Gender reassignment surgery (GRS) is complicated — and that goes all the way down to what you call it. Commonly known as "bottom surgery" in either direction, GRS can also be called "sex reassignment surgery." All these terms refer to the medical procedure that changes the genitals from one sex to another, explains Jess Ting, MD, a plastic surgeon who specialises in transgender surgery and assistant professor Icahn School of Medicine at Mount Sinai.
But GRS is more than just going under the knife to change your genitalia. For many people those physical changes go hand in hand with a total transformation, Dr. Ting says. "No amount of pain you go through with surgery can measure up to the mental pain you feel on a daily basis," says Mahogany Phillips, 49, a transgender woman in New York City. "GRS helps a trans person be able to look at themselves in the mirror, that's something cisgender people take for granted," she says. Phillips says she spent many sleepless nights researching whatever information she could find online about the surgery and watching YouTube videos of people who had transitioned: "I felt like I was making a stew, and I just wanted to put it all together; I discounted nothing because I knew every experience would be different."
Understanding a little more about what GRS entails is just one step toward compassionately recognising transgender people. "We're dependent on society to give transgender people some kind of acceptance," says Christine McGinn, DO, a plastic surgeon who specialises in transgender surgery. Here are some common GRS misconceptions — and the truth about each.
The belief: Trans people just want to "look the part."
The reality: Every trans person has their own story and reason why they want surgery to have genitalia that matches their gender identity. "We are whole people, so we can have feelings about many other things that are affected," says Alexa*, 28, a transgender woman who works as a scientific researcher. "As a girl who is interested in men, I appreciate how [GRS] will allow me to make love and connect more intimately with lovers, in a way that most women take for granted, and also how it will give me a better chance of getting married and having a home and a family." Dr. Ting adds that the main goal of surgery isn’t just cosmetic: It's functional operation of the genitals.
The belief: Everyone gets the same surgery.
The reality: Putting it broadly, for male to female gender reassignment surgery, doctors take a penis and make a vagina, clitoris, and labia out of the male parts, Dr. Ting says. Female to male surgery is more complicated, and requires taking skin from somewhere else on the body (like the forearm or thigh), folding it into a tube and reattaching it to the urethra — and the vagina has to come out, too (vaginectomy). Mastectomies and facial feminisation surgery are separate procedures, typically.
"I think that most people would be surprised by how malleable the human body is, especially as compared to gender identity," Alexa says. "You can take a girl and feed her testosterone and lies for years, and she will still know, deep down, that she is a girl... But if you take analogous parts of male or female genitalia — and they are extremely analogous — and rearrange them, the body will adjust to make it work as if it was there to begin with."
The belief: Once you get surgery, you're all set.
The reality: GRS is a major surgical procedure, and Phillips says having a safe place to heal can be a challenge for some people. "A lot of trans folks have been disowned by their family, thrown into the streets, and have nowhere to go," she says. Alexa agrees, saying that the first few weeks after the surgery were "the most painful of my life."
Phillips says her support system and personal faith are what got her through it. "I'm still healing [from surgery] but I rely on my strength and a lot of this process has to do with your outlook on life, and being a go-getter," she says.
The belief: Regret is a major risk.
The reality: Gender reassignment surgery is a huge deal, and everyone can agree on that, but there’s a pocket of people who fear someone would regret their decision and want to reverse it, Dr. McGinn says. “Anybody who works in the field knows that regret isn’t an issue,” she says. The fact that someone might have doubts about GRS speaks to how people view transgender individuals socially, she says. "Patients who are trans are like that from birth: It's not a lifestyle, it's something organic that's built into you," Dr. Ting adds. "I don't regret it at all," Alexa says. "If I had to make the same decision again today I would, without hesitation."
The belief: The genitals don't look convincing.
The reality: Dr. Ting says patients usually worry that the anatomy the surgeons create may not look legit in front of a sexual partner. It does look convincing, he says, although in general it's more challenging for surgeons to perform a female to male GRS. Some female-to-male patients have trouble getting fully erect for penetrative sex, for example, but Dr. Ting says there's a device they can put inside the penis to provide erectile function. "It's the same thing you use in elderly men or diabetic patients," he says. Dr. Ting is hopeful that eventually the technology will catch up to what people need: "This is a really young field of surgery, and already so many things have changed and improved," he says. "There are so many techniques than in five to 10 years it will evolve."
The belief: You can't orgasm after surgery.
The reality: It’s a myth that people who get gender reassignment surgery can’t have orgasms, Dr. McGinn says. “It takes time to learn how to have one in a different way,” she says. “There’s a variety in response and lots of women have issues having orgasms, sometimes men, so a lot of sex education is done in my office.” For surgeries in either direction, the doctors strive to preserve sensation, Dr. Ting says. Dr. McGinn adds that there are other factors that can make orgasms more difficult, such as the hormones and any antidepressants someone may be taking, but as long as you have nerve endings it's possible.
Alexa says she was surprised by how pleasurable penetrative sex could be. “I grew up reading women’s magazines about how important the clit was, so I assumed that would be it,” she says. “I was pleasantly surprised to find out how much you get from penetration and how integral it is to the experience.”
The belief: Surgery is the whole transition.
The reality: By the time someone is getting gender reassignment surgery, they’ve been living in their desired gender for at least two years, on hormones, and cleared by a mental health professional, Dr. Ting says. These are the standards of care set by the World Professional Organisation for Transgender Health, and they're requirements for most insurance companies that offer coverage. Half of Fortune 500 companies offer transgender health care benefits like surgical procedures, according to the Human Rights Campaign Corporate Inequality Index for 2017. Not every workplace is so accepting, and you can find a list of the companies that offer coverage for transgender people on the HRC website.
“There’s a lot more involved; patients have to fulfil requirements because insurance companies are strict,” Dr. Ting says. Phillips says her facial feminisation surgery was initially denied by Medicaid, so she got a lawyer and went to court. “I felt it wasn’t right, and I knew I wouldn’t stop until they said yes,” she says. “The judge stopped halfway through because she couldn’t believe the torture I’d been going through.” They won the case, and Phillips went on to be the first trans woman in the United States to have facial feminisation surgery covered by Medicaid.
The belief: You're not trans unless you get GRS.
The reality: Some transgender people who identify as male or female go their whole lives without getting GRS, explains Dr. McGinn. "Everyone doesn't want the surgery, but it should be available to those who do want it," Phillips says. While solid stats aren't available, one physician estimated in 2015 that between 25 and 30% of trans people get GRS. Most health professionals and trans people agree that you can absolutely be trans without having or wanting GRS — it's all about how you, as an individual, identify.
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