gender reassignment surgery is also known as

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

• Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
• Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.  

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth.   The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.  

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

• Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.  
• Clear and consistent documentation of gender dysphoria
• A "real life" test :   The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.  

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

• Beard and mustache growth  
• Deepening of the voice
• Enlargement of the clitoris  
• Increased growth of body hair
• Increased muscle mass and strength  
• Increase in the number of red blood cells
• Redistribution of fat from the breasts, hips, and thighs to the abdominal area  
• Development of acne, similar to male puberty
• Baldness or localized hair loss, especially at the temples and crown of the head  
• Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

• Aggression  
• Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

• Breast development  
• Loss of erection
• Shrinkage of testicles  
• Decreased acne
• Decreased facial and body hair
• Decreased muscle mass and strength  
• Softer and smoother skin
• Slowing of balding
• Redistribution of fat from abdomen to the hips, thighs, and buttocks  
• Decreased sex drive
• Mood swings  

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition.   This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

• Breast augmentation  
• Facial feminization
• Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
• Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.  
• Jaw surgery: The jaw bone may be shaved down.
• Chin reduction: Chin reduction may be performed to soften the chin's angles.
• Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.  
• Lips: A lip lift may be done.
• Alteration to hairline  
• Male pattern hair removal
• Reduction of Adam’s apple  
• Voice change surgery

Bottom surgery includes:

• Removal of the penis (penectomy) and scrotum (orchiectomy)  
• Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

• Subcutaneous mastectomy/breast reduction surgery.
• Removal of the uterus and ovaries
• Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people.   There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.  

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.  

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.  

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus.   Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

American Psychiatric Association. What is gender dysphoria? . 2016.

The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

Tomlins L. Prescribing for transgender patients . Aust Prescr . 2019;42(1): 10–13.  doi:10.18773/austprescr.2019.003

T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884.  doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20.  doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94.  doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504.  doi:10.1503/cmaj.160408

Streed CG, Harfouch O, Marvel F, Blumenthal RS, Martin SS, Mukherjee M. Cardiovascular disease among transgender adults receiving hormone therapy: A narrative review . Ann Intern Med . 2017;167(4):256-267. doi:10.7326/M17-0577

Hashemi L, Weinreb J, Weimer AK, Weiss RL. Transgender care in the primary care setting: A review of guidelines and literature . Fed Pract . 2018;35(7):30-37.

Van de grift TC, Elaut E, Cerwenka SC, Cohen-kettenis PT, Kreukels BPC. Surgical satisfaction, quality of life, and their association after gender-affirming aurgery: A follow-up atudy . J Sex Marital Ther . 2018;44(2):138-148. doi:10.1080/0092623X.2017.1326190

American Society of Plastic Surgeons. Gender confirmation surgeries .

American Psychological Association. Transgender people, gender identity, and gender expression .

Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

• History & Society
• Science & Tech
• Biographies
• Animals & Nature
• Geography & Travel
• Arts & Culture
• Games & Quizzes
• On This Day
• One Good Fact
• New Articles
• Lifestyles & Social Issues
• Philosophy & Religion
• Politics, Law & Government
• World History
• Health & Medicine
• Browse Biographies
• Birds, Reptiles & Other Vertebrates
• Bugs, Mollusks & Other Invertebrates
• Environment
• Fossils & Geologic Time
• Entertainment & Pop Culture
• Sports & Recreation
• Visual Arts
• Demystified
• Image Galleries
• Infographics
• Top Questions
• Britannica Kids
• Saving Earth
• Space Next 50
• Student Center
• Introduction

Gender-affirmation care

Development, advances in gender-affirming care.

• Where was science invented?
• When did science begin?

gender-affirming surgery

Our editors will review what you’ve submitted and determine whether to revise the article.

• Table Of Contents

gender-affirming surgery , medical procedure in which the physical sex characteristics of an individual are modified. Gender-affirming surgery typically is undertaken when an individual chooses to align their physical appearance with their gender identity , enabling the individual to achieve a greater sense of self and helping to reduce psychological distress that may be associated with gender dysphoria .

An individual’s physical sex may not match their gender identity when the person is intersex , having been born outside the binary of male and female and thus having ambiguous genitalia, or when the person identifies as transgender . Parents of an intersex child may elect to have surgical procedures carried out in order to have the child’s anatomy conform to binary notions of gender . A person’s ascribed legal sex may not match their gender identity as they mature. However, this situation raises serious concerns regarding the appropriateness of performing unnecessary medical procedures on the bodies of minors. Intersexuality is a normal biological variation and is not considered a medical condition. Therefore, medical interventions such as surgery and hormone therapy are typically unnecessary for intersex children.

Transgender individuals may seek gender-affirming surgery to align their physical body with their perception of their gender identity. Gender identity refers to an individual’s perception of their own gender, which may or may not correspond to their designated gender at birth. Gender identity encompasses the identification as male, female, both, neither, or somewhere else on the spectrum of gender. It is distinct from biological sex, which is determined by the sex chromosomes and anatomy of an individual. While the gender identity of most individuals corresponds to their ascribed biological sex, the gender identity of some individuals differs from their ascribed sex at birth, which can result in gender dysphoria and thereby lead the individual to seek gender-affirming surgery.

Individuals assigned male at birth may undergo one or more procedures to feminize their anatomy, including facial feminization surgery, penectomy (removal of the penis ), orchidectomy (removal of the testicles ), vaginoplasty (construction of a vagina ), and a tracheal shave (reduction of the Adam’s apple). Individuals who are assigned female at birth and who desire surgical intervention to masculinize their anatomy may seek breast reduction surgery, hysterectomy (removal of the uterus ), oophorectomy (removal of the ovaries ), and phalloplasty (construction of a penis).

Gender-affirming surgeries were performed during the 1920s and ’30s, primarily in Europe. These procedures were experimental and not extensively accepted by the medical community . At the time, it was widely believed that gender identity was immutable and that surgery could not alter it. However, Magnus Hirschfeld , a German sexologist and vocal advocate for sexual and gender diversity , assisted with the care of several transgender individuals.

Dora Richter was the first transgender individual to undergo complete male-to-female genital surgery under Hirschfeld’s supervision. Richter was one of several transgender individuals under Hirschfeld’s care at the Berlin Institute for Sexual Research. In 1922 Richter underwent an orchidectomy and, in 1931, a penectomy and vaginoplasty.

In 1930 and 1931 Lili Elbe also underwent several gender-affirming surgeries. These procedures included an orchidectomy, an ovarian transplant, and a penectomy. Elbe underwent a fourth surgery in June 1931, which consisted of an experimental uterine transplant and vaginoplasty. Elbe’s body rejected the transplanted uterus, and she died of postoperative complications in 1931.

During the 1950s and ’60s, significant advancements were made in the field of gender-affirming surgery, including the establishment of several major medical centres and the refinement of surgical techniques. Christian Hamburger, a Danish endocrinologist, performed a gender-affirming surgery in 1952 on Christine Jorgensen , a transgender individual, who underwent hormone replacement therapy and surgery to remove her testicles and create a vagina. Jorgensen became a public figure advocating for transgender rights and promoting awareness about gender-affirming surgery after their case received significant media attention.

Other medical centres in Europe and the United States began conducting gender-affirming surgeries around the same time, including the Johns Hopkins Gender Identity Clinic, founded in 1966. The founder of the clinic, psychiatrist John Money, believed that gender was a social construct and that gender-affirming surgery could be an effective treatment for individuals with gender dysphoria. Money’s theories had a significant impact on the field of gender-affirming surgery and helped to change the attitudes of the medical community regarding the procedure.

During the 1960s, new surgical techniques were developed, including advances in vaginoplasty and phalloplasty. In the 1950s Belgian surgeon Georges Burou devised a technique involving the use of skin grafts from the patient’s thigh to create a vaginal canal lining. For penises, he attached the phallus to a blood supply using tissue . This technique improved tissue perfusion and decreased the risk of complications such as tissue necrosis . These procedures marked a turning point in the development of gender-affirming care because they demonstrated the potential for successful genital reconstruction in transgender patients.

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

• Vaccines  
• Masking Guidelines
• Visitor Guidelines  

Gender Affirmation Surgeries

Featured Expert:

Fan Liang, M.D.

Surgeries are not required for gender affirmation, but many patients choose to undergo one or more surgical procedures. Talk with your doctor to discuss what surgical options may be right for you. The following is an overview of gender affirmation surgeries.

• Penile construction (phalloplasty/metoidioplasty) : This surgical procedure can include removal of the vagina (vaginectomy), reconstruction of the urethra and penile reconstruction. Surgeons may use either vaginal tissue or tissue from another part of the body to construct the penis.
• Vaginal construction (vaginoplasty) : This surgical procedure is a multistage process during which surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina, the clitoris (clitoroplasty) and the labia (labiaplasty).
• Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.
• Facial gender surgery can include a variety of procedures to create more feminine features , like reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. 
• Facial gender surgery can also include a series of procedures to create more masculine features , such as forehead lengthening and augmentation; cheek augmentation;  reshaping the nose  and chin;  jaw augmentation ; and thyroid cartilage enhancement to construct an Adam’s apple.
• Hysterectomy : This surgical procedure includes the removal of the uterus and ovaries (oophorectomy). There are options for oocyte storage and fertility preservation that you may want to discuss with your doctor. 
• Some people may combine this procedure with a scrotectomy , which is surgery to remove all or part of the scrotum. For others, the skin of the scrotum can be used in vulvoplasty or vaginoplasty ― the surgical construction of a vulva or vagina.
• The procedure reduces testosterone production and may eliminate the need for continuing therapy with estrogen and androgen-suppressing medications. Your health care practitioner will discuss options such as sperm freezing before orchiectomy that can preserve your ability to become a biological parent.

Recovery After Gender Affirmation Surgeries

Recovery time from a gender affirmation surgery or procedure varies, depending on the procedure. Talk to your doctor about what you can expect.

Treatment Caring for Transgender Patients

Fearing discrimination and hostility, transgender people are often reluctant to seek care. Discover how Paula Neira, Program Director of LGBTQ+ Equity and Education, Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, is working to ensure that all patients — regardless of gender identity — are treated with dignity and respect.

Find a Doctor

Specializing In:

• Transgender Health
• Gender Affirmation Surgery

Find a Treatment Center

• Center for Transgender and Gender Expansive Health

Find Additional Treatment Centers at:

• Howard County Medical Center
• Sibley Memorial Hospital
• Suburban Hospital

Request an Appointment

Transgender Health: What You Need to Know

Facial Masculinization Surgery

Gender Affirmation: Do I Need Surgery?

Related Topics

• LGBTQ Health
• Gender Affirmation

• FIND A PROVIDER

I'm a Candidate

I'm a Provider

Log In / Sign Up

I'm a candidate

Provider login

I'm a provider

List your practice

MTF Gender Confirmation: Genital Construction

The specifics, the takeaway.

Download the app

As part of a transgender individual’s transition, genital reassignment surgery alters male genitalia into female genitalia.

Written By: Erin Storm, PA-C

Published: October 07, 2021

Last updated: February 18, 2022

• Procedure Overview
• Ideal Candidate
• Side Effects
• Average Cost

thumbs-up Pros

• Can Help Complete A Gender Affirmation Journey

thumbs-down Cons

• Potentially Cost Prohibitive

Invasiveness Score

Invasiveness is graded based on factors such as anesthesia practices, incisions, and recovery notes common to this procedure.

Average Recovery

Application.

Surgical Procedure

$ 7000 - $ 24000

What is a male to female (MTF) gender reassignment surgery?

Male to female (MTF) gender reassignment surgery is also known as sex reassignment surgery (SRS), genital construction, and generally as Gender Confirmation Surgery. These procedures are used to remove and alter male genitalia into traditional female genitalia. Plastic surgeons will remove the scrotum, perform a penile inversion to create the neovagina, remove and alter penile erectile tissue to form the clitoral tissue of the clitoris, and construct labia usually from scrotal tissue. The prostate gland is left intact. These procedures create fully functional female genitalia in transgender patients.

Typically gender reassignment surgery is performed as a last step in a transgender individuals transition journey. Guidelines from The World Professional Association for Transgender Health (WPATH) state candidates must have letters of recommendation from their mental health provider and physician, have been living full time as a woman for one year, and have completed one year of hormonal therapy to be eligible.

Information on facial feminization surgeries, top surgeries (like a breast construction), and other male to female gender affirming surgeries as part of a gender transition for transwomen can be found in our comprehensive guide to MTF gender affirmation solutions .

What concerns does a MTF gender reassignment surgery treat?

• Transfeminine Bottom Surgery & Genital Construction : Male to female gender reassignment surgery creates female genitalia that are aesthetically authentic and functional. A vaginoplasty, penectomy, orchiectomy (testicle removal), clitoroplasty, and labiaplasty are typically performed.

Who is the ideal candidate for a MTF gender reassignment surgery?

The ideal candidate for MTF gender reassignment surgery is a transgender women seeking to complete her physical embodiment of her gender identity. This reconstructive genital surgery creates functioning female genitalia.

MTF gender reassignment surgery is not recommended for those who have not been on hormone therapy for one year, have not been living full time as a woman for one year, do not have letters of recommendation from their mental health provider and physician, children under the age of 18, and those with certain chronic medical conditions.

What is the average recovery associated with a MTF gender reassignment surgery?

Most patients experience four to six weeks of recovery time following a MTF gender reassignment surgery. Patients can expect bruising, swelling, and tenderness following the procedure. A urinary catheter is placed for one week and vaginal packing as well which may cause a sensation of fullness. Vaginal dilation is a component of the procedure and the patient will be advised on how to complete this progressive dilation at home over the course of a few weeks.

What are the potential side effects of a MTF gender reassignment surgery?

Possible side effects following a MTF gender reassignment surgery include bleeding, swelling, bruising, site infection, altered sensation, difficulty urinating, difficulty with sexual function, prolonged edema, and complications from anesthesia or the procedure.

What can someone expect from the results of a MTF gender reassignment surgery?

The results of MTF gender reassignment surgery are permanent. This procedure creates functional female genitalia and removes all male genitalia. The prostate gland is left intact which is important for transgender individuals ongoing healthcare and preventative screenings.

What is the average cost of a MTF gender reassignment surgery?

What to expect.

A MTF Gender Reassignment Surgery creates female genitalia. Here is a quick guide for what to expect before, during, and after a MTF Gender Reassignment Surgery:

Before Surgery

• Prophylactic antibiotics or antivirals may be prescribed
• Stop taking blood thinning medications two weeks prior to surgery. Blood thinners may include, Advil, Tylenol, Aspirin, and prescription anticoagulants
• Stop smoking four weeks prior to the procedure and continue cessation for four weeks post op
• No alcohol two days prior to the procedure
• Do not eat or drink six hours before

During Surgery

• General anesthesia
• A penile inversion is performed to create the vaginal canal
• The scrotum is removed
• Skin grafts are used to create the labia and vulva
• Erectile tissue is removed from the new vaginal walls, and erectile tissue from the head of the penis is used to create the clitoris
• ​The urethra is shortened

Immediately After Treatment

• Swelling, bruising, and tenderness

1 - 30 After Treatment & Beyond

• Resume most activities after a few days
• Swelling typically resolves within a few weeks
• Avoid strenuous activity for two to four weeks
• Remove urinary catheter and vaginal packing after one week
• Continue progressive vaginal dilation

Result Notes

• Results are permanent
• Proper aftercare will ensure optimal results

Gender confirmation surgeries for transgender individuals are an important component of transgender health and in creating an embodied gender identity. Gender reassignment surgery allows transgender women who feel it is a part of their transition to more fully embrace their gender identity.

