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When Zoe Tunnell, 31, finally got her breast implants, her gender euphoria was through the roof.
In the trans community, gender euphoria is a phrase used to describe the comfort and elation a person feels about their body or their identity. It’s the exact opposite of gender dysphoria ― the sense of unease that a person may feel if the sex they were assigned at birth doesn’t match their gender identity.
For Tunnell, top surgery did what years of hormone therapy alone couldn’t do: It gave her a shapely, more-than-an-A-cup figure in which she truly felt like herself. (Both breast augmentation and chest masculinization for trans men are considered top surgery.)
Tunnell has nothing against just doing hormones ― “I think a lot of people view breast augmentation for trans women as optional, and for some, it is. Hormones do enough to make them happy in their body, and that is such a wonderful thing,” she told HuffPost.
But for her, top surgery made everything click, gender-wise. It was something she wanted to do solely for herself, not for any outside validation or anything else.
“I think due to the overall hyper-sexualized and male-gaze-dominated view of breasts, getting breast implants gets labeled as a decision purely made for sexual reasons,” she said. “But for people like me, it isn’t a fun extra to look hotter or whatever narrative is being pushed lately. It’s vital to care as much as any other affirming procedure. It helps us feel like ourselves, more complete.”
Luckily, many in the plastic surgery community have strived to educate themselves on how to handle top surgeries sensitively, said Dr. Tim Sayed, a board-certified plastic surgeon in La Jolla and Newport Beach, California.
“Many plastic surgeons recognize that for most patients who are considering or going through a gender-affirming transition, this isn’t so much body dysmorphia that we usually think about but it’s rather an effort to have the external signs of physique and body image match the internal sense of gender identity,” he told HuffPost.
“Gender-affirming surgeries are life-saving and should be more easily accessible and affordable. Being trans is not a choice, but trans people are forced to prove we are who we say we are again and again.”
When Sayed meets with his trans clients, he first discusses where the patient is on her gender affirmation journey: “It is important to get a sense of what the aesthetic and self identity goals are for the patient,” he said.
Some aspects of breast augmentation are similar for trans and cisgender women, but some unique anatomic considerations must be considered, he said.
“These include things like the use of hormone therapy to enlarge the native breast gland, how well developed the muscle is, the relatively lower and lateral position of the areola and its smaller size, and the width of the breast bone,” the doctor explained.
While some insurance companies cover breast augmentation for trans women if it is deemed medically necessary, others exclude breast augmentation and consider it a cosmetic or elective surgery. (Most insurance companies provide coverage for people who require gender confirmation surgery, sometimes called bottom surgery.) Courts in the U.S. have repeatedly ruled that such treatments may be medically necessary while recognizing that treating gender dysphoria is a “serious medical need.”
If the insurance covers top surgery, specific criteria may need to be met first, Sayed said.
“This may include psychological evaluation to determine the level of commitment on the part of the patient for surgical body alteration, use of hormones to stimulate natural breast growth, and then the usual considerations regarding general health, smoking status and other factors that might influence wound healing and postoperative recovery,” he said.
Rose Montoya, 27, got top surgery two years ago. Some of the extra hoops trans women have to jump through before surgery ― in particular, obtaining a letter stating the medical necessity of the procedure from a mental health professional ― irk her and many others.
“Gender-affirming surgeries are life-saving and should be more easily accessible and affordable,” she said. “Being trans is not a choice, but trans people are forced to prove we are who we say we are again and again.”
No hurdles could hold Montoya back, though. She calls getting a boob job “the best decision I ever made.”
Below, we talk to Montoya and others about what went into their decisions to get breast augmentation and how they feel about their breasts today.
Responses have been lightly edited for clarity and style.
Talk a little bit about your journey coming out and your thought process on getting top surgery. What was your life like as a trans woman before you got your implants?
Rose Montoya, a 27-year-old from Los Angeles: Growing up, I always knew I was a girl. I called myself Queen Rose at the age of 4 and told my mom I’m a girl. I wasn’t taken seriously and I was shamed for it, so I suppressed those feelings. I learned what trans identity was when “Orange Is the New Black” came out.
