Surgeries
Many trans individuals seek out various surgeries for reasons such as relieving body dysphoria, blending into society, health concerns, personal safety, and qualifying to legally change their sex under Singapore law. Many other trans people are content with the changes from hormone therapy or social transitioning alone.
Every trans person is different. Surgery that is medically necessary for a trans person with severe gender dysphoria may be unnecessary for another who has little or no dysphoria. An individual trans person may need some surgeries but not others.
Either way, surgery is not what makes you your gender. You should only seek it if it is something you truly want and are comfortable with, rather than as the result of pressure from others’ ideas of what men’s and women’s bodies “should” look like, or in order to meet administrative requirements to be officially recognised as your gender. Laws change, but surgery is permanent.
Surgeries are often costly, running into the tens of thousands of dollars or more (e.g. a phalloplasty is usually around $150k). Right now, we are not aware of any local insurers who cover transition-related surgeries, as they deem them to be elective and cosmetic.
Avoid any peer pressure to have a specific operation or procedure, including from other trans people. In the end, you are the one who will have to live with your body, so take the time to be sure of what you are doing and what you are comfortable with.
Feminising Surgical Procedures
Breast Augmentation
If you are on estrogen as part of hormone therapy, you will grow natural breasts. However, you may wish to seek breast augmentation if you are disatisfied with your size, or if you are unable to go on hormone therapy. Breast augmentation surgery for trans women and other trans feminine individuals is no different from that performed for cis women, and usually involves having breast implants inserted. Infections or other complications are not common.
We strongly recommend against injecting silicon and other soft tissue fillers as a cheaper alternative. These can cause serious health problems, especially when done by someone with no medical training and in unhygienic conditions. The injected products may harden, cause pain, and migrate to other parts of the body. This disfigures your body and creates permanent unwanted changes. These injections can also lead to infection or chronic or acute systemic inflammation, which is especially serious, and potentially fatal, for people living with HIV. Many have died from such injections. It it is not worth the risk, especially not for financial reasons, given that the potential health complications will end up costing much more in the long run.
Orchidectomy (removal of testes)
After this surgery, you will no longer need anti-androgens as part of your hormone therapy; you might also be able to lower your estrogen dose.
Penectomy (removal of penis)
This procedure is not commonly done on its own, but in conjunction with a vaginoplasty.
Vaginoplasty (creating a vagina)
This complex procedure also aims to maintain sexual sensation.
Facial Feminisation Surgery (FFS)
While HRT causes facial feminisation, the degree of this is affected by factors such as age and genetics. You may want to seek cosmetic surgery to further feminise your face. FFS includes a variety of feminising plastic surgery procedures that change the proportions of the face. They include rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid).
If you plan to eventually go on HRT, it is recommended that you wait a year or two after beginning HRT before seeking cosmetic surgery, as the changes from HRT may affect the final result (or you may find that you don’t require FFS after HRT has done its work).
Waist Contouring
Suction-assisted liposuction may help to feminise your waist.
Reduction thyroid chrondroplasty
This reduces the size of the Adam’s apple.
Voice surgery
This raises the pitch of your speaking voice. Due to the risks involved with this particular surgery, speech therapy is recommended before seeking a surgical solution.
Masculinising Surgical Procedures
Top Surgery
Top surgery involves removing the breasts and creating a masculine chest, casually known as ‘top surgery’. Different surgical techniques exist based on the amount of tissue that needs to be removed:
- Small breasts with good skin elasticity – Keyhole or Periareolar.
- Moderately-sized chests (B cup) with good skin elasticity – Periareolar, Buttonhole Technique, Double Incision or Inverted-T.
- Large chest or moderately-sized chest with poor elasticity – Buttonhole Technique, Double Incision or Inverted-T.
- Very large chests – Buttonhole Technique, Double Incision.
You can find out more at topsurgery.net.
Any excess skin that is removed will leave a scar, which can be partially helped by topical scar cream. Depending on the technique used, possible complications include large scars, dips or bumps in the contour of the chest, nipples losing their sensation or dying, and excess skin.
If you plan to be on testosterone, it is recommended that you seek top surgery only after a year or two. T shrinks the breasts and may qualify you for less-invasive procedures with minimal scarring, as well as affect the final outcome.
Many surgeons provide before and after photos on their websites. We recommend also researching online reviews for those surgeons, and not just rely on their marketing.
