For many health and wellness professionals, gender-affirming care knowledge begins and ends with three basic interventions: hormone therapy, "top surgery" (chest reconstruction or breast augmentation), and "bottom surgery" (genital reconstruction procedures). While these generally form the foundation of medical transition care, they represent only a fraction of available options that can significantly impact patient wellbeing and treat gender incongruence.

The reality is that gender-affirming care encompasses a broad spectrum of behavioral, medical and surgical interventions—many of which remain unfamiliar to providers outside specialized gender clinics. This knowledge gap can leave patients without appropriate referrals and limit access to procedures that might be transformative for their specific needs.

The following eight procedures represent just some of the important tools that can make up a gender-affirming care toolkit, tools that deserve greater recognition among healthcare providers. Each offers unique benefits for specific patient populations and can play crucial roles in comprehensive transition care.

Hairline feminization surgery creates a more traditionally feminine hairline by lowering it and giving it a rounder shape. Dr. Dilan Fernando, co-founder of The Treatment Rooms London, explains that patients often come to him early in their transition when a masculine hairline creates significant gender dysphoria. "Quite often at those early stages, what we can offer is a restorative treatment," he notes, emphasizing that the procedure can be "a really big blocker" to progressing with transition if left unaddressed.

The procedure uses follicular unit extraction (FUE) techniques, often with minimal-shave approaches that preserve existing hair length—particularly important for transgender patients who may have spent years growing their hair out. Recovery is typically 4-5 days, and the transplanted hair continues growing naturally throughout the patient's lifetime.

For providers: Consider referring patients experiencing hairline-related gender dysphoria, particularly those in early transition who may benefit from addressing this concern before other procedures.

Beard hair transplantation and body hair transplantation can play integral roles for transmasculine patients seeking gender transformation surgery. Transgender men and transmasculine patients may find it difficult to grow facial hair to the extent they would like, even with hormone therapy. In these instances, surgeons can use a grafting technique to fill in areas such as the upper lip, cheek, jawline, or chin.

The procedure involves transplanting hair follicles from areas with dense growth (typically the back of the scalp) to facial areas. After facial hair transplant, the transplanted hair is expected to grow just like natural facial hair. This means it requires regular maintenance through shaving and trimming.

For providers: This option is particularly valuable for patients who cannot tolerate testosterone therapy or haven't achieved satisfactory facial hair growth after adequate time on hormone therapy.

Facial feminization surgery (FFS) encompasses multiple procedures designed to soften masculine facial features. FFS may be part of an overall plan of gender affirmation, aligning the appearance of the face and body with a person's gender. FFS procedures can reshape the forehead, brows, nose, cheeks and jaw. Common procedures include forehead contouring, brow bone reduction, rhinoplasty, and jaw/chin reshaping.

FFS usually does not happen in one operation. Instead, a staged approach, based on priorities, is recommended. This allows for careful planning and reduces surgical risks associated with lengthy procedures.

For providers: FFS requires specialized training in craniofacial surgery. Refer to surgeons with specific experience in transgender facial surgery rather than general plastic surgeons.

The “tracheal shave”—a bit of a misnomer, medically known as a chondrolaryngoplasty or sometimes a laryngochondroplasty—removes prominent cartilage from the voice box to reduce the visibility of the Adam's apple. Dr. Abie Mendelsohn, who has performed this surgery extensively, emphasizes that the procedure, as with most gender-affirming care, addresses both internal gender congruence and external safety.

Dr. Mendelsohn pioneered an endoscopic approach (performed through the mouth), eliminating external scarring—a crucial consideration for gender-affirming outcomes. "Not having a scar is maximally gender affirming," he notes, as visible surgical scars can be as "outing" as the original anatomical feature.

For providers: This procedure requires expertise in voice box anatomy to avoid potential complications involving the voice. Dr. Mendelsohn strongly advocates that only ENT surgeons should perform tracheal shaves, not facial plastic surgeons, due to the risk of vocal cord damage.

