Why surgery is different

Gender-affirming surgery (also called sex reassignment surgery, SRS, or "top" and "bottom" surgery) is the part of transition that cannot be paused or stopped. Social changes can be undone at social cost. Many hormone effects fade or partly reverse after stopping hormones. Surgically removed breasts, testes, ovaries, uteri and penile tissue do not grow back, and organs that are removed take their functions with them: breastfeeding, fertility and the body's own hormone production.

That asymmetry is why surgery sits at the centre of the debate about informed consent. A choice that cannot be undone needs a very high standard of understanding, and it has to hold up for someone who may see their body very differently ten years later. This hub summarises the main procedures, how often and at what ages they are done, what the outcome research can and cannot show, and what both detransitioned and trans-identified people say about living with the results. Each procedure has its own detailed page, linked below.

This page is not medical advice.

The procedures at a glance

Surgeries differ by sex. In females who identify as men or non-binary, surgery mostly removes healthy female organs (breasts, uterus, ovaries) and may then try to build a penis. In males who identify as women, surgery removes the testes and usually reshapes penile and scrotal tissue into a neovagina or vulva. No technique creates working organs of the opposite sex.

Facial feminisation, tracheal shave, breast augmentation in males and body contouring are not yet covered on their own pages. They share the same evidence problems described below. For regret after chest surgery in particular, see top surgery regret.

What the procedure pages show

Some themes come up on every procedure page:

• Complication rates depend on how they are counted. Mastectomy series report anything from 5% to 50% "any complication", depending on definitions and follow-up. Phalloplasty sits at the far end: a 2022 meta-analysis pooled a 76.5% complication rate, including 34% urethral fistula (Wang et al. 2022). Vaginoplasty series report cosmetic revision in 20–54% of patients.
• Losses that aren't counted as complications. When surgery works exactly as planned, it still ends breastfeeding, fertility or natural hormone production. These are expected results, so they never appear in complication tables. A 2023 case report described a detransitioned woman's grief at being unable to breastfeed, and found that breastfeeding is rarely mentioned in mastectomy consent materials (Gribble, Bewley & Dahlen 2023).
• Fertility regret can sit inside overall satisfaction. In a survey of transmasculine patients after hysterectomy, 38.6% reported some decisional regret about how fertility had been handled before surgery, even though few said they regretted the surgery itself (Johnson et al. 2023). See fertility.

Trends: more surgery, younger patients

Surgery numbers rose sharply in the late 2010s. A national US analysis estimated 48,019 people had gender-affirming surgery between 2016 and 2020. Annual numbers nearly tripled between 2016 and 2019 before a dip in 2020 during the pandemic (Wright et al. 2023). Breast and chest procedures made up 56.6% of all surgeries. People aged 19–30 received more than half of them. Adolescents aged 12–18 accounted for 7.7% (about 3,678 people over the period), mostly chest surgery, with 405 receiving genital surgery (STAT News summary).

Data on minors comes from a few sources:

• In Kaiser Permanente Northern California, a large US health system, the rate of mastectomy in girls aged 12–17 rose 13-fold between 2013 and 2020, from 3.7 to 47.7 per 100,000 person-years. Median age at referral was 16, and the youngest referred was 12. Only 65.6% of the 209 patients had more than a year of follow-up (Tang et al. 2022).
• A US clinic study of chest surgery in transmasculine youth included 33 patients who had surgery under 18. Sixteen of them were 15 or younger, and the youngest was 13. The study found that 32% reported long-term loss of nipple sensation (Olson-Kennedy et al. 2018).
• A Reuters analysis of insurance claims found at least 776 mastectomies in girls aged 13–17 with a gender dysphoria diagnosis between 2019 and 2021. These are likely undercounts, because self-paid procedures were not captured (Reuters 2022).

The rise matters because the patients changed. Most of the long-term regret research comes from adults treated under older, stricter screening protocols. Recent samples of detransitioners are dominated by young females, many with recent-onset identities and psychiatric histories (Littman et al. 2024). Findings from the earlier groups may not apply to them (Cohn 2023). The Cass Review (England's 2024 independent review of youth gender services) and other evidence reviews describe the same change in who is seeking treatment.

