Gender Overview

AFAB

Assigned female at birth (AFAB) is a term used to indicate a person who was designated female at birth. Typically people are assigned their gender at birth by their parents or by medical providers, usually based on the appearance of their external genitalia or by chromosomal testing pre or post-birth. 

This language is sometimes used as a shorthand by transgender and nonbinary people to describe their gender assigned at birth. A trans man might call himself AFAB for example, or a nonbinary person might also, e.g. “I’m AFAB nonbinary.” AFAB people might also use the language FTM, for “female-to-male,” though this is not as commonly used now to self-identify as it once was.

Agender

A term used to describe a person who doesn’t identify with any specific gender or identifies as genderless or gender-free. They might use they/them pronouns or an agender person might choose other pronouns, such as ze/zir, fae/faer or others.

AMAB

Assigned male at birth (AMAB) is a term used to indicate a person who was designated male at birth. Typically people are assigned their gender at birth by their parents or by medical providers, usually based on the appearance of their external genitalia or by chromosomal testing pre or post-birth. 

This language is sometimes used as a shorthand by transgender and nonbinary people to describe their gender assigned at birth. A trans woman might call herself AMAB for example, or a nonbinary person might also, e.g. “I’m AMAB nonbinary.” AMAB people might also use the language MTF, for “male-to-female,” though this is not as commonly used now to self-identify as it once was.

Androgynous

Androgynous is a term used to describe a person whose gender identity and/or gender expression is neither feminine nor masculine. It’s a word that means “man-woman” or “male-female,” and the term has been used in English since at least the 15th century. Androgynous people might identify as nonbinary, gender queer, gender non-conforming, or another gender term as well.

Bigender

A term used to describe a person who identifies as having two genders. They may feel like both a man and a woman and may use he/him and she/her pronouns interchangeably, or they might feel like two other genders and use other pronouns.

Cisgender

A term used to describe a person who identifies as the gender assigned to them at birth (e.g., a cisgender man is someone who identifies as male and was assigned male at birth, a cisgender woman is someone who identifies as female and was assigned female at birth). 

Fem/femme/feminine

A term used to describe a person who identifies with femininity and/or presents themself in a feminine way. Femme and feminine people may or may not identify as women (cisgender or transgender) and may also identify as nonbinary. Sometimes used by trans nonbinary people who do not identify as women or to encompass a spectrum of trans feminine identities, e.g. “transfemme” or “transfeminine.”

FTM

An abbreviation for “female to male,” the word FTM describes someone who was assigned female at birth and transitioned to male. Some other terms for FTM folks are trans men or transmasculine people or “assigned female at birth” (AFAB). 

Gender diverse

Gender diverse is an umbrella term for anyone whose gender identity or gender expression doesn’t fit into a cisgender or binary understanding of gender (“man” and “woman”). Gender diversity is present in all of human history and across all cultures. Gender diverse people might identify as transgender, nonbinary, gender non-conforming, genderqueer and more. Intersex people might also consider themselves gender diverse. 

Gender dysphoria

Gender dysphoria is a feeling that a person’s body or gender doesn’t match up with their internal sense of self. The DSM-IV definition of gender dysphoria is “psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” A diagnosis of gender dysphoria is sometimes necessary to receive gender-affirming care, including hormones (sometimes called HRT or gender-affirming hormone therapy) and gender-affirming surgery, in certain medical settings. Many transgender and nonbinary people experience gender dysphoria, but not all do. A trans-competent provider can help you figure out what your feelings mean for you and what treatment paths might fit.

Gender euphoria

Gender euphoria is a feeling of alignment and joy that happens when one’s gender identity is felt or expressed. It is a psychological state of bliss and comfort that happens when a person’s gender expression is aligned with their identity. Though gender dysphoria has been a medical term used to diagnose and treat transgender people, many trans and nonbinary people feel that gender euphoria – the positive feeling that happens with true expression – is a more fitting way to describe their experience of their identity and their transness.

Gender expression

Gender expression is how a person expresses their gender – perhaps just to themselves, or in how they show the world their gender identity. Gender expression can include clothing, hairstyle, behavior, pronouns, names, or anything else that communicates to yourself or others what your gender is to you.