To learn more about our content creation practices,  visit our Editorial Process page .

Source List

AEDIT uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

• American Society of Plastic Surgeons Gender Confirmation Surgeries plasticsurgery.org
• Karel E Y Claes Chest Surgery for Transgender and Gender Nonconforming Individuals PubMed.gov ; 2018-07-02

Related Procedures

MTF Gender Confirmation Solutions

MTF Gender Confirmation: Facial Feminization

Adam’s Apple Reduction

MTF Gender Confirmation: Transfeminine Top & Bottom Surgeries

View all procedures

Learn More About MTF Gender Confirmation: Genital Construction in The AEDITION

Gender Transitioning And Skincare: Taking Care Of Your Changing Face

Side effects of hormone therapy often show up on the skin in the form of acne, pigmentation, and uneven skin texture. Here’s what you need to know about the most common skin concerns and treatment options.

A Guide To Non-Surgical Facial Feminization

Facial feminization procedures have been gaining popularity among men hoping to look more approachable or transition to female as well as among women hoping to have a more feminine appearance.

Finding The Right Plastic Surgeon, Dermatologist, Or Cosmetic Dentist

When considering a cosmetic procedure, it is so important to find the right doctor for you.

Discover more articles

‘Try on’ aesthetic procedures and instantly visualize possible results with AEDIT and our patented 3D aesthetic simulator.

Find Top Aesthetic Providers Near You

Providers by locations.

• Alpharetta, GA Providers
• Boston, MA Providers
• Chevy Chase, MD Providers
• Glenview, IL Providers
• Lone Tree, CO Providers
• Metairie, LA Providers
• More Locations
• New Haven, CT Providers
• Prairie Village, KS Providers
• Scottsdale, AZ Providers
• Southfield, MI Providers
• Springdale, AR Providers
• Tampa, FL Providers
• Washington, DC Providers
• West Hollywood, CA Providers

Providers by Specialties

• Cosmetic Dentistry Providers
• Cosmetic Dermatology Providers
• Cosmetic Surgery Providers
• Dermatologic Surgery Providers
• Dermatology Providers
• Facial Plastic and Reconstructive Surgery Providers
• General Surgery Providers
• Hair Restoration Surgery Providers
• Head and Neck Surgery Providers
• Medspa Providers
• More Procedures
• Oculoplastic Surgery Providers
• Other Providers
• Plastic and Reconstructive Surgery Providers
• Vaginal Rejuvenation Providers

Providers by Procedures

• Acne Scar Treatment Providers
• Acne Treatment Providers
• Birthmark Removal Providers
• Blepharoplasty Providers
• Botox Providers
• Brow Lift Providers
• Buccal Fat Removal (Cheek Reduction) Providers
• Cheek Augmentation (Cheek Implants) Providers
• Cheek Surgery Providers
• Chemical Peels Providers
• Chin Surgery (Mentoplasty) Providers
• Dental Treatments Providers
• Dermabrasion Treatment Providers
• Dermal Fillers & Injectables Providers
• More Specialties

Find a Surgeon

Search by U.S. State, Procedure and Insurance Search by Country and Procedure Browse the Global Surgeon Maps

Gender Surgeons in United States

Learn about Surgeons in the U.S. who offer Male to Female (MTF) and Female to Male (FTM) procedures, also known as Gender Confirmation Surgery (GCS), Sex Reassignment Surgery (SRS) or Gender Reassignment Surgery (GRS).

Dr. Bauback Safa

Dr. Safa is an internationally renowned Reconstructive Microsurgeon and the Medical Director of the San Francisco Transgender Institute. He and his team have performed more than 700 Phalloplasty surgeries since 2012, making him one of the most experienced Phalloplasty surgeons in the world.

Dr. Scott Mosser

Dr. Mosser is an award-winning surgeon in San Francisco who has been helping transgender and non-binary patients for more than 13 years. He is board-certified by the American Board of Plastic Surgeons, co-founder of the American Society of Gender Surgeons (ASGS), Founder of the Gender Institute at Saint Francis Memorial Hospital, a member of WPATH, and co-chair of the Surgery and Beyond professional conference. Dr. Mosser is California’s FTN / FTM Top Surgery and Breast Augmentation expert.

Dr. Kriya Gishen

Dr. Kriya is an ivy-league trained plastic and craniofacial surgeon in Beverly Hills who specializes in Facial Feminization Surgery. Dr. Kriya is fellowship-trained in craniofacial surgery which gives her the knowledge and experience needed to perform reconstructive facial surgery with a high degree of skill and finesse. She is known not only for her surgical mastery but also for her deeply personal manner with her patients. In addition to Facial Feminization, Dr. Kriya is also highly proficient in Body Sculpting and Breast Augmentation.

Dr. Shareef Jandali

Dr. Jandali is a board-certified plastic surgeon in Connecticut who specializes in chest and breast surgery procedures. Dr. Jandali has earned a reputation for his advanced surgical skills, consistent results and personal approach to every patient. His expertise in the complex techniques used for gynecomastia surgery and breast reconstruction served as a solid foundation for becoming proficient in gender-affirming Top Surgery. Dr. Jandali further customizes these techniques based on each patient’s unique chest anatomy and surgery goals. He and his staff look forward to welcoming you to a transformative experience at Jandali Plastic Surgery.

Dr. Shahin Javaheri

Dr. Javaheri is a double board-certified plastic and reconstructive surgeon in San Francisco who specializes in facial, breast and body contouring procedures. With 27 years of experience, Dr. Javaheri has earned a reputation for his surgical skill, artistic touch and attention to detail. His work with transgender patients has focused on Facial and Body Feminization, Facial and Body Masculinization, Breast Augmentation, Body Sculpting and utilizing 3D technology to create patient-specific implants.

Dr. Tony Mangubat

Dr. Mangubat is a board-certified cosmetic surgeon in the Seattle area who has been performing gender-affirming for over twenty years. Dr. Mangubat specializes in Top Surgery, Breast Augmentation and Body Sculpting, Gender Confirming Facial Surgery and Hair Grafting. Dr. Mangubat’s excellent surgical skills, experience and dedication to transgender health have made him the most sought after surgeon for transgender surgery in the Pacific Northwest.

Dr. Hope Sherie

Dr. Hope Sherie is a board-certified surgeon who has extensive training in transgender surgery procedures, including FTM Top Surgery and Orchiectomy. She is well-known for popularizing the Buttonhole Top Surgery method. Dr. Sherie is pleased to offer the highest level of surgical care at her practice in Charlotte, North Carolina.

Dr. Mark Youssef

Dr. Youssef is a top Cosmetic Surgeon in the greater Los Angeles area and Director of the Transgender Surgery Institute of Southern California. For trans men, women and gender-nonconforming clients in Los Angeles, Santa Monica, San Diego and elsewhere in Southern California, Dr. Youssef offers Top Surgery, Breast Augmentation and Facial Feminization Surgery.

Dr. John L. Whitehead

Dr. Whitehead is a board-certified surgeon and gender surgery specialist at Restore Medical Center, the only practice in Miami that is 100% dedicated to gender-affirming surgery. Dr. Whitehead was trained in the art of gender reassignment surgery by Dr. Harold Reed, the now-retired urologist who performed gender surgeries for decades in Miami. Dr. Whitehead is proud to honor the legacy of Dr. Reed and to serve the needs of the transgender community. He performs gender-affirming Vaginoplasty, as well as Top Surgery and Hysterectomy.

Dr. Christopher McClung

Dr. McClung is a board-certified urologist in Columbus, Ohio who specializes in gender-affirming genital surgery. His path to becoming a Gender Surgeon started with providing surgical solutions for complex urinary complications in patients who had bottom surgery elsewhere. In 2017, Dr. McClung started offering primary gender-affirming surgeries, including Vaginoplasty and Phalloplasty, and his practice is now fully dedicated to providing this care.

Dr. Daniel Medalie

Dr. Medalie is a board certified plastic and reconstructive surgeon who has been performing Gender Surgery procedures since 1996. Based in the Cleveland area, Dr. Medalie offers Top Surgery and Metoidioplasty for transmasculine people, and Breast Augmentation and Tracheal Shave for transfeminine people. His vast experience and consistently natural-looking results, along with his trans-friendly staff, have made Dr. Medalie’s Cleveland Plastic Surgery a popular choice.

Dr. Heidi Wittenberg

Dr. Wittenberg is a highly experienced urogynecologist and reconstructive pelvic surgeon in San Francisco who works exclusively with trans and non-binary patients. Dr. Wittenberg is the Director of MoZaic Care, which specializes in gender affirming genital and pelvic surgeries, a Founder Surgeon and Co-Director of the first SRC accredited Center of Excellence in Gender Confirmation Surgery at Greenbrae Surgery Center, and the Medical Director of the Gender Institute at Saint Francis Memorial Hospital.

Dr. Toby Meltzer

Dr. Meltzer is a plastic and reconstructive surgeon who has been performing gender-affirming procedures since the early ’90s. Dr. Meltzer is widely recognized as one of the leading surgeons in the field of Gender Surgery, having completed over 4000 surgeries. He currently performs approximately 200 genital reconstruction surgery cases per year in Scottsdale, Arizona.

Dr. Charles Garramone

Dr. Garramone is one of the most experienced Top Surgery surgeons in the world, having performed thousands of Top Surgery procedures since 2005. With Dr. Garramone, you won’t have to worry about what your Top Surgery results will look like. His FTM Top Surgery technique is sought after by thousands of patients for its consistent and predictable results.

Dr. Mang Chen

Dr. Chen is a highly experienced Reconstructive Urologist in San Francisco who specializes in bottom surgery procedures for transmasculine individuals. He has performed hundreds of Phalloplasty, Metoidioplasty and related procedures, and has deep expertise in urological repair surgeries.

Dr. Loren Schechter

Dr. Schechter is one of the country’s foremost experts on transgender surgery. He is the Medical Director of the Gender Affirmation Surgery Program at Rush University Medical Center in Chicago. Dr. Schechter has been performing gender-affirming surgeries for more than 20 years. Since 2013, he has performed approximately 100-150 gender-affirming procedures every year. He offers the full spectrum of gender-affirming procedures.

Dr. Andrew Watt

Dr. Watt is a Reconstructive Microsurgeon at the Buncke Clinic, widely considered to be the birthplace of microsurgery. He is a highly accomplished Phalloplasty surgeon, having performed hundreds of microvascular Phalloplasty and related procedures with his team in San Francisco.

Dr. Adam Bonnington

Dr. Bonnington is a highly skilled obstetrician-gynecologist in San Francisco who is passionate about working with underrepresented patient populations and has a particular interest in caring for transgender and gender expansive individuals. Dr. Bonnington joined MoZaic Care as a Surgical Associate in 2020 and performs Vaginoplasty, Orchiectomy and Hysterectomy.

Dr. Walter Lin

Dr. Lin is a fellowship-trained Plastic Surgeon at the Buncke Clinic in San Francisco. Dr. Lin has a sub-specialization in reconstructive microsurgery and is dedicated to the advancement of care in microsurgical reconstruction of the extremities, breast, and lymphatic systems. His experience in these areas has contributed to his exceptional skills in gender-affirming Top Surgery and Breast Augmentation.

Dr. Angela Rodriguez

Dr. Rodriguez is a board-certified plastic surgeon in San Francisco who is dedicated full time to providing surgical care for transgender patients. Dr. Rodriguez had 14 years of craniofacial, aesthetic and pediatric plastic surgery experience before becoming a Gender Surgeon. She has a special interest in Facial Feminization and is also highly proficient in Vaginoplasty and Top Surgery.

Dr. Daniel Crane

Dr. Crane is a plastic surgeon who joined Dr. Drew Schnitt’s Inspire Aesthetics in 2022, expanding access to gender-affirming surgical care in South Florida. After completing a highly specialized aesthetic surgery fellowship where he performed countless breast, body contouring and facial surgeries, Dr. Crane worked with Dr. Schnitt to refine his skills with Top Surgery and Facial Feminization. His broad training in plastic and aesthetic surgery provides him with the knowledge and experience to help you achieve your transition goals.

Dr. Drew Schnitt

Dr. Schnitt is a board certified cosmetic, plastic, reconstructive and craniofacial surgeon who has been practicing in South Florida since 2002. His experience in cosmetic and craniofacial surgery makes him an excellent choice for gender-affirming facial surgery, as well as Top Surgery, Breast Augmentation and Body Sculpting.

Dr. Daniel Jacobs

Dr. Jacobs is an award-winning and board-certified plastic surgeon in San Francisco who joined The Gender Confirmation Center in July, 2022. Dr. Jacobs has more than 30 years of plastic surgery experience and provides outstanding surgical care for transmasculine, transfeminine and non-binary patients.

Dr. Joel Beck

Dr. Beck is a board certified plastic and reconstructive surgeon who has been performing transgender surgery procedures since 2003. Based in Charlotte NC, Dr. Beck routinely performs Facial Feminization Surgery, Breast Augmentation, Top Surgery, Body Contouring and Hair Restoration.

