Gender-affirming surgery

Richard was supportive of his daughter’s wishes to have surgery in the future, even though he felt that any parent would prefer their children not to need an operation.

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I am 100% supportive of what she wants to do, even though I kind of feel utmost sympathy pains at the thought of someone having an operation anywhere near my privates. I, yeah, I don’t relate to it in the sense that I’d never considered anything like that or thought of anything like that. It seems quite distant for me. But I am fully aware that it’s not my body, it’s her body. And I would prefer my daughter to not need to have an operation. I would have thought any parent would prefer their children not to need an operation. And I am sure it will be really emotional the thought of your child having an operation to any parent. I kind of think that we’re probably lucky that she hasn’t got any illness that is the reason for her to have an operation. And lucky that is an operation that hopefully will make her happy and she will be grateful for.

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Whilst not all trans or gender diverse people want or choose to have surgery, some choose to have gender affirming surgery.
We spoke to parents whose now-adult children had undergone gender affirming surgery and others whose children were considering it in the future.
In this section, you can also find out what the parents and carers we spoke to said about:
  • their young person’s wishes for surgery in the future; and
  • their own thoughts about gender affirming surgery.
There are a range of gender affirming surgical interventions available to trans adults as explained on the NHS website. A person can be referred to a surgeon based on the recommendation from the adult Gender Identity Clinic. A person is expected to have socially transitioned at least a year before they can be referred for gender affirming surgery.
For trans men, surgery may involve:
  • a bilateral mastectomy (removal of both breasts)
  • a hysterectomy (removal of the womb)
  • a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
  • phalloplasty or metoidioplasty (construction of a penis)
  • scrotoplasty (construction of a scrotum) and testicular implants
  • a penile implant
For trans women, surgery may involve:
  • an orchidectomy (removal of the testes)
  • a penectomy (removal of the penis)
  • vaginoplasty (construction of a vagina)
  • vulvoplasty (construction of the vulva)
  • clitoroplasty (construction of a clitoris with sensation)
  • breast implants
Some interventions, such as facial feminisation surgery (surgery to make your face a more feminine shape) and hair transplants are not routinely available on the NHS.
Altering of the genital region is often referred to as ‘bottom surgery.’ Surgery that involves breast tissue removal and chest contouring, and/or breast implants is often referred to as ‘top surgery.’
Gender affirming surgery may involve several procedures during one operation or might take place over a period of time. As with all surgery there could also be unexpected complications to deal with.

Experiences of parents whose adult children had surgery

E and D talked about their son having top surgery, how it went and how they felt about it as parents.

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Father: He wasn’t totally happy because he still had the problem with binding breasts and that was the issue for him.

Mother: They put a referral through to the [name] clinic. Eventually, he got seen in the NHS that was probably three or four years further on. He obviously, eventually, did all, got the assessment and they, they transferred him over and so now he’s totally under the NHS, under that clinic. And he saw them there and eventually he went onto the surgical pathway and had the mastectomy last April. So, it took quite a long time on the waiting list and everything. So, that’s eventually what he went and did.

Father: As far as we know. That’s only, that’s as far as he wants to go, really.

How did the surgery go?

Mother: I mean, technically, it went fine. He was very lucky. They had money for a waiting list initiative, so he ended up in a private hospital with a single room and the care was, the kind of technical care was excellent. I think he had a good surgeon who did the operation, you know, very well. He didn’t have any post op complications and recovered quite fast.

Father: He was very pleased with that. I mean, he’s been pleased with the outcome of that.

Mother: Yeah, I think he’s very pleased with the outcome. It all went according to—yeah, as I say, we can’t fault the care that he had in the hospital and technical care. You know, it’s just, it’s just a horrible thing to see happening to your children, an unnecessary operation. But, you know, on a perfectly healthy person. But, you know, what can you do? I had so many conversations with him to say, are you sure about this and are you sure about this. Do you really want to do it? And you did the same and he was absolutely adamant he wanted to go through with it.

