There are a lot of questions surrounding the medical steps involved in a gender transition. For many transgender people, surgery focused on the appearance of genitals — phalloplasty and vaginoplasty, sometimes referred to as "bottom surgery" — is a relatively low-priority concern. The Encyclopedia of Surgery estimates there are just 100 to 500 such surgeries in the United States every year. Others view genital surgery or other medical procedures — plastic surgery on the face or torso, hormone replacement therapy and more — as crucial parts of their gender transition.
For those who do desire surgery, procedures can be prohibitively expensive. The Philadelphia Center for Transgender Surgery puts the price tag for phalloplasty at roughly $21,250, while the Transgender Law Center notes that the procedure "can cost upward of $100,000." The video below shows the surgical process for one form of medical transition for transgender men.
As FiveThirtyEight noted in 2014, there are no known national surveys that measure the number of transgender individuals living in the United States, as "some people are afraid to answer, while others disagree on what 'transgender' even means." Any statistics about the total number of transgender people in the United States are a "rough estimate at best."
According to the National Center for Transgender Equality, passage of the Affordable Care Act "banned sex discrimination in health care settings that have a connection to federal funds" and barred most health care providers from refusing to treat patients — or treating patients differently — because of transgender status.
The Transgender Law Center also noted that even those who have health insurance are still likely to pay out of pocket for hormones, therapy and surgeries to confidently present in a way that matches their identity. Such a financial burden can result in "severe emotional turmoil, depression and even suicide."
As shown in the above video, total gender confirmation surgeries (which do not necessarily include bottom surgery) include chest contouring — a bilateral mastectomy that reshapes the chest and repositions the nipples — as well as a total hysterectomy, in which the uterus, cervix, ovaries and fallopian tubes are removed.
The final step of genital reconstruction surgery can include extending the clitoris, known as a metoidioplasty; creating a penis, also called a phalloplasty; urethral lengthening, referred to as a glansplasty to create the head of the penis; and receiving synthetic testicle implants, known as a scrotoplasty.
Jan. 25, 2017, 4:21 p.m.: This story has been updated.