Top Surgery Summer Special Price: $6500

• All Services A-Z
• Markey Cancer Center
• Gill Heart & Vascular Institute
• Barnstable Brown Diabetes Center
• Kentucky Children's Hospital
• Kentucky Neuroscience Institute
• Orthopaedic Surgery & Sports Medicine
• Digestive Health
• Primary Care
• Emergency Department
• Appointments
• Tests & Exams
• Find a Doctor
• Schedule an Appointment
• For Patients
• Amenities & Resources A-Z
• Appointment request online form
• Appointment reminders
• Patient Notice of Privacy Practices
• Become a Patient
• Clinical Trials
• Don and Cathy Jacobs Health Education Center
• Interpreter Services
• In-Network Insurance Plans
• Visit MyChart
• Maps & Directions
• Pastoral Care
• Office of Patient Experience
• Pharmacy Locations
• About Advance Directives
• Privacy Policy
• Notice of Nondiscrimination for UK Health Programs & Activities
• Subscribe to HealthMatters
• Wellness & Community
• For Visitors
• Food & Lodging
• Pay your bill
• Patient's Condition & Phone Number
• Tobacco Free Policy
• Authorizations & agreements
• Autorizaciones y Convenios
• Mail & eGreetings
• Thank a Great Provider
• Refer a Patient
• Request a Login
• Corporate Compliance
• Information Technology
• Manage Your Profile
• Brand Strategy
• Employee Health
• Enterprise Learning
• UK Human Resources
• Department Phone Directory
• Quality & Safety
• Cancer Clinical Trials
• Emergency Transport
• Physician Liaison Program
• UK•MDs Medical Contact Center
• Mission/Vision
• Employment at Eastern State Hospital
• Nurse Residency Program
• Continuing Nursing Education
• Nursing Faculty Orientation
• Nursing Staff Development
• Registered Nurse (RN) Internships
• Student Nurse Academic Practicum (SNAP)
• Tuition Reimbursement
• Acute Care Nursing
• Behavioral Health Nurse Services
• Central Monitoring System
• Critical Care Nursing
• Emergency Services
• Maternal Care Area Nursing
• Markey Cancer Center Nursing
• Nursing at Kentucky Children's Hospital
• Per Diem Nursing Pool
• Perioperative Nursing Services
• Rapid Response Nursing Teams
• Nursing Special Services
• Ambulatory Care Nursing Services
• Advanced Practice
• Care Delivery Model
• Certifications
• Career Center
• Clinical Nurse Expert
• Community Outreach
• Professional Advancement
• Professional Practice Model
• Service Line Triads
• UK HealthCare Research
• Genomics Core Laboratory
• Sanders-Brown Center on Aging
• Cancer Researcher Directory
• Making a Difference
• Awards & Recognitions
• Strategic Plan
• Visual Arts
• Performing Arts
• Learn about volunteering
• Office of Observation and Learning Experience
• Diversity, Equity & Inclusion
• Healthcare Jumpstart Program
• Scholarships
• Application Process
• How to become a RD
• Accreditation
• Tour facility
• Patient Stories
• Request an Appointment
• Medical Records
• Daisy Award Nomination Form
• Community Commitment
• Cooperative Extension Service
• Community Resources
• Office of Opioid Safety
• Safe Kids Fayette County
• UKHC Digital Platforms
• Learn about MyChart
• Log in to MyChart
• Request a MyChart account
• Proxy accounts

Appointment

• Botox treatments
• Chemical peels
• Dermal fillers
• Laser treatment
• Skin resurfacing
• Body contouring
• Buttock lift
• Cheek augmentation
• Chin enhancement
• Cosmetic breast surgery
• Ear pinning surgery
• Eyelid rejuvenation
• Fat grafting
• Liposuction

Gender affirmation surgery

• Male breast surgery
• Mommy makeover
• Nose reshaping (rhinoplasty)
• Our location & team

This is also known as sex-reassignment surgery or gender-reassignment surgery. These surgeries help patients’ physical appearance and function, as well as resemble their identified gender.

The surgery can be divided into “top surgery” and “bottom surgery.”

• “Top surgery” creates breasts for male-to-female transgender patients or removes breasts for female-to-male transgender patients.
• “Bottom surgery” for male-to-female transgender patients includes removing male genitalia and creating female genitalia.
• “Bottom surgery” for female-to-male transgender patients includes creating male genitalia from one’s own tissues or using of implants in combination with one’s own tissue.

WOULD YOU LIKE AN APPOINTMENT?

Connect with us on facebook.

• Write for us
• General Health
• Mindfulness
• Sexual Health
• Heart Health
• Pregnancy and Parenting
• Women's Health
• हिंदी मुखपृष्ठ
• पेज हिंदी भाषा में

From 🇮🇳 With ❤️

Gender Reassignment Surgery: Procedure, Benefits and Risks

Gender Reassignment surgery is also known as sex reassignment surgery. There are different gender re-confirmation surgeries like transgender surgical, Read more

What is a gender reassignment surgery?

• Gender Reassignment surgery is a title procedure where you understand what complete gender reassignment surgery involves. 
• It can be helpful in the comprehension by medical and mental health benefits of the procedures and hormonal therapy. 
• The period of living in deciphering gender roles before surgery is considered living in gender dysphoria. 
• The techniques can vary based on the individual's needs, trust, and recommendations from their healthcare team.
• It is crucial to consult with an experienced healthcare professional specializing in gender-affirming care to get personalized information.

What is the procedure of Gender Reassignment Surgery?

• It is essential to note that there are different steps and techniques that are involved in gender reassignment surgery.  
• It is necessary to note the specific steps and get involved in asking questions to the doctors. 
• There can be differences among surgeons and medical facilities; however, we can provide a general overview of the procedure commonly associated with the male to females and female-to-male gender reassignment surgery.

1. Male-to-female gender reassignment surgery:

• Orchiectomy: This is a surgical process that removes the testicles to reduce the testosterone hormone which can be the first step of MTF gender surgery. This procedure can create a neovaginal use of penile and scrotal skin; the unit can involve reshaping the genital area and removing the penis, they can design the remaining tissues to contrast the vaginal canal, and their surgeon can also create a blogroll hood and potentially clitoral glands.
• Breast augmentation surgery : This surgery involves or is chosen to undergo breast augmentation to achieve a more freeing appearance; this inclines the insertion of breast implants. Breast augmentin can help increase the feminine appearance and this includes inserting breast implants into the chest. Many trans people may choose to undergo breast augmentation to achieve a more feminine appearance
• Facial feminization surgery : Facial feminization makes sure some MTF individuals can opt for FFS and can include a range of surgical procedures to diminish the fat on the facial features. These can consist of a rhinoplasty, brow filler, and contouring or chin reduction. These may include rhinoplasty and can involve the removal of breasts to create a more masculine chest in female-to-male surgeries. They can also have rhinoplasty, nose shaping and brow lift, jaw contouring, and chin reduction.

2. Female-to-Male gender reassignment surgery:

• Breast Removal : Females to males generally involve the removal of the breasts to create a more masculine chest, and the procedure can include a mastectomy or the subcutaneous mastectomy . It can involve repositioning or resistant nipple swaps. 
• Metoidioplasty can use the clitoral tissues to create small pallies, while phalloplasty uses the clitoral tissue to create a neophallus. New penile metoidioplasty uses the clitorial tissue to make a neophallus while using the clitoral tissue to create a small pallus. This includes urethral lengthening.
• Hysterectomy and oophorectomy these surgeries involve the removal of the uterus and ovaries, respectively. They are typically referred to reduce the risk of complications and the need for ongoing hormonal management.

3. Benefits of gender reassignment surgery-

• Alleviation of gender dysphoria does affect many transgender individuals. Fender dysphoria is a side stress resulting from misalignment between their gender identity and signed sex at the broth. 
• Gender reassignment surgery can help alleviate the dysphoria by aligning their physical appearance with their identity and promoting a sense of well-being.
• It can help increase mental health and quality of life, and gender reassignment can be associated with improved mental health and outcomes and enhanced quality of life for transgender people.
• Enhanced self-esteem and body confidence are the transgender individual and gender reassignment surgery can lead to an improved sense of self-esteem. 
• With this newfound body, a conference can have better physical characteristics with a finger identity, produce great self-acceptance, and reduce distress related to body functioning.
• These surgeries can also help reduce the discrimination against transgender individuals undergoing surgery and can help mitigate the risk associated with gender conformity, such as discrimination and harassment or violence.

Complications, risks, and recovery of gender reassignment surgery?

• Changes in the sexual scenario or even changes in the sex organs can be a little difficult to deal with, thus it becomes important to talk to the doctors and clear your doubts. 
• There can be complications like fever , infections and wounds, changing color, bladder, problems with altered sexual function, and side effects of anesthesia.
• Many people can choose to have these surgeries and experience an improvement in their quality of life. 
• Depending on the procedure, there can be a 94 to 100 percent chance of an improvement in the person's quality of life, and depending on the preceding surgery you can be satisfied with the result. 
• There are many mental health benefits of these gender reassignment surgeries.

When should you call a doctor for gender reassignment surgery problems?

• After the surgery, there can be some common symptoms, like bleeding from time to time and that does go away after several years. 
• Signs of infection such as wounds and the change in color of the scars. Signs of infection include wounds that can change color or are not healed. 
• In case the wounds are not clearing up this is your sign to call your doctor.

Frequently Asked Questions

Is gender reaffirmation surgery helpful.

Yes, gender reaffirmation surgeries are helpful to the people getting the surgery.

What is the risk of gender reaffirmation surgery?

The risk of the bottom transfer surgery includes, but there are not limited to, bleeding and infection.

What happens after a gender reassignment surgery?

The genital parts are removed and changed to the desired parts in a gender reassignment surgery.

Is a female-to-male GRS successful?

The success to male surgery will depend on factors like a person's health and other factors.

How can one change their gender without the surgery?

Hormone therapy can help in changing gender without surgery.

Reviewed by

Bishwajeet Singh

Health Blog Editor

Bishwajeet Singh is an experienced medical content specialist specializing in creating easy-to-understand health and medicine information. His expertise lies in diverse health domains, including general wellness, nutrition, and preventive care. He brings a wealth of insights, promoting health understanding through her writing. View Profile

More by Bishwajeet Singh

Understanding the 4 Stages of Pneumonia: ...

about 1 year

10 Causes of Red Eyes and How to Treat Them

over 1 year

How to Maintain Erection For 30 Minutes: ...

How to Get Rid of Fungal Infection in Hands?

Related articles.

Exploring Tummy Tuck Procedures in Düssel...

The Effects of Animals on Human Health an...

about 2 months

Everything You Need to Know Before You Ha...

Can a Narcissist Change? Tips and Treatments

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins

Affiliation.

• 1 Office of Diversity and Inclusion, Johns Hopkins Medical Institutions, Baltimore, MD.
• PMID: 30557186
• DOI: 10.1097/SAP.0000000000001684

Background: Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery."

Methods: We evaluated the records of the medical archives of the Johns Hopkins University.

Results: We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic.

Conclusion: This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

PubMed Disclaimer

• The Legacy of Gender-Affirming Surgical Care Is Complex. Edmiston EK. Edmiston EK. Ann Plast Surg. 2019 Oct;83(4):371. doi: 10.1097/SAP.0000000000002008. Ann Plast Surg. 2019. PMID: 31524723 No abstract available.
• Reply to: The Legacy of Gender-Affirming Surgical Care Is Complex. Neira PM, Siotos C, Coon D. Neira PM, et al. Ann Plast Surg. 2019 Oct;83(4):372. doi: 10.1097/SAP.0000000000002009. Ann Plast Surg. 2019. PMID: 31524724 No abstract available.

Similar articles

• A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today. Roblee C, Keyes O, Blasdel G, Haley C, Lane M, Marquette L, Hsu J, Kuzon WM Jr. Roblee C, et al. Semin Plast Surg. 2024 Jan 19;38(1):53-60. doi: 10.1055/s-0043-1778042. eCollection 2024 Feb. Semin Plast Surg. 2024. PMID: 38495068 Review.
• A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery. Frey JD, Poudrier G, Thomson JE, Hazen A. Frey JD, et al. J Sex Med. 2017 Aug;14(8):991-1002. doi: 10.1016/j.jsxm.2017.06.007. J Sex Med. 2017. PMID: 28760257 Review.
• Gender-Affirming Surgery in Persons with Gender Dysphoria. Weissler JM, Chang BL, Carney MJ, Rengifo D, Messa CA 4th, Sarwer DB, Percec I. Weissler JM, et al. Plast Reconstr Surg. 2018 Mar;141(3):388e-396e. doi: 10.1097/PRS.0000000000004123. Plast Reconstr Surg. 2018. PMID: 29481407
• The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, de Jongh RT, Bouman MB, Steensma TD, Cohen-Kettenis P, Gooren LJG, Kreukels BPC, den Heijer M. Wiepjes CM, et al. J Sex Med. 2018 Apr;15(4):582-590. doi: 10.1016/j.jsxm.2018.01.016. Epub 2018 Feb 17. J Sex Med. 2018. PMID: 29463477
• Age at First Experience of Gender Dysphoria Among Transgender Adults Seeking Gender-Affirming Surgery. Zaliznyak M, Bresee C, Garcia MM. Zaliznyak M, et al. JAMA Netw Open. 2020 Mar 2;3(3):e201236. doi: 10.1001/jamanetworkopen.2020.1236. JAMA Netw Open. 2020. PMID: 32176303 Free PMC article.
• Decoding the Misinformation-Legislation Pipeline: an analysis of Florida Medicaid and the current state of transgender healthcare. Lockmiller C. Lockmiller C. J Med Libr Assoc. 2023 Oct 2;111(4):750-761. doi: 10.5195/jmla.2023.1724. J Med Libr Assoc. 2023. PMID: 37928129 Free PMC article. Review.
• Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis. Patel H, Camacho JM, Salehi N, Garakani R, Friedman L, Reid CM. Patel H, et al. Cureus. 2023 Mar 29;15(3):e36849. doi: 10.7759/cureus.36849. eCollection 2023 Mar. Cureus. 2023. PMID: 37123806 Free PMC article. Review.
• On, With, By-Advancing Transgender Health Research and Clinical Practice. Streed CG Jr, Perlson JE, Abrams MP, Lett E. Streed CG Jr, et al. Health Equity. 2023 Mar 3;7(1):161-165. doi: 10.1089/heq.2022.0146. eCollection 2023. Health Equity. 2023. PMID: 36895704 Free PMC article.
• Classification of Transgender Man's Breast for Optimizing Chest Masculinizing Gender-affirming Surgery. Wolf Y, Kwartin S. Wolf Y, et al. Plast Reconstr Surg Glob Open. 2021 Jan 25;9(1):e3363. doi: 10.1097/GOX.0000000000003363. eCollection 2021 Jan. Plast Reconstr Surg Glob Open. 2021. PMID: 33564589 Free PMC article.

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• Ovid Technologies, Inc.
• Wolters Kluwer
• MedlinePlus Health Information

Research Materials

• NCI CPTC Antibody Characterization Program

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Ontario.ca needs JavaScript to function properly and provide you with a fast, stable experience.

To have a better experience, you need to:

• Go to your browser's settings
• Enable JavaScript

Gender confirming surgery

How to apply for gender confirming surgery (also known as sex reassignment surgery) in Ontario. If you are eligible, this service is covered under OHIP .

As of March 1, you can seek an assessment for surgery from qualified health care providers across the province.

On this page Skip this page navigation

Affirming gender identity.

Gender confirming surgery (also known as sex reassignment or gender affirming surgery) does more than change a person’s body. It affirms how they think and feel about their own gender and what it means to who they are.

Ontario is funding surgery as an option for people who experience discomfort or distress with their sex or gender at birth.

How to qualify

Ontario funds two types of gender-confirming surgery: genital and chest.

To qualify for funding, you must:

• be assessed and recommended for surgery by either one or two healthcare providers (e.g. a qualified doctor, nurse practitioner, registered nurse, psychologist or registered social worker)
• have a referral for surgery completed and submitted to the Ministry of Health and Long-Term Care by a physician or nurse practitioner; and
• have the surgery approved by the Ministry of Health and Long-Term Care before the surgery takes place

Approval for genital surgery

To be approved for genital surgery, you’ll need:

• one of the assessments must be from a doctor or nurse practitioner
• you have a diagnosis of persistent gender dysphoria
• have completed 12 continuous months of hormone therapy (unless hormones are not recommended)
• you have lived 12 continuous months in the gender role you identify with (for genital surgery only)

If you have surgery before getting approval from the ministry, the cost of the surgery will not be covered.