Genderfluid

A term used to describe a person who feels like their gender identity and/or expression changes over time. They may feel more masculine sometimes and more feminine other times, or they might experience gender outside the binary spectrum entirely.

Gender identity

Gender identity is a person’s internal sense of what gender they are. A person’s gender identity may or may not match their gender assigned at birth. If it does, they are cisgender. (E.g. a cisgender woman is someone who identifies as a woman and was assigned female at birth.) If a person’s gender identity does not match their gender assigned at birth, they may identity as transgender, nonbinary, genderqueer, gender non-conforming, or use another name for their gender identity. (E.g. a transgender woman is someone who identifies as a woman and as transgender – they were not assigned female at birth and likely were assigned male at birth.) A person’s gender identity is their sense of who they are and may not “match” their external gender expression.

Gender non-conforming

A term used to describe a person whose gender expression (how they dress and act, perhaps what pronouns or name they use) doesn’t conform to societal expectations for their assigned gender at birth or perhaps to binary gender at all. 

Genderqueer

A term used to describe a person whose gender identity falls outside of the traditional binary categories of man/woman or masculine/feminine. Genderqueer people might identity as cisgender, or butch, or femme, or another gendered term, or they might identify as transgender and/or nonbinary as well.

Intersex

Intersex refers to someone whose physical sex characteristics or chromosomes don’t match societal expectations for what’s typically seen as male or female. Some intersex people are born with ambiguous external genitalia or presented as one sex when they’re born, but then discover at puberty that their body has developed differently from how they were raised. Others develop in a more typical way for their sex assigned at birth, but discover that their chromosomes don’t fit into either category. Intersex doesn’t just refer to one kind of experience—it covers a wide range of actual bodies and identities. An estimated 1.7% of people are born with intersex traits.

Intersex individuals can identify as male, female, neither or both. Intersex is different from transgender, because being transgender has to do with gender identity – someone’s internal sense of their gender – while being intersex has to do with physical characteristics and chromosomes.

Masc/masculine

A term used to describe a person  who identifies with masculinity and/or presents themself in a masculine way. Masc and masculine people may or may not identify as men (cisgender or transgender) and may also identify as nonbinary. Sometimes used by trans nonbinary people who do not identify as men or to encompass a spectrum of trans masculine identities, e.g. “transmasc” or “transmasculine.”

MTF

An abbreviation for “male to female,” the word MTF describes someone who was assigned male at birth and transitioned to female. Some other terms for MTF folks are trans women or transfeminine people or “assigned male at birth” (AMAB). 

Nonbinary

Nonbinary, also sometimes spelled non-binary, is an umbrella term for people who identify outside the gender binary, as neither a man nor a woman. Nonbinary people might identify as transgender – i.e. not the gender they were assigned at birth  – or they might not. They might identify or express themselves as genderqueer or gender non-conforming, or you might not be able to tell they are nonbinary from their external appearance at all. Many nonbinary people use they/them pronouns, but some choose other pronouns.

Passing

Passing is a term used to indicate being perceived as cisgender. E.g. a trans man who is “passing” is seen as a cisgender man and not recognized as being trans; this might be by choice or just because of how someone looks and presents themself. Some folks can “pass” as cisgender by taking hormones (gender-affirming hormone therapy, sometimes called HRT), changing their voice, body language, or other gender expression. Passing is sometimes a transition goal for people, while others are not interested in looking or being perceived as cis.

Stealth

“Stealth” commonly refers to a transgender person who does not share that they are transgender and may present as cisgender. Being stealth can be a choice that someone makes for their own privacy, for safety reasons, to avoid scrutiny or discrimination, or because they don’t feel it is necessary to talk about their medical history with some or all people in their life. 

Transgender

A term used to describe a person who has a gender identity that differs from the one they were assigned at birth. For example, a transgender man is someone who identifies as a man and was not assigned male at birth, a transgender woman is someone who identifies as a woman and was not assigned female at birth. Nonbinary people might identity as transgender (i.e. not the gender they were assigned at birth) or they might not.

