This page provides a brief summary of a gender affirming genital surgeries and offers guidance to help you support your trans patients if they undergo these surgical interventions.

GRS, or Genital Reconfiguration Surgery, is the name given to several different surgeries that change the shape and function of existing genitals. GRS may occur concurrently to, or after a hysterectomy, orchidectomy, or oophorectomy. Genital surgeries are not available to people under 18 years old.

Genital surgeries have picked up a few different names over the years, with Genital Reconfiguration Surgery simply being the most recent. You may have heard patients refer to it as bottom surgery, lower surgery, Sexual Reassignment Surgery, Gender Reassignment Surgery, a sex change surgery, inning-an-outie, vice versa, or others.

TransHub uses the term Genital Reconfiguration Surgery to be specific that the only thing changing during surgery is physiological, rather than gender. It’s always good to remember that genitals don’t have genders, people do, and your patient is already the woman, man or non-binary person they’ve always been.

While genital surgery is often seen as the ‘last part’ of gender affirmation, it is just another step along the way of some people’s journeys. There’s no right or wrong way to be or embody a gender, regardless of surgical status. Not all trans people want, seek or can have surgery, and being trans doesn’t necessitate surgery either. Find out more about that here.

Information for community members about GRS is available here.

The Standards of Care - 7th Ed (SoC7) is published by the World Professional Association for Transgender Health (WPATH) and offers guidance to clinicians working with trans patients all over the world, including criteria and recommended referral pathways for those seeking particular medical and surgical interventions.

The SoC7 does not specify an order by which surgeries should occur, if sought at all, and are guidelines, not legislated requirements.

A vaginoplasty is a procedure to surgically create a vagina and vulva from existing tissue. Depending on the procedure and technique used, the tissue used to create the different parts of the vagina and vulva may be taken from different donor sites. This surgery is generally sought by trans people who were presumed male at birth (PMAB), including women and non-binary people.

A vaginal cavity is created, and then tissue from the penis, testes, and in some cases lower intestine or other donor sites on the body are shaped to line the vaginal canal, and the external vulva including inner and outer labia. Often, what was the head (or glans) of the penis will be used to create the clitoris and surrounding tissue, in order to preserve sensation. The urethra is shortened and re-positioned to the required place in the vulva.

The main form of vaginoplasty available today is the ‘penile inversion’ method, in which the skin on the outside of the penis is used to create the lining of the vagina. Previously, the sigmoid vaginoplasty was more common, but is far less so today. Surgeons around the world are researching the use of other donor tissue sites such as inner skin layers around the abdomen, and the body of knowledge is constantly growing.

A phalloplasty comprises a number of procedures that surgically creates a penis, or phallus, from existing tissue, often including reconstruction of the urethra so as to allow for standing urination and the insertion of prosthetic testes into a scrotum that houses an erectile pump.

A phalloplasty may also include a simultaneous hysterectomy, oophorectomy, vaginectomy (to remove or partially remove the vagina/front hole) and other surgeries. This surgery is generally sought by trans people who were presumed female at birth (PFAB), including men and non-binary people.

The two main forms of phalloplasty may take place across as many as three stages, with a period of several months to a year between each.

Radial Forearm Free-Flap Phalloplasty (RFF)

The most recent development in phalloplasty surgeries. In the RFF procedure, the blood vessels and nerves in the donor tissue are kept intact, and then reattached to allow natural blood flow and sensation.

Anterior Lateral Thigh Phalloplasty (ALT)

This surgery has been around for a while longer, and can result in reduced sensation. In the ALT procedure, the blood vessels and nerves in the donor tissue are separated.

Latissimus Dorsi Phalloplasty

This surgery has been pioneered by a Serbian surgeon, and is not done by Australian surgeons.

A metoidioplasty is a procedure that creates a penis, or phallus, from a hormonally-enlarged clitoral shaft. This surgery is generally sought by trans people who were presumed female at birth (PFAB), including men and non-binary people.

