Surgical Procedures

Surgical procedures performed as part of a gender transition remove healthy tissue — breasts, testicles, ovaries, uterus — and construct genital structures that are not functionally equivalent to the original. These are irreversible procedures on anatomically healthy organs, often followed by lifelong complications or aftercare. Careful consideration is therefore not a formality but a medical necessity.

Figures for each procedure — complications, outcomes and prevalence, with sources — can be found at genderrisico.nl. The other dossiers available on the site are listed in the archive description of genderrisico.nl.

Types of procedures

• Mastectomy: removal of breast tissue. Permanent and increasingly performed on minors or young adults, despite limited long-term data. See mastectomy.
• Breast augmentation: implants for trans women. Implants have a limited lifespan and generally need to be replaced every 10–15 years. See breast augmentation.
• Vaginoplasty: construction of a neovagina, usually through penile inversion. The result is not a vagina but a surgically created cavity that must be dilated lifelong. See vaginoplasty.
• Phalloplasty or metoidioplasty: construction of a neophallus. Complication rates are high (over 50% in some series): fistulas, strictures and tissue loss. See phalloplasty and metoidioplasty.
• Orchiectomy: removal of the testicles. Permanent sterilization and lifelong dependence on hormones. See orchiectomy.
• Hysterectomy and oophorectomy: removal of the uterus and ovaries in trans men. Permanent and sterilizing.
• Facial feminization surgery (FFS): cosmetic osteotomies and alterations to the jaw, chin and forehead. See facial surgery.
• Voice surgery: adjustment of the vocal cords — irreversible and carrying a risk of permanent voice changes that turn out less favorably than intended.

Eligibility and access in the Netherlands

Genital surgery in the Netherlands takes place after a diagnostic process, primarily at Amsterdam UMC. Waiting times are long (often several years), prompting patients to undergo surgery in Belgium, Thailand or the United States, sometimes with limited aftercare in the Netherlands. Which procedures are performed in the Netherlands and under what conditions is explained at gendermolen.nl.

Since the Transgender Act of 2014, surgery has no longer been a legal requirement for changing the sex designation in official records. Reimbursement through the basic health insurance requires a referral from a recognized gender team; FFS is largely excluded from the basic health insurance.

Risks and complications

In addition to general surgical risks (infection, bleeding and anesthesia), the complication profile is considerable for each procedure.

• Vaginoplasty: strictures, fistulas, prolapse, loss of depth, urinary stream abnormalities, loss of sensation and the need for lifelong dilation to prevent closure. Repeat surgeries are not uncommon.
• Phalloplasty: urethral fistulas and strictures occur in tens of percent of cases; partial or complete tissue loss of the neophallus can occur. Erectile function requires an implant with its own complication profile.
• Mastectomy: loss of the ability to breastfeed is permanent; loss of sensation and scarring are the rule.

Adequate information about these complications is essential. Research indicates that patients are not always fully informed, partly because of time pressure and motivational pressure during the process.

Satisfaction, regret and detransition

Studies generally report high satisfaction, but rely on cohorts with substantial attrition and self-reporting by a motivated group — systematically overstating satisfaction. Research by Dhejne et al. (2011) found persistently elevated mortality and psychiatric morbidity, including after surgery. More recent research (including Littman 2021 and MacKinnon et al. 2022) and the growing visibility of detransitioners suggest that regret and detransition are less rare than previously assumed, particularly in the younger cohorts of the past decade.

The Cass Review (2024) emphasizes that particular caution is warranted with young people, precisely because the procedures are irreversible and the current population differs from the one on which the original Dutch Protocol was based. In 2026, the American Society of Plastic Surgeons stated that there is insufficient evidence for gender surgery in minors. In the Nordic countries, surgery for gender dysphoria remains reserved almost everywhere for adults. In the United Kingdom, the question was raised in 2026 as to whether genital gender surgery in young women falls under the UK anti-mutilation law. The fundamental question of whether medicine should restore health or may also serve well-being is discussed in medicine as restoration or as a well-being project.