A week after graduating college, I publicly came out and started hormones. I was 19. I hoped hormones would feminize my body and give more of an hourglass shape, but even after years, [they] didn’t. I wanted breast augmentation so badly but I couldn’t afford it and my insurance wouldn’t cover it, though many do for trans patients. I had immense dysphoria about how flat my chest was. It felt so masculine and didn’t connect to my identity. During the pandemic, I was forced to move in with my parents. While staying there, I was able to save money and I started a GoFundMe for my surgery. I was finally able to afford it and scheduled my surgery for September 2020. This was a radical act of self-love, not an act of desperation or out of hating my body. I loved my body enough to affirm it.
Zoe Tunnell, 31: I didn’t always know I wanted implants, but I always considered it a likely possibility. Since I began my transition at 28, I was well aware that hormones getting me the results I was hoping for on their own was a long shot. The women in my family are all pretty well-endowed, so I’ve always associated that sort of figure with femininity and it had an impact on my transition goals. After two years, I was still an A cup and it was a major source of dysphoria for me, so I made the decision.
Andrea, a 27-year-old from North Carolina: I realized I was trans around April 2020, during the first COVID lockdown, like a lot of other people. During the period off work, I began to seriously question a lot of things and felt like I had a safe space to come out. I had just turned 25 years old. I started hormones two months later in June 2020 because I was certain this was what I wanted.
I was on hormones for almost two years. By that point, I had developed small breasts from HRT. I was happy that I wasn’t flat-chested anymore, but I had a lot of dysphoria about them. They weren’t as “full” on the top as they were on the bottom ― I’ve been told tangentially this is common for some trans women ― and so bras and clothing always gapped and fit me weirdly. I’m relatively tall (5’8”) and my shoulders are broader than my hips, so I felt that my small breasts didn’t look proportional to my body compared to cis women who were around my height and build. I was misgendered much more frequently because of that compared to now.
I began to think of receiving a breast augmentation around 1.5 years into HRT. I knew that most trans women don’t get more than a modest amount of breast growth ― an A cup to a B cup, I think? ― and I feared I had grown as much as I could. I had heard from some transfeminine friends that their breasts grew more in their third or fourth years of HRT and beyond, but I was told by my primary care doctor that this basically depends on genetics and isn’t guaranteed. By May 2022, I hadn’t had any breast growth in a long time, so my doctor thought I might be a good fit for breast augmentation if I wanted it.
“Comfortable and joyful aren’t the same feeling. I didn’t want to just feel OK ― I wanted to feel happy.”
Serena Rice, a 31-year-old from Charlotte, North Carolina: When I was little, I knew I was different from the other boys my age. Growing up, I didn’t hate being a boy, but I always felt like I was something else and I always felt like dressing as a boy was like wearing a Halloween costume. As I entered puberty, I began to hate the changes to my body. I wished I had breasts and I wished I didn’t have facial hair. I wished I could click my heels and become a young woman, but that wasn’t what the universe intended for me at that time.
As I grew older, I became comfortable with my body — but comfortable and joyful aren’t the same feeling. I didn’t want to just feel OK ― I wanted to feel happy. I was in my 20s when I went to my first drag show, and it wasn’t long before I decided I wanted to start performing, too. With the help of friends, I created the stage persona Lilli Serena Frost, and I loved every moment I spent onstage as a showgirl.
Then, when 2020 came, coronavirus took the stage away from me, and I felt like a piece of my soul was missing. I sat at home, not wearing wigs or makeup, and I realized I was missing something huge. I missed being me. After a year of this feeling, I made the decision to schedule an appointment with my primary care doctor. I started taking hormones in 2021, and I began laser hair removal treatments. Not having breasts caused tremendous dysphoria for me, and I knew that was a problem I needed to fix. After being on hormones for a year, I had a consultation with an incredible doctor in Atlanta named Dr. Amy Alderman, and less than two months later, I had breast augmentation surgery. The work she did changed my life.
