SRS surgery, short for sex reassignment surgery, refers to a group of surgical procedures that change a person’s genital anatomy to match their gender identity. You may also see it called gender-affirming surgery (GAS) or gender confirmation surgery, which are more current terms for the same procedures. SRS can involve multiple operations performed over months or years, and the specific procedures depend on whether the goal is to construct a vagina, a penis, or to address other aspects of genital anatomy.
Transfeminine Procedures
The most common genital surgery for transgender women is vaginoplasty, which creates a vaginal canal, labia, and clitoris. The standard technique is penile inversion vaginoplasty, where surgeons use inverted penile skin to line the new vaginal canal. Scrotal skin is typically used as an additional graft because penile skin alone often doesn’t provide enough tissue for full coverage. The tip of the glans penis is reshaped into a clitoris, and the nerve bundles that provided sensation are carefully preserved so that the new clitoris retains feeling.
When there isn’t enough genital skin available, surgeons may turn to other tissue sources. Peritoneal pull-through uses tissue from the peritoneum (the membrane lining the abdomen), while intestinal vaginoplasty uses a segment of the colon or small intestine. Each approach has tradeoffs in terms of self-lubrication, tissue flexibility, and surgical complexity.
A full vaginoplasty also includes removing the testes, reshaping the urethra, and constructing labia from surrounding skin. Some people opt for an orchiectomy (removal of the testes) as a standalone procedure, either as a first step or as an alternative to full vaginoplasty. Cosmetic revisions to the external genitalia are common after the initial surgery. Between 25% and 50% of patients request a revision to refine the appearance of the labia, clitoral hood, or other structures, and these are generally considered a normal part of the process rather than a complication.
Transmasculine Procedures
Transgender men and transmasculine people have two main surgical options for genital construction: metoidioplasty and phalloplasty. The two differ significantly in size, complexity, and function.
Metoidioplasty uses the clitoris, which has typically enlarged from testosterone therapy, as the basis for a small penis. It’s constructed primarily from local genital tissue, requires fewer surgical stages, and tends to preserve more erogenous sensation. The tradeoff is size. The resulting penis is limited in length, which can make standing urination difficult without a modified technique and generally does not allow for penetrative sex.
Phalloplasty builds a larger penis using a tissue flap taken from another part of the body, most commonly the forearm or thigh. This creates a penis that’s large enough for standing urination at a urinal and penetrative sex (with a penile implant placed in a later stage). However, phalloplasty requires more surgical stages, carries a higher complication rate, and may result in less erogenous sensation than metoidioplasty. To restore feeling, surgeons connect a sensory nerve from the tissue flap directly to one of the clitoral nerves. Over months, nerve signals gradually grow into the new tissue, allowing both protective (touch, temperature) and erotic sensation to develop.
Both procedures can include construction of a scrotum from labial tissue, with testicular implants placed during a later stage. Urethral lengthening, which extends the urethra through the new penis so the person can urinate while standing, is one of the most technically challenging parts of either surgery.
Preparation Before Surgery
One of the most time-consuming steps happens months before the operating room: permanent hair removal. Any skin that will end up lining an internal canal needs to be cleared of hair first, or hair can grow inside the body after surgery and cause complications.
For vaginoplasty, the penile shaft and a wide strip of scrotal skin must be made permanently hair-free. Many surgeons recommend treating the entire scrotum because it’s hard to predict exactly which portion of scrotal skin will be used as a graft. For phalloplasty using a forearm flap, the inner surface of the forearm needs hair removal. Thigh flap phalloplasty requires clearing the donor site on the thigh.
Laser or electrolysis sessions are spaced at least six weeks apart to account for hair growth cycles, and surgeons typically want to wait three months after the final treatment before operating to confirm no regrowth. The entire hair removal process can take a year or more. Patients also need to avoid sun exposure for at least six weeks before and after each laser session.
Recovery and Dilation
Recovery from genital surgery is measured in months, not weeks. Most people stay in the hospital for several days after vaginoplasty or phalloplasty, and full activity restrictions can last six to eight weeks or longer.
For vaginoplasty patients, the most important part of aftercare is dilation: inserting a medical dilator into the vaginal canal at regular intervals to maintain its depth and width. For the first year after surgery, dilation happens multiple times a day. The frequency gradually decreases over time, but some level of ongoing dilation is a permanent part of life after vaginoplasty. Skipping dilation, especially in the early months, can cause the canal to narrow or shorten.
Phalloplasty recovery is often staged across multiple separate surgeries, each with its own recovery period. The most common complication is unplanned reoperation, occurring in about 15% of patients in one study, most often due to blood collection at the surgical site that needs to be drained. Smoking dramatically increases the risk of complications. Patients who had smoked within a year of surgery had roughly 20 times the odds of minor complications like wound infection, wound breakdown, or urinary tract infection.
Costs and Insurance
These are expensive procedures. Based on 2019 claims data published in JAMA Surgery, the median total cost for a vaginoplasty was about $59,700, while phalloplasty came in at roughly $148,500, reflecting its greater complexity and multiple stages. Out-of-pocket costs for insured patients were considerably lower, with a median of around $2,950 for vaginoplasty and $2,120 for phalloplasty.
Insurance coverage has expanded in recent years, but access remains inconsistent. A study of 435 insurance contracts from Fortune 500 companies found that 25% still contained language explicitly excluding transition-related care. Even among companies that scored perfectly on LGBTQ+ workplace equality indexes, only half had clear policy language about how to access gender-affirming surgery. The result is that many patients still pay out of pocket or face lengthy appeals processes.
Satisfaction and Regret
Research consistently finds that satisfaction after gender-affirming surgery is high and regret is rare. The overall regret rate is estimated at approximately 1%. A study using validated psychological instruments to measure satisfaction after gender-affirming mastectomy found a median satisfaction score of 5 out of 5, while the median regret score was 0 out of 100. No participants in that study had requested or undergone a reversal. The researchers noted that dissatisfaction was so uncommon it actually made statistical analysis difficult, because there wasn’t enough variation to study.