Only a small number of people with gender dysphoria have surgery to align their bodies with their desired sex — but the rate of complications is high.
One of the largest surveys of trans adults earlier this year indicated that one in six (16 percent) go under the knife to alter their physical appearance.
But research suggests that up to half of trans men and women suffer post-op issues or pain so severe they need medical attention or additional surgery months later.
The complex operations involve crafting the genitalia of the opposite sex using veins, arteries, muscles and skin from other body parts. The surgeries are risky due to surgeons having to connect delicate and complicated networks of blood vessels, as well as creating the ability to urinate.
For trans men, devices are often implanted to allow them to achieve erections and more enjoyable sexual experiences.
Sex change surgery rates have shot up in recent years, with one in six trans adults in the US opting to have gender-affirming surgery. The majority of those who go under the knife have genital surgery (84 percent between 2006-2011), but almost half of the people who have vagina construction surgery suffer complications years later. Most transmen (64 percent) who have penis construction surgery also have issues
Parker Laden, a 30-year-old nonbinary detransitioner, underwent a double mastectomy. They were left with pockets of fat on either side of their body. They were also given testosterone after just a 15-minute long consultation
Patients are often left with infections, pain and difficulty using the toilet or having sex post-surgery.
One of the biggest studies of its kind by the Women's College Hospital (WCH) in Ontario, Canada, earlier this year found that more than half of trans women who had 'bottom' surgery were in so much pain years later they needed medical attention.
For trans men who often have a mechanical device implanted, studies suggest a fifth need the implant removed within a year.
Sex change operations have been at the center of political debate in recent years amid concerns that patients who get them are vulnerable and not fully aware of the risks.
For example, studies suggest those who are transgender are six times more likely to suffer from autism, and up to 70 percent of trans youths are depressed.
But some studies, including one by the National Institutes of Health, suggest patients are happier after the surgery, further complicating the issue.
A phalloplasty involves creating a penis from skin taken from elsewhere on the body. The main two techniques are radial forearm flap, where skin is taken from the forearm (pictured left six weeks post-op) and anterolateral thigh flap, where skin is taken from the thigh (pictured right one-month post-op)
A large study last year found more than a third of penis implant procedures to give an erection had complications so bad further surgery was required.
Nine months after the procedure, more than a fifth of patients had had their devices removed, either due to infection or mechanical failures.
Some 67 of the prosthetic penises were inflatable, and 13 were semirigid.
An inflatable implant involves a silicone pump inserted into the scrotum, which can be squeezed to generate an erection.
A semirigid implant uses two flexible rods which keep the penis semirigid so it can be easily bent down or up during sex.
The rods are made of metal wire and wrapped in a silicone jacket. The implants may also be used in biological males who have erectile dysfunction.
For male-to-female transition, the procedures on offer include breast augmentation, where breast implants are inserted into the chest.
Voice feminization and facial feminization surgery include operations such as forehead and brow bone reshaping, jaw and chin contouring, nose reshaping (rhinoplasty), hairline advancement, and tracheal shave — a procedure to reduce the size of the Adam's apple.
Trans women can also get an orchiectomy to remove the testicles and a vaginoplasty to create a vagina, clitoris, labia majora and labia minora using a patient's existing genital tissue.
John Hopkins University found that up to 30 percent of transgender women who have had a vaginoplasty suffered an infection linked to the operation.
Some surgeons use a method called penile inversion, where they will cut between the rectum and the urethra and prostate. This creates a tunnel that turns into the new vagina.
The most common top surgery among trans men is chest masculinization in the form of a double mastectomy, where the breasts are removed.
Delicate and intricate bottom surgeries are also available, including a phalloplasty which uses a piece of tissue known as a flap, usually taken from the forearm or thigh, to construct a penis.
Dylan Mulvaney, a transgender women, underwent facial feminization surgery in December last year
A Russian doctor was the first to perform the operation in 1963, which is done in a single session lasting up to 12 hours.
The alternative is a metoidioplasty which uses a hormonally enlarged clitoris as the body of the penis. Hysterectomies involve the removal of the uterus and ovaries.
Dr Richard Santucci, an experienced surgeon at the Crane Center for Transgender Surgery who carried out a study on penis implants to give an erection, told DailyMail.com that in transgender patients, the procedure has 'a crazy high complication rate compared to cis males'.
He used to do 40 or 50 prosthetic penis procedures a year, but now he does 100 a year.
Dr Santucci said: 'We want to get better... Anytime something is proven in the literature to decrease infection rate, I do it.'
He added: 'The more the surgeon has specific experience with this exact operation, the better it gets.'
Statistics for transgender patients and their treatment have been sparse for decades due to the low number of people receiving care.
But the number of people identifying as the opposite sex has skyrocketed in recent years, partly due to growing acceptance, meaning the literature is finally catching up.
The number of transgender people in America has risen from one million in 2016 to 1.64 million in 2022, according to data from the Williams Institute.
Surgeries performed have also gone up fourfold, from 3.87 per 100,000 patients to 14.22 per 100,000 patients between 2000 and 2014, according to research by Harvard University and John Hopkins University School of Medicine.