What considerations did you make when figuring out what look you were going to go for? Did you feel pressured to go a certain size because of cultural beauty standards?
Rose: I wanted a natural look. I wanted my new body to look as if my body had naturally developed. I also didn’t want to experience worsened back pain since I already have scoliosis. I think it’s impossible to separate our societally based images of beauty, or of what a woman or what a man looks like. That being said, I just wanted to look like myself. The woman that I’ve always been. The woman I’ve always seen myself as inside.
Zoe: I went with a small D/large C. I can’t deny going so large was partially due to social influence ― I think that applies to most people, whether cis or trans/nonbinary who are getting augmentation to some degree ― but the decision was very much for my own happiness first and foremost.
Andrea: I wanted to get silicone implants that would give me some size but wouldn’t be too obviously fake. I like to exercise, and so I was a little concerned about having more trouble exercising if I went too large. I was also nervous about getting more harassment going too large or if my boobs were too obviously fake-looking, if that makes sense.
After trying some different ones on in a soft bra, I settled on 445cc silicone “gummy bear” implants that went under the muscle. I talked about it with my surgeon and she told me [that] after several months when the skin had stretched to accommodate the implants and the implants had settled, they would sag a little and look mostly natural. There were options for other types of implants that would give me more lift and cleavage but I decided against them because I wanted to go with the more natural look. Also, maybe I’m strange, but I like boobs that sort of sag!
At the same time, I was figuring out what I was looking for, I was told by many people, including a transphobic ex, that receiving any kind of plastic surgery would make me vapid, insecure, or even misogynistic, as if I was betraying other women by changing my body.
I’m not sure if receiving a boob job is a good thing in society’s eyes or not, but I wanted the implants in part because most clothing and bras wouldn’t fit me and because I was tired of misgendering and the occasional harassment. For trans women, being cis-passing is a matter of safety more than it’s a matter of personal happiness. I recognize there are many trans women who live full and happy lives with “trans-looking” bodies and breasts, and they’re still beautiful. But I’m never without fear when I step outside.
Serena: When I met with my doctor, I explained I wanted the largest size she could give me that didn’t make me look like a blow-up doll. I’m a performer, but I’m also a woman who has climbed the corporate ladder. It was important to me to have work done that fit my stage costumes just as well as it fit a blouse.
What was the process like doing this in terms of insurance and finding a doctor to do the procedure?
Rose: I knew that I wanted a surgeon who specifically worked with transgender patients. I did a lot of research and I had a couple of surgeons in mind. I had a consultation with Dr. Ellie Zara Ley at the Meltzer Clinic in Scottsdale, Arizona. I loved her results and her team and how comfortable I felt being around her. So once I could afford it, I booked my surgery.
Zoe: I was incredibly lucky two times over in that I was able to have a successful crowd-fund for my surgery and find a trans-friendly cosmetic surgeon. My insurance at the time refused to cover anything except the medication I took during recovery, so without the help from my friends and so many kind folks on the internet, I never would have been able to afford it.
Andrea: I tried to go through my insurance, but there were very few surgeons that would accept my insurance. They told me it was too much of a hassle. I found a few surgeons who would accept it, but I wasn’t as happy with how their results looked on other women on their website. My insurance would make me pay the first $6,000-ish and then cover the remaining few thousand. So I thought to myself, “I’m basically paying the full amount of the surgery to go to a worse surgeon who is further away from me.”
I decided to do it out of pocket with a payment plan instead and go to my first-choice surgeon, who was much closer to where I lived. I’m very fortunate in that I had money saved and work a job that made this possible.
Serena: I paid completely out of pocket for my surgery, which was doable for me. I am incredibly fortunate because that is not the case for everyone. I believe it’s always important to note that despite this being something I wanted, it isn’t what made me a woman. Trans women are women, and this surgery, while the right choice for me, may not be everyone’s choice.
What was the reaction to your boob job like from your loved ones or partner? And in public, did you feel like you were perceived differently?
