the procedures you want? Are there rules and recommendations? Do you want to keep some aspects of your genitals and sex organs? Is bottom surgery an all-or-nothing option? You may have lots of questions about bottom surgery—whether you’re looking to remove certain reproductive organs or hoping to affirm your gender identity. Here are some common terms, definitions, and questions you may have about bottom surgery:
- Bottom surgery
- Masculinizing surgery
- Feminizing surgery
- Sex change surgery
- Bottom surgery for trans women and transfeminine people
- Bottom surgery for trans men and transmasculine people
- Nonbinary bottom surgery
- Vaginoplasty
- Penis removal, reduction, or reconstruction
- Phalloplasty
- Orchiectomy
- Hysterectomy
- Preparing for bottom surgery
- Sex differences and sensitivity
- Recovering from bottom surgery
- Pain medications after surgery
- Activity limitations before and after bottom surgery
- How long do I have to be on hormones before I can get bottom surgery?
- How much does bottom surgery cost?
- How can I get bottom surgery covered by insurance?
- How long after bottom surgery will I feel normal?
- Does bottom surgery hurt?
- When can I start having sex after bottom surgery?
- Do I need to take hormones after bottom surgery?
Bottom surgery
Masculinizing surgery
Any surgical procedure that makes someone look more masculine falls into this category of surgery. This can include top surgery, bottom surgery, phalloplasty, jaw implants, certain types of facial fillers, liposuction, and other body sculpting procedures. Masculinizing top surgery is sometimes also called subcutaneous mastectomy or male/masculinizing chest contouring.
Feminizing surgery
Any surgical procedure that makes someone look more feminine falls into this category of surgery. This can include breast augmentation, bottom surgery, orchiectomy, jaw shaving, certain types of facial fillers, liposuction, and other body sculpting procedures. Facial feminization surgery is also called “FFS” for short. FFS means the specific surgeries that create a more feminine appearance, such as rhinoplasty, laryngeal shave, or jaw shaving.
Some of these procedures are covered by insurance as gender-affirming surgery, while others are considered cosmetic or aesthetic procedures. Reach out to your insurance company to learn more about your coverage.
Sex change surgery
Bottom surgery for trans women and transfeminine people
Trans women, transfeminine people, and folks who identify as FTM or AFAB may all seek bottom surgery. Some of the procedures they may want include orchiectomy or vaginoplasty. Orchiectomy is the removal of the testicles. Vaginoplasty is a surgical procedure that reconstructs the penis and urethra into a vulva, labia, clitoris, and vagina.
Bottom surgery for trans men and transmasculine people
Trans men, transmasculine people, and folks who identify as MTF or AMAB may all seek bottom surgery. Some of the procedures they may want include hysterectomy or phalloplasty. Hysterectomy is the surgical removal of the uterus (usually with the fallopian tubes). Phalloplasty is a surgical procedure that reconstructs the vulva, labia, clitoris, and vagina into a penis.
Nonbinary bottom surgery
Bottom surgery isn’t an inherently gendered procedure. Nonbinary people who want bottom surgery can get phalloplasty, orchiectomy, hysterectomy, or other types of surgery that will support their gender identity. Nonbinary people, including folks who aren’t using gender-affirming hormones, may need additional support obtaining the surgery they need.
Vaginoplasty
This type of bottom surgery reconstructs the penis, scrotum, testicles and urethra into a vagina. Trans women, transfeminine people, and nonbinary people may all seek vaginoplasty. The goals of vaginoplasty are to create realistic-looking genitalia with the ability to have sexual intercourse and experience an orgasm.
After surgery, it’s important to regularly dilate your vagina and follow your doctor’s guidance. When you are cleared to begin having penetrative vaginal sex, it’s important to use safer sex practices to protect the delicate new skin as it heals and reduce your risks of STIs.
Penis removal, reduction, or reconstruction
This type of bottom surgery makes the penis smaller, a different shape, or removes it. While this procedure is more common for cisgender people, some transgender people find that it is affirming to change their penis size or shape.