What the outcome evidence shows

Regret studies

The figure most often quoted is a pooled regret rate of about 1% across 27 studies and 7,928 patients (Bustos et al. 2021). Single-procedure studies report similar numbers. One example is a JAMA Surgery mastectomy cohort with a median score of 0 on the Decision Regret Scale (Bruce et al. 2023). Surgeons surveyed about their own patients estimated 0.2–0.3% (Narayan et al. 2021).

These numbers have structural weaknesses, covered in more detail on each procedure page:

• Follow-up is shorter than the time it takes regret to appear. Studies of regret and detransition report times of roughly 3 to 130 months before regret is voiced, with medians around 7.5–8 years in some cohorts. Most surgical studies follow patients for much less time (Cohn 2023).
• Many patients are lost to follow-up. In the Bruce cohort only 59% responded, and the non-responders were further out from surgery. In Tang's adolescent series, a third had less than a year of follow-up.
• People who regret often don't go back. In Littman's survey of 100 detransitioners, only 24% had told the clinicians who treated them that they had detransitioned (Littman 2021). A surgeon cannot record regret from patients who never return.
• "Regret" is defined narrowly. Many studies count only formal reversal requests or documented regret. Someone who has "made peace" with a body they would not choose again is usually counted as satisfied.

The honest conclusion is the one Cohn draws: the true rate is unknown. That uncertainty is itself something patients need to be told before they consent. For a wider look at regret, see transition regret.

Mental health and suicide after surgery

Surgery is often justified as necessary to prevent suicide. The population data doesn't show that it reduces suicide risk:

• A Swedish population cohort of all 324 people who had sex reassignment surgery between 1973 and 2003 found that, after surgery, they had about five times the risk of suicide attempts of matched controls (adjusted hazard ratio 4.9) and nearly three times the risk of psychiatric inpatient care (Dhejne et al. 2011).
• A widely publicised Swedish registry study originally reported that surgery reduced later mental health treatment. After reanalysis, the journal's correction stated that the results "demonstrated no advantage of surgery" for mood or anxiety care or for hospitalisation after suicide attempts (Bränström & Pachankis correction 2020).
• A 2024 study of US health records (TriNetX, 56 healthcare organisations) found suicide attempts in 3.47% of post-surgical patients versus 0.29% of general emergency patients. After propensity matching (statistically pairing them with similar patients) against people who had a vasectomy or tubal ligation, the risk was still 4.71 times higher (Straub et al. 2024).

None of these studies can show that surgery causes harm. The Straub study only matched for demographics, not baseline mental health, and the people who seek surgery already carry heavy psychiatric burdens. But the data cannot support the claim that surgery is reliably protective either. Elevated risk continues after surgery, which is why the Straub authors call for long-term psychiatric support. See suicide and transition for the full evidence.

Informed consent for irreversible surgery

Several separate problems undermine consent to surgery:

1. Speed and thin assessment. Detransitioners describe consultations that dealt with incision patterns and nipple options, not with why they wanted the surgery. In Littman's survey, 55% felt they had not been adequately evaluated before transition (Littman 2021). In a 2024 survey of young adult detransitioners, 28% had had surgery, and most felt poorly informed about risks and alternatives (Littman et al. 2024).
2. Losses that are hard to imagine in advance. A 16-year-old who cannot picture wanting to be touched, breastfeeding a baby, or having a career that a lifetime of hormone dependence will affect is not refusing information. They are being asked to judge a future self they don't know yet.
3. Pressure from the "transition or suicide" message. Consent given under the belief that the only alternative is death isn't free consent. Several detransitioners describe exactly this.
4. Mental health red flags passed over. In Littman's 2024 sample, 95% had at least one lifetime psychiatric diagnosis, mostly predating their trans identification (Littman et al. 2024). Jorgensen argues that mental health problems, trauma and neurodiversity are often inadequately explored before transition (Jorgensen 2023).