Approval for chest surgery

To be approved for chest surgery you’ll need:

• have a diagnosis of persistent gender dysphoria
• have completed 12 months of continuous hormone therapy with no breast enlargement (unless hormones are not recommended) if you’re seeking breast augmentation

After being approved for chest surgery, your family doctor or nurse practitioner can refer you to a specialist who can perform the surgery.

Apply for surgery

To apply for gender confirming surgery, your doctor or nurse practitioner needs to fill out and submit the application along with the assessments and recommendations for surgery, to the Ministry of Health and Long-Term Care. The application is for patients seeking services in Ontario, out of province but within Canada or outside of the country.

Your doctor or nurse practitioner will let you know if your application is approved.

Once you receive approval from the ministry, talk with your health care provider to get ready for the surgery

Additional resources

You can find useful information from organizations, such as:

• find out about their ongoing project, Trans Health Connection
• consult their service directory
• find out about the Gender Identity Clinic (Adult)

Information for healthcare providers

Find out more about your role in providing gender-confirming surgery funded by Ontario.

• Election 2024
• Entertainment
• Newsletters
• Photography
• AP Buyline Personal Finance
• AP Buyline Shopping
• Press Releases
• Israel-Hamas War
• Russia-Ukraine War
• Global elections
• Asia Pacific
• Latin America
• Middle East
• Delegate Tracker
• AP & Elections
• U.S. Open Tennis
• College football
• Auto Racing
• Movie reviews
• Book reviews
• Financial Markets
• Business Highlights
• Financial wellness
• Artificial Intelligence
• Social Media

Missouri now requires proof of surgery or court order for gender changes on IDs

State Rep. Justin Sparks, R-Wildwood, fields questions from reporters during a press conference to address a transgender woman using the women’s locker room at the Life Time fitness center in Ellisville, Mo., Friday, Aug. 2. (Ethan Colbert/St. Louis Post-Dispatch via AP)

• Copy Link copied

COLUMBIA, Mo. (AP) — Missouri residents now must provide proof of gender-affirmation surgery or a court order to update their gender on driver’s licenses following a Revenue Department policy change.

Previously, Missouri required doctor approval, but not surgery, to change the gender listed on state-issued identification.

Missouri’s Revenue Department on Monday did not comment on what prompted the change but explained the new rules in a statement provided to The Associated Press.

“Customers are required to provide either medical documentation that they have undergone gender reassignment surgery, or a court order declaring gender designation to obtain a driver license or nondriver ID card denoting gender other than their biological gender assigned at birth,” spokesperson Anne Marie Moy said in the statement.

LGBTQ+ rights advocacy group PROMO on Monday criticized the policy shift as having been done “secretly.”

“We demand Director Wayne Wallingford explain to the public why the sudden shift in a policy that has stood since at least 2016,” PROMO Executive Director Katy Erker-Lynch said in a statement. “When we’ve asked department representatives about why, they stated it was ‘following an incident.’”

According to PROMO, the Revenue Department adopted the previous policy in 2016 with input from transgender leaders in the state.

Some Republican state lawmakers had questioned the old policy on gender identifications following protests, and counterprotests, earlier this month over a transgender woman’s use of women’s changing rooms at a suburban St. Louis gym.

“I didn’t even know this form existed that you can (use to) change your gender, which frankly is physically impossible genetically,” Republican state Rep. Justin Sparks said in a video posted on Facebook earlier this month. “I have assurances from the Department of Revenue that they are going to immediately change their policy.”

Life Time gym spokesperson Natalie Bushaw previously said the woman showed staff a copy of her driver’s license, which identified her as female.

It is unclear if Missouri’s new policy would have prevented the former Life Time gym member from accessing women’s locker rooms at the fitness center. The woman previously told the St. Louis Post-Dispatch that she has had several gender-affirming surgeries.

Life Time revoked the woman’s membership after the protests, citing “publicly available statements from this former member impacting safety and security at the club.”

The former member declined to comment Monday to The Associated Press.

“This action was taken solely due to safety concerns,” spokesperson Dan DeBaun said in a statement. “Life Time will continue to operate our clubs in a safe and secure manner while also following the Missouri laws in place to protect the human rights of individuals.”

Missouri does not have laws dictating transgender people’s bathroom use. But Missouri is among at least 24 states that have adopted laws restricting or banning gender-affirming medical care for minors.

“Missouri continues to prove it is a state committed to fostering the erasure of transgender, gender expansive, and nonbinary Missourians,” Erker-Lynch said.

• Open access
• Published: 19 August 2024

Discontinuing hormonal gender reassignment: a nationwide register study

• Riittakerttu Kaltiala   ORCID: orcid.org/0000-0002-2783-3892 1 ,
• Mika Helminen 2 ,
• Timo Holttinen 3 &
• Katinka Tuisku 4  

BMC Psychiatry volume  24 , Article number:  566 ( 2024 ) Cite this article

912 Accesses

12 Altmetric

Metrics details

With increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.

A nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.

Of the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1–6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.

Conclusions

The risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.

Trial registration number (TRN)

Not applicable (the paper does not present a clinical trial).

Peer Review reports

In gender medicine, transition refers to people with sex-discordant gender identities making changes in their lives to live in their experienced gender, socially (appearance, name, personal pronouns), juridically (identity documents) or medically (hormonal and surgical medical interventions that modify secondary sex characteristics ) . Detransition refers to people aborting their initiated transition and reversing it, totally or partially, to live in a sex-accordant role by reversing the abovementioned steps of transition.

Recent decades have witnessed an exponential increase in those seeking medical interventions to support their transition (medical gender reassignment, GR), with an increasing share of younger individuals of the female sex [ 1 , 2 ]. Psychiatric morbidity among people who contact specialized gender identity services (GISs) has increased simultaneously [ 2 , 3 ] and is particularly pronounced among the youngest age groups [ 4 ].

It has long been assumed that very few patients embarking on medical GR regret their choice and seek to reverse it. From the 1970s to the 2010s, estimates of those regretting their initiated GR were only in the region of 2% [ 5 , 6 ]. However, more recent research suggests that alongside the increase in the number of people accessing medical gender reassignment, reversing the initiated transition seems to be increasing [ 7 ]. In recent samples, 20–30% of those who initiated hormonal GR discontinued hormonal treatment in four to five years [ 8 , 9 ]. It is possible that some patients discontinue hormonal treatment because they have reached their transition goals. Some changes, such as lowering of the voice, can be reached with relatively short hormonal treatments and are permanent, while maintaining some other changes require permanent treatment.

People abandoning their gender transition have reported various reasons for doing so, such as coming to terms with their natal sex, concerns about medical complications, attributing gender dysphoria to reasons other than gender identity, such as trauma or mental disorders, finding that the transition did not alleviate distress, struggles with sexual orientation and discrimination [ 10 , 11 ]. More importantly, those who have detransitioned have repeatedly reported that before their embarking on medical GR, insufficient attention was given to their mental health and psychosocial problems, which, in retrospect, they believed played a major role in their desire to transition. They have expressed concerns that assessments for medical gender reassignment were too superficial, with no search for explanations for their distress beyond an assumed stable sex-discordant identity requiring transition. [ 10 , 11 ]. This contradicts calls to lower the threshold for medical gender reassignment [ 12 , 13 ]. Several recent national guidelines and recommendations [ 4 , 14 , 15 ], however, emphasize the appropriate treatment of psychiatric comorbidities and associated difficulties as well as a psychosocial intervention facilitating identity exploration as first-line interventions for gender dysphoria before considering medical interventions, particularly for young people.

In Finland, gender identity assessments potentially leading to medical GR interventions are conducted at two of the country’s five university hospitals. Services for legal adults (> 18 years) have been available since the early 1990s [ 16 ] and became available to minors in 2011 [ 17 ]. The national guidelines require minors presenting with feelings of gender dysphoria to first undergo psychosocial intervention to support identity exploration and to receive appropriate treatment for any severe mental disorders [ 14 ], after which they can proceed to the centralized GIS, where diagnostic assessments are carried out by specialized mental health teams. Both GISs have separate diagnostic teams for minors and for adults. Hormonal GR interventions are initiated at the same hospitals in gynecological outpatient clinics, and after stabilization, hormonal treatment is transferred to services in the patients’ places of residence. Genital surgeries with gender identity indication are nationally centralized to one university hospital and require recommendations from both nationally centralized diagnostic GIS units. Psychiatric treatment for any concomitant mental health condition is provided at the specialized secondary care or primary health care facility in the patient’s place of residence. Until 2022, diagnostic assessments at the nationally centralized GIS were also a prerequisite for registered sex change, but since 3 April 2023, legal adults have been granted legal GR on the basis solely of their own request. Medical GR remains nationally centralized and is available case-by-case after a comprehensive diagnostic assessment by a multidisciplinary mental health team, as outlined in the national guidelines [ 14 , 18 , 19 ].

An important ethical principle in all medicine is to not harm. A more severe or life-threatening condition may justify greater risks in its treatment. In medical gender reassignment, hormonal and surgical interventions are performed on physically healthy bodies. If the patient subsequently regrets the changes brought by the treatments, not to mention undesired side effects, this can be considered harmful. As in other Western countries, alongside the vastly increasing number of referrals to the GIS, increasing numbers of younger people with increasingly common psychiatric needs have initiated medical GR in Finland [ 2 ]. This may be followed by increasing numbers of people who later feel otherwise about their medical GR. On the other hand, the purpose of the nationally centralized and comprehensive assessment before medical GR is to ensure reasoned treatment decisions and satisfactory patient outcomes, avoiding possible regrets. This may counteract the risks related to the more complex presentations among those seeking medical GR. Those abandoning their gender transitions have repeatedly claimed that the distress accompanying their situation is not appropriately addressed [ 20 ]. It is crucial to take seriously the desire to reverse medical GR and to ascertain its likelihood and predictors to target medical GR safely and provide appropriate services for those opting out of treatment that has resulted in irreversible changes in a healthy pretreatment body. In the present study, we referred to national registry data to determine which patients are likely to discontinue hormonal GR. More specifically, we asked:

How commonly did people who proceeded to hormonal GR after assessment in the nationally centralized GIS from 1996 to 2019 discontinue their established hormonal GR?

What are the predictors of discontinuation in terms of age, age at admission to the GIS, direction of transition, surgical treatment, psychiatric treatment needs and cohort effects?

Has the risk of discontinuing hormonal GR changed over time?

Design and setting

A register-based follow-up study was conducted using information held in health care registers in Finland. These comprehensive and reliable national registers can be used to study large patient groups and collate information from different registers (on an individual level) via the unique personal identity code assigned to each permanent resident of Finland. Register data can be applied for research purposes from the Finnish Social and Health Data Permit Authority Findata and Statistics Finland. Data extraction, linkages and pseudonymization are carried out by these authorities, and researchers are allotted a special secure connection for pseudonymized data only. Analyses producing unduly precise information potentially enabling a person to be identified must be amended to ensure the anonymity of the persons included. The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], no individual informed consent was needed.

A personal identity code is assigned at birth (or upon obtaining Finnish citizenship). This indicates sex (male or female). Legal sex change entails a new identity code. People are listed in the national registers according to their currently valid personal identity code. This code serves to retrieve data from various registers (including earlier data under the original identity code). Researchers cannot obtain information about identity code changes (changes in juridical sex). Researchers using the data never see the actual identity codes.

Data extraction

Subjects referred to either of the two nationally centralized GISs were identified from the hospital databases of Tampere and Helsinki University Hospitals. The first contact with a diagnostic team in either of the two GISs was recorded as the index date. The Finnish Social and Health Data Permit Authority Findata combined the lists from the two hospitals. A total of 3,665 individuals were identified as having contacted the nationally centralized gender identity units between 1996 and 2019. Of these, 1,359 had initialized and embarked on feminizing or masculinizing hormonal treatment (see below, next paragraph) and formed the subjects of the present study.

The register of the Social Insurance Institution of Finland (KELA), with information on prescription medications purchased and information on reimbursement, was used to obtain information on hormonal GR in the clinical GD group. Persons diagnosed with F64.0 (since 2020, also F64.8) in the nationally centralized gender identity units are entitled to special reimbursement (code 121) for their hormonal treatment, as are patients suffering from specified endocrine disorders. In the treatment of gender dysphoria, special reimbursement is available when hormonal treatment has continued for more than a year. The data on prescription medications were collected up to the end of 2021.

The Care Register for Health Care [ 22 ] was used for information on all treatment contacts to specialist-level psychiatric services from 1994 to 2022. The register, which has been in operation since 1994, includes all outpatient and inpatient contacts with specialist-level health services in Finland. For all contacts, admission and discharge dates were extracted. The Care Register for Health Care was further used to provide information on gender reassignment surgeries.

The Population Register provided information on those deceased and their dates of death.

Discontinuing hormonal GR

Subjects entitled to special reimbursement for hormonal treatments were considered to have discontinued their hormonal GR if they had purchased no hormones for more than 12 months before the end of the data collection or, if deceased, for 12 months or more before their death, or if they had been purchasing specially reimbursed feminizing hormones but had later switched to masculinizing hormones, or vice versa. To obtain reimbursements for prescription medications from the Social Insurance Institution of Finland (KELA), these medications can be purchased for only three months at a time. Thus, not purchasing them for over a year means that they are most likely not being taken. The last date of purchase of the originally prescribed hormonal GR medication was recorded. Patients who discontinue hormonal GR may require birth-sex accordant hormonal replacement to detransition after gonad removal or if their natural hormone production does not resume. For subjects whose specially reimbursed hormone treatment had changed from masculinizing to feminizing or vice versa, the last date of purchase of the originally initiated type of hormonal GR was recorded.

Types and durations of hormonal GR

In the analyses, hormonal GR was divided into feminizing and masculinizing. The duration of hormonal GR with special reimbursement was calculated in months from the dates of first and last/latest purchase of the originally initiated masculinizing/feminizing hormones.

Time variables

The subject’s year of birth was used in the analyses as a continuous variable. The year of initial contact with the GIS (index year) was categorized into intake cohorts with the first contact with the GIS in 1996–2005 vs. 2006–2012 vs. 2013‒2019. As the inclusion period did not fall into three even periods, the first period, with a clearly lower case load, was extended.

Age at first contact with the GIS (index date) was calculated from the dates of index contact and birth. Age in years was used in bivariate analyses as a continuous variable. In multivariable analyses, age was divided into adolescent (up to 22 years old) and adult (23+) at index contact.

Gender reassignment surgeries

The gender reassignment surgeries recorded were genital surgery (vaginoplasty, phalloplasty/metoidioplasty) and chest masculinization.

