So You Want to Be a Gender SurgeonJune 23, 2022
So you want to be a gender surgeon. You love the idea of creating new body parts and want to be one of the first surgeons to break into this up-and-coming field. Let’s debunk the public perception myths of what it means to be a gender surgeon and give it to you straight. This is the reality of gender surgery.
What Is Gender Surgery?
Gender surgery is the field of medicine concerned with alleviating gender dysphoria through surgical procedures. Gender dysphoria is defined as the unhappiness that patients in the gender-expansive community feel due to the incongruence between their gender identity and their physical characteristics.
We often think of gender surgery as synonymous with genital surgery; however, the scope of a gender surgeon is much broader. Any surgical procedure that is done to help alleviate gender dysphoria can be considered gender surgery. This includes masculinization and feminization of the face and chest, tracheal shaves, voice modification, body contouring, and even limb lengthening and shortening procedures.
Gender surgeons work with the full spectrum of gender patients, including transgender, non-binary, gender-fluid, and intersex patients.
Transgender patients are individuals whose gender identity differs from their assigned gender at birth. Within the gender surgery community, the appropriate terminology is either “assigned male” or “assigned female” at birth. We use this terminology as opposed to “biologically male” or “biologically female,” as the latter terms do not take into account the mental and psychological aspects of biology.
Non-binary individuals do not identify as solely male or solely female but rather view themselves as having features of both. There are also gender-fluid individuals whose gender identity varies depending on the social situation. For example, these individuals may identify as one gender while at work and another while outside of work. This isn’t to be confused with cross-dressing, which is typically done for sexual satisfaction as opposed to being an integral part of that person’s identity.
Lastly, there are intersex individuals who are born with some variation of both male and female sex organs.
Because gender surgeons work with a wide variety of gender patients, each with their own unique goals and needs, the treatment plan often varies significantly from patient to patient. When it comes to gender surgery, there is no one-size-fits-all solution.
This brings me to an important method of differentiating a gender surgeon’s practice: top surgery versus bottom surgery versus other masculinization and feminization surgeries.
Top Versus Bottom Versus Other Masculinization & Feminization Surgeries
The majority of gender surgeons focus primarily on top surgeries. This includes a variety of chest masculinization and feminization procedures, including mastectomies for trans men and breast augmentations for trans women.
This is the most common type of gender surgery, and these procedures are very similar to routine breast augmentation, reduction, and mastectomy procedures. They are also less functional compared with genital surgeries, so there is often less risk of complications. The combination of these two factors means that more surgeons are comfortable performing these types of procedures.
Gender surgeons who perform bottom surgery, which includes vaginoplasty, phalloplasty, and metoidioplasty, are much less common. The reason being is that the surgical creation of a vagina or penis is still quite new and these procedures are constantly evolving. It has only been within the last few years that training to perform these procedures has become more readily available. In the past, physicians interested in performing genital surgery had to do much of the research on their own and seek out mentors who were willing to train them.
That being said, bottom surgery does not always involve the creation of a new sex organ. Sometimes the role of the gender surgeon is to simply remove the incongruent sex organ to combat hormone production or to allow the patient to live more in accordance with their gender identity.
For example, a trans female that has an orchiectomy to remove one or both of the testicles may be able to significantly reduce the number of testosterone-blocking medications that she has to take — thereby reducing the risks and side effects of the medications.
In addition, a trans male may find having menstrual periods as a male to be very traumatic psychologically. In this scenario, having a hysterectomy to remove the uterus may allow him to live more in accordance with his gender identity.
Lastly, there are other gender surgeons who don’t perform top or bottom surgeries and perform other procedures that help alleviate gender dysphoria. This includes plastic surgeons who perform facial masculinization or feminization, body contouring, or fat grafting procedures; ENT surgeons performing tracheal shave or voice modification procedures; and even orthopedic surgeons performing limb-lengthening or -shortening procedures.
Misconceptions About Gender Surgery
Let’s clear up some of the misconceptions about gender surgery.
To start, many people believe that you have to be a part of the LGBTQ+ community, or have a family member that is, in order to do gender surgery. This is not true. If you are a kind, empathetic, and down-to-earth individual who truly wants to help gender patients, there will always be a place for you within the gender surgery community.
Gender surgery is a very niche specialty, so it is not necessary for every gender surgeon to fit some sort of perfect ideal. As a society, we need more physicians to go into gender surgery, period. Right now, the gender-expansive community is extremely underrepresented in healthcare, so we can’t wait for there to be more representation before we start expanding our ability to offer services to these patients. Doing so would only be a disservice to this already deeply marginalized population.