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Gender affirming surgery can be an important milestone for a trans or gender diverse person. In our interviews, four parents had children who had had gender affirming surgery as adults. Two parents were interviewed together about their son and both talked about their son’s top surgery. One mother’s daughter had experience of bottom surgery and another parent shared their daughter’s experience of facial feminisation surgery. In the interviews, these parents talked about their children’s reasons for wanting surgery (including body dysphoria), the process for being referred, the surgery itself and recovery.
While some types of gender affirming surgery are available on the NHS, others are not. For example, one parent’s daughter wanted facial feminisation surgery because she ‘felt so conscious, she had a very prominent masculine nose and, Adam’s apple.’ Jan shared that they, as a family, decided to pay for her daughter’s surgery privately, as this type of intervention is not offered on the NHS. To be cleared for the procedure, their daughter ‘had to have a very detailed session with a fully qualified psychotherapist.’ Jan felt that the surgery itself was a ‘big deal’ as it involved four different procedures, but also shared that their young person was happy with the result overall and needed the surgery to be able to ‘move forward.’

Jan talked about her daughter’s motivation to have facial feminisation surgery and how the surgery had gone.

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It was a big concern for her because she had a receding hairline and so part of the surgery was to pull that forward to make it look like she had a full head of hair. She had a very prominent brow, masculine brow, so that was being shaved. Very prominent masculine nose so that was being reshaped and then her Adam’s apple was being shaved as well. So that surgery took place last August. It was a big surgery to have done. There was an unexpected complication in that she lost the sight in her right eye as part of that. So, that added an additional dimension for her to have to deal with over and above the surgery itself and just generally being transgender. So, you know, she’s proven that she’s resilient. The surgery was like I say, it was a big deal, because it was four hours worth of four different procedures that were all happening at once. But it was something that was really top of her agenda to help her be able to move forward and to ease her kind of body dysmorphia that she had.

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Within the NHS, waiting times for surgery can be very long, but one mother felt her daughter did not have to wait long for bottom surgery. She said: ‘I thought it was remarkably quick. She probably didnt [think so] …she got told she was going for the operation in about October and I think she had the operation in March.’ However, it is important to note that this five-month wait followed two other waiting periods: an assessment process at the Gender Identity Clinic, and a waiting list for assessment. What this parent was disappointed about was the lack of care after her daughter’s surgery. She felt her and her daughter had ‘nobody to seek advice from’ when her daughter got unwell after leaving the hospital. She said that it was a ‘long recovery’ for her daughter, but that she was now on an ‘upward slope’ from the surgery. Bottom surgeries tend to be more invasive and more likely to involve more severe complications and long recoveries. For another person’s son, the recovery from his top surgery was much easier. His mother talked about how technically the surgery went very well. She said about her son: ‘He didn’t have any post op complications and recovered quite fast.’

VM’s daughter had bottom surgery on the NHS. She talked about how her daughter fell ill after the surgery and had to rely on local GP for help.

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I looked up the surgeon and he seemed to have done lots of them before. So, I would have said, she had a nurse who I never met. But assured her that she would be there for her throughout the whole operation process and anything she needed to know she would do. The day after the operation wed gone, we, she was drowsy and she needed to see someone. We went away and we came back and she said to us, The nurse has just told me she’s going to Australia for I cant remember now, four weeks so we were completely on our own. Which I cant quite get, I cant quite forgive that, really. So we left the hospital, came home and so we had nobody to sort of seek advice from, because this nurse had just said, I totally get she takes the time to go on holiday. But It was allI think my daughter said, phoned a couple of times, but they were a bit unhelpful, I felt, from my point of view. And then she did get ill and we had to talk, we were told to go to A&E – well, what good is going to A&E? What do they know about transgender operations? That would – probably even less than I do. And, at which point, she’s already, she hadnt signed on with a GP so we had, went round the corner and found a GP. Her temperature was going up and up and up and I was really worried. And we had, we eventually had a call with the GP who clearly knew nothing about transgender issues, but we knew because shed been told she might get an infection that, her temperature was really high and she needs antibiotics… This GPshe just said, They are there. Ive written a prescription out, go and get them. And that was great, because it’s what she needed. We needed someone to sort of believe us without saying, Well, I need to see you again and I need to. And, I thought, good on her. And she did and my daughter took them and got better. But I felt we were really let down by the people who should have said, Come and see us now. And they didnt.

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Parents sharing their children’s future surgery plans

For some parents we spoke to, future surgery was something that their children had discussed with them. In the interviews, parents stressed that their children were clear about what procedures they wanted. When one parent’s partner asked their daughter (age 16) what she wanted for Christmas she said she wanted a vagina. The parent shared: ‘That’s what she wants. She wants surgery. She wants to get sorted.’ Kate said she discussed surgery with her son ‘quite early on.’ She emphasised that her son wants top surgery and ‘to have his womb and his ovaries removed. But he doesn’t want, anything else done.’ She felt the interventions that her son wanted were done routinely regardless of a person’s trans status, so she was ‘less concerned about him having that part done.’
Parents also spoke about their children researching available procedures, where to go to start the treatment and the best surgeons available. Research could include looking for information online as well as talking (online or in person) to trans people who had had surgery.