Specialist-level psychiatric treatment contact

Specialist-level psychiatric treatment contacts other than those related to gender identity assessment were recorded. Having received specialist-level psychiatric treatment was used in the analyses as a comprehensive dichotomous variable (yes/no). Furthermore, having specialist-level psychiatric treatment contact before entering the GIS (yes/no) was used, as was having specialist-level psychiatric treatment two or more years after entering the GIS (yes/no).

Statistical analyses.

Bivariate associations between discontinuing hormonal GR and the explanatory variables were studied via cross-tabulations with chi-square statistics (Fisher’s exact test where appropriate) and the Mantel‒Haenszel test for categorical variables and t tests and ANOVA for continuous variables. Multivariate associations were studied via Cox regression, accounting for differences in follow-up times. Discontinuing hormonal GR was entered as the dependent variable. The independent variables entered were (1) direction of hormonal treatment (masculinizing/feminizing), year of birth and index year cohort; (2) GR surgeries; (3) age at first entering the GIS (adolescent vs. adult); and (4) and, finally, having received specialist-level psychiatric treatment (yes/no). Hazard ratios (HRs) with 95% confidence intervals are given. The cut-off for statistical significance was considered p  < 0.05.

There were 1,359 people who, after having been assessed in the nationally centralized GIS, had purchased masculinizing or feminizing hormones with a special reimbursement code. The mean (sd) age of the participants on admission to the GIS was 25.6 (9.3) years, and 49.1% of them were under 23 years of age. In total, 467 (34.4%) had received feminizing treatment, and 892 (65.6%) had received masculinizing treatment. At index contact with the GIS, those who subsequently initiated feminizing GR were older than those who proceeded to masculinizing GR (29.7 (11.1) vs. 23.4 (7.3) years, p  < 0.001). The mean (sd) duration of hormonal GR was 62.0 (57.0) months, with a median of 44.5 months, with no difference between masculinizing and feminizing treatments. Genital surgeries were more commonly performed on those who had proceeded to feminizing treatment (46.7% vs. 14.9%, p  < 0.001). Among those on masculinizing treatment, 41.5% had undergone chest masculinization. Among all patients proceeding to hormonal GR, 57.4% had ever had treatment contact with specialist-level psychiatric care.

A total of 107 subjects (7.9% of those who had started hormonal GR and obtained special reimbursement for it) had not been purchasing GR hormones for at least a year before the end of data collection (or before the subject died) or had changed from feminizing GR to masculinizing treatment, or vice versa. These were considered to have discontinued hormonal GR. Among those who had obtained feminizing GR, 10.5% had discontinued hormonal treatment, and among those who had obtained masculinizing GR, 6.5% ( p  = 0.004). Those who discontinued hormonal GR were slightly older at the index contact and at their latest purchase of specially reimbursed hormones than those who continued hormonal GR. The two groups had used hormonal GR for comparable periods. Those who discontinued and those who stayed on hormonal GR had comparable specialist-level psychiatric treatment contacts. (Table  1 )

Those who discontinued and those who continued hormonal GR had equally common specialist-level psychiatric treatment contact before contacting the GIS (15.3% vs. 17.8%, p  = 0.5) as well as two or more years after entering the GIS (59.9% vs. 57.0%, p  = 0.2).

Changes across intake cohorts

The basic characteristics of the subjects changed across intake cohorts. The mean (sd) age among those who had contacted the GIS from 1996 to 2005 and subsequently proceeded to hormonal GR was 31.1 (7.9); from 2006 to 2012, it was 25.7 (9.3); from 2013 to 2019, it was 24.8 (9.2) years ( p  < 0.001); and the proportion of adolescents (< 23-year-olds) was 13.7% vs. 48.9% vs. 53.6% ( p  < 0.001). The proportion of those seeking change towards masculinity increased, and the same change was observed among those discontinuing hormonal GR. The proportion of those with specialist-level psychiatric treatment contacts fluctuated between cohorts among those continuing hormonal GR but remained unchanged among those who discontinued it (Table  1 ).

Multivariable analyses

The hazard ratio (HR) for discontinuing hormonal GR was greater among those in the latest intake cohort (2013–2019) as compared to those in the earliest cohort (1996–2005) when the type of hormonal GR (masculinizing vs. feminizing) and year of birth were accounted for (Table  2 Model 1) and when surgical GR (Table  2 Model 2), age at index admission (adolescent vs. adult) (Table  2 Model 3) and, finally, specialist-level psychiatric treatment contact (Table  2 Model 4) were added. Genital surgeries were associated with a decreased HR for the discontinuation of hormonal GR. Earlier year of birth was very slightly but statistically significantly associated with increased HR for discontinuing hormonal GR in the first models but levelled out in subsequent models.

Confirmatory analyses

Because the oldest individuals in the sample may have discontinued hormonal GR due to reaching the age of natural decline in hormonal levels, the final model was repeated among individuals younger than 60 at the end of data collection, but this did not change the findings.

A further confirmatory analysis was carried out using data from those subjects whose index contact was before 2018 because of the rather short follow-up times among those who had started their gender identity assessments in 2018 or 2019. This caused no changes to the findings presented in Table  2 .

Changes in the discontinuation of hormonal GR over time

Survival curves for the three index date cohorts suggested that the discontinuation of hormonal GR emerged in a shorter time from the earliest to the latest intake cohort (Fig.  1 ). To explore this further, discontinuation within two years of obtaining special reimbursement for hormonal GR was scrutinized among those with index dates before 2018. Among the two earlier intake cohorts (combined due to small cell frequencies in the original categories), 1.3% of those who had started hormonal GR discontinued it within two years; among the latest intake cohort, 2.9% ( p  = 0.06).

Time (in years)* to discontinuing hormonal gender reassignment in the different intake cohorts (1 = 1996–2005, 2 = 2006–2012, 3 = 2013–2019). *modeled by Cox regression

In this nationally representative register study covering subjects proceeding to hormonal GR over three decades, 7.9% discontinued their established hormonal GR. The risk for discontinuing hormonal GR was greater in the latest intake cohort (2013–2019) than in the earliest cohort (1996–2005). Genital surgeries were associated with a decreased risk of discontinuing hormonal GR. Over the decades, the time to discontinuation grew shorter.

The proportion of those who discontinued treatment was smaller than that reported in the most comparable study [ 9 ] from the USA, where almost one-third of adolescents and young adults discontinued their hormonal GR within four years. The relatively low discontinuation rate in our study may be due to the comprehensive assessment in the nationally centralized GIS before initiating hormonal treatments. When severe psychiatric comorbidities are present, great care is taken in considering physical interventions [ 2 , 14 , 17 ]. The proportion of those who discontinued their established hormonal GR was nevertheless manifold compared with earlier reports of proportions regretting medical transition among samples who had initiated their treatments between the 1960s and 2010s [ 5 , 6 ]. However, both of those reports focused on actively expressed regrets, and in the latter study [ 6 ], the proportion lost to follow-up—with later development thus unknown—was high. The proportion discontinuing their established hormonal GR in the present study was comparable to the proportion defined as detransitioners (those who discontinued treatment and reverted to living in their original gender role) in a register-based study of 175 subjects initially assessed in 2017–18 in the UK [ 7 ]. However, in that UK study, a clearly greater additional share of the studied group also subsequently disengaged from the treatments or did not adhere to their treatment plan. In a study evaluating the situation of people diagnosed with GD in a specified GP practice population [ 8 ] and, as noted, in a register study in the USA [ 9 ], much greater shares discontinued their medical GR. Direct comparisons among these studies are not feasible because of their different focuses and methodologies. However, together with the most recent studies, our study suggests that discontinuing hormonal GR is a significant phenomenon in gender medicine, and studies reporting the experiences of detransitioners [ 10 , 11 ] suggest that it is often related to profound psychological distress.

In multivariate models accounting for differences in follow-up times and for changes in patient characteristics across intake cohorts, the risk of discontinuing hormonal GR was almost threefold among those patients who had contacted the GIS from 2013 to 2019 compared with those who had contacted the GIS from 1996 to 2005. Our findings also suggest that the time to discontinuation of hormonal GR may have shortened among the later patients; however, in the latest intake cohort, more discontinuations may still emerge, and this will eventually affect the final conclusions about the average time to discontinuation. The proportion of subjects who discontinued after short use, a maximum of two years of specially reimbursed medication use, nevertheless appeared to have increased. (This will mean a maximum of three years of total use, given the rules on special reimbursement). Over the whole study period, the number of people seeking GR increased manifoldly [ 2 ], as did the number of subjects proceeding to hormonal GR. Alongside with this, the risk of discontinuing established medical GR has also increased. The populations seeking medical GR may have changed in a way that limits positive treatment outcomes. It is already known that subjects currently seeking medical GR are, unlike earlier, predominantly birth-registered females, who are younger than before and present with more psychiatric comorbidities than before [ 1 , 2 , 3 , 20 ]. These observations may suggest that an increasing share of GD patients actually do not present with achieved, consolidated identity [ 20 , 23 ]. In particular, medical transition early in terms of identity development may increase the risk of unbalanced treatment decisions, and this risk appears to have increased towards the present day, with detransitioning as the next step. Greater attention to gender identity issues and GR in the media and social media as well as assertive advocacy for medical GR may play a role in these developments [ 20 , 24 , 25 ].

Somewhat unexpectedly, the need for specialist-level psychiatric care did not differentiate those who continued and those who discontinued hormonal GR. Approximately one in six of the patients who had started hormonal GR, both those who later discontinued and those who continued the treatment, had needed specialist-level psychiatric treatment before embarking on gender identity assessments. This number was clearly less than that of all patients who were in contact with the GIS [ 2 ]. It is expected that the two groups would be comparable at the time of the decision to initiate medical GR and suffer fewer psychiatric comorbidities than those who could not start medical GR. However, psychiatric treatment needs increased vastly after the index contact with the GIS in both groups who proceeded to medical GR, those who subsequently discontinued it and those who continued on hormonal GR. A more detailed analysis of the nature of psychiatric needs and subsequent identity struggles is needed to better understand the discontinuation of medical GR in the future. According to the multivariable analyses, the risk for discontinuing hormonal GR did not differ between those who had initially contacted the GIS during adolescence (< 23 years) and those who had contacted in adulthood. This may be due to assessments being particularly cautious with younger patients, whereas with middle-aged subjects, self-determination may be accorded greater significance.

Having undergone genital surgeries was predictive of a decreased risk of discontinuing hormonal treatments. This may be due to strict treatment protocols requiring psychological stability as part of eligibility for genital surgeries. A recommendation letter is required from both the nationally centralized GIS for gender surgeries to ensure both the patient’s capacity to consent and that their psychological and psychosocial resources will suffice to recover from major surgery.

Methodological considerations.

A strength of the present study is the use of nationwide registry data over three decades. The registers are comprehensive since treatment providers are required by law to report to them all the information on which this study relies. The subjects were identified in the databases of the hospitals where the nationally centralized GISs operate, thereby ensuring the reliability of sampling. The long inclusion period made it possible to analyse changes over time. A limitation is that only subjects who had obtained the special reimbursement code for their hormonal GR were included. There may be subjects who discontinued hormonal GR before their entitlement to special reimbursement (which can take place after a year), and their number is not known. Another limitation is that registers include no information on the reasons for discontinuing hormonal GR. Given the ample publicly funded health services and the special reimbursement for hormonal GR, financial problems are an unlikely reason. Further changes in identity, medical complications or concerns over them, not being helped by GR or social reasons, may contribute [ 10 , 11 , 20 ]. It is also possible that some achieved their goals and therefore discontinued, although this seems implausible in the case of discontinuation after many years. A more profound understanding of the reasons for discontinuing medical GR will require studies using information elicited directly from patients. A further limitation is that regarding the need for psychiatric treatment, this research focused on specialist-level service contacts reflecting severe psychiatric needs. Mild to moderate mental disorders are treated in primary health care. Thus, the need for psychiatric treatment was likely somewhat underestimated in the present study. A limitation is that the possible use of hormonal GR through unofficial routes was not addressed. Publicly funded medical GR interventions are possible only through nationally centralized gender identity services. Obtaining hormonal GR via unofficial routes would likely be related to medical GR not being considered timely in the official treatment route. This finding may suggest that the discontinuation of hormonal GR can be more common among those who obtain hormones unofficially. We combined minors (< 18 at intake to the GIS) and late adolescents (18–22-year-olds at intake) because before 2011, minors entered the assessments only occasionally. Brain development, personality development and identity consolidation continue well beyond the age of reaching legal adulthood [ 23 , 26 , 27 , 28 , 29 , 30 ]. Finally, discontinuing hormonal GR, desisting from identifying in a sex-discordant way, detransitioning and regretting medical GR are concepts referring partly to the same phenomenon but not totally overlapping [ 20 ]. A register-based study cannot reach these nuances.

Discontinuing established medical GR appears to be less common in Finland than reported elsewhere. This is likely due to careful, comprehensive assessment before initiating physical treatments. The risk of discontinuing established medical GR has nevertheless increased alongside increases in the number of patients seeking and proceeding to medical GR. In later intake cohorts, discontinuation also appears to emerge earlier. The threshold to initiate medical GR may have decreased, resulting in greater risks of suboptimal decisions. More research is needed on practically all aspects of detransitioning from medical GR.

Data availability

The authors are not allowed to give the data to any party. Information about how to apply Finnish register data for research purposes can be found in www.findata.fi.

Abbreviations

• Gender dysphoria

Gender identity service

Hazard ratio

Confidence interval

Thompson L, Sarovicid D, Wilsonid P, Sä Mfjordid A, Gillberg C. A PRISMA systematic review of adolescent gender dysphoria literature: 1) Epidemiology. 2022; https://doi.org/10.1371/journal.pgph.0000245

Kaltiala R, Holttinen T, Tuisku K. Have the psychiatric needs of people seeking gender reassignment changed as their numbers increase? A register study in Finland. Eur Psychiatry. 2023;66(1).

Thompson L, Sarovic D, Wilson P, Sämfjord A, Gillberg C. A PRISMA systematic review of adolescent gender dysphoria literature: 2) mental health. PLOS Global Public Health. 2022;2(5):e0000426.

Article   PubMed   PubMed Central   Google Scholar  

Cass Reviw. Independent review of gender identity services for children and young people 4 Independent review of gender identity services for children and young people: Final report [Internet]. 2024 [cited 2024 Jun 7]. https://cass.independent-review.uk/home/publications/final-report/

Dhejne C, Öberg K, Arver S, Landén M. An analysis of all applications for sex reassignment surgery in Sweden, 1960–2010: prevalence, incidence, and regrets. Arch Sex Behav. 2014;43(8):1535–45.

Article   PubMed   Google Scholar  

Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, et al. The Amsterdam cohort of gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and regrets. J Sex Med. 2018;15(4):582–90.

Hall R, Mitchell L, Sachdeva J. Access to care and frequency of detransition among a cohort discharged by a UK national adult gender identity clinic: retrospective case-note review. BJPsych Open. 2021;7(6).