When a person starts taking testosterone, the clitoral shaft will naturally enlarge. During a metoidioplasty, the existing clitoral shaft is raised higher up on the body, and the urethra is inserted through it. The clitoral ligaments are also detached, which allows the shaft to lengthen and drop into a position similar to a natal penis. A small graft is taken from the inside of the cheek and used as tissue for the urethra. A vaginectomy (removal of vagina) may also be completed at the same time.

While a metoidioplasty is often considered to be a single-stage surgery, your patient may request additional surgeries in order to achieve the desired results.

Before surgery

At appointments in the lead up to surgery, your patient might like to discuss their expectations and concerns, as well as their hopes and fears. It will be important to have an open conversation about what surgery can and cannot do. They may have been waiting many years for this particular surgery and feel that they have a lot riding on it. They may not be part of a supportive network or could be the centre of a thriving friendship circle. They might be clear about what they need from you, or really unsure. 

Your patient will also need to be referred to a mental health professional for support and assessment to confirm readiness for surgery.

Finding comprehensive, evidence-based information about gender affirming surgical processes can be a challenge, and so your patient might benefit from your additional research, including contacting a specific surgeon, if requested, or connecting with other health professionals to better understand and explain the process, possible complications, risk factors and outcomes. 

It’s also likely that a patient’s GP will be the first point of contact for any post-surgical care and complications, so having a sense of what might be happening, and being able to engage with additional clinician peer networks could prove advantageous. 

Many patients will request compassionate access to superannuation to cover the gap fees, and/or may not be able to afford private health insurance.

Surgery location

If your patient is contemplating surgery in Australia, it is prudent to encourage them to obtain private health insurance when and if they can afford it. This will help cover some of the costs such as the hospital stay. Their surgeon will be able to provide the applicable MBS Item Numbers that can be checked with the health insurer. 

If a patient is considering having surgery overseas, they will very likely appreciate a discussion about the benefits and risks of travelling overseas for surgery. This can be complex, especially if the surgery they’re seeking is not performed, or widely available, in Australia. 

For some patients, benefits can include cost saving, particularly if they’re not able to access private health insurance or Medicare in Australia, having greater choice of surgeons and being connected to a global community (trans people do a great job of offering comprehensive surgical reviews to the community).

Risks tend to arise from a lack of access to post-surgical care, including being able to effectively, and efficiently treat complications. Additional complications can arise if a patient is not being able to take the requisite time off work or study, and inadvertently damage the surgical site. 

Around surgery

Around the point of surgery, the surgeon and their staff will typically be supporting the patient through any fears and complications.

Some surgeons require patients to decrease hormones, particularly estrogen, for a period of time in the lead up to, and immediately following, vaginoplasty surgery. Your patient may want to discuss time-frames, expectations, and potential side effects from this. 

For those using estradiol implants, it’s worthwhile suggesting to your patient that surgery could be timed so that blood levels are low when surgery takes place, with the next implant due for insertion after surgery.

After surgery

As well as providing regular post-surgical care for your patient, you might find yourself supporting them through learning how their body now functions and feels.

Even if a surgical outcome is affirming for people, it can still be confronting. Discuss with your patient that it is normal to feel excited, but also very normal to feel overwhelmed, uncomfortable, to grieve, and to take time to become used to their body again. This isn’t an indication that they have made a mistake, or regret their decision, but a normal part of reconnecting with how their body appears and functions.

It can also be valuable to discuss how sensation may change, and what this might feel like. Having an honest conversation about how your patient will need to learn this for themselves over time can be helpful too. Refer to peer networks or a mental health professional, as needed.

It can take time to relearn how genitals experience sexual sensation and pleasure after any GRS procedure, and it may be helpful to reassure a patient that they can take their time to figure it out. Healing can take months, or in some cases years, and how they feel may change throughout that period of healing, and afterwards.

Referral to a sex therapist, sexologist, or touch therapist may be of assistance.