Phalloplasty
This type of bottom surgery reconstructs the clitoris, vaginal lining, and urethra into a penis. Trans men, transmasculine people, and nonbinary people may all seek phalloplasty. Some patients opt for metoidioplasty or clitoral release surgery when they don’t want to have a complete phalloplasty. The goals of phalloplasty are to create realistic-looking genitalia with the ability to have sexual intercourse and experience an orgasm.
After surgery, it’s important to follow medical guidance and use safer sex practices to protect the delicate new skin as it heals.
Orchiectomy
This type of bottom surgery removes the testicles. The scrotum is partially removed and resized, leaving the penis and urethra. Trans women, transfeminine people, and nonbinary people may all seek orchiectomy. After surgery, it’s important to follow medical guidance and use safer sex practices to protect the delicate new skin as it heals.
Hysterectomy
This type of bottom surgery removes the uterus (and sometimes, the ovaries and fallopian tubes as well). The surgery is completely internal, leaving the vagina and cervix. Trans men, transmasculine people, and nonbinary people may all seek hysterectomy.
After surgery, it’s important to follow medical guidance to allow yourself to heal. An ectopic pregnancy (when a pregnancy occurs and implants in the fallopian tubes or outside the uterus) after hysterectomy is a rare but potentially life-threatening event. Sexually transmitted illnesses, including HIV, can still occur after hysterectomy as well, so take steps to protect yourself!
Preparing for bottom surgery
Preparing for surgery is more than just paperwork. While bottom surgery happens below the belt and internally, you can take good care of your skin and body to ensure that you are ready for your procedure. Healthy skin and bones heal faster, so think of your self-care routine as an investment in your future wellness! Skin care before and after surgery can prevent keloid scarring as well. Proper hydration, using moisturizer, and taking a multivitamin can all help you get ready for your upcoming procedure. Follow your surgeon’s guidance and learn more about skin care here.
Sex differences and sensitivity
Bottom surgery, phalloplasty, orchiectomy, and other bottom surgeries all affect the nerve structures of the genitals. When the clitoris or penis is rebuilt, those nerve structures are preserved—but they do take time to recover, grow, and begin working again. Many people retain most of their sensitivity after surgery, but it can take a while for sensation to return.
Recovering from bottom surgery
Bottom surgery is a major surgery, so recovering will take time—up to six months for some people. Many people use a bidet, sit on a donut-shaped pillow, and use other comfort measures while they’re healing. It’s important to take a complete break from physical activity, including exercise, sex, or any activity that stresses the lower part of the body. Follow your surgeon’s guidance to get the most out of your healing and give your body a chance to settle into its new shape.
Pain medications after surgery
Since gender-affirming surgery is a major medical procedure, pain management is important to the healing process. Opioids, acetaminophen, ibuprofen, ice packs, a donut-shaped pillow to sit on, and other comfort measures can help you get through the first couple of months. Talk to your doctor about your pain needs to make a plan.
Activity limitations before and after bottom surgery
Prior to bottom surgery, there are no activity limitations unless specified by your surgeon. Obviously, you should try to avoid illness and injury prior to surgery—you don’t want to have to reschedule because you got hurt doing something! After bottom surgery, you will need to be extremely mindful about following your surgeon’s guidance to avoid infection and injury. Over time, you will be able to return to gentle exercise, such as slow walking. If you’re a swimmer, ask your doctor when you can get back in the water!
How long do I have to be on hormones before I can get bottom surgery?
The short answer: it depends. Some surgeons require their patient to be on hormones for at least one year, since the body changes dramatically while using GAHT. If hormones are not appropriate for your gender identity, it is possible to bypass this requirement with a letter from your doctor.
The WPATH Standards of Care criteria for genital surgery includes a requirement for 12 continuous months of hormone therapy, but if gender-affirming hormone therapy (GAHT, sometimes called HRT or hormone replacement therapy) isn’t medically safe or appropriate this doesn’t apply. The Standards of Care state that patients should be taking some form of hormone supplementation after orchiectomy—either estrogen or testosterone.