Boyd I, Hackett T, Bewley S. Care of Transgender patients: a General Practice Quality Improvement Approach. Healthcare. 2022;10:121.

Roberts CM, Klein DA, Adirim TA, Schvey NA, Hisle-Gorman E. Continuation of gender-affirming hormones among Transgender adolescents and adults. J Clin Endocrinol Metab. 2022;107(9):E3937–43.

Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition who subsequently detransitioned: a Survey of 100 detransitioners. Arch Sex Behav. 2021;50(8):3353–69.

Vandenbussche E. Detransition-related needs and support: a cross-sectional online survey. J Homosex. 2022;69(9):1602–20.

Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the health of transgender and gender diverse people, Version 8. Int J Transgend Health. 2022;23(S1):S1–259.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Rafferty J, American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health C on AS on LGB and TH. and W. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics [Internet]. 2018;152(4). http://publications.aap.org/pediatrics/article-pdf/142/4/e20182162/1529435/peds_20182162.pdf

Palveluvalikoimaneuvosto (COHERE Finland). Palveluvalikoimaneuvoston suositus. Alaikäisten sukupuoli-identiteetin variaatioihin liittyvän dysforian lääketieteelliset hoitomenetelmät [Internet]. 2020 [cited 2023 Jul 20]. https://palveluvalikoima.fi/documents/1237350/22895008/Alaik%C3%A4iset_suositus.pdf/c987a74c-dfac-d82f-2142-684f8ddead64/Alaik%C3%A4iset_suositus.pdf?t=1592317701000

Socialstyrelsen S. 2022 [cited 2023 Jul 20]. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2023-6-8586.pdf

Pimenoff V. On the care of transsexuals in Finland. Int J Transgenderism. 2006;9(2):23–33.

Article   Google Scholar  

Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolesc Psychiatry Ment Health. 2015;9(1).

Palveluvalikoimaneuvosto (COHERE Finland). Palveluvalikoimaneuvoston suositus. Transsukupuolisuudesta johtuvan dysforian lääketieteelliset hoitomenetelmät [Internet]. Helsinki. 2020 [cited 2023 Jul 20]. https://palveluvalikoima.fi/documents/1237350/22895838/Transsukupuolisuus+suositus.pdf/82b60104-291c-7d8c-9e88-1b1fc9bba527/Transsukupuolisuus+suositus.pdf?t=1592318544000

Palveluvalikoimaneuvosto (COHERE Finland). Palveluvalikoimaneuvoston suositus. Aikuisten muunsukupuolisuuteen liittyvän sukupuolidysforian lääketieteelliset hoitomenetelmät [Internet]. Helsinki. 2020 [cited 2023 Jul 20]. https://palveluvalikoima.fi/documents/1237350/22895623/Muunsukupuolinen+suositus.pdf/058ac8f5-560d-da00-7b03-20644f97674a/Muunsukupuolinen+suositus.pdf?t=1592318040000

Jorgensen SCJ. Transition regret and detransition: meanings and uncertainties. Arch Sex Behav. 2023;52(5):2173–84.

EUR-Lex. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of natural persons with regard to the processing of personal data and on the free movement of such data, and repealing Directive 95/46/EC (General Data Protection Regulation). 2016.

Gissler M, Haukka J. Finnish health and social welfare registers in epidemiological research. Vol. 14, Norsk Epidemiologi. 2004.

Kroger J, Martinussen M, Marcia JE. Identity status change during adolescence and young adulthood: a meta-analysis. J Adolesc. 2010;33(5):683–98.

Marchiano L, Outbreak. On Transgender teens and psychic epidemics. Psychol Perspect. 2017;60(3):345–66.

Google Scholar  

Haidt J. The anxious generation: how the Great Rewiring of Childhood is causing an epidemic of Mental Illness. Penguin Books LImited; 2024.

Paus T, Keshavan M, Giedd JN. Paus et al why do mental disorders emerge in adolescence. Nat Rev Neurosci. 2008;9(12):947–57.

Klimstra TA, Hale WW, Raaijmakers QAW, Branje SJT, Meeus WHJ. Maturation of personality in adolescence. J Pers Soc Psychol. 2009;96(4):898–912.

Luyckx K, Robitschek C. Personal growth initiative and identity formation in adolescence through young adulthood: mediating processes on the pathway to well-being. J Adolesc. 2014;37(7):973–81.

Baxendale S. The impact of suppressing puberty on neuropsychological function: a review. Acta Paediatrica, International Journal of Paediatrics. Volume 113. John Wiley and Sons Inc; 2024. pp. 1156–67.

Petanjek Z, Judaš M, Šimić G, Rašin MR, Uylings HBM, Rakic P, et al. Extraordinary neoteny of synaptic spines in the human prefrontal cortex. Proc Natl Acad Sci U S A. 2011;108(32):13281–6.

Download references

This research has received funding from the Wihuri Foundation and the Suomen Kulttuurirahasto. The funders had no role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.

Open access funding provided by Tampere University (including Tampere University Hospital).

Author information

Authors and affiliations.

Tampere University, Faculty of Medicine and Health Techonolgy, Tampere University Hospital and Vanha Vaasa Hospital, Tampere, 33014, Finland

Riittakerttu Kaltiala

Tays Research Services, Wellbeing Services County of Pirkanmaa, Tampere University, Faculty of Social Sciences, Tampere, Finland

Mika Helminen

Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland

Timo Holttinen

Department of Psychiatry, Helsinki University Hospital, Helsinki, Finland

Katinka Tuisku

You can also search for this author in PubMed   Google Scholar

Contributions

RK, MH, TH and KT all contributed substantially to the design of the work; TH and RK curated the data; RK performed the analyses; MH consulted in statistical analyses; RK, MH, TH and KT interpreted the results; RK had the main responsibility of drafting the manuscript; MH, TH and KT participated in drafting the manuscript and approved the version submitted. All the authors have agreed both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All the authors reviewed and approved the manuscript.

Corresponding author

Correspondence to Riittakerttu Kaltiala .

Ethics declarations

Ethics approval and consent to participate.

The present study obtained ethical approval from the ethics committee of Tampere University Hospital (R20040R) and relevant permissions from Findata (THL/5188/14.02.00/2020) and Statistics Finland (TK/1016/07.03.00/2020). In accordance with Articles 6e and 9i and j of Regulation (EU) 2016/679 of the European Parliament and of the Council [ 21 ], individual informed consent of each registrar was not needed.

Consent for publication

The manuscript does not contain information that would require consent for publication from individual subjects.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kaltiala, R., Helminen, M., Holttinen, T. et al. Discontinuing hormonal gender reassignment: a nationwide register study. BMC Psychiatry 24 , 566 (2024). https://doi.org/10.1186/s12888-024-06005-6

Download citation

Received : 13 June 2024

Accepted : 07 August 2024

Published : 19 August 2024

DOI : https://doi.org/10.1186/s12888-024-06005-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Gender reassignment
• Masculinizing hormones
• Feminizing hormones
• Detransition
• Register study

BMC Psychiatry

ISSN: 1471-244X

• General enquiries: [email protected]

latest in US News

Serial California Tesla road rage driver released from prison —...

Pa. voters find common ground with JD Vance, whose mom battled...

Armed crew flaunts guns inside colorado apartment building....

'Dolton Dictator''s former assistant, town trustee betrays her...

Pack of teens girls randomly attack 76-year-old man on NYC subway...

Couple 'getting busy' in Range Rover accidentally roll into river...

Rep. Jim Jordan subpoenas company run by Trump ‘hush money’...

Colorado's First Gentleman quits social media after Facebook spat...

Activist who warns young women about social contagion of trans top surgery is now facing breast cancer.

When Amy Sousa was diagnosed with Stage 3 breast cancer in April, she went into “icy cold panic” about whether doctors could shrink the 10-centimeter tumor in her right breast — or if she would need a mastectomy.

It’s a tragic, and ironic, place to be in for an activist who has spent the past five years warning young women about the “contagion” of transgender ideology and the celebratory trendiness of top surgery — having your breasts removed as part of gender-affirming care —  on social media .

“Radical double mastectomies on girls are not a product of their so called ‘mental illness,’ they’re a product of social indoctrination,” Sousa, who holds a master’s degree in psychology, told The Post from her home in Port Townsend, Wash.

“Kids are being disassociated from the realities of life and are being indoctrinated by publicity and marketing to think that surgery and lifelong drugs will make them happy.

“They’re being manipulated to turn something normally viewed as painful and serious to associate it instead with something to envy and with celebrity status.”

Now she’s using the pain and fear triggered by trying to save her cancerous breast from amputation to shine even more of a light on what she sees as sharp rise in the glamorization and marketing of top srugery for biological females who don’t identify as women or are transitioning to men.

In an essay on The Known Heretic Substack which she authors, Sousa, 48, wrote: “My battle with breast cancer is giving me a fresh lens through which to view transgender propaganda, marketing, and so-called ‘gender-affirming care.’”

Young people ages 13 to 17 are the biggest group that identify as transgender in the US — around 1.4% of the age group, or about 300,000 of them, according to the Williams Institute at UCLA.

The overall number of Americans undergoing gender-affirming surgery is on the rise, research in 2023 revealed , almost tripling between 2016 and 2019 alone.

Between 2018 and 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to data analysis based on insurance claims. This tally does not include procedures paid for out-of-pocket.

The sex reassignment surgery market was over $733 million in 2023 and is projected to surpass $2 billion by 2032, according to the Global Market Insights research firm.

Among the surgeons who specialize in “gender affirming surgery” are Dr. Dany Hanna of Frisco, Texas, who advertises “genital nullification,” and Dr. Siobhan Gallagher of Miami who popularized the phrase “yeet the teets” — slang for removing breasts — and has nicknamed herself “Dr. Teetus Deletus.”

Gallagher, who is originally from Ireland, has said she does more than 500 gender-affirmation surgeries a year, some of them to teens under 18.

She was reported to the Federal Trade Commission in 2022 for using her enormous social media platforms “to appeal to hundreds of thousands of underage social media users, advertise Gallagher’s ‘gender affirming’ plastic surgery services, and sell them to a vulnerable and impressionable population of children and youth experiencing distress with their gender identity and developing bodies.”

“Just realized I only get to yeet 4 teets next week,” Gallagher posted to Instagram atop a selfie of her looking sad.

Her account includes many post-op photos of patients celebrating as well as photos of things like artificial testicle implants and breezy videos like one which starts: “Let’s talk about nipples falling off (post-surgery) really quick.”

And it’s not just Gallagher. Instagram and TikTok are replete with videos of “Yeet the Teet” parties commemorating voluntary mastectomies, as well as users who post photos of their bandaged chests and talk about still being drugged up on morphine.

“Ya (trans) boy is getting top surgery tomorrow! Time to yeet those teets,” wrote one poster on Reddit as commenters cheered.

“Chesticles to da recepticles! wrote one.

“Boobye!”

“Misty-colored mammaries!”

“I just imagined them launching off your chest like twin space shuttles,” wrote another. “I can’t stop laughing.”

Earlier this year, celebrity makeup artist Gottmik , the first trans man to appear on “RuPaul’s Drag Race,” celebrated her double mastectomy on the show — walking the runway in a green latex skirt with disembodied fake arms embracing her and brandishing a scalpel next to “bloody” scars on her chest.

Gottmik — who was born a woman and transitioned to a man, uses she/her pronouns in drag and he/him when not, according to The Advocate — also carried a clear biohazard bag containing fake, bloody breasts.

On TikTok, a popular meme trend show post-op trans mastectomy patients shouting at the camera , “Holy sh-t, I’ve just had a transgender operation!”

“If you go on GoFundMe right now, there are so many girls trying to get their top surgery,” Sousa said. “It’s incredibly disturbing. These girls are mimicking each other. They’re following each other. And they’re creating this as a trend. I see this as a social contagion.

“They’re in the hospital after these radical double amputations, smiling and posting pictures while they’re showing their followers their chests that are still leaking blood,” Sousa added. “But if you go to a cancer site and look at the women who have gotten a double mastectomy because of cancer, you’ll see a much different look on their faces. They’re talking about how hard the recovery is and how they can’t lift anything and how much pain they’re in.”

Sousa, who graduated from NYU’s Tisch School of the Arts and once planned a life in the theater, has long lobbied for women and girls to have access to single sex spaces in sports

A turning point in her activism came in 2018, while attending women’s marches and other so-called “Pussy Hat” events. She encountered what she described as about five “men who called themselves women” on a web site who were accusing her and others of transphobia because of the use of the “pussy hat” phrase.

“I remembered I asked one of them is it transphobic to talk about my vagina, and he said yes,” Sousa recalled.

Sousa said the group doxxed her online, giving out her past addresses and her father’s phone number.

“I was genuinely scared,” Sousa said. “I thought I was just arguing with a bunch of jerks but when I did more research I saw how many women were being silenced by these [trans men].”

Sousa started her Known Heretic brand on X at that point and her substack shortly thereafter. She’s organized multiple protests against biological men in women’s sports and against child gender clinics in Seattle and against housing biological in women’s prisons.

But now her hardest fight is to regain her own health.

“Amy is battling to save her own life,” her close friend K Yang , a former LGBT non-profit coordinator turned anti-trans and anti-woke whistleblower, told The Post.

“I have witnessed her journey through breast cancer and treatment with shock and awe at the grace and dignity she has carried herself with. Amy’s inspiring women all around the world to stand up for themselves and find courage to openly resist the destruction of women’s rights in the name of trans and gender ideology.”

Since April, Sousa’s tumor has reduced from 10 centimeter to 2.5 centimeters with chemo and a strict Paleo keto diet.

“I hope that I’ll be able to save my breast and keep my body intact and whole,” Sousa said. “But if my breast has to be removed, it won’t be because I didn’t try everything.”

Dr. Gallagher and Dr. Hanna did not return phone calls from The Post.

Advertisement

• Open access
• Published: 26 August 2024

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

• Tanvi Kaur Ahuja 1 ,
• Akhil Dhanesh Goel 1 , 2 ,
• Manoj Kumar Gupta 1 , 2 ,
• Nitin Joshi 1 ,
• Annu Choudhary 1 ,
• Swati Suman 1 ,
• Kajal Taluja 1 ,
• Madhukar Mittal 3 ,
• Navdeep Kaur Ghuman 4 ,
• Navratan Suthar 5 &
• Pankaj Bhardwaj 1 , 2  

BMC Health Services Research volume  24 , Article number:  989 ( 2024 ) Cite this article

19 Accesses

Metrics details

Transgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

Peer Review reports

Introduction

Universal Health Coverage (UHC) means that all people have access to quality healthcare services (service coverage) without any financial hardships (catastrophic health expenditure) [ 1 ]. To achieve UHC, National Health Policy 2017 projects to increase the government’s health expenditure to 2.5% of GDP by 2025 [ 2 ]. In alignment with this objective, the budgeted health sector spending has increased from 1.3% (2019-20) to 2.1% of GDP (2021–2022). According to National Health Accounts 2018-19, Out of Pocket Expenditure per capita (in Rupees) is 2155 [ 3 ].