Top surgery usually involves about a week of recovery time, during which your arm movements may be restricted while your chest heals. It is advised that you have someone with you to help you in day-to-day tasks such as showering or reaching up for things as you may be unable to do so yourself. Button-down shirts make it easier to get dressed.
Hysterectomy (removal of uterus) and Oophorectomy (removal of ovaries)
If this is done as part of a phalloplasty or vaginectomy, the vaginal tissue can be used to construct the urethral canal. A hysterectomy or oophorectomy may be necessary if a trans man has fibroids, endometriosis, or as a preventative measure if there is a family history of cancer.
Vaginectomy (removal of vagina)
This is needed if the vaginal opening is to be closed.
Metoidioplasty
This is one form of genital surgery that constructs a small phallus by releasing the hood of the testosterone-enlarged clitoris and/or its suspension ligaments. This procedure maintains full sensation and allows the phallus to become erect on its own. If done in conjunction with a urethroplasty, you will be able to urinate standing up.
Phalloplasty
This is another form of genital surgery that constructs a phallus that more closely approximates the average size and appearance of a typical male penis. It is a much more invasive and expensive surgery than metoidioplasty, and is a multi-stage process that can take years and also requires a longer recovery time.
Phalloplasty makes use of tissue from another part of your body, most commonly the forearm (for best post-surgical sensation), thigh or abdomen, which can result in significant scarring in those areas. The skin graft is then fashioned into a penis and attached to nerves and blood vessels using microsurgical techniques, allowing erotic and tactile sensation in most but not all cases; some people find that sensitivity increases over time as the nerves heal.
The main advantages of a phalloplasty over metoidioplasty are size and appearance. The disadvantages are cost, a potential loss or reduction in erotic sensation, major scarring on the donor site, and an inability to get erect without a semi-rigid or inflatable rod implant.
Transplants
It is possible that penis transplants may eventually be a possible alternative to surgery. Successful human trials have been done on a small scale, and while these so far have been on cisgender men, there is nothing technically preventing this from being adapted to transgender men and non-binary trans masculine people as well, albeit with more complications. However, as with all transplants, these run the risk of rejection and will require a lifetime on anti-rejection drugs, which suppress the immune system and can make the patient vulnerable to illnesses.
One promising development that averts this problem includes taking the cellulose frame of a donor penis and populating it with stem cells from the donee. This gives the final organ the same DNA makeup as the rest of the donee’s body, and prevents it from being rejected. This is unlikely to be available for several years, but is an option you may wish to keep in mind if you are considering bottom surgery.
Scrotoplasty
Scrotoplasty is the construction of a scrotum that will contain saline or silicone testicular implants). This procedure is usually done together with either a metoidioplasty or a phalloplasty.
Urethroplasty
This creates a urethral canal through the new phallus and allows trans men to urinate standing up.
Misc
Other masculinising surgeries include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare. It may be recommended in some cases if hormone therapy has been ineffective or is not an option for other medical reasons.
Finding a Surgeon
There are currently no healthcare providers in Singapore who publicly offer surgeries specific to transgender individuals. There are, however, surgeons who will carry out more generic surgeries such as mastectomies, hysterectomies, breast augmentations, and facial modifications. Unfortunately, we are as yet unable to provide a comprehensive list of trans-friendly surgeons in Singapore.
Many trans people here opt to go overseas to places such as Bangkok for transition-related surgeries, as those surgeons tend to be cheaper and much more experienced; it is also easier to find reviews of their work online, and people willing to share their experiences and photos.
Some countries such as Thailand have a lot of surgeons experienced in trans-related surgeries. Trans online groups are often a good place to find information on procedures and recommended surgeons. However, it is important to do your own research, and to be careful and ask questions when you approach a surgeon. Many trans people have ended up with poor surgical outcomes due to being poorly prepared.
- Think about the sort of outcome that is important to you and ask surgeons if they can meet these expectations.
- Ask about different possible techniques, including how much experience the surgical team has with that particular operation.
- Ask about potential complications and what else could go wrong.
- Some trans people have ended up being operated on by less-qualified interns rather than the surgeons they went to, so do clarify who will be performing the surgery.
- If you are paying for the surgery yourself, ask whether the price includes any revisions if you are unhappy with the result.
Be sure to ask your surgeon for a letter confirming that the surgery has been performed. While such letters from overseas surgeons are no longer sufficient for changing legal sex in Singapore, they are still good to have as documentation.