One detransitioned woman, who had a mastectomy at 16 in 2013, wrote:

I had a very easy recovery from my mastectomy, with no complications, and by all metrics had a "good result" aesthetically… And yet I still experience all this pain. No one at the time told me I would have so much nerve pain and that it would never go away. I expected loss of sensation, not frazzled nerves. I was not truly informed and my surgery happened only 1 month after the consultation. I'd only been on T for 11 months. —detrans-throwaway7, detrans female

A male commenter whose bottom surgery led to regret described a similar process:

The psychiatrist, endocrinologist and surgeon just made me sign an "informed consent" and that was it, nobody informed me about the consequences... —AdorableSquash997, socially trans, regrets entire transition

Another described how doubts can be present at the time and still not be voiced:

I had top surgery at 16. I remember my surgeon asking me are you sure a few times and I remember not being sure and very quietly mumbling yes. No one was here for me. I'm 21 now and regret everything. —gurodog, questioning own transgender status

The informed consent critique and iatrogenic harm pages cover the wider arguments.

Detransitioner experiences of surgery

Female experiences

On /r/detrans, many commenters who had surgery as women talk about grief, phantom sensations, numbness and nerve pain. Several also describe a delay: relief, or simply nothing, at first, and regret months or years later. Some say the expected euphoria never came:

Waking up from surgery with big fresh scars (and the bodily sensation of it) was incredibly sobering compared to the floaty, beautiful ideas tied to this "soul-aligning" procedure that top surgery is marketed as. The euphoria never hit for me… —nervkeen_, detrans female

When the ovaries are removed along with the uterus, the loss is both reproductive and hormonal:

ya, big time. worst mistake. i regret it more than my mastectomy. (both are awful tho). being on these pills for the rest of my life, exhausted and feeling like trash all the time, not having a period anymore, unable to have kids and start a family of my own. —starberrles, detrans female

Male experiences

Male commenters describe lost sexual function, lifelong dilation, infections and the loss of natural testosterone. A recurring theme is that surgery itself acted as a shock that ended the belief behind it:

When I woke up from my SRS and accidentally glanced down whilst they were changing a dressing and saw the state of my body, my knee-jerk immediate thought was - "Oh my god. What have I let them do to me?"… The day I had surgery was the beginning of my mental detransition as it shocked my mind like a defibrillator shocking an incorrect heart beat back into rhythm. —Hedera_Thorn, detrans male

After orchiectomy, the loss is felt throughout the body, not only in the genitals:

I lost my testicles to gender transition, and i am sunk in shame knowing i did this to myself. I lost muscle, energy, sexual desire. —Reasonable-Fix-6380, desisted male

How surgery affects desire, arousal and orgasm is covered on the sexual function page.

Detransition without regret

Detransition and surgical regret are not the same thing. Some detransitioners say they don't regret their surgery, or that their feelings are mixed:

I had zero doubts. I was nineteen. But since then, I've detransitioned… I do not regret it, yet I still miss my breasts. It's equally as freeing as it is disappointing. —Lusin3577, detrans female

I mean... I detransitioned and don't regret my top surgery. I'm butch and am in good company; many of us have done it… If you have any hesitation, I would reschedule. You can always make the choice to do it later. —graybutch, detrans female

These accounts complicate a simple "regret" headline. They also show a common pattern in people who don't regret surgery: severe distress about a specific body part, and acceptance of a flat chest as a gender non-conforming woman, not as a man. The same commenters still advise anyone with doubts to wait.

Trans perspectives on surgical satisfaction

Many trans-identified people report high satisfaction with surgery, and their accounts should be represented accurately:

22 years post orchiectomy, about 8 years post SRS. Zero regrets about surgery. I would have made a better choice with my initial surgeon, but as to the procedure itself? I'd have done it way sooner if I could have. —AutumnGlow33, trans woman (MTF)

Trans commenters are also often frank about the burden of surgery and argue that complications are discussed too little in their own communities:

SRS is a very serious surgery that, similar to an organ transplant, requires at least a week of hospital stay and lifetime long postoperative care. It can be lifesaving, but we have to be honest and realistic as to where medical science stands and its current limitations. —DoctorOzone, trans woman (MTF)

It breaks my heart to read the horror stories, and I think people should continue to share their experiences, good and bad. Those with negative outcomes need more support and shouldn't be condemned as fear mongering. —Vladd88, trans woman (MTF)

Two things can both be true. Many people are satisfied with their surgery. And the systems that measure that satisfaction are poorly placed to see the people who are not. Sharing bad outcomes is not an attack on satisfied patients. It is the information that informed consent depends on.

