SRS stands for sex reassignment surgery, a term historically used to describe surgical procedures that alter a person’s body to align with their gender identity. While you’ll still see “SRS” widely used online and in older medical literature, the preferred term among both patients and healthcare professionals today is gender-affirming surgery. In a multicenter survey of 306 patients, 86% favored “gender-affirming surgery” as the name for this field, and 43% considered the phrase “sex reassignment surgery” inappropriate.
Gender-affirming surgery isn’t a single operation. It’s an umbrella term covering a range of procedures, from chest surgeries to genital reconstruction, that can be pursued individually or in combination depending on what a person needs.
Top Surgery: Chest Procedures
Most people in the transgender community refer to chest procedures simply as “top surgery,” a term that 83% of surveyed patients considered appropriate. These procedures differ depending on the goal.
For transmasculine patients (those assigned female at birth), top surgery removes breast tissue to create a flatter, more traditionally masculine chest. The most common technique is double incision mastectomy, where the surgeon makes two horizontal cuts across the chest that follow the natural contour of the pectoral muscles. For people with very small amounts of breast tissue, a keyhole approach uses a smaller incision along the lower edge of the areola. A third option, the buttonhole technique, preserves the nerves connected to the nipple by keeping it attached to a stalk of tissue, though this leaves slightly more bulk in the chest area.
For transfeminine patients (those assigned male at birth), chest feminization typically means breast augmentation with implants placed behind the breast tissue or under the pectoral muscle.
Bottom Surgery for Transfeminine Patients
Genital surgery for transfeminine individuals most commonly involves vaginoplasty, the creation of a vulva and vaginal canal. Several techniques exist, each with trade-offs.
Penile inversion vaginoplasty is the most widely performed method. The surgeon uses penile and scrotal skin to construct the vaginal canal and external anatomy. It has decades of track record and is available at the greatest number of surgical centers.
Peritoneal vaginoplasty is a newer approach that uses tissue from the peritoneum (the membrane lining the abdomen), harvested with robotic or laparoscopic tools. It can achieve greater vaginal depth and may be especially useful in revision cases, but it requires entering the abdominal cavity, takes longer in the operating room, and costs more due to the robotic equipment involved.
Intestinal vaginoplasty uses a section of the bowel to line the vaginal canal. Benefits include natural lubrication from mucus production, greater depth, and less dependence on dilation. Downsides are significant: it requires a bowel reconnection, can produce excess mucus and odor, and the transplanted bowel segment needs ongoing cancer screening.
Minimal-depth vaginoplasty (sometimes called vulvoplasty) creates the external vulva without a vaginal canal. This means a shorter surgery, faster recovery, no need for ongoing dilation, and lower risk of complications like rectal injury. It’s a good fit for people who don’t want or need a vaginal canal.
Bottom Surgery for Transmasculine Patients
Transmasculine individuals seeking genital surgery generally choose between two procedures: metoidioplasty and phalloplasty. The ability to urinate while standing is a common goal for both, which requires surgically lengthening the urethra.
Metoidioplasty works with the tissue already present. After testosterone therapy enlarges the clitoris, the surgeon uses local genital tissue to free and reposition it, creating a small phallus. The result is shorter in length than phalloplasty, but rates of successfully being able to stand to urinate are very high, and urethral complications are lower because the surgery relies on smaller, local tissue flaps with their own intact blood supply.
Phalloplasty constructs a full-sized phallus using tissue transplanted from another part of the body, most commonly the forearm (radial forearm flap) or the outer thigh (anterolateral thigh flap). The forearm flap tends to produce the best outcomes for standing urination. Because phalloplasty involves reconnecting blood vessels from a distant donor site, it carries a higher rate of urethral complications and is typically performed in multiple staged surgeries.
Pre-Operative Preparation
One of the most time-consuming preparation steps is permanent hair removal. Any skin that will end up inside the body or in contact with urine after surgery needs to be completely hair-free beforehand. For penile inversion vaginoplasty, the penile shaft skin must be cleared of hair because it will line the vaginal canal, where hair removal would be impossible after surgery. If scrotal skin is also used, a wide strip of that skin (or the entire scrotum, depending on the technique) needs treatment as well.
For transmasculine patients, only those undergoing phalloplasty with urethral lengthening need pre-operative hair removal, focused on the donor site. For a forearm flap, that means the inner surface of the forearm. For a thigh flap, the surgeon specifies the exact area.
Laser hair removal works for most people but isn’t effective on blond or white hair, which requires electrolysis instead. Surgeons typically recommend waiting at least three months after the final hair removal session before proceeding with surgery to confirm no regrowth occurs. The entire hair removal process can take a year or more.
Eligibility Criteria
The most widely used clinical guidelines, published by the World Professional Association for Transgender Health (WPATH) in their eighth edition, have been streamlined from earlier versions to reduce unnecessary barriers. For genital surgery, the current recommendation is at least six months of hormone therapy (when hormones are desired and medically appropriate) before proceeding, to ensure the person is stable on their treatment. Unlike older guidelines, the current standards do not require a specific duration of “real life experience” living in one’s gender role, though the role of social transition is discussed as part of the assessment process. A single evaluation from a qualified professional is sufficient to proceed.
Recovery After Vaginoplasty
Recovery from vaginoplasty is one of the longer processes in gender-affirming surgery and requires ongoing commitment. Strenuous activity is off-limits for six weeks, swimming and cycling for three months. Sitting can be uncomfortable for the first month but isn’t harmful. Brownish-yellow discharge is normal for four to six weeks, and some bleeding or spotting can continue for up to eight weeks. Sexual intercourse is generally cleared at three months.
The most demanding part of recovery is dilation, the regular use of medical dilators to maintain the depth and width of the vaginal canal. The schedule is intensive at first: three times a day for 10 minutes each session during the first three months. From three to six months, it drops to once daily. By six to nine months, every other day is sufficient, and after nine months, one to two times per week becomes the maintenance schedule. Skipping dilation, especially in the early months, risks losing vaginal depth. The minimal-depth approach eliminates this requirement entirely, which is one reason some patients choose it.
Complications
Like any major surgery, gender-affirming procedures carry risks. A 13-year review of vaginoplasty outcomes found that the most common complication was progressive difficulty urinating due to narrowing at the urethral opening, affecting 40% of patients, though this was correctable during a follow-up procedure. Narrowing of the vaginal opening occurred in 15% of cases, and loss of vaginal depth in 8%. Minor wound-healing problems were common at 33%. Serious complications like rectal injury were rare, occurring in about 3% of cases.
For transmasculine genital surgeries, urethral complications are the primary concern, particularly with phalloplasty. Metoidioplasty carries a lower complication rate in this area because it uses local tissue rather than transplanted flaps.
Satisfaction and Regret Rates
Research consistently shows high satisfaction after gender-affirming surgery. Systematic reviews of long-term outcomes find that the vast majority of both transmasculine and transfeminine patients are satisfied with their surgical results. In several studies, every single participant reported satisfaction with their genital surgery outcomes.
Regret rates are extremely low. Among transmasculine patients who had chest surgery, two large studies found that zero out of 98 participants and two out of 84 participants reported regret. For genital surgery in transfeminine patients, regret ranged from 0% to 6% across multiple studies, and when regret was reported, it was most often tied to dissatisfaction with a specific surgical outcome rather than a desire to reverse the transition itself.