Many people also believe that gender surgery is purely cosmetic — it is not. When you look at the data, patients with gender dysphoria are at a significantly higher risk of mental illness and substance abuse than the general population.
According to one study, approximately 82% of transgender youth experience suicidal ideation and approximately 40% have attempted suicide. Many gender surgery patients have long histories of self-harm as a result of the mental strain that being transgender, non-binary, gender-fluid, or intersex has placed on them. Many patients have even taken their own lives because of it.
As such, gender surgery is not cosmetic. It is often life-saving surgery.
It’s easy for people outside of the gender-expansive community to say that one’s gender identity is a choice and these procedures should be considered cosmetic; however, anyone who works with these patients will tell you it’s far from the truth. This isn’t a matter of novelty or sex life. Gender surgery is about the patient’s identity and safety more than anything.
That being said, another misconception is that every transgender patient wants the full spectrum of surgery. Although many patients go to a gender surgeon specifically because they offer these services, this isn’t the case for all people in the gender-expansive community.
What it means for someone to be “fully transitioned” varies from patient to patient. It’s not for the surgeon, society, or anyone else to determine, but rather for the patient to decide for themselves. For some, fully transitioning might just mean that they’ve accepted their gender identity, dress differently, and act more in accordance with their gender identity. For others, their journey may include the full spectrum of surgery and hormones. Most patients, however, fall somewhere in the middle. As a gender surgeon, it’s important to remember that surgery is not always a part of the patient’s personal journey.
How to Become a Gender Surgeon?
Becoming a gender surgeon is a bit more complicated than most other specialties.
After medical school, there are a few different pathways to becoming a gender surgeon, and which pathway you choose will be dependent on which area of gender surgery you wish to go into.
The most common pathway to becoming a gender surgeon is to complete a plastic surgery residency, followed by either a 1-year gender surgery fellowship or a 1-year microvascular fellowship.
The plastic surgery pathway allows you to perform the widest variety of gender surgeries, including chest masculinization and feminization procedures, vaginoplasty, phalloplasty, and metoidioplasty, as well as facial masculinization and feminization surgery, body contouring, and fat grafting. If you want to be fully trained in all aspects of gender surgery, then plastic surgery is the route you should take.
That being said, plastic surgery is the most competitive pathway to becoming a gender surgeon by far. For the past several years, plastic surgery has been the number one most competitive specialty to match into and requires you to be at the top of your class with great grades, Step scores, and research.
In addition, gender surgery fellowships are incredibly new and only recently came about within the last few years. As such, there are only a handful of gender surgery fellowships available — most of which only accept one fellow per year despite having many applicants per spot. Getting into one of these fellowship programs is incredibly difficult — even among plastic surgeons who have already “beaten the odds,” so to speak.
That being said, there are other, less competitive, pathways to becoming a gender surgeon as well. Physicians interested in performing bottom surgery may also enter the field by completing a residency in either urology or ob/gyn and then seeking additional training afterward. Physicians who are interested in performing procedures such as tracheal shaves or voice modification surgery are able to do so by completing an ENT residency.
Although ENT, urology, and ob/gyn are competitive to match into in their own right, they are still easier to match into than plastic surgery. In terms of competitiveness, ENT and urology are considered tier 2 or highly competitive, and ob/gyn is considered tier 4 or less competitive.
Given the sheer competitiveness of gender surgery and the length of training relative to other medical specialties, students best-suited for this specialty tend to be highly motivated and are often at the top of their class. Given the stigma associated with working with the gender-expansive community, these students also tend to be very open-minded and down-to-earth as well.
What You’ll Love About Gender Surgery
There’s a lot to love about gender surgery.
A big draw for many gender surgeons is that you have the opportunity to work with one of the most marginalized communities in the world and truly change your patients’ lives forever.
Many patients seek out gender surgery because they feel like they’ve lived their entire lives in someone else’s body. As a gender surgeon, you have the privilege of helping them fix that. And unlike hormone treatments and medications, which can take months, if not years, to show significant changes, gender surgery provides you with near-instant gratification.
Within hours, you can remove a body part that someone has lived their entire life being too ashamed to look at and replace it with a new body part that finally makes them feel whole. There are few specialties where you can have such profound, yet instant, gratification as gender surgery.