Incidence of catastrophic health spending is felt at a higher rate by vulnerable communities due to gender, socio-economic position, disability status, or sexual orientation, besides other characteristics. The Transgender (TG) community is one such community whose gender expression (masculine, feminine, other) differs from their assigned sex (male, female) at birth. They can be identified as trans-man or trans-woman [ 4 ]. In the Indian context, transgender individuals identify themselves differently including Hijras, Aravanis, Kothis, Jogtas/Jogappas, and Shiv-Shakthis. For the first time, this population was included in India’s 2011 census. Reports suggest that 4.8 million Indians identified themselves in the ‘other’ category.

Recent legal and policy changes in India have significantly affected gender-diverse communities. The Transgender Persons (Protection of Rights) Bill formulated in 2014 went through changes over a period of 5 years and was finally declared an Act in 2019. The Act highlighted the need to prohibit discrimination including denial of service or unfair treatment in relation to healthcare [ 5 ]. With respect to UHC, there are evident disparities in service coverage across the transgender population [ 6 ]. Transgender persons face a disproportionate burden of certain diseases, including HIV, viral hepatitis, and other sexually transmitted infections. They also pose a higher risk for mental health issues or substance abuse. Literature also suggests that transgenders may seek gender-affirming health services apart from general healthcare services. This might involve counseling support for themselves and their family related to gender id entity or undergoing gender transitioning procedures and surgeries. Transition-related treatment may include cross-sex hormonal therapy, hair removal, and gender-affirming surgeries.

In India, there are significant disparities in the availability and accessibility of healthcare. Existing research has identified various challenges and barriers encountered by transgenders in accessing and navigating the healthcare system. These include a lack of provider expertise in transgender care, the gap in health systems delivery mechanisms, lack of culturally sensitive healthcare training, inadequate financial coverage or low socio-economic condition, and poor community health-seeking behavior [ 7 ]. Rajasthan is one of the high focus states under the National Health Mission [ 8 ]. Since Western Rajasthan is a desert area, healthcare becomes even more challenging [ 9 ]. It further causes adverse impact on the desire and ability of transgender people to access healthcare. Poor healthcare access and health outcomes among the transgender population can also be attributed to lower levels of health literacy [ 10 ]. Rajasthan is one of the states with the lowest literacy rates among the transgender population [ 11 ].

In order to improve the health of transgenders and address the barriers to healthcare, it is crucial to identify the health priorities. A growing body of research regarding the healthcare experiences of transgenders exists worldwide, but there is still a paucity of research in the Indian context. This study has been conducted with the aim of reviewing the health issues and challenges faced by them in the existing healthcare system in Western Rajasthan. Although behavioral and social factors play a pivotal role in transgender health, this research focused on health needs and healthcare system-related barriers and challenges.

Research questions:

What are the basic health needs of the transgender community?

What are the barriers they encounter in the process of obtaining healthcare services?

How are the experiences of transgender persons in healthcare facilities?

What is the level of knowledge among healthcare providers regarding health of transgender persons?

How can healthcare services be enhanced for the transgender population?

Methodology

The study was conducted in the state of Rajasthan during the year 2022.

Research Design: This study utilizes a descriptive qualitative research design to allow in-depth insight into the existing health-related needs of transgender persons, their experiences in healthcare facilities and the barriers they encounter in meeting their needs. The study was approved by the Institutional Review Board of All India Institute of Medical Sciences, Jodhpur in July 2022.

Setting: The study was conducted in a community-based organization.

Sampling and sample size: Purposive sampling was utilized for this research. Transgender people above or equal to 18 years of age residing in different geographical region of western Rajasthan were approached with the help of established Civil Service Organizations (CSO). People who responded back were included in the study.

Data collection: All recruitment and data collection procedures were completed by public health scholars trained in research under the supervision of a community medicine professor. Multi-stakeholder interviews were conducted. It includes identification of relevant stakeholders to understand facilitators and barriers of the topic of interest. The identified stakeholders included specialist healthcare providers, representatives of civil service organizations and transgender persons (target population). All the individuals who agreed to participate in the study were approached by the interviewer. They were explained the purpose of the study and an appropriate time was decided to ensure active participation. This was also done keeping in view the sensitivity of the subject matter. All the interviews and the focus group discussion were conducted face-to-face in English and translated to Hindi for participants who did not understand English. Key informant interviews ( n  = 7) of specialist healthcare providers central to providing transgender care were conducted. The specialists included of a psychiatrist, plastic surgeon, endocrinologist, gynecologist, and community medicine experts. All interviews with specialist healthcare providers had a duration of 20–30 min. Transgenders residing in different geographical region of western Rajasthan were invited for a focus group discussion (FGD). Informed consent was taken from all the study participants who agreed to participate in the study. Audio and video recordings were done for focus group discussion as well as key informant interviews. The focus group discussion lasted for 2 h. Apart from this, CSO representatives were also interviewed ( n  = 3) i.e., a nurse, social worker and the administrative head of the organization. Data was collected over a period of 2 months.

Before the focus group, socio-demographic data was recorded, including age, gender, education, and income. An FGD guide and interview schedules were prepared and used for focus group and key informant interviews, respectively. They were designed to cover information about:

Knowledge and experience on transgender issues.

Challenges in providing transgender care.

Methods for improvement of the healthcare system.

Analytic approach: Audio-recorded focus group data and key informant interviews were transcribed and translated into English by four researchers. The data obtained through key informant interviews were also transcribed. The data was analyzed manually using thematic analysis. The available data was actively and repeatedly read to familiarize and valuably orient towards the available raw data. Subsequently, codes were identified using an inductive approach i.e., they were reflective of the issues that were apparent in the data and were not dependent or guided by any existing theoretical frameworks. In the next step, themes were constructed by analyzing, combining, and comparing codes. The developed themes were such that they reflected the significance of the entire dataset. Lastly, the themes were reviewed, defined, and named, along with the identification of narratives that justify and explain all the mentioned themes. In the final stage of analysis, the identified themes from the coded data were used to construct a framework using grounded theory approach such that it accurately represents a concise picture of the data.

Ethical considerations: Confidentiality emerged as an ethical concern in this study. All transgender individuals were provided with detailed information about the purpose, procedures, potential risks, and benefits of research. Participants were ensured that their participation was voluntary, and they had the right to withdraw at any time without consequence. All data and identifying information collected during the discussion was restricted to the research team and anonymized to prevent identification of individual participants.

A total of 12 transgenders participated in the FGD. Their socio-demographic characteristics are summarized in Table  1 . All Participants in the study belonged to Rajasthan, India. Eleven out of the total 12 participants self-identified themselves as transgender woman. The mean age of transgender individuals who participated in the study was 23.8 ± 3.6. The selected cohort represented a range of educational qualifications from secondary school to post-graduation. The majority of the participants were employed, but none was employed in the government sector. More than half of the participating individuals had an income of less than INR 10,000 (66.7%) (Table  1 ).

Health needs of the transgender community

The need for regular screening of non-communicable diseases at peripheral healthcare centers was expressed by the transgender participants. Lack of accessible and/or affordable health services and social barriers contribute to anxiety and depression among them, which further leads to their inability to control the use of tobacco and alcohol. This indicates the need for mental health support tailored specifically for this population.

Healthcare provider 1 (HCP-1) “ Gender dysphoria is diagnosed in later stages of life, late adolescence, or early adulthood because individuals are not able to seek help due to a lack of knowledge on available medical options and familial pressure.”

Specifically, they expressed the need for public healthcare facilities to provide gender transitioning procedures ranging from hormone replacement therapies to sex reassignment surgeries.

Figure  1 illustrates coding tree for health needs of transgender participants.

Coding tree for health needs of transgender participants

Barriers enumerated by transgenders in accessing healthcare services were segregated into personal, healthcare system and social barriers (Table  2 ).

Personal barriers

Transgender participants revealed a lack of awareness regarding the provision of transgender identity cards being issued by the Ministry of Social Justice and Empowerment. Moreover, the growing need was identified to educate them regarding their entitlements which may have implications on health. These include but are not limited to recognition of their gender identity, provision of medical facilities for their surgical and hormonal needs, and facilitation of access in hospitals and other healthcare facilities. (Transgender Act 2019)

During a key informant interview, one of the medical practitioners highlighted the need to introduce and explain the range of medical options available to transgenders for their transition.

HCP-2 “ Internationally, I have worked in fertility clinics. Before undergoing hormonal therapies or surgeries, transgender patients usually preserve oocytes and sperms to bear children in the future. The basket of available options must be known to the community. This also improves their quality of life.”

The health outcomes of an individual are dependent on their timely health-seeking behaviors. An interview revealed that many transgenders prefer the traditional removal method of male genitals rather than conventional gender affirming surgery. This reflects multiple dimensions such as lack of awareness regarding appropriate health practitioners and discrimination by the qualified professionals. Other underlying reasons for this include the lack of public hospitals providing these services and the unaffordable costs of surgeries. A study participant has also revealed being comfortable getting the surgery done by the ‘guru’ . Moreover, the distance between their households and healthcare facility makes it inaccessible for them.

Health system barriers

Both transgender persons and healthcare providers reported a lack of knowledge of any insurance schemes specifically for transgenders or insurance coverage for the minority population under the available schemes. Their awareness regarding the inclusion of gender-specific needs such as sexual reassignment surgeries or hormonal therapies in the existing insurance schemes was limited.

The study participants also addressed the need for the inclusion of a third gender column in the patient information / outpatient cards across all the hospitals. This is in alignment with the Transgender Persons (Protection of Rights) Bill, 2019, which prohibits discrimination against them in healthcare [ 5 ]. It would also lead to a transgender-inclusive environment in the hospital and greater acceptance by other people.

TG participant 7 “ Whenever we go to the hospital, we are asked whether to write male or female. There is no option of transgender in the OPD cards.”

In India, nationally recognized identity cards are being provided by the Ministry of Social Justice and Empowerment as a step towards mainstreaming their identity. One participant revealed that recently when she visited a hospital, the authorities denied accepting the TG identity card. This incident reflects the need of generating awareness across all sectors, including healthcare, to prevent the exclusion of transgender people in society.

TG participant 8 I had fever for a few days, I went to a hospital for treatment. I gave my transgender ID card issued by the ministry. They said this is not valid.

Accessibility

Majority of the participants revealed having negative experiences in healthcare settings. They reported that they had to wait very long to access health services.

One participant complained about the long counselling procedure and time to access hormone replacement therapy. Furthermore, many qualified practitioners discourage and demotivate the use of hormones. This reluctance among medical practitioners to prescribe hormones often compels transgenders to refer to the unfiltered content on the internet, resulting in the self-administration of hormones. Since transgenders are unaware of the side effects of unregulated dosages of hormones, it can result in adverse health outcomes.

Sometimes, the health facilities with available resources are situated far away from the residence of transgenders leading to difficulty in access. In one of the key informant interviews, a medical practitioner shared her experience with a transgender patient whose vaginal canal got stenosed as a complication of post Sex Reassignment Surgery (SRS). Since the health facility was around 500 km from her hometown, she could not reach the hospital on time.

Availability

One of the most significant barriers to healthcare reported by transgenders was a dearth of healthcare providers trained to address their specific health problems. Healthcare providers also emphasized the need for training to understand the best practices for their care. Some parts of clinical training should also include the importance and impact of physician-patient communication. The use of correct pronouns should be taught to collect sufficient and accurate information on their gender identity and thus, making the hospital settings friendly for them. Additionally, awareness sessions should also be conducted for medical professionals to make them comfortable and culturally competent while dealing with this section of society.

Some participants also shared that there is a need for designated facilities in healthcare, such as separate queues in OPDs and dedicated wards or beds in hospitals. It was felt that these facilities’ absence contributed to their fear and delay in access and utilization of desired appropriate care. Due to contributory social factors, such as real or perceived stigma, it is challenging for them to accommodate within the general ward. Medical providers had contrasting views in lieu of the unavailability of designated facilities. While most believed that providing separate queues and beds for them in hospitals was essential, one of the doctors felt this would promote social exclusion.

TG participant 1 Where should we stand in hospitals? Queues made for males or females? Separate beds shall be assigned for us so that we can access the services without hesitancy or fear of discrimination . HCP-3 Providing them separate facilities for all services cannot be the ultimate solution. Will this promote equity or rather advance social exclusion? We should think about it.

Moreover, there is a lack of specialist care in hospitals that are accessible to them. There is no provision to address transgender-specific health problems at the primary healthcare level. Lack of robust referral mechanisms leading to delayed or denied care was also reported.

Affordability

Transgenders are not registered and do not have access to benefits under the insurance schemes functioning in the country. All hospitals in the country do not provide gender transition services. Those services provided by the private sector often have charges beyond their paying capacity. As a result, accessing and affording healthcare becomes a challenge for them. This is one reason that urges them to go to unqualified traditional medical practitioners for gender transitioning surgeries or ‘Dai Nirwan.’

Breast augmentation is another common procedure utilized by transgenders. One participant discussed the availability of various implant materials and how their costs vary depending on the quality. Additionally, due to financial reasons and lack of awareness, low-quality implant materials are utilized in surgeries, which increases their risk for breast cancer.

Social barriers

The non-medical factors play a crucial role in impacting health outcomes. Addressing social determinants is central to reducing existing health inequities. In this study, all the participants reported stigma and discrimination while sharing their experiences in healthcare settings. They further added that this discouraged them from utilizing available health services.

The participants reported that even the healthcare providers were uncomfortable with their presence and did not treat them like other patients.

Poor housing conditions and lack of job opportunities further push them into this vicious cycle of stigma and sickness. Transgenders have also reported experiencing psychological distress due to a lack of social support. Positive attitude and gender-supportive relationships in society can promote their well-being. The need for their inclusion in society through awareness generation by government initiatives was emphasized.

TG participant 3 We can promote family planning through condom advertisements, so why not involve transgender figures in government health awareness advertisements and campaigns .

Healthcare provider expertise in TG health

All the healthcare providers felt the need for training to improve physician-patient communication and transgender persons care. A culturally competent healthcare perspective is fundamental for treating the transgender population. Those providers who had experience with such patients were more likely to provide perspectives on their care and barriers than those who had never encountered such cases. They highlighted that very few transgender patients are registered in the hospitals of Rajasthan. This can be attributed to the stigma associated with their presence rather than assuming they do not wish to seek healthcare services.

This study sought to investigate and fill the gap in the domain of transgender healthcare. The purpose of the research was to characterize the health needs and barriers faced by transgender individuals in navigating through the health system. Previous international and Indian studies have reported a lack of transgender-sensitive care. The findings of this research corroborate this premise. There is a wide and serious gap between the population’s needs and the healthcare system’s ability to respond to these needs.

