Gender Confirmation Surgery: Stages, Costs, and Aftercare

In recent years, the subject of gender confirmation surgery has become one of the most important, sensitive, and challenging topics in medical science. Many individuals whose gender identity does not align with their physical body decide to change their gender to achieve greater internal harmony and peace. This path is a combination of psychological treatments, hormone therapy, and cosmetic surgeries, and the treatment process cannot be completed without each of them. Gender confirmation surgery is not just a medical procedure; it has various legal, social, financial, and care aspects that individuals must be aware of before deciding to undergo it. This article fully addresses the topics related to gender confirmation surgery from various perspectives.

What is Gender Confirmation Surgery?

Gender confirmation surgery, also referred to as gender affirmation surgery or gender reassignment surgery, is a process during which an individual changes their gender identity. In essence, the individual's gender identity does not match the sex assigned at birth, and the individual's mental and sexual identity is inconsistent with their physical body. In this case, medical surgery leads to a change of gender and the body's alignment with their internal identity. Gender confirmation surgery is performed in several distinct stages, including multiple psychotherapy sessions, hormone therapy, top surgery (breast/chest surgery), bottom surgery (genital surgery), and post-operative psychological, social, and physical care. The goal of this surgery is to reduce the emotional and mental problems resulting from gender incongruence and to improve the quality of life for these individuals.



What is the Difference Between Gender Affirmation and Gender Reassignment?

In medical science, the two terms mentioned are generally related to the same subject but also have some differences. Gender Affirmation focuses only on the medical and surgical aspect and the redefinition of individuals' sex in terms of anatomy and physicality. In contrast, Gender Reassignment involves several different stages according to which the individual selects their gender identity, social, legal, and medical aspects. In fact, medical surgery and anatomical change can be said to be only a part of Gender Reassignment, making the latter a broader concept.

Who is Gender Confirmation Surgery Suitable For?

Some transgender individuals and individuals with gender incongruence do not necessarily choose surgery and may only pursue things like hormone therapy or social transitions. This surgery is suitable for individuals who:

• Their gender identity does not match their physical body. For example, they are female but emotionally and psychologically feel that they are male.
• The person must undergo the necessary psychological and medical evaluation to determine whether they are ready for surgery and this change.



Types of Gender Confirmation Surgeries

Gender confirmation surgery is one of the complex medical procedures that must be performed by professional specialists in this field and in several stages. This procedure is usually performed in two stages: top surgery and bottom surgery.

Top Surgeries: Breast Reconstruction or Mastectomy

The first stage of medical surgery for gender confirmation is related to the upper body. In this stage, for Female-to-Male (FTM) transition, top surgery (mastectomy or chest reconstruction) is performed. Protruding breasts are removed, and a chest with a masculine appearance is created. In Male-to-Female (MTF) transition, the breasts are enlarged and augmented to take on a feminine appearance.

Bottom Surgeries or Genital Reconstruction

The next stage involves surgery on the lower body. This surgery will be performed some time after the first surgery, at the discretion of the medical team.

• In Vaginoplasty (for MTF transition), a vagina, labia (genital lips), and clitoris are created to resemble female genitalia in terms of appearance, function, and sensation as much as possible. Various techniques are used for this procedure, such as penile inversion, skin grafts from the groin or forearm, and bowel graft.
• The Female-to-Male (FTM) surgery, or Phalloplasty, is more complex than the MTF procedure and is considered one of the most difficult surgeries in the world. The goal of this surgery is to create a male penis with the capability of urinating from the tip and preserving sexual sensation. This surgery is also performed using several different techniques, such as forearm or thigh flaps.



Facial Surgeries for Feminization or Masculinization

Another stage of gender affirmation that individuals often undergo after top and bottom surgeries is facial surgeries. In this method, cosmetic and reconstructive surgeries are performed to adjust the face, neck, chin, cheeks, jawline, nose, or larynx.



Comparison of MTF and FTM Surgeries

These two procedures have significant differences in various aspects such as surgical stages, complexity, recovery time, and cost. Generally, the surgical path for FTM transition is more complex. In this method, doctors strive to create a male penis with the ability to urinate and even engage in sexual intercourse. This procedure is much more expensive than the MTF surgery. Furthermore, the recovery period for the FTM method is longer than that for the MTF method.