Reversal and reconstruction

No transition surgery can be truly "reversed". What is possible is a second, different operation that rebuilds an approximation:

• After mastectomy: breast reconstruction with implants, fat grafting or flap surgery. Detransitioners report mixed results and real barriers to getting it: some insurers that paid for the mastectomy refuse to cover reconstruction, and some surgeons refuse to see them. See top surgery regret.
• After phalloplasty: the phallus can be removed and urethral lengthening undone, but the forearm or thigh donor scar is permanent. Lost ovaries and uterus cannot be replaced.
• After vaginoplasty: the canal can be closed or converted to zero depth, and urologists in a few centres attempt phallic reconstruction. Original erectile tissue and sensation cannot be restored.
• After orchiectomy: testicular implants and lifelong testosterone replacement. Fertility is gone.

Detransitioners often note the imbalance: getting surgery was easy, but getting help afterwards is hard.

I find the hardest part is finding a surgeon to undo some stuff. It's harder to do that than change anything on your body permanently with however many surgeries you want, but the moment you want to go back, suddenly it's weird and odd. —krone6, MTF currently questioning gender

In an online survey of detransitioners, many described needing medical help with surgical complications and reversal procedures but meeting dismissive or uninformed providers. Only 18% felt they had received enough support overall (Vandenbussche 2022). Jorgensen calls detransitioners "survivors of iatrogenic harm" who need care that gender medicine guidelines largely do not provide (Jorgensen 2023).

Where to go from here

• If you are weighing surgery, each procedure page lays out the techniques, complication ranges and the accounts that rarely reach a clinic brochure. Detransitioner videos and the study archive add more detail, and the /r/detrans statistics show transition and detransition timelines.
• If you have had surgery and are detransitioning, the support directory lists gender-exploratory therapists and detrans support groups. Some have experience with post-surgical detransition and reconstruction decisions. See also healing and recovery.

References

• Cohn, J. (2023). The Detransition Rate Is Unknown. Archives of Sexual Behavior. study page, source.
• Gribble, K. D., Bewley, S. & Dahlen, H. G. (2023). Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm. Frontiers in Global Women's Health. study page, source.
• Straub, J. J. et al. (2024). Risk of Suicide and Self-Harm Following Gender-Affirmation Surgery. Cureus. study page, source.
• Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. study page, source.
• Littman, L., O'Malley, S., Kerschner, H. & Bailey, J. M. (2024). Detransition and Desistance Among Previously Trans-Identified Young Adults. Archives of Sexual Behavior. study page, source.
• Vandenbussche, E. (2022). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality. study page, source.
• Jorgensen, S. C. J. (2023). Iatrogenic Harm in Gender Medicine. Journal of Sex & Marital Therapy. study page, source.
• Cass, H. (2024). Independent review of gender identity services for children and young people: Final report. study page.
• Wright, J. D., Chen, L., Suzuki, Y., Matsuo, K. & Hershman, D. L. (2023). National Estimates of Gender-Affirming Surgery in the US. JAMA Network Open 6(8):e2330348. source; STAT News summary.
• Tang, A. et al. (2022). Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents. Annals of Plastic Surgery 88(4 Suppl):S325–S331. source.
• Olson-Kennedy, J. et al. (2018). Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatrics. source.
• Reuters / Komodo Health (2022). Number of transgender children seeking treatment surges in U.S. source.
• Bustos, S. S. et al. (2021). Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence. Plastic and Reconstructive Surgery – Global Open. source.
• Bruce, S. D. et al. (2023). Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy. JAMA Surgery. source.
• Narayan et al. (2021). Guiding the conversation—types of regret after gender-affirming surgery and their associated etiologies. Annals of Translational Medicine. source.
• Wang et al. (2022). Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis. Sexual Medicine Reviews. source.
• Johnson et al. (2023). Fertility preservation choices and decisional regret after gender-affirming surgery in transgender men or gender nonbinary persons. F&S Reports 5(1):87–94. source.
• Dhejne, C. et al. (2011). Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2):e16885. source.
• Bränström, R. & Pachankis, J. E. (2020). Correction to Bränström and Pachankis. American Journal of Psychiatry 177(8):734. source.