After mental health therapy, hormone replacement therapy can mark a major milestone in a transgender person's transition.

Kansas City Star/Getty Images

Gender Affirmation Surgery

It's difficult to know for certain what the actual numbers are, but the Williams Institute estimates that that about 0.3 percent of the general U.S. population identifies as transgender, although not all of those 1.5 million people will desire or undergo gender affirmation surgery [sources: Gates, Steinmetz]. Each year between 100 and 500 gender reconstruction surgical procedures are done in the U.S. to treat gender dysphoria. The United States is not a major player in gender dysphoria treatment; estimates range that up to 2,500 people worldwide affirm their gender through surgery every year — and Thailand has long been considered the premiere destination for gender surgeries [sources: Toro, Encyclopedia of Surgery].

Gender affirmation surgery is performed under the guidelines of World Professional Association for Transgender Health's (WPATH) globally accepted Standards of Care for Gender Identity Disorders (SOC). The types of surgeries to be conducted are decided by the patient's desire and comfort level, as well as finances. Not every patient will want or need the same surgeries, and the process is tailored for each individual. Certain procedures are considered medically necessary to treat gender dysphoria, while other common gender confirmation surgeries such as rhinoplasty and brow lifts are considered cosmetic; for some this new outward appearance may hold more significance than the reconstruction of internal and external genitalia.

Surgeries for trans men (or those assigned female at birth (AFAB)) include:

  • Bilateral mastectomy;
  • Complete hysterectomy
  • Reconstruction of the genitalia with a metoidioplasty (a procedure that allows a surgeon to construct a phallus from the clitoris)
  • Ring metoidioplasty (to lengthen the urethra)
  • Scrotoplasty (the construction of a scrotum)
  • Vaginectomy (to close of the vaginal canal)
  • Phalloplasty (the construction of the penis)

A penile implant (a prosthetic otherwise used to treat erectile dysfunction) and testicular implants may also be added to the reconstructed penis and testes. Although the mean length of a reconstructed penis is roughly 2 inches (5 centimeters), 80 percent of trans men in one study reported they were able to engage in sexual intercourse, and most experienced orgasms [source: Harrison].

Trans women, or those assigned male at birth (AMAB), a group larger in number than trans men, may begin their physical transformation with breast augmentation (implants), as well as with cosmetic surgeries to feminize the face and body, such as facial feminization surgery (FFS), and gluteal, hip and thigh implants before undergoing genital reconstruction. Surgeries to create female genitalia include:

  • Clitoroplasty (the construction of a clitoris)
  • Labiaplasty (the creation of a labia from scrotum skin)
  • Orchiectomy (testicle removal)
  • Prostatectomy (the removal of prostate)
  • Urethroplasty (the reconstruction of the urethra)
  • Vaginoplasty (the creation of the vaginal canal, made from penile tissue or a colon graft)
  • Penectomy (removal of the penis) is usually done concurrently with vaginoplasty, and a clitoral hood is typically constructed from the glans penis.

In the U.S. surgical costs in 2015 may run anywhere from about $25,000 for male-to-female transitions and upwards of $100,000 or more for female-to-male transitions, although typical costs fall between $7,000 and $50,000 [sources: Leitsinger, AP]. Transgender Brits pay about 10,000 pounds ($15,000) [source: Telegraph]. And for an extra $8,000, patients transitioning from female to male in Thailand can, for example, upgrade from a 1 inch (2.5 centimeter) penis to one with a few more inches [source: Ehrlich].

Transgender people who have undergone gender affirmation surgeries are, in almost all cases, happy they did so. In the U.K., for instance, only 2 percent of people who've undergone gender reconstructive surgeries report regretting their physical transformation, compared to 65 percent of cisgender (non-transgender) people who report regretting their plastic surgery choices [source: Tannehill]. And in the U.S. less than 1 percent of trans women regret their genital reconstruction, a percentage that's been decreasing alongside the risk of developing long-term complications [source: Tannehill]. More than 80 percent of patients report long-term satisfaction despite (treatable) complications such as vaginal hair growth (a 29 percent prevalence among trans females) and urinary problems (almost the same, at 27 percent) [source: Goddard]. The rate of regret for trans men is difficult to estimate, as they are smaller in number than trans women [sources: Jarolím, Tannehill].

Sure, there's the case of Charles Kane, who famously transitioned from a man to a woman in 1997, and then back again. After living as Samantha Kane for seven years, Charles decided he would never pass as a "real woman," neither to himself or to the public, and felt hormone therapy altered his brain into making the original decision [source: Scutti]. But, Kane is a rarity.