Transition

Gender transition is the process of changing one’s gender identity and/or expression, and it can take place in many different ways. For example, a person might change their name, hairstyle, clothing style, body language, or pronoun usage. They might also change their legal name or gender marker on government documents. While not everyone needs or wants medical support for their transition, many folks use hormones such as estrogen and testosterone to support their transition. Some people also pursue gender-affirming surgery and other procedures for their gender transition, including top surgery, bottom surgery, breast augmentation, electrolysis, liposuction and body sculpting, facial feminization surgery (FFS), feminization laryngoplasty, and more. 

Two-spirit

Some Indigenous people use the term two-spirit to describe their identity. This term acknowledges the traditional belief that some people have both male and female spirits within them. Certain tribes and nations have their own names for these types of people, such as the Lakota winkte and the Navajo nadleeh. 

Transfeminine

Transfeminine or transfemme or transfem identity are terms sometimes used by AMAB (assigned male at birth) nonbinary people to describe their feminine but not female or woman identities. They are also sometimes used as umbrella terms for people who hold feminine transgender identities (inclusive of trans women) or gender transitions, such as dressing more feminine or taking estrogen. Though transfeminine might be used as an umbrella term, not all trans women or people taking estrogen identify with femininity and even those who do express femininity in many different ways.

Trans man

A man who is transgender. Transgender is a term used to describe a person who has a gender identity that differs from the one they were assigned at birth. A transgender man is someone who identifies as a man and was not assigned male at birth. Some other terms for trans men are FTM, transmasculine people, or “assigned female at birth” (AFAB). Not all terms resonate with all people, and language is always evolving.

Transmasculine

Transmasculine or transmasc identity are terms sometimes used by AFAB (assigned female at birth) nonbinary people to describe their masculine but not male or man identities. They are also sometimes used as umbrella terms for people who hold masculine transgender identities (inclusive of trans men) or gender transitions, such as dressing more masculine, getting chest-flattening top surgery, or taking testosterone. Though transmasculine might be used as an umbrella term, not all trans men or people taking testosterone identify with masculinity and even those who do express masculinity in many different ways. 

Transexual

A term used to describe a person who is transgender, historically often referring to someone who has used or desires to use gender-affirming hormones and/or gender-affirming surgeries as part of their transition. Transgender is a more commonly used umbrella term now, but some people do still choose to identify as transexual. They might also identify as FTM (female-to-male) and MTF (male-to-female).

Trans woman

A woman who is transgender. Transgender is a term used to describe a person who has a gender identity that differs from the one they were assigned at birth. A transgender woman is someone who identifies as a woman and was not assigned female at birth. Some other terms for trans women are MTF, transfeminine people, or “assigned male at birth” (AMAB). Not all terms resonate with all people, and language is always evolving.

Feminine identity

MTF

An abbreviation for “male to female,” the word MTF describes someone who was raised as a boy and transitioned later in life. Some other terms for MTF folks are trans women or transfeminine people or “assigned male at birth” (AMAB). Some people like the shorthand of MTF when describing their gender (as it indicates both their assigned at birth and current gender). Others prefer not to use this term, as they don’t feel it fits how they view their identity or gender.

Transfeminine

Transfeminine or transfemme or transfem identity are terms sometimes used by AMAB (assigned male at birth) nonbinary people to describe their feminine but not female or woman identities. They are also sometimes used as umbrella terms for people who hold feminine transgender identities (inclusive of trans women) or gender transitions, such as dressing more feminine or taking estrogen. Though transfeminine might be used as an umbrella term, not all trans women or people taking estrogen identify with femininity and even those who do express femininity in many different ways.

Nonbinary femme

Some nonbinary people also identify as feminine or femme or with expressions of femininity. They might or might not also identify as “feminine of center,” transfeminine or transfemme, or with another gender term.

Feminine of center

Some people choose “feminine of center” to describe a gender identity towards the feminine side of a masculine to feminine continuum.