Lesley talked about her and her son doing research on top surgery and said her son can’t wait for it to happen. She hoped he can have the surgery on the NHS.

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He’s already, he’s spoken to a lot of younger trans men who have undergone the surgery, top surgery. He’s identified the surgeon that he wants, yeah. Ideally, it would be good if it could be done on the NHS. That he has in mind, the sooner the better. Whether that means that I think the youngest is 17 when you can do it private and that’s, there is some specific individuals who do that. So he’s, his research of the surgeons, their technique bedside manner. He’s spoken to loads of trans guys who would say, that guy is good. don’t touch him with a barge pole or whatever else. He knows who it’s gonna be.

He’s done all the research. Are you doing research?

Yes. Yeah, I’ve done, I’ve done the research too, yeah [Laughs]. I have backed him up.

How has it been doing all that research work for you?

It, actually it’s been really proactive, it’s proactive and I think it’s really, really reassuring, because what it feels like, it’s not like something that is on a whim. But you can see that it’s life changing and that and the difference it can make to in terms of positive mental health is huge. We were speaking to a non-binary trans person the other week about that at a point when they realised that they might have a lump in their breast and getting them really excited that that potentially could mean the removal of their breasts. I think then realising well that’s not a typical way that you would respond to, needing a mastectomy, which led them to fundamentally recognising that they were, they were trans and non-binary. And so the way that my son thinks about top surgery is almost on a similar way. Just can’t wait for it to happen, cause of the difference it will make to who he is.

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Parents’ views about gender affirming surgery

In our interviews, parents were largely understanding of their children’s choices to have surgery and the importance of surgical intervention to their child’s wellbeing. For future surgery, most parents and carers supported their children in doing research with them, discussing their plans and providing emotional support. But not everyone felt the same. Elijah worried that being trans meant a life of medicalisation and unnecessary surgery for his child. He also talked about age threshold for deciding on surgery. It is important to note that not all trans people want or choose to have surgery. Parental support and acceptance are key to the wellbeing and mental health of young trans and gender diverse people and so is access to timely care. Denial and delaying of care causes harm.*

For Elijah deciding on surgery was a momentous’ decision for a 13 year old. He was against those under 18 choosing pills and surgery.

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We’re quite firm on this, because from our point of view, as parents, we need to stay firm a troubled 13 year old cannot make momentous decisions about which go into a life of medicalisation and surgery. So we need to stay firm and compassionate, but firm in this.

Should someone under 18 be able to choose pills and surgery, I’m against that, if I’m honest with you. I don’t think up, if you can vote at 18, I think you can make decisions with your body at that point. You’re teenagers when you’re a stew of raging hormones and confusion to make a long term decision that could sterilise you, remove healthy tissue, I don’t think’s healthy and I’m against it.

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Even where parents didn’t like the idea of their children having surgery they often recognised the positive benefits it would have for their children, and emphasised the importance of respecting their children’s choices and autonomy to decide over their own bodies. E said that what she thought was ‘unnecessary surgery’ was a ‘horrible thing to see happening to your child’. However, she also said that her son was very adamant about having it and agreed with D that their son was ‘very pleased with the outcome’ of the surgery. For other parents, like Richard and Lesley, supporting their child’s decisions about future surgery was part of affirming and valuing their gender identity.

Lesley said she had no concerns about future top surgery for her son, because she recognised that he is trans.

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Do you have any concerns around surgical interventions?

I don’t. And the reason why is that I fundamentally recognise that my son is trans and that’s not gonna change that it’s not like, I don’t think, I don’t believe that he’s gonna break off in four year’s time I think well, I got it wrong and I’m actually cis. And if he does that, that’s okay. But I don’t have any concerns about going forward with the top surgery at all.

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* See for example:
Puckett, J. A., Matsuno, E., Dyar, C., Mustanski, B., & Newcomb, M. E. (2019). Mental health and resilience in transgender individuals: What type of support makes a difference? Journal of Family Psychology 33(8).
Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental support and mental health among transgender adolescents. Journal of Adolescent Health, 53(6).
Priest, M. (2019) Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm, The American Journal of Bioethics, 19(2).

School

Most of the parents we spoke to had children who were in school. They described a range of experiences related to how their child's gender...