The socio-demographic profile of the participants in this study revealed that the income of the majority of the participants was below INR 10,000. This finding is in alignment with the results (70%) of a study conducted among transgenders in Vadodara, Gujarat, India [ 12 ].

The FGD gave an opportunity to the study participants to express their general and gender-specific health needs. The health needs of the participants in this study included available medical services common to the general population and certain specific transgender needs, particularly psychiatric support, hormonal therapies, and sex-reassignment surgeries. This is in accordance with the previous studies, which also identified general health problems that need to be addressed, including the high prevalence of diabetes and hypertension, substance abuse, anxiety, and depression [ 13 ].

Transgender individuals discussed a range of experiences and barriers encountered in the healthcare system in accessing the available services. The barriers were categorized at the healthcare system, social and individual levels. The system-level barriers ranged from policy issues to hospital or organizational problems. It included a lack of coverage for the transgender population in government health insurance schemes. The introduction of a comprehensive package master in the Ayushman Bharat scheme has now addressed the lack of coverage for transgenders in the existing insurance schemes. It includes the existing packages as well as specific packages for transgenders [ 14 ]. This paves the way for a new chapter in their care. The unavailability of trained healthcare providers is another major problem. In 2019, National Medical Commission (NMC) updated the medical education curriculum and added a new module on Attitude, Ethics, and Communication (AETCOM) competencies [ 15 ]. It could be used as an opportunity to introduce culturally sensitive communication training for medical professionals, especially focusing on LGBTQ + community, to advance our aim to achieve equity. In addition to the unavailability of trained doctors, the inaccessibility of healthcare facilities and unaffordability also negatively impact the people’s health. All these underlying factors contribute to their practice of getting surgeries done by traditional and untrained medical practitioners. These findings are consistent with another study conducted in India to assess the health-seeking behavior of transgender people. They also reported long waiting times in hospitals affecting their health behaviors and are confirmed to have undergone medical procedures performed by gurus or technicians [ 16 ].

The finding of concern that emerged in our study sample was the use of unprescribed hormone therapy. This finding is similar to a study conducted in Maharashtra to assess the practices related to hormonal therapy [ 17 ]. It states that participants reported going for unsupervised hormone replacement therapy due to unaffordability, lack of trained healthcare providers and prior experiences in healthcare settings [ 17 ]. In order to avail the hormonal therapy, transgender patients require to undergo psychological counseling’s for confirmation of gender dysphoria. In our study, transgender individuals felt that the psychotherapy sessions are too long, leading to a delay in the initiation of hormone replacement therapy. World Professional Association for Transgender Health (WPATH) mentioned in their Standards of Care (SOC) that any minimum number of sessions cannot be fixed and is an individualistic approach. It depends whether someone wishes to avail psychological support before, during, or throughout the transition process [ 18 ]. Gender transitioning may involve but not be limited to procedures such as hormonal therapy and sex reassignment surgeries. Moreover, there are only a few public health facilities providing gender-transition services and there is no government support in the form of subsidies to avail these services from a private hospital. The government, is however, working on extending and empaneling public and private hospitals in order to make these services accessible to the population.

This need assessment study also attempted to address the social determinants barring healthcare access. Stigma, discrimination, support from family and friends, and difficulty in seeking housing determine health and healthcare accessibility. These factors have also been highlighted by the study conducted in Vadodara, India [ 12 ]. It re-emphasizes the findings from our study that social determinants such as lack of economic and educational opportunities, rejection, and isolation from society have an impact beyond gender identity issues, rather, they pose a risk to the psychological status of the transgender population.

The health disparities and barriers to care faced by transgenders should be addressed to promote health equity and justice. Comprehensive approaches to improve access, utilization, and quality of healthcare services are currently lacking. These challenges can also be addressed at the following levels:

Individual Level.

Healthcare system Level.

Community Level.

Garima Greh facilities have been introduced as shelter homes for transgender individuals where basic amenities are being provided to them [ 19 ]. They can be utilized as launchpad sites to improve their awareness of their rights and available entitlements and medical interventions. IEC materials can be displayed at Garima Greh facilities for health promotion and modification of their health-seeking behaviors. Similar to ASHA workers who are community members working for their healthcare, volunteers can be appointed from their community. Training of these volunteers can be done (Training of Trainers) so that they can improve their health-seeking behavior, increase awareness, and aid in the overall empowerment of the community.

All hospitals and clinical settings shall provide a safe and welcoming environment for gender-diverse people [ 20 ]. The fact that their physical, mental, and cultural differences affect their behaviors must be known but, more importantly, understand these differences and assigning them value is the key. Actions can be taken to promote transgender identity across healthcare settings by displaying Information, Education and Communication (IEC) material regarding their health needs and promoting their acceptance in society – ‘This hospital is LGBTQIA + friendly.’ Transgenders can also be part of the healthcare system, whereby; they can act as resource persons and promote the inclusivity of gender-diverse individuals. Medical students shall be trained to communicate sensitively to the needs of transgenders, and doctors shall be trained in a culturally competent way to treat their gender-specific needs. To promote access and utilization of health services, specific transgender clinics are being set up across the country. All participants in the study felt this would help them to access available services without hesitancy. Separate general health camps for regular and dental check-ups can also aid in health promotion and equity. Another potential solution to promote transgender health is through digital solutions. Tele-consultation can be an effective way to address their needs as well as to protect them from social stigma and discrimination that hinder their access and utilization of available services.

According to World Health Organization (WHO), social determinants account for 30–55% of health outcomes [ 21 ]. The most effective way to address SDH is by action at the community level. General campaigns and community awareness sessions are essential to promote acceptance by the general population. Moreover, the study suggests that there is a need for awareness and sensitization of transgenders regarding the basket of medical options available for them such as techniques for fertility preservation.

In summary, the study demonstrates the health issues of transgenders and reflects upon the various factors influencing health and access to care. It urges the stakeholders to contemplate the need to safeguard the rights of transgenders by providing equitable access to the available resources.

This study is an attempt to explore health needs from beneficiary as well as service provider perspectives. Our findings are consistent with the previous literature. Findings from this study provide evidence base for future research and a helpful tool for the policymakers and advocates to better address the needs of transgender people.

The study’s major limitation was that only one focus group discussion was undertaken due to limited time and difficulty in accessing the desired population. However, one FGD allowed for exploration of issues related to transgender experiences and healthcare needs. It allowed the researchers to gather detailed narratives that might not emerge from individual interviews. Given the paucity of literature in the Western Indian context, a single focus group discussion can be valuable for informing advocacy efforts and policy reforms. Participants in the study were recruited through purposive sampling and did not differentiate between cultural identities of transgender persons; therefore, the results might vary geographically and according to the social context, thus, limiting the external validity. The health needs might vary between transgender male and female populations, but there was only one transgender male participant in our study. Additionally, the service providers’ knowledge was not directly assessed by explicitly questioning the standards of care.

Proposed framework

Based on study findings, a Gender Responsive Healthcare System Framework is designed. (Fig.  2 ) This framework illustrates and emphasizes on the need for planning, interventions, and actions at 3 levels – policy (a), health system (b), social, and individual (c) in alignment with the identified themes represented in Table  1 . The framework describes how the barriers can be addressed at these 3 levels to have a robust and gender-responsive healthcare delivery system in India.

The concept of healthcare is multi-dimensional. Combined action is required at the administrative, service provider and beneficiary level for a gender responsive healthcare system. Inclusion of the transgender population in existing health insurance schemes is central to reducing their out-of-pocket expenditure and helping them gain recognition in the society through the treatments that they wish to access. Outpatient cards in hospitals should include options of male, female and transgenders/others (gender diverse) creating a safe and welcoming environment. Existing health programs shall also target transgender population for reducing the burden of infectious diseases such as tuberculosis and non-communicable diseases. At the healthcare system level, medical professionals competent to provide transgender specific care and availability of specialists shall be ensured. A robust referral mechanism from primary healthcare centers to higher levels could ensure uninterrupted care for the transgender population. Moreover, hospitals have distinct queues, for men and women. There is a need to understand that gender is not a visibly readable or unchanging phenomenon, rather it is a social construct. Proper queue management can address not only the issues of stigma, but also make healthcare accessible to them. At an individual level, good health seeking behavior and familial support can aid in improving health outcomes. Altogether, these efforts at the policy, health system and individual level can lead to improvement in accessibility, availability, affordability and acceptability of services by the transgender people.

Gender Responsive Healthcare System Framework

This study has explored experiences of transgender people navigating through the healthcare system. These accounts have highlighted their health needs and the barriers they face in accessing care. They expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified ranging from absence of targeted policies to individual behavior. Targeted efforts and intersectoral collaboration are required for effective establishment and delivery of healthcare services.

Data availability

The data generated and reviewed are fully available in this article and its supplementary files. For any further data, Dr. Tanvi Kaur Ahuja ([email protected] could be contacted).

All relevant data analyzed during this study are included in this published article and its Supplementary Information files.

Universal health coverage (UHC). [Internet]. [cited 2023 Jan 27]. https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc ).

nhp.gov. in [Internet]. [cited 2023 Jan 27]. national_health_policy_2017.pdf. https://www.nhp.gov.in/nhpfiles/national_health_policy_2017.pdf .

nhsrcindia.org [Internet]. [cited 2023 Jan 27]. NHA 2018-19_07-09-2022_revised_0.pdf. https://nhsrcindia.org/sites/default/files/2022-09/NHA%202018-19_07-09-2022_revised_0.pdf .

Transgender P. | Lesbian, Gay, Bisexual, and Transgender Health | CDC [Internet]. 2022 [cited 2022 Nov 14]. https://www.cdc.gov/lgbthealth/transgender.htm .

Transgender Persons (Protection of Rights) Act. 2019. An Act to provide for protection of rights of transgender persons and their welfare and for matters connected therewith and incidental thereto [Internet]. 2020 Jan 10 [cited 2022 Nov 18]; http://indiacode.nic.in/handle/123456789/13091 .

TransGender/Others -. Census 2011 India [Internet]. [cited 2022 Nov 14]. https://www.census2011.co.in/transgender.php .

Pandya Akumar, Redcay A. Access to health services: barriers faced by the transgender population in India. J Gay Lesbian Ment Health. 2021;25(2):132–54.

Article   Google Scholar  

National Institute of Health &. Family Welfare [Internet]. [cited 2023 Apr 1]. http://www.nihfw.org/NationalRuralHealthMission.html .

Mangal DK. PS. raj_health_systems_research_summary_.pdf [Internet]. [cited 2023 Feb 25]. https://www.copenhagenconsensus.com/sites/default/files/raj_health_systems_research_summary_.pdf .

Hostetter CR, Call J, Gerke DR, Holloway BT, Walls NE, Greenfield JC. We are doing the Absolute Most that we can, and no one is listening: barriers and facilitators to Health literacy within Transgender and Nonbinary communities. Int J Environ Res Public Health. 2022;19(3):1229.

Article   PubMed   PubMed Central   Google Scholar  

Mal S, Mundu G. Spatial Disparities of Indian Transgender Population: A Censual Analysis. 2023;4:6560–71.

Arvind A, Pandya A, Amin L, Aggarwal M, Agrawal D, Tiwari K, et al. Social strain, distress, and gender dysphoria among transgender women and Hijra in Vadodara, India. Int J Transgender Health. 2022;23(1–2):149–63.

Google Scholar  

Sperber J, Landers S, Lawrence S. Access to Health Care for Transgendered persons: results of a needs Assessment in Boston. Int J Transgenderism. 2005;8(2–3):75–91.

Ministry of Social Justice. and Empowerment signed a MoU with National Health Authority [Internet]. [cited 2022 Nov 21]. https://pib.gov.in/pib.gov.in/Pressreleaseshare.aspx?PRID=1854141 .

Medical Council of India. AETCOM_book.pdf [Internet]. [cited 2023 Apr 1]. https://www.nmc.org.in/wp-content/uploads/2020/01/AETCOM_book.pdf .

Fernandes S, Jadhav H. A study to access morbidity profile and health-seeking behavior among transgender persons in a metropolitan city. Int J Med Sci Public Health. 2020;0:1.

Rajueni K, Royal A, Pawar S, Kumar A, Kumar V. Practices for accessing hormone therapy in male to female transgenders in Maharashtra, India. Clin Epidemiol Glob Health. 2022;15:101071.

Article   CAS   Google Scholar  

The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People [Internet]. [cited 2022 Nov 18]. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf .

गरिमा. गृह | Garima Greh [Internet]. [cited 2023 Mar 31]. https://transgender.dosje.gov.in/GarimaGreh/About .

American Medical Association. Welcoming Environment.pdf [Internet]. [cited 2023 Apr 1]. https://www.glma.org/_data/n_0001/resources/live/Welcoming%20Environment.pdf .

Social determinants of health [Internet]. [cited 2022 Nov 21]. https://www.who.int/health-topics/social-determinants-of-health .

Download references

Acknowledgements

The authors would like to acknowledge the contribution of Sambhali trust, Jodhpur and Nai Bhor Sanstha, Jaipur for helping us to get in touch with the transgender participants.

This research received no funding.

Author information

Authors and affiliations.

School of Public Health, All India Institute of Medical Sciences, Jodhpur, India

Tanvi Kaur Ahuja, Akhil Dhanesh Goel, Manoj Kumar Gupta, Nitin Joshi, Annu Choudhary, Swati Suman, Kajal Taluja & Pankaj Bhardwaj

Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India

Akhil Dhanesh Goel, Manoj Kumar Gupta & Pankaj Bhardwaj

Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur, India

Madhukar Mittal

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Jodhpur, India

Navdeep Kaur Ghuman

Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, India

Navratan Suthar

You can also search for this author in PubMed   Google Scholar

Contributions

T.A., A.G. Conceptualized the research study done, A.G., M.G., N.J., P.B. framed the Methodology was framed, T.A., N.K., M.M., N.S., N.G., A.C. contributed in collection of data; T.A., A.G. prepared the Original draft; T.A., A.G., S.S., K.T. Reviewed and edited the manuscript; P.B. M.G., N.J. Supervised the research study, All authors have read and agreed to the published version of the manuscript.

Corresponding authors

Correspondence to Tanvi Kaur Ahuja or Akhil Dhanesh Goel .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by the Institutional Review Board in July 2022. The certificate reference number granted by the Institutional Ethics Committee is AIIMS/IEC/2022/4023. Informed consent was taken from all participants who agreed to participate in the study. Participants were informed that they could withdraw consent to participate at any time during the interview. All methods were performed in accordance with the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Ahuja, T.K., Goel, A.D., Gupta, M.K. et al. Health care needs and barriers to care among the transgender population: a study from western Rajasthan. BMC Health Serv Res 24 , 989 (2024). https://doi.org/10.1186/s12913-024-11010-2

Download citation

Received : 29 May 2023

Accepted : 18 April 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11010-2

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Transgender persons
• Gender dysphoria
• Focus groups
• Mental Health
• Non-communicable diseases
• Health services

BMC Health Services Research

ISSN: 1472-6963

• General enquiries: [email protected]