What is gender?

Sex, gender and sexuality mean different things:

Your sex refers to your physical or biological characteristics — for example, whether you have a penis, vagina or breasts, your hormones and your genes.

Your gender is how you feel about yourself — whether you feel masculine or feminine, or a mixture of both. It’s your sense of who you are.

Your sexuality is who you’re attracted to sexually and romantically.

There are many ways to define your sex, gender and sexuality. For example, some people are born with both male and female features (‘intersex’), some people identify as both male and female at the same time, and others are attracted to members of the same sex (‘homosexual’, ‘gay’ or ‘lesbian’). People who are attracted to people of a different sex to their own are referred to as ‘heterosexual’ or ‘straight’.

Transgender people identify with a gender that is different from their physical sex. People with gender dysphoria feel discomfort because their body doesn’t match their gender. It can cause sometimes cause serious distress, anxiety and emotional pain, but gender dysphoria is not a mental illness.

What is gender confirmation surgery?

Gender confirmation surgery (formerly called gender reassignment surgery) allows people with gender dysphoria to permanently alter their body parts associated with their biological sex. It is also possible to change your physical appearance by taking hormones.

Counselling is usually recommended — especially prior to any surgery — both for children and for adults with gender dysphoria.

Gender confirmation surgery usually involves several operations:

For people born as males, surgery can involve removing the penis and testicles, and sometimes the prostate gland. Tissue from the penis is used to make a vagina and clitoris, which will have sensation. The lips around the vagina (the labia) can be constructed from tissue from the scrotum. The tube that takes urine out of the body, the urethra, is shortened. After surgery, the person uses a vaginal dilator to keep their vagina open.

Many people also have surgery to make them look more feminine — for example, breast implants, or cosmetic surgery to change their lips, eyes, nose or Adam’s apple.

For people born as females, surgery may involve removing the breasts (mastectomy), ovaries and uterus (hysterectomy). The vagina is closed and a penis and scrotum are made from other tissue — for example, from the arm, thigh, back or the inside of the wall of the tummy. Sometimes a penis is made from the clitoris, which has previously been enlarged by using hormone therapy.

The urethra is lengthened so that the person can use the toilet standing up. Sometimes a penile implant, a firm rod or inflatable device, is placed inside the penis to make it possible to get an erection.

Is the surgery right for me?

Gender confirmation surgery is not for everyone. Many people are comfortable to live with gender dysphoria or to have hormone therapy only. Choosing gender confirmation surgery is a big decision. It's almost impossible to reverse.

But for other people, gender confirmation surgery is medically necessary to treating their gender dysphoria. Research shows that almost all of these people report feeling satisfied and happy after their surgery.

As with any surgery, there are risks involved including bleeding, infections, blood clots, damaged tissue and changes in feeling in the skin. Afterwards, some patients have problems going to the toilet or achieving sexual pleasure and/or orgasm.

It’s important to discuss the pros and cons in detail with your doctor. It’s a good idea to ask to see pictures of how other patients look after surgery.

Questions to ask your surgeon include:

• What different surgical techniques are available?
• What are the advantages and disadvantages of each technique for me?
• What results can I expect?
• What are the possible risks and complications?

For help in having the discussion, visit healthdirect’s Question Builder.

Before the surgery

Usually, surgery is the last step in the physical transition process, and it can take several years to reach that point.

Before your surgeon will consider you for gender confirmation surgery, they will usually need you to be formally diagnosed with gender dysphoria and to have had counselling. The first step is to see your doctor, who can refer you for an assessment.

Most patients have hormone therapy for at least 12 months before surgery. This will make them look more like the other sex. For example, females will take androgens and might start growing hair on their face. Males will take oestrogen and anti-androgens, which will make them look more feminine.

For many people, the social aspects of gender confirmation surgery are harder to adjust to than the physical aspects. For this reason, your surgeon might require you to live in your desired gender for 12 months before surgery — for example, by dressing appropriately, using an appropriate name, working or studying and attending family events. This is so you have plenty of time to be sure about all the family, personal, educational, employment, economic and legal changes you could encounter after surgery.

After the surgery

Making sure you do everything your doctor tells you and going to all follow-up appointments will help you get the best outcome from your surgery.

You will need ongoing hormone therapy and counselling as you adjust to your new body and lifestyle. If you have a new vagina, you will probably need to use a vaginal dilator regularly.

Some people find they face discrimination or become socially isolated after surgery. They may regret the decision and how the surgery worked out. If you feel anxious or depressed after the surgery, talk to your doctor.

Cost and legal matters

Gender confirmation surgery can be very expensive — up to about $30,000, depending on which procedures you need. This includes the surgeon’s and anaesthetist’s fees, specialist visits, hospital costs, counselling and hormone therapy.

Many of these costs are covered by Medicare as long as you have a referral. You can check which procedures are covered by Medicare at MBS Online. However, because the surgery is usually performed privately in Australia, you can expect to pay a gap (when the doctor charges more than Medicare pays).

Many private health funds cover gender confirmation surgery. It is important to check with your health fund first about your level of cover. There is a range of health insurance comparison sites available online, such as privatehealth.gov.au.

After the surgery, you can apply to register your sex as male, female or non-specific with the Registry of Births, Deaths & Marriages in your state. You can also update your gender with Medicare if you like.

You are legally protected by the Sex Discrimination Act from discrimination on the grounds of sexual orientation, gender identity or intersex status. Visit the Australian Government Attorney-General’s Department for more details.

For more information

• The Gender Centre (NSW) provides resources and support.
• Transgender Victoria has plenty of resources and information.
• Reachout has information for young people confused about gender.
• The Australian Professional Association for Trans Health (AusPATH) lists some relevant service providers.
• The International Society for Sexual Medicine has information for patients.