Estrogen

Estrogen is a naturally occurring hormone that is typically produced in all bodies, but in different amounts for different bodies. For gender-affirming hormone therapy (GAHT, sometimes also called HRT or hormone replacement therapy), our Care Team prescribes synthetic bioidentical estrogen, also known as 17-beta estradiol.

Progesterone

Progesterone is another hormone that can be used during someone’s gender transition. Sometimes people take this with estrogen, or with another medication. At Plume, our Care Team tends to prescribe bioidentical progesterone. This is called micronized progesterone or Prometrium (the brand name). Progesterone is usually taken as a capsule swallowed in the evenings before bed.

There is little research on the use of progesterone for trans people, but many folks feel that this hormone helps with changes like breast development, including rounding out the breasts and areolar development, adding fullness to the hip area, and possibly improving mood and increasing libido. It appears to be safe, so if you want to try it, there doesn’t appear to be much risk.

T-blocker

Some gender-affirming medications can change your hormonal makeup by stopping your body from producing certain hormones. Since everyone’s body makes different amounts of estrogen and testosterone, blockers simply “block” one type of these hormones. Often, blockers are used in combination with other hormones to support gender transition. Spironolactone is one type of T blocker.

Masculine identity

FTM

An abbreviation for “female to male,” the word FTM describes someone who was assigned female at birth. Some other terms for FTM folks are trans men or transmasculine people or “assigned female at birth” (AFAB). Some people like the shorthand of FTM when describing their gender (as it indicates both their assigned at birth and current gender). Others prefer not to use this term, as they don’t feel it fits how they view their identity or gender.

Masculine of center

Some people choose “masculine of center” to describe a gender identity towards the masculine side of a masculine to feminine continuum.

Nonbinary and masc

Some nonbinary people also identify as masculine or with expressions of masculinity. They might or might not also identify as “masculine of center,” transmasculine or transmasc, or with another gender term.

Trans man

A man who is transgender. Transgender is a term used to describe a person who has a gender identity that differs from the one they were assigned at birth. A transgender man is someone who identifies as a man and was not assigned male at birth. Some other terms for trans men are FTM, transmasculine people, or “assigned female at birth” (AFAB). Not all terms resonate with all people, and language is always evolving.

Transmasculine/transmasc

Transmasculine or transmasc identity are terms sometimes used by AFAB (assigned female at birth) nonbinary people to describe their masculine but not male or man identities. They are also sometimes used as umbrella terms for people who hold masculine transgender identities (inclusive of trans men) or gender transitions, such as dressing more masculine, getting chest-flattening top surgery, or taking testosterone. Though transmasculine might be used as an umbrella term, not all trans men or people taking testosterone identify with masculinity and even those who do express masculinity in many different ways.

Testosterone

Testosterone (often called “T”) is a naturally occurring hormone that is typically produced in all bodies, but in different amounts for different bodies. For gender-affirming hormone therapy (GAHT, sometimes also called HRT or hormone replacement therapy), our Care Team prescribes synthetic testosterone. This medication is very similar to the testosterone all bodies naturally make. 

Puberty blocker

Some gender-affirming medications can change your hormonal makeup by stopping your body from producing certain hormones. Since everyone’s body makes different amounts of estrogen and testosterone, blockers simply “block” one type of these hormones. Often, blockers are used in combination with other hormones to support gender transition. Ask your Care Team about how blockers can help you during your gender transition!

Hair loss

For people who are using testosterone as a gender-affirming medication, hair loss can be a common worry. T changes the pattern of hair growth and its texture. Some people notice very little hair loss, while others go bald! So you know, Plume prescribes hair restoration medications to folks who are worried about losing their hair while taking T.

Binding

Binding is the practice of flattening or minimizing the appearance of your chest. Some people bind with sports bras while others wear a special garment called a binder. Binding is safe and can help alleviate gender dysphoria, but there are some precautions to help prevent injury.

Stealth

“Stealth” commonly refers to a transgender person who does not share that they are transgender and may present as cisgender. Being stealth can be a choice that someone makes for their own privacy, for safety reasons, to avoid scrutiny or discrimination, or because they don’t feel it is necessary to talk about their medical history with some or all people in their life. 

