Transgender and intersex people follow many different paths to realize their gender expression.

Some do nothing at all and keep their gender identity and expression private. Some aspire to social transition — telling others about their gender identity — without medical intervention.

Many only pursue hormone replacement therapy (HRT). Others will pursue HRT as well as various degrees of surgery, including chest reconstruction or facial feminization surgery (FFS). They may also decide that bottom surgery — also known as genital surgery, sex reassignment surgery (SRS), or preferably, gender confirmation surgery (GCS) — is the right choice for them.

Bottom surgery generally refers to:

  • vaginoplasty
  • phalloplasty
  • metoidioplasty

Vaginoplasty is typically pursued by transgender women and AMAB (assigned male at birth) nonbinary people, while phalloplasty or metoidioplasty, is typically pursued by transgender men and AFAM (assigned female at birth) nonbinary people.

SurgeryCost runs from:
vaginoplasty$10,000-$30,000
metoidioplasty$6,000-$30,000
phalloplasty$20,000-$50,000, or even as high as $150,000

Leading transgender healthcare providers will either follow an informed consent model or the WPATH standards of care.

The informed consent model allows the physician to inform you of the risks of a certain decision. Then, you decide for yourself whether to proceed without any input from any other healthcare professional.

The WPATH standards of care requires a letter of support from a therapist to begin HRT, and multiple letters to undergo bottom surgery.

The WPATH method draws criticism from some people in the transgender community. They believe it takes control out of the hands of the person and implies that the transgender person deserves less personal authority than a cisgender person.

However, some care providers argue that ethical standards don’t contradict informed consent. Requiring letters from therapists and physicians appeals to some hospitals, surgeons, and care providers, who may look at this system as legally defensible if necessary.

Both of these methods are considered by some in the transgender community to be an improvement of the previous and widespread gatekeeper model. This model required months or years of “real-life experience” (RLE) in their gender identity before they could have HRT or more routine surgeries.

Some argued that this presumes transgender identity to be inferior or less legitimate than cisgender identity. They also believe that RLE is a mentally traumatic, socially impractical, and physically dangerous period of time in which a transgender person must out themselves to their community — without the benefit of the physical transformations that hormones or surgeries bring.

The gatekeeper model also tends to use heteronormative, cisnormative criteria for qualifying the real-life experience. This poses a significant challenge to transgender people with same-sex attractions or gender expressions outside a stereotypical norm (dresses and makeup for women, hyper-masculine presentation for men), and essentially erases the experience of nonbinary trans people.

In the United States, the main alternatives to paying the high out-of-pocket costs include working for a company that follows the Human Rights Campaign Foundation’s standards for its Equality Index, or by living in a state that requires insurers to cover transgender care, such as California or New York.

In Canada and the UK, bottom surgery is covered under nationalized healthcare, with varying levels of supervision and wait times depending on the region.

When choosing a surgeon, pursue in-person or skype interviews with as many surgeons as possible. Ask many questions, to get a sense of each surgeon’s variations in their technique, as well as their bedside manner. You want to choose someone that you’re comfortable with, and who you believe is the best fit for you.

Many surgeons give presentations or consultations in major cities throughout the year and may make appearances at transgender conferences. It also helps to reach out to former patients of the surgeons that interest you, via online forums, support groups, or mutual friends.

There are three main methods of vaginoplasty performed today:

  • penile inversion
  • rectosigmoid or colon graft
  • non-penile inversion vaginoplasty

In all three surgery methods, the clitoris is sculpted from the head of the penis.

Penile inversion

Penile inversion involves using the penile skin to form the neovagina. The labia major and minora are primarily made from scrotal tissue. This results in a sensate vagina and labia.

One main drawback is the lack of self-lubrication by the vaginal wall. Common variations include using the remaining scrotal tissue as a graft for additional vaginal depth, and using the intact mucosal urethra recovered from the penis to line part of the vagina, creating some self-lubrication.

Rectosigmoid vaginoplasty

Rectosigmoid vaginoplasty involves the use of intestinal tissue to form the vaginal wall. This technique is sometimes used in conjunction with penile inversion. Intestinal tissue helps when penile and scrotal tissue is scarce.

This method is often used for transgender women who began hormone therapy at puberty and were never exposed to testosterone.