Rose: Most of my family told me that I didn’t need it. A lot of people thought that the surgery was about vanity or societal pressure or perpetuating unhealthy beauty standards. But none of them understood what dysphoria felt like. None of them truly knew what it was to be trans, at least not on a personal level.
After I had surgery, though, everyone could immediately tell the difference in my confidence. The way I hold myself changed. I became more outgoing. I became more of myself than ever before.
People like this new version of me a lot. In public and online, I definitely get objectified more. It’s interesting because I’ve always gotten looks being a trans person in public but the glances that I receive have changed. People don’t look at me with disgust or confusion as often anymore. Now they look at me with interest or lust. I’m not sure I feel any safer, but I do feel more confident and more like myself.
Zoe: The reaction from everyone whose opinions I care about has been outstanding. They supported me from day one and have been nothing but complimentary and lovely. My partners have definitely had no complaints, either. As far as the general public goes, it’s a double-edged sword. If I wear a low-cut top while going out to run errands, the chances of me getting clocked and harassed are much lower than they used to be, which is depressing for several reasons but does make my life easier. However, as a trans woman who has a decent online presence, I am constantly objectified and harassed by creeps, ranging from the vilest things you’ve ever heard to, “Oh you post pictures with cleavage, why not just open an OnlyFans and get it over with.” It’s endless and something I run into every single day.
Andrea: I’m fortunate that friends and family were supportive. The first time I ever even jokingly floated the idea of getting a boob job was about three or four months into HRT. It wasn’t a thing I wanted immediately, it was a joke like, “Maybe someday I’ll get a boob job and have huge tits” or something.
My partner at the time, now my ex, had a very hard time with me being trans and told me in no uncertain terms that she would leave me if I ever got any type of trans surgery, including bottom surgery. She was one of the people who told me it would be misogynistic of me to get surgery and it would mean I’m insecure and stupid. Even now that we’re broken up and have gone no-contact with each other, her words still stick with me. I wonder if I’ve betrayed the average woman by getting a boob job.
As for the general public, I’ve been misgendered and harassed less. I can get away with wearing more comfortable clothing (like a T-shirt) and still look more feminine, which makes me happy.
Serena: My best friends and family were beyond supportive. I’m incredibly blessed when it comes to my friends. My boyfriend, mom, and two of my best friends all took excellent care of me following my surgery.
Unfortunately, work was the one place I had an issue. I was sexually harassed by someone I worked with at my former employer. He was far too fascinated by my breasts, and his fascination led him to ask questions that made me feel violated as a woman and as a person of trans experience. I had to resign because I couldn’t stay there.
How do you feel about your top surgery today? Any regrets or things you’d do differently?
Rose: Having a chest that isn’t flat makes me feel like I have the body I was always meant to have. I don’t believe in the idea of feeling like I was born in the wrong body. I don’t mean to invalidate anyone else’s feelings, but I don’t feel that way. My body is perfect and it is mine. I love my body so much that I’m willing to affirm it in the hopes that I can feel more connected to it and honor it.
What’s interesting is I don’t have any dysphoria about my chest anymore, but because that was my biggest source of dysphoria, now my biggest source of dysphoria has changed to the next “biggest” thing: I’ve had other surgeries since then, including a tracheal shave, and a genioplasty, or the feminization of my chin. And I want to get more work done. I don’t regret showing myself the love that I deserve. I don’t regret having surgery. It was the best decision I ever made.
Zoe: I don’t have any regrets. For all the extra hassle from chasers and otherwise, my mental health has never been better. I am more confident, I can look in a mirror and feel good about it, and my body feels right in a way it rarely did before surgery. One of the best decisions I ever made and one I’d happily make again.
Andrea: As I said earlier, I feel more complete now that I’ve received this surgery. It significantly decreased my dysphoria. I actually wonder if I could’ve gotten away with going a bit larger than the 445cc and still had the natural-looking result I wanted, but it’s not a serious regret.
Serena: I don’t have words for how happy I am. My life had changed forever. I feel not even the smallest iota of dysphoria now that I’ve had this work done. My only regret is not doing it sooner.