Another term you might hear is “passing.” Passing is a term used to indicate being perceived as cisgender. For example, a trans man who is “passing” is seen as a cisgender man and not recognized as being trans; this might be by choice or just because of how someone looks and presents themself. Some folks can “pass” as cisgender by taking hormones (gender-affirming hormone therapy, sometimes called HRT), changing their voice, body language, or other gender expression. Passing is sometimes a transition goal for people, while others are not interested in looking or being perceived as cis.

Facial & aesthetic surgery

Facial surgery

Facial surgery is any surgery that alters the look of the head, face, or neck. This highly specialized field includes surgeries for the brow, cheeks, jaw, nose, chin, ears, lips, and other facial features.

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.

Nonbinary facial surgery

Since every nonbinary person defines their own gender expression, there is no one-size-fits all surgery for nonbinary folks. Nonbinary facial surgery might include rhinoplasty, brow reduction surgery, and jaw shaving or jaw injections. 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.

Masculinizing surgery

Any surgical procedure that makes someone look more masculine falls into this category of surgery. This can include top surgery, bottom surgery, certain types of facial fillers, jaw injections, liposuction, and other body sculpting procedures. 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.

Types of facial feminization surgery (FFS)

Any surgical procedure that makes someone look more feminine falls into this category of facial feminization surgery (FFS). This can include jaw shaving, certain types of facial fillers, liposuction, rhinoplasty, and other facial sculpting procedures. 

Some surgeons require their patient to be on hormones for at least one year before getting facial feminization surgery. This is because the body and facial features can change 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 do not state criteria for surgical procedures such as feminizing or masculinizing facial surgery. In this way, FFS and other facial surgeries are different from procedures such as top surgery or bottom surgery. However, mental health professionals can play an important role in helping their clients to make fully informed decisions about the timing and implications of such procedures in the context of the overall coming-out or transition process.

There is no set price for facial feminization surgery (FFS). Each procedure is different and each surgeon may charge a different amount. However, the average cost of each procedure is fairly standardized. For example, the average cost of cheek implants is $3,669, the average cost of chin augmentation is $3,137 and the average cost of lip augmentation (without injectable fillers) is $2,299, according to the most recent statistics from the American Society of Plastic Surgeons. Laryngeal shaving costs $3,000-$4,000. 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.

Nose job or rhinoplasty

Rhinoplasty, commonly known as a “nose job,” is a facial surgery that changes the shape or size of someone’s nose. The surgeon may break, reset, shave down, or otherwise sculpt the nose to look more feminine. The average cost of rhinoplasty is $5,483, according to the most recent statistics from the American Society of Plastic Surgeons.

Brow reduction surgery

Brow reduction surgery makes extremely subtle micro adjustments to the bones of the forehead and eye ridges to look more feminine. The surgeon may shave down or even reset these bones during the procedure.

Top 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.

Nonbinary chest surgery

Since every nonbinary person defines their own gender expression, there is no one-size-fits all surgery for nonbinary folks. Nonbinary chest surgery includes top surgery, breast reduction surgery, and breast augmentation.

Chest surgery

This term describes any type of surgery that changes the look of someone’s chest and includes top surgery, mastectomy, and breast augmentation.

Breast augmentation

Breast augmentation is an aesthetic surgery that creates the look of breasts using silicone or gel implants. Top surgery for trans women, transfeminine people, or others who want to affirm their gender with a more feminine-looking chest generally includes implanting, reshaping, repositioning, or augmenting the breast/chest tissue. It is sometimes called MTF top surgery. It also typically includes reshaping and repositioning the nipples (nipple grafts). Some people choose to remove their nipples entirely. 

Some people choose to transfer fat from one part of their body to their chests in order to create breasts. This is called “fat grafting.” Others use medical implants. Using silicone or saline to augment breast size is a multi-step process called “lipofilling.” After inserting a thick pouch under the chest or pectoral muscles—either through incisions in the armpit area or a small incision in the belly button—the pouches are filled. This happens slowly over multiple visits so the skin has time to stretch and recover. The pouches or implants can be adjusted to the desired size in most cases to give a feminine, curvy look.