The patients that you get to work with as a gender surgeon are also some of the most interesting and down-to-earth people you’ll ever meet. Society has judged them their entire lives. Many have lost friends and family members or been verbally and physically abused just for being true to themselves. And yet, through all of that, these patients still get out of bed each day and tell the world, “I am who I am and I don’t care what you think of me.”
Because you’re working with such a unique population as a gender surgeon, no 2 days are ever the same either. Each patient has their own unique goals and needs, so you constantly have to adapt your treatment plan accordingly.
In addition, being such a new specialty, you are always on the cutting edge of medicine as a gender surgeon. Although some may see this as a negative, you have the opportunity to constantly learn and grow as a surgeon.
As procedures such as vaginoplasty and phalloplasty become more common, the techniques and surgeries will evolve as well. As a gender surgeon, you have the unique opportunity to be a part of something new, help advance the field of medicine, and offer services to people that thought they’d never have access to. You’ll learn something new almost every day and will constantly be stimulated intellectually. If you enjoy a challenge, gender surgery will not disappoint.
What You Won’t Love About Gender Surgery
While gender surgery is an awesome specialty, it’s not for everyone.
To start, the training to become a gender surgeon is longer, more competitive, and less standardized than most other specialties. Although there will undoubtedly be more gender surgery fellowships opening in the future, we are still at least 10 to 20 years away from where it’ll be as common as even some of the more niche specialties like microsurgery.
The lifestyle of a gender surgeon is also incredibly demanding — even by most surgeons’ standards. Only a handful of physicians in the country are currently performing genital gender surgery, so it is highly unlikely that there will be more than one in any given practice.
As such, there’s often nobody else to take care of your patients when issues arise. Most gender surgeons have to be available for their patients 24 hours a day, 7 days a week, 365 days a year.
Taking a personal day, traveling out of town, or getting a drink with friends can often be a luxury to a gender surgeon.
Starting a gender surgery practice also requires much more work up front than most other specialties.
Gender surgery is a team effort. You need urologists and gynecologists to assist with hysterectomies and genital surgeries. You need craniofacial-trained plastic surgeons or ENT surgeons to help with facial masculinization or feminization and voice modification procedures. You need mental health providers to write clearance letters. And you need endocrinologists and primary care physicians to help manage patients’ hormone regimens. Due to the stigma associated with gender surgery, it can be difficult to find physicians to work with, given social and religious beliefs.
In addition to clinical staff, you also need a team of lawyers and advocates to fight insurance companies to get these procedures covered, as there are many people who believe that they should be considered “cosmetic” and therefore be paid out of pocket.
This is further complicated by the fact that these procedures are relatively new and there is not much historical data regarding reimbursement or whether patients tend to be litigious, or sue, after receiving surgery. For these reasons, obtaining malpractice insurance or even just finding hospitals that will allow you to perform these surgeries can be a monumental challenge.
As a result of these difficulties, compensation for gender surgeons is often lower than their colleagues in reconstructive or cosmetic plastic surgery. Although compensation varies widely, you can expect to make somewhere between $300,000 to $350,000 a year as a gender surgeon. This is on par with the low end of what reconstructive surgeons make, but significantly less than what cosmetic surgeons make.
In addition, it is not uncommon for gender surgeons to lose money on their gender surgeries and have to do reconstructive or cosmetic procedures on the side in order to keep their practice afloat. Although this will likely change in the future as more insurance companies start to cover these procedures, as it stands right now, gender surgery is not the best fit if you’re optimizing for money.
Should You Become a Gender Surgeon?
How can you decide if gender surgery is right for you?
If you are passionate about surgery and have a desire to help one of the most marginalized patient populations in society, gender surgery may be a good fit.
You should be open-minded and flexible, and willing to learn and adapt as the specialty grows and techniques evolve.
You should also be highly motivated and willing to put in the time and effort it takes to match into plastics, urology, ENT, or ob/gyn residency and then gender surgery fellowship.
Lastly, you should be willing to sacrifice a cushy lifestyle and high compensation for the satisfaction of knowing that you’re saving lives and helping people find happiness in the body they’re in.
Are you hoping to become a gender surgeon? To get into medical school and match into plastics, you’ll need to be at the top of your class. As you look for experts to work with, seek out those who are actual MD physicians who crushed their MCAT and USMLE, gained multiple top medical school acceptances, matched into competitive residencies, and even had medical schools fighting over them by throwing merit-based scholarships to sway their decision. Only the top performers can best show you how to most effectively improve your own performance.
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This post appeared on Med School Insiders.