How much does bottom surgery cost?
There is no set price for bottom surgery. Each procedure is different and each surgeon may charge a different amount. Vaginoplasty (one-stage with penile inversion, clitoroplasty, and labiaplasty) can cost $25,000 or more, plus the cost of anesthesia and a hospital stay. Phalloplasty (including scrotoplasty, testicular implants, glansplasty, and transposition of the clitoris) can cost $25,000 or more, plus the cost of anesthesia and a hospital stay.
Anesthesia and in-patient nursing care are essential to complete and recover from bottom surgery. These support services can cost $2,000 for anesthesia and $4,000 or more for overnights in the hospital.
Some people use insurance to pay some or all of their surgery costs. Others crowdfund, pay out of pocket, or rely on gender-affirming grants.
How can I get bottom surgery covered by insurance?
Every insurance plan is different, so check your plan’s coverage for gender-affirming surgery. You may also need to work with a primary care doctor, get a letter of support for the procedure you want, and find a surgeon who knows how to perform bottom surgery.
How long after bottom surgery will I feel normal?
Many people say they feel intense gender euphoria when they wake up from surgery. Even before the bandages come off, they feel happy in a completely new way. Most people experience pain and discomfort for the first few days after surgery, but can get back on their feet within two weeks. Everyone’s experience is different—so don’t rush yourself.
Does bottom surgery hurt?
Bottom surgery is performed under anesthesia, so you will be unconscious during the procedure. The recovery period can be uncomfortable and even painful for some people. Your doctor will offer you medications to manage your pain. Some people say that the drains, tape or bandages, and general soreness are more painful than the incisions themselves. While the healing period can be long, most people who undergo bottom surgery say that feeling at home in their bodies makes the discomfort worth it.
When can I start having sex after bottom surgery?
It depends on the type of sex! You can give oral sex, engage in mutual masturbation, and offer sensual touch any time you and your partner want to connect. Cuddling, kissing, and other forms of sex that don’t directly involve your private parts may be best until you’re cleared by your doctor and in the mood, too.
You will need to abstain from being touched, including oral sex and using toys, until your doctor says it’s safe. Genital healing takes months, and your nerve endings will need time to recover from your procedure. Additionally, you may need to wait for your vagina, urethra, urinary tract, abdomen, and perianal area to heal after surgery. These sensations can be painful at times and lessen your interest in sex.
For penetrative sex, including vaginal and oral sex, follow your surgeon’s guidelines. It may take some practice and patience to get used to your body’s new sensations—but you’ll find your groove.
Do I need to take hormones after bottom surgery?
While not all types of bottom surgery remove the sex organs, some do:
- Hysterectomy, removal of the uterus
- Salpingo-oophorectomy, removal of one (unilateral) or both (bilateral) ovaries and fallopian tubes. Some people opt to have this procedure at the same time as a hysterectomy, or else as its own surgery.
- Orchiectomy, removal of the testicles
Because these types of procedures remove the sex organs, they are called “gonadectomy” surgeries. Having a gonadectomy will change the amount of hormones someone’s body naturally makes. For example, after an orchiectomy, the body will stop producing testosterone.
The WPATH Standards of Care recommend that someone who wants to remove their sex organs take GAHT for one year (12 continuous months) as appropriate to their transition goals, unless hormones are not clinically indicated for the individual. This is to introduce a period of reversible estrogen or testosterone suppression, before the irreversible surgical procedure.
The WPATH Standards of Care also state that patients should be taking some form of hormone supplementation after gonadectomy. If someone gets an orchiectomy or hysterectomy (with or without salpingo-oophorectomy), they are recommended to take either estrogen or testosterone GAHT—whatever is appropriate for their gender identity and transition goals.
Gonadectomy takes away reproductive function (but won’t affect your ability to have and enjoy sex.) If you’re considered a procedure of this type, take some time to think about fertility preservation or family planning.
