GRS, short for gender reassignment surgery, refers to a range of surgical procedures that reshape a person’s body to match their gender identity. You may also see it called gender-affirming surgery (GAS) or sex reassignment surgery (SRS). These terms all describe the same category of procedures, though “gender-affirming surgery” has become the preferred term in medical settings because most people who pursue these procedures see themselves as affirming their gender rather than changing it.
GRS is not a single operation. It can include genital reconstruction (often called bottom surgery), chest reconstruction (top surgery), facial surgery, and body contouring. Not every transgender person pursues surgery, and those who do may choose only certain procedures.
Genital Surgery for Transfeminine Patients
For transgender women and transfeminine individuals, the primary genital procedure is vaginoplasty: the creation of a vagina, vulva, and clitoris. The most common technique is penile inversion vaginoplasty, where skin from the penis is used to line the vaginal canal, sometimes supplemented with scrotal skin grafts. A newer approach uses peritoneal tissue, the membrane that lines the abdominal cavity, to create the vaginal lining instead.
The two approaches differ in a few practical ways. About half of patients who undergo the standard penile inversion technique report no vaginal moisture afterward. With the peritoneal technique, roughly 70% of patients report some degree of increased wetness during arousal. Recovery timelines are similar, with patients typically resuming gentle daily activities within the first week after surgery.
Complication rates for vaginoplasty are relatively low. In a study of 407 patients, early graft failure requiring revision occurred in about 1% of cases. Serious complications like fistulas (abnormal connections between the vaginal canal and rectum) occurred in 0.5% of patients, and urethral narrowing in 0.2%.
Genital Surgery for Transmasculine Patients
Transgender men and transmasculine individuals typically choose between two procedures: metoidioplasty and phalloplasty.
- Metoidioplasty works with existing genital tissue. After testosterone therapy enlarges the clitoris, the surgeon releases it from surrounding structures and repositions it to create a small phallus, averaging about 6 cm (roughly 2.4 inches). The procedure uses local tissue and does not require a donor site from another part of the body. About 74% of patients are able to urinate standing up afterward.
- Phalloplasty builds a full-sized phallus using tissue transplanted from another part of the body, most commonly the forearm or outer thigh. It is a more complex, often multi-stage procedure that leaves a scar at the donor site. Standing urination rates are higher, around 95% overall, though about a quarter of patients develop complications like urethral narrowing or fistulas that may need additional surgery.
Neither procedure produces natural erections. Phalloplasty patients who want rigid erections can later have a penile implant placed. Metoidioplasty patients may experience some natural firmness from the erectile tissue already present.
Chest Surgery (Top Surgery)
For transmasculine patients, top surgery removes breast tissue to create a flat, masculine chest contour. Four main techniques exist, and the best fit depends on breast size and skin elasticity.
The double-incision method is by far the most common, used in about 85% of cases. It works best for people with larger breasts and involves removing skin and tissue through a horizontal incision below the chest, then grafting the nipples into a new position. For people with smaller chests, limited-incision techniques like keyhole (8% of cases) or periareolar (6%) leave smaller scars and preserve the nipple on its natural blood supply, but they can only remove a limited amount of tissue.
For transfeminine patients, breast augmentation with implants follows similar principles to cosmetic breast augmentation but is typically performed after at least a year of hormone therapy, which allows some natural breast development first.
Facial and Body Procedures
Facial feminization surgery (FFS) reshapes bone and soft tissue to soften typically masculine facial features. One of the most common components is forehead contouring, where the bony ridge above the eye sockets is removed, reshaped, and replaced to create a smoother, more rounded forehead. Other procedures can address the jawline, chin, nose, and brow position. FFS is often pursued alongside or independently of genital surgery.
Facial masculinization surgery exists as well, though it is less commonly sought since testosterone therapy typically produces significant changes in facial structure on its own.
Requirements Before Surgery
International guidelines from the World Professional Association for Transgender Health (WPATH) recommend that adults pursuing genital surgery be stable on hormone therapy for at least 6 months beforehand, unless hormones are medically inappropriate or not desired. For adolescents, the recommended minimum is 12 months of hormone therapy before procedures like vaginoplasty, phalloplasty, or chest surgery.
Mental health assessment is part of the process, but WPATH’s current guidelines explicitly state that psychotherapy should not be mandatory before treatment. The purpose of assessment is to ensure that any mental health concerns that could affect surgical outcomes have been addressed, not to serve as a gatekeeper.
There are also physical preparation steps that take time. Patients undergoing vaginoplasty need hair removal on the skin that will be used to line the vaginal canal. Laser hair removal has largely replaced electrolysis for this purpose, as it covers larger areas more efficiently. Surgeons generally recommend waiting at least 3 months after the final hair removal session before operating, to confirm no regrowth occurs.
Recovery and Long-Term Maintenance
Recovery varies widely depending on the procedure. For vaginoplasty, the most time-intensive aspect of recovery is dilation: using medical dilators to maintain the depth and width of the new vaginal canal. The typical schedule starts at three times daily for the first three months, drops to once daily from months three to six, then tapers to once or twice a week after nine months. Dilation must continue regularly for at least the first year, and most surgeons recommend some ongoing maintenance long-term.
Dilator size increases gradually every three months, starting at about 1⅛ inches in diameter and progressing to 1½ inches by the end of the first year. Each session takes about 10 minutes.
Sensation and Sexual Function After Surgery
One of the most common concerns people have about GRS is whether they will retain sensation. The evidence is reassuring. After vaginoplasty, the neoclitoris (constructed from the sensitive tip of the penis) provides erogenous sensation, and the vaginal canal develops vibratory and pressure sensation comparable to a natal vagina. High rates of orgasmic ability are reported.
After phalloplasty, sensory outcomes are more variable. The largest published series show that sensation in the new phallus returns over several months but measures slightly less than what is typical in non-surgical males. Still, erogenous sensation and the ability to orgasm are present in nearly all patients after recovery. Researchers have noted that sensory recovery after genital reconstruction is faster and more complete than in almost any other surgical scenario involving nerve regeneration.