Step-by-Step Stages of Gender Confirmation Surgery

The gender confirmation process may take several months or even several years. This procedure has several different stages that must be completed thoroughly and accurately.

Step 1: Psychological Evaluation and Specialist Confirmation

Before any action, the individual must have several specialized counseling sessions with a psychologist or psychiatrist specializing in gender dysphoria. In these counseling sessions, the doctor confirms whether the person truly needs gender confirmation surgery.

Step 2: Obtaining Court Authorization for Gender Confirmation

In some countries, including Iran, the individual needs a court order and legal approval to officially change their gender and legal documents.

Step 3: Pre-operative Tests and Examinations

Before any surgery, the individual's general health must be checked. Blood tests, hormonal tests, and examination of the heart, lungs, and other body organs are performed.

Step 4: Choosing the Surgeon and Determining the Type of Surgery

Each of the surgical procedures is performed using different methods. At this stage, the exact type of surgery must be determined in consultation with the surgeon. The risks, intended result, post-operative care, and expenses should all be thoroughly discussed with the patient by the surgeon and their team.

Step 5: Physical and Psychological Preparation Before Surgery

Prior to the procedure, the patient must accomplish a few crucial steps. These include keeping a healthy weight and quitting alcohol and tobacco. Additionally, the patient should concentrate on eating better and getting more restful sleep. It's also advised to discuss the impending procedure honestly with family members. Lastly, the medical team must be consulted as needed.



How Much Does Gender Confirmation Surgery Cost?

The cost of gender confirmation surgery depends on various factors such as the extent of changes, the country, the type of surgery, the surgeon's expertise, and the facilities used. Generally, this surgery is costly, both in Iran and in other countries, and insurance usually does not cover all of it. The approximate cost of this operation is estimated to be around 400 million to 900 million Tomans.



Post-Operative Costs (Medication, Care, and Follow-up)

As mentioned in the section above, the cost of gender confirmation surgery includes various components, including post-operative costs. Statistics show that about 10% to 20% of the cost is related to aftercare expenses, meaning approximately 40 to 150 million Tomans. These costs will include the following:

• Pain relievers, antibiotics, and hormonal medications
• Subsequent visits to the surgeon or specialist and consultation fees
• Physiotherapy or rehabilitation care for genital reconstruction
• Costs related to legal procedures and changing identification documents
• Hospitalization expenses at the hospital or treatment center

Recovery Period and Post-Operative Care

Gender confirmation surgery, like any other operation, requires a recovery period for the complete reconstruction of the body. This period will include the following stages:

Wound Healing Process and Home Care

During this period, maintaining cleanliness, preventing infection, following the necessary instructions for dressing changes, and taking medications are very important and vital. The movement restrictions prescribed by the doctor must also be fully observed.

Importance of Rest and Nutrition

During the recovery period after gender confirmation surgery, the person must have a healthy diet including sufficient protein and fluid intake. Eggs, dairy, fish, carrots, broccoli, red meat, apples, kiwi, liver, and legumes are foods that nourish the body well during this period.

Dilation and its Role in Healing

In MTF gender confirmation surgery, an instrument called a dilator is used to maintain the width and depth of the vagina, effectively keeping it open. Performing this stage after the operation is mandatory and necessary because the fresh vaginal tissue tends to close and narrow and may develop adhesions.

Time to Return to Daily Activities

Generally, the person can perform simple daily activities after a few weeks, but physical work and exercise may require several months.

What are the Potential Risks of Gender Confirmation Surgery?

Generally, and in rare cases, this surgery can have risks such as infection, bleeding, delayed healing, undesirable scarring, or sensory functional problems. However, data shows that the rate of serious complications from this operation, in both men and women, is very low, and most individuals have been satisfied with the improved quality of life after surgery.

Sexual Life After Gender Confirmation

It is possible to have sexual intercourse after gender confirmation surgery. Research indicates that the quality and satisfaction of sexual life increase after the operation. To engage in sexual intercourse, the individual's wounds must have completely healed, and the person must be psychologically ready for sexual relations.