Because estrogen, progesterone, and T blockers can all stimulate breast growth, the WPATH Standards of Care recommend that anyone seeking breast augmentation as a gender-affirming top surgery take E for one year or more.

Breast implants

Small, contoured pouches of silicone, gel, or another body-safe material that are inserted under the chest or pectoral muscles. Breast implants make someone’s breasts look larger, fuller, or more lifted depending on their placement.

Breast removal, reduction, or reconstruction

Not everyone calls their chest by the same terms. For some people, the word “breast” may not be their preferred term or may cause gender dysphoria. In the surgical field, “breast” is not considered a gendered term, as every person has breast tissue. Surgeons sometimes refer to top surgery and mastectomy as breast removal, reduction, or reconstruction.

Mastectomy

A treatment for breast cancer or other health issues, mastectomy is the total removal of all breast tissue. This procedure can be preventative for people who have the BRCA gene, a gene receptor that dramatically increases the likelihood of developing breast cancer. Often, people who undergo a mastectomy also get breast implants.

Top surgery

“Top surgery” is a general term that describes gender-affirming surgery on the chest. Top surgery is considered an aesthetic surgery that helps someone align their appearance with their gender identity and alleviate gender dysphoria. It can include breast augmentation, mastectomy, breast reduction, or masculinizing surgery.

Some surgeons require their patient to be on hormones for at least one year before getting top surgery, since the body changes dramatically while using GAHT. The WPATH Standards of Care state that the criteria for any gender-affirming top surgery are:

• Persistent, well-documented gender dysphoria;
• Capacity to make a fully informed decision and to consent for treatment;
• Age of majority in a given country (if younger, follow the SOC for children and adolescents);
• If significant medical or mental health concerns are present, they must be reasonably well controlled.

The Standards of Care recommend that people who want breast augmentation (implants/lipofilling) as gender-affirming top surgery undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. This is suggested because taking E or other medications will maximize breast growth and help obtain better surgical (aesthetic) results.

The criteria for top surgery for trans men, transmasculine people, nonbinary folks, and FTM people are different. This type of masculinizing top surgery does not come with the recommended prerequisite of gender-affirming hormone therapy. This may vary from surgeon to surgeon—some doctors say that being on T for a year or more will change the texture of your breast tissue, shift your body fat, and give you a more masculine appearance. This would support a better surgical outcome. 

If hormones are not appropriate for your gender identity, it is possible to bypass this requirement with a letter from your doctor. 

There is no set price for top surgery. Top surgery for trans men, transmasculine people, FTM folks, and nonbinary people can range from $6,000 to $10,000, not including anesthesia and aftercare. Breast augmentation for trans women, transfeminine people, MTF folks, and nonbinary people can range from $8,000-$9,500, not including anesthesia and aftercare. Breast augmentation can happen in multiple stages. After the initial surgery, there would be a second or even third appointment to slowly expand the implants and ensure that your breasts look the way you want.

Top surgery is not usually a procedure where you would need to stay in the hospital overnight, but some people do hire a nurse to help them while they are recovering. People who travel out of town or to another country to have their surgery would pay travel costs, including hotel, meals, and transportation. Some people use insurance to pay some or all of their top surgery costs. Others crowdfund, pay out of pocket, or rely on gender-affirming grants.  

Top surgery (for trans men or trans masculine people)

Top surgery for trans men, transmasculine people, or others who want to affirm their gender with a flatter chest generally includes removing breast/chest tissue. It is sometimes called FTM top surgery. It also typically includes reshaping, repositioning, or making the nipples smaller (nipple grafts). Some people choose to remove their nipples entirely. Some common types of top surgery are known as keyhole, buttonhole, double incision (DI), inverted-T or T-anchor, and peri areolar.

Types of surgical incisions in masculinizing chest surgery

Trans men, transmasculine people, nonbinary people, FTM folks, and others who want a more masculine appearance may all want this type of top surgery. When you meet with your surgeon for a consultation, you will let them know your desired outcome. This includes the size and shape of your chest, whether you would like to keep your nipples, and what incisions will be used. Some types of incisions and procedures are:

Keyhole

Keyhole is a small incision made around the lower half of the areola. Breast tissue is removed through this incision. The ultimate scar is fairly inconspicuous and rounded to the edge of the nipple. It is recommended for people with small breasts and firm skin. 