Intestinal tissue has the added benefit of being mucosal, and therefore self-lubricating. This technique is also used to reconstruct vaginas for cisgender women who developed atypically short vaginal canals.

Non-penile inversion

Non-penile inversion is also known as the Suporn technique (after Dr. Suporn who invented it) or the Chonburi Flap.

This method uses perforated scrotal tissue graft for the vaginal lining, and intact scrotal tissue for the labia majora (same as a penile inversion). The penile tissue is used for the labia minora and clitoral hood.

Surgeons who use this technique purport greater vaginal depth, more sensate inner labia, and improved cosmetic appearance.

Phalloplasty and metoidioplasty are two methods that involve the construction of a neopenis.

Scrotoplasty may be performed with either surgery, which modifies the major labia into a scrotum. Testicular implants usually require waiting for a follow-up surgery.

Metoidioplasty

Metoidioplasty is a much simpler and quicker procedure than phalloplasty. In this procedure, the clitoris, already elongated to 3-8 centimeters by HRT, is released from the surrounding tissue, and repositioned to match the positioning of a penis.

You may also choose to do a urethral lengthening with your metoidioplasty, also known as a full metoidioplasty.

This method uses donor tissue from the cheek or from the vagina to connect the urethra to the new neopenis, allowing you to urinate while standing.

You may also pursue a Centurion procedure, wherein the ligaments underneath the major labia are repositioned to add girth to the neopenis. Removal of the vagina may be performed at this time, depending on your goals.

After these procedures, the neopenis may or may not maintain an erection on its own and is unlikely to provide meaningful penetrative sex.

Phalloplasty

Phalloplasty involves using a skin graft to elongate the neopenis to 5-8 inches. The common donor sites for the skin graft are the forearm, thigh, abdomen, and upper back.

There are pros and cons to each donor site. The forearm and thigh skin have the most potential for erotic sensation after surgery. However, the back scar tends to be the least visible and allows for additional penis length.

The abdomen and thigh flaps remain connected to the body throughout surgery.

The forearm and back sites are “free flaps” that must be entirely detached and reconnected via microsurgery.

The urethra is also lengthened via donor tissue from the same site. A penile implant may be inserted in a follow-up surgery, providing the ability to maintain a full erection suitable for penetrative sex.

Leading up to bottom surgery, most people require hair removal via electrolysis.

For vaginoplasty, hair will be removed on the skin that will eventually comprise the lining of the neovagina. For phalloplasty, hair is removed on the site of the donor skin.

Your surgeon will require you to stop HRT two weeks before surgery, and refrain for two weeks after surgery. Talk to your surgeon about other medications that you take regularly. They’ll let you know if you need to stop taking them before the surgery, too.

Some surgeons require a bowel prep before bottom surgery as well.

Vaginoplasty may result in loss of sensation in part or all of the neoclitoris due to nerve damage. Some people may experience a rectovaginal fistula, a serious problem that opens the intestines into the vagina. Vaginal prolapse may also occur. However, all of these are relatively rare complications.

More commonly, people who get a vaginoplasty may experience minor urinary incontinence, similar to what one experiences after giving birth. In many cases, such incontinence subsides after some time.

Full metoidioplasty and phalloplasty carry the risk of urethral fistula (a hole or opening in the urethra) or a urethral stricture (a blockage). Both can be repaired via minor follow-up surgery. Phalloplasty also carries the risk of rejection of the donor skin, or infection at the donor site. With scrotoplasty, the body may reject the testicular implants.

Vaginoplasty, metoidioplasty, and phalloplasty all carry a risk of the person being displeased with the aesthetic result.

Three to six days of hospitalization is required, followed by another 7-10 days of close outpatient supervision. After your procedure, expect to refrain from work or strenuous activity for roughly six weeks.

Vaginoplasty requires a catheter for about one week. Full metoidioplasty and phalloplasty require a catheter for up to three weeks, until the point at which you can purge the bulk of your urine through your urethra on your own.

After vaginoplasty, most people generally need to dilate regularly for the first year or two, by using a graduated series of hard plastic stents. After that, penetrative sexual activity is normally enough for upkeep. The neovagina develops microflora similar to a typical vagina, although the pH level leans much more alkaline.

Scars tend to either be hidden in the pubic hair, along the folds of the labia majora, or simply heal so well as to not be noticeable.