Voice coaching offers a non-surgical pathway to voice modification. Sophie Edwards, a transgender voice training coach, explains that many people don't realize "it's a misconception that hormones will change your voice when you transition. It usually does for trans men, but not for trans women."

Voice coaching can achieve significant results without surgical risks. Edwards notes that "a lot of girls are surprised by how much can be done just by voice training" and recommends trying voice training first before considering surgery.

The process involves learning techniques for pitch modification, resonance, and speech patterns. Unlike surgery, voice coaching allows for gradual progress and can be combined with other transition steps at any point.

For providers: Voice coaching can be particularly valuable for patients hesitant about surgical interventions or those wanting to explore non-surgical options first. Consider this as a first-line approach before voice surgery referrals.

When voice coaching isn't sufficient, surgical voice feminization can provide permanent pitch elevation. Dr. Mendelsohn performs the endoscopic technique developed by Dr. Hyung-Tae Kim in South Korea, which shortens the vocal cords to raise fundamental frequency.

This procedure involves fusing the front portion of the vocal cords, creating a shortening effect that raises pitch while preserving singing ability and voice modulation. Results are permanent, eliminating the need for ongoing maintenance appointments. Earlier types of voice feminization surgery have involved thinning or tightening the vocal chords, which generally produces less-than-desirable outcomes.

For providers: Insurance coverage is increasingly available for this procedure. Patients benefit from working with voice therapists both before and after surgery to optimize outcomes.

Dr. Mendelsohn also offers testosterone injection therapy directly into the vocal cords for voice masculinization—an innovative approach for patients who don't achieve desired voice changes from systemic testosterone or cannot tolerate systemic hormone therapy.

The procedure involves four spaced injections performed in-office without local anesthesia. "After the first injection, generally speaking, patients will say they get like 12 or 24 hours of like significant drop," Dr. Mendelsohn describes. By the fourth injection, patients typically see "significant and long-term adjustments."

For providers: As with voice feminization, this technique is particularly valuable for patients who have already undertaken voice coaching, but whose voice is resistant to changes from systemic testosterone or who otherwise cannot tolerate hormone therapy, and who want more deepening than coaching can provide.

Gender-affirming body contouring uses liposuction and fat grafting to create more traditionally masculine or feminine body shapes. There is a subset of transgender individuals, who after having undergone hormone therapy and/or gender affirming surgeries, want body contouring so that the overall body shape is congruent to the body image. 

Contouring is also frequently part of masculinizing top surgery or top surgery revision, especially for folks in larger bodies (such as myself), to help prevent what are commonly referred to as “dog ears” i.e. excess skin and fat that form at the incision sites under the armpits.

Masculinizing body contouring generally involves removing fat from the hips, thighs, abdomen, and buttocks to square out the chest and shoulders. This creates thinner, more masculine hips and thighs, and a more V-shaped torso (broad shoulders and slim waist). For feminizing patients, the reverse applies—removing fat from traditionally masculine areas like the belly and potentially grafting to the lower body to enhance curves.

For providers: Consider timing recommendations carefully. Many surgeons suggest waiting at least one year after starting hormone therapy to allow for natural fat redistribution before surgical intervention, but not everyone wants or can tolerate hormone therapy.

These lesser-known procedures fill crucial gaps in gender-affirming care beyond the traditional hormone therapy and surgical options most providers know. As Dr. Abie Mendelsohn emphasized during his interview, gender-affirming care doesn’t need to necessarily follow a predetermined pathway. 

"There is this cookbook and recipe type approach to gender affirming care," where providers think patients need to follow a list of predetermined steps in a specific order. "Please just listen," to your patients, he urged. "The person in front of you has their own path that’s right for them." By expanding awareness of these interventions, healthcare professionals can better serve patients' diverse needs and ensure appropriate referrals when indicated.