Legal Conditions and Restrictions for Gender Confirmation Surgery

Gender confirmation surgery is performed in every country according to its specific laws. This operation is completely legal and regulated in Iran, under the supervision of legal and medical authorities, and has the necessary permits. The following are some of the restrictions and laws for this surgery in Iran:

• The person must be of legal age (18 years or older).
• Obtaining authorization from the court is mandatory.
• A specialist psychiatrist or psychologist must confirm the need for gender confirmation surgery.
• Married individuals usually must separate before the surgery.
• Individuals with chronic cardiovascular diseases are not permitted to undergo this operation.



Non-Surgical Alternatives (HRT, Social Transition)

For individuals who have a gender identity mismatch with their physical body, surgery is not the only option. There are other alternative methods that cost less and may have fewer psychological and social consequences for individuals.

• In Hormone Replacement Therapy (HRT), instead of FTM surgery, testosterone hormone is used to change the voice, grow facial and body hair, increase muscle, and reduce body fat. Similarly, for MTF transition, hormone therapy is performed using estrogen and anti-androgens to cause breast growth, soften the skin, reduce thick hair, and change body fat distribution. Note that in this method, individuals' legal documents remain with their original sex and do not change.
• Social Transition: In this method, the individual's name, clothing, and social behaviors are changed so that the person can experience their desired gender identity. The person's identity documents will also not change in this method.



Conclusion

Gender affirmation surgery is a very sensitive and complex topic, involving various medical, psychological, legal, and social stages. If confirmed by a specialist psychiatrist, the person can undergo gender confirmation surgery. This operation is performed in several stages (top and bottom surgery) and requires high specialization and experience from the medical team. Gender affirmation surgery in Iran is also completely legal and can be performed according to the country's laws. Choosing a specialist medical team, the individual's psychological and social readiness, and post-operative care ensure that the outcome of the surgery is very satisfactory, and the person experiences life with a physical body that matches their gender identity.

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Frequently Asked Questions

What legal permits are required for gender confirmation surgery?

Receiving an official court order and medical and psychological confirmation is mandatory.

What should be expected after gender confirmation surgery?

The body's appearance will largely transition to the desired gender identity. However, post-operative care must be fully observed. Given that the person's appearance aligns with their gender identity, their self-confidence increases, and they will feel better in society.

When can gender confirmation surgery be performed?

Individuals can undergo gender confirmation surgery after the age of 18 with the necessary legal and medical approvals.

How painful is Female-to-Male gender confirmation surgery?

The level of pain depends on the type of surgery. However, pain can be controlled using painkillers. Nevertheless, in MTF surgery, Vaginoplasty (due to tissue reconstruction and removal of testicles and penis) will have the most pain. In FTM surgery, Phalloplasty (penis creation) and Mastectomy (breast removal) will have the most pain.

How expensive is gender affirmation surgery?

The cost of gender affirmation surgery depends on various factors such as the type of surgery, the doctor's expertise, and the facilities used. This operation is considered costly. The cost of this surgery in Iran varies between 500 million to 900 million Tomans.

How long does gender confirmation surgery take? Depending on the type of surgery, this operation may take three to eight hours. FTM surgery usually requires more time

How do I know if gender confirmation surgery is right for me?

To be sure of the answer to this question, you must undergo specialized consultations with a psychologist and a surgical physician.

Does bottom surgery look real?

Yes, in both MTF and FTM surgery, the vagina and penis will have a natural and normal appearance.

Is it possible to become pregnant after gender confirmation surgery?

In MTF surgery, no, because the ovaries and uterus are removed. In FTM surgery, this is possible if the ovaries are preserved. However, pregnancy would be with the previous physical sex, not with the new gender identity.

Is gender confirmation surgery permanent?

Yes, in terms of appearance and reconstructed organs. However, some care, such as hormone therapy and the use of dilators, may still be necessary.

How long does the recovery period after gender confirmation surgery take?

The recovery period varies depending on the type and severity of the surgery and each individual's physical condition, but generally, the person needs about four to eight weeks of rest to return to their daily life.

Is it possible to achieve sperm after bottom surgery?

No, sperm production only occurs in the bodies of men with real testicles and will not be created in FTM surgery.