And the figures are much higher in more recent years. Around 9,000 transgender surgeries are now performed every year in the US.
Of the 80 trans women sampled in the Canadian study, almost 54 percent reported ongoing pain up to two years after their vaginoplasty surgery. Many had more than one symptom, which included vaginal dryness, numbness, malodor and issues with the wound's healing
Researchers from different hospitals in Texas reviewed 80 transgender patients with phalloplasty who underwent penile prosthesis placement between April 2017 and November 2020.
Up to 86 percent of patients who have a successful phalloplasty — plastic surgery to construct a penis — request a prosthesis placement afterward, and they have been found to raise levels of sexual satisfaction.
The patients were followed up after at least six months, with an average follow-up time of just over two years.
Some 36 percent of patients had a complication that required further surgery, and 20 percent of patients had an infection.
The high prevalence of post-op issues is due to the created phallus structure, Dr Santucci, one of the study's authors, explained.
Penile inversion technique, where surgeons will cut the rectum and the urethra and prostate. This creates a tunnel that turns into the new vagina
He said: 'If I have a cis male, his penis has got a ton of structures, and it's got these very hard corpora [columns of spongy tissue running through the shaft of the penis] that you almost have to think about as your tires, they're very tough, and they fill up blood and make the phallus rigid. The implant is laid inside of those really tough corpora and then the corpora are closed. So they're in there, they can't migrate, they can't infect very easily.
'Whereas I'm laying this thing in the middle of an envelope of fat and skin envelope, and I have to anchor it somewhere. So I'm taking really serious sutures [stitches of wire] and I'm nailing the suture through the bone through the underside of the pubic bone, and then tying that together.'
He added: 'It's just a completely different operation. Same procedure, but that phallus is not a phallus; it's an envelope of skin and fat.'
Nine months after the procedure, 21 percent of patients had had their devices removed due to infection or mechanical failures.
Mechanical failures, where the implant stopped working, occurred an average of nine months after surgery.
Eleven of the 16 patients with an infection had one that was so serious that the penis implant had to be removed.
One patient had it removed due to pain, and another because the implant had become exposed and was sticking out.
Infection began an average of 35 days after getting the prosthetic penis.
In another study of 792 patients who underwent the same surgery, serious complications requiring surgical intervention, such as implant removal, were seen in 36 percent of cases.
The number of chest reconstruction surgeries among children in the US jumped five-fold from 2016 to 2019, from 100 to 489 annually
After an average follow-up of 2.6 years, 40 percent of patients no longer had their original implant.
A separate study in Canada published in January 2023 found that more than half of trans women who have 'bottom' surgery were in so much pain years later they required medical attention.
Up to a third of patients also struggled to use the toilet or suffered sexual issues a year after the operation, which sees patients transitioning from male to female given a surgically constructed vagina.
Researchers from the WCH in Ontario, Canada, analyzed the medical records of 80 patients who sought care from the WCH's newly opened Postoperative Care Clinic between 2018 and 2020, three months to five years after having the operation.
All 80 patients had the original vaginoplasty procedure outside of the Women's College health system but were experiencing symptoms that needed follow-up care.
Some had traveled as far as India and Thailand to have the operations, which the researchers say may explain the relatively high number of medical complaints.
The most common symptoms reported by post-op patients were pain (53.5 percent), bleeding (42.5 percent) and dilation issues (46.3 percent).
Severe side effects were much rarer, but in 12 cases — or 15 percent — patients experienced vaginal stenosis, the narrowing and shortening of the vagina.
In two other cases, patients had severe infections around the surgical site, and another two were hospitalized with mental health problems.
Much more common were minor outcomes like difficulty urinating (22.5 percent), sexual problems (33.8 percent), and poorly healing wounds (21.3 percent).
A total of 15 patients (18.8 percent) also told the clinic they were dissatisfied with the appearance of their new vulva and wanted some cosmetic revision.
Most complaints of ongoing pain were treatable with topical medication or more regular check-ups.
Although classified as 'minor' in medical records, many of these symptoms had the potential to grow into much more serious difficulties had patients not sought treatment, the study emphasized.
The rate of children undergoing the procedure rose 13-fold since 2013 (pictured left). Some patients were as young as 12 (show top right). The vast majority had no regrets about the surgery, with only two children saying they wished they had not gone through with it
For this reason, 'surgical centers should be providing ongoing post-operative care, especially in the first year after surgery,' researchers urged.
This is especially crucial given the rise in popularity of the procedure in recent years and its high cost, which can push those seeking the surgery to cheaper and less well-regulated surgeons overseas.
Bottom surgeries such as vaginoplasties and phalloplasties — genital reconstruction undergone by women transitioning to men — cost around $25,000.
'It is quite clear from the most up-to-date studies that vaginoplasty and other genital surgeries don’t work in the way that people hope they will,' said Stella O'Malley, psychotherapist and director of campaign group Genspect.
'The reason why there is so many problems is because this is an incredibly difficult surgery. Young vulnerable people need to know about the challenges they will face post surgery but few of them do.'
