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Surgical procedures

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

Types of procedure

  • Mastectomy: removal of breast tissue. Permanent and increasingly performed on minors or young adults, despite limited long-term data. See mastectomy.
  • Breast augmentation: implants in trans women. Implants have a finite lifespan and as a rule must be replaced every 10–15 years.
  • Vaginoplasty: construction of a neovagina, usually via penile inversion. The result is not a vagina but a surgically created cavity that must be dilated for life. See vaginoplasty.
  • Phalloplasty or metoidioplasty: construction of a neophallus. Complication rates are high (up to over 50% in some series): fistulas, strictures, tissue loss. See phalloplasty.
  • Orchidectomy: removal of the testes. Permanent sterilisation and lifelong hormone dependency.
  • Hysterectomy and oophorectomy: removal of the uterus and ovaries in trans men. Permanent and sterilising.
  • Facial feminisation surgery (FFS): cosmetic osteotomies and modifications to the jaw, chin and forehead. See facial surgery.
  • Voice surgery: alteration of the vocal cords — irreversible and with a risk of lasting voice change less favourable than intended.

Indication and access in the Netherlands

Genital surgery in the Netherlands takes place after a diagnostic process, mainly at Amsterdam UMC. Waiting times are long (often several years), which leads patients to undergo operations in Belgium, Thailand or the US, sometimes with limited follow-up care in the Netherlands.

Since 2014 surgery is no longer a legal requirement for sex registration. Reimbursement via the basic insurance requires a referral from a recognised gender team; FFS largely falls outside the basic insurance.

Risks and complications

Besides general surgical risks (infection, bleeding, anaesthesia), the complication profile of each procedure is substantial.

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

Adequate information about these complications is essential. Research suggests that patients are not always fully informed, partly because of time and motivation pressure within the pathway.

Satisfaction, regret and detransition

Studies generally report high satisfaction, but lean on cohorts with substantial attrition and self-report from a motivated group — which systematically overestimates satisfaction. Research by Dhejne et al. (2011) showed persistently elevated mortality and psychiatric morbidity, also after surgery. More recent research (among others Littman 2021, 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) stresses that particular restraint is required in young people, precisely because the procedures are irreversible and the current population differs from the one on which the original Dutch Protocol was based.

See also