Concentric circle

Concentric circle is a variation of the Keyhole technique that removes a “donut” of skin around the areola to remove excess skin at or within the margin of the areola. (It’s also called the periareolar, circumareolar, or donut technique.) This technique is used when there is some excess skin present and/or a large areola that needs to be reduced in size. 

Lollipop 

Lollipop is a circular incision around the areola is combined with a vertical incision which extends down the chest from the underside of the areola. This incision removes a moderate amount of skin and can resize the areola. The lollipop incision surgery technique is not used frequently because it is designed for people who have a little extra skin tissue, want to leave their nipples in the same position, and are not candidates for a concentric circle incision.

Double incision free nipple graft

Double incision free nipple graft is an incision is made in or near the crease at the bottom of the breast and the nipples and areolas complexes are removed, trimmed to the desired stage, and then grafted back onto the newly reshaped chest. This process combines breast tissue removal with the removal of a large amount of skin. Double incision free nipple graft incision is used for moderately sized or larger breasts and those with substantial excess skin excess or skin that is very lax. This incision creates the types of bold, horizontal chest scars that you may have seen folks sporting in photos or at the beach!

Inverted “T”

Inverted “T” is an incision is made around the areola and then down to and along the crease at the lower part of the breast, making a T or anchor shape. (This type of incision is commonly used in most breast reduction procedures but is less commonly used in top surgery because it creates the look of smaller breasts instead of a mound shape.) With the inverted T, the nipples can either stay where they are on the chest or be removed and repositioned.

Buttonhole

The buttonhole procedure is used as an alternative to the inverted-T. In the buttonhole, there is one incision made around the areola and a second incision made along the crease at the lower part of the breast. However, there is no vertical incision connecting the two. The buttonhole removes less skin and does not reposition the nipple and areola. It creates a mound-like shape (as opposed to a breast-type shape) on each side of the chest.

Fish mouth 

The fish mouth incision goes around the nipple and extends into a short incision on either side of the areola, making the shape of a fish’s mouth. This incision removes unwanted chest tissue and results in a flatter chest, may preserve more nipple sensation, and has a very non-traditional incision location, across the mid-level of the chest.

While you may have aesthetic preferences about scar placement and shape, the surgeon will ultimately decide what types of incisions are appropriate for your top surgery. This decision is based on your initial breast or chest size, your skin’s degree of laxity (how much it droops or its reflexiveness), the size and location of your areola, and the shape of your chest wall.

Nipple placement

As part of top surgery, you may get to decide whether to keep your nipples and where your nipples will go on your newly reshaped chest. Most top surgery retains the nerve structures of the nipple. Your surgeon will mark your chest to show the position of your nipples prior to your top surgery.

Nipple removal

Some people don’t want to keep their nipples when they get top surgery, so they opt to have them removed during the procedure. If you decide to keep your nipples, it is very common to have them resized so they are in proportion to your new chest. When the surgeon makes the incision in your chest, your nipples can be reduced in size at the same time by extending the incision around the whole areola (nipple area) and removing a “donut” of skin.

Bottom surgery 

Bottom surgery

Bottom surgery is a gender-neutral name for a surgery that reconstructs the genitals, erectile tissue, urinary tract, urethra, or other reproductive organs. Bottom surgery reconstructs your private parts to look more feminine, masculine, or androgynous—whatever feels right for your gender identity. 

Some surgeons require their patient to be on hormones for at least one year before getting bottom surgery, 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.

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.

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

This is an older term for bottom surgery. Genital reconstruction was once called a “sex change.” Now, medical professionals and our community prefer the term “bottom surgery,” which is more inclusive and more accurate.

Bottom surgery (for trans women/transfeminine people)

Trans women, transfeminine people, and folks who identify as MTF or AMAB 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/transmasculine people)

Trans men, transmasculine people, and folks who identify as FTM or AFAB 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!