As gender-affirming surgery becomes more popular, an increasing number of 'detransitioners' who regret having the irreversible procedure have come forward.
One such de-transitioner, who goes by the name of Shape Shifter claimed he regretted his mastectomy and vaginoplasty after they led to fistula and other painful consequences.
Shape explained how neither having a working penis nor a vagina that functions and required to take hormones for the rest of his life, feels like a medical experiment gone horribly wrong
He said woke doctors did not warn him of the negative consequences of surgery because it would be 'bad for business'.
The surgery itself was performed by Dr Sherman Leis of The Philadelphia Center for Transgender Surgery. Leis is regarded as the United States' most experienced gender reassignment surgeon.
But soon after the operation was completed in 2015 in his mid-20s, Shape Shifter quickly realized he had made a terrible mistake and that he was just a gay man who enjoyed presenting in a feminine way.
The procedures he has undergone — which include the removal of his penis and the creation of a 'neo-vagina' — are irreversible.
They have left him with osteoporosis, scoliosis, a 'vagina' that his body believes is a wound and which it tries to close up, as well as a host of mental health conditions, including depression and a reduced sex drive.
Shape Shifter believed that making the initial switch to a woman would make him finally feel happy in his own body, but he ended up feeling even more depressed than before the surgery.
He said: 'I was happy maybe for a month or two but then got even more depressed after surgery. My neo-vagina started constricting. I thought I was going to spread my legs and get f****d and that never really happened after I gave away my penis.
'I was online telling people how depressed I was. A lot of people thought it was because of the surgery... but I had no energy, I was so lethargic, I had brain fog and no sex drive at all.'
He added: 'I will never be able to get my penis back which is extremely traumatic for me. I want it back and I can't. Sex is traumatic for me now because I've had botched surgeries.'
Shape believes that a lot of people might reconsider having surgery in the first place if they knew of the possible complications, but he believes it would be 'bad for business' if surgeons alluded to such realities.
Meanwhile, Canadian detransitioned woman Michelle Zacchigna, 34, who goes by the pen name Michelle Alleva, had a mastectomy 11 years ago.
She wrote in a blog post: 'I have met so many people who have been irreparably harmed by that same "treatment".'
She said: 'I know people with ongoing vocal pain from testosterone use. I know people who are devastated by their inability to ever breastfeed their children.
'I know people who might never enjoy sexual intimacy again, either because they are horrified by their own bodies — because their libidos are completely shot — or because sex is now physically painful.
'I know people who have been made infertile by this 'treatment.' (I, myself, have sat sobbing as I process the reality that, during the darkest years of my life, I was insistent on eradicating one of the last indicators of 'female' I had, when I had resolutely wanted to bear children my entire life before then.)
'I know people deep in addiction because they are convinced it is the only way they can make it through the day after everything they've been through.
'I know people who can't get out of bed because they believe the best parts of life have been stolen from them. I have seen (and felt) so much pain. So much. I still keep myself one step back from it.'
'It altered our bodies, it destroyed our natural functioning, it gave us chronic pain and lifelong complications; and it left us feeling broken and alone,' she wrote.
Michelle went back-and-forth with mental health issues - in which a number of diagnoses were made but her gender dysphoria left unexplored. She's pictured here after her mastectomy
Ms Cole has 'detransitioned' back to being female and now campaigns against trans ideology. Breast removal and other procedures are 'like Nazi-era experiments,' she said
Michelle underwent surgery to remove her breasts and uterus and is now suing the healthcare providers who are reported to have facilitated her transition.
'I will live the rest of my life without breasts, with a deepened voice and male-pattern balding, and without the ability to get pregnant,' she wrote.
'Removing my completely healthy uterus is my greatest regret.'
A 2020 systematic review and meta-analysis of 'the quality of life in people with transsexuality after surgery', looking at 1,099 patients, found quality of life was generally better for people who underwent surgery but that trans people remain at risk for low life quality and mental health issues.
It noted that '[transexuality] can convert to a source of identity crisis due to the... effects on the personality and behavioral system of the individuals as well as their social adjustment.'
Ritchie, a 35-year-old detransitioner from the UK, was born a male but underwent hormone treatments at age 26. Two days before his 31st birthday, he had his genitals removed.
At age 35, he stopped identifying under his trans name and has since been on a journey to 'reclaim what's left'.
The surgery, called penile inversion with scrotal graph, involves surgeons making a cut between the rectum and the urethra and prostate. This creates a tunnel that turns into the new vagina.
'It is as horrifying as it sounds,' he said in a YouTube video. 'The existing surgeries are quite brutal.
'The moment I woke up, even before I knew it had gone catastrophically bad I was like, f***, this was a mistake.'
In a Twitter thread, he said: 'I have no sensation in my crotch region at all. You could stab me with a knife and I wouldn't know. The entire area is numb, like it's shell shocked and unable to comprehend what happened, even four years on.
'Years later, I have what looks like a chunk of missing flesh next to my neo-vagina, it literally looks like someone hacked at me.'
